Nancy McClung, PhD, RN - Photo credit: Mike Glatzer
What if preventing cancer were as simple as getting a shot in the arm? That is the reality for over 90% of cancers caused by the human papillomavirus (HPV).1
However, statistics from the Centers for Disease Control and Prevention (CDC) reveal that less than 50% of the US population within the targeted age range has received all recommended doses of the HPV vaccine.2
Oncology nurses must stay attuned to the critical vaccination information, including prevalence and prevention, treatment and immunization, and future advances.
HPV-RELATED CANCERS IN THE UNITED STATES
HPV infections affect nearly every sexally active person at some point in their life. Although many infections are asymptomatic and resolve without treatment, others are implicated in the 10,800 cases of cervical cancer, 12,900 cases of oropharyngeal cancer, 5900 cases of anal cancer, 3300 cases of vulvar and vaginal cancer, and 900 cases of penile cancer diagnosed in the United States every year. Additionally, about 300,000 new cases of high-grade cervical (precancerous) lesions are identified annually through screening.3
When given before exposure to the virus, the HPV vaccine effectively prevents over 90% of these occurrences. It is the only vaccine currently available for the prevention of cancer.
Nancy McClung, PhD, RN, epidemic intelligence service officer and nurse epidemiologist with the International Center for Immunization and Respiratory Diseases, Office of Infectious Diseases, at the CDC in Atlanta, Georgia, is part of a team involved in policy work and research into the impact of the HPV vaccine in the United States. At the 2019 Annual Epidemic Intelligence Service Conference, she presented the results on the prevalence of HPV infections in female patients in the United States. Since 2006, when the vaccine was introduced, adolescent vaccination-preventable HPV infections have decreased by 86%. For women aged 20 to 24 years, the decline has also been significant, at 71%.4
These numbers reflect steadily increasing vaccination rates, although the HPV vaccine is still given less than other, more established vaccines. In 2013, the team began monitoring HPV vaccine–preventable infections in male patients; they expect to see similarly encouraging results as data become available. The most common HPV-caused cancer in male patients occurs in the oropharynx. “We know HPV causes cancer because we find HPV in all kinds of anogenital cancers, including cervical, anal, penile, vulvar, and vaginal. The virus is detected through biopsy only after becoming cancerous,” McClung said.
Most HPV-caused cancers cannot be detected in the precancerous stage; cervical cancer is the exception and can be detected earlier through screening and subsequently treated. “Parents can prevent cancer in their children by vaccinating them. Providers can prepare and plan for vaccinating adolescents the same day and same time as other routine vaccinations, such as tetanus and meningitis. This vaccine is working. We are confident that it will prevent cancer.”
HPV VACCINATION RECOMMENDATIONS
Recommendations for the HPV vaccine were approved in 2006 for female patients and in 2011 for male patients. Because the vaccine works best before exposure to the virus, parents should have their children vaccinated before they are sexually active. It bears repeating that HPV is a very common virus with a high risk of exposure at some point in an individual’s life. McClung stressed that the vaccine is preventive, not therapeutic; it will not cure the infection or cancer.
Although 3 variations of the HPV vaccine are available, only 1 is currently used in the United States. The earlier quadrivalent vaccine (2006- 2015) protected against HPV types 6 and 11 (anogenital warts) and 16 and 18 (most types of HPV cancers), whereas the 9-valent vaccine (2016-present) protects against the same strains as well as 5 additional types.
The CDC recommends routine HPV vaccination at age 11 or 12 years, although clinicians may start it in children as early as age 9. Two doses are recommended for most people starting before their 15th birthday, with the second dose given 6 to 12 months after the first. Patients require a third dose if the first 2 doses were given less than 5 months apart.5
Teens and young adults who start the series between ages 15 and 26, as well as immunocompromised individuals aged 9 to 26 years, should receive 3 doses of the HPV vaccine, with the second dose given 1 to 2 months after the first, followed by the third dose 6 months later. The CDC also recommends HPV vaccination for individuals already sexually active or exposed to HPV to protect against other types of the virus. Vaccinated individuals not only protect themselves from HPV infection but also indirectly protect those who are unvaccinated. This is known as herd protection, and cost-effectiveness models predict that reductions in HPV infections in unvaccinated men and women are likely, given enough numbers of vaccinated individuals.6
The HPV vaccine is extremely safe. Adverse reactions are similar to those of other vaccinations, with the most common being pain, redness, and swelling at the injection site and, less frequently, mild fever. The vaccine is available to every child in the United States, and nurses at all levels of care and care settings can be the voice to the public for the HPV vaccine and its role in preventing cancer.
SIPULEUCEL-T AND PROSTATE CANCER TREATMENT
Clinicians are also using vaccines to treat cancer. Sipuleucel-T (Provenge) was approved by the FDA in 2010 as a first-line treatment option for men with metastatic, minimally symptomatic, castrate-resistant prostate cancer. Meredith Morgan, PhD, a nurse practitioner at the University of Michigan’s Cancer Center in Ann Arbor, specializes in genitourinary cancer. She spoke with Oncology Nursing News® recently about the benefits of sipuleucel-T.
“The mechanism of action of this autologous, cellular immunotherapy—though somewhat unknown—directs the immune system to attack prostate cancer cells,” Morgan said. “Sipuleucel-T does not influence PSA [prostate-specific antigen] levels, and we don’t see a real difference in scans of patients treated with the vaccine, making it challenging to measure its success. What we do know, however, is that patients tend to live an average of 4.1 months longer when treated early. Sipuleucel-T is well tolerated, and adverse reactions are generally mild and short-lived. The vaccine is not useful, however, for patients with end-stage cancer. And although it is quite expensive, the cost of the drug is often covered by insurance.”
