Incidence of vulvar high-grade precancerous lesions and cancer in Denmark before and after introduction of HPV vaccination

Pathological variants in HPV-independent vulvar tumours

Vulvar cancer is a rare gynaecological disease that can be caused by infection with human papillomavirus (HPV). The mutational frequencies and landscape for HPV-associated and HPV-independent vulvar tumor development are supposedly two distinctly different pathways and more detailed knowledge on target biological mechanisms for individualized future treatments is needed. The study included formalin-fixed paraffin-embedded (FFPE) samples from 32 cancer patients (16 HPV-negative and 16 HPV-associated), treated in Örebro, Sweden from 1988 to 2008. The Oncomine™ Comprehensive Assay v3 was used to detect variants across 161 different tumor relevant genes. Data analysis included quality assessment followed by variant analysis of DNA with the Oncomine Comprehensive v3 workflow and with a custom filter using the VarSome Clinical software. The RNA-analysis was performed with the Oncomine Comprehensive v3 workflow. Totally, 94% of DNA libraries and 81% of RNA libraries were of adequate quality for further downstream analysis. With the Oncomine™ filter chain there was an increased number of variants in the HPV-negative group (2.5 variants) compared to the HPV-associated group (1.5 variants). Using custom filter and the Varsome Clinical software; additional single nucleotide variants (SNV) were detected where the vast majority were classified as likely benign/benign. HPV-negative tumors had a larger fraction of variants of unknown significance (VUS), and likely pathogenic/pathogenic compared to the HPV-associated tumours. The top 10 frequently mutated genes in HPV-indepentent tumors were TP53, POLE, PTCH1, BRCA2, CREBBP, NOTCH2, ARID1A, CDKN2A, MSH2, and NOTCH1. Three fusion genes were detected; TBL1XR1(1)::PIK3CA(2) (n = 2) and NF1(5)::PSMD11(2) (n = 1). Copy number variations (CNV) were more common in HPV-associated tumors (n = 13/16, 81%) compared to HPV-negative tumors (n = 9/14, 64%). The most frequent CNV was found in the cMYC gene, followed by CDK2 (n = 5) and CDK4 (n = 4). The main outcome of this study show that vulvar cancer harbour genetic variations of different types and specifically, HPV-independent tumours are molecularly very heterogeneous and harboured more SNVs while HPV-associated tumors more frequently presented with gene amplifications. The PI3K/AKT/mTOR1 pathway was affected in both the groups as well as the cell cycle regulation pathway. Similarly, the DNA repair gene POLE was found mutated in both vulvar cancer groups.

Human papillomavirus-associated cancers, precancers, and genital warts in Denmark, 2000-2022 - Current burden of disease and population impact of multi-cohort HPV vaccination

OBJECTIVES

We present incidence trends of cancer and precancer at human papillomavirus(HPV)-associated sites, and genital warts, including the current burden of HPV-associated disease in Denmark, a country with multi-cohort HPV vaccination.

METHOD

Cases were identified from high-quality nationwide registries (2000-2022). The age-specific incidence rate, age-standardized incidence rate (ASR) and estimated annual percentage change (EAPC) were calculated according to sex and calendar year. The current burden (2020-2022) of HPV-associated disease was estimated as the average annual number of each lesion multiplied by the disease-specific HPV-attributable fraction.

RESULTS

ASRs of cervical precancer and genital warts declined markedly in the post-HPV vaccination period - for genital warts corresponding to an EAPC of -13.7 % (-15.0;-12.4)(women) and -8.8 % (-9.4;-8.2)(men), respectively. ASRs of HPV-associated cancer sites increased continuously in men (EAPC: 2.8 % (2.2;3.5)), and the same was observed for non-cervical HPV-associated cancer sites in women (EAPC: 2.5 % (2.0;3.0)). Cervical cancer, however, decreased in the post-HPV vaccination period (EAPC: -2.7 % (-3.8;-1.5)). Age-specific incidence rates of HPV-associated cancer sites decreased slightly in younger women and were stable in younger men, while incidence rates in older men approached or even surpassed that of older women. Data on the current burden showed that cervical precancer and genital warts are still the major contributors to HPV-associated disease, and oropharyngeal cancer now accounts for more annual cases on a population level than cervical cancer.

