Transcript HPV Infection - TSNO Region IV

HPV-RELATED CANCER
Understanding the Burden of HPV Disease and the Importance of the
HPV Vaccine Recommendation
Lois Ramondetta, MD
Professor Gynecologic Oncology
MD Anderson Cancer Center
Chief Gynecologic Oncology at LBJ
Hospital
Objectives





Review the epidemiology of HPV.
Compare the impact of HPV infection on cancer in
females and males.
Examine prevention mechanisms for HPV.
Analyze societal resistance to HPV vaccine
Formulate community education plans that support
HPV prevention.
HPV Infection



Almost ALL will be infected with at least one type of HPV at some
point
Most will never know they’ve been infected
Estimated 79 million Americans currently infected

14 million new infections/year in the US

HPV infection most common in teens - 20s
Jemal A et al. J Natl Cancer Inst 2013;105:175-201
HPV Types Differ in Their
Disease Associations
~40 Types
Mucosal
sites of infection
High risk (oncogenic)
HPV 16, 18
Cervical Cancer
Anogenital Cancers
Oropharyngeal Cancer
Cancer Precursors
Low Grade Cervical Disease
Cutaneous
sites of infection
~ 80 Types
Low risk (non-oncogenic)
HPV 6, 11
Genital Warts
Laryngeal Papillomas
Low Grade Cervical Disease
“Common”
Hand and Foot
Warts
Cervical Cancer Screening
Pap (Papanicolaou) Test



A test which collects cells from
the surface of the cervix and
looks for abnormal cells
Precancer can be detected and
treated before cervical cancer
develops
HPV testing added as part of
screening, resulting in improved
sensitivity while safely allowing
for extension of screening
intervals
New Cervical Cancer Screening Guidelines:
ACS, USPSTF, ACOG
ACS
2012
USPSTF
2012
ACOG
2012
Age to start
Age 21 years
Women ages Pap every 3 years
21-29 years
Age 21 years
Pap every 3 years
Age 21 years
Pap every 3 years
Women ages Cotesting every 5 years
30-65 years (preferred)
or
Every 3 years with Pap
alone
Cotesting every 5 years
Cotesting every 5 years
(preferred)
or
Every 3 years with Pap
alone
Screening Same as for nonamong fully vaccinated
vaccinated
or
Every 3 years with Pap
alone
Not reviewed
Same as for nonvaccinated
*All guidelines recommend that women who have been adequately screened can discontinue Pap at age 65.
ACS: American Cancer Society
USPSTF: US Preventive Services Task Force
ACOG: American College of Obstetricians and Gynecologists
Section 1:
HPV is common and easily transmitted
HPV Infection/Exposure

Can occur with any intimate sexual contact

Intercourse is not necessary for infection

Nearly 50% of high school students have already engaged in sexual
(vaginal-penile) intercourse

1/3 of 9th graders & 2/3 of 12th graders have engaged in
sexual intercourse

24% of high school seniors have had sexual intercourse with four
or more partners
Jemal A et al. J Natl Cancer Inst 2013;105:175-201
Cervical Cancer


Cervical cancer - most common HPV-associated cancer

500,000 cases & 275,000 deaths world-wide in 2008

11,000+ cases & 4,000 deaths in 2011 in the U.S.
37% cervical cancers occur between the ages of 20 - 44

13% (or nearly 1 in 8) between 20 - 34

24% (or nearly 1 in 4) between 35 - 44 http://
CDC. HPV–associated cancers—US, 2004–2008. MMWR 2012;61(15):258–261.
Cervical Cancer Counts by Age. US Cancer Statistics data from 2010, CDC.gov.
HPV-Associated Cervical Cancer
Rates by State, United States
- Rates are per 100,000 and age-adjusted to the 2000 U.S. Standard Population (19 age groups – Census P25-1130) standard.
- Data from population-based cancer registries participating in the CDC’s supported National Program of Cancer Registries or NCI’s -supported Surveillance, Epidemiology, and
End Results Program, includes all states meeting USCS publication criteria for all years 2006–2010 and covers approximately 94.8% of the U.S. population.
- Results†Source: http://www.cdc.gov/cancer/hpv/statistics/state/cervical.htm
Oropharyngeal and Anal Cancer
Oropharynx is principal site of head & neck cancers



