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    Cervical cancer screening and prevention 2016


    HPV vaccination

    Three HPV vaccines are available to prevent HPV infection. They target the most common oncogenic HPV subtypes including 6, 11, 16, and 18. The newest nonavalent vaccine protects against an additional 15% of cervical cancers attributed to 5 HPV subtypes: 31, 33, 45, 52, and 58, extending protection against 80% of all cervical cancer. To examine the public health impact of replacing the bi- or quadrivalent vaccine with the nonavalent (targeting 9 serotypes) vaccine, studies have modeled data based upon current HPV vaccination rates, sexual behavior, and cervical cancer progression. Switching to the nonavalent compared to the bi- or quadrivalent vaccine, if current vaccination rates in the United States were maintained, would decrease the incidence of cervical cancer by 73% versus 63%, respectively, and reduce cervical cancer-associated mortality by 49% versus 43%.8 The nonavalent vaccine is also cost-effective, resulting in the same health benefit, at current rates of vaccination, as covering an additional 11% of women with the bi- or quadrivalent vaccine with a projected savings of $2.7 billion.
    Estimates indicate that 60% of girls in the United States start HPV vaccination but only half complete the series, resulting in a nationwide vaccination rate of approximately 33%.9 Parental obstacles to HPV vaccination include lack of information about the vaccine, perception that it is unnecessary, concern about side effects, and lack of doctor recommendation.10
    Education coupled with the October 19, 2016 Advisory Committee on Immunization Practice recommendation to the CDC that only 2 HPV vaccinations, at least 6 months apart, confer adequate immunization for young adolescents (ages 9–14) may improve vaccination rates in the United States.11 Data from Victoria, Australia, which has achieved an 80% 3-dose HPV coverage rate through a nationally funded, school-based vaccination program, have demonstrated a decreased incidence of high-grade cervical lesions by 0.38% in girls younger than 18, proving that an ounce of prevention is worth a pound of cure.12

    Abstract references

    1. Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review, 1975-2012. Bethesda (MD): National Cancer Institute; 2015. Available at: http://seer.cancer.gov/csr/ 1975_2012.
    2. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015;65:5–29.
    3. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, cancer incidence and mortality worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available at: http://globocan.iarc.fr.
    4. Gustafsson L, Ponten J, Bergstrom R, Adami HO. International incidence rates of invasive cervical cancer before cytological screening. Int J Cancer 1997;71:159–65.
    5. Gustafsson L, Ponten J, Zack M, Adami HO. International incidence rates of invasive cervical cancer after introduction of cytological screening. Cancer Causes Control 1997;8:755–63.
    6. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. CA Cancer J Clin 2012;62:147–72.
    7. Moyer VA. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force [erratum in Ann Intern Med 2013;158:852]. Ann Intern Med 2012;156:880–91, W312.
    8. Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015;125:330–7.

    Commentary references

    1. Wright TC, Cox JT, Massad LS, Twiggs LB, Wilkinston EJ. 2001 Consensus guidelines for the management women with cervical cytological abnormalities and cervical cancer precursors: Part 1. Cytological abnormalities. JAMA. 2002;287:2120-9.
    2. Massad LS, Einstein MH, Huh WK, et al. 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors.
    J Low Genit Tract Dis. 2013;17:S1-27.
    3. Katki HA, Schiffman M, Castle PE, et al. Five years of CIN 3+ and cervical cancer among women with HPV testing of ASCUS Pap results. J Low Genit Tract Dis. 2013;17:S36-42.
    4. Katki HA, Schiffman M, Castle PE, et al. Five year risk of CIN 3+ and cancer for women who test Pap-negative, but are HPV-positive. J Low Genit Tract Dis. 2013;17:S56-63.
    5. Sawaya GF. New guidelines. It’s complicated. Obstet Gynecol. 2013;121(4):703-4.
    6. Wright TC, Stoler MH, Behrens CM, et al. Primary cervical cancer screening with human papillomavirus: end of study results from the ATHENA study using HPV as the first-line screening test. Gynecol Oncol. 2015;136:189-97.
    7. Huh WK, Ault KA, Chemlow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim guidance. Obstet Gyecol. 2015;125:330-7.
    8. Durham DP, Ndeffo-Mbah M, Skrip LA, et al.  National and state level impact and cost-effectiveness of nonavalent HPV vaccination in the United States. PNAS. 2016;113(18):5107-12.
    9. CDC. HPV Vaccine Coverage Maps—Infographic. https://www.cdc.gov/hpv/infographics/vacc-coverage.html.
    10. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to human papillomavirus vaccination among US adolescents. A systematic review of the literature JAMA Peds. 2014;168(1):76-82.
    11. CDC. CDC recommends only two HPV shots for younger adolescents. http://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html.
    12. Brotherton JL, Fridman M, May CL, et al. Early effect of the HPV vaccination program on cervical abnormalities in Victoria, Australia: an ecological study. Lancet. 2011;377:2085-2092.

    Ilana Cass, MD
    Dr. Cass is an Assistant Professor of Obstetrics and Gynecology, UCLA/Cedars-Sinai Medical Center, Los Angeles, Calif.


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