MARCIA DAY CHILDRESS: Good afternoon.
I'd like to welcome you to today's medical center hour.
I'm Marcia Day Childress from the Center
for Biomedical Ethics and Humanities
here in the School of Medicine, and we're
delighted to bring you these weekly programs on medicine
and society.
What if there were a vaccine that could prevent cancer?
Well, there is.
Indeed, a vaccine targeted to several strains
of the ubiquitous human papilloma
virus, otherwise known as HPV.
This vaccine has been available and in use since 2006.
When administered in adolescence and young adulthood especially,
the vaccine guards against cancers, several of them lethal
caused by several types of HPV.
With reference to this powerful preventive tool,
we've titled this medical center hour "Taking a Shot
at HPV and Cancer."
In this hour, we'll explore the sociopolitical context
of the HPV vaccination in Virginia and beyond.
We're going to use clips from the 2014 documentary
film called Someone You Love: The HPV Epidemic.
And we're going to draw on the expertise of a panel of persons
whose work in medical science, clinical care, and prevention
circles around HPV.
We're going to draw on their expertise
as they discuss the importance of HPV vaccination for boys,
as well as girls.
And they're going to talk as well
about concerns that still limit the use of the HPV vaccination.
Our panel is actually going to be moderated today
by Emma Mitchell, who's here on my immediate right-- assistant
professor of nursing and co-director of Global
Initiatives in the School of Nursing here at UVA.
Seated next to her is Mark Stoler,
who's professor emeritus of pathology and clinical
gynecology here at UVA.
Next to him is Emily Young, a community-based family
physician who also works at UVA Student Health.
And on my far right, Kari Ring, an assistant professor
of gynecologic oncology in the Department of OBGYN
and also affiliated with the Cancer Center here at UVA.
We are doing this program in partnership
with the Cancer Center.
And I'd like to thank all of them in advance.
We'll thank them at the end.
And we will also have time at the end for your comments
and questions.
I should also mention that Doctors
Ring, Young, and Mitchell declared no financial conflict.
Dr. Stoler disclosed that he does continue
to serve as a consultant for Merck,
one of the pharmaceutical companies
that developed and manufactures an HPV vaccine.
So I will turn things over to Emma Mitchell and our panel
for "Taking a Shot at HPV and Cancer."
Welcome.
EMMA MITCHELL: Thank you.
Thank you so much and thank you everyone
for joining us today for this really important topic.
I'd like to also thank some of the organizers
for this event, many of whom sit with us on a statewide task
force.
Increasing HPV vaccination is a statewide priority
here in Virginia.
We were the first state to introduce
legislation requiring sixth grade girls to be vaccinated.
But the ease with which parents can opt out
combined with the misinformation circulating about HPV
vaccination means that we in Virginia
still lag in vaccine initiation and completion.
To center our discussion today on the importance
of preventing HPV associated cancers and diseases
through vaccination, we're going to show a series of clips
from the CDC-produced film Someone You Love.
The film focuses on cervical cancer prevention,
but after we show it we will also
discuss prevention of oropharyngeal and other types
of HPV associated cancers and diseases with our panelists.
Last evening we had our second annual screening
of the entire film, which shows the stories of five
women and their experiences with cervical cancer.
So we'll share a shortened version
of the film threaded throughout our panel discussion today.
We have some prearranged questions and discussion points
we'd like to share with you.
And then we'll open up for discussion and questions
at the end.
So we'll begin with our first film clip now.
Thank you.
So I'd like to begin by asking Dr. Stoler,
can you describe a little bit more
about what it means for HPV to be ubiquitous
and what the subsequent health conditions are
that people can experience after contracting it?
MARK STOLER: Sure.
Thank you.
AUDIENCE: Turn on your microphone, please.
MARK STOLER: Is it it on now?
AUDIENCE: Yep.
MARK STOLER: It's on.
OK.
There it is.
All right.
So I should also add to my disclosure,
I'm not just a consultant to Merck.
I was part of the clinical trials that
are ongoing that led to the approval, both of Merck's HPV
vaccines.
So with that disclosure, this idea
that HPV is ubiquitous-- so there are over 200 types of HPV
and every one of us have multiple types
in various locations on our skin.
Of the 200 types, maybe 40 or 50 types are sexually transmitted.
The rest are transmitted by close contact,
best we can tell.
Of the 50 types that are sexually transmitted,
we test for when we do screening 14 types.
And seven of those 14 types caused more than 90%
of the cancers that we are going to talk about.
And those seven types are in the current GARDASIL 9 vaccine--
the seven high-risk types that are associated with cancer,
and HPV 6 and 11 that are associated with genital warts.
So that gives you an idea of how ubiquitous
and how common HPVs are.
If we were to screen the women in the general population,
as we do every day when they come in for pap testing and/or
co-testing--
we're going to talk about screening--
roughly 10% of the women at any given time are positive.
So this is a very common infection.
And that's positive-- looking for only the 14
of the 200-and-something types that we're talking about.
Now, briefly in terms of cancer, everybody
knows about cervical cancer.
We screen for cervical cancer.
We've been doing it for 60 years,
primarily with pap smears.
We started doing it because everybody knew somebody
who had cervical cancer.
If you go back 50 years ago, cervical cancer
was probably the number one cancer in women,
and it still is number two or three in terms
of worldwide cancer incidence.
