HPV-related anogenital cancers. Sarah Bradley, MD Clinical Assistant Professor Wisconsin Comprehensive Cancer Control Summit May 28, 2015

Transcription

1 HPV-related anogenital cancers Sarah Bradley, MD Clinical Assistant Professor Wisconsin Comprehensive Cancer Control Summit May 28, 2015

2 Cervical cancer Nearly 100% caused by HPV Harald zur Hausen, Stockholm, 2008

3 Pathophysiology of HPV

4 Persistent HPV infection Cancer HPV infection is necessary but not sufficient Persistent infection occurs in 10-15% Average time from infection cancer is years Risk factors for persistent HPV Oncogenic, high risk subtypes 16 and 18 cause 70-75% of all cervical cancer Smoking Compromised immunity

5 Secondary Prevention of Cervical Cancer Pap smear screening 3 million abnormal paps/year in the US Evaluation with follow up pap or colposcopy Moderate/severe dysplasia treated with excision or cryotherapy

6 10 Cervical cancer in WI, Per year (2010) 160 new cases 50 deaths Age adjusted incidence (per 100,000) Wisconsin Cancer Reporting System, 2014

7 HPV Causes Other Genital Cancers

8 HPV-related cancers in the US

9 Vulvar Cancer Cases/year US 4,900 WI 95 Vaginal Cancer Cases/year US 3,000 WI 15

10 Vulvar and vaginal cancer in WI 3 Per 100,000 women, age adjusted Vulvar cancer Vaginal cancer Wisconsin Cancer Reporting System, 2014

11 Penile cancer Rare in the US 50-60% attributed to HPV Higher rates in developing countries

12 Anal cancer 85-93% attributed to HPV Progression from HPV anal dysplasia cancer Incidence is increasing in the US Last 30 years 3-fold increase in men 1.7X increase in women

13 Anal cancer incidence in WI Age adjusted rate (per 100,000) Age adjusted rate (per 100,000) Wisconsin Cancer Reporting System, 2014

14 HPV infection: prevalence, transmission and auto-inoculation

15 HPV Prevalence in the US 14 million new infections/year At any given time in the US population % of the population has genital HPV 7.3 % have oropharyngeal HPV 79 million people with current infections Lifetime risk > 80 % Dunne et al. MMWR. 2014;63(4): Dunne et al. JAMA. 2007; 297(8): Hariri et al. J Infect Dis 2011;204(4): Sanders et al Oral Dis; 18(5),

16 Transmission of HPV Easily transmitted by contact alone Skin to skin Genital to genital Condoms only 60% protection Oral to genital? Oral to oral Autoinoculation May explain some oral/anal HPV infections Steinau et al. Prevalence of cervical and oral human papillomavirus infections among US women. Journal of Infectious Disease, Stanley et al. HPV infection, anal intra-epithelial neoplasia (AIN) and anal cancer: current issues. BMC Cancer

17 The Case for HPV Vaccination HPV causes 5% of all cancers in the US >33,000 cases/year The HPV vaccine is effective Durability of protection at least 10 years Healthy People 2020 goal 80% HPV vaccine completion rate for year olds Lowry et al. Lancet Oncol 2015; 16(5):

18 How are we doing?

19 UW Health Provider Education: Lessons from a quality improvement intervention

20 UW HPV Vaccination Taskforce Formed in 2013 in response to low HPV vaccination rates 39% 3-dose completion for girls Subgroup of the UW Immunization Taskforce Developed an educational lunch and learn presentation Our Kids Need the HPV Vaccine Presented at 14 UW pediatric and family practice clinics May-October 2014

21 Our Kids Need the HPV Vaccine Content HPV infection and relationship to cancer Safety and efficacy of the HPV vaccine Current UW rates broken down By clinic and provider By boys and girls Strategies to overcome barriers to vaccination

22 Our Kids Need the HPV Vaccine Data collection Participants surveyed before and 6 months after Knowledge and attitudes about HPV vaccination Barriers to HPV vaccination Discussions recorded Analysis ongoing

