Premalignant Cervical Disease and Delayed HPV Vaccination Carolann Risley, MSN, WHNP, Kim Geisinger, MD University of Mississippi Medical center

Purpose Describe the number of women under 21 who were diagnosed with premalignant cervical cancer and correlate their history of vaccination. Preliminary results of retrospective analysis . Deans and Directors – said your dissertation ? will come from something that really bothers you.

What is the Problem? HPV causes cancer. HPV vaccination is grossly underutilized. Mississippi - highest rate of cervical cancer deaths. Lowest rate of HPV Vaccination. BUT – MS has highest vaccination rates for all other vaccines. If we excel in vaccination, why are our HPV vaccination rates so low. Recommended not required. But still other vaccines like Meningococcal, Tdap, not required and they are higher.

Lack of provider recommendation is reported as the most likely cause of the low uptake of the vaccine. Center for Disease Control and Prevention

Pap smear screening decreased Consensus guidelines – 2012 American Cancer Society, pathology organizations ASCCP ACOG – American College of Obstetrics and Gynecologists US Preventative Task Force HPV disease typically grows slowly 5-10 years HPV genotype prevalence younger - clear WHNP – First question – What do you think about those pap guidelines? Part of problem – less pap smears caused less preventative exams for adolescents and less opportunity of vaccination.

When to start screening Paps – Age? U.S. Preventive Services Task Force (USPSTF) Age 21. Recommend against screening women aged under 21. “A” recommendation American College of Obstetricians and Gynecologists (ACOG) Age 21 Regardless of the age of onset of sexual activity. “A” recommendation

Who, Where, When – Sample N=179 Retrospective Analysis – 15,201 records Who - Females age 14 – 20 Where – USA, Mississippi State Health Department When – Between 2011-2014 – 4 years What – High grade Pap Test Results – Moderate, Severe Why – vaccinated or not? Data I will show you is on girls under 21 that still received a pap and had severe premalignant cervical cancer.

Data Analysis Total paps – 15,508 done (14 – 20 YOA) Total abnormal high grade paps – 179 – 1% F/U Biopsy done Total biopsy done w results – 110 – 62% High grade From 110 bx = 62% potential to progress to cancer. Lost to Follow-up (56 not avail – no f/u w umc, 13 inadeq bx – 12 1 provider); 110 -70 CIN 1,NA, In CIN2,3,CIS

Age at Abnormal Pap Smear

Sample with HPV vaccine 1 Dose – 28.5% No HPV 0 Dose – 58.7%

Sample - HPV Shot vs No HPV Shot Frequency Percent Yes Had HPV 1 shot 51 28.5 No HPV shot given 105 58.7 No record 23 12.8 Total 179 100.0 100.0 Look into the numbers of hpv shot given and when and correlate 1vs3 shot to data, doubt this is helpful. Most helpful will be the association with other vaccines. Don’t forget to mention the hep B shot given to infants!! Highest incidence hep b in IV drug users.

HPV vaccination given late vs early Using the current CDC guidelines HPV vaccination age recommended HPV 9-12 years old, Only 1 of the 179 females in sample were vaccinated between 9-12 Mean age – 16 shot given

Age at HPV Shot 1

Take Home Point – Too late Mean age at 1st HPV shot – 16, potential already exposed to virus Lower immune response Only 1 out of 179 females with premalignant cervical cancer received the HPV shot at recommended age 12

Other significance in this data Race and abnormal pap smears and biopsy Even though White to Black had even number of abn paps the degree of biopsy severity – higher in black. – Disparity Mortality 2014 Blacks 3x more likely Whites ICC Expand on this later – show number of pap white and black and show degree dysplasia

Pearson chi square = Black Females were significantly more likely to receive the HPV vaccine than White Females. Vaccine Hesitancy? 12.166 df = 2 p = 0.002

Missed Opportunities prior to Disease Onset 37 prior vaccine visits T dap Meningococcal Varicella 53 Doses 32 Doses 38 Doses

Software / Clinic prompts MIIX State Data base – immunizations DOES NOT have HPV listed in the Vaccination View that prompts the nurse to offer the vaccine, For example, Tdap, Hep B, etc. All listed The RN must manually input HPV on this table in this sample.

Clinical questions – Future implications? 1. Should we adjust screening guidelines for females if they have not been vaccinated at age 9-12 2. Data shows increase in abnormal high grade paps at age 17 3. Should we adjust screening guidelines for race ? 4. P U S H HPV Vaccination If we know black and Hispanic/Latin Americans higher death rate, then maybe change guidelines accordingly Precedent set with treating HTN – whites get this drug, blacks this drug

Joke Q: What's the best kind of cancer? A: The one you don't get. #HPV vaccine is #cancer prevention! #2shots2stopCancer

END OF Slides Remaining slides for my information.

Consensus Guidelines based Clinical Trial - ATHENA Trial and ALTs Trial Clinical trials – science sound, but stats debated, can we generalize to our population. Genomics – generalize to the individual and that individual cohort. Age – “Cervical Cancer rare in adolescents and young women” –Schiffman, M, Castle,P. 2007. Lancet HPV and Cervical Cancer

Persistent HPV high-grade Causes Cancer Concern lasts more than 6 months Causes action in clinical world

Question Did anyone in the most severe cin3 or cis have hpv vaccine?