Primary prevention

Smoking, alcohol use, and social history should be obtained at initial consultation. Smoking cessation and alcohol counseling should be offered, as patients are at risk for second primaries because of field cancerization. There is currently no recommendation for human papillomavirus (HPV)-positive patients to change their sexual behavior.

The 9-valent HPV vaccine can prevent high-risk HPV infection and, thus, the development of HPV-associated oropharyngeal cancer. Patients should be educated on the safety and importance of the vaccine, particularly in children prior to the age of sexual debut. Early postmarket studies demonstrated the success of the vaccine in decreasing the incidence of HPV-associated cancers, including oropharyngeal cancer, in vaccinated cohorts.[31][32]​​ Larger public health vaccination efforts are expected to drive down the rising incidence of HPV-associated oropharyngeal cancer over the next few decades.

The 9-valent HPV vaccine is approved in the US for girls and women ages 9-45 years for the prevention of cervical, vulvar, vaginal, anal, and oropharyngeal cancers and other head and neck cancers caused by HPV types 16, 18, 31, 33, 45, 52, and 58. It is also approved in the US for boys and men ages 9-45 years for the prevention of anal and oropharyngeal cancers and other head and neck cancers caused by HPV types 16, 18, 31, 33, 45, 52, and 58. The oropharyngeal and head and neck cancer indication for the 9-valent vaccine in the US is an accelerated approval based on effectiveness of the vaccine in HPV-associated anogenital disease. Continued approval for this indication may change, based on the results of a confirmatory trial.

The Centers for Disease Control and Prevention (CDC) recommends routine vaccination against HPV for girls and boys ages 11 or 12 years, but early vaccination from the age of 9 onwards may be considered.[33] The American Academy of Pediatrics recommends routine HPV vaccination between the ages of 9 and 12 years, at an age that the provider deems optimal for acceptance and completion of the vaccination series.[34]​ The CDC recommends catch-up HPV vaccination for all persons up to and including the age of 26 years who are not adequately vaccinated.[8]​ Shared clinical decision-making regarding HPV vaccination is recommended for some adults ages 27-45 years who are not adequately vaccinated and who are most likely to benefit from vaccination.[35]​​[36]

Further details on current vaccination schedules and special patient populations can be found in the latest ACIP vaccination schedules for children and adults. CDC: Child and adolescent immunization schedule by age Opens in new window CDC: Adult immunization schedule by age Opens in new window

The table that follows summarizes recommendations on HPV vaccination from the CDC.[33][36]

Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.

Ages 9-12 years; not yet vaccinated against HPV

Without immunocompromise

Intervention
Goal
Intervention

HPV vaccination; 2-dose series

HPV vaccination is routinely recommended at age 11-12 years, but can start at age 9 years.

HPV vaccination is recommended to start at the age of 9 years for those with a history of sexual abuse or assault.

A 2-dose series (given at 0 months and 6-12 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those age 9-14 years at initial vaccination who have received 2 doses at least 5 months apart.

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

With immunocompromise

Intervention
Goal
Intervention

HPV vaccination; 3-dose series

HPV vaccination is routinely recommended at age 11-12 years, but can start at age 9 years.

HPV vaccination is recommended to start at the age of 9 years for those with a history of sexual abuse or assault.

For those with immunocompromising conditions, including HIV infection, a 3-dose series (given at 0 months, 1-2 months, and 6 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those with immunocompromise of any age who have received 3 doses given at 0, 1-2, and 6 months.

The following minimum intervals apply:

  • Dose 1 to dose 2: 4 weeks

  • Dose 2 to dose 3: 12 weeks

  • Dose 1 to dose 3: 5 months

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Pregnant

Intervention
Goal
Intervention

Delay HPV vaccination until after pregnancy

HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.

Goal

Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy

Ages 12-14 years; not yet vaccinated against HPV, or not adequately vaccinated

Without immunocompromise

Intervention
Goal
Intervention

Catch-up HPV vaccination; 2-dose series

A 2-dose series (given at 0 months and 6-12 months) is recommended.

A minimum interval of 5 months is required between doses; give the second dose if this has not yet been given, or repeat the second dose if this was administered too soon.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those ages 9-14 years at initial vaccination who have received 2 doses at least 5 months apart.

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

With immunocompromise

Intervention
Goal
Intervention

Catch-up HPV vaccination; 3-dose series

For those with immunocompromising conditions, including HIV infection, a 3-dose series (given at 0 months, 1-2 months, and 6 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those with immunocompromise of any age who have received 3 doses given at 0 months, 1-2 months, and 6 months.

The following minimum intervals apply:

  • Dose 1 to dose 2: 4 weeks

  • Dose 2 to dose 3: 12 weeks

  • Dose 1 to dose 3: 5 months

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Pregnant

Intervention
Goal
Intervention

Delay HPV vaccination until after pregnancy

HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.

