High-risk HPV prevention and overtreatment reduction amongst Young females
Efforts to save time, money, and REDuce harm/morbidity amongst women diagnosed with oncogenic hpV
Isabella Batki
28 February 2017
What is HPV?
Human papilloma virus (HPV) is the most prevalent sexually transmitted infection in this country. About 14 million new cases occur each year.1 It is spread from the mucous membrane one person to that of another person’s through sexual contact.3 About 90% of HPV cases are benign and clear within a year or two.1 HPV has been classified into two categories: low-risk cases, also known as wart-causing, and high-risk cases, which are cancer precursors.1 This policy brief will deal primarily with the high-risk strains as they are the types that lead to cancer. Approximately 14 out of 40 known HPV types are considered to be high-risk strains.3 The diagnosis of high-risk, pre-cancerous HPV is a frightening one received by about half of all women diagnosed with HPV and some 5% of such diagnoses will result in some type of cancer, be it cervical, oral-pharyngeal, and anal, amongst others. Advances in screening mechanisms, most notably the Pap smear, have without a doubt been key to the decrease in incidence of HPV and cancers related to HPV types 16 and 18, which play a role in causing 70% of cancers worldwide. The development of Gardisil and Cervarix, both vaccinations against several strains of HPV, have also been major players in the reduction of HPV incidence.5
90% of women and 80% of men will become infected with some type of hpv in their lifetime1
What’s the issue?
HPV has an estimated economic burden of around $4 billion in the U.S. between screening and treatment mechanisms. The United States health care system has utilized the Center for Disease Control (CDC) in conjunction with the National Cancer Institute (NCI) in an effort to reduce the number of cancer-causing HPV infections in our country, however, increasing attention should be paid to the education and vaccination of more young patients. In addition to the issue of cost, young females are frequently over-treated after receiving a high-risk HPV diagnosis. Many high-risk diagnoses will clear within a year or two on their own.1 However, there still exists the temptation to treat any abnormality referred to as “pre-cancerous” or “pre-carcinogenic” very aggressively, which can often lead to over-treatment of cases that may have just cleared if left alone.15 This can inflict excess suffering upon the patient as well as unnecessarily expend health care dollars. This is not to say that cervical cancer screening is wholly detrimental. Since 1950, the incidence of cervical cancer has decreased almost 60% thanks to the development of the Pap smear. However, with the current practices of screening and early diagnosis, a difficult trade-off arises: catching the rarer, more dangerous cervical abnormalities while also risking the overtreatment of the more common, benign abnormalities. Hence, strides can be made within our health care system to rein in costs resulting from excess treatment of high-risk HPV. Additionally, this policy brief will provide an overview as to how education, vaccination, and the use of medical jargon can affect treatment and health care costs with regards to high-risk HPV.
Who is affected?
Both females and males can become infected with HPV. Risk factors for the disease include having multiple partners, having lower socioeconomic status, contraception use, religion, and race. The most heavily affected group is women from the ages 20-24.6 Men are excluded from this statistic because there is no test that has been approved to accurately determine if a man has HPV. Lack of access to care plays an enormous role in the persistence of high-risk HPV in patients who have low incomes, do not speak English well, and do not have transportation. These patients who do not have access to screening are at a much higher risk for cancer because high-risk HPV may progress while preventive measures were not taken.
Figure 1. HPV rates by age group, pre/post vaccine.
Interventions
Education regarding vaccination. From a very fundamental level, high-risk HPV can be prevented by simply expanding educational resources to parents and their children. The Center for Disease Control has made tremendous efforts in attempting to educate both parents and children about how HPV is spread and what precautions can be taken to prevent it. One way to prevent misdiagnoses of pre-cancerous HPV is to eliminate the possibility of becoming infected in the first place. This is a very cost-effective way of eliminating the need to spend health care dollars on the morbidity and mortality caused by the disease in the future. In the past few years, immunizations against several HPV types have been approved to administer to patients. Primary prevention via vaccination is an extremely effective way to attempt to eliminate the possibility that a patient becomes infected with high-risk cancer-causing HPV. The vaccine for HPV types 11, 16, and 18 was made available to females in 2006 and more recently became available to males as well.1 The recommended age of administration is 11-12 years for both groups.9 Even more recently, vaccinations have become available offering protection to upwards of nine types of HPV.1 It is estimated that over the next 35 years, HPV vaccinations will save the country almost $3 billion.
Figure 2. Number of unvaccinated boys and girls in U.S.