More common than all the other cancers combined.
But the effects of screening in the United States
have led to the following situation.
So today, we have about 12,000, 13,000 cancers
in women picked up in the United States-- cervical cancers,
and about 3,500 deaths.
More than 2/3 of those cancers are in women
who've never been screened.
Screening is incredibly protective,
as we'll talk about it.
So if you take the 12,000 or 13,000 cervical cancers
and you say, well, what about men?
Men have actually more cancers due to HPV than women
have cervical cancers.
And that's because we can't screen
for oropharyngeal cancers.
There's about 18,000 oropharyngeal cancers a year
in the United States that occur in a specific area
within the throat, mostly around the area of the tonsil
and the back of the tongue.
15,000 of those are men, 3,000 of those are in women.
So there is more oropharyngeal cancer that's due to HPV in men
than there are cervical cancers in women,
because of the effect of screening.
What other cancers are there that we can talk about?
Anal cancer, penile cancer, vulvar cancer, vaginal cancer.
If you add them all up, women still
get more HPV related cancer than men,
but both sexes are equally at risk.
And that's why when we talk about vaccination at least,
we should talk about equality of medical access and prevention
for both men and women.
So to summarize, about 45,000 cancers
occur in the United States a year
in men and women due to HPV.
What if we can make it 4,500?
45,000 cancers-- if you just talk
about cervical cancers, 3,500 cancers a year sounds abstract.
Let's make it more concrete.
10 women a day die of cervical cancer
despite 60 years of screening as hard and as best as we can.
What if we could make it one woman a day
instead of 10 women a day?
Notice I'm not saying zero.
Perfection is the enemy of good.
But if we could take out 90% of the HPV related cancers,
it would do more for cancer prevention
than everything else we do in cancer in one fell swoop.
And with that, I think we can continue.
EMMA MITCHELL: Thank you.
We'll do our second clip now.
Thank you.
So we heard about some of the barriers
that people and patients experience to screening.
But when it comes to vaccination, Dr. Young,
I'd like to ask you, in your practice, what
are some of the barriers that you
see your patients and parents have
and how do you approach conversations
about the stigma associated with HPV vaccination?
EMILY YOUNG: Yes.
Is this on?
OK.
So I'm a family doctor and I see everyone.
0 to 101 I think is my oldest patient.
And I primarily focus on a lot of pediatrics, as well
as woman's health.
And the biggest barrier that I see
is continuing the result from that time when
the HPV vaccine first came out and there
was a big rush of excitement about, well,
if we give this vaccine, then we're encouraging
our kids to have sex.
The biggest thing that I do to counteract this
is pull out the sex talk and the concern about their kids
having sex from talking about the vaccine,
and normalize giving the vaccine to them.
So the vaccine for kids is due anywhere from nine to 26 years
old for males and females, and recommended by the ACIP
to be given at 11 to 12 years old.
And this is at the same time as we
give the tetanus and pertussis and diphtheria vaccine
or booster, as well as the meningococcal vaccine.
So there was a study done at UNC Chapel Hill that
identified what would be the most effective way
for providers to talk to their patients about these vaccines
and increase the vaccination rate.
The main outcome was that short, direct,
and brief is the best way to overcome those barriers.
Doing a lengthy conversation and talking about sex
at the same time, which can be a very, very
difficult conversation when you're talking about a nine
to 12-year-old, pulling out that conversation from the vaccines
is going to be kind of important in order
to make sure that our vaccination rates increase.
And then lastly, training providers
to do this direct conversation is important
instead of just a placebo of not doing any training.
So the way that I approach is I--
hey, Johnny is now of the age where he's 11 to 12.
We have three vaccines available for you
today in your well-child check.
Or if they're coming in for a sick visit
where they don't have a fever, I introduce
that he's due for a Tdap booster, as well as the HPV
vaccine, which is the vaccine out there that
prevents cancer and the only one that we
have that prevents cancer.
And then he's due for the meningococcal vaccine, which
prevents a really serious neurological infection if it
happens.
Do those vaccines sound OK to you?
And most the time, parents are completely perfect with that.
They see this as another vaccine.
It is just another vaccine.
It's a very important one for this kid in these people's
futures in making sure that they understand that it's just
as important as the other ones and it shouldn't be more scary,
because it doesn't have any increase in side effects.
The side effects are the same as the other vaccines essentially.
A little bit of redness and pain in the muscle,
maybe a little bit of some feeling crappy afterwards,
because that's the immunological response turning on in our body
is making us feel crappy that day.
And it's not really anything that some ibuprofen can't help,
and I think parents are reassured to hear that.
So I do have the sex talk obviously very honestly
with patients, but I just don't think that it should
be tied to the HPV vaccine.
It's a really complicated idea for people
to grasp, that you have this virus,
you can catch it at some point, you
will catch it in a sexually transmitted way at some point.
It's transient or ubiquitous.
Almost everybody gets it.
It usually goes away by 30, but if it persists,
then we have to watch it a little bit more closely.
And if it does persist, it can cause cancers
of certain areas of the body.
That obviously is a very step-wise idea,
that if you start off at one point and it causes this,
and then it causes this and it causes this,
but we have a vaccine that prevents that whole pathway.