HPV-related in 60-80% of cases
HPV type 16 accounts for more than 90%
of HPV positive cases
In the US, 10,000-12,000 new cases yearly
 A.K. Chaturvedi JCO 2011
Anal Cancer

In US, greater than 7,000 new cases yearly
 More than 80% are HPV related
HPV-Associated Cervical Cancer Rates by
Race and Ethnicity, United States, 2004–2008
Jemal A et al. J Natl Cancer Inst 2013;105:175-201
Average Number of New HPV-Associated
Cancers by Sex, in United States,
2005-2009
n=694
n=3039
n=1003
n=2317
n=1687
n=3084
Oropharynx
n=9312
n=11279
Jemal A et al. J Natl Cancer Inst 2013;105:175-201
Annual Report to the Nation on the Status of
Cancer: HPV associated cancers

From 2000 to 2009, oral cancer rates increased
4.9% for Native American men
 3.9% for white men
 1.7% for white women
 1% for Asian men




Anal cancer rates doubled from 1975 to 2009
Vulvar cancer rates rose for white and AfricanAmerican women
Penile cancer rates increased among Asian men
HPV-Associated Oropharyngeal Cancers


Prevalence increased from 16.3% (1984-89) to
71.7% (2000-04)
Population-level incidence of HPV-positive cancers
increased by 225% while HPV-negative cancers
declined by 50%
If trends continue, the annual number of HPV-positive
oropharyngeal cancers is expected to surpass the annual
number of cervical cancers by the year 2020
Chaturvedi, 2011, J Clin Oncol- data from SEER
Numbers of Cancers and Genital Warts
Attributed to HPV Infections, U.S.
CDC. Human papillomavirus (HPV)-associated cancers. Atlanta, GA: US Department of Health and Human Services,
CDC; 2013. Available at http://www.cdc.gov/cancer/hpv/statistics/cases.htm
Complications related to current methods of
cervical cancer prevention



Infertility due to treatment of cervical cancer by hysterectomy
Cervical conization and loop electrosurgical excision procedure
(LEEP) procedures associated with adverse obstetric morbidity
Subsequent pregnancies are at risk of



Perinatal mortality
Severe and extreme preterm delivery (<32/34 or <28/30 weeks)
Severe and extreme low birth weight (< 2000g or 1500g)
These outcomes have a considerable impact—not only on
the mothers and infants concerned—but also on the cost of
neonatal intensive care
Section 2:
High HPV vaccination rates have
measurable population-level effects
HPV Prophylactic Vaccines
Recombinant L1 capsid
proteins that form “virus
like” particles (VLP)
 Non-infectious and nononcogenic
 Produce higher levels of
neutralizing antibody
than natural infection

HPV VLP
HPV Vaccine
Quadrivalent/HPV4
(Gardasil)
Merck
6, 11, 16, 18
Females: Anal, cervical,
vaginal and vulvar precancer
and cancer; Genital warts
Males: Anal precancer and
cancer; Genital warts
Pregnancy
Hypersensitivity to yeast
3 dose series: 0, 2, 6 months
Name
Bivalent/HPV2
Manufacturer
Types
GlaxoSmithKline
(Cervarix)
16, 18
Indications
Females: Cervical precancer and
cancer
Males: Not approved for use in
males
Contraindications
Pregnancy
Hypersensitivity to latex (latex
only contained in pre-filled
syringes, not single-dose vials)
Schedule (IM)
3 dose series: 0, 1, 6 months
Quadrivalent HPV vaccine (Gardasil)
Recommendation for Males
Age 11 - 12 for prevention of anal cancer and gential warts
 Age 13 - 21 who haven’t started or completed series
 Age 22 - 26 may get vaccine
 Teen -26 who identify as gay or bisexual and haven’t started or
completed series

