Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin, and today we have two guests, Dr. Ramondetta, who is a professor of gynecologic oncology and also works at LBJ in MD Anderson's name, and Dr. Eric Sturgis, who is a professor of head and neck surgery here at MD Anderson. Today we're going to be talking about the human papilloma virus, which is a sexually transmitted disease of 40 different types that increasing has had links to several different types of cancers. Dr. Ramondetta, as a gynecologic oncologist, obviously you are seeing a lot of people with cervical cancer. It seems that the evidence is pretty irrefutable now that these HPV vaccines can present up to 90% of these cancers.
Dr. Ramondetta: Yeah, so what that's based on is the fact that HPV is known to cause a couple of steps towards the cervical cancer. So HPV can cause a pre-cancer of the cervix as well as vaginal and vulvae warts. We have already seen especially in countries that are doing better jobs than we are in vaccinating their kids a significant decrease in these pre-cursors and in the warts. The vaccines that are out now will prevent about 70% of the cervical cancers that are out there but we expect with the new vaccine coming out later this year that we may be able to prevent up to 90%.
Lisa Garvin: Other gynecological cancers also have a high rate of causation with HPV viruses, correct? I mean cervical, not cervical that's the obvious one --
Dr. Ramondetta: -- vaginal, vulvae and cervical.
Lisa Garvin: So some of them like I had read like about 69% of vulvae cancers may be caused by an HPV virus?
Dr. Ramondetta: Correct. What's the bigger concern even more so we do have a lot of cervix cancer and it's a terrible thing when it happens because you know you could have prevented it, but the expense and the time and the distress that the treatment and the diagnosis of the pre-cancers cause is really one of the biggest health problems and health resource allocation problems that we have in the United States today. Meaning that if you're diagnosed with an abnormal pap smear or a vaginal wart, you end up having repeated visits and minor surgeries that can lead even to issues with pregnancy loss and this is even before diagnosed with the cancer.
Lisa Garvin: As we moved on, at first Gardasil I believe was the first vaccine to come out and the focus was on young girls, but now it appears that boys can also benefit from an HPV vaccine. Dr. Sturgis, do you want to address that one?
Dr. Eric Sturgis: Yes. I would say that for my area the most common cancer related HPV would be of the oropharynx [phonetic]. So the tonsils and the base of the tongue, the very back part of the tongue, which you cannot see, and about three-quarters of these are attributable to HPV and we have now data that supports that the vaccines do reduce the prevalence of oral infection. So it will be many years before we actually show proof that it prevents cancer but certainly the infection is the first step on that path to cancer and we have good evidence that it prevents infection. So these are mostly cancers that occur in middle-aged men more than women and it's actually at this point in time there's more oropharyngeal cancers each year in the United States than there are cervical cancers.
Lisa Garvin: When was that connection made between HPV and oropharyngeal tumors?
Dr. Eric Sturgis: It started back in the 90s but really the conclusive studies were in the early 2000s.
Lisa Garvin: The thing with HPV is a lot of people, how many people would you say carry one version or more of HPV?
Dr. Eric Sturgis: For genital HPV it's pretty well accepted that both men and women, about 80%, will have an infection at some point in their life. Most of those are cleared over a 2-year period naturally but certainly not all and for oral prevalence rates we don't fully have as extensive data as we do for genital infection but somewhere around at any one point in time somewhere around 10 to 15% of men will have an oral infection and about 5 to 10% of women will have an oral infection.
Dr. Ramondetta: And that's more like 20 plus percent for at any one time women having an HPV infection. At any one time 20% of the US population will be infected.
Lisa Garvin: But most people typically don't see symptoms as you say?
Dr. Ramondetta: That's right, and we don't know why some people have the virus stick around longer. There are some ideas. Some of them might be immunosuppression so people who maybe are transplant patients or people who take chronic steroids and smokers tend to keep those infections longer, but we don't know which one of those people who got exposed is going to end up with a pre-cancer and then eventual cancer and just to give you an idea there are actually even in Texas alone over a 1,000 cases yearly of cervix cancer and this is just in Texas. Again, the concept is this is really unique. We actually have a great, we know what causes cervix cancer, we know how to prevent it by not being exposed, we know that the vaccine can prevent the infection and we know how to find it with early stages and this is really unique to any other cancer type and, in fact, stands out even with the whole oropharyngeal issue is that they're at a disadvantage because there is no screening test. So the issue is if you want to play, you want to gamble and assume you're not going to be one of those people who get the cancer-related infection, then you can do that but we actually know that we reduce the infection if we give you the vaccine.
Lisa Garvin: And from what I understand the success of these vaccines really far outstrip some of the more normal vaccines we think of like flu and whooping cough and the success rates are phenomenal for the use?
Dr. Eric Sturgis: Certainly for the efficacy of the vaccine is certainly higher than say a standard flu shot at preventing infection.
Dr. Ramondetta: The key is that you have to get it as a prevention and you have to get it as early as you can. So, again, the recommendations are age 11 and 12, boys and girls, and the reason for that is it's preventative so most likely they have not been exposed and, number two, their immune systems are going to remember this immunity that they need to have against HPV much longer than if you give it to somebody older.
Lisa Garvin: As vaccines go, this is a fairly short window. So you have to kind of get it between 11 and 21 if you're man and 11 and 26 if you're a woman. So once you get past your mid-20s, it's not effective?
