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FDA approval of pembrolizumab (Keytruda) plus chemoradiotherapy

in FIGO stage III to IVA cervical cancer, Jyoti S. Mayadev, MD, spoke about how the regimen’s approval would be a “major step” for the aforementioned population and how she planned to integrate it into her care.

Mayadev, a board-certified radiation oncologist and professor of radiation medicine and applied sciences at the University of California, San Diego School of Medicine, stated that the approval would be a “huge win” with respect to progression-free survival (PFS) based on supporting findings from the 

2023 Annual Global Meeting of the International Gynecologic Cancer Society (IGCS),

treatment with pembrolizumab plus chemoradiotherapy produced a significant PFS benefit compared with chemoradiation alone (HR, 0.70; 95% CI, 0.55-0.89; 

 Additionally, findings from a subgroup analysis highlighted that the PFS benefit with the pembrolizumab-based combination extended to those with FIGO stage III to IVA disease (HR, 0.58; 95% CI, 0.42-0.80).

Mayadev also described the tolerability and quality-of-life benefits associated with the pembrolizumab combination in the KEYNOTE-A18 trial. Additionally, she stated that potential next steps for research may involve integrating adaptive technology to potentially reduce toxicity following chemoradiation among patients with cervical cancer.

“Uptake of any new agent requires a multidisciplinary team approach. It requires workflows,” Mayadev said regarding her strategy for adopting the newly approved regimen in her clinic. “For our particular institution, we would somewhat seamlessly go into the FDA approval. At the same time, we would try to help others in the community. We, as a scientific global community for gynecologic oncology and radiation oncology, will come together and start to incorporate how we can move forward with the FDA approval.”

FDA approves pembrolizumab with chemoradiotherapy for FIGO 2014 stage III-IVA cervical cancer. News release. January 12, 2024. Accessed January 15, 2024. https://bit.ly/3NZNGPb

Lorusso D, Xiang Y, Hasegawa K, et al. ENGOT-cx11/GOG-3047/KEYNOTE-A18: A randomized, double-blind, phase 3 study of pembrolizumab plus chemoradiotherapy for high-risk locally advanced cervical cancer. Presented at 2023 Annual Global Meeting of the International Gynecologic Cancer Society; November 5-7, 2023; Seoul, South Korea. Abstract SE004/1614.

The FDA approval of pembrolizumab plus chemoradiation benefits patients with stage III to IVA cervical cancer based on findings from the KEYNOTE-A18 trial, according to Jyoti S. Mayadev, MD.

Jyoti S. Mayadev, MD, on Pembrolizumab/CRT FDA Approval in Cervical Cancer

Julianne Cooley, MS, a computational and data science research specialist at the California Cancer Reporting and Epidemiologic Surveillance in the University of California Davis Comprehensive Cancer Center, spoke with CancerNetwork

 about her research on cervical cancer screening and survival rate patterns among patients 65 years and older.

In her study, Cooley explored how survival rates among older patients with late-stage cervical cancer diagnoses were lower compared with those of younger patients, and how the current screening paradigm may be impacting this older population.

Don’t forget to subscribe to the “Oncology Peer Review On-The-Go” podcast on 

Julianne Cooley, MS, spoke with CancerNetwork® about older patients with later stage cervical cancer who have lower survival rates compared with their younger counterparts. 

Oncology Peer Review On-The-Go Podcast: Cervical Cancer Screenings/Survival in Those 65+ Years

In this week’s episode of “Oncology Peer Review On-The-Go,” 

speaks with Michael D. Randell, MD, FACOG, of OBGYN Atlanta, to learn more about the new cervical cancer screening guidelines released by the American Cancer Society. In the interview, Randell expresses his concerns with the updated guidelines, and details what he recommends to patients.

Don’t forget to subscribe to the “Oncology Peer Review On-The-Go” podcast on Apple Podcasts, Spotify or anywhere podcasts are available.

The latest episode of Oncology Peer Review On-The-Go sits down with Michael D. Randell, MD, FACOG, to discuss the latest updates to cervical cancer screening guidelines by the American Cancer Society.