CONCLUSION

Danish data show decreased incidence of cervical lesions and genital warts in the post-vaccine era. Despite population impact of HPV vaccination, HPV-associated disease remains a public health issue and increasingly among men.

Influence of stage and age on survival of patients with vulvar cancer in Germany: a retrospective study

OBJECTIVES

To evaluate the 5-year survival rate of patients with vulvar cancer, taking into account prognostic factors (International Federation of Gynecology and Obstetrics (FIGO) stage and age) and the influence of lymph node involvement and tumour size as well as the correlation between FIGO stage and age at onset.

DESIGN

Retrospective cohort study.

SETTING

German cancer registries.

PARTICIPANTS

The study included 17 017 patients diagnosed with vulvar cancer between 2004 and 2014 with follow-up until 2017. Exclusion criteria were incomplete documentation, age<18 years and death certificate only.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was overall and relative survival according to FIGO stage and age and the distribution of FIGO stages by age group. Secondary outcomes analysed were tumour size and lymph node status as risk factors for mortality.

RESULTS

The median age at diagnosis was 70 years. The overall 5-year survival rate was 69.5% (95% CI: 68.7% to 70.3%). The 5-year relative survival rates ranged from 91.9% (95% CI: 90.5% to 93.3%) to 21.3% (95% CI: 15.6% to 27.0%) for FIGO I to FIGO IVB and from 89.2% (95% CI: 87.6% to 90.8%) to 68.0% (95% CI: 65.3% to 70.7%) for age groups <55 to >75 years. Younger patients were significantly more often diagnosed with a low FIGO stage (p<0.001). Lymph node status and tumour size were independent factors influencing survival (HR: 1.79 (95% CI: 1.73 to 1.84; p<0.001) and 1.88 (95% CI: 1.80 to 1.96); p<0.001, respectively). The median follow-up time was 57 months.

CONCLUSION

Notably, the steepest decline in survival occurred within the first 3 years after diagnosis. Patients with the highest FIGO stages and those in the oldest age group had the worst survival rates. Furthermore, patients in the oldest age group were more likely to be diagnosed at higher stages. Lymph node status and tumour size were additional independent prognostic factors for mortality.

An integrated model for prognosis in vulvar squamous cell carcinoma

BACKGROUND

Vulvar squamous cell carcinoma (VSCC) is a relatively rare gynecologic cancer. Unlike cervical squamous cell carcinoma (CSCC), in which nearly all cases are caused by HPV infection, most VSCCs are HPV-independent. Patients with VSCC also have worse overall survival (OS) than those with CSCC. Unlike CSCC, the risk factors of VSCC have not been extensively studied. Here, we investigated the prognostic values of clinicopathological parameters as well as biomarkers in patients with VSCC.

METHODS

In total, 69 cases of VSCC accessions were selected for analysis between April 2010 and October 2020. The risk factors of VSCC were screened using Cox models to establish nomograms for predicting survival outcomes.

RESULTS

Following the multivariate COX model for OS, independent predictors including advanced age (hazard ratio [HR] 5.899, p = 0.009), HPV positivity (HR 0.092, p = 0.016), high Ki-67 index (HR 7.899, p = 0.006), PD-L1-positivity (HR 4.736, p = 0.077), and CD8 + tumor-infiltrating lymphocytes (TILs) (HR 0.214, p = 0.024) were included in the nomogram for OS; multivariate COX model for progression-free survival (PFS) was used to screen prognostic factors including advanced age (HR 2.902, p = 0.058), lymph node metastasis (HR 5.038, p = 0.056), HPV positivity (HR 0.116, p = 0.011), high Ki-67 index (HR 3.680, p = 0.042), PD-L1-positivity (HR 5.311, p = 0.045), and CD8 + TILs (HR 0.236, p = 0.014) to establish the PFS nomogram model. Based on the C-index (0.754 for OS and 0.754 for PFS) from our VSCC cohort and the corrected C-index (0.699 for OS and 0.683 for PFS) from an internal validation cohort, the nomograms demonstrated good predictive and discriminative ability. Kaplan-Meier curves also supported the excellent performance of the nomograms.