Nonavalent human papillomavirus
vaccine


HPV-types 6/11/16/18/31/33/45/52/58
Coming soon near you!
HPV Vaccine Safety


Most common adverse events reported-considered mild
For serious adverse events, no unusual pattern or clustering that
suggest events caused by HPV vaccine

Similar to safety reviews of MCV4 and Tdap vaccines

57 million doses of HPV vaccine in US since 2006
HPV Vaccine Safety Monitoring: VAERS
& IOM

No new safety concerns identified among male or
female recipients of HPV4 vaccine
 Among the 7.9% of reports coded as “serious”, most
frequently cited are headache, nausea, vomiting,
fatigue, dizziness, syncope, generalized weakness
•
Inadequate evidence found for causal relationships between
HPV vaccination and 12 other specific health events studied

Syncope frequently reported among adolescents
 Adherence to a 15-minute observation period after
vaccination is encouraged
Institute of Medicine. Adverse Effects of Vaccines: Evidence and Causality. Washington DC. The
National Academies Press, 2012.
http://www.cdc.gov/vaccinesafety/vaccines/HPV/Index.html#monitor
24
HPV Vaccine Safety
The most common adverse events reported were
considered mild
 For serious adverse events reported, no unusual
pattern or clustering that would suggest that the
events were caused by the HPV vaccine
 These findings are similar to the safety reviews
of MCV4 and Tdap vaccines


57 million doses of HPV vaccine distributed in
US since 2006
HPV Vaccine Safety Data Sources
Post-licensure safety data (VAERS)1
 Post-licensure observational comparative studies
(VSD)2
 Ongoing monitoring by CDC and FDA
 Post-licensure commitments from manufacturers

Vaccine in pregnancy registries
 Long term follow-up in Nordic countries


Official reviews


1Vaccine
WHO’s Global Advisory Committee on Vaccine Safety 3
Institute of Medicine’s report on adverse effects and vaccines, 20114
Adverse Events Reporting System, http://vaers.hhs.gov/index
Safety Datalink, http://www.cdc.gov/vaccinesafety/Activities/VSD.html
3http://www.who.int/vaccine_safety/Jun_2009/en/
4http://www.iom.edu/Reports/2011/Adverse-Effects-of-Vaccines-Evidence-and-Causality.aspx
2Vaccine
HPV Vaccine Impact:
HPV Prevalence Studies

NHANES Study




National Health and Nutrition Examination Survey (NHANES) data used
to compare HPV prevalence before the start of the HPV vaccination
program with prevalence from the first four years after vaccine
introduction
In 14-19 year olds, vaccine-type HPV prevalence decreased 56 percent,
from 11.5 percent in 2003-2006 to 5.1 percent in 2007-2010
Other age groups did not show a statistically significant difference over
time
The research showed that vaccine effectiveness for prevention of infection
was an estimated 82 percent
Cummings T, Zimet GD, Brown D, et al. Reduction of HPV infections through
vaccination among at-risk urban adolescents. Vaccine. 2012; 30:5496-5499.
HPV Vaccine Impact:
HPV Prevalence Studies, continued

Clinic-Based Studies
Significant decrease from 24.0% to 5.3% in HPV vaccine
type prevalence in at-risk sexually active females 14-17
years of age attending 3 urban primary care clinics from
1999-2005, compared to a similar group of women who
attended the same 3 clinics in 2010
 Significant declines in vaccine type HPV prevalence in both
vaccinated and unvaccinated women aged 13-26 years who
attended primary care clinics from 2009-2010 compared to
those from the pre-vaccine period (2006-2007)

Kahn JA, Brown DR, Ding L, et al. Vaccine-Type Human Papillomavirus and Evidence
of Herd Protection After Vaccine Introduction. Pediatrics. 2012; 130:249-56.
HPV Vaccine Impact:
Genital Warts Studies

Ecologic analysis used health claims data to examine trends in
anogenital warts from 2003-2010 among a large group of
private health insurance enrollees



