Cervical Cancer Vaccines: What Is The Real Story?

The headline on the press release says, “More Than Half of Texas Physicians Do Not Always Recommend HPV Vaccine to Girls.”  That sounds bad. 


The “sub headline” in the press release says, “Approximately 50 percent do not recommend the vaccine.”   That sounds really bad.


The problem is that the headline is misleading and the “sub headline” isn’t true.


When you read the actual research paper, you find out that 75-87% of the doctors are making the right recommendation most of the time. 


Given the strong social and political interest in this topic, those differences have significant implications, especially given the headline and sound bite world we live in today.  And that could influence how this paper may be used to drive public policy.


First, a bit of background:


We know that the majority of cervical cancers in the United States are caused by two types of human papilloma virus, or HPV. 


A cervical cancer vaccine was introduced in the United States in 2006 which could significantly reduce the risk of cervical cancer from these viruses.  We also know that the vaccine has not been used as often as was predicted, with somewhere between  6% and 25% of 11 to 18 year old girls in this country having been vaccinated to date.  We also know that routine vaccination is recommended for 11-12 year old girls by several reputable organizations and federal panels. 


The reason for the young age is that the vaccine is not effective once a girl becomes sexually active.  Additional recommendations, including those from the American Cancer Society, include offering the vaccine for girls as early as 9 years old, and as a “catch-up” for girls ages 13-18.  The Society also recommends a discussion between a woman and her health care professional about cervical cancer vaccination if she is between the ages of 19-26.


The current report appears in the August issue of the journal Cancer Epidemiology Biomarkers and Prevention. 


The researchers had three primary questions they wanted to answer with their study:


First, they wanted to find out whether or not physicians were recommending cervical cancer vaccination to 11 and 12 year old girls.  Second, they wanted to know if physicians would recommend the same vaccine to 11 and 12 year old boys if it became available, understanding that studies have shown the same vaccine now used in girls will also reduce genital infections with HPV in boys.  Finally, the researchers wanted to know if physicians agreed that HPV vaccination in 11-12 year old girls should be mandatory.


The study was conducted in Texas, which has an interesting political history with regard to cervical cancer vaccination.  Briefly, after the vaccine became available, the Texas governor issued an order that the vaccine would be mandatory in 2007 for girls entering the sixth grade in Texas.  However, after strong political protests, the legislature voted to rescind that order.


The researchers conducted an email survey to answer the questions they had posed above.


Focusing on just the physician recommendations to vaccinate 11 and 12 year old girls, the study concluded, “Half of the physicians in this study did not follow current recommendations for universal HPV vaccination of 11-to-12 year-old girls.”


Doesn’t sound too good, does it?


But wait a moment.  In a graph in the paper, it says that 75.4 of the doctors “always/usually recommend vaccine to girls” in the primary target population of 11-12 years old. If you look at the same number for girls ages 13-17, the percentage actually climbs to 87.5%.


As a physician who has been in practice, and as someone who is very interested in the need to get doctors to recommend appropriate cancer screening tests to patients, that number actually sounds pretty good.  In fact, I think it would be very difficult to get much better than that, especially in the 13-17 year old category.


Essentially, the headline all depends on whether you think there is much practical difference between “always” and “usually.”  Frequently, researchers combine those categories into a single number because of the practical implications.  Indeed, in their own graphical presentation of the data, the researchers in this paper combined the data.  It’s when they wrote the conclusions that they elected to highlight that differences.


And that “sub headline” which says that approximately 50% of the physicians in Texas do not recommend the vaccine should just go away. It is a serious misstatement of the facts in the paper.


Using this information, the authors conclude that “additional efforts are needed to improve clinicians’ awareness of and adherence to national recommendations.”


The study also noted that the most effective way to get these girls vaccinated is to mandate the vaccine.  “State vaccination requirements that would ensure high uptake of HPV vaccines also have the potential to narrow existing racial, ethnic, and economic disparities in cervical cancer incidence and mortality…(More than) 40% of Texas physicians in this 2008 study supported mandatory HPV vaccination.”


The authors do point out that there are several barriers to vaccination, including costs and misperceptions of safety and effectiveness—as well as personal parental beliefs—that may impact the rate of vaccination.  But they also imply that doctors aren’t doing their job as well as they should. 