CONCLUSION

Our prognostic nomograms suggested that (1) shorter OS and PFS were associated with PD-L1-positivity, high Ki-67 index, and low CD8 + TILs; (2) HPV-independent tumors were associated with poorer survival outcome, and mutant p53 status showed no prognostic significance.

Epidemiology of vulvar cancer in Croatia

AIM

To assess the incidence and mortality trends of invasive vulvar cancer in Croatia between 2001 and 2019/2020.

METHODS

The incidence data for the period 2001-2019 were obtained from the Croatian National Cancer Registry. The number of deaths from invasive vulvar cancer by age groups between 2001 and 2020 was obtained from the Croatian Bureau of Statistics. Joinpoint regression analysis was used to assess the trends and trend changes.

RESULTS

Joinpoint regression analysis of vulvar cancer incidence rate showed a non-significant average annual percent increase (APC) of 0.8 (95% confidence interval [CI]=-0.3-2.0) during the whole period. There was also a non-significant increase in women under 60, with an average APC of 1.0 (CI = -1.6-3.7) during the whole period; similar results were obtained in women over 60 years of age (APC=0.9; CI=-0.3-2.1). The average annual percent increase in vulvar cancer mortality rate was 0.2% (CI = -1.0-1.5), with a similar trend in women over 60 years of age (APC=0.1; CI=-1.3-1.5). Mortality in women under 60 years of age was not assessed due to a very small number of deaths observed in the study period.

CONCLUSION

In the studied period, the incidence of invasive vulvar cancer in Croatia was stable. Age-standardized rates (for all-ages, under 60, and over 60 years of age) increased, but the increase did not reach the level of statistical significance. The pattern in younger and older age groups was the same. The mortality rates over the last decade were stable.

Trends in Net Survival from Vulvar Squamous Cell Carcinoma in Italy (1990–2015)

(1) Objective: In many Western countries, survival from vulvar squamous cell carcinoma (VSCC) has been stagnating for decades or has increased insufficiently from a clinical perspective. In Italy, previous studies on cancer survival have not taken vulvar cancer into consideration or have pooled patients with vulvar and vaginal cancer. To bridge this knowledge gap, we report the trend in survival from vulvar cancer between 1990 and 2015. (2) Methods: Thirty-eight local cancer registries covering 49% of the national female population contributed the records of 6274 patients. Study endpoints included 1- and 2-year net survival (NS) calculated using the Pohar-Perme estimator and 5-year NS conditional on having survived two years (5|2-year CNS). The significance of survival trends was assessed with the Wald test on the coefficient of the period of diagnosis, entered as a continuous regressor in a Poisson regression model. (3) Results: The median patient age was stable at 76 years. One-year NS decreased from 83.9% in 1990–2001 to 81.9% in 2009–2015 and 2-year NS from 72.2% to 70.5%. Five|2-year CNS increased from 85.7% to 86.7%. These trends were not significant. In the age stratum 70–79 years, a weakly significant decrease in 2-year NS from 71.4% to 65.7% occurred. Multivariate analysis adjusting for age group at diagnosis and geographic area showed an excess risk of death at 5|2-years, of borderline significance, in 2003–2015 versus 1990–2002. (4) Conclusions: One- and 2-year NS and 5|2-year CNS showed no improvements. Current strategies for VSCC control need to be revised both in Italy and at the global level.

