

Certified medical assistant Karla Huerta holds vials of the HPV vaccination drug Gardasil at Amistad Community Health Center in Corpus Christi, Texas. (Matthew Busch/For The Washington Post)

The nation’s leading cancer doctors are pushing pediatricians and other providers to help increase use of the HPV vaccine, which studies show could help avert tens of thousands of cancer cases during young Americans’ lives. Yet a decade after its controversial introduction, the vaccine remains stubbornly underused even as some of those diseases surge.

The vaccine’s low uptake among preteens and adolescents belies its universally acknowledged effectiveness in preventing the most common sexually transmitted infections linked to the human papillomavirus. Those infections can cause a half-dozen cancers, including more than 90 percent of anal and cervical cancers; 70 percent of vaginal, vulvar and oropharyngeal, or middle throat, cancers; and 60 percent of penile cancers.

The oncologists’ goal is to rebrand the vaccine to focus on cancer prevention. They are determined to dismantle what researchers say is the No. 1 obstacle to wider inoculation: pediatricians and family doctors who aren’t strongly recommending the vaccine.

The HPV vaccine can prevent a number of common cancers, but still has a low uptake rate ten years after it's release. Here are some reasons why. (Deirdra O'Regan/The Washington Post)

Studies show that a forceful endorsement from a physician is the most important factor in whether children get the vaccine, which is recommended for ages 11 and 12. Yet a frustrating level of “provider hesitancy” persists.

“The failure belongs to us,” acknowledged Jason Terk, a pediatrician in Keller, Tex. “It’s an epic fail.”

Terk has been working with experts at MD Anderson Cancer Center in Houston to spread the word. Lois Ramondetta, one of the hospital’s gynecologic oncologists, has taken to the road to meet with practitioners across the state.

Last month, she delivered a blunt message to the staff of Su Clinica in Harlingen, deep in the state’s south valley: If they didn’t increase HPV vaccination of their young patients, those youths would face a greater risk of developing deadly cancers as adults. Boys would be especially vulnerable to throat cancers, a growing scourge of middle-aged men.

“If you are not recommending the vaccine, you are not doing your job,” Ramondetta said. “It’s the equivalent of having patients in their 50s and not recommending a colonoscopy — and then having them come back with cancer.”

For Su Clinica’s doctors, the candid discussion hit home and quickly prompted changes in some procedures. Gynecologist Rose Gowen said many of the staff were especially surprised by the urgent need to vaccinate boys.

Ramondetta understands why the challenges are so pervasive. “Pediatricians never see the cancers caused by HPV, so some of them don’t recognize the vaccine’s importance in preventing cancer,” she said. “They don’t know how to talk about it with patients, or they wait too long. And their knowledge level is not where it should be.”

While the HPV vaccination rate varies widely from state to state, it has ticked up nationally over the past few years. Yet the latest statistics from the Centers for Disease Control and Prevention show that in 2014, 40 percent of teenage girls and 22 percent of boys had gotten all three doses. That’s far below the 80 percent to 90 percent rate for the vaccine booster for tetanus, diphtheria and pertussis — as well as for the shot to prevent meningitis — that most states require for middle-schoolers.

The 64,000-member American Academy of Pediatrics has urged members to use the vaccine. But Cleveland pediatrician Margaret Stager, who works on adolescent health issues for the organization, said it remains “brand-new territory” for many doctors, especially older physicians.

“They have seen whooping cough, meningitis, measles and mumps and have real-life evidence of the power of vaccines to save lives,” she said. “Now we have a whole new fundamental concept, because this vaccine is trying to prevent cancer several decades from now.”

A 2014 U.S. study, for example, projected that nearly 29,000 additional cases of cervical cancer would be averted over young girls’ lifetimes with a vaccination rate of 80 percent compared with 50 percent. Cancer doctors hope that pressing the case with such statistics can provide reinforcement for public health officials at the CDC and in state and local governments, as well as for the other medical groups encouraging doctors and parents.



Medical assistant Karla Huerta prepares to give HPV vaccinations to children at the Community Health Center in Corpus Christi, Tex. (Matthew Busch for The Washington Post)

Much of their current activity dates to 2013 when the President’s Cancer Panel, alarmed by how the HPV vaccination rate was leveling out, called for a drastic acceleration. The National Cancer Institute funded several efforts to identify barriers to vaccination, and earlier this year, all 69 NCI-designated cancer centers issued a first-of-its kind consensus statement saying the HPV vaccine was “tragically underused” and calling on doctors to strongly recommend it. The American Society of Clinical Oncology followed with a similar statement.