I simply don’t agree that the data on its face supports that conclusion, and I don’t agree that the data necessarily reflect the opinions and/or practices of physicians across the country.  When I dug deeper into the study, I found I had questions about how representative the sample was of all practicing physicians, not to mention questions about how many internists and gynecologists actually treat 11 to 12 year old girls in their practices.  I also thought the study was (unintentionally) biased towards younger physicians whose opinions may not reflect the larger (and older) primary care physician workforce.


Some final items:


I want to make it clear that in my opinion this vaccine is useful in preventing cervical cancer.  I have no personal opinion (nor does the American Cancer Society) as to whether or not the vaccine should be mandatory.  The Society does recommend routine vaccination of girls 11-12 years old.


As I mentioned to a reporter during an interview yesterday, I believe that readers of this blog should be aware of potential conflicts of interest when I write about particular research reports.


In this case, one of the senior authors on the paper lists the following conflicts:


She is a co-Principal investigator on an investigator-initiated grant funded by the company that currently is the sole supplier of the cervical cancer vaccine in the United States; serves as a research consultant/collaborator on a research project sponsored by that company; and sits on one of that company’s advisory boards.


I would add that the study was funded by the Texas Medical Association Foundation.  I applaud them for supporting this research, as well as their efforts to vaccinate children in areas of the state with low vaccination rates.


I could not find any indication that the company which makes the vaccine directly or indirectly supported this research, or made some type of grant which helped get the study completed.


The key “take away” message for me is that this particular study is a case example of how one can get attention by emphasizing the problem, as opposed to applauding the success.  In my personal opinion, it shows how you can tilt the impact of a scientific paper depending on the message you want to send and the headlines (and sub headlines) that you write. 


To sum it all up, whether you think this glass is half empty or half full may just depend on your point of view.


J. Leonard Lichtenfeld's Biography

Dr. Len

J. Leonard Lichtenfeld, MD, MACP: Dr. Lichtenfeld currently serves as Deputy Chief Medical Officer for the American Cancer Society in the Society's Office of the Chief Medical Officer located at the Society's Corporate Center in Atlanta. Dr. Lichtenfeld joined the Society in 2001 as a medical editor, and in 2002 assumed responsibility for managing the Society's then newly created Cancer Control Science Department which included the prevention and early detection of cancer, emerging cancer science and trends, health equity, quality of life for cancer patients, the science of cancer communications and the role of nutrition and physical activity in cancer prevention and cancer care.  In 2014, Dr. Lichtenfeld assumed his current role in the Office of the Chief Medical Officer where he provides extensive support to a number of Society colleagues and activities. As a result of his over four decades of experience in cancer care, Dr. Lichtenfeld is frequently quoted in the print and electronic media regarding the Society's positions on a number of important issues related to cancer. He has testified regularly in legislative and regulatory hearings, and participated on numerous panels regarding cancer care, research, advocacy and related topics. He has served on a number of advisory committees and boards for organizations that collaborate with the Society to reduce the burden of cancer nationally and worldwide. He is well known for his blog (www.cancer.org/drlen) which first appeared in 2005 and which continues to address many topics related to cancer research and treatment. A board certified medical oncologist and internist who was a practicing physician for over 19 years, Dr. Lichtenfeld has long been engaged in health care policy on a local, state, and national level.  He is active in several state and national medical organizations and has a long-standing interest in professional legislative and regulatory issues related to health care including physician payment, medical care delivery systems, and health information technology. Dr. Lichtenfeld is a graduate of the University of Pennsylvania and Hahnemann Medical College (now Drexel University College of Medicine) in Philadelphia.  His postgraduate training was at Temple University Hospital in Philadelphia, Johns Hopkins University School of Medicine and the National Cancer Institute in Baltimore. He is a member of Alpha Omega Alpha, the national honor medical society.  Dr. Lichtenfeld has received several awards in recognition of his efforts on behalf of his colleagues and his professional activities.  He has been designated a Master of the American College of Physicians in acknowledgement of his contributions to internal medicine.  Dr. Lichtenfeld is married, and resides in Atlanta and Thomasville, Georgia.

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