In recent years, Americans have become less aware that the human papillomavirus (HPV) causes cervical cancer. This is a conclusion based on survey data presented the American Association for Cancer Research (AACR) 2023 Annual Meeting, being held April 14-19, 2023 at the Orange County Convention Center in Orlando, Florida. [1]

Survey respondents also showed low awareness that HPV can cause anal, penile cancer and oral cancer (including cancer in back of the throat known as oropharyngeal cancer).

The study was funded by Henry Ford Health.

A common infection
HPV is spread through intimate skin-to-skin contact, including vaginal, anal, or oral sex. Today, more than 42 million Americans are infected with types of HPV that caused disease. And each year, about 13 million Americans, including teens, become infected.  Of these infected people nearly 45 000 HPV-associated cancers are diagnosed annually in the United States, with nearly 60% detected in women and 40% in men. [2]

“Over 90% of HPV-associated cancers could be prevented with the HPV vaccination, yet vaccine uptake remains suboptimal,” noted the study’s lead author, Eric Adjei Boakye, Ph.D., assistant scientist in the Department of Health Sciences and the Department of Otolaryngology at Henry Ford Health in Detroit.

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Currently, about 54.5% of U.S. adolescents have received all recommended doses of the HPV vaccine, well short of the U.S. government’s goal of having 80% of adolescents fully vaccinated. [3]

Eric Adjei Boakye, Ph.D., assistant scientist in the Department of Health Sciences and the Department of Otolaryngology at Henry Ford Health in Detroit.

Declining Awareness
Previous research has indicated that awareness that HPV can cause several types of cancer can increase a person’s likelihood of getting vaccinated.

To assess current awareness about HPV and cancer, Adjei Boakye and colleagues examined data from theNational Cancer Institute’s  Health Information National Trends Survey (HINTS) from five timepoints between 2014 (HINTS 4 cycle 4) and 2020 (HINTS 5 cycle 4). Each time-point featured responses from between 2,000 and 2,350 individuals. [1][4]

The survey asked respondents, “Do you think HPV can cause i) anal; ii) cervical; iii) oral; and iv) penile cancers?” Responses were “yes,” “no,” and “not sure.”

In 2020, researchers found that 70.2% of respondents knew that HPV can cause cervical cancer, down from 77.6% in 2014.

Anal, oral, and penile cancers
Awareness that HPV can cause anal, oral, and penile cancers was low throughout the duration of the study. For anal cancer, awareness fell from 27.9% in 2014 to 27.4% in 2020. For oral cancer, awareness fell from 31.2% in 2014 to 29.5% in 2020. For penile cancer, awareness fell from 30.3% in 2014 to 28.4% in 2020.

Adjei Boakye said the results of the study suggest a significant need to educate the public that HPV can cause all four of the cancer types included in this study, plus vulvar and vaginal cancer.

“Given the connections between HPV-associated cancer awareness and HPV vaccination uptake, it is important we increase the population’s awareness of this link, as it may help increase vaccine uptake,” he said.

First approval: female-centric
The U.S. Food and Drug Administration (FDA) approved the first HPV vaccine for girls and women aged 9 to 26 in 2006. In 2009, the FDA expanded the vaccine approval to boys and men, noting that the vaccine could protect against anal, oral, and penile cancers. Currently, the Centers for Disease Control and Prevention recommend that boys and girls receive the HPV vaccination at age 11 or 12. Two doses of the vaccine are recommended for those who begin the series before their 15th birthday. Three doses are recommended for those who start the series later. [5][6]

The initial public health campaigns surrounding the vaccine created strong associations with cervical cancer.

“The talk about HPV was very female-centric when the vaccine was first approved and recommended. As a result, a lot of people know about HPV causing cervical cancer, but not the other cancers. Our results suggest that interventions to increase awareness of all HPV-associated cancers would benefit public health,” Adjei Boakye note

Multiple causes
The decline in awareness about HPV and cervical cancer most likely has multiple causes and will require multiple strategies to reverse. He suggested one cause could be an increased focus in training health care providers to promote and administer the vaccine, which may have diverted resources from public information campaigns. “Boosting awareness will require a concerted effort from health care providers and public health experts,” Adjei Boakye suggested.

“Research has shown a high degree of public trust in HPV information when received from health care providers; therefore, providers should use every clinical visit as an opportunity to educate patients about the causal link between HPV and HPV-associated cancers, and also about the cancer prevention benefits of the HPV vaccine,” Adjei Boakye added.

Adjei Boakye said future research may assess public opinion on the vaccine in the wake of the COVID-19 pandemic.

Study limitation
“One potential limitation of the study is its cross-sectional design; the survey assessed different groups of people at each timepoint. Also, people who said they had never heard of HPV were not asked the follow-up questions; therefore, overall public awareness may be even lower,” Adjei Boakye concluded.

[1] Adjei Boakye E, Nair M, Domgue JF, Abouelella DK, Khan HY, Osazuwa-Peters N. Over 10 years since HPV vaccine approval, awareness of the causal link between HPV
and HPV-associated cancers remains low in the US. In: Proceedings of the 114th Annual Meeting of the American Association for Cancer Research; 2023 April 14-19; Orlando, FL. Philadelphia (PA): AACR; 2023. Abstract nr 4210 / 11.
[2]Liao CI, Francoeur AA, Kapp DS, Caesar MAP, Huh WK, Chan JK. Trends in Human Papillomavirus-Associated Cancers, Demographic Characteristics, and Vaccinations in the US, 2001-2017. JAMA Netw Open. 2022 Mar 1;5(3):e222530. doi: 10.1001/jamanetworkopen.2022.2530. PMID: 35294540; PMCID: PMC8928005.
[3] Increase the proportion of adolescents who get recommended doses of the HPV vaccine — IID‑08. Healthy People 2030. Office of Disease Prevention and Health Promotion. Online. Last accesses on April 16, 2023.
[4] What is HINTS. Health Information National Trends Survey. National Cancer Institute. Online. Last accessed on April 16, 2023.
[5] HPV Vaccination Recommendations. Vaccine and Preventable Diseases. Center for Disease Control and Prevention (CDC). Online. Last accessed on April 16, 2023.
[6] Malo TL, Gilkey MB, Hall ME, Shah PD, Brewer NT. Messages to Motivate Human Papillomavirus Vaccination: National Studies of Parents and Physicians. Cancer Epidemiol Biomarkers Prev. 2016 Oct;25(10):1383-1391. doi: 10.1158/1055-9965.EPI-16-0224. PMID: 27694109; PMCID: PMC5108584.

Featured image photo courtesy: 20216 -2023 Mari Lezhava on Unsplash.

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