Primary Prevention

The HPV vaccine protects against HPV strains that cause six types of cancers, including cancers of the cervix, oropharynx (throat), penis, vagina, vulva, and anus.

Estimates show upwards of 80% of the population will be infected by HPV. Given the virus's widespread nature, vaccine series completion is recommended by age 13 for optimal cancer prevention.

HPV vaccination currently lags behind other preteen vaccines. Using the best practices to increase HPV vaccination and reduce geographic disparities will ensure all young Californians benefit.

Vaccination represents a key pillar for HPV-associated cervical cancer elimination efforts. Health systems are encouraged to increase the California Immunization Registry (CAIR) utilization so that state and local vaccination coverage data can be used to address community needs.

Objective 1:

By 2025, increase initiation of HPV vaccine among 13-year olds from the baseline of 57% to 90%.

Data source: California Immunization Registry, 2018

Objective 2:

By 2025, increase series completion of the HPV vaccine among 13-year olds from the baseline of 35% to 80%.

Data source: California Immunization Registry, 2018

Objective 3:

By 2025, reduce the geographic disparity gap in HPV vaccination rates for 13-year-old Californians.

Strategies for Objectives 1, 2 and 3

1. Increase the number of clinicians strongly recommending the HPV vaccine at the same time they administer meningococcal conjugate and

tetanus‑diphtheria-acellular pertussis (Tdap) vaccines.

2. Incorporate evidence-based strategies to improve HPV vaccination in clinics serving adolescents, including:

• Issuing standing orders,

• Using electronic health record (EHR) prompts for providers,

• Scheduling next appointment, the same day as the first dose is given,

• Offering vaccine-only appointments,

• Implementing patient reminder/recall systems,

• Ensuring a pro-vaccine office culture,

• Making presumptive recommendations for HPV vaccine, and

• Educating providers and staff on HPV disease and prevention through vaccination. Resources available to support interventions include Clinician and Health Systems Action Guides available through the American Cancer Society.

3. Partner with Medi-Cal Managed Care and commercial health plans to use available data to identify providers with low HPV vaccine coverage and provide support and assistance to them, including with implementation of strategies listed above.

4. Support improved access to HPV vaccine through school-based clinics, pharmacies, local health departments, and other vaccination clinics (e.g., vaccine‑only appointments).

5. Increase the number of medical facilities, clinicians, school health centers, and pharmacies contributing HPV immunization data to the CAIR. This can be done by promotion of CAIR to health systems and individual providers, education on the existing mandate for all Medi-Cal Managed Care plans to enter immunizations into CAIR, and education on the Vaccines for Children Program to policymakers.

6. (Objective 1 and 2): Encourage public and private health plans, health systems, and providers to assess HPV vaccination coverage of 13-year-old patients using available data (quality performance metrics, immunization registry, EHR, etc.).

7. (Objective 3): Pilot an HPV-focused learning collaborative following the ECHO model (Extension for Community Health Outcomes) with select rural providers to enable participants to learn from experts and each other, gain access to evidence-based and capacity-building resources, and receive guidance in applying quality improvement processes to address HPV vaccination in their practices.

Promoting adherence to healthy eating and daily physical activity are effective ways to prevent obesity-related cancers. Unfortunately, healthy eating, daily physical activity, and obesity are major public health challenges in California, especially for low-income, minority populations.

The following objectives provide effective pathways to combat obesity-related cancers. Promoting increased intake of:

• whole fruits,

• whole vegetables,

• whole grains,

• and fewer sugary beverages is a science-based approach to reduce the risk of obesity-related cancers.

Increasing adherence to federal physical activity guidelines will decrease colon cancer risk by reducing inflammation in the colon and will reduce postmenopausal breast cancer risk by reducing estrogen levels in the breast.

Given the limited resources available for health promotion, interventions to change behavior should involve children, adolescents, and women of child-bearing age to maximize behavior impact and cancer prevention benefit over a lifetime.

School-based health promotion programs that encourage students to eat more fruits and vegetables, consume fewer sugary beverages, and be more active have been effective. Pregnancy is a teachable moment used to motivate improvements both in daily food choices and in physical activity.