Since the introduction of the vaccine in the prostate cancer space, the FDA has approved several alternative oral medication options. Assessing patient appropriateness for sipuleucel-T is important, as other therapeutic treatments may be equally as effective in providing survival benefits. Once a clinician has identified a patient as a candidate for sipuleucel-T, the preparation of their personalized therapy begins.
“The first step takes place in an apheresis center, such as those operated by the Red Cross, where a vein assessment is completed. Patients with inadequate veins will require an implanted port; patients with adequate veins will have a dialysis-type catheter inserted, 1 in each arm. Over a 3- to 4-hour period, blood is removed, immature antigenpresenting cells are collected, and the blood is returned to the patient,” Morgan explained. “The collected cells are shipped to the drug manufacturer’s lab, where a protein [immune cell activator] is added to boost the immune power of the cells. After a 3-day turnaround time, these super white cells are shipped out and courier-delivered to the infusion setting, where they are given the same day,” Morgan added.
The treatment plan comprises 3 rounds of apheresis and infusion. The entire process is time sensitive and requires precise coordination to ensure the drug is delivered and administered within the allotted window. Nurses should instruct patients to drink plenty of water before the apheresis process, avoid caffeine, eat a calcium- rich breakfast, wear clothing with loose-fitting sleeves, and arrange for a ride home, as the blood removal procedure can be exhausting.
Nurses administering the immunotherapy wear standard personal protective equipment and follow the same safety checks as those for other transfusions. Opening the medication box, spiking the drug, and beginning the procedure of infusion must be completed within a tight time frame. Verifying patient information and the expiration date and time requires 2 registered nurses as a safety measure. Adherence to protocols provided by the drug manufacturer is a key responsibility for nurses who are administering the therapy. Infusions are given using primary intravenous tubing with no filter.
Adverse events associated with sipuleucel-T are generally infusion related. Patients are premedicated with acetaminophen and diphenhydramine and instructed to continue taking acetaminophen post infusion as needed for chills, fever, muscle aches, and joint pain. These symptoms are shortlived and much more tolerable than reactions associated with traditional chemotherapy. Some patients, such as those receiving steroid medications or with hematologic disorders, are not candidates for this treatment.
IMMUNIZATION CONSIDERATIONS FOR PATIENTS WITH CANCER
Routine vaccination is also an important consideration for patients with cancer, as some vaccine-preventable diseases may be linked to worse outcomes in this population. The CDC issues routine vaccination recommendations for patients based on age, evidence of immunity, and special criteria, such as immunocompromising conditions.7
Based on the severity of those conditions in patients, clinicians may need to delay vaccinations. Activated vaccines should be given prior to immunotherapy or chemotherapy or following completion of treatment.8
Influenza can lead to serious complications in patients with cancer. As such, nurses must stay abreast of current developments regarding flu vaccines to ensure they provide accurate information to their patients about the timing and effectiveness of vaccine administration.
THE FUTURE OF CANCER VACCINES
Research, development, and testing of vaccines for the treatment of a variety of cancers are ongoing. These therapies include tumor cell vaccines, antigen vaccines, dendritic cell vaccines, and vector-based vaccines. Vaccine study is under way for common cancers such as glioblastomas and other brain cancers, lymphoma, melanoma, and breast, cervical, colorectal, kidney, lung, pancreatic, and prostate cancers. This is an exciting area of research with the potential to significantly affect oncology nurses’ perception and use of vaccines for patients with cancer. Nurses will be at the forefront of patient education as new treatments and preventive measures become available. As clinical trials move forward, oncology nurses will also be instrumental in guiding patients through the enrollment process and sharing information as it is disseminated throughout the healthcare community. The day may come when preventing a variety of cancers is truly as simple as a getting a shot in the arm—the idea may not be that far-fetched after all.
- Why is HPV vaccine important? Centers for Disease Control and Prevention website. cdc.gov/hpv/hcp/hpv-important.html. Updated March 10, 2017. Accessed May 9, 2019.
- HPV vaccination coverage data. Centers for Disease Control and Prevention website. cdc.gov/hpv/hcp/vacc-coverage/index.html. Updated August 23, 2018. Accessed May 9, 2019.
- Infographic: screening won’t protect your patients from most HPV cancers. Centers for Disease Control and Prevention website. cdc.gov/hpv/hcp/hpv-important/more-than-screening-infographic.html. Updated August 23, 2018. Accessed May 9, 2019.
- McClung N. Human papillomavirus prevalence among females in the United States, overall and by race/ethnicity, National Health and Nutrition Examination Survey, 2003[PS1] -2006 and 2013-2016. Presented at: 68th Annual Epidemic Intelligence Service Conference; April 29-May 2, 2019; Atlanta, GA.
- Vaccination schedules & recommendations. Centers for Disease Control and Prevention website. cdc.gov/hpv/hcp/schedules-recommendations.html. Updated March 10, 2017. Accessed May 9, 2019.
- Malagon T, Laurie C, Franco E. Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review. Expert Rev Vaccines. 2018;17(5):395-409. doi: 10.1080/14760584.2018.1471986.
- Table 1. Recommended adult immunization schedule for ages 19 years and older, United States, 2019. Centers for Disease Control and Prevention website. cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated February 5, 2019. Accessed May 10, 2019.
- Shah M, Kamboj M. Immunizing cancer patients: which patients? which vaccines? when to give? Oncology (Williston Park). 2018;32(5):254-258.