Feb 19, 2015

Dr. Jones: If you have the option of vaccinating your child against cancer, would you? Yes? Well, why don't you? This is Dr. Kirtly Jones from the department of obstetrics and gynecology at University of Utah HealthCare, and we're talking about the HPV vaccine on The Scope.

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Dr. Jones: Vaccines are developed to protect people from contagious bacteria and viruses. We have influenza vaccines to help protect us from the flu. Our children are required to have vaccines for measles, mumps and rubella, all contagious viruses, before they go to school. I have to have proof that I've had the influenza vaccine every year to work at the University Hospital.
There is a very contagious virus that causes genital cancer in women and men, and other kinds of cancer; cervical cancer in women, penile cancer in men, and maybe oral cancer in some people. We have a vaccine that can reduce the risk of this cancer, so why aren't we vaccinating our kids?
In Utah, we have the lowest rate of HPV vaccination in the United States. Today in the studio I'm talking to Dr. Deanna Kepka who is a Huntsman Cancer Institute investigator and an assistant professor in the College of Nursing at the University of Utah. She is a member of a cancer control and population sciences research group. Welcome, Dr. Kepka.

Dr. Kepka: Thank you so much. It's a pleasure to be here.

Dr. Jones: Great. So HPV, what is it?

Dr. Kepka: HPV stands for the human papillomavirus, and I'm going to focus my discussion on the sexually transmitted form of the human papillomavirus which is transmitted via genital to genital contact and contact with bodily fluids.

Dr. Jones: Okay. Well, we know that this brand, this family of viruses can also cause warts on your skin, your fingers and toes, usually, but we're talking about the other kind of skin, the genital skin.

Dr. Kepka: Yes. There's about 40 types of HPV that are oncogenic. Oncogenic means that they are cancer-causing.

Dr. Jones: And so what is the role of HPV in cervical and penile cancer? Are all these cancers caused by HPV, or just some of them?

Dr. Kepka: In terms of cervical cancer, nearly all or almost all cases of cervical cancer are caused by the human papillomavirus.

Dr. Jones: Yeah. Well, I want to give our listening audience just a couple of numbers to think about. Cervical cancer is pretty common. There were 12,000 cancers in women diagnosed last year. About one in a hundred American women will be diagnosed with cervical cancer in a lifetime. There are a quarter of a million women living with cervical cancer and there are 4,000 deaths a year.
Cervical cancer isn't the only cancer that's associated with the HPV virus. In fact, about 33,000 cancers caused by the HPV virus are diagnosed each year in men and women. So we're talking about genital cancers and the virus that's transmitted via sex. How well does this vaccine work? We have a vaccine. Can you tell me little about it?

Dr. Kepka: We have a vaccine, the human papillomavirus vaccine, also known as Gardasil or Cervarix. It was approved for girls in 2006 and for boys in 2011, and the ideal age to receive the vaccine is at 11 and 12 because that's when the immune system is best able to respond to the vaccine and develop immunity to the HPV viruses that are protected in the vaccine. And the vaccine has been shown to be very effective with very limited side effects.

Dr. Jones: Yes. I read that for the specific types of virus, it's 100% effective in protecting against those particular kinds of viruses.

Dr. Kepka: Yes. And we have some new news. Right now the vaccine, Gardasil and Cervarix, protect against 70% of cervical cancer, but we have a new vaccine that has just been approved this year called Gardasil 9. and it protects against nine types of HPV types that cause 90% of cervical cancers.

Dr. Jones: Oh, that's good. That's new news to me. That's great news.

Dr. Kepka: So it's a new vaccine. It's called Gardasil 9 and that was just approved by the advisory committee and the immunization practices in the last month.

Dr. Jones: Cancer is scary, and for women cervical cancer can be fertility ending because the treatment could be removing the cervix and the uterus, but there's another little problem down there that's caused by HPV that can also be protected against with this vaccine.

Dr. Kepka: Genital warts.

Dr. Jones: Right. Nobody wants to talk about it but I've taken care of so many women who have this and men and they're embarrassed.

Dr. Kepka: Yeah. There's more than 300,000 cases of genital warts in the U.S. each year. It's very common.

Dr. Jones: 300,000. And these viruses are highly contagious, right?

Dr. Kepka: Yes.

Dr. Jones: It's estimated that about 50% of women who've had sex with at least one partner have this virus, have one brand of this virus. Maybe not the cancer-causing brand but it's very common. Do you have an idea of what's the problem in Utah? Why are we number 50, which is not a good thing. We're lowest of the low.

