The American Cancer Society (ACS) has updated its guideline for HPV vaccination, adapting a 2019 update from the Federal Advisory Committee on Immunization Practices (ACIP). The ACS first issued a guideline for routine use of the HPV vaccine in 2007, with an update issued in 2016. This third version of the guideline is published in CA: A Cancer Journal for Clinicians, the ACS’s flagship medical journal.

For the update, members of the ACS’s Guideline Development Group (GDG) participated in content review of two new 2019 ACIP recommendations, and were charged to propose any modification or adaptation after reviewing the evidence evaluated by ACIP and its interpretation, as well as some recent studies and considerations related to implementation efforts to increase rates of population coverage and on-time vaccination. While there was broad general agreement, there were also some areas of difference between the ACIP recommendations and judgments of the GDG in the context of cancer prevention aims and nationwide efforts to increase vaccine utilization.

The ACS’s update addresses three key issues: The ACS adaptation emphasizes that vaccination may be routinely offered at age 9-12; it endorses harmonization of catch-up vaccination for all individuals through age 26 while continuing to include a qualifying statement about reduced effectiveness of vaccination at older ages (i.e. young adults as compared to teens and pre-teens); and does not endorse the recommendation for shared clinical decision-making about vaccination for adults aged 27-45 years.

Age to begin vaccination

Girls and boys should get 2 doses of the HPV vaccine at ages 9 to 12 years.

Qualifying Statement: Routine HPV vaccination between ages 9-12 years is expected to achieve higher on-time vaccination rates, resulting in increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine at age 9 or 10 years.

 Catch-up vaccination

Children and young adults up to age 26 years who have not received the HPV vaccine should get vaccinated. Vaccination of young adults will not prevent as many cancers as vaccination of children and teens.

Qualifying Statement: Providers should inform individuals aged 22-26 that vaccination may be less effective in lowering their cancer risk.

Adult vaccination

The ACS does not recommend HPV vaccination for persons older than 26 years.

Qualifying statement: ACS does not endorse shared clinical decision-making for adults ages 27-45 due to the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision-making on patients and clinicians, and the lack of sufficient guidance on selection of individuals who might benefit.

“We’re seeing evidence that  starting vaccination at age 9 or 10 has potential benefits that are expected to lead to higher vaccination rates, resulting in increased numbers of cancers prevented compared to starting at ages age 11 and 12,” said Debbie Saslow, PhD, managing director, HPV & GYN Cancers. “It’s for that reason we felt it was important to say that starting at age 9 or 10 is more than OK; it’s preferable to achieve the full cancer-preventing potential of this vaccine.”

The ACS decision not to endorse shared clinical decision-making for vaccination between ages 27 and 45 was based primarily on the minimal cancer prevention benefit expected from vaccination of individuals in that age range. In addition, there has been a global shortage of HPV vaccine that is expected to continue for the next several years.

“The combination of HPV vaccination and cervical cancer screening has the potential to prevent tens of thousands of cancers caused by HPV each year in this country and to eliminate cervical cancer as a public health problem in the coming decades,” conclude the authors. “Vaccination of all children between ages 9 and 12 years will prevent >90% of the cervical, oropharyngeal, anal, vaginal, vulvar, and penile cancers that are caused by HPV and, combined with screening and the treatment of cervical precancers, can lead to the first elimination of a cancer in history.”

Article: Saslow D, Andrews K, Manassaram-Baptiste D, Smith RA, Fontham E. Human Papillomavirus Vaccination 2020 Guideline Update: American Cancer Society Guideline Adaptation. CA: Cancer J Clin 2020 DOI: 10.3322/caac.21616