The Fight Against Cervical Cancer is Winnable. So Why Is Kansas Losing?

If all it took were a few shots to virtually eliminate the chances of contracting one type of cancer, you’d think at-risk people would be lining up for treatment in droves.

There is, in fact, a three-dose regimen that experts say essentially prevents cervical cancer, which is newly diagnosed in more than 12,000 American women per year and kills about 4,000.

But vaccination rates against the human papillomavirus (HPV), which causes nearly all cases of cervical cancer, continue to lag far behind levels sought by the U.S. medical community – something health officials blame largely on parents’ and physicians’ reluctance to talk with adolescents about a sexually transmitted infection.

And the issue is particularly acute in Kansas, which the U.S. Centers for Disease Control and Prevention (CDC) says is the worst in the nation in assuring that adolescent girls receive at least one dose of the vaccination. Kansas also ranks last, along with Utah, in ensuring adolescent girls receive the full regimen.

Now a concerted effort is underway to improve the HPV vaccination rate in the state, with partners that include the Kansas Foundation for Medical Care and the University of Kansas Cancer Center (KUCC), which is making HPV outreach a key component of its effort to achieve enhanced recognition by the National Cancer Institute (NCI).

The campaign will get a boost this week from Dr. Melinda Wharton, director of the CDC’s Immunization Services Division, who’s scheduled to stop in Kansas City, Topeka and Wichita for a three-day visit beginning today.

Better late than never in trying to bolster the HPV vaccination rate in Kansas, says Dr. Roy Jensen, director of the KU Cancer Center.

“It’s kind of like, when is the best time to plant a tree?” Jensen says. “Well, the best time to plant a tree was yesterday, or 10 years ago. But today is the second best time, so we need to get started on this if we have our eye on the future like it should be.”

HPV prevalence

HPV is the most common sexually transmitted infection in the United States. The CDC says virtually all sexually active men and women contract it at some point in their lives.

In most cases, it resolves on its own. But when it persists, it can cause health problems like genital warts and cancer in both men and women. It can also cause cancers of the penis, anus, tongue and tonsils.

In 2006, the U.S Food and Drug Administration approved Gardasil as the first HPV vaccine. Three years later it approved another vaccine, Cervarix.

To achieve maximum effect, physicians administer the three doses over the course of six months to adolescents before they become sexually active.

Researchers don’t know how much protection is afforded by only one or two doses, according to the CDC. That’s why it says it’s important that both sexes get all three.

Either way, Kansas stacks up poorly. For females between the ages of 13 and 17, about 57 percent nationwide receive at least one HPV vaccination; in Kansas, the figure is about 40 percent. Similarly, nearly 40 percent nationwide receive all three doses; in Kansas, the figure is 21 percent.

A national health roadmap unveiled in 2010 by the U.S. Department of Health and Human Services calls for achieving an 80 percent HPV vaccination rate among 13- to 15-year-old males and females by the year 2020.

By that measure, everyone has work to do, says Stephanie Lambert-Barth, project manager for the Kansas HPV Vaccination Project, the campaign that the Kansas Foundation for Medical Care is spearheading with its partners.

“Kansas is not doing well,” she says, “but it has been a struggle everywhere.”

The foundation is managing the project for the state of Kansas, which received nearly $800,000 in federal grant money through the Department of Health and Human Service’s Prevention and Public Health Fund.

The 15-month project, which runs through October, includes the “3 Protect Kids” marketing campaign, which takes its name from the three vaccines recommended for preteen children: Tdap, meningococcal, and HPV.

Seeking a solution

Dr. Kevin Ault, an OB/GYN at the University of Kansas Hospital and a cervical cancer expert, says that cervical cancer rates tend to be higher among rural women, given their relative lack of access to health services. With Kansas’ large rural population, Ault says, the same factor could account for the state’s poor record of HPV vaccination.

Rhode Island, which is tops in the nation in vaccination adolescent females against HPV, provides free vaccines to providers for children and adults.

Yet even the nation’s foremost medical authorities don’t know for sure what makes one state better than another in administering the HPV vaccine, says Wharton, the CDC official who is coming to Kansas this week.

“This is a complicated story,” she said in a phone interview, “and I don’t think there is a formula we have identified we can share, and say, ‘If you just do this, it will be better.’”

But Wharton said health officials know that a strong recommendation from the family doctor is key to driving up HPV vaccination rates.

It sends the wrong message, she said, when a physician recommends Tdap and meningococcal and then makes it sound like HPV is optional or shies away from talking about it because the virus is sexually transmitted.

Wharton said physicians should simply and forthrightly list the three vaccines that are recommended for 11- and 12-year-olds and move ahead.

“We don’t get into conversations before we give Tdap about how tetanus is spread, and we don’t talk about droplet transmission before we give the meningococcal vaccine,” she said. “So there’s no reason we have to bring up sexual transmission before we give the HPV vaccine.”

Looking at the data

In a national teen immunization survey conducted in 2013, the parents of girls cited “lack of knowledge” as the top reason for not vaccinating their child against HPV. “Not recommended” was the top reason cited by parents of boys.

Dr. Pam Shaw, a pediatrician with the University of Kansas Hospital, says family medicine and pediatric practices at KU hospital have had success by simply informing parents that the visit at 11 or 12 years old involves the three vaccines.

Getting families to initiate the series is one issue, Lambert-Barth says. The other issue is making sure busy parents follow through on the complete three-shot regimen.

“So things like reminders and recalls are very important,” Lambert-Barth says, “but very few practices are really using those.”

Some groups have raised safety concerns, citing a handful of media reports attributing deaths to the vaccine. One alleged instance, which garnered media attention last year, involved a Wisconsin mother who claimed her 12-year-old daughter’s death was caused by the vaccine.

The Milwaukee Journal Sentinel, however, reported in October that the medical examiner had concluded the girl’s death was due to an antihistamine overdose.

Both the CDC and Food and Drug Administration have determined that the vaccine is safe based on large safety studies that have been conducted since the vaccine became available in 2006.

Opponents of the vaccine say it also sends the wrong message to adolescents.

Kenda Bartlett, executive director of Concerned Women for America, a group that promotes adherence to biblical principles in public policy, says it signals to them that it’s OK to initiate sex.

But Ault says studies across clinical settings in different countries, including one he co-authored in 2012, have been “remarkably consistent” in showing that does not happen.

“I think we have settled that problem or that perception,” he says.

Wharton of the CDC said she recognizes there are those who believe HPV vaccination is incompatible with their family values.

But, she counters, “It’s also a value for all parents to protect their children from the things you can protect them from.”

Mike Sherry is a reporter for KCPT television in Kansas City, Mo., a partner in the Heartland Health Monitor team.