Dr. Corinn Cross: Welcome to Peds Cast, a podcast
brought to you by Children's of Alabama. I'm pediatrician Dr. Cori Cross. Today
we'll be discussing the vaccine for the Human Papilloma Virus, also known as
the HPV vaccine. We're joined by Dr. Wendy Landier, who is a Professor of
Pediatrics in the Division of Pediatric Hematology Oncology in the School of
Medicine at the University of Alabama at Birmingham. And she's the Deputy
Director of the Institute for Cancer Outcomes and Survivorship at the
University of Alabama Birmingham. Dr. Landier, thank you so much for joining us
today.

Wendy Landier, PhD, CRNP, FAAN: Thanks so
much for having me.

Host: So the HPV vaccine is typically given at around 11 or 12 years of
age at their yearly checkup. And this is a vaccine series of two or three
doses, depending on your age. But the HPV vaccine is interesting because we
aren't just vaccinating against HPV or genital warts. We're actually preventing
HPV caused cancers such as cervical cancer. Can you explain to our listeners a
little bit about this vaccine and how it works?

Wendy Landier, PhD, CRNP, FAAN: Sure. So the
HPV vaccine was introduced in the United States in 2006. It is a vaccine that
can prevent cancers that are caused by the HPV or Human Papilloma Virus. It's
recommended for all children beginning at the age of nine and can be given all
the way up to age 45.

Host: How is it that a vaccine that prevents Human Papilloma Virus
actually prevents cancers?

Wendy Landier, PhD, CRNP, FAAN: Infection
with the Human Papilloma Virus can lead to the development of cancers. The
Human Papilloma Virus is a very common sexually transmitted infection. In fact,
it's the most common sexually transmitted infection in the United States. And
80% of people living in the United States will eventually be infected with the
Human Papilloma Virus. Most people can clear infection with that virus and do
not go on to develop cancer. But for the unfortunate people that are unable to
clear that infection, it can move on and cause a cancer of the cervix, the
anus, the penis, or the oral pharynx are the most common sites of HPV related
cancer.

Host: How did you decide to start researching the HPV vaccine and why
is it so relevant to your Institute for Cancer Outcomes and Survivorship?

Wendy Landier, PhD, CRNP, FAAN: So in our
Institute for Cancer Outcomes and Survivorship, we are very interested in how
cancer survivors can go on to lead healthy and long lives. Childhood cancer
survivors in particular, have a very high rate of surviving cancer. Currently,
the survival rates for childhood cancer at five years are about 85%.

So we expect most children diagnosed with cancer today to go on
and live long lives, and we want those lives to be healthy. The HPV vaccine can
prevent future cancers, and it turns out that childhood cancer survivors are at
a threefold increased risk for developing HPV related cancers compared to their
peers in the general population.

So when the HPV vaccine was released for use in the general
population, we wanted to see if that was something that we would be able to
harness and use for our childhood cancer survivors, and we decided we would
move forward with some studies to help us understand better the use of that
vaccine as well as the immunogenicity of that vaccine in our childhood cancer
survivor population.

Host: That makes perfect sense. And then you said that the cancer
survivors who go on are at I believe you said three to five times an increased
risk of getting HPV related cancers later in life. Is that correct?

Wendy Landier, PhD, CRNP, FAAN: It's a
threefold increased risk. Yes.

Host: Threefold increase. They are at an increased risk of getting any
cancer later in life as well. Right. There's a, an increased risk if you've had
one cancer to have a second or am I incorrect there?

Wendy Landier, PhD, CRNP, FAAN: There is
definitely some truth to that statement, but not all cancer survivors are at
increased risk of second cancers, but many of them are. Some of it has to do
with underlying genetics, but some of it also has to do with the treatment that
the child has received for their cancer. So, for example, children that receive
radiation have a higher risk of developing cancers in that radiation field, and
children who've received certain chemotherapies have a higher risk of
developing certain cancers later on.

Host: So it would make sense though that obviously everybody wants to
go on and lead a healthy life, but if this is a preventable cancer and
prevented so easily with a vaccine that you would focus on this. You studied
the HPV vaccination rates for cancer survivors. What did you find?

Wendy Landier, PhD, CRNP, FAAN: Yes. So we
studied those vaccination rates between the years of 2012 and 2015. So after
the vaccine had been available to the general public for several years, and
what we found was that the rate of uptake of the HPV vaccine was substantially
lower than in the general population. We found that only about 24% of childhood
cancer survivors had received the HPV vaccine.

Host: Now, is there a reason for that? Are they getting less vaccines
in general, or is it specific to this vaccine?

Wendy Landier, PhD, CRNP, FAAN: That is a
really excellent question, and we really wanted to understand better why it was
that the uptake in survivors is lower. There are several factors we believe
that are related to this problem, but by and large, the biggest factor that we
were able to understand was that these survivors were not getting a
recommendation from their healthcare providers to get the vaccine.

And we saw a tenfold increased risk of vaccine non-initiation
among survivors who were not receiving recommendations from their healthcare
providers to get the HPV vaccine.

Host: Is it in part, because sometimes while you're going through
treatment, the normal childhood protocol of vaccines is sometimes postponed and
you don't necessarily have to postpone all of them, but some of them are live
and some of them aren't. So sometimes kids get off their regular schedule. Do
you think it's part of that and then when you're playing catch up, this one
falls off the radar? Or do you think there's a real reason why this just isn't
being recommended?