Screening at a later age in young women and larger gaps between screenings. Screening young women too frequently has shown to result in unnecessary health care costs as well as an increase in harm to the patient. Recently, new regulations formed by the American College of Obstetrics and Gynecology decided that women should not receive a Pap smear until at least the age of 21. They also determined that screening should occur at intervals of three years apart if the original Pap smear proved to be normal, a shift away from the previously recommended screening each year. 10 Additionally, the age of screening specific to high-risk HPV types was delayed until age 25, which some providers believe is even still too young as it usually takes much longer for cervical cancer to develop.13 One study that compared high-risk HPV screening at age 25 versus age 30 showed that screening at the younger age resulted in almost 55% more cervical intraepithelial neuroplasias but simultaneously doubled the number of biopsies performed, exemplifying the trade-off between early detection and skyrocketing costs spent on unnecessary procedures. Biopsies were noted as a severe factor contributing to the harm of the patient.13
Increasing selectivity of women who must undergo endocervical curettage. Women who are determined to have high-risk HPV display cellular abnormalities upon Pap smear testing. Depending on what type of abnormal cells are shown, women may be referred to have a cervical biopsy of the affected portion of the cervix in order to determine what type of cells are causing the abnormality. One type of biopsy is the simple cervical biopsy, where cells are collected from the cervix using a curette in a procedure called endocervical curettage (ECC).5 ECC adds quite a bit of cost to colposcopies but contributes the ability to increase the sensitivity of the test in being able to pinpoint cervical cell abnormalities.5 ECC is less cost-effective in women under the age of 50. For this age group, the cost of ECC is approximately $97,000 per life saved.14 This is still considered relatively cost-effective if there exists a willingness to pay over $80,000 per cervical cancer death, however it is still substantially less cost-effective for women of this age compared to their older counterparts.14 Although it currently varies on a provider to provider basis, some physicians choose to avoid ECC in young women who display abnormalities that are “low grade” even when other professionals would choose to perform an ECC regardless in order to completely rule out carcinogenicity.5 The latter approach could fall under the heading of over-treatment. The former approach proves to be more cost-effective, using close monitoring as a powerful tool to ensure the patient’s well-being and quality of care.
Figure 3. Recommended screening for various outcomes.
Avoid the use of harsh vocabulary when diagnosing patients. In the past, women who tested positive for high risk HPV were commonly also told that they possessed “pre-cancerous cells”. This phrasing can be tempting to treat as cancer because of the label that is automatically applied by diagnostic standards. Labeling a lesion or abnormality as such has proven to make it far more difficult for physicians to resist treatment, even if it is not as dangerous as the term implies. By changing the wording of “pre-cancerous” HPV to a label more technical and objective, we may be able to reduce some of the frantic attitudes that health care providers possess, or at least encourage the provider to consider other methods and more patience is observing the case to see if it clears on its own. This is especially important with regards to HPV when patients who are most likely completely healthy are shifted suddenly into being potential cancer victims, all because the formal label says as much.4 Physicians have been pushing for the labeling of pre-cancerous HPV as “cervical intraepithelial neoplasia”, which is slightly less threatening than the usage of “cancer”. Medical jargon can have an extraordinary effect on the reactionary tendencies of both providers as well as patients, and limiting the jargon can help to reduce stress all around. Once there is less alarm associated with the diagnosis, physicians will be less likely to provide a one-size-fits-all treatment, usually involving an invasive and often unnecessary biopsy procedure. The less unnecessary procedures provided, the less cost there is expended unnecessarily.
Next steps
The health care system has already taken several steps in order to reduce over-diagnosis and over-treatment in reference to HPV and cervical cancer, as described under “Interventions”. There are still more measures the US health care system can take to expedite the process of reducing the morbidity and cost of such issues.
Figure 4: Decrease in HPV prevalence post-vaccination era.
Continue pushing for more education and vaccination. Continuing education and vaccination efforts are highly efficient ways to reduce the number of high-risk infects in mass quantities. The United States could always stand to further improve educational efforts with regards to sexual education as well as educating about the urgency and necessity of vaccination. There still exists the ability to improve vaccination rates amongst young males and females. As shown in figure 2, only 6 out of every 10 girls are vaccinated while only 4 of every 10 boys are vaccinated.11 Since the vaccination for boys was developed more recently than the one for girls, it is important that we as a health care system continue to push for the vaccination of young males as it contributes to the spread of disease. Publicly funded educational programs such as those put on by the CDC should be revised and expanded in order to reach the maximum number of patients possible.
Continue to reassess screening tactics. It is obvious that there is still much dispute as to when and how often women should be screened for high-risk human papilloma virus. Further research is recommended to formulate screening mechanism that accommodate new findings, incidence of the disease, and developments in vaccinations.