HPV Vaccination Coverage Rate in a Rural Area: An Observational, Retrospective, and Cohort Study

In order to reduce the incidence and mortality rate of cervical cancer, the World Health Organization (WHO) declared the Global Strategy Goal for 2030, advocating for reaching a vaccination coverage rate of >90% against human papillomavirus for girls by the age of 15 years. The main objectives of this study were (1) to determine the papillomavirus vaccination coverage among women 15−40 years old and (2) to identify the at-risk subgroups and possible barriers to achieving WHO’s 2030 goal. Multicentre, observational, retrospective, and community-based cohort studies were conducted on women from a rural area in southern Catalonia until 31 December 2021. A total of 23,136 women were included, with a mean age of 26.6 (SD = 5.6) years. The average dose number was 1.7 (SD = 0.7). The results showed overall vaccination coverage of 17.4% among the target women. This coverage was unequal across regions (16.6−24.5%, p < 0.001), primary healthcare teams (15.5−24.3%, p < 0.001), and age groups (56.7% (15−19-year-olds) vs. 3.8% (35−40-year-olds), p < 0.001), related to accessibility to vaccination and economic−geographical indicators. Clinical practice guidelines on screening individuals at risk in terms of vaccination access and public vaccination protocols should be implemented in order to improve the vaccination coverage rate.

Factors Associated with Human Papillomavirus Vaccination and the Intention among Undergraduate Nursing Students: A Cross-Sectional, Correlational Study

PURPOSE

To examine factors associated with overall human papillomavirus (HPV) vaccination status, completion of HPV vaccination, and intention to receive vaccination among nursing students.

DESIGN

A Cross-sectional, correlational study.

METHODS

Data from 86 students were analyzed using logistic and multiple regression.

FINDINGS

Among knowledge, attitudes and beliefs, and recommendation, more positive attitudes and beliefs were the only factors associated with initiation and/or completion of HPV vaccination and the intention to receive HPV vaccination.

CONCLUSIONS

More positive attitudes and beliefs need to be enhanced for HPV vaccination.

CLINICAL EVIDENCE

Changes in attitudes and beliefs can be important targets of interventions to increase HPV vaccination.

Changes in HPV prevalence in Danish women with vulvar cancer during 28 years - A nationwide study of >1300 cancer cases

OBJECTIVE

A substantial proportion of vulvar cancers are caused by high-risk human papillomavirus (hrHPV), but hrHPV prevalence in vulvar cancer has mainly been investigated in smaller studies which did not evaluate time trends. Our aim was to assess hrHPV prevalence in >1300 Danish vulvar cancers diagnosed during 1990-2017, including changes in hrHPV prevalence over time.

METHODS

In a nationwide pathology register, we identified women diagnosed with vulvar cancer at thirteen hospitals from all Danish regions. Archival tumor tissue was collected from local repositories and, upon pathology review, sent to a central laboratory for HPV testing using INNO-LiPA. We calculated hrHPV prevalence according to time, age and histology, and evaluated the overall and age-specific estimated annual percentage change (EAPC).

RESULTS

We included 1308 vulvar cancer cases, with a median age of 72 years at diagnosis. The overall hrHPV prevalence was 52.0% (95% CI: 49.3-54.7). HPV types 16/18 were found in 39.6% of cases, whereas nine-valent HPV (9vHPV) vaccine types 16, 18, 31, 33, 45, 52, and 58 were found in 50.8%. The hrHPV prevalence showed an increasing trend over time, with an EAPC of 0.35% (95% CI: 0.00-0.71). The hrHPV prevalence was higher in younger women throughout the study period, and increasing trends over time were seen in both older (age ≥ 60) and younger (age < 60) women. The hrHPV prevalence was higher in non-keratinizing (71.0%) and warty/basaloid (78.0%) carcinomas than in keratinizing (39.4%) and verrucous (36.4%) carcinomas.

CONCLUSIONS

Our results indicate that the 9vHPV vaccine could potentially prevent a substantial proportion of vulvar cancers in Denmark.