It's a complicated and convoluted thing
to explain to people who don't understand or are
laypeople in science, essentially.
So just talking about the vaccine
as it's the only one that we have that
prevents cancer, that is the main message
that we've transitioned to talking about
in the primary care setting.
And it's been working.
EMMA MITCHELL: Great.
Thank you so much.
I think that helping to reframe the narrative,
as you're saying, against those misconceptions
and giving providers the tools to have
those frank, direct conversations, as you
suggested, are really important.
Can you or our other panelists speak
to a little bit of the other types of barriers
that people experience in vaccinating other
than stigma or misconceptions?
MARK STOLER: Well, I'd like to just make
a comment on what Emily said, which
is this relationship between giving the vaccine
and stimulating sexual activity, per se.
Because there are now--
nothing like a little data, right?
But there are multiple studies--
multiple studies that have looked
at this from a sociological or behavioral aspect.
And not a single one has shown that giving them
the HPV vaccine increases sexual behavior.
Quite the contrary.
It makes them more aware of their own sexuality
and maybe more careful in considering it.
So it's a great example of the difference between perception
and science or perception and data.
From my standpoint, having been there
when it was approved in 2006 and seen the incredibly slow uptake
in the US relative to the rest of the world, to me
the barriers are that our health system doesn't
promote organized vaccination.
If you go to Australia, you go to England,
it's recommended for sixth grade kids.
Well, you show up for the sixth grade, you get your first shot.
You get your second shot at Thanksgiving
and your third shot at spring break.
And that's the way it is.
And they have you at school and no problem,
and everybody accepts it.
That's a far cry from what we do here in the US.
But I would strongly agree that normalizing the conversation
is the key to success.
And I think there's good data showing study after study
that in pediatric practices and family practices, you,
the guys who give the vaccines at the right target age,
that's what you've got to do.
KARI RING: I think it's also--
it's helped us a little bit in that there's now
data that's come out that if you get
your vaccines before the age of 14,
you actually only need two shots instead of three shots.
So not only is it a stop gate where
we're giving other vaccines, but I say to parents--
and unfortunately, I'm seeing patients
usually on the other end of the spectrum
that have gotten cancer, but that
doesn't mean that I don't get on my soapbox with their families
during their visit--
is that they only have to get two shots instead
of three shots if you give it to them at the recommended age.
And so I think that has helped us a little bit.
EMILY YOUNG: And just to piggyback off that.
My main thing is that when I see a kid,
I'm advocating for who they are as an adult
and when I will see them in the clinic.
And to think back if they are now coming in at 21 years old
and their parents chose not to give them
the vaccine at 11 to 12 years old,
I almost think that's not fair that they didn't get it,
they didn't have that ability to make their own choice
against preventing cancer for themselves.
So I think about what their choice would
be when they hit that 21 year age or even 50-year-old age,
is like, well, was that fair to them
to have that ability to prevent cancer taken away from them?
And the answer is no.
So my job is to make sure that the parents understand
what this means to their kid later on.
And if they leave the office not understanding,
then that's my fault. That's not theirs, that's mine.
And the reason that the 11 to 12-year-old
is so important to give is not only because it reduces
the barrier of only doing two shots instead of three,
but it's an increased immunological response
at 11 to 12 years old.
And that's why we give it at that age.
It's approved down to nine years old, which is awesome
and we give it as early as nine.
But the 11 to 12-year-old age group
is where that immunological response is so high.
If they wait until they can make their own decisions at 18
or 21, that immunological response is decreased.
Still effective, but decreased.
And if their parents choose not to give it
to them at the 11 to 12 years old,
they're missing that immunological response.
EMMA MITCHELL: Thank you.
That is really the emphasis of where we try
to aim our prevention efforts.
Dr. Stoler likes to say screen the mom and vaccinate the kid.
But very recently we've had the FDA approve an extended age
period for the recommendation for HPV vaccination.
It will take some time before the ACIP approves that.
But Dr. Stoler, can you talk a little bit
about what that means and how that will impact our patients?
MARK STOLER: So the expansion of the age range, up to age 45
now, I look at as a major advance.
Because the end goal is to decrease the prevalence
of the virus in the population.
The faster you do that, the faster
we start seeing the downstream effects--
no genital warts, no abnormal pap smears, no biopsies,
no surgeries, and ultimately no cancers.
And so that was the rationale.
The reason it wasn't originally that range
was the idea that sexually active individuals are already
exposed to the viruses, and the vaccine is prophylactic.
If you've been infected with HPV 16
the virus that causes 50% of cervical cancer,
you're not going to get any benefit from an HPV 16
component in the vaccine.
But that being said, we now have much better epidemiologic data.
And for the average 35 or 40-year-old,
now that we have a vaccine that has nine viral types,
the probability that you're going
to be exposed to all nine, even if you
have a happy and healthy sex life, less than 1%.
So for every virus that you haven't been exposed for,
it's a Russian roulette kind of experience, if you will.
For everyone you haven't been exposed for,
the vaccine is perfectly effective.
There was one other comment about barriers versus benefits.
There are three HPV vaccines in existence.
The two from Merck.
GARDASIL 9 now replacing GARDASIL.
GARDASIL had four viruses--
viral proteins.
GARDASIL nine has nine.
