In 2018, the U.S. Food and Drug Administration (FDA) extended the upper age indication for the human papillomavirus (HPV) vaccine from 27 up to 45 years. Earlier this year, the Advisory Committee on Immunization Practices (ACIP) said not everyone in this older age range needs it, according to a clinical guideline synopsis published in JAMA, which addresses the age expansion and summarizes discussion points for “shared clinical decision making” in determining who in this older age group could benefit most from HPV vaccination.
However, even though adults are now included in the updated age range for the HPV vaccine, it does not come without challenges. Physicians must understand who the best candidates are for the HPV vaccine and how to work with patients to create an appropriate plan for prevention.
“This was a very controversial recommendation because there’s only so much vaccine and we know that giving it to the young people is almost 100% protective,” said Sandra Fryhofer, MD, an Atlanta general internist who serves as the AMA’s liaison to ACIP. Read this interview with Dr. Fryhofer about getting adults vaccinated.
“At the same time, there are some older patients—and primary care physicians know who those patients are—that could benefit,” Dr. Fryhofer said. “The important thing here is we really need to get these adolescents vaccinated before they’re exposed to the virus. That’s where we’re going to get the most bang for our buck.”
While it is important for physicians to emphasize the importance of HPV vaccination in adolescents, Dr. Fryhofer—a member of the AMA Board of Trustees—offered this advice for doctors about how to approach HPV vaccination in adults.
Use shared decision-making
Many adults 27–45 will have already been exposed to HPV earlier in life, which makes universal vaccination for all adults not cost effective, says the synopsis. Physicians should obtain a thorough sexual history and educate patients about the potential value of the HPV vaccine for their circumstance through shared decision making.
“Vaccine safety is not an issue, but the vaccine may not be as effective in those who've had multiple lifetime sex partners and thus are more likely to have been previously infected with vaccine-type HPV strains,” she said.
Additionally, people in a long-term mutually monogamous relationship are not likely to get a new HPV infection, said Dr. Fryhofer. However, “at any age, a new partner is a risk factor for a new HPV infection.
Those with fewer prior sex partners who are now at risk of exposure to a new HPV infection from a new sex partner, are the most likely to benefit from HPV vaccination.”
“Your patients need to understand the potential value of the vaccine for their circumstances,” said Dr. Fryhofer. “And then of course, you and your patient have to decide whether or not to vaccinate
Emphasize cancer prevention
The HPV vaccine is highly effective and has even demonstrated high levels of immunogenicity for patients up to age 45. It can also help prevent cervical and anal intraepithelial neoplasia, oropharyngeal cancer, other genital cancers, and condyloma.
“We have to emphasize the cancer preventing potential and the fact that it’s a prophylactic vaccine—it doesn’t treat HPV related disease, and it doesn’t prevent progression. Unfortunately, there’s no clinical antibody test and there’s no antibody titer that can predict immunity,” said Dr. Fryhofer. “It’s a vaccine that stops you from getting this infection in the first place.”
“It’s really an insurance policy to help your family stay safe,” she said. “It’s one thing that we definitely can do to prevent cancer.”
Have healthy conversations
“We all run into patients who can be vaccine-resistant. I would recommend that physicians consider a method called the AIMS [announce, inquire, mirror and secure] method for having healthy conversations about vaccination,” said Dr. Fryhofer.
Physicians should first announce that the vaccination will happen as soon as people are ready, she said, followed by understanding each patient by inquiring about their concerns. For mirroring, Dr. Fryhofer recommends physicians “make sure they know you understand them by repeating, but not parroting what they said and asking if that’s what they mean.”
“Then secure or consolidate every conversation by securing trust,” she said. “The way you respond to a concern will determine whether or not you build that trust.”
Learn more from the AMA about how physicians can help address global burden of cancer inequality.