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Human papillomavirus in 2019: An update on cervical cancer prevention and screening guidelines

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Release date: March 1, 2019
Expiration date: February 29, 2020
Estimated time of completion: 1 hour

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ABSTRACT

The human papillomavirus (HPV) causes most cases of cervical cancer. Healthcare providers can help prevent this cancer by recommending HPV vaccination when appropriate, regularly screening women for cervical cancer, and following up on abnormal test results.

KEY POINTS

  • Immunization against HPV can prevent up to 70% of HPV-related cervical cancer cases.
  • Gardasil 9 is the only HPV vaccine currently available in the United States and is now approved for use in males and females between the ages of 9 and 45.
  • In girls and boys younger than 15, a 2-dose schedule is recommended; patients ages 15 through 45 require 3 doses.
  • Vaccine acceptance rates are highest when primary care providers announce that the vaccine is due rather than invite open-ended discussions.
  • Regular cervical cancer screening is an important preventive tool and should be performed using the Papanicolaou (Pap) test, the high-risk HPV-only test, or the Pap-HPV cotest.


 

References

About 12% of women worldwide are infected with human papillomavirus (HPV).1 Persistent HPV infection with high-risk strains such as HPV 6, 11, 16, and 18 cause nearly all cases of cervical cancer and some anal, vaginal, penile, and oropharyngeal cancers.2 An estimated 13,000 cases of invasive cervical cancer will be diagnosed this year in the United States alone.3

Up to 70% of HPV-related cervical cancer cases can be prevented with vaccination. A number of changes have been made to the vaccination schedule within the past few years—patients younger than 15 need only 2 rather than 3 doses, and the vaccine itself can be used in adults up to age 45.

Vaccination and routine cervical cancer screening are both necessary to prevent this disease3 along with effective family and patient counseling. Here, we discuss the most up-to-date HPV vaccination recommendations, current cervical cancer screening guidelines, counseling techniques that increase vaccination acceptance rates, and follow-up protocols for abnormal cervical cancer screening results.

TYPES OF HPV VACCINES

HPV immunization can prevent up to 70% of cases of cervical cancer due to HPV as well as 90% of genital warts.4 The US Food and Drug Administration (FDA) has approved 3 HPV vaccines:

  • Gardasil 9 targets HPV types 6, 11, 16, and 18 along with 31, 33, 45, 52, 58—these cause 90% of cervical cancer cases and most cases of genital warts5—making it the most effective vaccine available; Gardasil 9 is the only HPV vaccine currently available in the United States
  • The bivalent vaccine (Cervarix) targeted HPV 16 and 18 only, and was discontinued in the United States in 2016
  • The quadrivalent HPV vaccine (Gardasil) targeted HPV 16 and 18 as well as 6 and 11, which cause most cases of genital warts; the last available doses in the United States expired in May 2017; it has been replaced by Gardasil 9.

The incidence of cervical cancer in the United States dropped 29% among 15- to 24-year-olds from 2003–2006 when HPV vaccination first started to 2011–2014.6

VACCINE DOSING RECOMMENDATIONS FOR PRIMARY PREVENTION

HPV vaccination timeline, male and female

The Advisory Committee on Immunization Practices (ACIP) revised its HPV vaccine schedule in 2016, when it decreased the necessary doses from 3 to 2 for patients under age 15 and addressed the needs of special patient populations.7 In late 2018, the FDA approved the use of the vaccine in men and women up to age 45. However, no change in guidelines have yet been made (Table 1).

In females, the ACIP recommends starting HPV vaccination at age 11 or 12, but it can be given as early as age 9. A 2-dose schedule is recommended for the 9-valent vaccine before the patient’s 15th birthday (the second dose 6 to 12 months after the first).7 For females who initiate HPV vaccination between ages 15 and 45, a 3-dose schedule is necessary (at 0, 1 to 2, and 6 months).7,8

The change to a 2-dose schedule was prompted by an evaluation of girls ages 9 to 13 randomized to receive either a 2- or 3-dose schedule. Antibody responses with a 2-dose schedule were not inferior to those of young women (ages 16 to 26) who received all 3 doses.9 The geometric mean titer ratios remained noninferior throughout the study period of 36 months.

However, a loss of noninferiority was noted for HPV-18 by 24 months and for HPV-6 by 36 months.9 Thus, further studies are needed to understand the duration of protection with a 2-dose schedule. Nevertheless, decreasing the number of doses makes it a more convenient and cost-effective option for many families.

The recommendations are the same for males except for one notable difference: in males ages 21 to 26, vaccination is not routinely recommended by the ACIP, but rather it is considered a “permissive use” recommendation: ie, the vaccine should be offered and final decisions on administration be made after individualized discussion with the patient.10 Permissive-use status also means the vaccine may not be covered by health insurance. Even though the vaccine is now available to men and women until age 45, many insurance plans do not cover it after age 26.

Children of either sex with a history of sexual abuse should receive their first vaccine dose beginning at age 9.7

Immunocompromised patients should follow the 3-dose schedule regardless of their sex or the age when vaccination was initiated.10

For transgender patients and for men not previously vaccinated who have sex with men, the 3-dose schedule vaccine should be given by the age of 26 (this is a routine recommendation, not a permissive one).8

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Cancer screening: A modest proposal for prevention

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