And then there was Cervarix, the GSK vaccine
that had only 16 and 18.
And I want to bring back to the concept of genital wart
prevention.
In England, they used to spend more money
on genital warts in terms of total medical care
than they did on cervical cancer.
Genital warts-- I'm not going to ask for a show of hands.
[LAUGHTER]
But this is not a pleasant thing.
And all I can say is, is that genital warts have disappeared
in clinically vaccinated populations.
So for instance, in Australia, where
for the past eight years--
they started a couple of years later than we did--
85%, 90% of the population has been vaccinated,
there are no genital warts clinically.
You just don't see a case.
You can't have a case to teach somebody
what a genital wart looks like.
They're gone.
They're not only gone in the people who
have been vaccinated, they're pretty much gone in the people
who haven't been vaccinated.
The concept of herd for that last 10%--
the concept of herd immunity is really well demonstrated.
And so if you wait till 21, I don't
have to tell you how many cases of genital warts
you see in people who haven't been vaccinated.
But I guarantee you haven't seen a case in somebody who
has gotten the shot.
EMILY YOUNG: Right.
I think as far as access to care,
of course we have the same issues with access
to care as we have for all other immunizations.
But I think another problem is that because we've
done such a good job of screening for cervical cancer,
not as many people either know someone who had cervical cancer
or who have a family member who have cervical cancer.
And so people just aren't talking about it as much.
What I say to patients is, if there
was a vaccine for breast cancer, you
know that everybody would go get it.
And it's true in that everyone has
a loved one who had breast cancer or their family
has been affected by a more common cancer like this.
So I'm like, it's just like that.
And when I say that, people are like, huh,
I would get a breast cancer vaccine.
[LAUGHTER]
And I find that relating it to people that people know
or their loved ones helps.
EMMA MITCHELL: Thank you.
Thank you.
Let's see our final clip from Someone You Love.
Thank you.
So we've mentioned Australia as a case study a few times.
They've been in the headlines very recently
as they're targeted to be on track for eradicating
cervical cancer.
And this is really accomplished through a combination
of prevention strategies.
Most importantly vaccination, but additionally screening
through innovative technologies and high quality follow-up.
Closer to home, in September 2018,
the USPSTF, The US Preventative Services Task Force,
issued a new set of guidelines for screening.
And this will really continue to be important,
because our vaccination rates lag.
So primarily we want to promote vaccination,
but screening is still necessary in that process.
So Dr. Ring, can you talk a little bit
about those screening recommendations
applicable here?
KARI RING: Yeah.
So the recommendations say that we
should screen women age 21 to 65 for cervical cancer.
And there are three main ways that you can screen.
One is with cytology alone.
So that's the pap smear, where we collect cells
from the cervix at the time of a speculum exam.
The second is co-testing, where we do both a pap smear, as well
as test for HPV strains through a PCR test,
and we do them together at the same time-- we send them off.
And the last is HPV screening alone.
We know that the risk for infection with HPV
is highest in your teens and early 20s.
And so between 21 and 30, we do cytology alone.
Because that's the highest risk for someone
to have a transient infection, where
we can see a positive HPV test, but no
changes on the pap smear.
Starting at 30, you can either do co-testing
or you can do primary HPV screening.
EMMA MITCHELL: Great.
KARI RING: And there are different time intervals.
It's all--
[LAUGHTER]
EMMA MITCHELL: So the complexity of the screening
guidelines is sometimes a barrier, I think, for--
KARI RING: I think most providers--
and I can't speak for everyone in the community,
but I think most people over 30 are still doing co-testing.
But as Dr. Stoler has mentioned, there
is a move towards HPV primary screening
alone, because that is probably the most
predictive of downstream abnormal cytology going
forward.
MARK STOLER: Let me make a comment,
because every woman that's ever been screened
or had a pap smear--
for 50 years we told people, come in for your annual pap
smear, right?
And annual pap smears we're great.
But we made up the interval.
We never did a study.
[LAUGHTER]
KARI RING: Reassuring.
MARK STOLER: It just sounded good.
You got to go to your doctor every year.
Let's get a pap smear.
So the current guidelines actually
are backed up by epidemiology and science,
and they recommend screening every three years
with pap smears or every five years
if you add in the HPV test.
And the reason the intervals are different and thus
makes it confusing--
it makes it confusing and it makes
it seem like we're taking away something.
In fact, there's a law in Virginia
that says you're entitled to an annual pap smear.
But you don't need an annual pap smear.
I'm here to tell you, you don't need it.
All right.
And that doesn't mean you don't have
to go see your doctor every year,
but you don't need cervical cancer screening every year
if you do a good test.
Today, I'm also here to tell you that a good test means
do an HPV test.
Because all the power in screening
is on the side of the HPV test.
If you do the HPV test, the pap smear adds virtually nothing.
And that's why I'm an advocate and I've
written some papers about primary screening
versus co-testing.
So I don't care if you do co-testing or primary screening
as long as you do the HPV component of the screen
for women over 30 or eventually it will be for women over 25.
And we can talk about 21 to 25, whether it's worth
screening at all perhaps in some different venue.
EMMA MITCHELL: So just to add a further point--
and please jump into to clarify--
with pap and cytology, the process that we're mentioning,
a provider uses a speculum to collect
cells to visualize for cancerous or pre-cancerous
cellular changes.
