Prevention of a Sexually Transmitted Disease versus Prevention of a Serious Female Cancer: Remarkably Divergent Views of HPV Vaccination

“Novel approaches to more effectively communicate the objective facts that vaccination against human pappilomavirus is a highly effective and safe strategy designed to rather substantially reduce the risk for the development of major potentially life-threatening illnesses…”

Human pappilomavirus vaccination as a strategy to prevent a serious cancer

To an oncologist, and particularly to any clinical oncologist who has ever had experienced managing women with recurrent or metastatic cervical cancer, there can surely be no debate [1,2]. A relatively simple vaccination strategy that has the very realistic potential to ultimately prevent 70–90% of cases of invasive cervical cancer if initiated and completed prior to a young woman's sexual debut must be considered a truly major public health triumph [3]. It is anticipated that there will be approximately 12,000 new cases of invasive cervical cancer in the USA this year resulting in approximately 4000 deaths [4]. Imagine at some point in the not-so-distant future completely preventing 70–90% of these events.

And worldwide there will be at least 500,000 new cases of invasive cervical cancer next year resulting in more than 250,000 deaths [3]. Further, it is almost certain these figures are vastly understated due to recognized inadequacies with the public health infrastructure of developing world countries that are required to accurately report cancer incidence. Again, imagine preventing 70–90% of these cases with the associated recognized striking reduction in morbidity and mortality.

Finally, it is critical to note for the nononcologist health professional reading this editorial that the current management of metastatic and recurrent cervical cancer unquestionably remains among the least effective and least satisfactory in all of cancer medicine [1,2]. The pain and suffering associated with this condition can truly be difficult if not impossible to comprehend, and particularly in societies that lack even the most basic health delivery infrastructure or the absolutely essential availability of potent narcotic analgesia.

And although perhaps not in the direct line-of-sight of practicing family physicians, gynecologists, gynecologic oncologists or medical oncologists, it is not difficult to appreciate the cost savings in the management of cervical cancer (to an individual, employer, payer or society) associated with eliminating the required surgery, radiation or chemotherapy, home assistance or palliative/end-of-life care.

Finally, it is important in this discussion to acknowledge another human pappilomavirus (HPV)-associated cancer impacting both women and men whose rapid increase has been labeled by some as an ‘epidemic’ [5,6]. It has been estimated that as many as 70% of new cases of oropharyngeal cancers are associated with HPV exposure and persistent infection, in striking contrast to earlier experience with the vast majority of such cases being smoking related [5,6].

While there are no concrete Phase III trial data demonstrating the utility of HPV vaccination in preventing this type of cancer, it is biologically highly unlikely that this preventive strategy would not be as effective as documented with cervical neoplasia. Of course, it must be recognized that the natural history of HPV-associated oropharyngeal cancers is not as well studied as is the situation with malignancies of the cervix and it is uncertain if as yet unidentified clinically relevant differences may exist between HPV exposure and the development of the types of cancers or their specific locations in the upper aerodigestive tract versus cervical cancer.

“And perhaps, most importantly, many parents continue to quite erroneously believe the primary purpose of human pappilomavirus vaccination is to prevent a sexually transmitted disease rather than to prevent serious cancers.”

However, it is important to acknowledge several important obvious and not-so-obvious differences between these settings worthy of consideration in discussions of HPV vaccination as a cancer preventive strategy. First, unlike the situation with cervical cancer, there is no simple noninvasive diagnostic test to discover an oropharyngeal cancer in a premalignant state or very early stage in its invasive natural history as has been the case for several decades with cervical cancer (e.g., Pap smears). Second, despite the recognized morbidity associated with the management of invasive cervical cancer, disfigurement associated with treatment of oropharyngeal cancer has the additional consideration of being unable to be ‘private’. Finally, in contrast to the distressing current status of existing therapies in cervical cancer, a number of exciting but extremely expensive novel antineoplastic approaches are, or soon will be available to manage advanced, recurrent or metastatic oropharyngeal cancer. Thus, there is currently the potential for major cost-avoidance benefits associated with preventing HPV-associated oropharyngeal cancers.

HPV vaccination as a strategy to prevent a sexually transmitted disease

To others who oppose the concept of vaccination, in general, or vaccination for a sexually transmitted illness (like HPV), the previously noted objective facts appear to be largely or completely irreverent. Their arguments against HPV vaccination may include all, or some, of the following:

Cervical cancer is an uncommon illness in the USA/developed world and the modest/limited risk does not justify HPV vaccination [3];

Cervical cancer can be prevented by employing long-established effective and continually evolving screening strategies (Pap smears; HPV testing) [3];

A firm belief of certain parents that their daughters (or son's) will not be at risk for HPV infection because ‘she’ (or ‘he’) will not have sexual relations with a partner who is infected with HPV;

The current ‘age’ recommendation for HPV vaccination does not reflect the reality of when parents believe there should be consideration of the potential risk for their daughter's (or son's) initial sexual exposure;

The vaccine is expensive and a family would have to make a decision to prioritize vaccination over more important healthcare or other needs;

The government is more interested in the financial benefits of a company manufacturing the vaccine rather than the welfare of individuals;

The government should not be permitted to mandate vaccination, especially if this does not relate to a highly communicable infectious event [7];

Current HPV vaccination is not ‘even close’ to being 100% effective in preventing persistent HPV infection, so the actual benefits of vaccination are questionable [3];

Despite claims of advocates to the contrary, it has not yet been proven that HPV vaccination actually prevents invasive cervical cancer at anything like 70%, or is an effective strategy to prevent oropharyngeal malignancies; rather only that it prevents persistent infection and precursors of the malignancy.

So, where do we go from here? In the opinion of this commentator the medical establishment, which includes individual clinicians, local, state and federal public health officials, policy makers, not-for-profit cancer organizations and cancer-associated advocacy groups focused on cancers caused by HPV infection unfortunately have been strikingly unsuccessful in delivering the clear unambiguous message that HPV vaccination of both young adolescent females and males will save thousands of lives. And perhaps, most importantly, many parents continue to quite erroneously believe the primary purpose of HPV vaccination is to prevent a sexually transmitted disease rather than to prevent serious cancers.

Novel approaches to more effectively communicate the objective facts that vaccination against HPV is a highly effective and safe strategy designed to rather substantially reduce the risk for the development of major potentially life-threatening illnesses [3], and that insuring its optimal benefits mandates that vaccination be initiated and completed during the early adolescent years may go a long way to correct the dangerous misconceptions regarding the reasons for, and demonstrated utility associated with its administration.