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Am Fam Physician. 2008;77(6):852-863

Author disclosure: Dr. Cox is a member of the data and safety monitoring board for the Merck quadrivalent HPV vaccine trials. Dr. Mahoney is a member of the advisory board and speakers bureau for Merck & Co. Inc. Dr. Moscicki is a member of the speakers bureaus for Merck & Co. Inc. and GlaxoSmithKline.

Guideline source: American Cancer Society

Literature search described? Yes

Evidence rating system used? Yes

Published source: CA: A Cancer Journal for Clinicians, January/February 2007

The American Cancer Society (ACS) guideline for the early detection of cervical cancer was last reviewed and updated in 2002.1 Since then, two vaccines against the most common cancer-causing types of human papillomavirus (HPV) have been developed and tested in clinical trials (i.e., quadrivalent HPV vaccine [Gardasil] and bivalent HPV vaccine [Cervarix], not yet approved by the U.S. Food and Drug Administration [FDA]).27 An expert panel was convened by the ACS to review the data on HPV vaccines and to develop recommendations for their use.8 This group worked independently from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, but reviewed the same data sources. Recommendations from both groups for the use of the quadrivalent HPV vaccine were published in 2007 and are summarized in Table 1.24,810 The ACIP recommendations, which the American Academy of Family Physicians endorses, apply specifically to the quadrivalent vaccine because it currently is the only FDA-approved HPV vaccine. The ACS recommendations are meant to include the quadrivalent vaccine and, pending FDA approval, the bivalent vaccine.

ACIP recommendation*ACS recommendation*
Routine HPV vaccination with three doses of the quadrivalent vaccine (Gardasil) is recommended for girls 11 and 12 years of age9,10 Routine HPV vaccination is recommended for girls 11 and 12 years of age8
Girls as young as nine years can be vaccinated9,10 Girls as young as nine years can be vaccinated8,10
HPV vaccination is recommended for all females 13 through 26 years of age to catch up missed doses or to complete the vaccination series24,9,10 HPV vaccination is recommended for all females 13 through 18 years of age to catch up missed doses or to complete the vaccination series8,10
The quadrivalent vaccine is not licensed for use in females younger than nine years or older than 26 years9 HPV vaccination is not recommended for women older than 26 years8
The quadrivalent vaccine is not licensed for use in males9 HPV vaccination is not recommended for males8
Cervical cancer screening recommendations have not changed for women who receive HPV vaccination9
A history of abnormal Papanicolaou test results, a positive HPV test result, or genital warts does not preclude a woman from receiving HPV vaccination9
Women should be advised that there is no clear evidence of vaccine protection for women who were previously infected with HPV vaccine types24,9 The vaccine ideally should be administered before potential exposure to genital HPV because the potential benefit is likely to diminish as the number of lifetime sex partners increases24,8
Data are insufficient to recommend for or against universal vaccination of women 19 to 26 years of age in the general population†; a decision about vaccination should be based on an informed discussion between the woman and her physician regarding her risk of previous HPV exposure and potential benefit from vaccination

HPV-related disease includes genital warts; recurrent respiratory papillomatosis; cytologic abnormalities; and cervical, vaginal, and vulvar cancers and their associated precursor lesions. In addition, HPV is causal in a significant percentage of anal, penile, and head and neck cancers.11,12 Virtually all cervical cancers are causally related to persistent HPV infection13; HPV types 16 and 18 account for 70 percent of cervical cancers14 and 50 percent of cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3) lesions.15 Most HPV infections are transient and resolve or become undetectable within two years.1618 However, when HPV infection persists, the stepwise development of invasive cancer takes an average of 20 years.19

Genital HPV is transmitted primarily by skin-to-skin contact, usually through vaginal or anal intercourse, although intromission is not necessary. The risk of transmission by digital-genital and genital-oral contact appears likely but has not been well studied.20 Infection is common within a few years after first sexual intercourse, with almost three fourths of new infections occurring in women 15 to 25 years of age.17,21 An estimated 80 percent of sexually active men and women acquire a genital HPV infection at some point in their lifetime.22

Although cytologic screening has resulted in marked decreases in cervical cancer incidence and mortality (74 and 75 percent decreases, respectively), racial and ethnic disparities remain in incidence, mortality, and survival.23 HPV DNA testing for the presence of high-risk HPV types is indicated in two cervical screening scenarios: in conjunction with cervical cytology screening in women 30 years and older,1,24,25 and for the triage of abnormal Papanicolaou (Pap) test results read as atypical squamous cells of undetermined significance in women 21 years and older.26,27

