What if scientists created a vaccine to prevent cancer but the public largely ignored it? Sadly, that’s where we are with the human papillomavirus, or HPV, vaccine, one of the few preventive cancer vaccines in existence.
“HPV vaccine uptake is low in the U.S., with up-to-date vaccinations for adolescents age 13 to 17 at around 49%,” said Dr. Parth Shah, a public health researcher at Fred Hutchinson Cancer Research Center. “Even worse, only 16% of adolescents in the U.S. are up to date by age 13. This is a public health crisis.”
An expert in HPV vaccine uptake, Shah spoke earlier this month at the annual meeting of the American Society of Clinical Oncology, ASCO 2019, offering his analysis of why the U.S. is lagging behind other countries in vaccinating its population against HPV-driven cancers.
Spread by intimate contact, HPV is found in almost all sexually active adults. It’s usually harmless and goes away on its own but when it doesn’t, it can drive a number of devastating cancers including cervical, anal, penile, vulvar and most head and neck cancers. In the U.S., HPV is responsible for over 33,000 cancer diagnoses annually; last year, cervical cancer alone killed 311,000 women worldwide.
Longtime Fred Hutch virologist Dr. Denise Galloway, holder of the Paul Stephanus Memorial Endowed Chair, made critical discoveries that definitively linked the HPV virus to cervical and other cancers, and Hutch scientists are currently researching the use of the HPV vaccine as a potential treatment for certain pre-cancers.
A behavioral scientist, pharmacist and member of the Hutchinson Institute for Cancer Outcomes Research, or HICOR, Shah proffered a few science-based tips on the best way health care providers can talk to parents and teens about the importance of this key cancer vaccine.
A combination of factors has contributed to the lackluster response to the cancer vaccine in the U.S., according to Shah. Some are related to controversial public policy — such as school mandates that often come with “very generous” opt-outs for parents — while others are due to inconsistent or nonexistent policies, a consequence of schools being governed by local jurisdictions, all with different challenges and priorities.
“Sometimes providing preventive services is just not among the priorities in a resource-limited environment,” Shah said. “Additionally, schools just lack the infrastructure to do mass vaccinations.”
Parents who refuse to vaccinate their children usually do so because of individual reasons, he said, citing data from national surveys conducted by the Centers for Disease Control and Prevention, or CDC.
“What tends to be true across the board for boys and girls are these top five reasons,” he said. “Parents don’t vaccinate because of safety concerns and side effects; lack of knowledge about its availability; they believe it’s not necessary; they haven’t received a provider recommendation; and/or they claim their child isn’t sexually active so it’s just not needed.”
A provider’s recommendation is “uniquely powerful” for getting vaccinations, Shah stressed, pointing out that 80% of vaccines are provided by pediatric, family medicine and OB-GYN practitioners.
“Data is pretty consistent that we have a twofold increase in vaccination when a provider recommends it,” he said.
Pharmacies also hold promise when it comes to boosting vaccination rates — particularly for people living in rural areas or so-called “medical deserts,” but many people don’t know that’s an option.
“In all 50 states, pharmacies provide vaccinations,” he said. “But parents aren’t really aware that pharmacists can provide vaccines. There’s a real educational and awareness gap in accessing these services.”
Laws governing this practice can vary from state to state, he said, with some pharmacists limited to providing vaccines to adults only. Reimbursement may also be problematic if private and public health insurers don’t recognize pharmacists as vaccine providers, but all in all, Shah said pharmacists were a trusted and untapped resource.
Training primary care doctors to be effective communicators about the HPV vaccine is essential, Shah said, and there are ways to do it effectively. A presumptive communication approach, he said, takes the ambiguity out of the vaccination and characterizes it as a regular part of standard care.
Use these research-tested approaches when talking with parents who have questions or concerns.
Age. Kids respond more strongly to HPV vaccine when they are younger. This may give better protection against some cancers.
Sex. This really isn't about sex. The HPV vaccine is about preventing cancer.
Safety.This vaccine is one of the most-studied medications on the market. The HPV vaccine is safe, just like the other vaccines given at this age.
Effectiveness. More than 30,000 Americans get cancer from HPV every year. Most could be prevented with the HPV vaccine.
Guidelines. Experts at the CDC agree that kids should get the HPV vaccine by age 11 or 12 to prevent several cancers.
Boys. HPV infections don’t care if you’re a boy or girl. The virus can cause cancer and many other diseases in both genders.
Requirements. School requirements don’t always keep up with medical science. The HPV vaccine is an important vaccine that can prevent many cancers.
“It’s essentially a statement that presumes parents are ready to vaccinate their children,” he said. “For example, ‘Let’s get the vaccine today since she is due.’ The data show that anytime there’s a presumptive communication approach, it’s superior to the usual kind of communication about vaccination.”
He also pointed to a technique he and colleagues developed called the Announcement Approach, which providers can take when communicating about the HPV vaccine.
“The first step is a statement where you note the child’s age and then announce that they are due for vaccines that prevent several diseases,” he said. “Focus on the disease and place HPV cancer in the middle of the list. Then tell them you’re going to vaccinate today. For example, ‘Now that Sophia is 12, she’s due for three vaccinations. Today, she’ll get vaccines against meningitis, HPV cancers and whooping cough. We’ll give them at the end of the visit.’”
If a parent hesitates after that statement, Shah advised doctors to slow down and connect with them.
“Ask them what their main concern is and make sure that you’re listening,” he said, pointing to a handful of effective messages that can then be used, all available at HPVIQ.org. “Then address that concern with a research-tested message.”
His top tip: Always include a cancer prevention message. And don’t push.
“If you’re counseling for vaccination, bringing up cancer prevention works better than any other message out there,” he said. “Also avoid urgency when addressing questions or concerns. If the parent hesitates, that’s an indication that you need to slow down the conversation and delve into what those concerns are. Parents want to know that you’re listening to them.”
The bottom line, Shah said, is the reason behind the vaccine.
“This is a vaccine that prevents cancer,” he said.
Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at firstname.lastname@example.org.
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