Wendy Landier, PhD, CRNP, FAAN: Yes, you
make some very good points and it's multifactorial. Childhood cancer survivors,
some of them may have been receiving treatment during the timeframe when
normally children would be getting this vaccine at ages 11 to 12. And so for
them, they may just have kind of missed that time point and then they don't,
it's not recognized that they need to catch up.

When a child has cancer, they very often are followed in their
cancer center or in their pediatric hematology oncology center for many years
beyond their treatment and sometimes the focus of that follow up care is really
on the disease and not so much on preventive care. This happens in other
subspecialties as well, where children who have chronic illnesses are followed
by subspecialists and sometimes the primary care that they would normally
receive at certain milestone birthdays and time points, sometimes that gets
overlooked when there's a lot going on with their underlying disease or their
follow-up care for that disease. And so we think that has something to do with
it. We also think that there's sometimes confusion on the part of the primary
care providers as to whether it's okay to go ahead and proceed with vaccination
in these children when they do come to primary care practices.

Host: That's all understandable. And, being a pediatrician, I
completely agree with your assessment of probably what's going on. Now, you've
recently designed a study, that is looking at HPV Protect Intervention. Can you
tell us a little bit about this intervention and sort of where you're going
with it?

Wendy Landier, PhD, CRNP, FAAN: Sure. So the
HPV Protect Intervention really came about as a result of the two studies we
had done previously where we had understood that childhood cancer survivors had
a low rate of uptake of the HPV vaccine. And we also did a study in which we
tested the HPV vaccine in childhood cancer survivors. So we administered the
three dose series and we measured the safety and the immunogenicity of the HPV
vaccine in those survivors. And what we found was that the safety was similar
to the general population, and the immunogenicity was non-inferior, meaning
that the survivors mounted a similar immune response as the general population did.

And so with the information that we gleaned from those two
studies, we moved on to the HPV Protect Intervention. This intervention is
designed for healthcare providers. So our target is really the healthcare
providers because we learned from our prior work that the most common reason
that survivors do not receive the vaccine is because they have not received a
recommendation.

So there's really three components to this HPV Protect
Intervention. The first is communication training, and it's all focused on
pediatric oncology providers, because we know that these survivors come back to
the pediatric oncology setting. And so we want to focus on the pediatric
oncology providers who are trusted by the families and by the children, and
have relationships with those children.

So we teach them methods of communicating the importance of the
HPV vaccine to those families with an emphasis on cancer prevention. We provide
them with a toolkit to help facilitate acquisition of the vaccine if they're
not able to give it in their clinic, where it can be given in the community.

 So the providers are able
then to easily refer their patients to where they can get the vaccine. And then
we provide ongoing assessment and peer feedback to the providers to let them
know how they're doing. And we do that by monitoring the rate of vaccination in
the clinic and feeding that back to them so they know how they are doing with
the intervention.

Host: That's amazing. As a pediatrician, I would imagine that the
clinics that are participating in this trial are probably seeing an uptick, not
just in the vaccination rates of the cancer survivors, which is what you're
looking at, but my guess is that the training and just the information that
you're giving to the clinic and the staff is really being carried through to
all of the patients, and that there's probably an uptick in, in vaccination
rates for HPV in general.

Wendy Landier, PhD, CRNP, FAAN: Well you're
absolutely right. We based this intervention on an intervention that's already
being used for general pediatric practices. And so the principles carry through
absolutely to all levels of pediatrics. We're just focusing on the pediatric
oncology providers, but the benefits are there for all. Absolutely.

Host: That's wonderful. Now, looking ahead, and I don't know if you can
answer this or not, but looking ahead, do you anticipate vaccines playing a
larger role in cancer survivorship?

Wendy Landier, PhD, CRNP, FAAN: I think they
do. I think what we've learned, especially recently with the COVID-19 pandemic,
is that, in cancer survivorship, vaccines can be very much at the forefront,
that we are really interested in the health of these children and young adults.
And as they grow into adulthood and beyond that the health that they have
secured through completing their cancer treatment and being successfully
treated for that cancer, that health needs to be protected, ongoing throughout
their lives.

Vaccines are such an incredibly important tool in really helping
our survivors to stay healthy across the lifespan. And so, yes, I absolutely
agree. They will play an ongoing role in the health of our cancer survivors.
And we certainly hope in the future there'll be other vaccines to even prevent
the original cancers.

But currently we have the HPV vaccine, which is a fantastic and
very effective way of preventing cancer for our survivors. So our goal is
really to make sure that they take advantage of that vaccine that's available
to them.

Host: Yeah, it really is the gold standard. In summary, is there
anything else you'd like to share with our listeners today?

Wendy Landier, PhD, CRNP, FAAN: I think that
in summary, I'd just like to remind everyone that our childhood cancer
survivors do have a threefold increased risk of developing HPV related cancers.
We have a very effective vaccine that can be given to prevent them from
acquiring the infection that can lead to cancer. So it needs to be given at a
time, even before they acquire the infection to prevent future cancers. It's
safe. Our survivors attain the same level of immunity that their general
population peers do, and that provider recommendation is absolutely key to
increasing HPV vaccine uptake in the children that have survived cancer.

So, in this case, really an ounce of prevention is surely worth
even more than a pound of cure. It's so very important for our childhood cancer
survivors.

Host: I couldn't agree with you more. Thank you so much for joining and
sharing your expertise with us today.

Wendy Landier, PhD, CRNP, FAAN: You're so
welcome. Thank you for inviting me.

Host: For more information or to refer patients to Children's of
Alabama, visit childrensal.org. That concludes this episode of Children's of
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of Peds Cast. I'm your host, Dr. Cori Cross.