Vulvar High-Grade Squamous Intraepithelial Lesions and Cancer as a Risk Factor for Anal Cancer: A Review

OBJECTIVES

Anal squamous cell carcinoma (ASCC) has a higher incidence described in certain groups, namely, in women with vulvar high-grade squamous intraepithelial lesions (vHSILs) and/or human papillomavirus squamous cell carcinoma (VSCC). This review describes terminology, vHSIL, and VSCC in their association with ASCC and the published recommendations for early detection of this cancer in these women.

MATERIALS AND METHODS

A narrative review was conducted by the authors on vHSIL and VSCC as risk factors for ASCC.

RESULTS

The ASCC and VSCC incidence are increasing. Women with vHSIL and/or VSCC can present with ASCC at diagnosis, being one of the highest-risk groups. Suspicious symptoms include rectal bleeding, pain, and a sensation of an anal mass. Digital anorectal examination can help detect early ASCC. Sensitivity of anal cytology in women with vHSIL and VSCC seems low, with the exception of immunosuppressed women with genital neoplasia (cervix, vagina, and vulva). There are still insufficient data on high-resolution anoscopy in women with vHSIL and/or VSCC as a screening method.

CONCLUSIONS

Clinicians need be aware that women with vHSIL and VSCC comprise one of the highest-risk groups for ASCC. Inquiring suggestive symptoms of ASCC and a digital anorectal examination can help in the early detection of this type of cancer.

Viral Causality of Human Cancer and Potential Roles of Human Endogenous Retroviruses in the Multi-Omics Era: An Evolutionary Epidemiology Review

Being responsible for almost 12% of cancers worldwide, viruses are among the oldest known and most prevalent oncogenic agents. The quality of the evidence for the in vivo tumorigenic potential of microorganisms varies, thus accordingly, viruses were classified in 4 evidence-based categories by the International Agency for Research on Cancer in 2009. Since then, our understanding of the role of viruses in cancer has significantly improved, firstly due to the emergence of high throughput sequencing technologies that allowed the “brute-force” recovery of unknown viral genomes. At the same time, multi-omics approaches unravelled novel virus-host interactions in stem-cell biology. We now know that viral elements, either exogenous or endogenous, have multiple sometimes conflicting roles in human pathophysiology and the development of cancer. Here we integrate emerging evidence on viral causality in human cancer from basic mechanisms to clinical studies. We analyze viral tumorigenesis under the scope of deep-in-time human-virus evolutionary relationships and critically comment on the evidence through the eyes of clinical epidemiology, firstly by reviewing recognized oncoviruses and their mechanisms of inducing tumorigenesis, and then by examining the potential role of integrated viruses in our genome in the process of carcinogenesis.

Incidence of penile intraepithelial neoplasia and incidence and survival of penile cancer in Denmark, 1997 to 2018

PURPOSE

Squamous cell carcinoma (SCC) of the penis is rare. Some studies have suggested that the incidence is increasing but the available literature is equivocal. We examined the incidence of high-grade penile intraepithelial neoplasia (PeIN), the incidence and 5-year relative survival as well as mortality of penile SCC in Denmark over the latest 20 years.

METHODS

New cases of high-grade PeIN and penile cancer were identified from high-quality nationwide registries. Age-standardized (World) incidence rates per 100,000 person-years and average annual percentage change (AAPC) were estimated. For penile SCC, 5-year relative survival was calculated, and Cox regression was used to examine the effect of selected characteristics on mortality.

RESULTS

Altogether, 1,070 new cases of high-grade PeIN were diagnosed (1997-2018) and the incidence increased from 0.87 to 1.84 per 100,000 person-years from 1997-1998 to 2017-2018 (AAPC = 4.73; 95% CI: 3.54-5.94). We identified 1,216 penile cancer cases (1997-2018) (95.7% SCC). The incidence of penile SCC increased slightly from 0.85 per 100,000 person-years in 1997-1998 to 1.13 per 100,000 person-years in 2017-2018 (AAPC = 1.01; 95% CI: 0.24-1.79). The 5-year relative survival of penile SCC did not change substantially, whereas the mortality tended to decrease.