23 Educational intervention 60-minute session All clinic staff and providers Lunch and learn with food provided Attendance: approx. 209 Avg. 14 per session (min=5; max=21) 16.1% MD/DO 7.0% advanced practice providers 30.2% RN 24.6% LPN/MA 21.1% CMA 1.0% med student

24 Pre-test: knowledge, practice, perceptions Name (optional)* Clinic role* The HPV vax is recommended for: Females ages to * Males ages to * How strongly do you recommend HPV vax for girls/boys?* How do your patients/parents react to discussion of HPV vax?* In your estimate, what % of patients/parents are receptive to HPV vax? What % of your eligible patients receive the HPV vax? What are the barriers to HPV vaccination in your practice? * Asked again in post-test, 6 months after session

25 Pre-test: Responses Recommended ages (mean) Females from 10.5 (min 8; max 18) to 25.4 (min 11; max 40) Males from 10.8 (min 8; max 18) to 25.1 (min 12; max 40) How strongly do you recommend HPV vax for: Females: 6.4 (scale 1-7; 7=high) Males: 6.3 How well do patients/parents react to HPV vax discussion? 4.8 (1-7 scale; 7=high) Percentage of patients/parents receptive to HPV vax? 61.7% Percentage of eligible patients who receive HPV vax? 58.7% (UW Health rate never higher than 44%)

26 Pre-test: early analyses Those who reported that patients/parents reacted more positively to discussions about the HPV vax Reported stronger recommendations of HPV vax for females and males Estimated that a greater percentage of eligible patients receive HPV vax

27 Pre-test: Provider-reported barriers Analysis by UW Ob-Gyn grad assistant Grounded theory approach Independent coders Themes most often mentioned by providers (in order) Parent hesitancy especially sex stigma Lack of information Unfavorable media coverage Adverse reactions

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29 Clinic talk 30-minute talk (Drs. Bradley, Geier) Followed by discussion Recorded, transcribed, and analyzed for themes

30 Q&A/discussion session: Qualitative analyses Recorded, transcribed, categorized, coded by UW Ob-Gyn grad assistant Reported barriers (in order) Parent hesitancy especially sex stigma Adverse reactions Issues with electronic health records Unfavorable media coverage

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32 Comments on parent hesitancy/sex stigma How do you handle the parent that just says you know my son is not having sex until he is fifteen, I don t even want to talk about this now, that is the most common issue with me that there is some sort of moral stance. Often parents feel that it gives their children license to have sex

33 Comments on lack of information My biggest barrier is when parents aren t particularly familiar with the vaccine, they come in at age eleven and you know it s a concept that s tough to get your head around because these are kids that are often prepubescent and so they re faced with making decisions about preventative measures that may not be important for years to come Patients are not very educated on HPV it s not as well known as other vaccines.

34 Q&A/discussion session: Qualitative analyses Provider questions (in order) Age recommendations Vaccine series How to recommend Adverse reactions Questions related to data from educational talk Vaccine durability Protection provided by vaccine

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36 Questions related to the vaccine series I ve had parents concerned that it s been you know two years since they had their first one and should they really complete it, does it really matter at this point?

37 Q&A/discussion session: Qualitative analyses Provider suggestions for increasing rates More/better information for parents and patients System issues especially better follow-up for 2 nd, 3 rd shot

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39 Post-test: Online survey Individual, anonymous link ed six months after educational session Reminders after one and two weeks; additional ad hoc reminders All clinic staff at 15 clinics: attendees and non-attendees 149 post-test responses At least 42% (n=88) responded to both preand post-test surveys

40 Post-test: Online survey Name (optional)* Clinic role* The HPV vax is recommended for: Females ages to * Males ages to * How strongly do you recommend HPV vax for girls/boys?* How do your patients/parents react to discussion of HPV vax?* Was the HPV provider education session helpful? Have your practices regarding HPV vax changed? How? What more could UW Health system do to facilitate HPV vax? Would you like more info about HPV? Any further comments?

