Doctors Talk: HPV

Doctors Talk: HPV

Katie Lockwood, MD, MEd: I think one of the things that's hard about HPV, especially even for pediatricians, is that it's a disease that we don't see often, and the effects, which are cervical cancer and other cancers, happen when our patients are out of our care as adults. And so, I think sometimes even the pediatricians don't talk about HPV as much as we probably should because it's not a disease that we treat, but our patients are getting HPV when they're under our care. Most cases of HPV happen between the ages of 15 and 24. So, it's really important that we do talk to our patients about HPV even though it's something that we think of more as an adult disease.

Paul Offit, MD: You're right. It's like a stealth virus. You're infected with it, and then the infection appears to go away, but 20 or 25 years later, then it is a cause of cancer, head and neck cancers, anal and genital cancers. It's the, frankly, only known cause of cervical cancer, and you don't want to have to wait to get cancer, and this can all be avoided. But you're right.

In many ways human papillomavirus, HPV, reminds me of hepatitis B virus. And that, too, when contracted as a young person can cause liver cancer and can cause chronic liver disease. But that's also something that pediatricians don't see until later, so they become less compelled about that particular disease.

But HPV is a cause of cancer that can affect as many as 30,000 people a year, can cause as many as 5,000 deaths a year, and it is preventable by vaccination.

Katie Lockwood, MD, MEd: It's interesting that you made that parallel to hepatitis B because a lot of parents ask, why am I giving a vaccine to my child before they're sexually active? And it's a hard question to answer. But the question is also, when is the right time, right? You want to catch children before they're sexually active and could get HPV, but we don't know when that's going to happen. And there are many vaccines that we give before a theoretical risk down the line. So, what we do is we try to go when your immune system is going to respond the best and when the vaccine will work the best.

We know that after 15 years of experience with this vaccine that giving it in that preteen period, as early as 9 but definitely between 11 and 12, is when the vaccine works best. So, why not give it then even though we know the child might not be at risk for HPV at that time, we're going to be ready when they are at risk.

Paul Offit, MD: Exactly, vaccines are preventative; they prevent something. So, you want to be able to make sure that the child is fully immune by the time there's any chance that they could begin to have sexual activity, which begins much earlier than most parents would like to believe. I mean, when I was on the Advisory Committee for Immunization Practices, they presented data on when people could have that first sexual encounter, and it was surprising how many girls and boys at 15 years of age, 16 years of age had a sexual encounter. I can tell you everybody that sat in that room thought, yeah, that's not my child, but it certainly could’ve been.

So, the other thing is that I think about 80% of people by the time they graduate from college would’ve been exposed to this virus. It's often something that you don't realize you've been exposed to until 20 or 25 years later, you find that you have an HPV-associated cancer. So again, it's preventable, and the only way to prevent it is to make sure you're fully vaccinated or fully immune by the time you have any chance of having sexual activity.

Katie Lockwood, MD, MEd: And since we started doing the vaccine, HPV in teenage girls has dropped by 88%, and cervical cancers have dropped by 40%. And so, we are able to actually change our screening guidelines down the road for cancer based off of something that we do in pediatrics.

Paul Offit, MD: And HPV is one of those diseases that can be eliminated by vaccination. It can because the vaccination is powerful. It's funny, there are only a few diseases where the vaccine is actually better at inducing an immune response than the disease itself, and the HPV vaccine is one of those examples.

Katie Lockwood, MD, MEd: And a lot of people say, well, what about my son? Boys don't get cervical cancer. But as you mentioned, there are many other types of cancer that the HPV vaccine prevents that boys do get, and we know that 4 out of 10 cases of HPV happen in boys. Also, we know that many boys are spreading HPV to women that they're sexually active with. So, it's really important that we include boys in this conversation.

Paul Offit, MD: Boys account for one-third of the cancers, head and neck, anal and genital cancers. So, of course boys can get cancer from HPV too, and they should be prevented from having to suffer that.

Katie Lockwood, MD, MEd: In my primary care practice, as I mentioned, I don't see cervical cancer, and I don't treat patients for cervical cancer, but sometimes they come in with concerns about genital warts. And this is another impact of HPV that really does have a psychological impact and a social impact on patients. And so, this is one of the first vaccines I can think of that has such an impact on those social relationships and psychology of patients. It's really important that we treat for the genital warts even if they would never have developed cancer.

Paul Offit, MD: Right, genital warts aren’t a cancer, but they can be disfiguring and certainly emotionally difficult. You know, I think that if you want to convince parents of boys to get a vaccine, all you have to do is show a picture of what genital warts looks like. I mean, it's very hard to live with that, and this is again a way to prevent it.

There are types of human papillomavirus that cause genital warts. The types that would prevent it are in these vaccines, so you can be prevented from having genital warts by being vaccinated.

Katie Lockwood, MD, MEd: And over time, we've expanded the HPV vaccine to include more serotypes.

Paul Offit, MD: That's right. There are many, many serotypes of human papillomavirus, but there are some that are particularly likely to cause cancer; some that are particularly likely to cause anal and genital warts. So, initially we had four serotypes in the vaccine. Currently it's nine serotypes in the vaccine. That offers even broader protection.

Katie Lockwood, MD, MEd: Right now everyone who's getting the vaccine is getting coverage for all nine types.