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ORLANDO -- Awareness of the association between HPV infection and cancer has declined, even as the number of cases of HPV-related cancers continues to increase, a national health trends survey showed.

From 2014 to 2020, the proportion of survey respondents who knew that HPV causes cervical cancer declined from 77.6% to 70.2%. Awareness of HPV's association with other cancers lagged far behind, in the high 20s or low 30s. In general, awareness of the virus's link to oral, anal, and penile cancers changed little across the five study periods.

The findings have major public health implications, as studies have shown that awareness of the HPV-cancer relationship is associated with uptake of the HPV vaccine, said Eric Adjei Boakye, PhD, of Henry Ford Health in Detroit, at the American Association for Cancer Research annual meeting.

"The implications going forward are that there is a need to increase awareness and also to target interventions to increase awareness and counteract HPV vaccine disinformation, which is very prevalent," he said. "If we don't do that, there is a very high risk that we will not meet the Healthy People 2023 goal [for HPV vaccination], which is 80% and we are now at 62%. Traditionally, [the vaccination rate] has only been increasing by about 2% or 1% per year."

The awareness levels might actually have been overestimated, Boakye continued. Only survey participants who said they had heard of HPV (about 70%) were asked about their awareness of the virus's association with cancer.

The lagging awareness is concerning because "HPV-positive oropharyngeal cancer and anal cancer are two of the cancers that are still increasing in incidence in the United States," he noted.

Preoccupation with COVID and the push to get people vaccinated for that viral illness might have distracted attention from HPV messaging over the past 3 years, said Richard Bakst, MD, of Mount Sinai Health System in New York City. Physician discussions about HPV and cancer can help patients make informed decisions, but the influence only goes so far.

"It is important to emphasize that HPV cancers can be entirely prevented with vaccination," Bakst told MedPage Today via email. "With that said, as physicians, our job is not to sell any treatment or vaccination but to provide patients and parents with all the information they need to make an educated decision."

Because of the recent focus on COVID, "it is hard for me to really be concerned about these numbers except for the fact that so few know this information," said Lois Ramondetta, MD, of the University of Texas MD Anderson Cancer Center in Houston. "The concerning thing is that with 80% of the world's population being exposed to a virus that causes six to seven cancers and for them not to know, it is a heartbreaking realization regarding health education."

"I have long felt that there is a huge under-emphasis during elementary, middle school, and high school education regarding self-care," she added, "whether that be energy balance (food/exercise), sleep, intimacy education, stress education, and specifically, exposure to toxins and how to reduce exposure."

It's also important to educate patients on understanding the difference between causation (HPV and cancer) and correlation (poorly described association between HPV vaccination and any safety concerns), she noted. "The safety of vaccinations needs to be part of school education and the support for science in general."

More than 45,000 new HPV-related cancers occur each year in the U.S. More than 90% of those cancers could be prevented by HPV vaccination, Boakye noted. The U.S. previously failed to meet the Healthy People 2020 goal of 80% vaccination.

Studies have shown that awareness that HPV causes several types of cancer can improve HPV vaccine uptake, he continued. Efforts have been undertaken to improve awareness of the HPV-cancer association. Whether the efforts have in fact improved awareness remains unclear.

To examine the awareness issue, Boakye and colleagues analyzed data from the (HINTS) from 2014 to 2020. HINTS involves a nationally representative sample of U.S. civilian, non-institutionalized adults.

The analysis involved a total of 10,933 survey participants. Women accounted for 58% of the study population, non-Hispanic whites for 68%, and urban dwellers for 89%.

All of the participants were asked whether they had heard of HPV. Those who responded "yes" were then asked, "Do you think HPV can cause anal, cervical, oral, and penile cancers?"

Awareness of the association between HPV and cervical cancer declined the most from 2014 to 2020 (7.4%). Participants' awareness of HPV's causative role in the other cancers lagged far behind and changed little during the five survey periods:

• Anal cancer: 27.9% in 2014 and 27.4% in 2020
• Oral cancer: 31.2% and 29.5%, respectively
• Penile cancer: 30.3% and 28.4%

Given that the vast majority of people infected with HPV do not develop cancer, promoting the benefits of vaccination can be a "hard sell," said Ramondetta, who often couches the discussion in terms of a "cheat sheet" for the immune system.

"The vaccine is absolutely safe, and it works and it lasts," she added. "It is just a way to give your immune system a cheat sheet on recognizing the virus when it enters the body. Some immune systems can do OK without the cheat sheet but having it doesn't hurt them, and for those that needed a little extra study preparation, the vaccine is just the trick!"

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