Oncology Peer Review On-The-Go: 1-on-1 with Dr. Michael Randell: New ACS Guidelines for Cervical Cancer

In this interview we discuss treatment disparities and the impact on survival among patients with locally advanced cervical cancer with Christine M. Fisher, MD, MPH, a radiation oncologist at the University of Colorado in Denver. Dr. Fisher and her colleagues recently 

 a paper that analyzed differences in treatment and survival results among cervical cancer patients.

What was the impetus to study the national trends of the use of standard of care treatment in cervical cancer patients? Is there data already to suggest that not all patients receive the standard of care based on current guidelines?

The impetus is that we are still seeing women present with advanced cervical cancer, recurrent cervical cancer, and even dying from cervical cancer, which is ultimately a preventable disease. Worldwide, the burden on young women is quite high with about half a million cases per year. In my own practice, as a cervical cancer specialist, I have seen women come in, in a recurrent setting, who haven’t had all of the components of standard of care upfront, and I was suspicious and concerned that this may lead to poorer outcomes in terms of survival for these patients.

For locally advanced patients I am looking to see that they got external beam radiation, brachytherapy or internal radiation, and a form of concurrent chemotherapy. In terms of the middle component, brachytherapy, there is data that that is declining as a modality, and I think that is primarily due to the time and expertise required. We have data suggesting that this skillset of being a brachytherapist is declining, and we don’t have a good substitute for that in cervical cancer. That said, a broad description of the standard of care in cervical cancer patients and the utilization across the country-which would include external beam radiation, chemotherapy, and brachytherapy-had not been previously undertaken. We wanted to really understand what those patterns were across the country and see how that might impact survival.

Could you describe the patient dataset you analyzed and what you found in this study?

Absolutely. We used a dataset called the National Cancer Database (NCDB), so this is done as a collaboration between the American Cancer Society and the American College of Surgeons. This database is pretty incredible in that it captures almost three-quarters of all cancer centers across the United States, so this allows us to look at a snapshot of cancer care across the country. This is not just large academic, comprehensive cancer centers like the University of Colorado, but also much smaller centers in a diversity of settings-so this is pretty unique rather than looking at data from one single cancer center-to actually see how different populations, different approaches to care can impact outcomes.

The other important thing besides patients’ patterns of care is that it provides overall survival. So one can look at different approaches and modalities and see if any differences in overall survival exist based on what approaches are used. So our goal in this study was to look at outcomes regarding use of radiation after the initial external beam radiation-this is referred to in the paper as a boost, and that could be done with brachytherapy. Unfortunately, for some patients there was no boost at all. So that was the first component of our question and the second was whether sensitizing chemotherapy, which demonstrated a survival benefit in randomized clinical trials, was being used optimally in a localized cancer population.

Within the dataset, we looked at patients with cervical cancer from 2004 to 2012 and excluded those with early disease or metastatic disease, so focusing on the locally advanced population. These are women that can be cured with the best approach, despite having very large or locally advanced tumors, but often won’t be cured if one or all of the critical components of care is not used. That is to say that these are the women where the best approach has the best impact on surviving cancer. Overall, we found that under half the women get all of the components of standard care treatment.

Those who did get the best treatment, all three critical modalities, were generally treated at academic centers, high-volume centers, or comprehensive cancer centers where the expertise in cervical cancer and brachytherapy, in particular, exist. Those that did not get standard of care treatment (particularly with no boost documented at all) were those treated at smaller centers, those who may have been underinsured, low income patients, and black patients. The overall survival that we looked at was directly impacted by treating with the standard of care. So looking at a 5-year outcome, there were about twice as many women alive when treated with the standard of care vs those that got only external beam, which is a huge difference in terms of outcomes.

Any of the results that were particularly surprising to you?