41 Post-test: Responses N=149 Roles: 30.6% MD/DO 6.7% advanced practice providers 32.8% RN 14.2% LPN/MA 15.7% CMA 0% medical students

42 Post-test: Responses Recommended ages (mean) Females from 10.4 (min 9; max 15) to 25.1 (min 11; max 30) Males from 10.6 (min 8; max 14) to 24.1 (min 11; max 30) How strongly do you recommend HPV vax for: Females: 6.7 (scale 1-7; 7=high) Males: 6.6 How well do patients/parents react to HPV vax discussion? 5.1 (1-7 scale; 7=high)

43 Post-test: Responses Was the provider education session helpful? 31.3% of post-test respondents had not attended Of those who had attended: 97.7% yes 2.3% no Have your practices regarding HPV vax changed? How? (open response) 55% no response Of those who responded: 79.1% had improved their practices 20.1% had not changed their practices

44 Post-test: early analyses Those who perceived that patients/parents reacted better to discussions of the HPV vax self-reported stronger recommendation for females. Those who said they had improved their practices regarding the HPV vax selfreported stronger recommendations for males

45 Lessons learned Costs-benefits of individual, anonymous links Buy-in from clinic managers/staff is key

46 How are we doing at UW?

47 Healthy People 2020 Goal = 80% UW Health Rate = 39%

48 UW Health HPV Dose Completion Rates (across all clinics) 100% 90% 80% 70% 60% 50% 40% 30% 9.8% 12.7% 13.4% 13.4% 16.3% 17.8% 17.5% 17.1% 13.0% 15.2% 15.4% 15.2% 20% 11.5% 10.5% 13.0% 12.8% 13.4% 11.4% 14.5% 14.4% 12.4% 10.9% 13.7% 13.6% 10% 0% 12.5% 15.6% 15.2% 14.6% 12.2% 15.6% 15.2% 13.7% 12.3% 15.6% 15.2% 14.1% Feb '14 Aug '14 Nov '14 Feb '15 Feb '14 Aug '14 Nov '14 Feb '15 Feb '14 Aug '14 Nov '14 Feb '15 Male Female Total 1st Dose 2nd Dose 3rd Dose

49 100% UW Health HPV Dose Completion Rates Pilot vs. Non-Pilot Clinics 90% 80% 70% 60% 50% 40% 30% 13.7% 15.9% 16.1% 15.9% 10.0% 12.4% 12.8% 11.7% 20% 12.2% 10.8% 13.9% 13.8% 13.1% 11.2% 13.1% 11.9% 10% 0% 11.6% 15.4% 14.7% 13.8% 15.4% 16.1% 17.2% 14.0% Feb '14 Aug '14 Nov '14 Feb '15 Feb '14 Aug '14 Nov '14 Feb '15 Clinics with Education Sessions Clinics without Education Sessions 1st Dose 2nd Dose 3rd Dose * Includes male and female patients.

50 100% UW Health HPV Dose Completion Rates GPAM and DFM 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 15.4% 17.4% 17.6% 17.2% 11.8% 12.0% 12.3% 13.3% 9.3% 11.4% 14.6% 9.4% 10.0% 11.7% 14.3% 11.8% 12.1% 10.2% 15.6% 14.3% 14.8% 13.7% 14.0% 12.6% GPAM DFM GPAM DFM GPAM DFM GPAM DFM Feb '14 Aug '14 Nov '14 Feb '15 * Includes male and female patients. 1st Dose 2nd Dose 3rd Dose

51 What can other institutions do? Identify an HPV workgroup Provide physician/staff education HPV champion Video Provide patient/parent education Community talk, handout, media Create incentives $, CME, MOC

52 Questions? Thank You Sarah Bradley, MD Lindsay Geier, MD Nicholas Schmuhl, PhD