Dr. Eric Sturgis: Well, let's make sure we get that clear. The recommendation from the CDC is to get it at age 11 and 12. So, the highest infection rates are in the teens and 20s. So we want to get the vaccine before the infection. What they call catch up vaccination is recommended for people who women who are 26 and under they should be vaccinated if they didn't get it when they were 11 or 12 and for men and boys up to age 21 they should. Even if they are past that time they should have gotten it, they should go back and get a catch up vaccination.
Lisa Garvin: I do know there's been a public awareness crisis with Gardasil. In particular, I know here in Texas in 2007 our Governor, Rick Perry, signed an executive order for whatever reasons to make all girls in 6th grade get this vaccination, which it was quickly overturned, but it was used as kind of a political football. How does that make you all feel when you've got something that works yet there's so many people using it as a rock to throw at others?
Dr. Ramondetta: I think it's a tragedy. I think it's very upsetting and makes me very angry that this has at all become political. We do feel like this is a medical breakthrough, that it is the first time that we have a vaccine that can prevent cancer and we'd really like to make the most of it and seeing any patient with cancer is a terrible thing, you always feel bad about it, but we don't know what causes most cancers. With this one to know that you could have prevented it by vaccinating the patient it's just unacceptable and honestly morally wrong to not use this, everything that we have in our power to prevent our kids from getting cancer.
Lisa Garvin: Because you know someone used the scenario that if you had a blue pill that you could give to people and say, hey, this prevents X type of cancer, would you take it? Most people would say yes.
Dr. Ramondetta: Yes. Absolutely. The truth is there's a lot of rumors out there, there's a lot of people who believe things that they read on the Internet, but there has been extensive safety evaluations of the vaccines. They are easy to access, they're easy to look at and there has been large cohort studies that have looked at but they are not there is any increase in even specific issues. Like, for instance, there was a concern at some point that the vaccines were related to a neurologic abnormality or an immunologic abnormality and large studies have been done and shone no effective correlation.
Lisa Garvin: So how does you take this to the next level? I mean obviously there has to be some sort of public awareness campaign or how do we educate people and how do we get it to become part of the pantheon of vaccines that people get?
Dr. Eric Sturgis: Well, I mean I think for one we know that or we now understand that most of the hesitance to get the vaccine from parents has to do with essentially a lack of knowledge either by their pediatrician, the provider for the children, or lack of knowledge from the parents themselves that say these vaccines were even understood that they were needed to prevent cancer. So that gives us an opportunity. We certainly can do shows like this so we can make people aware that it's important that their kids get vaccinated to prevent these cancers and also educate those that have this misconception that somehow there's a safety issue for these vaccines. I think the good news is from state legislatures around the country things are moving forward and not backward as far as making vaccines, these vaccines more available adding in some mandatory opportunities for middle school students and what have you. So I think some of the initial fear mongering about this vaccine is starting to subside and I think we're heading in the right direction.
Dr. Ramondetta: I think the one other opportunity that we have is to approach the education from a different standpoint and that's one place where I think MD Anderson and other cancer centers play a unique role. This vaccine as you said was initially brought out as a way to prevent cervix cancer as a way of preventing a sexually transmitted disease, but what we're really talking about and what we have the opportunity to do especially when cancer centers joining together through some efforts of the CDC and the NCI is to join together and to talk about this as an anti-cancer vaccine, which it is. This opportunity for us to come together, which we have already started to do. We had a recent meeting amongst cancer centers who are all working to understand what's working and not in their particular states, plus the new FDA approval of the newest HPV vaccine, which doesn't have a name yet but the HPV 9 vaccine which will cover nine different HPV types and it's expected to be much more effective than the other two that are out there gives us the opportunity to really try to get this education out there as a cancer center not as a gynecologist or specifically as a pediatrician but to take what we know about the downstream effects of an HPV cancer and teach both providers and the public about what could happen if you don't get vaccinated.
Lisa Garvin: Just in glancing over some figures before I came to talk to you all, they said ballpark figures, of course, that about 20,000 cancers a year in women are HPV related and anywhere from 10 to 12,000 male cancers are HPV related. So are those numbers increasing or what --
Dr. Eric Sturgis: -- well, certainly for, it's even more than that I would say. So we have to remember that there's somewhere between a million, million and a half new cervical pre-malignancies every year; that's a huge number. There's about a million new cases of genital warts every year just in this country. So those are tremendous public health effects. The oropharyngeal site for HPV cancers is increasing in numbers. For men it's about 5% increased every single year, which that's in the range or actually a little more than the increasing rates of melanoma that we're seeing in this country. For anal cancer, for vulvae cancer, these two sites for whatever reason are also increasing in numbers each year in the United States. So, while we can screen for cervical cancer some of these other sites which are either rare like vulvae or anal cancer, are hard to screen. In other words, the site is hard to examine, we cannot see these pre-malignant changes like the oropharynx, we're going to have increasing problems until these 11-year old kids nowadays are reaching their middle-aged years. So we've got, you know, three decades of a problem ahead of us and we need to get these vaccination rates up as quickly as possible.
Dr. Ramondetta: We are so behind in comparison to almost all other countries and just to give you an idea and some numbers we're vaccinating for girls with the three series only about 30% of our girls are getting the three series and less than 10% of the boys are getting the three series. In comparison to Australia, which is vaccinating about 75% of their kids, the United Kingdom doing between 80 and 90%, and I have to mention Rwanda, who is also vaccinating 93% of their girls and boys.