With an HPV test, which is processed through PCR,
as Dr. Ring said, we're actually looking
for the presence of the DNA of the high-risk strains.
So a primary HPV test would then tell you,
you have an increased risk for developing
cervical cancer versus a pap telling you,
we are visualizing cellular changes.
As I mentioned, we will continue to need cervical screening
and high quality follow-up because of our lag
in HPV vaccination.
But one of the exciting things, too,
are the innovative technologies that
are being developed to try to increase access
to screening for those who are under-screened or unscreened.
And some of these include women being
able to collect their own samples.
So I have the pleasure of being here today
because that's my area of research.
We're looking at whether we can help women increase access
to cervical cancer screening through HPV DNA testing
with samples that they collect themselves.
We have two studies looking at whether they
can do this at home with a navigator or somebody similar
helping them to explain the process,
or in combination with mobile mammography.
But the idea is that if you can do this primary HPV test,
you can tell women what their risk is.
And if they know what their risk then
is of developing cervical cancer,
it may help them to overcome some of the barriers
that they experience with screening.
EMILY YOUNG: One of the things that I
think is important to focus on is
that this is really for the age of 30 years old and over
for women screening for HPV.
And this is kind of a convoluted idea
that I had to spend some time understanding, that when
we say that HPV is ubiquitous, we
mean that almost everybody who is a teen or in their 20s
will get some form of HPV.
So they all have that infection.
They might not have cervical change.
So it's important to do pap smears
to detect that cervical change.
But we know that they probably have HPV,
so we don't really need to screen for HPV when they're
teens or 20s.
We just need to look to see if there's cervical change or cell
change to see if they're developing any signs of cancer.
When they hit 30, at that point, HPV usually
goes away by itself nine out of 10 times between eight months
to two years.
So most of the time, people who have HPV,
regardless of the strain, might not
know that they actually have it.
It's asymptomatic.
If they get to their 30s and they still
have the HPV infection and it still is persistent or chronic,
at that point it might cause change
to the cells on the cervix, and that can
be precancerous or cancerous.
And at that point, a persistent HPV infection
correlates to your direct risk of having cervical cancer.
And that's why we're focusing on that HPV screening
in that age group of 30 to 65.
So it really is, yes, everybody will
have HPV early in their life.
Nine out of 10 of them will get rid of it.
One out of 10 of them won't get rid of it.
They can have HPV and not have cancer.
1% of that whole group of people who have had HPV
will probably develop a cancer of some sort-- head or neck
or genital.
So it's a small amount, but because everybody has it
at some point-- and this is millions of people--
almost 80 million people that have it at one point--
because so many people have it, that still
is an even 1% chunk of HPV-causing cancer.
That's a huge number of people getting cancer.
Besides HIV, HPV is the most fatal virus
out there, because it kills.
And the reason is because it's so common.
MARK STOLER: Comment?
EMMA MITCHELL: Mm-hm.
MARK STOLER: So let me help you're thinking.
You did terrific.
[LAUGHTER]
EMILY YOUNG: Thank you.
MARK STOLER: We've been listening.
All right.
But I think a couple extra comments are in order,
because it's a common misconception about what
the HPV test is and isn't.
So if you come in and say, give me an HPV test
as part of my cervical cancer screening,
and your HPV negative, doesn't mean you don't have HPV.
Doesn't even mean you don't have the HPVs
that we're testing for.
The test has been engineered-- and this is why it takes
multi--
we're talking $30 to $40 million trials
to bring an HPV test to market in the United States.
Tests are engineered not to detect absolute HPV
positive or negative.
The tests are engineered to detect
the level of those 14 viruses that predicts cervical cancer
risk.
And that's where people don't understand what's going on.
So in some future, this age distinction
is going to go away.
It's not that you can't use an HPV test in 25-year-old women.
It's that how you respond to the HPV test
in a 25-year-old or a 21-year-old
is different than a 30-year-old.
In a 30-year-old, if you're HPV 16 positive,
you're going to get a colposcopy and see Dr. Ring for biopsies.
If you're 21, maybe you have to be positive a couple of times.
So that's an important point about--
the test is really a test for cancer risk,
not a test for HPV.
The other thing is is that when you're
positive-- remember I said 30-year-old women, 10% of them
are going to be positive.
Well, we don't want to send all 10% of them
for advanced visualization and biopsies.
So nobody who gets a primary HPV test just gets that test.
Then they get a reflex test to figure out if they really
need to get a colposcopy.
That current test is cytology, but there are even better tests
coming down on the market.
KARI RING: I think another important point is,
we know that there are some populations that
are higher risk for persistent HPV infections.
So people who are chronically immunocompromised,
people with HIV.
But for a large majority of the population-- and there's
lots of science going on trying to figure this out--
we don't understand why it is persistent in some patients
versus others.
And so I think that's another important point for people
and patients to understand, is that, yes, for most people
it's clear.
But we don't understand for the majority of people
why it's persistent in some patients.
And that's why follow-up is so important.
EMMA MITCHELL: It also is why it brings us back
to the importance of vaccination.
That primary prevention through vaccination
is really our strongest tool.
So maybe, if we could each say just a couple brief moments
about the take away message of the importance of vaccination,
then we can open it up for some questions.
