Introduction
Pharmacists have really stepped up as accessible primary care providers during the COVID-19 pandemic. It’s been a crazy ride, but it has helped define the profession. While COVID-19 is still very much on everyone’s mind, other important and prevalent diseases are falling through the cracks, such as heart disease and cancer (which are still the most common causes of death and disability in our society). In this article, we will discuss one important way to prevent cancers caused by human papillomavirus (HPV)—and the critical role that pharmacists could play.
Background: HPV and cancer
There are over 100 types of HPV, which can infect different parts of the body. Some types of HPV are primarily sexually transmitted. Some of these can cause anal and genital warts, and others can lead to more serious consequences such as cervical, penile and anal cancers (Figure 1). HPV can also cause certain cancers of the head and neck. 1
Figure 1.
Estimated human papillomavirus contribution to cancer
Sources: Global data – GLOBOCAN 2012 (https://gco.iarc.fr/); US data – https://www.cdc.gov/cancer/hpv/statistics/cases.htm.
HPV is the most common sexually transmitted infection. It is estimated that more than 70% of sexually active Canadian men and women will have a sexually transmitted HPV infection at some point in their lives. 2 Most HPV infections occur without any symptoms and resolve without treatment. However, in some people, HPV infections can persist. This is especially dangerous if the persistent infection is an oncogenic type. Persistent HPV infection with oncogenic subtypes of the virus is the major cause of cervical, vulvar and vaginal cancers and anal cancer, as well as, increasingly, the cause of various oropharyngeal cancers (Figure 2). 1 Currently, US data have shown that oropharyngeal cancers in men now outnumber cervical cancer in women. 3 And unfortunately, there is no early screening mechanism for oral cancers, like Pap screening for women.
Figure 2.
Human papillomavirus–related cancers
Three HPV vaccines are currently approved for routine vaccination (Figure 3): bivalent (2), quadrivalent (4) and nonavalent (9) vaccines. These vaccines protect against HPV types 16 and 18, accounting for 70% of cervical cancers. The nonavalent targets 5 additional strains, accounting for an additional 15% of cervical cancers. 4 Types 6 and 11 in HPV4 and HPV9 target genital warts. 4
Figure 3.
Human papillomavirus (HPV) vaccines
Indications: HPV vaccination is now approved by Health Canada for all women and men aged 9 to 45 years, including men who have sex with men and immunocompromised patients. In Canada, the National Advisory Committee on Immunizations (NACI) recommends HPV vaccination for school-aged children and for at-risk women and men aged older than 26 years, with no upper age limit. 4
With the advent of immunization for HPV in 2007, we now have data from multiple countries confirming the decrease in abnormal Pap tests, the reduction of early abnormalities, the reduction of cervical cancer and precancers and the dramatic decrease in genital warts.5-12
Australia is the first country in the world to have announced the impact of widespread immunization, with their estimate of fewer than 4 per 100,000 cases expected in the next 10 years. This would be considered an elimination of cervical cancer as a public health issue. 13
The key to that success is immunization.
However, we have a problem. With the pandemic, all prevention, including HPV immunization, has decreased. Measles immunization, for example, has decreased by 57% worldwide. Indeed, family physician visits were down by over 50% in the first part of the pandemic. 14 Furthermore, many school immunization programs have been interrupted due to COVID-19. Indeed, we have lost the 2020-2021 vaccination years for school-aged children. Pharmacists should ask parents and their children about their vaccination status—many are falling through the cracks—for the initial vaccination or the second/third dose.
We need strategies for Canadians to get immunized against HPV! We must have “all hands on deck.” We need pharmacists, as a very well-trusted and accessible division of health care providers, to focus on HPV vaccination, even as we struggle with COVID-19 and its impact.
Why now? Because cancer won’t wait. Cancer will not wait for a more convenient time, for COVID-19 to be finished, for patients to see their physician and have a leisurely discussion of risk. Cancer continues, relentlessly. So, when you see a patient receiving oral contraceptives, drugs for travel, immunization for travel, condoms, antibiotics or just about anything, it is time to discuss prevention. Even if someone is filling a prescription for statins or blood pressure medications, the conversation can be about self-care and prevention and then prevention of cancer, not just heart disease.
Proactive case finding: If you want to make a difference in cancer prevention, you cannot wait to be asked—you must be proactive. You can use case-finding tips to find patients who could benefit from a discussion about HPV-related cancer prevention (Table 1).
Table 1.
Case-finding tips for human papillomavirus–related cancer prevention
| Oral contraceptives |
| Other methods of contraception (e.g., condoms) |
| Travel medications/vaccinations |
| Prescriptions for children (can inquire about school vaccinations, both initial and second/third doses) |
| Other vaccinations: influenza, COVID-19 |
| Any other preventive therapy (e.g., antihypertensives, statins)—this shows that patients are interested in prevention |
Conversation starters can help (Table 2). Approach these situations as an opportunity to provide more holistic care for your patients. Be positive (don’t say “You’ll die if you don’t do this”). Make it part of your routine practice. You can say: “We discuss this with all of our patients.” Be opportunistic: if you are administering an influenza or COVID-19 vaccination, that is a good time to talk about other forms of prevention: “Great that you are getting this vaccination, now let’s talk about further prevention . . .” (but remember that vaccines should be staggered by at least 2 weeks before a COVID-19 vaccine and 4 weeks after receiving COVID-19 vaccine).