[‘Seriously flawed’ study linking behavioral problems to Gardasil has been retracted]

Cancer doctors have been reaching out to primary-care physicians and consumers throughout the country. Jennifer Young Pierce, a gynecologic oncologist at the Medical University of South Carolina, has held town halls around her state to talk up the vaccine. In Upstate New York, doctors at the Roswell Park Cancer Institute are taking part in a regional vaccine coalition and have met with local dentists and legislators interested in promoting HPV vaccination.

Meanwhile, the NCI is planning a large clinical trial to determine whether a single dose would be as effective as the current regimen. That could sharply accelerate utilization, especially in developing countries, where cervical cancer is among the deadliest cancers.

“We’re doing this to help the women of the world,” said NCI acting director Douglas Lowy, who was instrumental in discoveries that paved the way for the vaccine.

About 79 million Americans are infected with HPV, and 14 million become newly infected each year. While the body’s immune system clears most of the infections, high-risk strains are directly linked to 27,000 new cancers a year.

The vaccine is recommended for preteens because their bodies have the most robust responses, and it works best before sexual activity begins. (Intercourse isn’t necessary to contract HPV.) In 2006, the vaccine was first approved as Gardasil for girls, followed a few years later for boys, amid controversy that has never completely dissipated. Critics questioned the safety of the vaccine, made by Merck, and said it would encourage teenagers to be promiscuous — concerns that research has shown to be unfounded.



Ruth Marroquin, 13, looks away as she is vaccinated against HPV. (Matthew Busch for The Washington Post)

Unlike other childhood shots, the one for HPV isn’t required by most states; only Virginia, Rhode Island and the District have mandates. The vaccination rate varies sharply across the country, with relatively high rates in the Northeast and California and lower rates in the South.

Yet the vaccine is having an impact overall. A CDC study published earlier this year showed that the prevalence of the virus was reduced by almost two-thirds among teenage girls, compared with the years before the vaccine became available.

And this month, Merck announced that a review of 58 studies published in the last decade in North America, Europe, Australia and New Zealand found that vaccination sharply reduced cervical pre-

cancers and genital warts.

As for side effects, the most common are swelling and pain at the injection site, with occasional fainting. Several large studies over the past decade have more than proved the vaccine’s safety, the CDC says.

But the concerns of some parents still aren’t assuaged. Aimee Gardiner, who is leading a group to repeal the Rhode Island mandate, said she won’t have her children inoculated. “I don’t think the risks of HPV are high enough to warrant getting the vaccine,” she said.

Similarly, the National Vaccine Information Center, an advocacy group founded by parents who opposed routine childhood inoculations, continues to raise questions about the research behind the HPV vaccine and its safety.

[HPV vaccinations don’t lead to riskier sexual behavior among girls, study suggests]

But in many cases, the chief obstacle is physician ambivalence more than parental opposition. Researchers at Harvard Medical School and the University of North Carolina reported last fall that an online survey of 776 doctors showed that many talked about HPV vaccination in a way likely to discourage parents. More than a quarter of the doctors said they didn’t strongly endorse the vaccine and a similar proportion didn’t recommend it for preteens.



Abraham Vidaurre, 12, checks his arm after receiving the HPV vaccine. (Matthew Busch for The Washington Post)

In Texas, Terk says he advises fellow pediatricians to recommend the shots in a matter-of-fact manner, to “bundle it” with other inoculations and to avoid talking about sex unless asked. “If you approach it in a confident, presumptive way, many parents will say, ‘Let’s do it,’ ” he said.

The HPV vaccine has a fraught history in Texas. In 2007, Republican Rick Perry became the nation’s first governor to require girls to get the vaccine, which caused a firestorm in part because of his close relationship with a former chief of staff who was a lobbyist for Merck. The Legislature overturned the mandate.

MD Anderson has been leading a major HPV initiative since 2014 that involves other cancer centers, pediatricians, nurses and school officials. During a meeting last summer, 69-year-old Michael Terry described his struggle with HPV-related throat cancer, saying, “You need to know how miserable it is to suffer from this disease.”

Terry, whose father was Luther Terry, the 1960s-era U.S. surgeon general who issued a landmark report about the dangers of tobacco, talked about undergoing surgery, chemotherapy and radiation and about living with splitting headaches, neck aches and difficulties swallowing. His concluding plea: “Vaccinate, vaccinate, vaccinate, boys and girls.”

In the fall, pediatrician Lori Anderson took a couple of pediatric residents from her community health clinic in Corpus Christi to hear Ramondetta speak at a Texas Pediatric Society meeting. The oncologist showed an emotionally wrenching documentary about cervical cancer called “Someone You Love.” When the lights went up, some of the doctors were in tears.

“I think it was an ‘aha moment’ for the residents,” Anderson said. With her help, they organized a recent school health fair in the beach community of Port Aransas.

Two dozen children got vaccinated against HPV.