Cervical Cancer, HPV, and Prevention

CERVICAL CANCER, HPV, AND PREVENTION 31

Jennifer Cox

American Sentinel University

CERVICAL CANCER, HPV, AND PREVENTION 31

Cervical Cancer, HPV, and Prevention

Human papillomavirus (HPV) is the most common sexually transmitted disease in the world. The virus causes genital warts and is associated with cervical, vaginal, vulvar, anal, penile, and oropharyngeal cancers. Cervical cancer is the second most common cancer in women worldwide. High risk HPV types 6, 11, 16, and 18 has been linked to be the causative factor in the majority of cervical cancers and genital warts, as well as other anogenital and head and neck cancers in males and females. Through awareness, knowledge, and education on HPV, early detection through routine pap testing and HPV vaccination can greatly reduce and prevent morbidity and mortality of cervical cancer and HPV associated cancers in men and women.

History of HPV

One of the most important discoveries in the last 25 years has been the demonstration that cervical cancer is caused by certain types of the Human Papilloma Virus (Castellsague, 2008). In 1972, the association between the human papilloma virus and skin cancer was proposed by the Polish scientist Stefania Jablonska who later discovered the HPV strain 5 was directly related to skin cancers. Based off of her research and much research before him, German scientist Harald zur Hausen proposed a hypothesis in 1976 that HPV caused cervical cancer. Through many years of research, he discovered HPV had hundreds of different types. In 1984, he discovered HPV type 16 was present in cervical cancer tumors, and a year later, associated HPV type 18 was also present in cervical cancer tumors (Zur Hausen, 2009).

Harald zur Hausen is also credited with the discovery of the HPV type 6, one of the causative factors of genital warts. The other is HPV type 11. In 2008, Harald zur Hausen was awarded the 2008 Nobel Prize for his research on HPV. His research has lead to the development of two HPV vaccinations currently on the market aimed at reducing and preventing the occurrences of HPV associated cancers.

Human Papillomavirus (HPV)

Human papillomavirus (HPV) is the most common sexually transmitted infection affecting more than 20 million people in the United States with an estimated six million new HPV infections occurring annually (CDC, 2010a). The HPV virus is found in approximately 70% of all cervical cancers, 90% of genital warts, and 90% in HPV associated cancers (National Cancer Institute, 2012). HPV infection is highest among the adolescent and young adult population with a prevalence rate of 64%; and by the age of 50, nearly 80 % of women will be infected by the HPV virus (National Cervical Cancer Coalition, 2013). HPV is transmitted through sexual contact, contact with infected genital skin, mucous membranes, or bodily fluids from an infected partner (Myrth & Dollin, 2007). Most people who become infected with HPV do not develop symptoms and do not know they have it as our immune system generally rids itself of the infection within two years, yet HPV lies dormant. Unprotected sex and multiple sexual partners are the greatest risk factors for contracting HPV infection.

There are over 100 different types of HPV; more than 40 HPV types can infect the genital area; and over 13 HPV types are related to HPV associated cancers involving the cervix, vulva, anus/rectal, penile, and throat (CDC, 2013). HPV types can be classified into high risk and low risk. HPV low risk types 6 and 11 are the causative factor for genital warts, while high risk type 16 and 18 are strongly linked to HPV associated cancers (Bosch, Qiao, & Castellsague, 2006). Type 16 is the cause of approximately 50% of cervical cancers worldwide, and types 16 and 18 together account for over 70% of all cervical cancers (National Cancer Institute, 2012). HPV type associated cancer has been linked to causing over 90% of all cervical cancers, 90% of anal cancers, 65% vaginal cancers, and over 70% of oropharyngeal cancers (CDC, 2013).

