We read with interest the recent updated human papillomavirus (HPV) vaccination guideline presented by Saslow et al on behalf of the American Cancer Society (ACS) Guideline Development Group.1 Although the recommendations offer sound guidance to promote vaccination, we disagree with the authors’ decision to universally reject shared decision making for all unvaccinated individuals aged 27 through 45 years, a measure that both the Advisory Committee on Immunization Practices and the Children’s Oncology Group recommend.2,3 Forgoing catch-up vaccination in adults aged older than 26 years is a missed opportunity to provide immunization for traditionally undervaccinated and at-risk groups, in particular those residing in rural communities and survivors of pediatric and young adult (PAYA) cancers. HPV vaccination rates in rural communities are consistently lower than those in other settings.4,5 Barriers include lack of trust in researchers and in health care.6 Rural communities bear higher burdens of cervical cancer and high-risk HPV types7 and now, with the lack of ACS endorsement, have additional reason to decline vaccination for their children: “If it’s not safe for me, why would I vaccinate my child?” Although protection against HPV infection is lower in individuals aged 26 years and older, emerging data have suggested a potential role for vaccination in the secondary prevention of cervical dysplasia among high-risk populations such as those in rural communities.8 The ACS recommendation as currently worded removes the opportunity for this group to benefit, if even by a small amount, from vaccination. Survivors of PAYA cancers, of whom there are nearly 800,000 in the United States alone, also can benefit from catch-up vaccination.9 HPV-associated cancers are a significant concern for survivors of PAYA cancers: compared with age-matched peers, these individuals have a 40% (females) and 150% (males) greater risk of developing HPV-associated cancers.10 This risk is especially high among survivors of lymphoma and those who underwent allogeneic stem cell transplantation11-13 because viral acquisition and persistence increase during periods of immunosuppression or impaired immune recovery after cancer therapy.14 In a single-center, 20-year review of female survivors of Hodgkin lymphoma, nearly 50% of survivors developed cervical or anogenital cancer later in life.15 Qualityof-life concerns are no less significant: between 20% and 40% of PAYA stem cell transplant recipients require multiple excisional or ablative procedures to treat HPV-associated precancerous cervical, lower urinary tract, and anal lesions, causing anatomic disfigurement, long-term pain, sexual dysfunction, and an increased risk of miscarriage.16 It is important to note that the median age at which HPV-associated cancers occur in survivors of PAYA cancers is 38 years,10 suggesting that catch-up HPV vaccination in this population could reduce HPV-associated cancer incidence. Clarity and consistency in guidelines are essential. Provider recommendation is the single most significant determinant of whether survivors of PAYA cancers receive the HPV vaccination,17 and provider recommendations are largely shaped by society guidelines, such as those developed by the ACS.18 Without direct recommendation of HPV vaccination in these guidelines, providers may mistakenly perceive the vaccine as only relevant for patients aged younger than 26 years. Consequently, the guidelines may promote underestimation of both the risk of developing and the ability to prevent HPV-associated malignancies in older patients. Unlike the ACS guidelines, current survivorship care guidelines from the Advisory Committee on Immunization Practices and Children’s Oncology Group prevent such misjudgments by including the catch-up HPV vaccine recommendation. Contradictory guidance from professional societies can undermine educational outreach, provider recommendations, and care delivery and ultimately impact outcomes. Because HPV cancers disproportionately impact survivors of PAYA cancers and rural residents, our collective commitment to reduce the burden of HPV cancer in our communities must include unified guidance and recognition of those at greatest risk. HPV vaccination initiatives; community education; awareness strategies; and a clear, consistent guideline recommendation can help to reduce cancer-related risks and prevent unnecessary morbidity and mortality for all populations.

中文翻译：

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在高危人群中追赶人乳头瘤病毒疫苗的案例：农村社区和儿科和年轻成人癌症的幸存者

农村社区的 HPV 疫苗接种率始终低于其他环境。4,5 障碍包括对研究人员和医疗保健缺乏信任。6 农村社区承担着更高的宫颈癌和高危 HPV 类型负担7，现在，随着缺乏 ACS 认可，有额外的理由拒绝为他们的孩子接种疫苗：“如果这对我来说不安全，我为什么要给我的孩子接种疫苗？” 尽管 26 岁及以上的人对 HPV 感染的保护较低，但新出现的数据表明，疫苗接种在农村社区等高危人群的宫颈发育不良二级预防中具有潜在作用。 8 目前措辞的 ACS 建议消除了该群体从疫苗接种中受益的机会，即使是少量受益。PAYA 癌症的幸存者，20% 至 40% 的 PAYA 干细胞移植受者需要多次切除或消融手术来治疗 HPV 相关的宫颈癌、下尿路和肛门癌前病变，导致解剖学毁容、长期疼痛、性功能障碍和风险增加16 值得注意的是，PAYA 癌症幸存者发生 HPV 相关癌症的中位年龄为 38 岁，10 这表明在该人群中补种 HPV 疫苗可以降低 HPV 相关癌症的发病率。指南的清晰性和一致性至关重要。提供者推荐是 PAYA 癌症幸存者是否接受 HPV 疫苗接种的最重要决定因素，17 提供者推荐主要由社会指南制定，例如 ACS 制定的指南。18 如果这些指南中没有直接推荐接种 HPV 疫苗，提供者可能会错误地认为疫苗只适用于 26 岁以下的患者。因此，该指南可能会导致低估老年患者发生 HPV 相关恶性肿瘤的风险和预防能力。与 ACS 指南不同，免疫实践咨询委员会和儿童肿瘤学小组的现行生存护理指南通过包含补种 HPV 疫苗的建议来防止此类错误判断。来自专业协会的自相矛盾的指导会破坏教育推广、提供者推荐和护理服务，并最终影响结果。因为 HPV 癌症不成比例地影响 PAYA 癌症的幸存者和农村居民，我们在社区中减少 HPV 癌症负担的集体承诺必须包括对风险最大的人的统一指导和认可。HPV疫苗接种计划；社区教育；意识策略；清晰、一致的指南建议有助于降低所有人群的癌症相关风险并预防不必要的发病率和死亡率。