Objective 1:

By 2025, increase the number of pregnant women and women of child-bearing age who limit sugary drink intake and consume the recommended servings of fruit and vegetables by 10%.

Strategies

1. Make it standard of care for gynecologists and obstetricians to remind their patients of child-bearing age that a diet rich in fresh or frozen fruits and vegetables, minimally processed, and limited added sugar reduces obesity for both her and her baby should she become pregnant.

2. Encourage the providers of Women, Infant and Children (WIC) nutrition programs to increase their subsidies for fresh and frozen vegetables and fruit to make it possible for their low-income pregnant women clients to snack on fresh or frozen fruit and vegetables, minimally processed, every day.

3. Encourage family members or friends to keep the pregnant woman's refrigerator continually stocked with vegetable soup and with fresh or frozen fruits and vegetables, minimally processed.

4. Encourage employers to provide a refrigerator at work in which employees can store fresh fruit and vegetables for lunch and workplace snacking.

5. Work with prenatal and postnatal care providers to encourage pregnant women/recent mothers to consume fresh or frozen fruits and vegetables, minimally processed, regularly.

Objective 2:

By 2025, increase the number of children and adolescents who report not drinking a sugary beverage and who consume the recommended daily servings of fruit and vegetables by 10%.

Strategies

1. Encourage communities to promote children’s consumption of non-sugary beverages via health education and bans on the sale of sugary beverages in child-friendly community environments, especially schools and public parks.

2. Encourage elementary school teachers to take students regularly on field trips to the local farmers market and local community garden to educate them about fruits and vegetables and good nutrition.

3. Encourage elementary school teachers to include lessons on the nutritional benefits of regularly eating minimally processed fruits and vegetables and avoiding food products with added sugar, especially sugary drinks.

4. Encourage school foodservice directors to offer a vegetable or fruit that is NOT on the list of the ten most common vegetables or fruits in the school cafeteria at least once a month, to increase students’ exposure to a wider variety of fresh or frozen fruits and vegetables, which are minimally processed.

5. Encourage communities, with extra outreach to U.S.-born Latino communities, to involve children and teens in community gardening, ideally at school.

6. Encourage communities to have enough sources of fresh/frozen vegetables so that 90% of residents reside within two miles of where they can buy a variety of fresh/frozen vegetables for their families.

Objective 3:

By 2025, increase the number of children and adolescents who engage in a minimum of 60 minutes of structured and unstructured physical activity daily each week by 10%.

Strategies

1. Encourage parents to walk their children to school.

2. Encourage families to do fun, low-impact, in-home, short-bout exercises using YouTube.com videos such as the Walk at Home series of videos.

3. Encourage elementary school teachers to break up the school day with 10-minute exercise breaks in class.

4. Encourage school boards of education to partner with community organizations (e.g., YMCA) to ensure that their students are able to engage in 60+ minutes of moderate to vigorous physical activity per day.

5. Encourage municipalities to create more opportunities for active recreation, including parks with family recreation programs, biking paths and hiking trails, especially in low-income neighborhoods.

6. Support Safe Routes to Schools programs to make it safer for teens to walk, skateboard, or bicycle to school.

Due to the tobacco industry hooking a new generation of users, the rate of tobacco use has increased in recent years. There is currently an epidemic of youth and young adult use of new tobacco products such as vaping devices.

Also, disparities in tobacco use continue, especially with Medi-Cal members who comprise over 40% of California's smokers.

Cancer centers are also increasingly called upon to integrate tobacco treatment into cancer care. The improvement of tobacco assessment and treatment is needed. The California Cancer Registry, the California Smokers’ Helpline, cancer centers, schools, providers, and other statewide, regional and local private and public partners play a vital role in helping to assess the burden of tobacco use among these groups.

1. Educate Californians about emerging tobacco products and its dangers.

2. Promote tobacco treatment practices to further reduce the prevalence of all tobacco products.

The following objectives and strategies are designed to continue California's progress in reducing the morbidity and mortality associated with tobacco use, with special attention to youth and young adults, the Medi-Cal population, and cancer patients.

Objective 1:

By 2025, reduce the prevalence of current tobacco product use among high school-aged youth from 12.7%* to 6.3% and young adults 18-25 from 24.6%** to 12.3%.