CONCLUSION

Penile SCC is increasing slightly in Denmark, while a pronounced increase in the incidence of high-grade PeIN is seen. The 5-year relative survival from penile cancer was relatively stable over time. Increasing exposure to HPV infection at the population level may have contributed to the observed increase in PeIN and penile SCC. Awareness of HPV may also have contributed to the increased detection of PeIN.

CO2 laser colposcopic guided surgery for the see and treat management of VHSIL: a preliminary experience

The purpose of this study is to evaluate the efficiency of CO2 laser colposcopic guided surgery performed in an outpatient see and treat setting in the management of VHSIL. Women with a suspected diagnosis of VHSIL and no vulvoscopic suspicion of vSCC were enrolled. An electronic register of CO2 laser treatment was created where description of performing parameters (excision or ablation) was specified and personal history was recorded. Statistical analysis was performed by Fisher’s exact test. Relative risks (RR) of risk factor were calculated and expressed in odds. From September 2014 to September 2018, we enrolled a total of 63 patients who underwent CO2 laser procedure and had a minimum follow-up time of 2 years at Careggi University Hospital in Florence. Forty-eight (76.2%) patients underwent laser excision and 15 (23.8%) patients underwent ablative treatment without histological results. Undertreatment was performed in 3 cases (6.3%) with definitive histology of vSCC. Therapeutical appropriateness of CO2 laser excision was reached in 85.4% of the cases (41/48). No volunteer loss to follow-up was registered; thus, fidelity to treatment was assess at 100%. Recurrence rate within 2 years attested in 8/60 followed patients (13.3%). No personal factor was found to influence the VHSIL course. CO2 laser excision may represent an excellent therapeutic option to VHSIL because it provides adequate oncological purpose with good cosmetic and functional results and high patients’ loyalty to treatment. An expert team could allow to undergo patients with VHSIL suspicion to unique diagnostic and therapeutic procedure with significant benefits.

Prevalence and type distribution of human papillomavirus infections in Danish patients diagnosed with vulvar squamous cell tumors and precursors

OBJECTIVE

To study the prevalence and type distribution of human papillomavirus (HPV) in patients with vulvar high-grade precancerous lesions and vulvar squamous cell carcinoma (VSCC).

METHODS

Formalin-fixed and paraffin-embedded (FFPE) tissue samples from Danish patients diagnosed with vulvar precancerous lesions or VSCC in the period from 2010 to 2012 were obtained. HPV-DNA detection was carried out by the use of polymerase chain reaction (PCR) using GP5+/GP6+ primers and genotyped by sequencing. A systematic literature search on the PubMed database was performed to investigate the prevalence and genotype distribution worldwide.

RESULTS

In the present study population (n = 149) 52 vulvar high-grade squamous intraepithelial lesions (HSIL), 2 differentiated vulvar intraepithelial neoplasia (dVIN), and 95 VSCC cases were identified. HPV was detected in 85 patients (57.0%). Overall, a higher proportion of the vulvar high-grade precancerous lesions were HPV positive compared to VSCC (83.6% vs. 42.1%, p < 0.001). Additionally, HSIL had a significantly higher HPV-positive rate compared to keratinizing VSCC (84.6% vs. 33.3%, p < 0.001). However, the HPV positivity was comparable between HSIL and non-keratinizing VSCC (84.6% vs. 82.4%, p = 0.825). One dVIN was HPV positive whereas the other was HPV negative. HPV-16 was the most common HPV type (68.2%), followed by HPV-33 (18.8%) and HPV-18 (8.2%).

CONCLUSIONS

Most vulvar HSIL and non-keratinizing VSCCs appear to be HPV associated. However, we find a high HPV association in keratinizing VSCC, which needs to be further studied. HPV-16 remains the predominant genotype, but HPV-33 also seems to play a role in the development of VSCC.