Dr. Kepka: Yes. We are lowest of the low for the three-dose completion among girls at the recommended ages of 11 and 12. Looking at data for girls from 13 to 17, and we're the lowest in the nation for boys for first dose. We don't even have enough data to look at second and third dose.
Why is this happening? That's a very good question. Part of what my work here at the University of Utah is looking at this. I'm in the process of doing focus groups and surveys with physicians, and I've recently started in collaboration with the state of Idaho the HPV Vaccination Intermountain West Coalition. Our task is to do a needs assessment and an environmental scan and really try and understand what's happening with our rates are so low in both states.

Dr. Jones: Right. Don't kids get some other vaccines at about that age?

Dr. Kepka: Yes. So in Utah we're seeing a large number of missed opportunities. And what we mean by missed opportunities are when a child comes in for another recommended immunization, whether that's TDAP, a tetanus vaccine or meningococcal, and then they don't get the HPV. So they are ready, they have their sleeve rolled up, they are getting two other adolescent vaccinations and then they're not getting the HPV vaccine. We're seeing almost 40% of girls showing a missed opportunity in the past five years for the HPV vaccine, girls that should be eligible for this vaccine.

Dr. Jones: Who's fault is that? I mean, I'm getting a little defensive here. I'm sure I've seen these girls who are brought in by their moms because they had funky periods at 13 and I often do, actually. I'm pretty good at this. It's the "Oh, by the way" discussion. "Now that Sally is here, I want to talk to you guys about this particular vaccine for her." Because I don't usually give the other two vaccines in [inaudible 00:07:14] clinic, but we do give this one. So is it the doctors who aren't talking about it?

Dr. Kepka: Well, studies have shown that if a provider gives a strong HPV vaccine recommendation, and what I mean by strong, "Okay, Suzy, it's time for your TDOT, meningococcal and HPV vaccine today. Let's get that done." That's a strong recommendation. Parents and patients are more likely to agree to.

Dr. Jones: So do you have an idea why doctors aren't bringing up the HPV vaccine when they see kids between the ages of 9 and 15?

Dr. Kepka: We've done a survey of about a hundred pediatricians in the state of Utah and most of them do largely support the vaccine but the few that I don't, in anecdotal qualitative responses to my survey, they said, "This is just a vaccine. It's not important for the population that I serve."

Dr. Jones: That's a code word.

Dr. Kepka: Yes. The children that I serve are not going to be sexually active before marriage and they're only going to have a one sexual partner. But even people who are in monogamous relationships are still at risks for HPV. HPV is not just transmitted via intercourse. It can be sexual activity.

Dr. Jones: Right. And many people who started off life thinking, "This is my one and only, forever and ever," life changes.

Dr. Kepka: Life happens.

Dr. Jones: Life happens to people and if you can protect kids in advance, if you could wave your magic wand, what one thing would you do to increase uptake of this vaccination for our children?

Dr. Kepka: I would ask physicians and primary care providers and nursing staff and medical assistants to make that strong recommendation, to ask parents when they come with 11 and 12-year-old kids and anyone who hasn't receive the vaccine for a catch-up immunization, it's time for HPV.

Dr. Jones: Great.

Dr. Kepka: And then I'd also make sure that parents have appointments to come back for doses two and three.

Dr. Jones: Right.

Dr. Kepka: That's a major problem. And some follow-up reminders.

Dr. Jones: Now, is this covered by insurance and are there free vaccines for kids?

Dr. Kepka: Yes. Children who are underinsured or uninsured are eligible for the Vaccines for Children program to receive the vaccine through that program at no cost. There may be a vaccine administration fee but they will not be charged for the cost of the vaccine. That's for kids up until age 18, through age 18, and other than that is covered by all insurance programs for boys and girls because it's been recommended by the CDC for quite some time now.

Dr. Jones: Well, I think we as a nation struggle with talking frankly to parents and to our children about sexuality, about contraception, about protection, about immunization against HPV, and I'm hoping maybe the HPV vaccine will help open the door to discussions about health in all of these domains. Wouldn't that be terrific?

Dr. Kepka: Yes. I mean, we know if uptake of the vaccine was at the CDC recommended goals for healthy people 20/20 which is 80% three-dose completion among girls and boys, we would be preventing almost 22,000 cancers per year that are HPV-related in the United States. And we'd also be preventing all those abnormal pap tests which are expensive and stressful and time consuming. So there's a lot more we could be doing.

Dr. Jones: And the treatment for those abnormal pap tests can be harmful to a young woman's future fertility. So if you want to protect your daughter's and your son's, maybe, future fertility, you may want to be thinking about this in a pro-active way. Thank you.

Dr. Kepka: Thank you.

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