Vacunacion vph

The

n e w e ng l a n d j o u r na l

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m e dic i n e

clinical therapeutics

HPV Vaccination for the Prevention of Cervical Intraepithelial Neoplasia
Jessica A. Kahn, M.D., M.P.H.
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Majorclinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the author’s clinical recommendations.

A sexually active 18-year-old woman presents to her internist for an annual examination. During the review of her family history, she notes that her mother recently received a diagnosis of“pre–cervical cancer” and underwent a loop electrosurgical excision procedure. The patient’s mother has advised her to get the “cervical-cancer shot.” Should this patient receive a human papillomavirus (HPV) vaccine, and how effective would vaccination be in preventing cervical cancer?

The Cl inic a l Probl em
Genital HPV infection is usually acquired through sexual contact and is extremelycommon. In a nationally representative study of women in the United States, 25% of persons between the ages of 14 and 19 years and 45% of persons between the ages of 20 and 24 years were HPV-positive.1 It is estimated that more than 80% of both men and women in the United States will be infected with HPV at some point in their lives.2 HPV is often acquired within months after the first sexualintercourse: in a study of university women who had recently had sexual intercourse for the first time and reported having only one partner, almost 30% became HPV-positive within 1 year.3 Although HPV infection is usually asymptomatic, anogenital warts or cancers or other HPV-associated cancers develop in a subgroup of infected women and men. The clinical outcome of greatest significance for publichealth is cervical cancer. Globally, cervical cancer is the second most frequent cancer among women; each year, approximately 490,000 women receive this diagnosis and 270,000 die from cervical cancer.4 In the United States, the implementation of cytologic screening programs with the Papanicolaou (Pap) test has led to a decrease in rates of cervical cancer, since screening identifies precancerouscervical lesions that can be treated before they progress to cancer. Despite such screening, in 2008, approximately 11,000 women in the United States received a diagnosis of cervical cancer and 3900 died from the disease.5 The direct medical costs associated with the prevention and treatment of HPVrelated anogenital warts and cervical disease in the United States are estimated to be $4.0 billionannually,6 and productivity losses due to deaths from cervical cancer are estimated to be $1.3 billion annually.7
From the Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati. Address reprint requests to Dr. Kahn at the Division of Adolescent Medicine, MLC 4000, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, or atjessica.kahn@cchmc.org. N Engl J Med 2009;361:271-8.
Copyright © 2009 Massachusetts Medical Society.

Pathoph ysiol o gic a l Fe at ur e s a nd Effec t of Ther a py
HPVs are double-stranded DNA viruses that infect cutaneous or mucosal epithelial surfaces. The genome of the virus encodes two nucleocapsid proteins (L1 and L2) and at least six early proteins (E1, E2, and E4 through E7) that allow forreplication of
n engl j med 361;3 nejm.org july 16, 2009

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The New England Journal of Medicine Downloaded from www.nejm.org by EUGENIA MEZA GEREZ on August 30, 2010. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.

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viral DNA and the assembly of...