Podcast Summary: Dr. Chapa’s Clinical Pearls

Episode: SCIENCE CHANGES: New Data on HPV Vaccination Peri-Leep/Cone
Date: October 5, 2025
Host: Dr. Chapa

Overview: Episode Theme & Purpose

This episode focuses on a major shift in clinical guidance regarding the use of HPV (Gardasil 9) vaccination around the time of LEEP or cone excisional procedures for high-grade cervical dysplasia (CIN2/3). Dr. Chapa discusses a new large-scale study from the Netherlands (the Vacin Trial, published September 2025 in the Lancet Obstetrics, Gynecology, and Women’s Health) that challenges the standing ACOG (American College of Obstetricians and Gynecologists) guidance on offering HPV vaccination peri-procedurally to unvaccinated, immunocompetent women. He uses the episode to emphasize that medical science is always evolving—no guidance is ever truly "settled."

Key Discussion Points & Insights

I. Evolution in Cervical Dysplasia & HPV Management

• Recaps progress from classic Pap smear to liquid cytology, primary HPV screening, and now to molecular/dual stain technology (P53/Ki67) as the latest advance for triage ([00:25]–[02:00]).
• Highlights how cytology is becoming less relevant:

  "Cytology is pretty much now irrelevant. If you follow the dual stain technology, which doesn’t even look at the cells at all..." (Dr. Chapa, [01:35])

• Outlines the preventive rationale for Gardasil vaccination and its evolution from bivalent to quadrivalent to Gardasil 9 ([02:00]–[03:18]).

II. Historical Guidance vs. New Evidence

• Since about 2013, growing evidence suggested that perioperative HPV vaccination (“adjuvant” use) may reduce dysplasia recurrence after LEEP/cone ([03:15]–[05:00]).
• ACOG (July 2023) guidance recommended considering vaccination perioperatively for immunocompetent previously unvaccinated women aged 27–45 ([05:00]–[06:50]):

  “...consider adjuvant HPV vaccination for immunocompetent previously unvaccinated people aged 27 to 45 years who are undergoing treatment for CIN2, end quote.” (Dr. Chapa quoting ACOG, [05:40])

III. The Vacin Trial: 2025 Game-Changer

• Introduces the Vacin Trial, Netherlands:
  • Largest multicenter phase IV randomized placebo-controlled trial on peri-procedural HPV vaccination ([06:55]–[08:20]).
  • Studied 3 Gardasil 9 injections vs. placebo around time of LEEP/cone for CIN2/3.
• Key Results (Dr. Chapa quoting directly from the article, [08:40]):

  “...Our trial suggests that adjuvant HPV vaccination is not effective in reducing the recurrence of CIN 2 to 3 lesions, contradicting conclusions of previous works and previous guidance. End quote.” “...guidelines should be more reticent in recommending additional prophylactic HPV vaccination after treating CIN lesions.” ([09:50])

• Dr. Chapa’s reaction:

  “Yikes. Okay, let me say that again. Yikes. I mean, so, guys, now, I’m not telling you what to do...you do you, honey. You do you, bruh. Because this is where shared decision-making comes in.” ([09:05])

IV. Details of the Vacin Trial & Statistical Interpretation

• Study design:
  • 3-dose Gardasil 9 vs. placebo IM given perioperatively (some just before, some after LEEP/cone) ([15:10]–[16:50]).
  • 24 months follow-up.
• Results:
  • Recurrence rate: 9% in placebo vs. 6% in vaccine group (absolute 3% reduction).
  • Quote:

    “P value was not good, our P value was above 0.5 and the confidence interval hovered and hugged 1, which showed there was no difference.” ([17:40])

• Clinical vs. statistical significance:

  “While that is statistically true, is a 3% clinically valid. I don’t know. I don’t know if that’s a big enough number to move anybody’s needle...it’s a 3% reduction compared to placebo for something that’s not cancer.” ([19:10])

• Asserts the trial is Level 1 evidence and directly contradicts earlier practice recommendations ([20:15]–[21:30]).

V. Implications for Practice & Science

• Repeated emphasis: “Science is settled—never” ([07:15], [13:40], [22:00]).
• Advocates for ongoing questioning and adjustment of clinical recommendations as new high-level evidence emerges.
• Counseling patients:

  “Talk to the patient and tell her science is never final. Testing the science is how we do science.” ([24:40])

• Safety note:

  “Nobody grew an extra eyeball because they received Gardasil with this trial, nor has anybody ever grown an extra eyeball because they received Gardasil.” ([25:30])

• Summing up, Dr. Chapa encourages shared decision making, weighing tiny absolute risk reduction versus lack of statistical significance.

Notable Quotes & Memorable Moments

• On the state of science:

  "This proves, guys, this proves... science is settled never. Because the way that you do science is you keep testing the science." ([07:10])

• Reacting to the new trial’s conclusion:

  "Our study provides level one evidence that contradicts these Current guideline recommendations. Oh no, you didn’t..." ([22:10])

• Addressing medical organizations:

  "In a time where some medical professional organizations sound more like pharmaceutical commercials… What does the data say? Let's make it a no spin platform here." ([22:50])

• On the human side:

  "You do you, honey. You do you, bruh. Because... this is where shared decision-making comes in." ([09:05])

• On safety:

  "Nobody grew an extra eyeball because they received Gardasil with this trial, nor has anybody ever grown an extra eyeball because they received Gardasil." ([25:30])

Timestamps for Key Segments

• 00:25 — Review of cervical cancer screening evolution
• 02:45 — History of HPV vaccination & prevention
• 05:00 — Prior data and ACOG July 2023 guidance
• 07:10 — "Science is settled never" principle
• 08:30 — Introduction & findings of the Vacin Trial (Netherlands, Lancet 2025)
• 09:50 — Direct quote from trial urging more “reticence” in guideline recommendations
• 15:10 — Vacin trial methodology (Gardasil 9 protocol, timing)
• 17:40 — Trial results, p-values, confidence intervals, and clinical significance debate
• 19:10 — Dr. Chapa’s personal perspective on 3% reduction
• 22:00 — Confronting established guidelines, call for “no spin”
• 24:40 — Patient counseling and shared decision-making
• 25:30 — Safety reassurance about Gardasil
• 26:18 — Episode wrap-up and recurring message on evolving science

Conclusion: Clinical Pearls & Takeaways

• HPV vaccination (Gardasil 9) as a perioperative measure for recurrence prevention after CIN2/3 treatment is now under question by new Level 1 evidence—the Vacin Trial.
• The absolute reduction of recurrence (3%) did not reach statistical significance, challenging current ACOG recommendations.
• No new safety concerns arose; Gardasil remains safe.
• Science is never "settled"—ongoing re-evaluation is fundamental.
• Transparent, up-to-date patient counseling and shared decision-making are key in light of evolving evidence.

Stay informed, question the science, and always consider new high-quality studies when making clinical recommendations.