Raman spectroscopy for guidance of vulvar cancer surgery: a pilot study

For vulvar squamous cell carcinoma (VSCC), the mainstay of treatment is surgical removal with tumour-free margins. Surgeons still operate without objective tools that provide margin-status. This study assesses Raman spectroscopy potentiality for distinguishing ex-vivo VSCC from healthy tissue in 11 patients. Grid-based Raman maps were obtained from processed spectra. Water content and C-H band ratio (2,910-2,966 cm^-1 / 2810-2890 cm^-1) were calculated per spectrum and used as linear discriminant parameters. Healthy tissue was differentiated from VSCC with 0.90 discriminative power, 0.79 sensitivity and 0.86 specificity.This is an important step towards the development of objective tools for VSCC surgical guidance.

[HPV vaccination and the prevention of genital warts and precancerous lesions-current evidence and evaluation]

Human papillomaviruses (HPVs) can cause both benign and malignant tumors. To date, more than 200 HPV types have been discovered, of which 12 are currently classified as high risk for cervical cancer. HPV types that affect the anogenital tract are sexually transmitted. Since 2006, prophylactic HPV vaccines have been available and should be administered before first sexual contact.HPVs infect epithelial cells and are worldwide the most common sexually transmitted viruses. Apart from cervical cancer, HPVs cause other anogenital cancers such as vulvar, vaginal, and anal cancer but also oropharyngeal cancer (or head and neck cancers). HPV types 16 and 18 are also found at these sites. HPV types 6 and 11 are associated with genital warts; other HPV types can cause harmless skin warts.HPV vaccines are safe and highly effective, if they are administered before exposure to HPV. Systematic reviews and meta-analyses have shown that HPV vaccination effectively prevents HPV infection, but also precancerous lesions of the anogenital tract and genital warts. Recent vaccination data also demonstrate reductions in cervical cancer incidence.The uptake rates of HPV vaccination vary worldwide by program and acceptance. In comparison to other European countries, Germany has a low uptake rate. The Standing Committee on Vaccination (STIKO) recommends HPV vaccinations for all girls and boys ages 9 to 14 years in Germany. In 2018, only half of all 18-year-old girls in Germany were completely immunized against HPV.Organized vaccination programs, whether population-based or school-based, are necessary in order to increase vaccination uptake rates.

Real-World Effectiveness of Human Papillomavirus Vaccination Against Vulvovaginal High-Grade Precancerous Lesions and Cancers

BACKGROUND

Vaccination against human papillomavirus (HPV) has proven to be effective against severe cervical lesions and genital warts, whereas no previous study has provided real-world data on the HPV vaccine effectiveness against high-grade vulvovaginal lesions.

METHODS

A cohort of all women age 17-26 years living in Denmark during 2006-2019 was followed in nationwide registers for individual-level information about HPV vaccination and first diagnoses of vulvar and vaginal high-grade squamous intraepithelial lesions (HSIL+) or worse. The cumulative incidence of vulvar and vaginal HSIL+, respectively, was estimated with the Aalen-Johansen estimator, and Cox proportional hazards regression was used to estimate hazard ratios (HRs) for vulvar and vaginal lesions separately, comparing women vaccinated at age 16 years or younger and at age 17-26 years with unvaccinated women.

RESULTS

The cohort consisted of 514 537 women, of which 50.6% were vaccinated at baseline (<16 years), 31.8% were vaccinated during follow-up (17-26 years), and 17.6% remained unvaccinated. The cumulative incidence was less than 0.6‰ for vulvar HSIL+ and less than 0.2‰ for vaginal HSIL+. Adjusted analyses showed reduced HRs for both vulvar (HR = 0.22, 95% confidence interval = 0.13 to 0.38) and vaginal HSIL+ (HR = 0.16, 95% confidence interval = 0.04 to 0.55) for women vaccinated at age 16 years or younger compared with unvaccinated women. For women vaccinated at 17-26 years of age, the reductions in HRs were smaller for vaginal HSIL+ and close to 0 for vulvar HSIL+.

CONCLUSIONS

HPV vaccination before 17 years of age reduces the risk of vulvar and vaginal HSIL+ based on real-world data.