I expected a small percentage of women to not get the standard of care therapy. For a variety of reasons I was really surprised to learn that more than half the women treated in the United States fell into this category. In our country where we have access to the most advanced technology innovation, and often are developing it, it is disappointing to see that many women are suffering and dying due to potentially inadequate treatment. It also confirmed prior studies that have been done as well as experience showing that the addition of brachytherapy and chemotherapy are really irreplaceable in this subset of patients. Overall, it was surprising that we have this preventable loss of young women’s lives by really adhering to the standard of care therapies.

What’s next? Are you and your colleagues now trying to understand how to help improve cervical cancer patient care across the United States?

Absolutely. I think for those with a cervical cancer diagnosis, they should really aim to be seen at a comprehensive cancer center, an academic center, or at least try to seek out a high-volume center near where they live. Asking their oncologist about their experience and comfort with cervical cancer and brachytherapy is appropriate. Patients, their families, and even their primary care physicians can all help ensure that each woman gets the best possible care for the best outcomes.

Globally though, much of the responsibility and privilege of helping cervical cancer patients really rests on our primary care colleagues, including gynecologists, who can actually help prevent these women from becoming a cancer patient in the first place. I have served personally as the vice chair of the Colorado Department of Public Health board that looks at cervical cancer screening and prevention and we really focused on getting good screening across Colorado. So that group focuses on human papilloma virus (HPV) testing and PAP testing to ensure secondary prevention-that is, picking up early changes that may occur from a viral infection before cancer has time to develop. Even better though, would be to actually prevent the infection and those cellular changes from starting in the first place. We have an HPV Task Force in Colorado where we work to target counties with populations that don’t have good rates of screening and have higher rates of invasive cervical cancer. We can actually work to generate heat maps where we can best put resources for vaccination and screening, and really target the women and populations that are not well plugged into the healthcare system. So, overall, vaccination and prevention of this cancer is by far the best way to help women in the United States and worldwide.

Thank you so much for joining us today, Dr. Fisher.

In this interview we discuss a recent study that found that more than half of patients with locally advanced cervical cancer in the United States did not receive standard of care.

Treatment Disparities in Locally Advanced Cervical Cancer Impact Survival

As part of our coverage of the 2015 European Cancer Congress, held September 25

29 in Vienna, we are speaking with Jack Cuzick, PhD, John Snow Professor of Epidemiology at Queen Mary University of London. At this year’s meeting, Dr. Cuzick will be participating in a session discussing the HPV vaccine for cancer prevention.

The two HPV vaccines have been on the market for several years now. How has the use of these vaccines changed since they were first brought to market?

 Well, very recently there has actually been a third vaccine that has been approved in the United States and most of Europe. It actually has nine types of HPV as opposed to the four types in Gardasil and the two types in Cervarix. Over the years there has been a move towards vaccines that have the two additional types-that is types 6 and 11-which protect against genital warts. That is why Gardasil has had more of the market more recently than Cervarix.

Has there been any noticeable decrease in the rates of cervical or other cancers since these vaccines have been approved?

 It is really too soon to see any impact on cancer rates. The vaccines are primarily given between the ages of 12 and 14 and cancer is very uncommon before the age of 25 or 30. We haven’t seen any impact on cancer rates as yet, and we don’t expect to do so for another 5 years or so. However, precursor lesions, so-called CIN lesions, we are already beginning to see an impact on those. They are detected in screening and are the precursors for cervix cancer. There is now clear evidence for a decrease in those in younger women.

The vaccines have been proven to have high protection rates against multiple cancer types. Have rates of adoption of the vaccine been high, and, if not, what populations are still lacking?

 The adoption rates are highly variable. Very high rates have been seen in the United Kingdom and in Australia where a school-based program has been instituted. Children can get vaccinated as part of the routine of attending school and [the vaccine is] covered by the government. High rates have also been seen in Denmark, which has a very effective clinician-based program.

In other parts of the world, even where there are adequate resources, there has not been the infrastructure to achieve high coverage rates. For example, [coverage is] 30% to 40% in the United States and that level or lower in much of Europe.

Are there any specific populations? Is it more likely for younger females to get vaccinated than younger males?

