Diagnostic Cancer Trends Showcase Urgent Need to Increase HPV Vaccination

Maurie Markman, MD

As the great baseball catcher and philosopher Yogi Berra noted, “When you come to a fork in the road, take it.” And in my opinion, we surely are at that juncture with human papillomavirus (HPV) vaccination.

First, consider the data related to the occurrence of cervical cancer and the effect of screening for this malignancy in the United States. A recent report, which examined the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results database from 2001 to 2019, found more than 220,000 cases of cervical cancer recorded.¹

Although there was a decrease in the overall incidence of this malignancy, for 1 group of women (aged 30-34 years) there was an increase in the cancer, theorized to be in part because of the change in recommendations in 2012 by the US Preventive Services Task Force to reduce the frequency of screening.¹

In a report published in January 2023, investigators used the California Cancer Registry to examine data for 12,442 women 21 years or older who developed cervix cancer between 2009 and 2018. The findings showed, strikingly, that 17.4% were older than 65 years at the time of diagnosis.² Of those, 71% presented with late-stage disease (stages II-IV), compared with 48% of those younger than 65 years. This report emphasizes the magnitude of the persistent, serious issue of cervical cancer incidence, despite the recognized societal benefits associated with standard-of-care screening.

Finally, another report published in November 2022 highlighted the issue of cost of routine cervical cancer screening in a setting where the value may be debated.³ In 1996 the US Preventive Services Task Force recommended against the procedure for women older than 65 years who are at average risk and had adequate prior screening.⁴ The report noted that although the extent of cervical cancer screening-related services in the older women has decreased over the past 2 decades, more than 1.3 million women aged 65 years or older had cervical screening in 2019 at a cost of more than $80 million, according to the Medicare database.³

But perhaps the most important study to highlight on the past and current demographics of cervical cancer is the January 2023 report from the American Cancer Society. It noted “a 65% drop in cervical cancer incidence during 2012 through 2019 among women in their early 20s, the first cohort to receive the [HPV] vaccine.”⁵

It is difficult to overstate the magnitude of this observation as well as the documented success of HPV vaccination as a strategy to prevent cancer.

Further, although it is appropriate to focus on the overall effectiveness of this vaccination approach to cancer prevention, it is also important to acknowledge its demonstrated safety. For instance, it is interesting to contrast the demonstrated clinical use of tamoxifen to reduce the incidence of and deaths from breast cancer with the significant adverse effects, including the risk of endometrial cancer.⁶ Critically, HPV vaccination is devoid of the risk for such serious toxicities.

Yet, we are at a point in time when a scientifically valid, highly clinically relevant, and safe intervention that has a realistic potential to dramatically—a word that should rarely be employed in the medical literature—reduce the risk of cancer is questioned by a large segment of society.

The story of scientific advancements leading to effective therapeutics has been communicated many times over the past years , including the rapid development and subsequent implementation of safe and effective COVID-19 vaccination strategies, which leveraged many remarkably successful governmental/academic/ industry collaborations.⁷

Multiple reasons have been suggested for why a large segment of the US population distrusts the scientific and public health communities.^8,9 The focus of this commentary is not on these hypotheses, regardless of how well demonstrated they may be, but rather to highlight the critical need for the situation to be fixed, and soon. And there is no greater issue to highlight than learning how to effectively communicate the objectively documented benefits and lack of harm associated with HPV vaccination.

As noted by Martin Rees in his provocative book If Science is to Save Us, “We live in a world where more and more of the decisions confronting governments involve scientific evidence. Obviously, pandemics and climate change have been at the forefront of our minds recently, but politics on health, energy and the environment all have a scientific dimension. However, these policies have economic, social, and ethical aspects as well. And on these aspects, scientists speak only as citizens. Yet if public debate is to rise above mere sloganeering, everyone needs to have enough of a ‘feel’ for science to avoid becoming bamboozled by propaganda and bad statistics.”¹⁰

Critical to the point of the commentary, Rees wrote: “What makes science seem forbidding is the technical vocabulary, the formulae, and so forth. Despite these impediments, the essence (albeit without the supportive arguments) can generally be conveyed by skilled communicators.”

There is no simple solution to the complexity of providing straightforward, objective, scientifically valid, nonthreatening, nonideological, and nonpolitical messaging of the enormous benefits of HPV vaccination before individuals become sexually active.

But in the interests of both individual and public health, we must vigorously continue to explore strategies to reduce the barriers that have led vaccine-hesitant and vaccine-resistant individuals to ignore a safe and effective approach to the future development of a life-changing—and life-shortening—cancer.¹¹

References

1. Shahmoradi Z, Damgaciogliu H, Clarke MA, et al. Cervical cancer incidence among US women, 2001-2019. JAMA. 2022;328(22):2267-2269. doi:10.1001/jama.2022.17806
2. Cooley JJP, Maguire FB, Morris CR, et al. Cervical cancer stage at diagnosis and survival among women ≥65 years in California. Cancer Epidemiol Biomarkers Prev. 2023;32(1):91-97. doi:10.1158/1055-9965. EPI-22-0793
3. Qin J, Holt HK, Richards TB, Saraiya M, Sawaya GF. Use trends and recent expenditures for cervical cancer screening-associated services in Medicare fee-for-service beneficiaries older than 65 years. JAMA Intern Med. 2023;183(1):11-20. doi:10.1001/jamainternmed.2022.5261
4. Cervical cancer: screening, 1996. US Preventive Services Task Force. January 1, 1996. Accessed February 24, 2023. bit.ly/3xPKr4g
5. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. Ca Cancer J Clin. 2023;73(1):17-48. doi:10.3322/caac.21763
6. Jayasekera J, Zhao A, Schechter C, et al. Reassessing the benefits and harms of risk-reducing medication considering the persistent risk of breast cancer mortality in estrogen receptor-positive breast cancer. J Clin Oncol. 2023;41(4):859-870. doi:10.1200/JCO.22.01342
7. Collins F, Adam S, Colvis C, et al. The NIH-led research response to COVID-19. Science. 2023;379(6631):441-444. doi:10.1126/science.adf5167
8. Fieselmann J, Annac K, Erdsiek F, Yilmaz-Aslan Y, Brzoska P. What are the reasons for refusing a COVID-19 vaccine? A qualitative analysis of social media in Germany. BMC Public Health. 2022;22(1):846. doi:10.1186/s12889-022-13265-y
9. Pierri F, Perry BL, DeVerna MR, et al. Online misinformation is linked to early COVID-19 vaccination hesitancy and refusal. Sci Rep. 2022;12(1):5966. doi:10.1038/s41598-022-10070-w
10. Rees M. If Science is to Save Us. 2022; Polity Press.
11. Normile D. Japan reboots HPV vaccination drive after 9-year gap. Science. 376(6588):14. doi:10.1126/ science.abq2801