Data sources: California Student Tobacco Survey (CSTS), 2017-2018* and CHIS, 2018**

Strategies

1. Promote evidence-based curriculums in K-12 schools, such as the Stanford Tobacco Prevention Toolkit, and encourage the California Department of Education to provide Tobacco Use Prevention and Education funding to all schools.

2. Educate local communities about the health risks of emerging tobacco products, including vaping and nicotine salt products, policies such as California’s “Tobacco 21” law restricting tobacco product sales to persons under 21 years old, risks from dual use of tobacco products and other substances such as cannabis.

3. Educate school/college counselors and other clinical providers to assess and treat tobacco product use or exposure among youth and young adults, especially with vaping and for patients under 21 years of age, including the use of nicotine replacement therapy if indicated.

4. Promote the use of the California Smokers’ Helpline services, including quit vaping services, and other resources such as smokefree.gov, in school/college and clinical settings for youth and young adults with Ask Advise Connect protocols.

5. Decrease tobacco industry marketing on social media platforms and other online sources, which may target youth and young adults.

6. Support efforts that will reduce access and availability of tobacco products to persons under 21 years of age, secondhand smoke exposure to all nonsmokers, and increase enforcement of in-person or online sales restrictions to persons under 21 years old with coordination between California Department of Justice and other programs funded by CDPH and California Department of Education.

Objective 2:

By 2025, increase the number of children and adolescents who report not drinking a sugary beverage and who consume the recommended daily servings of fruit and vegetables by 10%.

Data source: CHIS, 2018

Strategies

1. Produce a report that tracks Medi-Cal tobacco assessment and treatment at a state and regional level, compared to the general population, and characterize populations and disparities; include secondhand smoke exposure among children and treatment of household smokers, as has been collected by the California Child Health and Disability Prevention program.

2. Track tobacco assessment and treatment in cancer screening programs, especially lung cancer screening which requires addressing tobacco use.

3. Encourage providers serving Medi-Cal populations to complete tobacco assessment and treatment training and engage in learning collaboratives or quality improvement initiatives for tobacco, such as that offered by CA Quits.

4. Integrate the California Smokers’ Helpline into safety net health systems that serve Medi-Cal members, from providers (including dentists, pharmacists, behavioral health, and cancer providers) and managed care plans to regional health information exchanges.

5. Encourage population-based health strategies with the California Smokers’ Helpline to provide FDA-approved tobacco cessation medications, outreach, and engagement including incentives (e.g., Medi-Cal Incentives to Quit Smoking project incentives included mailed nicotine patches and a $20 gift card).

6. Engage and highlight best practices of tobacco assessment and treatment among health and social service organizations that serve the Medi-Cal population such as children’s services, maternal health, and behavioral health.

Objective 3:

By 2025, increase tobacco assessment rates among patients in the California Cancer Registry from the baseline of 56% to 80%.

Data source: CCR, 2012-2016

Strategies

1. Produce a report of statewide and regional tobacco assessment rates among all patients with cancer, focusing on the 12 tobacco-related cancers and include special populations (e.g., Medi-Cal).

2. Encourage and track California cancer clinics/centers to incorporate tobacco treatment as a program goal or quality improvement project (e.g., American Society of Clinical Oncology’s Quality Oncology Practice Initiative tobacco quality metric).

3. Train California cancer providers and registry abstractors/staff about documentation of tobacco status assessment, including e-cigarettes/vaping and secondhand smoke exposure.

4. Increase and track the number of California cancer centers that have tobacco treatment programs and/or electronic referrals to the California Smokers’ Helpline.

5. Encourage the adoption of the National Cancer Institute’s Tobacco Use Questionnaire, which is validated for cancer clinical trials but can also be used for clinical care.

6. Encourage CDC or CDPH to require data collection about tobacco treatment for cancer registries (not just tobacco assessment), as the Surgeon General concludes suggestive evidence that smoking cessation after a cancer diagnosis improves all‑cause mortality.

Cases of melanoma and nonmelanoma skin cancers are increasing yearly, with more people developing skin cancer from indoor tanning along, than lung cancer due to smoking.

Preventing the disease involves developing an understanding of the risks associated with UV radiation from the sun and other sources, including indoor tanning beds, and then making lifestyle choices to reduce one’s exposure.