The vaccination has been focused on girls between the age of 12 and 14, where these coverage rates have been very high. Only recently has the vaccine been offered to boys, initially in Australia. The reason for that initially was cost. The price of the vaccine has come down dramatically in terms of cost per dose. Australia and other countries are now adopting that to give in boys. For boys, the benefits early on will only be in genital warts, because the cancers they get typically occur much later in life. It will be many decades before we see an effect of the vaccine on cancer rates for boys.

What is the future for these vaccines? What other cancer types or patient populations are being researched?

 There is much interest in extending vaccine coverage to older women. One of the reasons that we haven’t done this initially is that the vaccine is not effective if you have already been infected with the virus. It is a prophylactic vaccine. It is not a therapeutic vaccine. However, with the new vaccines that may be covering as many as nine types [of HPV], it is unlikely that a woman will have been exposed to all of these types so there is a lot of interest in whether or not … older women need to be screened. They get one vaccination and that may provide almost a lifetime protection, which would be very nice for parts of the developing world such as Africa, South America, and parts of Asia.

Great, well thank you so much for taking a few minutes to speak with us about this important topic.

European Cancer Congress

In this interview we discuss the latest on HPV vaccines for cancer prevention and some of the struggles countries face in achieving widespread adoption.

HPV Vaccines Continue to Improve, But More Uptake Required

Today we are discussing cervical cancer screening guidelines with Dr. Karen Smith-McCune, of the department of obstetrics, gynecology, and reproductive sciences at the University of California in San Francisco, and Dr. Debra Papa, who specializes in gynecology at the UMass Memorial Medical Center in Wooster, Mass. The US Preventive Services Task Force and the American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology updated their guidelines for the prevention and early detection of cervical cancer in 2012, incorporating the newer human papillomavirus (HPV) testing along with the established Pap smear screening test that has been widely implemented and is the routine cervical cancer screening method. 

Dr. McCune, could you differentiate between the US Task Force guidelines and those that were issued by the ACS cervical cancer guideline committee?

 Both groups recommend two options for screening for women between the ages of 30 and 65. Those women can have a Pap smear test every 3 years or the Pap plus HPV test, or the co-test every 5 years. One set of guidelines from the ACS group classifies the co-test as the preferred strategy, which they base on the evidence, but they did indicate that the evidence for this recommendation is weak. The guidelines from the Task Force do not give a preferred designation to either of the options. In fact, the Task Force recommendations highlight the patient’s preference by indicating that co-testing is an option for women who want to lengthen their screening interval. So, we are left with the question-is co-testing the preferred option as indicated by the ACS group or are really both options the same? And that is really the question I addressed in my recent [viewpoint] article in JAMA Internal Medicine.

How have these guideline changes and, specifically, the incorporation of the newer HPV test, how has this changed screening practices and for which women? Dr. Papa, let’s start with you?

As Dr. McCune said, the addition of the HPV test to Pap smears is for women 30 and older because HPV is so common for women in their 20s, so it’s not a good screen at that time. But what it does do if both tests are negative- studies out of Kaiser in California have shown that a woman’s risk is very low if both test results are negative. The test has a very good negative predictive value so the interval can be 5 years [between screenings]. So, the addition of HPV has allowed us to lengthen the interval. It has also been shown that the HPV test is able to detect cervical dysplasia earlier. However, what has happened is that you can get a normal Pap smear and a positive HPV test and so there are guidelines for that finding as well.

Dr. McCune, do you have anything to add? 

I have a slightly more negative view of what has resulted with the incorporation of the HPV test. I agree that it does give a very confident result if both are negative and that should really drive a change in practice towards less frequent screening. However, it has led to a lot of confusion. There is now the potential of two results from two different tests with a grid of possible results that, frankly, becomes quite confusing for clinicians. So if the result is that the Pap is negative and the HPV test is negative, that is very good and very reassuring that the woman has nothing potentially dangerous happening and doesn’t need another test for 5 more years. And like I said, I hope that will drive practices toward less frequent screening. The worst outcome is if co-testing is adopted but people continue to screen as they are doing now, every year or every other year, which will just result in a huge burden on the healthcare system.

