The case for catch‐up human papillomavirus vaccination in at‐risk populations: Rural communities and survivors of pediatric and young adult cancers
Authors: Alec J. Kacew, Allison C. Grimes, Michael Roth, Deanna Teoh, Wendy Landier, Garth W. Strohbehn, Electra D. Paskett
Journal: CA A Cancer Journal for Clinicians (2020)

We read with interest the recent updated human papillomavirus (HPV) vaccination guideline presented by Saslow et al on behalf of the American Cancer Society (ACS) Guideline Development Group.1 Although the recommendations offer sound guidance to promote vaccination, we disagree with the authors' decision to universally reject shared decision making for all unvaccinated individuals aged 27 through 45 years, a measure that both the Advisory Committee on Immunization Practices and the Children's Oncology Group recommend.2, 3 Forgoing catch-up vaccination in adults aged older than 26 years is a missed opportunity to provide immunization for traditionally undervaccinated and at-risk groups, in particular those residing in rural communities and survivors of pediatric and young adult (PAYA) cancers. HPV vaccination rates in rural communities are consistently lower than those in other settings.4, 5 Barriers include lack of trust in researchers and in health care.6 Rural communities bear higher burdens of cervical cancer and high-risk HPV types7 and now, with the lack of ACS endorsement, have additional reason to decline vaccination for their children: "If it's not safe for me, why would I vaccinate my child?" Although protection against HPV infection is lower in individuals aged 26 years and older, emerging data have suggested a potential role for vaccination in the secondary prevention of cervical dysplasia among high-risk populations such as those in rural communities.8 The ACS recommendation as currently worded removes the opportunity for this group to benefit, if even by a small amount, from vaccination. Survivors of PAYA cancers, of whom there are nearly 800,000 in the United States alone, also can benefit from catch-up vaccination.9 HPV-associated cancers are a significant concern for survivors of PAYA cancers: compared with age-matched peers, these individuals have a 40% (females) and 150% (males) greater risk of developing HPV-associated cancers.10 This risk is especially high among survivors of lymphoma and those who underwent allogeneic stem cell transplantation11-13 because viral acquisition and persistence increase during periods of immunosuppression or impaired immune recovery after cancer therapy.14 In a single-center, 20-year review of female survivors of Hodgkin lymphoma, nearly 50% of survivors developed cervical or anogenital cancer later in life.15 Quality-of-life concerns are no less significant: between 20% and 40% of PAYA stem cell transplant recipients require multiple excisional or ablative procedures to treat HPV-associated precancerous cervical, lower urinary tract, and anal lesions, causing anatomic disfigurement, long-term pain, sexual dysfunction, and an increased risk of miscarriage.16 It is important to note that the median age at which HPV-associated cancers occur in survivors of PAYA cancers is 38 years,10 suggesting that catch-up HPV vaccination in this population could reduce HPV-associated cancer incidence. Clarity and consistency in guidelines are essential. Provider recommendation is the single most significant determinant of whether survivors of PAYA cancers receive the HPV vaccination,17 and provider recommendations are largely shaped by society guidelines, such as those developed by the ACS.18 Without direct recommendation of HPV vaccination in these guidelines, providers may mistakenly perceive the vaccine as only relevant for patients aged younger than 26 years. Consequently, the guidelines may promote underestimation of both the risk of developing and the ability to prevent HPV-associated malignancies in older patients. Unlike the ACS guidelines, current survivorship care guidelines from the Advisory Committee on Immunization Practices and Children's Oncology Group prevent such misjudgments by including the catch-up HPV vaccine recommendation. Contradictory guidance from professional societies can undermine educational outreach, provider recommendations, and care delivery and ultimately impact outcomes. Because HPV cancers disproportionately impact survivors of PAYA cancers and rural residents, our collective commitment to reduce the burden of HPV cancer in our communities must include unified guidance and recognition of those at greatest risk. HPV vaccination initiatives; community education; awareness strategies; and a clear, consistent guideline recommendation can help to reduce cancer-related risks and prevent unnecessary morbidity and mortality for all populations. No specific funding was disclosed. Alec J. Kacew has received research support from the Pritzker School of Medicine and the American Society of Hematology for work performed outside of the current study. Allison C. Grimes has received grants from the Cancer Prevention Research Institute of Texas for work performed outside of the current study. Deanna Teoh has received grants from Acelity and salary support for her role as a local principal investigator for an industry-sponsored trial from GlaxoSmithKline for work performed outside of the current study. Wendy Landier has received grants from the National Cancer Institute of the National Institutes of Health and nonfinancial support to her institution from Merck, Sharp & Dohme for work performed outside of the current study. Garth W. Strohbehn's institution has received fellowship funding support from Abbott Laboratories Inc and he holds a filed provisional patent not applicable to the current study. Electra D. Paskett has received grants from the National Cancer Institute of the National Institutes of Health for work performed as part of the current study and has received grants from the Merck Foundation, Pfizer, the Breast Cancer Research Foundation, Foxconn, and the One Family Foundation for work performed outside of the current study. Michael Roth made no disclosures.