Cervical Cancer

Cervical cancer is global in nature as it is the second most common cancer among women worldwide as 500,000 women are diagnosed, and 275,000 women will die each year (Cervical Cancer Action, 2012). In the United States, 12,357 women were diagnosed with cervical cancer and 4,000 women died in 2009 (CDC, 2012). The median age at diagnosis is 48 years old, and the median age of death related to cervical cancer is 57 years old with Hispanics having the highest incidence rate of 11.8 per 100,000 women, followed by blacks at 9.8 (SEER, 2012). Cervical cancer has twice the incidence rate and a higher death rate in Hispanic women than non Hispanic women in the United States (Wagner, 2009). African American women have the highest mortality rate from cervical cancer compared to white women because they tend to decreases their rate for Pap smear testing as they age (Ackerson, 2011). Cervical cancer is directly related to the HPV virus and can be prevented and detected early through primary and secondary preventions strategies.

Cervical cancer can be prevented through early vaccination, routine pap testing, and HPV testing. Research data has shown 42% of females are infected with HPV at any given time although the number is probably much higher as it is an asymptomatic disease. Not all people infected with HPV will develop HPV associated cancers, but there are many risk factors that predispose one to acquiring the HPV infection. The most common risk factor is multiple sexual partners and unprotected sex, although HPV can be transmitted skin to skin and orally. Other risk factors include sex at an early age, genital warts or predisposing STD infections, weakened immune system such as HIV, multiple childbirths, long term oral contraceptives use, and smoking, which double the risk of cervical cancer (Bosch et al., 2006).

HPV Infection in Men

While it has been widely researched that high risk types, mainly HPV 16 and 18, are associated with cervical cancer, research has shown high risk HPV types can also increase a man’s risk of developing anal, rectal, penile, and oropharyngeal (throat) cancers. Approximately 73% of men have been affected by HPV contributing to 93% of anal cancers, 36% penile cancer, 70% of oropharyngeal cancers; and gay and bisexual men are 17 times more likely to be diagnosed with HPV, and higher among HIV infected men (Mehta & Sharma, 2011).

It has been estimated that, by 2020, HPV will cause more oropharyngeal cancers than cervical cancers in the United States (National Cancer Institute, 2012). The U.S oropharyngeal cancer incidence is 6.1; PA is 16.4 compared to Mississippi at 21, and Utah being the lowest at 10 (CDC, 2009). While HPV high risk types 16, 18, 31, 33, and 35 have been identified in oropharyngeal cancers, HPV 16 accounts for approximately 90% of all HPV oropharyngeal cancers (Marklund & Hammarstedt, 2011). Currently, there is not a routine HPV testing guideline for men. Men usually find out they have a HPV associated type cancer as a result of symptoms following a biopsy. For this reason, HPV vaccination, education, and self- awareness is crucial in males in an effort to protect them from HPV associated cancers. Sexual education and HPV knowledge from parents and health care providers is lacking toward men as the nature of the subject may be more difficult to talk about in males. Health care providers must make an attempt to discuss the HPV vaccine with all parents of adolescent males in reducing the occurrences of genital warts and HPV associated cancers.

HPV Vaccination

HPV vaccination is the strongest weapon in preventing HPV infections and HPV associated cancers. Currently, there are two vaccines approved for HPV protection. In 2006, the U.S. Food and Drug Administration (FDA) approved Gardasil, developed by Merck, the first vaccine approved for females’ ages 10 to 26 years of age. Gardasil protects against four HPV types; 16 and 18 which is found in cervical cancer and HPV associated cancers, and type 6 and 11, known to cause genital warts (Tomljenovic & Shaw, 2012). In 2009, the FDA approved a second HPV vaccine, Cervarix, developed by GlacoSmithKline, which only protects against HPV types 16 and 18, the two main causative types of cervical cancer. Both vaccines have been shown to be 100 % effective in preventing infections associated with HPV. Both vaccines are given in three doses, the first two a month apart, and the third dose six months after the first dose was given. While both vaccines were originally designed to target only females; in 2010, the FDA approved Gardasil to be used in HPV protection among men. Vaccination of males is aimed at preventing HPV infections and associated cancers in males, such as anal, penile, and oropharyngeal, as well as providing indirect protection to females by reducing HPV transmission. HPV protection is now spread equally among males and females in the targeted age group.