I agree with that. I think that physicians do need to change their mindset and so do patients. Sometimes, it is not easy for patients to understand that a Pap test can be given every 3 years or a co-test every 5 years. And I do agree that a negative Pap and a positive HPV test can be confusing and also that patients usually are upset knowing that they are HPV positive, so we as clinicians need to reassure them and try to educate about guidelines for how handle the Pap negative, HPV-positive test.

In April of this year, the FDA approved the cobas HPV test for primary cervical cancer screening, so that is one of the HPV tests we are discussing. Does that FDA approval have any additional impact on clinical practice?

I would just hope that clinical practice won’t change until the evidence for the cobas test is published because we have not seen those final trial data in the literature yet. And I would wait for the evidence from that test to be reviewed by guideline committees that are hopefully free of financial and intellectual conflicts of interest. And then we’ll see what the clinical guidelines would recommend about using that test. Until that happens, I hope nothing will change.

I agree 100%. I don’t think we should not change anything clinically at this point until we do get guidelines. Pap smears are not going to go away. Because what we don’t want to do is increase costs, and we don't want to increase the number of women going for colposcopies and the cobas HPV test may have that potential, and we don't yet fully know how to use it. Right now, we are still adopting these newer guidelines from 2012 which we still need to straighten out and have everyone on board. So I agree, we won’t do anything in the near future, certainly not until we have guidelines come out from committees.

How do both of you facilitate your patient’s decision for cervical cancer screening? Dr. McCune, let’s start with you.

I think it’s important to talk to a patient about her preference for a screening interval because that is the main difference between the two testing strategies. Some women who grew up in the era of the annual Pap smear may want an option that gives them a more frequent test so they would be appropriate to screen with a Pap every 3 years. Other women will prefer the convenience of less frequent testing so co-testing is perfect for them. I think women should be made aware that the co-test option could lead to a cycle of repeated testing and evaluation because HPV infection is usually just a benign and self-limited infection and doesn't reflect a risk of cancer. So as long as women are aware of that risk going into the co-test I think it may help to reduce their anxiety and stigmatization that can occur if they find out that they have HPV.

I do co-testing essentially on my women who come in for their annual exam. And if they are Pap normal but HPV positive I will genotype them for HPV16 and HPV18 [strains] and do a colposcopy if they are 16 and 18 positive. If they are not 16 and 18 positive, I will repeat the co-test in a year. The ATHENA study seemed to show that again this can detect cancer earlier but again you have to be careful so that you are not referring too many women for a colposcopy because that is the full goal of this type of screening. We are already doing a very good job in the United States, and we have decreased the rate of cervical cancer because of the advent of Pap smears. So we have to be careful because we have been doing a good job already, and we don’t want to just increase the number of women having to go for colposcopies. So I absolutely do co-testing for women. 

Thank you both so much for joining us today.

: My pleasure. Thank you very much for having me.

In light of the recent FDA approval of HPV testing for women as a screening method for cervical cancer, we discuss changing guidelines with two experts. 

Cervical Cancer Screening Guideline Update

Today we discuss cancers associated with the human papillomavirus (HPV) and HPV vaccination methods. The “Annual Report to the Nation on the Status of Cancer,” published in the 

, shows that although cancer rates overall are on the decline, cancers associated with HPV are rising and there still appears to be a low vaccination coverage among teenagers for HPV. We are joined today by one of the authors of this study, Edgar Simard, PhD, MPH, senior epidemiologist of surveillance research, who studies the impact of prevention and screening on cancer incidence at the American Cancer Society. 

Can you tell us about the type of data that was used in this report for the analysis and conclusions?