The study found significant declines after 2007 in females aged 1519 year (38% decrease from 2.9/1000 PY in 2006 to 1.8/1000 PY
in 2010)
Smaller declines were observed among those 21-30 years but not in
those over 30 years
A similar study evaluated genital wart trends in males and
females attending public family planning clinics and found


Significant decrease of 35% (.94% to .61%) in females under 21
years of age and a 19% decrease in males less than 21 years
No decreases were reported in the older males or females
HPV Vaccine Impact:
High HPV Vaccine Coverage in Australia




80% of school-age girls in Australia are fully
vaccinated
High-grade cervical lesions have declined in women
less than 18 years of age
For vaccine-eligible females, the proportion of genital
warts cases declined dramatically by 93%
Genital warts have declined by 82% among males of
the same age, indicating herd immunity
Garland et al, Prev Med 2011
Ali et al, BMJ 2013
HPV Vaccine Impact:
High HPV Vaccine Coverage in Australia



•
80% of school-age girls in Australia-fully vaccinated
 High-grade lesions declined in women less than 18 years of
age
Proportion of genital warts declined by 93%
 For vaccine eligible females
Genital warts declined by 82% among males of the same age,
indicating herd immunity
In the US, prevalence of vaccine types declined by more than
half (33% of teens fully vaccinated)
Garland et al, Prev Med 2011
Ali et al, BMJ 2013
ESTIMATED 3-DOSE COVERAGE
Markowitz L et al, JID, 2013
Markowitz L et al, Vaccine, 2012
Ali H et al, BMJ, 2013
The Perfect Storm


Vaccine issues sensationalized by popular media
Different reasons for why some don’t get the first shot and
why some don’t finish all 3 shots

Parents think sexuality instead of cancer prevention

Many clinicians aren’t giving strong recommendations

Parents have questions that are seen as hesitation by doctors

Systems interventions depend on clinician commitment

Phased girls then boys recommendations initially confusing
National Estimated Vaccination Coverage Levels among
Adolescents 13-17 Years,
National Immunization Survey-Teen, 2006-2012
90
80
70
60
Tdap
50
MCV4
Percent Vaccinated
1 HPV girls
40
3 HPV girls
1HPV boys
30
3 HPV boys
20
10
0
2006
2007
2008
2009
2010
Survey Year
CDC. National and State Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2012
MMWR 2013; 62(34);685-693.
2011
2012
Coverage of 1 or More Doses of HPV Vaccine, Female
Adolescents Age 13-17 Years, 2012
1st Shot
51% of eligible girls
24% of eligible boys
All Three 30% girls and 7% boys.
2013 - 2014 HPV Vaccination
Legislation Across U.S.
WA
MT
ME
ND
MN
OR
VT
I
D
WI
SD
NY
MI
WY
CT
IA
NV
RI
PA
NB
NJ
UT
CA
N
H
MA
IL
OH
IN
CO
MD
DE
WV
KS
VA
MO
KY
NC
AZ
OK
NM
TN
AR
SC
MS
AL
GA
Mandatory for school
attendance

Require schools to provide
information to
parents/guardians; allow
pharmacists to provide
vaccination, etc.

TX
AK
LA
FL
HI

Only Virginia and D.C. have enacted mandatory HPV vaccination for school attendance
No 2014 legislation
Source: NCSL
2006 - 2014 HPV Vaccination
Legislation Across U.S.
WA
MT
ME
ND
MN
OR
VT
I
D
WI
SD
NY
MI
WY
CT
IA
NV
RI
PA
NB
NJ
UT
CA
N
H
MA
IL
OH
IN
CO
MD
DE
WV
KS
VA
MO
KY
NC
AZ
OK
NM
TN
AR
SC
MS
TX
AK
AL

