Preventing cervical cancer with HPV vaccine

Human papillomaviruses (HPV) are the subject of the cover article of AFP's November 15th issue, authored by Drs. Gregory Juckett and Holly Hartman-Adams from the West Virginia University Robert C. Byrd Health Sciences Center School of Medicine. While "low risk" HPV types 6 and 11 cause up to 95 percent of genital warts, "high risk" HPV types 16 and 18 cause the majority of cervical cancers. In recognition of these risks, the American College of Obstetricians and Gynecologists recently recommended that women older than 30 years receive high-risk HPV DNA testing in addition to cytology for cervical cancer screening.

Previous issues of AFP reviewed the efficacy of the quadrivalent HPV recombinant vaccine and recommendations for its administration by the American Cancer Society and the CDC's Advisory Committee on Immunization Practices. HPV vaccine is only the second cancer-preventing vaccine, after hepatitis B vaccine (which prevents liver cancer). However, Drs. Juckett and Hartman-Adams observe in their article that implementing HPV vaccine recommendations has been challenging:

Controversy about HPV vaccination involves its high cost (approximately $150 per injection), uncertain duration of protection, and concerns that it provides tacit approval of sexual activity and a false sense of security. In addition, the necessity of vaccinating girls as young as nine to 11 years, before they become sexually active, unsettles many parents. There has been criticism for aggressive marketing of HPV vaccine to older women already exposed to HPV, while less attention has been given to the subpopulations at highest risk.

AAFP News Now recently reported that HPV vaccination rates in 2009 varied widely from state to state, with 44.3 percent of teenage girls nationally having received at least one dose and 26.7 percent having completed the 3-dose series. Just last week, a U.S. Food and Drug Administration advisory committee meeting reviewed the evidence that HPV vaccination prevents anal cancer in men who have sex with men. How the committee's reported decision to approve HPV vaccine for this indication will affect future national recommendations for vaccination in males remains to be seen.

How has the availability of HPV vaccine affected your practice? What approach do you take in discussions with adolescents and parents? We would love to hear about your experiences.

Asthma management: a stepwise approach

The November 15th issue of AFP features an updated clinical review of medical therapies for asthma, based on the 2007 Expert Panel Report of the National Asthma Education and Prevention Program (NAEPP). This review recommends a "stepwise approach" for asthma management in patients 12 years and older, depending on the severity of asthma and response to first-line medications. Persons with intermittent symptoms may use an inhaled short-acting beta-agonist as needed; older children and adults with persistent asthma generally require daily inhaled corticosteroids, and possibly additional medications.

Another component of effective management is the use of written asthma action plans for patients to monitor asthma control outside of planned office visits and to take physician-approved steps to address worsening symptoms. The article includes examples of asthma action plans for children and adults, as well as a link to a short video about asthma action plans on Familydoctor.org.

For information about related clinical issues such as the role of allergens in asthma, treatment of asthma in young children, managing acute exacerbations, and practice-level approaches to planned asthma care, you can consult our AFP By Topic collection.

Telephone triage for suspected influenza

Although the Centers for Disease Control and Prevention's weekly flu tracking report showed "low" influenza activity in the U.S. as of the publication date of AFP's November 1, 2010 issue, we know that it is only a matter of time before family physicians' offices are filled with patients either seeking the vaccine or presenting with symptoms of an acute infection. Accordingly, this issue contains several key resources for managing influenza, including a focused clinical review of testing and treatment; a Tip on the effectiveness and limitations of oseltamivir (Tamiflu) for reducing flu duration in children; and an updated influenza management guide from the University of California at San Francisco's Department of Family and Community Medicine. The guide suggests using "telephone triage" to reduce office visits that can potentially transmit influenza to other patients and staff:

Telephone triage can assess severity of symptoms and identify patients at risk of complications who would benefit from expedited access to antiviral medications, which can then be prescribed by telephone or fax. This approach provides timely access to treatment while reducing waiting room exposures. Conversely, if telephone triage identifies concerning symptoms that would require outpatient or emergency department evaluation, this can be arranged and expedited.

For additional information about best practices and a sample protocol for telephone triage, you can refer to a previous editorial by Jonathan L. Temte, MD, PhD. This editorial and other up-to-date resources, including the CDC's 2010-11 vaccination guidelines, are all included in AFP's Influenza Topic Collection. Finally, you can also click on the CDC's Flu.Gov widget, located on the lower right border of this blog, for updates and alerts throughout the influenza season.