Advertisement
Fighting Cancer Before It Starts
Fighting Cancer Before It Starts
By Elizabeth L. Ciemins, PhD, MPH, MA
April 3, 2026
Human papillomavirus (HPV) is responsible for approximately 37,800 cancer cases in the United States every year, including cancers of the cervix, oropharynx, anus, penis, vagina, and vulva.1 We have a vaccine that prevents them, and yet vaccination rates remain below targets, leaving far too many patients unprotected.
A new study published in Academic Pediatrics, led by AMGA researchers and co-authored by national vaccination experts, offers a practical, evidence-informed roadmap for changing that.2 The study examines how five geographically diverse AMGA member health systems successfully shifted routine HPV vaccination initiation from ages 11–12 to age 9, and what other health systems can learn from their experience.
Why Age 9?
Current Centers for Disease Control and Prevention (CDC) guidelines recommend initiating HPV vaccination at ages 11 to 12, with catch-up vaccination through age 26,3 but an emerging and compelling body of evidence supports starting at age 9. Earlier initiation creates more touchpoints for vaccination before adolescence, increases the likelihood of completing the full two-dose series before potential HPV exposure,4,5 and shifts the clinical conversation away from sexual activity and toward cancer prevention. Evidence also confirms that immune response and long-term protection are equivalent regardless of the age at which the series begins.6
Earlier initiation creates more touchpoints for vaccination before adolescence, increases the likelihood of completing the full two-dose series before potential HPV exposure,4,5 and shifts the clinical conversation away from sexual activity and toward cancer prevention.
HPV vaccination has already demonstrated its population-level impact: HPV infection rates among 14- to 24-year-old females have declined by more than 80% since vaccine introduction,7 and the prevalence of anogenital warts and cervical precancer has fallen by more than 50% among U.S. adolescents.8 Earlier initiation stands to extend these gains further by improving series completion rates4,9 and maximizing the window of protection before potential exposure.
Despite these advantages, routine age 9 initiation remains far from standard practice. Awareness gaps among providers and families, the absence of an explicit CDC recommendation for age 9 initiation, and inertia toward established protocols have all contributed to slow adoption.10,11
What the Study Found
AMGA recruited five member health systems, spanning the Southwest, Northeast, West, and Midwest, and ranging from 350 to 2,000 physicians, that had each made deliberate, measurable progress in HPV vaccination among 9- and 10-year-olds. Using the Consolidated Framework for Implementation Research (CFIR) as a guiding structure, the research team collected 497 surveys and conducted 10 in-depth interviews with pediatricians, nurses, clinic managers, quality leaders, and immunization strategists across these organizations.
The results were striking. Pre-implementation vaccination rates for 9- and 10-year-olds ranged from essentially zero to 17%. Following their respective interventions, launched between 2018 and 2022, rates climbed 15 to 49 percentage points higher. No single intervention drove these gains. Instead, success emerged from layered, mutually reinforcing strategies operating at the organizational, provider/staff, and patient/family levels.
Strategies That Made the Difference
Several interventions stood out as widely adopted and highly impactful across the participating systems.
Leadership ownership/buy-in and data transparency. Organizations that shared age-specific vaccination rate data with clinical and administrative leadership, and then cascaded those data to frontline providers, found that buy-in followed. Seeing the gap between where a practice stood and where it could be proved motivating at every level of the hierarchy.
Electronic health record (EHR) optimization. Updating the EHR to prompt HPV vaccination beginning at age 9, combined with standing orders that allowed nurses and medical assistants to administer the vaccine under protocol, was repeatedly described as transformative. Standardizing the prompt across clinic settings reduced variation and removed the burden of individual provider decision-making at each encounter.
Physician and staff champions. Identifying a dedicated champion, often a physician who could speak peer-to-peer, helped normalize age 9 initiation and served as a credible, sustained voice for the initiative within each organization.
Reframing the conversation. Initiating at age 9 allowed providers to discuss the vaccine entirely in the context of cancer prevention, sidestepping the sexual transmission framing that generates hesitancy among many families. This shift in messaging, i.e., "We're preventing cancer, not addressing sexual activity," proved particularly effective with hesitant families and those whose children were younger.
ˆ The most successful organizations began planting the seed at ages 6–8 well-child visits, well before the vaccination appointment. Reminder postcards, patient portal messages, exam room posters, and even a podcast were used to normalize the expectation and reduce surprise at age 9.
The Bottom Line for Health Systems
The study's findings are both encouraging and actionable. Health systems do not need to reinvent the wheel. The same quality improvement levers that have driven vaccination rates for other adolescent vaccines, i.e., data feedback, leadership alignment, EHR integration, staff education, and clear patient communication, apply here. What's different is the framing: Age 9 initiation opens a new clinical window, a new messaging opportunity, and ultimately a greater chance of protecting patients before exposure occurs.
AMGA member health systems can move the needle on HPV vaccination with a practical evidence base
Elizabeth L. Ciemins, PhD, MPH, MA, is chief research officer for AMGA.
The full study, published as open access in Academic Pediatrics, is available here.
References
- National Cancer Institute. 2025 HPV and cancer. National Institutes of Health. Available at cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer. Accessed March 23, 2026.
- Centers for Disease Control and Prevention. 2021. Human papillomavirus (HPV) vaccination recommendations. Available at cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Accessed March 23, 2026.
- S.C. O'Leary and H.M. Frost. 2023. Does HPV vaccination initiation at age 9 improve HPV initiation and vaccine series completion rates by age 13? Hum Vaccin Immunother 2023; 19: 2180971.
- K. Saxena, N. Kathe, P. Sardana, et al. 2023. HPV vaccine initiation at 9 or 10 years of age and better series completion by age 13 among privately and publicly insured children in the US. Hum Vaccin Immunother 2023; 19: 2161253.
- O.E. Iversen, M.J. Miranda, A. Ulied, et al. 2016. Immunogenicity of the 9-valent HPV vaccine using 2-dose regimens in girls and boys vs a 3-dose regimen in women. JAMA 2016; 316: 2411.
- H.G. Rosenblum, R.M. Lewis, J.W. Gargano, et al. 2021. Declines in prevalence of human papillomavirus vaccine-type infection among females after introduction of vaccine — United States, 2003–2018. MMWR Morb Mortal Wkly Rep 2021; 70: 415.
- M. Drolet, E. Benard, N. Perez, et al. 2019. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 2019; 394: 497.
- A.K. Minihan, P. Bandi, J. Star, et al. 2023. The association of initiating HPV vaccination at ages 9–10 years and up-to-date status among adolescents ages 13–17 years, 2016–2020. Hum Vaccin Immunother 2023; 19: 2175555.
- D.M. Holman, V. Benard, K.B. Roland, et al. 2014. Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr 2014; 168: 76.
- M.B. Gilkey, W.A. Calo, M.W. Marciniak, et al. 2017. Parents who refuse or delay HPV vaccine: differences in vaccination behavior, beliefs, and clinical communication preferences. Hum Vaccin Immunother 2017; 13: 680.
- E.L. Ciemins, A. Rooney, J.A. Yaun, et al. 2025. Initiating Human Papillomavirus Vaccination at Age 9: Strategies for Success From 5 US Health Systems. Acad Pediatr 2025; 25: 102869.
