Why Are Physicians Hesitant in Recommending the HPV Vaccine to Girls?

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By Michael M. Frumovitz, M. D., M.P.H. Assistant Professor, Department of Gynecologic Oncology

There will be almost 11,000 cases of cervical cancer and over 330,000 cases of high-grade cervical dysplasia (or "precancer") in the United States this year. Almost every one of these cases will be a result of exposure to the human papilloma virus or HPV. The health industry will spend almost $4 billion this year to treat HPV and HPV-associated diseases, a huge amount of money not mentioned often in the current health care debate.

There are currently two HPV vaccines manufactured. Both vaccines are virtually 100% effective in preventing HPV transmission if administered prior to exposure to the virus. Cervarix (GlaxoSmithKline) is a bivalent vaccine that prevents cervical dysplasia and cancers caused by the HPV subtypes 16 and 18. These two are the most common high-risk or "oncogenic" subtypes and account for almost 70% of all high-grade dysplasia and cervical cancers. Gardasil (Merck) is a quadrivalent vaccine that also prevents HPV 16 and 18 infections as well as infections with HPV 6 and 11, the two subtypes that account for almost 90% of benign genital warts.

In the United States, only Gardasil is FDA approved and commercially available with Cervarix's approval by the FDA seemingly imminent. Since approval in the late spring of 2006, Gardasil has had less uptake in the United States than originally anticipated. This low penetration into the general population has been seen even after the Centers for Disease Control recommended routine vaccination for all girls and women ages 9-26 through its Advisory Committee on Immunization Practices in the summer of 2006.

A recent study suggests that physicians may be one of the reasons why this important vaccine is not more widely accepted. Less than half of the physician respondents said they recommend the vaccine to all their female patients who are candidates for it. Ideally, this vaccine should be given prior to sexual debut as it only prevents transmission in girls who have never been exposed to HPV. In the United States, 25% of girls will be sexually active by the age of 15 and almost 50% of HPV exposure occurs within the first 18 months after sexual debut. Therefore, it's important to vaccinate girls ages 11-12, as the CDC recommends.

Some physicians are reluctant to discuss it with young girls and their parents since these often can be awkward conversations, as you can imagine. A study by our department, however, showed that more than two-thirds of parents said they would accept the vaccine for their daughters if it was offered to them (Slomovitz BM, Sun CC, Frumovitz M, Soliman PT, Schmeler KM, Pearson HC, Berenson A, Ramirez PT, Lu KH, Bodurka DC. Are women ready for the HPV vaccine? Gynecol Oncol. 2006 Oct;103(1):151-4.). 

Maybe if more physicians knew that parents understand the importance of these vaccines and expect their children's doctors to discuss it with them, physicians would be less hesitant to do so.

HPV Vaccine - Questions & Answers (CDC)
HPV (Human Papillomavirus) Vaccines for Cervical Cancer (NCI)

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