Senkomago V, et al. “Human Papillomavirus-Attributable Cancers — United States, 2012-2016.” MMWR Morb Mortal Wkly Rep. 2019;68:724-728, http://bit.ly/2PE1pwI.
HPV causes a variety of cancers, including more than 90% of anal and cervical cancers, 70% of vaginal and vulvar cancers, and more than 60% of penile cancers.
While tobacco and alcohol have been associated with oropharyngeal cancers, recent studies show that approximately 70% of oropharyngeal cancers in males also may be linked to HPV.
Cervical cancer is the most common HPV-associated cancer among women, whereas oropharyngeal cancers are the most common HPV-associated cancers among men.
Recent epidemiologic data
The Centers for Disease Control and Prevention (CDC) analyzed data from the U.S. Cancer Statistics to assess the incidence of HPV-associated cancers and to estimate the annual number of cancers caused by HPV, both overall and by state, during 2012-2016. Data from all states and the District of Columbia met high-quality data criteria in all study years, covering 100% of the U.S. population.
During the study period, a mean of 43,999 HPV-associated cancers (24,886 female and 19,113 male) were reported in the United States annually. An estimated mean of 79% (34,800) of these cancers were attributable to HPV, including 32,100 (92%) attributable to HPV types targeted by the 9-valent HPV vaccine (9vHPV) (see table).
The largest number were oropharyngeal cancer (12,600), followed by cervical (9,700), anal (6,000), vulvar (2,500), penile (700) and vaginal cancers (600). Among cancers estimated to be attributable to the types targeted by 9vHPV, 19,000 (59%) occurred among females, and 13,100 (41%) occurred among males.
The annual number of cancers estimated to be attributable to the types targeted by 9vHPV varied by state from 40 in Wyoming to 3,270 in California. (See report for data by state.)
Vaccine effectiveness and safety
In the U.S., 9vHPV (Gardasil 9 [Merck & Co Inc., Whitehouse Station, N.J.]) is available to protect against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58. The majority of HPV-associated cancers are caused by HPV 16 or 18. Types 6 and 11 are non-oncogenic and cause anogenital warts.
Population-based studies show that HPV infections and high-grade cervical precancers have decreased significantly since the HPV vaccine was introduced in the U.S. More time may be needed to assess the full impact of HPV vaccination, since progression from persistent HPV infection to invasive cancer occurs over many years.
In addition, the Vaccine Safety Datalink did not detect statistically significant risk for any of pre-specified adverse events following 9vHPV (anaphylaxis, allergic reaction, appendicitis, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, injection site reaction, pancreatitis, seizure, stroke, syncope and venous thromboembolism), and the Vaccine Adverse Event Reporting System did not detect new or unexpected safety concerns.
Although HPV vaccination coverage estimates in the 2018 National Immunization Survey-Teen show that coverage rates are increasing, only about half of adolescents are up to date despite the vaccine’s significant effectiveness and excellent safety profile. Vaccination coverage with the recommended number of doses remains well below the Healthy People 2020 target of 80% for adolescents.
Initiate HPV vaccine as early as 9 years of age
The AAP recommends beginning the HPV vaccination series between 9 and 12 years of age, at an age that the provider deems optimal for acceptance. This earlier immunization age enhances the potential completion of the vaccination series and provides earlier protection, which could result in fewer cancer incidences. (See AAP News article “Why AAP recommends initiating HPV vaccination as early as age 9,” http://bit.ly/39m936L.)
Harmonized catch-up recommendations across genders
Data from the MMWR report underscore the importance of HPV vaccination not only for girls but also for boys, since significant numbers of cancers attributable to the types targeted by 9vHPV also occur among males.
Catch-up vaccination has been recommended since 2006 for females through 26 years of age. Since 2011, catch-up vaccination has been recommended for males through 21 years of age and certain populations such as men who have sex with men through 26 years of age.
In June 2019, the CDC’s Advisory Committee on Immunization Practices recommended catch-up HPV vaccination for all females and males through 26 years of age.
Which type of HPV-associated cancer was reported most frequently during 2012-2016?
A. Cervical
B. Vaginal
C. Penile
D. Anal
E. Oropharyngeal
Answer:E
Dr. Kamidani is a pediatric infectious diseases fellow at Emory University School of Medicine. Dr. Pickering is adjunct professor of pediatrics at Emory University School of Medicine.
