HPV

An oncologists perspective

What is an adult oncologist doing here?

The national burden of HPV related cancers

• 33,000 cases cancer annually in sites where HPV found

12,000 Head and Neck—72% HPV related, projected to be 91% by 2025

12,000 Cervical– 91% HPV related4000 Anal– 91% HPV related4000 Vulvar/vaginal– 72% HPV related1000 Penile– 65% HPV related

The worldwide burden of HPV related cancers

• 500,000 cases of cervical cancer• 273,000 deaths due to cervical cancer

annually• 21,000 cases vulvar/vaginal cancer• 11,000 cases of penile cancer• 25,000 cases of anal cancer• 22,000 cases of head and neck cancer

HPV infection: the trojan horse

• >80% of HPV infections cleared• Chronic cervical infection leads to dysplasia• 37% of cervical cancers occur in women aged 20-

38• Latency

15-20 years with normal immune system5-10 years in immunosuppressed

Similar latencies suspected for other sites of HPV carcinogenesis

HPV Cancer trends 1

• Rising rates of all HPV related cancers• Estimated that by 2020, HPV related head and

neck cancers will surpass HPV related cervical cancers

• Anal cancer rates have increased 160% in men, 80% in women in the past 30 years

HPV cancer trends

• Most related to highly oncogenic HPV type 16 and 18

• Cervarix protects against these • Gardisil protects against HPV 6, 11, 16, 18• Gardisil 9 protects against these AND 31, 33,

45, 52, 58

National efforts“The President's Cancer Panel finds underuse of HPV vaccines a serious, but correctable threat to progress against cancer.”

Paul Offit MD editorial summer 2014

• Why are adolescents and their parents embracing meningococcal and Tdap vaccines but not the HPV vaccine? One possible explanation is a clash between perception and reality, People just don’t understand how serious an infection HPV can be. In a typical year in the United States about 150 people die from meningococcus, four from tetanus, none from diphtheria, 20 from pertussis, and roughly 4,000 from cancers caused by HPV. People are more than 20 times more likely to die from HPV than from the other four diseases combined.

• About 79 million people in the United States have been infected with HPV, and 14 million new infections occur every year. As a consequence, 18,000 women and 8,000 men suffer preventable cancers of the cervix, anus, penis and throat; it’s the most common, and except for H.I.V., the most fatalsexually transmitted disease.

• Another common misperception is that the HPV vaccine is ineffective and immunity is short-lived. But the truth is that the HPV vaccine is virtually 100 percent effective at preventing the precancerous lesions caused by the types of HPV contained in the vaccine, which would most likely prevent most cervical cancers. Regarding how long immunity will last, the HPV vaccine is made in the same manner as the hepatitis B vaccine, for which immunity lasts at least 30 years. Immunity provided by the HPV vaccine is likely to be no different.

Prevention, an oncologists fantasy!

• HPV infection is preventable but not treatable• Few visible stigmata of infection with the

carcinogenic varieties• Condoms only protect against 70% of infections• HPV vaccination enhances protection, best

when started early• Early evidence that even one vaccine can confer

protection

Personal efforts to help promote population health

• Adopt as flagship cause as Idaho ACP Governor• Idaho Medical Association Resolution passed July 2013

RESOLVED That the Idaho Medical Association adopt policy in support of the Centers for Disease Control and Prevention guidelines on genital human papillomavirus vaccination (HPV), and provide information to Idaho Medical Association physicians regarding access to HPV vaccinations for their patients of both sexes at all income levels regardless of insurance coverage status.

• Blogging http://drpate.stlukesblogs.org/2013/06/12/what-michael-douglas-didnt-tell-you-about-hpv/

• TV PSAs https://www.youtube.com/watch?x-yt-cl=85027636&feature=player_embedded&x-yt-ts=1422503916&v=fdljLpbKFeU

• SLHS system Quality Initiative August 2014• Intermountain West HPV Coalition member since 2014

New Ideas: spread the burden, spread the risk, not the virus

• Recruit the kids themselves with school or afterschool activities – Melanie and colleagues: YWCA, Boy and Girl Scouts,

PSAs at kids movies.• Recruit dentists, orthodontists, and hygienists– They interact with childrens’ mouths and childrens’

parents. Obvious nonsexual way to introduce HPV protection.

• Provide educational material to dental offices, kids libraries, the public pool, etc.

Moving forward

• The goal is to increase statewide immunization of both boys and girls before sexual debut.

• How do we give providers the extra time needed to talk to parents?

• How do we overcome sexual fears? Vaccinate before you date

• Everyone eventually wants grandkids-- Focus on “not if, but when”.

• REBRANDING – not Gardasil, the HPV vaccine but Gardasil, the anticancer vaccine

Parting thoughts

• Sexual contact is not necessary• Kissing and skin to skin contact is enough• We vaccinate against tetanus even though we

don’t expect our kids to step on a rusty nail. Why wouldn’t parents want to take all action possible to prevent infection and subsequent cancer in their kids

• We need to recruit dentists, phys ed teachers, coaches, in the fight against HPV related cancers.