Goal

Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy

Ages 15-26 years; not yet vaccinated against HPV, or incompletely vaccinated

No doses of HPV vaccine received

Intervention
Goal
Intervention

Catch-up HPV vaccination; 3-dose series

For those vaccinated against HPV at ages 15 years or older at initial vaccination, a 3-dose series (given at 0 months, 1-2 months, and 6 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those ages ≥15 years who have received 3 doses given at 0 months, 1-2 months, and 6 months.

The following minimum intervals apply:

  • Dose 1 to dose 2: 4 weeks

  • Dose 2 to dose 3: 12 weeks

  • Dose 1 to dose 3: 5 months

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Incompletely vaccinated; ages 9-14 years at initial vaccination

Intervention
Goal
Intervention

Catch-up HPV vaccination; give one additional dose

Those who were ages 9-14 years at initial vaccination and received 1 dose or 2 doses less than 5 months apart require 1 additional dose of HPV vaccine.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those ages 9-14 years at initial vaccination who have received 2 doses at least 5 months apart.

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Incompletely vaccinated; age ≥15 years at initial vaccination

Intervention
Goal
Intervention

Catch-up HPV vaccination; give one or two additional doses

Those who began HPV vaccination at age ≥15 years are considered to be incompletely vaccinated if they have received less than 3 doses, or if subsequent doses were administered too soon.

For those ages 15 years or older at initial vaccination, a 3-dose series (given at 0 months, 1-2 months, and 6 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those ages ≥15 years who have received 3 doses given at 0 months, 1-2 months, and 6 months.

The following minimum intervals apply:

  • Dose 1 to dose 2: 4 weeks

  • Dose 2 to dose 3: 12 weeks

  • Dose 1 to dose 3: 5 months

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Pregnant

Intervention
Goal
Intervention

Delay HPV vaccination until after pregnancy

HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.

Goal

Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy

Ages 27-45 years; not yet vaccinated against HPV, or incompletely vaccinated

No doses of HPV vaccine received

Intervention
Goal
Intervention

Consider catch-up HPV vaccination; 3-dose series

Use shared clinical decision making in discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.

For those vaccinated against HPV at ages 15 years or older at initial vaccination, a 3-dose series is recommended.

A 3-dose series (given at 0 months, 1-2 months, and 6 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those age ≥15 years who have received 3 doses given at 0 months, 1-2 months, and 6 months.

The following minimum intervals apply:

  • Dose 1 to dose 2: 4 weeks

  • Dose 2 to dose 3: 12 weeks

  • Dose 1 to dose 3: 5 months

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Incompletely vaccinated; ages 9-14 years at initial vaccination

Intervention
Goal
Intervention

Consider catch-up HPV vaccination with administration of one additional dose

Use shared clinical decision making in discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.

One additional dose of HPV vaccine may be considered for those ages 9-14 years at initial vaccination who received only 1 dose, or 2 doses less than 5 months apart.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those ages 9-14 years at initial vaccination who have received 2 doses at least 5 months apart.

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Incompletely vaccinated; age ≥15 years at initial vaccination

Intervention
Goal
Intervention

Consider catchup HPV vaccination with one or two additional doses

Use shared clinical decision making in discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.

Those who began HPV vaccination at age ≥15 years are considered to be incompletely vaccinated if they have received less than 3 doses, or if subsequent doses were administered too soon. In this scenario, consider catchup vaccination using shared decision making.

A 3-dose series (given at 0 months, 1-2 months, and 6 months) is recommended.

Goal

Prevention of HPV and HPV-associated disease, including oropharyngeal cancer

The HPV vaccination series is complete, with no additional dose needed, for those ages ≥15 years who have received 3 doses given at 0 months, 1-2 months, and 6 months.

The following minimum intervals apply:

  • Dose 1 to dose 2: 4 weeks

  • Dose 2 to dose 3: 12 weeks

  • Dose 1 to dose 3: 5 months

No additional dose is recommended when any HPV vaccine series of any valency has been completed using the recommended dosing intervals.

Pregnant

Intervention
Goal
Intervention

Consider HPV vaccination after pregnancy

HPV vaccination is not recommended during pregnancy (although routine pregnancy testing is not recommended before vaccination). No intervention is needed if vaccination is given inadvertently during pregnancy.

Following pregnancy, decisions about HPV vaccination should be made using shared clinical decision making following discussion with the patient, taking into account individual patient characteristics and preferences and healthcare provider discretion.

Goal

Defer vaccination due to lack of evidence regarding HPV vaccination safety in pregnancy

Secondary prevention

Patients should be counseled about the importance of abstention from smoking and alcohol consumption to reduce the incidence of second primaries. Patient support such as Alcoholics Anonymous, cancer survivor groups, and psychological counseling may help.

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