Dr. Simard: The “Annual Report to the Nation on the Status of Cancer” is published every year by a group of leading cancer surveillance scientists through a collaboration of the American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute, and the North American Association of Central Cancer Registries. We focus on two main outcomes in the report. The first is the cancer death rates, and those are assessed by evaluating information reported on death certificates to every state health department that are then aggregated by the CDC. We then analyze the aggregated data to evaluate trends over time and cancer death rates. The second data source that we use for the main body of the annual report is population-based cancer registry data, used to assess incidence rates; that’s new cases of cancer that occur that are then aggregated at the national level to look at trends and cancer incidence rates over time.

What were the broad conclusions from this study?

Dr. Simard: The broad conclusions were that the overall cancer death rate has continued to decline. This has been noted since the early 1990s. This decline was noted among both men and women and of every racial and ethnic group, and for all of the major cancer sites. These are lung, breast, colorectal, and prostate cancers. During the most recent 10-year time period for which we have available data, from 2000 to 2009, death rates increased among men and women for cancers of the liver, pancreas, melanoma of the skin among men, and for cancer of the uterine corpus among women.

 Let’s focus on the HPV findings. Can you briefly describe how one becomes infected with HPV and the cancers that are associated with this virus?

HPV infection is quite common. HPV is passed through genital contact most often through vaginal and anal sex, and it may also be passed from one person to another during oral sex and through genital-to-genital contact. It should also be known that HPV can be passed from one partner to another even when someone has no signs or symptoms of HPV infection. So while many people are infected with HPV at some point in their lives, most people clear the infection and therefore have no risk of developing cancer due to the infection later in life. The risk of cancer really comes for those people who have what is called a persistent HPV infection, which means their immune system is unable to clear the infection and they are infected for decades. That increases their risk for getting a number of different cancers that we describe in the report.

What are some of the cancers that one can get through chronic HPV infection?

Dr. Simard: The most common cancer that people get from HPV infection is one that is really well known, and that is cervical cancer. The vast majority of cervical cancers are due to HPV infection among women. Persistent HPV infection also causes many anal, vaginal, vulvar, as well as oropharyngeal cancers.

What were the specific takeaways for HPV-related cancers and were any of the results surprising?

Dr. Simard: For the HPV-related cancers, we looked at incidence rates during the most recent 10-year time period, so again, from 2000 to 2009. We found that incidence rates of HPV-associated oropharyngeal cancer increased among white men and women, and also that rates of anal cancer increased among white and black men and women. We also found that rates of vulvar cancer increased among white and black women, and this is in contrast to rates of cervical cancer that have continued to decline among virtually all women. The increases that we noticed for most of these cancers, by race and ethnicity, as well as by sex, have really been noted by a number of previous studies, so they weren’t necessarily surprising. But why the rates of, for instance, oropharyngeal cancers are increasing among white men and women only and not black men and women, or people of other races and ethnicities, is not known. Some of the differences by race and ethnicity in terms of isolated increases in oropharyngeal and anal cancers are still somewhat of an unknown.

There are now several HPV vaccines that have been approved for several years. The vaccines can protect against several of the strains of HPV that are known to cause cancer. The vaccines were first approved for girls between the ages of 9 and 26, and then in boys for the same age. What are the major recommendations for both girls and boys for HPV vaccination, and what types of outcomes and cancers does the vaccine protect against?

Dr. Simard: The HPV vaccines are given as three shots to protect against HPV infection and HPV-related diseases. Two vaccines, Cervarix, which is the bivalent vaccine that protects against HPV types 16 and 18, and Gardasil, which is the quadrivalent vaccine that protects against HPV types 16 and 18, which are associated with most HPV-related cancers, as well as HPV types 6 and 11, which are associated with the occurrence of anal and genital warts, have both been approved to protect against cervical cancers in women. Gardasil also protects against genital warts, and as I mentioned, it has been shown to protect against cancers of the anus, vagina, and vulva. Both vaccines are available for females, and Gardasil is available for males. In terms of the current recommendations by the Centers for Disease Control and Prevention and the advisory committee on immunization practices, both preteen girls and boys are recommended to receive the vaccine at ages 11 or 12. The HPV vaccines are recommended for all teen girls and women up to age 26 who did not get all three doses of the vaccine when they were younger, and for all teen boys and men through age 21 who did not get all three doses of the vaccine when they were younger. It is also recommended for gay and bisexual men or any men who have sex with men, as well as men with compromised immune systems, including HIV infection, through age 26.