Table 2.
Conversation starters for human papillomavirus (HPV)–related cancer prevention
| Condition | Conversation starter |
|---|---|
| All patients | “As part of the full scope of care that I provide to all of my patients, I always ask about prevention of illnesses.” |
| Patients using contraceptives | “Just to be thorough, I know your family physician does regular Pap smears, but have they discussed HPV and cancer risk with you?” |
| Patient receiving an antihypertensive or statin | “It’s great that you are taking steps to prevention heart disease/stroke. We should also talk about prevention of the other big one, cancer.” |
| Patient receiving a vaccination for influenza, travel or COVID-19 | “It’s great that you are getting vaccinated to prevent xxxxx. We
should also talk about prevention of cancers.” Or: “These days, we all know how deadly viruses can be. Let’s talk about some other viruses like HPV.” |
| Filling a prescription for a child | “Did you know that due to COVID-19, many schools have stopped routine vaccination programs? Let’s discuss the vaccination status of (child’s name). I don’t want anyone falling through the cracks.” |
What else can you do? “Cancer Won’t Wait” is an initiative of the Federation of Medical Women of Canada (Figure 4). It brings together likeminded clinicians to provide education, collaboration and support for those interested in the prevention of cervical and other HPV-related cancers. We invite pharmacists to join in the movement.
Figure 4.
Cancer Won’t Wait
HPV resources.
Cancer Won’t Wait
All of Us Against HPV
HPV Prevention Week
https://fmwc.ca/hpv-prevention-week/
Immunization Canada—HPV
Conclusion
The COVID-19 pandemic has led to a greater appreciation of the primary care role of the pharmacist. There is a great need and opportunity for pharmacists to play a greater role in cancer prevention—let’s start with HPV-associated cancers. Stay safe!
References
- 1. Canadian Cancer Statistics 2016. Special topic: HPV-associated cancers. Available: https://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2016-EN.pdf?la=en (accessed Apr. 16, 2021).
- 2. Government of Canada, Public Health. Human papillomavirus. www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/human-papillomavirus-hpv.html (accessed Apr. 16, 2021).
- 3. Van Dyne EA, Henley SJ, Saraiya M, et al. Trends in human papillomavirus–associated cancers—United States, 1999-2015. MMWR Morbid Mortal Wkly Rep 2018;67(33):918-24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Government of Canada. Human papillomavirus vaccine: Canadian immunization guide. Available: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-9-human-papillomavirus-vaccine.html (accessed Apr. 16, 2021).
- 5. Garland SM, Kjaer SK, Muñoz N, et al. Impact and effectiveness of the quadrivalent human papillomavirus vaccine: a systematic review of 10 years of real-world experience. Clin Infect Dis 2016;63(4):519-27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Checchi M, Mesher D, Mohammed H, Soldan K. Declines in anogenital warts diagnoses since the change in 2012 to use the quadrivalent HPV vaccine in England: data to end 2017. Sex Transm Infect 2019;95(5):368-73. [DOI] [PubMed] [Google Scholar]
- 7. Palmer T, Wallace L, Pollock KG, et al. Prevalence of cervical disease at age 20 after immunisation with bivalent HPV vaccine at age 12-13 in Scotland: retrospective population study. BMJ 2019;365:l1161. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Innes CRH, Williman JÁ, Simcock BJ, et al. Impact of human papillomavirus vaccination on rates of abnormal cervical cytology and histology in young New Zealand women. NZ Med J 2020;133(1508):72-84. [PubMed] [Google Scholar]
- 9. Brotons M, Monfil L, Roura E, et al. Impact of a single-age cohort human papillomavirus vaccination strategy in Catalonia, Spain: population-based analysis of anogenital warts in men and women. Prev Med 2020;138:106166. [DOI] [PubMed] [Google Scholar]
- 10. Guo F., Cofie LE, Berenson AB. Cervical cancer incidence in young U.S. females after human papillomavirus vaccine introduction. Am J Prev Med 2018;55(2):197-204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Luostarinen T, Apter D, Dillner J, et al. Vaccination protects against invasive HPV-associated cancers. Int J Cancer 2018;142(10):2186-7. [DOI] [PubMed] [Google Scholar]
- 12. Lei J, Ploner A, Elfström KM, et al. HPV vaccination and the risk of invasive cervical cancer. N Engl J Med 2020;383(14):1340-8. [DOI] [PubMed] [Google Scholar]
- 13. Hall MT, Simmss KT, Lew J-B, et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study. Lancet Public Health 2019;4(1):E19-E27. [DOI] [PubMed] [Google Scholar]
- 14. Glazier RH, Green ME, Yu FC, et al. Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada. CMAJ 2021;193:E200-10. [DOI] [PMC free article] [PubMed] [Google Scholar]