Human papillomavirus (HPV) causes nearly all cervical cancers and is attributed to some cancers of the vagina, vulva, penis, anus, and oropharynx. Although most HPV infections are asymptomatic and usually resolve within 1 to 2 years, persistent infections can lead to precancer and cancer. According to the Centers for Disease Control and Prevention (CDC), approximately 44,000 HPV-related cancers occur yearly in the United States.1 Of those cancers, the majority are cancers of the cervix (~13,000) and cancer of the oropharynx (~19,000). HPV vaccination is a vital component in preventing these cancers, but the CDC reports that only about half of qualified adolescents are up to date on vaccinations, the reasons for which are multifactorial.
Although the incidence of cervical cancer in the United States has decreased markedly, we are seeing an alarming increase in the rate of newly diagnosed oropharyngeal cancers. Speaking with The ASCO Post, Carole Fakhry, MD, MPH, Associate Professor of Otolaryngology-Head and Neck Surgery at Johns Hopkins School of Medicine, said, “The incidence rate of oropharyngeal cancers continues to increase in the United States. This is driven by HPV-positive tumors. There are currently no screening recommendations. We have trials evaluating the feasibility of screening and encourage anyone who is interested to participate in such a clinical trial.”
“For those who are eligible for the HPV vaccine, that is likely the best way to prevent HPV-related oropharyngeal cancers.”— Carole Fakhry, MD, MPH
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Asked about prevention, Dr. Fakhry said, “For those who are eligible for the HPV vaccine, that is likely the best way to prevent HPV-related oropharyngeal cancers. Although we don’t have a randomized study showing that the vaccine reduced oral HPV infection or oropharyngeal cancer, there are several lines of evidence which point in this direction. Therefore, we expect the vaccine will have a role in the primary prevention of oropharyngeal cancer.”
Populations at Risk
Although the synergistic relationship between smoking and alcohol intake is a major risk factor for oral and head/neck cancers, chronic infection with certain types of HPV has also emerged as a key risk factor. In fact, we are seeing oropharyngeal cancers among a younger, healthy population of nonsmokers, although these cancers don’t exclusively arise among nonsmokers or younger patients. We are seeing a growing incidence among older individuals.
Moreover, research over the past few years points to education attainment as another risk factor for cancers of the oropharyngeal area. Studies have demonstrated that mortality rates for patients with oral cavity and pharyngeal cancers decreased significantly among men and women with more than 12 years of education, regardless of race or ethnicity (except for black women), whereas the rates increased among white men with up to 12 years of education. Mortality trends vary substantially for HPV-related and HPV-unrelated cancer.
Socioeconomic Status and Outcomes
Amy Y. Chen, MD, MPH, FACS, Willard and Lillian Hackerman Professor and Vice Chair of the Department of Otolaryngology, Head and Neck Surgery at Emory University School of Medicine, Atlanta, addressed this risk factor with The ASCO Post. “In studies that I’ve conducted, we’ve found a distinct variability in outcomes according to socioeconomic status. We feel that education can be a proxy for socioeconomic status.”
“HPV immunization is very important, and it’s our job to make people understand its value in preventing certain cancers.”— Amy Y. Chen, MD, MPH, FACS
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Dr. Chen noted that there were a lot of factors to tease out in determining social risk factors, but she said that research in this area demonstrates that patients with HPV-positive oropharyngeal cancers had higher levels of education, income, and overall socioeconomic status. Moreover, epidemiologic data show that among all races and ethnicities, men had higher rates of HPV-associated cancers of the oropharynx than women. Black and Hispanic men and women had lower rates of HPV-associated oropharyngeal cancers than white and non-Hispanic men and women.
“Given the sexually transmitted connection between HPV and certain cancers, there is no link between someone who had a partner with cervical cancer and oropharyngeal cancer due to oral sex. Much of this investigative science is going to boil down to the host’s ability to clear the virus and why some individuals have better virus-clearance ability before it gets into the pathologic stage. There’s a lot we don’t understand in this emerging clinical scenario.”
Prevention Strategies Needed
Data show that about 70% of oropharyngeal cancers are caused by high-risk HPV infection.2 Major health organizations recommend all children between the ages of 11 and 12 be vaccinated. Older girls and women up to age 26 should receive “catch-up” shots if they have never been vaccinated. The same goes for boys and men aged 13 to 21. However, despite these recommendations, adherence to HPV vaccination remains low.
Dr. Chen commented, “HPV immunization is very important, and it’s our job to make people understand its value in preventing certain cancers. Unfortunately, there is misinformation spread to the general public about vaccinations, which causes hesitation and anxiety. So, it’s a challenge to public health institutions to attack this issue with facts about life-saving vaccinations that resonate with people.” ■
DISCLOSURE: Drs. Fakhry and Chen reported no conflicts of interest.
1. CDC: How many cancers are linked with HPV each year? Available at https://www.cdc.gov/cancer/hpv/statistics/cases.htm. Accessed Sept. 20, 2019.
2. CDC: HPV-associated cancer statistics. Available at https://www.cdc.gov/cancer/hpv/statistics/index.htm. Accessed Sept. 20, 2019.