Passed

Failed
GA
LA
FL
HI
Only Virginia and D.C. have enacted mandatory HPV vaccination for school attendance
Source: NCSL
Vaccination Estimates among Adolescent
Girls 13-17 Years by Race/Ethnicity,
NIS-Teen 2011
**
**
**
** statistically significant (p<0.05)
2011 NIS-Teen available at http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm#nisteen
HPV Vaccination Uptake among Adolescent
Boys



Available data represents vaccination activities
prior to implementation of routine recommendation
approved in October, 2011
8.3% of boys 13-17 years of age have initiated the
series
So far vaccine uptake (coverage) follows the same
pattern as observed for girls
Higher coverage among boys living below the poverty level
 Higher coverage among Black and Hispanic boys
 Based on only one year of data

2011 NIS-Teen available at http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm#nisteen
Actual and Achievable Vaccination Coverage if
Missed Opportunities were Eliminated:
Adolescents 13-17 Years, NIS-Teen 2011
Among girls
unvaccinated for
HPV, 78% had a
missed opportunity
Missed opportunity: encounter when some but not all ACIP-recommended vaccines are given
HPV-1: receipt of at least one dose of HPV
2011 NIS-Teen available at http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm#nisteen
Avoid Missed Opportunities





HPV vaccine can safely be given at the same time as
the other recommended adolescent vaccines
Provide HPV vaccine during routine sports, or camp
physicals
Review immunization record even at acute care visits
Encourage parents to keep accurate vaccination
records and to review the immunization schedule
Systems interventions depend on clinician commitmentdetermine what would work best for YOUR practice
Why We Need to Do Better in HPV
Vaccination of 12 year olds
Currently 26 million girls <13 yo in the US; If
none of these girls are vaccinated then:
168,400 will develop cervical cancer and
54,100 will die from it
 Vaccinating 30% would  Vaccinating 80%
prevent 45,500 of these
cases and 14,600 deaths
would prevent 98,800
cases and 31,700
deaths
For each year we stay at 30% coverage instead of
achieving 80%, 4,400 future cervical cancer cases and
1400 cervical cancer deaths will occur.
Is she really too young? Take 1
(a conversation you may be familiar with)
Doctor: Meghan is due for some shots today: Tdap,
meningococcal conjugate vaccine, and HPV.
Parent: Why does she need an HPV vaccine? She’s only 11!
Doctor: We want to make sure she gets the shots before
she becomes sexually active.
Parent: Well I can assure you Meghan is not like other girlsshe’s a long way off from that!
Doctor: We can certainly wait if that would make you feel
more comfortable.
Rationale for vaccinating early:
Protection prior to exposure to HPV
82%
18 to 24
Markowitz MMWR 2007;
Holl Henry J Kaiser Found 2003;
Mosher Adv Data 2006
Strength of HPV Vaccine Recommendation
for Female Patients, Pediatricians and
Family Physicians (N=609)
Allison et al. https://cdc.confex.com/cdc/nic2011/webprogram/Paper25181.html
A Strong Recommendation at 11
Doctor: Meghan is due for some shots today: Tdap, meningococcal
conjugate vaccine, and HPV.
Parent: Why does she need an HPV vaccine? She’s only 11!
Doctor: HPV vaccine will help protect Meghan from cancer caused by
HPV infection. And I want to make sure Meghan receives all 3 doses
and develops protection long before she becomes sexually active.
Parent: But it just seems so young…
Doctor: We’re vaccinating today so your child will have the best
protection possible well before the start of any kind of sexual activity.
HPV vaccine is also given when kids are 11 or 12 years old because it
produces a better immune response at that age. That’s why it is so
important to start the shots now and finish them in the next 6 months.
This vaccine can’t wait.
Questions Should Be Encouraged,
Not Interpreted as Refusal
Doctor: Olivia needs her Tdap and meningococcal
vaccines today. We could also give her the HPV vaccine.
Parent: Do you think she needs all of those today? Can’t
we just skip the HPV one? I’m not sure she really needs
that anyway.
Doctor: Sure, we can wait until her next visit to give her
that one.
Parents who do not intend to vaccinate
daughter in next 12 months, NIS-Teen
2008-2009
Lack of knowledge**
Not needed
Not sexually active
No provider recommendation
Safety concerns
0
* Not mutually exclusive.
** Did not know much about HPV or HPV vaccine.
5
10
15
Percent
20
25
Receipt of HPV Vaccine Does Not Increase Sexual Activity
or Decrease Age of Sexual Debut




