Cancer Prevention Through HPV Vaccination

Cancer PreventionThrough HPV Vaccination:An Action Guide for DentalHealth Care Providers

Cancer Prevention Through HPV Vaccination: An Action Guide for Dental Health Care ProvidersACKNOWLEDGMENTSThe National HPV Vaccination Roundtable would like to thank allmembers of the Provider Training Task Group for participating inthe development of the six clinical action guides. Visit our websiteto view the entire suite of guides.1We offer sincere appreciation to the following individuals for their contributions to this guide:Margot Savoy, MD, MPH, FAAFPSharon Perlman, DDS, MPHJennifer Nkonga, MSCherie Ann Nathan, MD, FACSMichael Moore, MD, FACSAmerican Academy of Family PhysiciansAmerican Association of Public Health DentistryAmerican Cancer SocietyHead and Neck Cancer AllianceHead and Neck Cancer AllianceA Collaborative Project: The Clinician & Systems Action Guides are a collaborative project of the Provider Training TaskGroup of the National HPV Vaccination Roundtable. Guides do not necessarily represent the views of all HPV Roundtablemember organizations.Funding: Funding for this guide was made possible (in part) by the Centers for Disease Control and PreventionCooperative Agreement grant number NH23IP922551-01, CFDA # 93.733. The content in this guide does not necessarilyreflect the official policies of the Department of Health and Human Services, nor does the mention of trade names,commercial practices, or organizations imply endorsement by the U.S. Government.Version 2.0 released September 2019.www.hpvroundtable.org2

3You have the power to reduce the incidence of humanpapillomavirus (HPV) cancers and pre-cancers amongpatients in your care. HPV cancer prevention starts with you.Oral health professionals play a critical role in combating growing rates of HPV-positive oropharyngealcancers, which affect the tonsils and the base of the tongue. Oral health professionals should stronglyand clearly recommend HPV vaccination to all age-eligible patients.The ProblemThe SolutionHPV-positive oropharyngeal cancer has surpassedcervical cancer as the most prevalent HPV cancer.Certain strains of HPV cause 70% of oropharyngealcancers in the U.S., affecting about 13,500 people eachyear. One in nine American men have oral HPV,i andcancers of the oropharynx are about four times morecommon in men than women.ii Oral HPV has beendetected in newborns when the mother has an HPVcervical infection,iii and research shows that 2.5% ofadolescents have HPV.iv Although most cases of HPVresolve without incident, HPV causes about 34,800cases of cancer in men and women each year in theU.S., including cancers in the oropharynx, cervix,vagina, vulva, penis, and anus.vThe HPV vaccine is cancer prevention. Boys and girlsshould get the HPV vaccine series at age 11 or 12. Thevaccine can be given starting as early as age 9. The HPVvaccine is most effective when given before age 13 toachieve the best immune response, and it provideslong-lasting protection.ix For patients who were notvaccinated on time at 11–12, vaccination may beprovided up to age 26 for females and males.HPV is linked with:70 91 63%of oropharynx%of cervicaland analcancers%of penilecancersviHigh-Risk Factors for Oropharyngeal Cancervii,viii Chewing tobacco Heavy smoking (more than a pack a day) Chronic inflammation Having a weakened immune system Poor oral hygiene Current marijuana use Having 16 or more lifetime vaginal or oral sex partners Men with two or more same-sex oral sex partnersHPV vaccination works. The HPV vaccine preventsinfection by the HPV types that cause the vast majorityof HPV cancers and genital warts. In fact, infections withthe HPV types that cause most HPV cancers and genitalwarts have dropped 71% among teen girls since childrenfirst started getting the vaccine in 2006.x71%drop in HPV infectionsamong teen girls since2006It is estimated that approximately 90% of the newlydiagnosed HPV-attributable cancers in the United Statescould be prevented by receipt of the HPV vaccine,xi andthere is evidence that the vaccine may help prevent oralHPV infections.xii Get more facts.2Educate patients and parents of age-eligible childrenabout the link between HPV and oropharyngealcancers, and advocate for HPV vaccination as cancerprevention. With the annual number of oropharyngealcancers on the rise, dental providers play an importantrole in educating their patients about ways to preventthis type of cancer. You and your colleagues shouldunderstand and encourage HPV vaccination. On thepages that follow, you will find a list of actionable stepsyou can take to reduce the burden of HPV cancers withinyour community today.