Secondary recommendations for HPV vaccination are summarized in Table 2.8,9

General recommendations and precautions
HPV testing before vaccination is not recommended8,9
HPV vaccine can be given to women with minor acute illnesses (e.g., diarrhea, respiratory tract illnesses with or without fever) but should not be given until recovery from a moderate or severe illness9
The second most common adverse event reported after HPV vaccination is vasovagal syncope, which is common in persons 10 to 18 years of age who receive any vaccine; observation of patients for 15 minutes after vaccine administration is advised9
The use of noncomprehensive visits (e.g., those for minor illness or sports physical examinations) and alternative vaccination sites for adolescents who are unable to access comprehensive preventive care is encouraged8
Immunocompromised patients
HPV vaccine can be given to women who are immunocompromised by disease or medications, but the immune response and vaccine effectiveness may be reduced9
Pregnant and lactating patients
Pregnant women should not receive the HPV vaccine; if a woman becomes pregnant after initiation but before completion of the three-dose vaccine regimen, administration of the remaining doses should be delayed until after completion of the pregnancy9
If a vaccine dose is administered during pregnancy, no intervention isneeded9; a registry is available for pregnant patients who are vaccinated with the quadrivalent HPV vaccine (Gardasil)
Lactating women can be vaccinated9

Rationale and Evidence for Vaccination

Two prophylactic HPV vaccines have been developed that elicit strong and sustained immunity to HPV types 16 and 18 in clinical trials27,9,28; one of the vaccines also protects against two low-risk HPV types that are associated with 90 percent of cases of genital warts.3,4 Clinical trials showed that these vaccines are 75 to 100 percent effective in preventing persistent type-specific HPV 16 or 18 infection and 90 to 100 percent effective in preventing CIN 2/3, the accepted disease end point for cervical cancer, in patients who adhered to the study protocol.27,28

Few safety issues were observed during the trials, and most adverse effects were mild or moderate. The most common injection site reactions were pain, redness, and swelling, with severe intensity being reported more often in vaccine recipients than in placebo recipients.24,8,9 The most common systemic adverse effects were fever, headache, and nausea; these effects were reported by a similar proportion of vaccine and placebo recipients (69 percent). No deaths secondary to vaccine were reported. Although the quadrivalent HPV vaccine is classified as FDA pregnancy category B, ACIP does not recommend that it be given during pregnancy.9 However, ACIP has noted that the quadrivalent HPV vaccine is safe for breast-feeding women.

Because HPV is often acquired soon after the onset of sexual intercourse,20,21 routine vaccination before or shortly after first intercourse (i.e., at 11 or 12 years of age) is important to achieve optimal effectiveness. In the United States, 24 percent of girls report being sexually active by 15 years of age,29 and 7 percent of high school students (male and female) report that they had intercourse before 13 years of age.30 The risk of exposure to carcinogenic and noncarcinogenic HPV types increases with the number of lifetime sex partners.20,21 National survey data have shown that approximately 50 percent of women older than 19 years of age have had four or more sex partners.31 Because women with more than four lifetime sex partners were excluded from the quadrivalent vaccine trials and those with more than six lifetime partners were excluded from the bivalent vaccine trials, the ACS concluded that there is insufficient evidence from the general population to recommend for or against vaccination of women 19 to 26 years of age, and no evidence for women older than 26 years.8 Women 19 to 26 years of age who have been sexually active should be counseled that the vaccine may not protect them from all of the vaccine HPV types.8

The quadrivalent vaccine has demonstrated robust immune responses in adolescents (male and female) between nine and 15 years of age.10

Anticipated Impact of HPV Vaccination

Because HPV 6, 11, 16, and 18 are associated with approximately 40 percent of histologically confirmed CIN, vaccination is expected to lead to reductions in abnormal Pap test results, colposcopy referrals, cervical biopsies, and excisional procedures.15 Decreases in the number of surgical procedures will also reduce procedure-associated complications.32 There is insufficient evidence to alter screening recommendations.8 Women who receive the HPV vaccine should continue to follow current Pap screening guidelines.2,3,8,9

It is hoped that HPV vaccination will decrease existing disparities in cervical cancer incidence, mortality, and morbidity. In particular, provision of free HPV vaccines to all eligible girls up to 18 years of age under the federal Vaccines for Children Program is expected to benefit many medically underserved girls who may not receive regular screening as they get older. Similar racial and ethnic disparities in acute hepatitis B infections among children younger than 19 years were virtually eliminated in the United States between 1990 and 2004 after universal hepatitis B vaccination was recommended.33

Vaccine Implementation and Administration

The HPV vaccine can be given during the preadolescent health care visit at age 11 or 12 years, in addition to the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Boostrix, Adacel) and quadrivalent meningococcal conjugate vaccine (Menactra). This visit also gives physicians a platform to ensure compliance with other recommended vaccinations and to provide health guidance. Reminder systems can be used to ensure completion of the three-dose HPV vaccine series.

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