This process will need to involve partners in the health care system, education, advocacy, and government to develop and implement measures to ensure healthy habits that promote sun-safe behaviors. Communities also need to collaboratively address the social norms regarding tanned skin and the importance of developing policies that support UV radiation protection and warn the public about the dangers of excessive UV exposure from outdoor recreational activities and tanning devices.

The following objectives do not currently have identified baseline measures and may be established as part of an implementation plan.

Objective 1:

By 2025, reduce UV exposure and the number of sunburns in outdoor occupational workers.

Strategies

1. Establish baseline data for outdoor occupational workers, including people working in construction and agricultural settings. Determine their associated melanoma incidence and mortality by county paired with UV exposure behaviors, number of sunburns, and existing diagnoses of skin cancer via the 2020 National Health Interview Survey (NHIS) of skin cancer risk.

2. Engage employers of outdoor occupational workers to include sun-safety information in workplace wellness programs, encourage wearing of sun protection, schedule breaks in the shade, allow time to reapply sunscreen, increase the amount of shade available, decrease UV exposure by covering bright surfaces, promote telehealth dermatology educational strategies and outreach, and create work schedules that minimize sun exposure.

3. Develop a social media campaign to educate outdoor occupational workers about the risks of UV exposure, sunburns, and development of skin cancer. Promote adoption of sun-safe behaviors with specific emphasis on those at highest risk, including white and Hispanic males using the CDC’s Sun Safety Tips for Men, the #SunSafeSelfie campaign, scheduling annual skin checks, and becoming role models for sun safety programs.

4. Reassess UV exposure by outdoor occupation (construction versus agricultural workers). Add 2020 NHIS skin cancer questions to the California Health Interview Survey in 2024 with additional questions on educational outreach (employers, social media, coordinated community interventions) to assess behavior changes that reduce UV exposure, the number of sunburns per year, and associated skin cancer diagnoses.

Objective 2:

By 2025, reduce UV exposure and the number of sunburns in people participating in outdoor recreation.

Strategies

1. Upon release of the 2020 NHIS skin cancer data, baseline measurements for UV exposure and the number of sunburns will be established per age-group and distribution in California counties.

2. Assist school districts in improving access to playground shade structures using CDC’s Shade Planning for American Schools.

3. Promote skin cancer educational resources (CDC and Wipe Out Melanoma – California Initiative) for use in elementary through junior high curriculums to illustrate the benefits of sun safe behaviors and ways to reduce UV exposure.

4. For outdoor recreational or tourism settings, promote increased use of shade in high use areas, move activities to shade structures, schedule activities during low‑UV times of day, and make sure plans for new outdoor recreational spaces include shade.

5. Promote staff and visitor sun safe behaviors through established programs, such as the Pool Cool, Sun Safe, and Promoting Sun Safety among Zoo Visitors. Encourage visitors and staff to use sun protection with policies for staff, having staff teach and model sun safety behaviors, posting signs to remind visitors to protect themselves, provide sunscreen dispensers, and allow activity breaks for application of sunscreen.

6. Promote other delivery methods for personal sun safety items, including selling hats with a wide brim, protective clothing, and umbrellas. Provide broad spectrum sunscreen with an SPF of 15 or higher, and post instructions for proper use.

Objective 3:

By 2025, reduce indoor tanning use by sexual minority men (gay and bisexual men) in California.

Strategies

1. Establish current baseline rates of tanning bed use throughout California by county, comparing specific demographics, including sexual minority men, using the California Health Interview Survey 2009 tanning bed use questions augmented with questions related to motivations for using tanning beds, distance to tanning beds, diagnosis of skin cancers, and potential skin cancer protection behaviors.

2. Establish a UV Exposure Advisory Board to guide selection of specific strategies and activities to reduce use of tanning beds and associated sunburns in the counties identified in the baseline assessment of exceeding tanning bed use and number of sunburns.

3. Conduct focus groups of sexual minority men who disproportionately use tanning beds to develop appropriate social media campaigns for reduction in UV exposure through use of tanning beds.

4. Develop and evaluate a social media campaign with the aid of the UV Advisory Board targeting sexual minority men, according to the CDC Community Guide for modifying behavior associated with tanning bed use.