Ernest Hawk Discusses the NCI-Designated Cancer Centers’ Joint Statement on the HPV Vaccine

July 15, 2016

In this interview we discuss a joint statement from MD Anderson and 68 other NCI-designated cancer centers that calls for increased HPV vaccination for the prevention of cancer.

1.Recently, MD Anderson issued a joint statement with 68 other National Cancer Institute (NCI)-designated cancer centers to call for increased human papillomavirus (HPV) vaccination for the prevention of cancer. How did this collaboration come about, and what do you hope is gained from it?

DR. HAWK: The collaboration came about through a convergence of opportunities. First, MD Anderson had recently increased its focus on cancer control, including efforts to increase HPV vaccination to reduce/eliminate cervical and other HPV-related cancers. Independently, both the NCI and the Centers for Disease Control and Prevention (CDC) also had an interest in boosting HPV vaccination, given the astonishingly low rates among boys and girls in the United States. For example, the 2012–2013 President’s Cancer Panel report on the need to accelerate HPV vaccine uptake was a call to action for all stakeholders, including federal and state governments, healthcare professionals, public health organizations, and cancer centers, among others, to contribute to efforts to achieve the multi-pronged approach put forth in the report to protect millions of men and women in the United States and around the world from the burden of avoidable cancers.

Subsequently in 2014, the NCI awarded supplements to 18 cancer centers. The short-term goals for these 1-year supplements were to conduct an environmental scan in the centers’ catchment areas, and develop/enhance linkages with existing coalitions and programs, with a focus on HPV vaccination uptake in pediatric care settings. The Moffitt Cancer Center then convened an initial summit of awardees to discuss the tools, strategies, and approaches to environmental scans that would be taken across all centers. Finally, at the completion of those scans, MD Anderson, the NCI, CDC, and Moffitt jointly convened a summit of all NCI-designated cancer centers in November 2015. Approximately half of the 69 centers attended to discuss the scans’ findings and their implications, and to plan for future collective actions. It was at this summit that the decision to endorse HPV vaccination as a priority cancer preventive strategy across all centers was made. The statement was subsequently developed and then adopted by all 69 cancer centers. Although NCI-designated cancer centers are at the cutting edge of cancer research, care, and prevention, they have rarely come together outside of seeking congressional support for research. However, they saw the need to increase HPV vaccination to reduce the cancer burden. We hope that through this collective action, we will draw the attention of the public and of pediatric care providers to highlight the tremendous opportunity we have to prevent HPV-associated cancers. More broadly, it provides a precedent for the nation’s cancer centers to spark future collective action around other important cancer prevention and control issues.

2.How does this joint statement line up with the recent “Cancer Moonshot” program initiated by President Obama earlier this year?

DR. HAWK: The joint statement is directly aligned with the desire of President Obama and Vice President Biden to work constructively together to eradicate cancer. HPV vaccination represents an important example of actions that can be taken today to make a very big difference in the cancer burden of tomorrow. These are the types of evidence-based actions that leaders of the National Cancer Moonshot are emphasizing. Although cervical cancer is much less common in the United States and other developed nations than it is in developing countries due to the public acceptance of cervical screening for precancerous lesions and cancers, there are, nevertheless, poor and underserved areas within our country that experience much higher rates of cervical cancer than the nation as a whole. In addition, other organs at risk for HPV-related cancers (eg, oropharynx, anal), in which there are no established screening techniques, account for a significant proportion of HPV-associated cancers within developed countries.

3.Why do you think HPV vaccination rates still remain low (40% of girls and just over 21% of boys receiving the recommended 3 doses) across the United States, and compared with the rest of the world? What are the current barriers to receiving the vaccination?

DR. HAWK: Both healthcare providers and their patients experience barriers to recommending and receiving the HPV vaccine. Data show that pediatricians are not recommending the HPV vaccine to their patients, as they do with other vaccines that are given at the same age, such as the meningococcal vaccine and the tetanus-diphtheria-acellular pertussis (Tdap) booster immunization. Some studies suggest this may be due to financial concerns relating to stocking the vaccine, and to providers’ adequate and timely reimbursement. In addition, data suggest knowledge gaps in healthcare providers’ understanding of HPV as a cause of genital warts and its link to other non-cervical cancers as a major barrier to making a recommendation. Lack of a proper understanding of all of the health issues related to HPV may lead some providers to view it as a relatively unimportant health threat, or a health threat that is relevant only to girls. It is important to address these barriers among providers because parents frequently cite not receiving a provider recommendation as the primary reason for not vaccinating their child, in addition to believing that their child is too young to receive the vaccine, concerns over the vaccine’s safety and adverse effects, and wanting to receive more information about the vaccine before allowing their child to receive it.

Financial concerns have also been documented as a barrier among parents. However, the Affordable Care Act now covers the cost of the vaccine, although some individuals continue to remain uninsured. And while uninsured children may receive the vaccine at no cost through the Vaccines for Children Program, their provider must be registered with the program. Finally, some of the low coverage among males may be attributed to parents being unclear about the need to vaccinate boys or the perception that the consequences of HPV infection are less severe among boys. However, cases of oropharyngeal cancer are anticipated to exceed those of cervical cancer soon. It is important that both parents and providers understand that the HPV vaccine is a cancer prevention vaccine for both boys and girls, and that it prevents most other genital cancers, anal cancers, and many oropharyngeal cancers, in addition to cervical cancer. Countries where high rates of vaccination have been achieved have generally implemented national government–funded and nationally promoted HPV vaccination programs that leveraged school-based models. For example, in Australia beginning in 2007, all girls aged 12 to 13 years received the HPV vaccine within their schools after returning a consent form from their parents. Older girls, up to 17 years of age, could also receive the vaccine in school, as part of a limited-time catch-up program. Girls beyond school age could receive the vaccine through general practitioners or other community providers. This program was eventually extended to males in 2013.

4. What do doctors need to do in order to best educate themselves and their patients about the HPV vaccination and its benefits?

DR. HAWK: There are a wealth of freely available online resources created for healthcare professionals to better educate themselves on HPV and the vaccine, which assist clinicians in raising awareness of the vaccine among their patients. The CDC and the NCI offer some of the best resources, all readily accessible on their websites (see text box, right). In addition, MD Anderson is developing provider education to reduce missed clinical opportunities to recommend and administer HPV vaccines. Doctors should be aware that the data show that physician recommendation is strongly associated with HPV vaccine acceptance and initiation; many parents desire information around HPV and the vaccine before agreeing to vaccinate their child. Consequently, it is important that providers educate themselves so that they can feel confident in their recommendation and in explaining the vaccine to parents. The numerous educational resources that exist for healthcare professionals, along with the Advisory Committee on Immunization Practices’ recommendation, and now the backing of the nation’s cancer centers, should bolster providers’ confidence in recommending and discussing the HPV vaccine with their patients.

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.