Kaiser Permanente Center for Health Research
1,398 girls who were 11 or 12 in 2006, 30% of whom were
vaccinated, followed through 2010
No difference in markers of sexual activity, including
 pregnancies
 counseling on contraceptives
 testing for, or diagnoses of STDs
Risk perceptions after HPV vaccination were not associated
with riskier sexual behaviors
Bednarczyk et al Pediatrics Oct 2012
Mayhew A et al Pediatrics. Mar 2014
How to respond to Mom
Doctor: Olivia needs the HPV, Tdap and meningococcal vaccines
today.
Parent: Do you think she needs all of those today? Can’t we just
skip the HPV one? I’m not sure she really needs that anyway.
Doctor: HPV vaccination is very important to help prevent cancer
caused by HPV infection. I want to help protect Olivia from
cancer and I know you want that too. That’s why I’m
recommending that Olivia receive the first dose of HPV vaccine
today.
Parent: I didn’t realize that.
Doctor: She’ll need to come back in for the next 2 doses of the
HPV vaccine for full protection. Please make your appointments
at the front desk for the 2nd and 3rd doses of the HPV vaccine.
What about boys?
Take 1
Doctor: Henry is due for 3 vaccinations today: Tdap, MCV4
and HPV vaccine.
Parent: Why does he need HPV vaccine- isn’t that just for
girls?
Doctor: It could help protect his partners in the future.
Parent: That seems like the girl’s responsibility. Henry is a
nice boy—if nothing will happen to him, then why bother?
Doctor: It’s completely up to you.
Recommendation for Males

Quadrivalent HPV vaccine (Gardasil) recommended
for boys at age 11 or 12 years for prevention of
anal cancer and gential warts
 Also
for boys 13 through 21 who haven’t started or
completed series
 Young men, 22 through 26 years of age, may get the
vaccine
 Teen boys through age 26 who identify as gay or
bisexual and haven’t started or completed series should
be vaccinated
Clincian Knowledge of Recommendation for
Males

Qualitative research with clinicians demonstrated
less knowledge about indications and benefits for
males
 When
responses were provided, most mentioned
protecting their partners; some mentioned prevention of
genital warts
 Few clinicians stated that HPV could cause anal, penile
or oropharyngeal cancers in men
Get it for your son, take 2
Doctor: Henry is due for 3 vaccinations today: Tdap, MCV4 and
HPV vaccines.
Parent: Why does he need HPV vaccine- isn’t it just for girls?
Doctor: Boys should also get HPV vaccine when they are 11 or
12 years old. HPV causes cancers in men too. Over 7000 men
each year develop a cancer of the mouth, tongue or throat that
is caused by HPV, and this number is rising. HPV also causes
cancer of the penis and anus.
Parent: Wow, I had no idea. Yes, lets him that one too!
Doctor: Henry will need to come back for the second and third
shots- make an appointment today for those visits.
How Can Clinicians Help?
1. Give a STRONG recommendation

Ask yourself, how often do you get a chance to prevent cancer?
2. Start conversation early and focus on cancer prevention


Vaccination given well before sexual experimentation begins
Better antibody response in preteens
3. Offer a personal story


Own children/Grandchildren/Close friends’ children
HPV-related cancer case
4. Welcome questions from parents, especially about safety

Remind parents that the HPV vaccine is safe and not associated with
increased sexual activity
Take-home points
1.
HPV causes around 32,500 cancers annually

2.
3.
cervix (11,000), oropharynx (12,000), anus/rectum (5,000), vulva
(3,000), penis/vagina (1500)
HPV vaccination most effective prior to exposure and can be
transmitted prior to first coitus
Reminder of ACIP recommendation and AAP guidelines:
 Routine HPV vaccination recommended for males and
females ages 11-12
 Catch-up ages 13-21 (males); 13-26 (females)
 Permissive use ages 9-10 (males and females); 22-26
(males)
A Preventable Disease