Do you want to start, Dr. Stoler?
MARK STOLER: Sure.
So my message is consistent.
Screen the moms, vaccinate the kids.
But now we can screen and vaccinate the moms
and vaccinate the kids.
Because this is one example where more is better.
The more vaccine we get into people,
the faster we lower the prevalence of disease.
The other important point about vaccination
that they brought up briefly that they're
having this eradication of cancer
conversation in Australia.
Well, it's not going to zero.
But if we were to vaccinate the population
the way it should be, that within 10 years--
and Australians have been doing it
to 10 years-- between 10 and 20 years,
you drive the prevalence low enough
that screening doesn't work.
Remember all the other cancers I talked about?
Vulvar cancer, penile cancer, anal cancer, head and neck
cancer--
we can't screen for them.
Because those 15,000 cases sounds like a lot,
but if we hadn't done pap smear screening,
there'd be 100,000 cases of cervical cancer.
That's why everybody knew it-- knew about it.
And below a certain prevalence in the population,
screening doesn't work.
So they're really talking about the end of screening.
And that's the goal here.
Doesn't mean all the cancers will go away,
but there will be so few cancers that we can't
sustain a screening program.
And in that transition, we're going to need better tests,
like the HPV test.
EMILY YOUNG: My main point is that this
is another vaccine that is recommended
as safe and effective, just as the other vaccines that we give
for 11 and 12 years old, as well as other vaccines
later on in life.
So it's a normal vaccine.
It is safe and effective.
The risky choice is to not choose it.
The safe choice is to choose it for our kids.
KARI RING: I stick to the, it's a cancer prevention vaccine.
That's strictly what it is.
And I tell people I would love to be out of a job--
[LAUGHTER]
--as far as cervical cancer goes.
EMMA MITCHELL: Great.
Thank you.
Thank you all so much.
So we've talked about how misinformation
is such a barrier to people vaccinating.
And our goal here today was to give you data, give you
some strategies, and give you some real information
about the importance of the vaccine,
the safety of the vaccine, and how
we will watch as the age of the vaccine recommendation
rolls out into clinical practice,
but as we continue to advocate for it.
So thank you so much.
I think we'll open it up a little bit for some questions
from the audience.
MARCIA DAY CHILDRESS: Thank you all.
You've raised a lot of good points,
offered a lot of information.
We have an audience with members from a variety
of disciplinary pathways.
And so we have a nice opportunity for people
to offer comments, ask further questions,
and just generally consider both of the issues of screening
and vaccination for HPV.
We have a couple of people with microphones.
They will bring the mic to you if you
have a question or comment.
And we do ask, please, that you identify yourself
before you ask your question or offer your comment.
AUDIENCE: Hi.
I'm Bridget Therese.
I'm an M1 here.
And I was wondering if you know what
the thoughts are on whether the population that
received GARDASIL 4--
was young enough for that, but then it's going to age up,
will be recommended to receive GARDASIL 9.
KARI RING: Go ahead.
EMILY YOUNG: So currently, ACIP, or the main body that
recommends immunization guidelines to the director
of the CDC, who then adopts them as the main guidelines
in the United States, they say that if you did receive
the GARDASIL that has the quadrivalent or the bivalent--
so the four proteins or the two proteins--
that you can continue on and get the last shot.
So say you got two shots of one of those.
You can get the third shot using the GARDASIL 9,
and you can continue on that series of getting the three
shots without thinking that, oh, you need to restart it.
There is some evidence that the additional five HPV
strains that are present in the GARDASIL 9
give you extra benefit in protecting you
against extra cancers, specifically head and neck
cancers.
So some people are saying that, yes, maybe you
should go ahead and get the three vaccines over again.
But there is no data to recommend that.
And the ACIP currently says that if you
had three shots of the other two vaccines, you're done
and you're protected against the main goal, which is preventing
the majority of cancers.
MARK STOLER: So it's a 20% incremental benefit.
So if you're fully vaccinated with GARDASIL--
nobody's going to pay for a GARDASIL 9 series for you.
On the other hand, the data exists
that it's safe to give it.
So if you wanted that 20% extra benefit
and wanted to pay for the three shots,
it's not going to hurt you.
But it's really a marginal benefit.
Now, as was said, if you've started the vaccines--
GARDASIL 9 has only been on the market for a year or so.
So if you've got your first shot with GARDASIL,
you can finish with GARDASIL 9.
That also works terrific.
So that's the current status.
AUDIENCE: Hi.
I'm Miriam Bender.
I'm the chair of Women's Health Virginia.
And I have a question about clinical practice and behavior.
We've seen evidence that direct communication,
that Emily referred to, is the most effective thing.
And CDC has a program called "You
Are The Key," meaning, provider, you
are the key to communicating.
But we also have heard that many providers haven't really
gotten that message and don't take the initiative
to say to the patient or the patient's parent,
this is a cancer prevention, it's part
of the routine vaccines.
They still give the patient/parent
a choice and say, well, do you want
Susie to get the vaccine today?
And when mom says, no, the doctor
says, oh, OK, we can do it next year or whenever.
The other thing is that practices
don't seem to be ready to change with a system
so that you get callbacks.
So that even with initiation, you
don't get completion of the series.
