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Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States

BMJ 2009; 339 doi: (Published 08 October 2009) Cite this as: BMJ 2009;339:b3884

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Oropharynx cancer inadequately considered in cost-analysis of HPV vaccination program.

It was with great interest that we read the article by Kim and Goldie
on the cost-effectiveness of including boys in an HPV vaccination
program.(1) However, we believe that some assumptions made by the
authors, particularly those pertaining to oropharyngeal cancers, are

First, the HPV prevalence for oropharyngeal cancer is underestimated
based on the most current estimates for the US (“setting” for this
analysis). The figure given in the article, 31%, is based on worldwide
estimates;(2) however, prevalence of HPV in the US has been shown to be
much higher.(3,4) In fact, source data(5) for the review article(2)
referenced by the authors provides US-specific HPV prevalence as 47% (42%
for types 16/18), and other more recent high-quality studies from the US
have found rates as high as 72%.(3) Further, a recent population-based
study within the Colorado SEER registry found a HPV prevalence rate of 79%
for oropharyngeal cancers diagnosed after 1994.(4)

Second, because of misclassifications inherent to the SEER database,
where base of tongue cancers are classified under the generic term
“tongue” cancer and hence contribute to oral cancer incidence, the
oropharyngeal cancer incidence rate used in this analysis is inaccurately
low. Careful consideration of this misclassification when analyzing SEER
data (as performed by Chaturvedi et al.(6)) has yielded an incidence rate
in the US of approximately 6 for men and > 1 for women. Furthermore,
the authors have used an older SEER dataset (1975-2001) to arrive at the
determined incidence rates when clearly a more recent dataset was
available.(SEER website) Consequently, the underestimation of both HPV
prevalence and incidence of oropharyngeal cancer would have lead to an
underestimation of the impact vaccination of boys would have on these

Third, the authors used the same quality of life adjustment for all
cancers except cervical cancer. Studies evaluating the quality of life
for head and neck cancer patients have demonstrated that significant
differences exist between tumor sites. Oropharyngeal cancer patients, who
tend to be diagnosed at later stages and as a result undergo more
intensive multimodality treatments, often experience significantly
decreased quality of life, both immediately and years after treatment, as
compared to patients with oral cavity cancer.(7-10)

Fourth, the authors have unfortunately used a generic estimate for
head and neck cancer treatment costs which assumes cost is the same for
both oral cavity cancer and oropharyngeal cancer. Because the
overwhelming majority of oropharyngeal cancers present in advanced stage
and the US standard of care for oropharyngeal cancer treatment is
definitive radiotherapy typically with chemotherapy and/or surgery, the
cost per case for oropharyngeal cancer is likely a major underestimate.

Because we see on a daily basis middle-aged men suffering from and
dying of oropharyngeal cancer and its treatment, we are certainly biased
in our enthusiasm for the prevention of this disease. However, such bias
does not dispute the fact that such cost analyses must use the best and
most accurate data available.

1. Kim JJ, Goldie SJ. Cost effectiveness analysis of including boys
in a human papillomavirus vaccination programme in the United States. BMJ
2009; Oct 8;339:b3884.

2. Watson M, Saraiya M, Ahmed F, Cardinez CJ, Reichman ME, Weir HK,
et al. Using population-based cancer registry data to assess the burden of
human papillomavirus-associated cancers in the United States: overview of
methods. Cancer 2008; Nov 15;113(10 Suppl):2841-54.

3. D'Souza G, Kreimer AR, Viscidi R, Pawlita M, Fakhry C, Koch WM, et
al. Case-control study of human papillomavirus and oropharyngeal cancer. N
Engl J Med 2007; May 10;356(19):1944-56.

4. Ernster JA, Sciotto CG, O'Brien MM, Finch JL, Robinson LJ, Willson
T, et al. Rising incidence of oropharyngeal cancer and the role of
oncogenic human papilloma virus. Laryngoscope 2007; Dec;117(12):2115-28.

5. Kreimer AR, Clifford GM, Boyle P, Franceschi S. Human
papillomavirus types in head and neck squamous cell carcinomas worldwide:
a systematic review. Cancer Epidemiol Biomarkers Prev 2005; Feb;14(2):467-

6. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence
trends for human papillomavirus-related and -unrelated oral squamous cell
carcinomas in the United States. J Clin Oncol 2008; Feb 1;26(4):612-9.

7. Pourel N, Peiffert D, Lartigau E, Desandes E, Luporsi E, Conroy T.
Quality of life in long-term survivors of oropharynx carcinoma. Int J
Radiat Oncol Biol Phys 2002; Nov 1;54(3):742-51.

8. Nordgren M, Jannert M, Boysen M, Ahlner-Elmqvist M, Silander E,
Bjordal K, et al. Health-related quality of life in patients with
pharyngeal carcinoma: a five-year follow-up. Head Neck 2006; Apr;28(4):339

9. Hammerlid E, Bjordal K, Ahlner-Elmqvist M, Boysen M, Evensen JF,
Biorklund A, et al. A prospective study of quality of life in head and
neck cancer patients. Part I: at diagnosis. Laryngoscope 2001; Apr;111(4
Pt 1):669-80.

10. Bjordal K, Ahlner-Elmqvist M, Hammerlid E, Boysen M, Evensen JF,
Biorklund A, et al. A prospective study of quality of life in head and
neck cancer patients. Part II: Longitudinal data. Laryngoscope 2001;

Competing interests:
EMS participated as a one-time consultant to Merck in 2007 for a 1 day meeting discussing the role of HPV in head and neck cancer for which he was reimbursed travel costs (<_1000 and="and" a="a" one-time="one-time" honorarium="honorarium" _1000.="_1000." he="he" has="has" not="not" previously="previously" or="or" subsequently="subsequently" received="received" any="any" funds="funds" reimbursements="reimbursements" fees="fees" from="from" merck.="merck."/>

Competing interests: No competing interests

16 October 2009
Erich M. Sturgis, M.D., M.P.H.
Associate Professor, Department of Head and Neck Surgery and Department of Epidemiology
Kristina R. Dahlstrom, M.S.
The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030