While HPV infection can have side effects for women, is it true that men and boys do not generally have any symptoms of HPV infection?

Dr. Simard: I wouldn’t say that they don’t have any symptoms. You asked about vaccination side effects?

Not side effects of the vaccine, but actual HPV infection symptoms. Women can have symptoms, but do boys and men also develop symptoms of actual HPV infection?

Dr. Simard: They certainly can, especially when you think of the occurrence of anal and genital warts. That would be one instance where a symptom is physical to the naked eye. The other point I wanted to mention, since you asked about the outcomes that the vaccines protect against-the randomized clinical trials that have been conducted to evaluate the efficacy of the vaccines for various outcomes followed men and women from when they were vaccinated to look at whether they were protected against the occurrence of preneoplastic or precancerous lesions. For instance, looking at cervical cancer, both vaccines show protection for women in terms of reducing the incidence of precancerous lesions of the cervix. But women and men were not followed for the occurrence of invasive cancer because that type of trial would take too long to conduct. We know that in terms of the indication for each vaccine, they protect against the occurrence of the precancerous lesions for which they are indicated.

Your study mentions that while the goal is to vaccinate approximately 80% of girls aged 13 to 17 in the United States, the actual percentage of girls who received all three shots of either of these vaccines, at least in 2010, was only 32%. Do we know some of the reasons why these numbers are well below the goal?

Dr. Simard: Yes, we used a different data source to look at the trends in vaccination coverage between 2008 and 2010, and that was the national immunization survey for teens, or NIS-TEEN, which is our telephone survey conducted by the CDC that is representative of the entire US teen population. We did find an increase in coverage between 2008 and 2010, and as you know, about 32% of girls aged 13 to 17 in 2010 had received three doses of the vaccine, but that is really well below the 80% goal that we have set for the Healthy People 2020 target. The reasons for why the vaccine uptake is low are really multifaceted. The survey data we analyzed didn’t really delve into why the coverage levels were low, but we do have knowledge from other studies as to what those reasons may be. Really, the most important reason in terms of our assessment of the literature is really provider recommendation. What I mean by that is that the most important determinant of whether a child will receive the HPV vaccine is whether or not their physician or healthcare provider recommended it to them and their parents, in terms of having the parent accept the vaccine. There are other things as well that may play a role. For instance, health insurance status and issues around cost of the vaccine, as well as parental knowledge and acceptance of the vaccine. There may also be a role for school mandates as well.

Hopefully, the vaccination of boys against HPV will continue to rise. You mentioned primary care providers as being instrumental to this. Are there strategies to bring about awareness to get more boys and girls vaccinated, both from the parent and child side and the physician side?

Dr. Simard: There are a number of campaigns in terms of getting information out there for parents and physicians. Really the CDC takes the lead in disseminating that type of information, but the American Cancer Society also is involved in some of these activities. The main message, I think, for everyone, whether it be a parent or a healthcare provider, is the fact that the HPV vaccine is an anticancer vaccine. We are lucky to have a vaccine that protects against these different cancers, and we definitely encourage following the vaccine recommendations to increase uptake among boys and girls. The point is that later in the future with these vaccinated cohorts of boys and girls, we will hopefully see decreases in the incidences and death rates of HPV-related cancers in decades to come.

Do you think that the school mandate for vaccination is useful and may happen in the short term?

Dr. Simard: I think that is really questionable because there are other, maybe political and infrastructural issues with regards to a school mandate. Really, what we found in our critical review of the knowledge out there, is that provider recommendation is probably the most important determinant.

Thank you so much for joining us today, Dr. Simard.

In this interview we discuss HPV-associated cancers, which are on the rise, and the low vaccination coverage for HPV with Edgar Simard, PhD, MPH, senior epidemiologist of surveillance research, who studies the impact of prevention and screening on cancer incidence at the American Cancer Society.

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