4Actions At-A-GlanceVisit the action associated with each item below for detailed guidance.Know your unique roleAction 1Practice cancer preventionAction 2Refer patients for vaccinationsAction 3CollaborateAction 4Engage your teamAction 5Create a pro-immunization environmentPatient Education ToolsIf you are reading a printed version of this guide, please see the Appendix for full links tohyperlinked words, as indicated by superscript numbers (e.g., Get more facts2).

Cancer Prevention Through HPV Vaccination: An Action Guide for Dental Health Care ProvidersACTIONS DENTALPROVIDERS CAN TAKEAction 1 Know your unique roleDental providers play a unique role3 in HPV cancerprevention. Although dental providers cannot screen fororal HPV, you can reduce the incidence by promotingHPV vaccination. View this short video4 from the National HPVVaccination Roundtable for more information aboutHPV and oropharyngeal cancer. Read the American Dental Association (ADA)Council on Scientific Affairs’ statement,5 whichurges dentists to educate themselves and theirpatients about the connection between HPV andoropharyngeal cancer. Build on your existing practices. Dental providersare already involved in secondary and tertiaryprevention (e.g., nutrition and tobacco counseling).Offering primary prevention in dental offices is alogical and clinically appropriate approach.xiii Capitalize on patient visits. Adolescent patients tendto see the dentist twice yearly, which may be moreoften than they see their primary care provider—thisis a window of opportunity for dental professionalsto provide counseling to parents about the HPVvaccine and HPV’s link to oral cancer.xiv Consider how you can take active measuressuggested by the American Academy of PediatricDentistry’s policy statement6 on HPV vaccination.Action 2 Practice cancer preventionParents may be unaware of the link between HPV andoral cancer. Educate parents of your pediatric patients7(starting around age 9 or 10) about the risks of HPVand the importance of getting the HPV vaccine byreinforcing that the HPV vaccine is cancer prevention. Post information in patient waiting rooms. Include a question about immunizations on themedical history form. Begin the discussion about the HPV vaccine whiletaking your patient’s comprehensive health historyand when performing routine oral cancer screenings.Tell your patients that oral exams include looking forpossible physical symptoms (lumps and bumps).5 Emphasize that cancer prevention begins with theparent. Learn tips for talking to parents about the HPVvaccine,8 and be prepared to answer their questions. Include HPV cancer prevention information on yourwebsite9 and social media pages. Suggest parentsvisit the HPV Cancer Free Family10 Facebook groupwhere members of the National HPV VaccinationRoundtable can answer parents’ questions, or followthe Roundtable’s Twitter page.11

Cancer Prevention Through HPV Vaccination: An Action Guide for Dental Health Care ProvidersAction 3 Refer patients forvaccinationsParents may be ready to get their child vaccinated afterspeaking with you about the HPV vaccine. Harness thisopportunity by sharing information and making referrals. Refer patients to their primary care provider. Stressthe importance of vaccination at ages 11–12 andfollow up with patients on their next visit. If patients lack a primary care provider, share yourrecommendation, or encourage them to contact thelocal health department. Distribute the printed HPV vaccine “Rx pad”reminders made available by Team Maureen.126Action 4 CollaborateConsider partnering with pediatricians and primary careproviders to ensure the continuum of care. Togetheryou can develop and share examples of clear, concisemessages, such as: You have the power to protect your childagainst several types of cancer. We now have a vaccine to prevent severaltypes of cancer. HPV causes around 70% of throat cancer. As a parent, you have the power to helpensure your children are healthy throughvaccination. Take your child to the doctor and dentistnow to prevent health problems later.Action 5 Engage your team Educate your entire team about the link betweenHPV and oropharyngeal cancer,13 and ensure theyknow the difference between oral cancer andoropharyngeal cancer.14 Share short videos of HPV oropharyngeal cancersurvivors15 to convey the importance of the vaccine. Create a cancer prevention culture in your officeby arming staff with the right language16 to speakprofessionally and confidently about the vaccine,and establish processes to make appropriaterecommendations to your patients. Let it be knownthat your practice believes in cancer prevention. Review the ADA’s Evidence-based Clinical PracticeGuidelines for the Evaluation of Potentially MalignantDisorders in the Oral Cavity,17 which detail sixclinical recommendations. The panel concludedthat no available adjuncts demonstrated sufficientdiagnostic test accuracy to support their routine useas triage tools during the evaluation of lesions in theoral cavity. The ADA offers continuing education18 onthis topic.