HPV vaccination offers the greatest health benefit to persons who receive all three doses of the vaccine before exposure to HPV through sexual activity, yet uptake has remained below the national average. According to estimates, the use of the HPV vaccine will reduce cervical cancer incidence by 70 % (Wagner, 2009). Therefore, there has been a national push to vaccinate all adolescents as early as10 years of age in achieving the best immunity from HPV. The CDC recommends HPV vaccination for all males and females ages 10 to 26 years of age starting with routine HPV testing during the six grades mandatory vaccination schedule (CDC, 2013b).

Many states are pushing for mandatory vaccination but have sparked much controversy over children’s rights, parental beliefs, and vaccination safety. Currently, only Virginia and Washington, D.C. have mandatory HPV vaccination with a parent op out option. There are also sexual myths surrounding the vaccine that it will promote sexual promiscuity which remains a challenge in vaccination efforts; therefore successful vaccine compliance is dependent on parental, patient, and health care provider’s awareness, knowledge, and attitudes of the vaccine (Rodriquez, 2010). With the inclusion of males, the scope of the HPV public health problem will now be focused as a public health issue affecting males and females. This change could improve the public and political attitudes towards HPV prevention policies, thus decreasing a gender bias toward women’s sexual health (Tomljenovic & Shaw, 2012).

Community Statistics

Healthy People 2020 goal is to reduce the death rate from cancer of the uterine cervix below a target of 2.2 deaths per 100,000 females and to increase the number of women who receive cervical cancer screening to 90% (U.S. Department of Health and Human Services, 2012). In 2009, Pennsylvania reported 506 newly cervical cancer cases with 180 reported deaths (CDC, 2009). The PA cervical cancer rate was 7.9% with Hispanics being the most at risk at 10.9%, blacks at 10%, followed by whites at 7.6% (CDC, 2009). PA has a 2.3 death rate and an 81.3% for pap testing within the last three years (Kaiser Family, 2012).

HPV associated cancers have been directly linked to the HPV virus. As a result, the Centers for Disease Control and Prevention (CDC) have included the reduction of HPV infection rates and an increase in HPV vaccination rates with a targeted vaccination goal of 80% into the Healthy People 2020 plan (Office of Population Affairs, 2010). The CDC has recommended all males and females between the ages of 11 and 12 to receive the HPV vaccination with a catch up to all males and females aged 10-26 years old in preventing HPV infection and HPV associated cancers (CDC, 2010b). PA ranked eighth with 41% of 13-17 year olds receiving all three doses of the HPV vaccine (Variance, 2013).

The national HPV vaccination rate remains low at 35% for all three doses in females, and only 8.3% in males (CDC, 2011). As many states have gotten people to accept the first dose, the uptake is lacking in completing all three doses within the six month time frame. For girls who received at least one dose of the HPV vaccine, coverage increased from 48.7% in 2010 to 53% in 2011, but 29% did not receive all three doses (CDC, 2011). For boys who received at least one dose of the HPV vaccine, coverage increased from 1.4% in 2010, to 8.3% in 2011, but 72% did not complete all three doses (CDC, 2011). HPV related awareness and vaccination campaigns have decreased over the past two years as the shift is now dependent on health care providers encouraging the vaccine.

Development of Community Project

Based on community and national statistics, the proposed plan was to educate males and females 18 to 26 years of age on the correlation between HPV infection and cervical cancer. It focused on HPV knowledge, risk factors, and the importance of vaccination in protecting oneself from HPV associated cancers later in life. It also focused on the importance of secondary prevention measures such as screening and early detection through routine pap testing for females, and early detection for males by visiting a primary care provider. A review of the literature was conducted and found that although people knew about HPV, HPV awareness and knowledge was low on how HPV is related to cervical cancer and HPV associated cancers.

This age group was picked because it is during this age that sexually activity begins to flourish and multiple sexual partners can occur. It is also an age where females begin to visit the gynecologist for pap testing and birth control pills. It is an age where sexual promiscuity and experimentation with drugs and alcohol can develop in males and females where condom use is inconsistent increasing the risk of contracting the HPV infection.