First Global Guide: HPV Vax for Cervical Cancer Prevention

Zosia Chustecka

March 21, 2017

A new global guideline aimed at clinicians worldwide offers evidence-based recommendations on the use of human papillomavirus (HPV) vaccination for the prevention of cervical cancer. Issued by the American Society of Clinical Oncology (ASCO), this new guidance takes into account the varying levels of economic and structural resources and offers four levels of recommendations, depending on the circumstances of each country.

Published online in the Journal of Global Oncology, this is the second set of recommendations about HPV vaccination for cervical cancer prevention issued by the society. ASCO issued a position statement last year that called for aggressive efforts to increase uptake of the HPV vaccines to "protect young people from life-threatening cancers."

HPV infection causes virtually all cervical cancers in the world, ASCO said in a statement about the new global guideline.

"As an organization of cancer doctors, ASCO continues to endorse HPV vaccination programs and efforts to help spare more women around the world from this very difficult cancer," said Silvina Arrossi, PhD, co-chair of the expert panel that developed the global guideline. She is also an official and researcher at the Instituto Nacional del Cancer in Buenos Aires, Argentina.

"Although HPV vaccine has been around for more than a decade, the uptake of the vaccine has been less than ideal in many places, including in high-resource countries such as the United States," Dr Arrossi said in the statement.

In the United States, a national survey in 2013 found that just more than a third of girls (36%) had completed the HPV vaccination course, ASCO noted last year, and the Centers for Disease Control and Prevention (CDC) reported in 2014 that HPV coverage for girls had increased to 57.3% for girls in 2013, but described this as "unacceptably low."

In some countries where there has been media coverage of potential side effects of the HPv vaccine, coverage has dropped to very low levels. It is reported to be only 1% in Japan (where there is ongoing litigation over compensation for alleged vaccine injury), and a recent media report suggests that only 1 in 5 girls (20%) have received HPV vaccination in Denmark (where alarm has been raised about potential chronic conditions allegedly associated with the vaccine in the medical literature). The European Medicines Agency (EMA) reviewed the safety of HPV vaccines, and about these reports of chronic symptoms in particular. It concluded that there was no causal link. However, the EMA's handling of the issue has been criticized by the Nordic Cochrane Center.

Four Levels of Resource Settings

The new global guideline includes specific recommendations with respect to four levels of resource settings: basic, limited, enhanced, and maximal. The levels pertain to financial resources of a country or region, as well as the development of its health system, including personnel, infrastructure, and access to services.

A key recommendation is that in all environments, independent of the resource settings, two doses of HPV vaccine are recommended for girls aged 9 to 14 years, with an interval of at least 6 months and up to 12 to 15 months between doses.

For girls who are aged 15 years and older, the recommendation in maximal and enhanced resource settings are that if the girl has received her first dose before age 15, she may complete the two-dose series, but if she has not received the first dose before age 15, she should receive three doses. In both of these scenarios, vaccination may be given through age 26 years.

In geographic areas with limited or basic resource settings, if there are sufficient resources remaining after vaccinating girls aged 9 to 14 years, girls who received one dose may receive additional doses between ages 15 and 26 years, the guidance states.

Boys may also be vaccinated in all settings, the guidance states, but it notes that vaccinations should occur only if there is at least 50% coverage in the priority female target population, resources are sufficient, and such vaccination is cost-effective.

ASCO notes that this global guideline reinforces selected recommendations offered in the World Health Organization guideline, CDC guidelines, the National Advisory Committee on Immunization guideline (Canadian), German guidelines, and the Immunise Australia guideline.

Dr Arrossi reports no relevant financial relationships. Several coauthors report relationships with pharmaceutical companies, including Merck Sharp & Dohme (manufacture of Gardasil HPV vaccine), and GlaxoSmithKline (manufacturer of Cervarix HPV vaccine).

J Glob Oncol. Published online March 17, 2017. Full text

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