And I'd like your advice or opinions for the audience
and for myself about how we can best get practitioners
to move to that next step.
In the initial round, it seemed pediatricians were doing better
than family practitioners.
But it still is a challenge across the board.
KARI RING: Like a whole public health--
[LAUGHER]
Well, I hear you.
I would echo your concerns.
As a GYN oncologists, like I said,
I'm on the back end of this.
And so there's a large volume of work going on
in the GYN oncology community to try to increase awareness
to this, education campaigns to primary care providers.
Because unfortunately, while all of us
GYN oncologists feel very passionate about it,
we have to get it into the primary care system.
So I think there's a lot of education campaigns going on
throughout different communities,
not just to the primary care physicians,
but to different socioeconomic groups.
One of our fellows is actually working on that
and trying how to access communities and social networks
to see how we can better educate them.
Because it's true that when advice
comes from someone in your socioeconomic group,
people tend to pick up on it more.
So there's lots of, I think, education research going on
around that.
I think that's a huge problem and part of the reason
that we're where we are as vaccination rates go.
I think as far as completing vaccinations is also
a big concern.
I think that's where it's also helpful to push it
in the 11 to 12 age range, because again, you only
need two rounds, so you have a higher completion rate.
And so I think that's where it's important to emphasize that.
EMILY YOUNG: Mm-hm.
I definitely hear you that we need
to increase how strongly providers recommend this.
And that's one of the points of research,
is that providers just aren't recommending it
as strongly as they need to.
My method is as a family doctor, building rapport
with my patients is really important.
And so a lot of times I know the patients
really well by the time we're talking about HPV vaccine.
I use a lot of humor in my visits.
And so it's more of a not a recommendation,
but you're going to get this today kind of thing.
[LAUGHER]
KARI RING: Congratulations.
MARK STOLER: It's the way to do it.
It's the way to do it.
EMILY YOUNG: And, oh, wait, you don't want it?
No, you want this.
You're going to get it today.
Wait.
No, you don't want to get it?
No, you're going to get it today, again.
So it's definitely a difference in the strength
of the recommendation from when I was educated
in medical school or residency.
We did at that time think about HPV vaccination as a really hot
button or controversial topic.
And it shouldn't be.
It's not about sex.
It's a vaccine to prevent cancer.
It's not going to cause sex.
And so--
[LAUGHTER]
But your kids are going to have sex anyways, hopefully,
as healthy adults.
But we won't go there yet.
MARK STOLER: So there's another way to increase compliance,
and that's through the payment system.
So it's actually already a quality assurance measure
in many practices--
a HEDIS measure.
Pediatricians are measured how compliant--
a big thing that pediatricians do is vaccinate.
It's the biggest thing they do probably from my standpoint.
And what percentage of your practice
is getting HPV vaccination?
Why are you not?
You could make cancer screening better, too,
if you made people comply with guidelines
in terms of doing co-testing or HPV testing
and doing them at the right intervals.
So that, I think, is coming, where
you're not going to get paid as much by the insurers
or you're not going to get paid at all unless the kid gets
the vaccine.
EMILY YOUNG: I also, I make them--
I don't make anybody do anything--
but I ask them to put a reminder in their phone
for when the next ones are due.
So either the patient themselves or the parents,
so that that gives them a little bit more agency.
I also write it on their after-visit summary, wherever
else they can write it down.
And then I write it down in my charting system,
too, so that next time I see them,
even if they got it at 11, if the next time they come back
is at 16 because they want to get another meningococcal shot,
at that point I can say, OK, we need to do HPV number two.
Because we do try to give it at appropriate intervals,
but if that interval is interrupted for any reason
or prolonged, we can still continue the series
and give it sequentially so we don't have to restart.
So if I do see them again for the meningococcal vaccine
or a sick visit or college physical or sports physical,
at that time I can be flagged to give it again.
But we do need better systems of how
to flag providers to strongly recommend it.
AUDIENCE: Hi.
I'm Rebecca.
I'm a public health and bioethics student.
So outside of this whole idea that the HPV vaccine
promotes sexual promiscuity, do you guys
see the national narrative of the anti-vaxer movement
affecting this at all?
Or is that something that's just not really in focus as much?
EMMA MITCHELL: I think it is.
I think it absolutely is.
And I think that the anti-vaxer movement
has taken a lot of hold in social media, which
we know has been research-specific to the HPV
vaccine and has been found to influence people's perceptions.
We did a little analysis of the sentiment of tweets
over a course of a two-week period.
In the School of Nursing we did this research,
and we found that most often, people
were retweeting opinions and not the position, statements,
or policies of recommendations and organizations.
And so I certainly think that the anti-vaxer movement
is influencing and is part of what
we need to be doing in changing the narrative.
Dr. Stoler?
MARK STOLER: This is a war.
It's a war.
I would not minimize--
we didn't bring it up, because it's a very complex topic.
As a student, I encourage you to figure this out.
[LAUGHTER]
KARI RING: Small project.
One-year project.
MARK STOLER: The anti-vaccine movement
has had a tremendous negative effect
on the health of a populations.
And it's not just the HPV vaccine.
Just put the word vaccine in The New York Times
and there's an article about measles and mumps,
and we have an epidemic of diseases
that nobody's seen in the last 20 years because
of the anti-vaccine movement.