Lyndon Baines Johnson Hospital
Uninsured/underinsured
MDACC Outreach Program
Study Population (n=139)
Median age (range) 46.2 (25, 72)
Race1
African American
Hispanic
White
Asian/Other
Marital Status
Married/partnered
Single
Divorced/Widowed/Other
Education (missing, n=1)
Grade 5 and below
Grade 6 – 8
Grade 9 – 11
HS grad or GED
Associate degree/some
college or trade school
College graduate
35 (25.2)
76 (54.7)
26 (18.7)
2 (1.4)
56 (39.6)
55 (40.3)
28 (20.1)
15 (10.9)
26 (18.8)
34 (24.6)
41 (29.7)
17 (12.3)
5 (3.6)
Language
English
Spanish
99 (66.0)
40 (26.7)
Smokers
65 (47.8)
Number of children
None
1-2 children
3-4 children
5+ children
8 (5.9)
48 (35.3)
46 (33.8)
34 (25.0)
Stage at diagnosis
IB1 and below
IB2
IIA, IIB
IIIA, IIIB
IVA, IVB
31 (22.3)
25 (18.0)
39 (28.0)
29 (20.9)
15 (10.8)

At diagnosis, 75.5% presented with vaginal bleeding


46% had pelvic and/or back pain
66.4% visited ER for symptoms prior to diagnosis

36.8% visited the ER on 2 or more occasions

67% stated they did not have a primary care physician

21% patients received transfusions for bleeding;
Item
Pts with
stage lB1
and below
Pts with
pstage lB1 value
and higher
• Had Harris County Gold Card prior to
diagnosis
62.5%
37.3%
.01
• Visited ER for symptoms
13.8%
81.4%
<.001
• Median # months between onset of
symptoms and when patient sought care
6 (0, 18)
6 (1, 60)
.20
• Median # yrs (range) since last Pap test
3 (.5, 20)
6 (1, 26)
.23
0%
26%
.003
• Has a primary care physician
66.7%
23.3%
<.001
• % who answered YES when asked “When
you were told you had cancer did you
worry about spiritual issues?”
15.6%
27%
.19
• % who answered YES when asked “When
you were told you had cancer did you
worry about guilty feelings?”
34.4%
35.6%
.90
• Children live with patient
33.3%
42.2%
.39
13%
30.8%
.048
• Received tranfusion(s) for vaginal bleeding
• Patient cares for other family members
Why We Need to Do Better in HPV
Vaccination of 12 year olds
 Currently 26 million girls <13 yo in the US; If none of
these girls are vaccinated then:
 168,400 will develop cervical cancer and
 54,100 will die from it
 Vaccinating 30% would
prevent 45,500 of these
cases and 14,600 deaths
 Vaccinating 80% would
prevent 98,800 cases
and 31,700 deaths
For each year we stay at 30% coverage instead of achieving
80%, 4,400 future cervical cancer cases and 1400 cervical
cancer deaths will occur.
Adapted from Chesson HW et al, Vaccine 2011;29:8443-50
MD Anderson Work Groups

Comprehensive Cancer Control Cervical Work Group
 Summit 2012, 2013, 2014
 College of American Pathologists (CAP):

Prevention/Screening grant development
HPV interest group
 Research
 Basic Science
 Collaborative


See Test, & Treat
HPV Research Initiative

Gynecologic Oncology (Cervix)
Head and Neck
Anal Cancer
Penile cancer

Retreat August 9th



Survivor Support
64




Stigma
Poverty
Uninsured
Health Literacy
Questions?
Lois Ramondetta, MD
[email protected]
For more information,
including free resources for yourself and
your patients, visit:
cdc.gov/vaccines/teens
Email questions or comments to
CDC Vaccines for Preteens and Teens:
[email protected]