The human papilloma virus (HPV) is responsible for approximately 42,700 HPV-associated cancers in the United States each year based on estimates from the U.S. Centers for Disease Control and Prevention. Cervical cancer is the most common HPV-associated cancer among women, while oropharyngeal cancers are most common among men. A preventive vaccine for HPV is available for children as early as nine years of age, but more education for parents and pediatricians is needed in order to facilitate the prevention of these cancers.
"This preventive cancer vaccine offers the most protection from HPV-associated cancers, but children and pre-adolescents need to be vaccinated at a young age before they are exposed to the virus. Studies have shown and recommendations are that we vaccinate children between ages 11 and 12, although we can start as early as nine years," says Isabel Scarinci, PhD, MPH, a professor in the UAB Division of Preventive Medicine and associate director for Globalization and Cancer at the UAB Comprehensive Cancer Center. "If children get the vaccine up to age 14, they will need only two doses. Those 15 and older will require three doses."
The Food and Drug Administration (FDA) recently approved expansion of the vaccine for people up to age 45. "We want as much coverage as we can get for people. However, the vaccine's emphasis should be for younger children, because their immune systems will give them higher protection," Scarinci says. "The data says the vaccine offers protection up to age 45, but it will not provide the protection that it gives younger people."
Scarinci contracted polio when she was eight months old because, due to illness, she missed the second dose of the polio vaccine during a polio epidemic. As a result, she has made HPV vaccination her mission. "I have been fortunate, but I saw how polio affected the world," she says. "If you had told my mother in 1963 that polio would be eliminated, she would have laughed. But today there are only three countries remaining that have not eradicated polio. HPV-associated cancers are also diseases we can prevent. The main difference is that I got polio almost immediately after missing the vaccination, but our un-vaccinated children may get HPV-associated cancers in their adulthood."
Scarinci says they are tackling HPV prevention on two fronts: first, by educating pediatricians so they can provide a stronger message to parents about the benefits of the HPV vaccine. "The early release of the vaccine was associated with discussions of sexual activity, which caused concern for many parents. Even though those parents had their children vaccinated at birth for hepatitis B - also a sexually transmitted infection - the many different stakeholders felt that this link to sex had to be removed," Scarinci says. "The second piece is parental education. Parents need to be more informed so they can be advocates for their children and promote HPV vaccinations in schools."
The UAB Comprehensive Cancer Center has established a statewide Alabama HPV Vaccination Coalition to integrate efforts that can help increase the vaccination rate in Alabama. The latest data from the Alabama Department of Health shows a 19 percent HPV vaccination rate for children 11 to 15 who received the required doses. 39 percent only got one dose.
"We need to mobilize parents and providers to get the vaccinations," Scarinci says. "Our cancer center is committed to not only finding the cure for cancer, but also to prevent cancers."
Another aspect of preventing HPV-associated cancers is the need to screen adults who never received the vaccine. Women need to continue to be screened for cervical cancer, and men and women need to work with their dentists for early detection of oropharyngeal cancer. "There are places in Alabama and other states where cervical cancer is prevalent but could be prevented with regular screening. Many women avoid screening because of multiple barriers such as lack of transportation, not wanting to go to a doctor's office, embarrassment, and competing demands," Scarinci says.
Cervical cancer annual rates have declined by 75 percent or more in the U.S. over the past 50 years because of the introduction of regular Pap tests. However, the decline has not been the same for all women. African American women have higher cervical cancer rates and are more likely to die from the disease than Caucasian women.
To help find ways to increase women's participation in cervical cancer screening, the UAB Comprehensive Cancer Center is leading a randomized trial in the Mississippi Delta, funded by the American Cancer Society, that offers the option of self-collection for women who have not been screened for cervical cancer for four or more years. "This new technology allows women to collect their own sample for HPV testing at home. They don't have to have a pelvic exam, they just collect the sample on a paper card and smear it. It changes colors and they put it in an envelope," Scarinci says. "The sample is numbered so the person is not identified."
The goal of the study is to test whether un-screened or under-screened African American women who are given a choice between self-sampling and having a Pap test at the local health department are more likely to engage in cervical cancer screening than women who are given only the option of going to the local health department for a Pap test.
Investigators at the UAB Comprehensive Cancer Center aren't limiting their work to our home turf. They have started an initiative called Globalization and Cancer. No other cancer center in the United States has taken that approach. "The word globalization is used on purpose," Scarinci says. "We are not going to other countries just to help them. We learn from them. We bring back lessons learned to our underserved populations here. Of course, we bring our experiences to those countries as well. It is a two-way street."
For their first study in Brazil, the UAB group worked with Brazilian Community Health Workers on the self-collection issue. "Adherence to self-collection for HPV testing in Brazil was 100 percent," Scarinci says. "As a result of working with them, we can use what we have done there in our Mississippi Delta initiative."
Scarinci says that the UAB Comprehensive Cancer Center is putting Birmingham on the map with its innovative approach to cancer control. "It's how we work locally, and it takes a village to do it," she says. "Social mobilization requires physicians, parents, and civic organizations to deliver a consistent message, so it's not just in the hands of the cancer center anymore. It's in the hands of everyone."