In Japan, the anti-vaccine disinformation program
has led to a cessation of HPV vaccination.
So Japan will be-- it's not that they don't have HPV
and they certainly have cervical cancer.
And for whatever years that they stop vaccinating,
they'll be that far behind the rest of the world
in bringing these cancers under control.
So it's a huge problem.
And it's really data and science and good information
versus bad, how do you get that out
into the population of non-scientists?
EMILY YOUNG: These people are scary.
And not just in the sense that they're
causing a huge public health issue, but they scare people.
I brought my son in for his MMR, and I'm
an evidence-based doctor.
And even with getting the MMR shot, I was like, oh, my gosh,
is he going to get autism?
Just because they scared the poop out of me already.
And it wouldn't be a bad thing if he had autism,
because it's another kind of person--
it's another kind of normal.
But they scare us so much with their force
that that's what parents hear and envelop.
And even if they aren't people who are anti-vaccines,
they still come in with questions,
because people have scared them or the community
has scared them.
And so those people who come in or parents
or patients who come in with fear,
they're easy to transition into the fact-based idea
that the vaccine is safe and effective.
There are people then in the second category who
come in who accept all other vaccines,
but are wary of the HPV vaccine for whatever reason.
And they're also easy to transition into that idea
that it's safe and effective, and we can go ahead and give it
today or maybe at next visit after I give them information
and they go home and they read about that information
themselves, and then make their decision.
That third category of people who are completely
against vaccines, I'm almost never
successful in transitioning them into getting the HPV vaccine,
because they are so thoroughly engrossed in their idea
that it's going to cause something bad in the body.
And so they're the group that I think
is the ones that are propelling this public health
crisis forward.
And I haven't been successful in reaching them.
AUDIENCE: So I got to say, our first line of defense against
anti-vax-- and I am the mother of an autistic child,
so I speak with conviction--
our first line of defense is the primary care physician.
You're the one that has the relationship with the patient.
You're the one that has to change their mind.
You're the one that has to put forward the data.
You're the one that has to make a difference.
And it's critical.
It just can't be that we allow people to walk out
of the office and not go ahead and at least make
that follow-up appointment and say,
really, this is so important, I really just
want to make another follow-up appointment just
to talk to you about it again, even if they're absolutely
against it.
Let me give you this data, and let's
make a follow-up in a couple of weeks and talk about it again.
I just think it's that important.
When this came out--
I have four kids.
I couldn't get them there fast enough.
And people that want to make this about sex--
fine.
Don't tell me that you don't want
your kids to ever have sex.
That would be a lousy life.
[LAUGHTER]
We want our children to eventually procreate and have
wonderful lives.
And this protects them and allows them to be there
for their children someday.
These are the things we have to put forward.
And these are the things we have to convince the population.
And that peer pressure has to be against the anti-vax group.
There has to be more pressure against that
than there is for it.
Enough said.
EMILY YOUNG: Agree.
KARI RING: Agreed.
MARCIA DAY CHILDRESS: We have time
for maybe one more question or comment.
AUDIENCE: I'm Sara Yoder.
I'm a physical therapist.
I work at the Cancer Center and I
work with some of our head and neck patients.
So that being said, I'm curious, you
mentioned Australia and cervical cancer outcomes.
What about head and neck outcomes?
Is there any data associated in Australia with that?
MARK STOLER: Too early.
KARI RING: Too early.
MARK STOLER: It's too early, because there is no screening.
And these people are getting infected in their teens
and 20s, and then they're showing up with cancer
in their late 20s and 30s and 40s.
So it's too early.
And I should add that the label for these vaccines
doesn't say anything about head and neck cancer.
Because there's no screening, because where
these cancers develop are not amenable to pathology samples,
there have been no clinical trials for head and neck
cancer.
But as your friendly neighborhood pathologist,
I'm here to tell you that head and neck cancer due to HPV
is exactly the same biology and pathogenesis as all
the other HPV related cancers.
So there is absolutely no reason from anything
we know scientifically that HPV vaccination--
we'll put it in the positive.
HPV vaccination, from everything we know scientifically,
will absolutely help prevent head and cancer, which,
as you know every day, is a horrendous experience
for the patient.
MARCIA DAY CHILDRESS: Great.
Well, I'd like to thank our friendly neighborhood
pathologists and our other--
and it's lovely to offer a program
with such generous local expertise.
We're really grateful for this conversation, which
interestingly reminds me that in, I think, 2006 or 2007,
we actually did a Medical Center Hour about HPV
when it was first new.
And a great deal of that debate was
around the ethical questions of whether it
was appropriate for the state to mandate a vaccine for one
sex, but not the other.
At that point, the recommendation
was only for girls.
So we can see we've come a ways.
There's a lot more data, there's a lot more information,
and there are a lot more people who
are using the kind of conversation script
that Dr. Young is using with patients.
So I'd like to thank all of our panelists and for you
for being here.
I encourage you to come back.
Next week we have a program called "Lola's Song:
A Family's Journey of Change and Health Care Transformation
After Medical Error."
It's our annual Richardson Memorial Lecture,
which examines issues in the sometimes uncomfortable area
of medical error and patient safety.
So we'll be here next Wednesday, same time, same place.
And again, please thank our panelists for today.
[APPLAUSE]