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

2. 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.

3. 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.

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

7. 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.

8. 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

9. Who, Where, When – Sample N=179
Retrospective Analysis – 15,201 records
Who - Females age 14 – 20
Where – USA, Mississippi State Health Department
When – Between – 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.

10. 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); CIN 1,NA, In
CIN2,3,CIS

11. Age at Abnormal Pap Smear

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

13. Sample - HPV Shot vs No HPV Shot
Frequency Percent
Yes Had HPV 1 shot
No HPV shot given
No record
Total
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.

14. 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

15. Age at HPV Shot 1

16. 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

17. 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

19. 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

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

21. 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.

22. 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

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

26. END OF Slides
Remaining slides for my information.

27. 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 Lancet HPV and Cervical Cancer

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

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