It is our collective responsibility to protect the future health of all children. The seeds of cancer are often planted during childhood, so we must treat cancer prevention as a serious child-care issue.
—Ronald A. DePinho, MD
As health-care providers, we have an obligation and a responsibility not only to care for our patients, but also to educate them—and the general public—about their cancer risk and ways to reduce or prevent it. We are living in the golden era of cancer prevention and treatment, made possible by investments in fundamental research. One major victory—truly, a scientific dream come true—is the development of the human papillomavirus (HPV) vaccine, which can protect against cancers caused by HPV infection. Regrettably, however, it’s not being used to its full potential.
Since the HPV vaccine first became available in 2006, HPV infections have dropped by more than half among girls aged 14 to 19 in the United States.1 This may sound encouraging, but we could be doing so much better. Research shows that less than 40% of girls and just over 20% of boys in the United States receive all three doses of this safe and effective vaccine.2 Vaccine uptake is low due to a variety of reasons, but the two most frequently cited by parents are that they didn’t receive a physician recommendation for it and that they lacked knowledge or needed more information about the vaccine.
Missing the Mark
The reality is that this cancer vaccine has the potential to prevent the vast majority of HPV-related cancers, including cervical, throat, anal, vaginal, vulvar, and penile cancers. Yet, we’re clearly missing the mark.
Every year in this country, 27,000 people get cancer caused by HPV—that’s one person every 20 minutes of every day.3 The annual disease burden in the United States is significant. In Texas alone, annual HPV-related disease costs for men and women approach $170 million.4
Each year for American women, there are 1.4 million new cases of low-grade cervical dysplasia,5 1 million new cases of genital warts,6 330,000 new cases of high-grade cervical dysplasia,5 over 12,000 new cases of cervical cancer, and, worst of all, 4,000 cervical cancer deaths each year.7 That’s 3 million HPV-related cases at a cost to our health-care system of $8 billion8 and the cause of significant pain and suffering for patients, most of which could be avoided if the HPV vaccine had been available and properly used in these patients.
Reaching the Goal
The National Institutes of Health initiative Healthy People 2020 (healthypeople.gov) has set a goal of achieving an 80% HPV vaccination adherence rate in both boys and girls. So the question is, what can be done to reach that goal?
I believe one key answer is education. Through education, improved early screening, and the development of new and better therapies, we have an opportunity to make these cancers as rare as polio, smallpox, and diphtheria.
As one of the newly announced targets in our Moon Shots Program, dozens of researchers, clinicians, prevention and public health experts, and governmental relations leaders at The University of Texas MD Anderson Cancer Center are working to identify practical solutions and strategies to enhance awareness, improve vaccination rates, and ultimately reduce the incidence and mortality of HPV-related cancers. It’s not a simple task, but it’s one that we’re committed to accomplishing through three major flagship projects currently underway, the first of which, public policy and education, is the focus of this column.
The second flagship project focuses on target discovery through our Cancer Genomics Lab and target validation and drug discovery through our Institute for Applied Cancer Science. The third flagship project aims to build upon our success in immunotherapy treatments and novel clinical trials using peptide vaccines coupled with immune checkpoint inhibitors. In the early phases of this moon shot, we are targeting rare tumors, gynecologic cancers, and head and neck cancers. This project is enabled by MD Anderson’s Center for Co-Clinical Trials, Institute for Applied Cancer Science, and Immunotherapy platform.
But let’s look more closely at our first flagship project, which targets policy, education, and screening through health policy, governmental relations, and professional and public education. We are committed to increasing HPV vaccination using policy and education to (1) reduce missed clinical opportunities to recommend and administer HPV vaccines and (2) to increase acceptance of HPV vaccines by parents, caregivers, and adolescents.
Engaging Health-Care Providers
How do we make that happen? Our multidisciplinary team of experts is an educational army working to share our knowledge with our peers in health care. We cover all medical disciplines, including pediatricians, primary care providers, nurse practitioners, midlevel providers, nurses, fellows, and beyond and provide helpful tools, like curriculum reviews, continuing medical education videos, and communication training to help inform provider discussion with parents, caregivers, and adolescents.
Health-care providers are most successful when they are well versed in the safety and efficacy data and better informed on how to discuss a sometimes-difficult subject with unsure parents and nervous kids. But it must be done, and we must rely on pediatricians and primary care providers to make this a priority.
Just recently, we brought together experts from the National Cancer Institute (NCI), the American Cancer Society, the Centers for Disease Control and Prevention (CDC), and more than 35 of the nation’s NCI-designated cancer centers for a summit titled, “Increasing HPV Vaccination in the U.S.: A Collaboration of NCI-Designated Cancer Centers.” A highlight of the summit was the presentation of findings from recently completed, federally funded environmental scans, which revealed barriers to increasing vaccination rates in pediatric settings as well as successful strategies that might be adapted across the country. Collaboration was another major focus, with centers currently developing a consensus statement of shared endorsement for the HPV vaccine.
