Blame the doctor, blame the patient: Both can do better.
Why aren’t more women taking the one existing vaccine that can prevent a cancer—the vaccine against human papillomavirus (HPV) that prevents cervical cancer and others? It’s available, safe and the numbers are very compelling for its efficaciousness. Yet in 2012, only a third of teenage girls had taken the required three doses, according to the Centers for Disease Control and Prevention (CDC).
Part of the blame falls on me and my fellow physicians: we’re just not doing a great job of getting the word out and encouraging our patients to get the HPV vaccine. Part of the blame falls on women who are not taking the vaccine, and part also falls on parents who are not getting their girls and boys vaccinated.
HPV vaccine and cancer
Before we talk about blame, let’s talk about the facts:
- The two biggest things these HPVs cause—and there more than 100 strains of HPV virus—are warts and cervical dysplasia, which if left untreated can evolve into cervical cancer
- HPV is a sexually transmitted disease that in the U.S. causes about 19,000 cancers in women every year and 8,000 in men, according to the CDC
- Cervical cancer is the most common cancer women get from HPV, but it can also cause vulvar cancer and vaginal cancer (rarely)
- Men are most likely to get throat cancer from HPV but also anal, perianal and penile cancers
- HPV also causes a percentage of head and neck cancers
- Girls and boys are encouraged to take the vaccine beginning at age 11 or 12, before they become sexually active (the vaccine is approved for children as young as age 9)
- The vaccination strategy is to target the most frequently occurring strains that cause cancer
- Strains #16 and 18 cause 60-70 percent of cancers, and if you throw in the next handful of harmful strains, you’re close to targeting 90 percent of the strains that cause cervical cancer.
Blame the doctors for low HPV vaccination rates
The CDC survey showed that doctors often failed to bring up the HPV vaccine when they saw girls and boys of vaccination age for other reasons—even if they were there to receive other vaccines. The head of the CDC says doctors are the single most influential factor that determines whether people get vaccinated.
As gynecologists, we’re not big vaccinators because typically we don’t see many young teenagers, which is the recommended age for girls to get the vaccine. But look at our rates and you see that 2/3rds of our patients who are women in their 20s are probably not vaccinated. We can do better, and I think we are doing better.
With the flu and pertussis vaccines that affect pregnancies, vaccines are now coming into the wheelhouse of OB/GYNs. I’m hoping that promoting those vaccines opens the gate for us to be more active promoting the HPV vaccine. We don’t want to forget about our patients in their 20s who are not vaccinated.
But we need to cast an extremely wide net to include not just OB/GYNs but all physicians, particularly primary care physicians, pediatricians and family practice doctors. Those are the doctors seeing girls and boys at the recommended vaccination age, and so do their mid-level providers, such as nurse practitioners and physician assistants.
Without a doubt, all of us in the medical community can do a better job promoting this vaccine.
Blame the patient, too
Just as we can’t make patients heed our advice, we also can’t make them take the HPV vaccine. Why the resistance?
People feel they are over vaccinated. In the last 15 to 20 years, a lot more vaccines have come along. Now you have hepatitis vaccines, chicken pox vaccines and others that we didn’t have when I was a kid. In general, the public gets a little leery when they are told that they need all those vaccines.
There’s a feeling of: There are so many, do we really need all these? I didn’t have them when I was a kid and I’m fine, so I’m not bringing in my kid to have them.
Then there’s always the background concerns: Well, isn’t there something bad about vaccines, that they cause autism or something like that? There have been scares over the delivery system, and all that lack of bona fide information spirals out of control. It’s just easier for people to negatively react to that.
Another inhibitor is the nature of HPV, it’s sexually acquired and that’s a loaded can of worms right there. Yes, it’s FDA approved for 9,10,11, 12 year olds. But most parents are confident that their 9,10,11,12 year olds are not sexually active, so they don’t need it: Why would I vaccinate someone who doesn’t need it?
Reality is a bit different. If you ask parents whether their high school kid is sexually active, very few of them will acknowledge that they are. But when you look at the data, 50 percent of them are, so there’s a disconnect between reality and parent perception, which doesn’t help.
Another factor is probably the success of screening in this country. We’ve reduced cervical cancer by 70 percent with the good old fashion Pap smear. In developing countries cervical cancer is the second highest cancer for women. Here, a mom might not know anyone who has ever had cervical cancer, and think, I know my daughter is getting screened for it anyway, so I’m not going to get her the HPV vaccine.
But the vaccine works better than the screening. And what about vaginal, vulvar, anal and perianal cancers? The Pap smear doesn’t address those.
How to improve HPV vaccination rates
That comes back to education on the providers’ part. Education is the way to overcome it. So is making it a priority. For busy clinicians, the HPV vaccine is maybe priority number 12 or 13 on their list of things to do, and it gets ignored.
Our vaccination rates in the U.S. are 33 percent for teen girls, 34.5 percent for women age 19-26, and a measly 2.3 percent for males age 19-26. Those are full coverage rates, meaning they have had all three doses. Rates for having one dose are higher, for example, 53.8 percent for girls age 13-17, 20.8 percent for boys age 13-17.
Now compare the vaccination rate in the U.S. to the rate in Australia. They’re at more than 90 percent. In Australia it has become rote for physicians to recommend the HPV vaccine. It has to become rote for us, too.