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Reply to The case for catch‐up human papillomavirus vaccination in at‐risk populations: Rural communities and survivors of pediatric and young adult cancers
CA: A Cancer Journal for Clinicians  (IF508.702),  Pub Date : 2020-10-16, DOI: 10.3322/caac.21648
Debbie Saslow, Kimberly S. Andrews, Deana Manassaram‐Baptiste, Robert A. Smith, Elizabeth T. H. Fontham

We appreciate the letter from Kacew et al regarding the updated American Cancer Society (ACS) human papillomavirus (HPV) vaccination recommendations,1 which represent an adaption of the recommendations from the Advisory Committee on Immunization Practices (ACIP).2 In particular, Kacew et al take issue with the ACS Guideline Development Group's not endorsing the ACIP's recommendation that adults aged 27 to 45 years who have not been vaccinated should have an opportunity to undergo shared decision making related to catch‐up vaccination. The authors argue that: 1) rural and other at‐risk populations will interpret the ACS nonendorsement to mean that the vaccine is not safe for adults aged 27 to 45 years, and this could lead to doubts regarding its safety in children; 2) although there is lower protection against HPV infection when vaccination occurs at older ages, nonendorsement will detract from emerging data that suggest a potential role for vaccination in the prevention of recurrent cervical dysplasia among high‐risk populations; and 3) the updated guideline removes the opportunity for these groups to benefit from vaccination, if even only by a small amount. We will address each of these issues.

The importance of vaccinating girls and boys between the ages of 9 and 12 years, and especially ages 9 to 10 years, is based on the effectiveness of the vaccine during this age range and the decreased effectiveness of the vaccine when it is administered at older ages, especially after the age of 18 years.3, 4 We are sensitive to the challenges of achieving high vaccination rates in rural areas and among survivors of pediatric cancers, but the proper target groups for vaccination are average‐risk boys and girls aged 9 to 12 years, and then, after the age of 12 years, there still are 14 years in which to “catch up” before age 26 years, a period during which young adults have an opportunity to obtain some, albeit less, protection against developing HPV‐related cancers. As we pointed out in the new guideline,1 shared decision making for vaccination after age 26 years, let alone being vaccinated, would have miniscule benefit, consume untold hours of clinical time, and perhaps instill false confidence, which is likely the reason that the ACIP only endorsed shared decision making, and did not make a direct recommendation, for catch‐up vaccination from ages 27 to 45 years.2 The authors mention the potential benefit of secondary prevention for cervical dysplasia and other neoplastic conditions, but this purpose is therapeutic, off‐label, and not relevant to the recommendation from the ACIP. Similarly, cancer survivors should be under special care and are beyond recommendations for the general population. Kacew et al speculate that rural residents will interpret a lack of endorsement of catch‐up vaccination after age 27 years as suggesting that the vaccination is not safe. In fact, we stated, “Although HPV vaccination is safe for adults aged 27 to 45 years, there would be limited public health benefits from vaccinating people in this age range.”1 What is more likely to occur is that the catch‐up population aged 27 to 45 years would have a shared decision‐making conversation that includes a discussion of the patient's history of sexual activity, which will have the unintended consequence of refocusing discussions concerning childhood vaccination back on sexual activity, a well‐known barrier to childhood HPV vaccinations. Finally, with regard to the new guideline removing the opportunity for rural populations to undergo vaccination from ages 27 to 45 years, it does not. Adults are free to make their own decisions, the ACIP still endorses shared decision making, and health plans will cover it.

We are in complete agreement with the goal of achieving higher rates of HPV vaccination in rural populations, but believe emphasis primarily should be on those aged 9 to 12 years, and, if not accomplished then, on those aged 13 to 26 years, and at the earliest opportunity.