From a governmental perspective, Congress made HPV vaccine education a priority through the Prevention and Public Health Fund, created in 2010 as part of the Affordable Care Act. Aimed at providing stable and increased investment in public health activities to prevent disease and promote health and wellness in communities nationwide, this program is proving successful.
From 2011 to 2014, $17.4 million in federal funding was awarded to 18 states and 4 cities to increase HPV vaccination coverage among adolescents through joint initiatives with immunization stakeholders, communication campaigns, and strategies targeted to improve immunization providers’ knowledge, skills, and adherence to current HPV vaccination recommendations. According to data from the CDC’s 2014 National Immunization Survey-Teen, 4 of the 11 public health jurisdictions that received funding in 2013 from the Prevention and Public Health Fund to increase HPV vaccine coverage demonstrated significant increases in either ≥ 1- or ≥ 3-dose coverage among girls and women.2 These data suggest that the funding is beginning to have an impact, and it is hoped that over time, more jurisdictions will follow suit.
Initiating efforts at the state level, experts in our Cancer Control platform, HPV Moon Shot program, and governmental relations worked with the Texas legislature to raise awareness about the impact of HPV-associated cancers on the state. In collaboration with other stakeholders, we served as the primary resource on legislation requiring the state to develop a statewide strategic plan to address HPV-associated cancers by improving vaccination rates, enhancing and expanding access to screening and treatment, and other evidence-based programs aimed at significantly reducing cancer mortality in Texas.
In the area of screening, we’ve been able to tap into our global, collaborative network to make a broad impact. With our 31 sister institutions in 22 countries, the opportunities are limitless and the desire for information, support, and training is significant.
In the United States, Project ECHO: Extension for Community Healthcare Outcomes (New Mexico), a collaborative model of medical education and care management,9 is allowing experts to provide best-practice care for common and complex diseases in rural and underserved areas through telementoring. This approach involves biweekly, 1-hour teleconferences including case presentations and discussions with specialists. These sessions are supplemented with hands-on training and instruction to assist local providers in managing their patients with greater confidence.
Using the ECHO model, we partnered with several institutions to educate and support primary care providers and midlevel providers in Texas’ lower Rio Grande Valley, where cervical cancer rates are 31% higher than in other areas of Texas. Coupled with public education regarding cervical cancer screening and HPV vaccination, Project ECHO is already making an impact in the lives of many underserved and often uninsured women in this region.
Protecting the Health of Children
A variety of controversies often surround vaccines. However, research has proved that the HPV vaccine is safe and effective. It has also been shown in several large studies that receiving the vaccine does not lead to increased sexual promiscuity. I’ll say it again: This is a cancer vaccine that protects against a contagious virus that infects 80% of the world’s adult population, causes more than 400,000 deaths each year, and disfigures millions more. This cancer vaccine is safe and effective, and it has the potential to put an end to many of the hardest-to-diagnose and most difficult-to-treat cancers.
I am the parent of three young children, and they have all received the HPV vaccine. There are many things that worry me as a parent, but HPV-related cancers can now be crossed off my list. Knowledge has prevailed to protect them. It is our collective responsibility to protect the future health of all children. The seeds of cancer are often planted during childhood, so we must treat cancer prevention as a serious child-care issue. ■
Disclosure: Dr. DePinho reported no potential conflicts of interest.
1. Markowitz LE, Hariri S, Lin C, et al: Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003-2010. J Infect Dis 208:385-393, 2013.
2. Centers for Disease Control and Prevention: Teen vaccination coverage: 2014 National Immunization Survey-Teen (NIS-Teen). Available at cdc.gov/vaccines/who/teens/vaccination-coverage.html. Accessed December 8, 2015.
3. Centers for Disease Control and Prevention: How many cancers are linked with HPV each year? Available at cdc.gov/cancer/hpv/statistics/cases.htm. Accessed December 8, 2015.
4. Fonseca V: Cervical cancer and HPV-related disease in Texas. 82nd Annual Texas Public Health Association Conference. Presented February 2007.
5. Schiffman M, Solomon D: Findings to date from the ASCUS-LSIL Triage Study (ALTS). Arch Pathol Lab Med 127:946-949, 2003.
6. Fleischer AB, Parrish CA, Glenn R, et al: Condylomata acuminata (genital warts): Patient demographics and treating physicians. Sex Transm Dis 28:643-647, 2001.
7. American Cancer Society: Cancer Facts & Figures 2014. Atlanta, American Cancer Society, 2014.
8. Chesson HW, Ekwueme DU, Saraiya M, et al: Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine 30:6016-6019, 2012.
9. Agency for Healthcare Research and Quality: Project ECHO: Extension for Community Healthcare Outcomes (New Mexico). Available at https://healthit.ahrq.gov/ahrq-funded-projects/project-echo-extension-community-healthcare-outcomes. Accessed December 8, 2015.
Dr. DePinho is President of The University of Texas MD Anderson Cancer Center in Houston.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO.