MUSC background

The Human Papillomavirus

An equal-opportunity threat

The human papillomavirus (HPV), best known for causing cervical cancer, is also responsible for an alarming spike in the incidence of oropharyngeal squamous cell carcinomas (OPSCC) in both men and women since the 1990s, hitting middle-aged, male, white nonsmokers hardest. If steps are not taken to curb its incidence, HPV-positive OPSCC could replace cervical cancer as the most common HPV-related cancer by 2020. Strong physician endorsement of HPV vaccination for both boys and girls could help reduce this risk for the next generation.

Although the Advisory Committee on Immunization Practices (ACIP) proposed in 2009 that all 11- or 12-year-old girls receive the quadrivalent HPV vaccine and extended that recommendation in 2011 to boys of the same age, a recent study of Georgia providers revealed that only 46% strongly recommended the vaccination in girls and only 20% in boys.1 This is of concern since, according to James R. Roberts, M.D., MPH, Professor of Pediatrics at MUSC Children’s Hospital, “A strong provider recommendation goes a long way in improving vaccination rates.”

Why, when the HPV vaccine represents the only anti-cancer vaccine, are physicians reluctant to recommend it, especially in boys? The answer lies at the intersection of economics, sexual politics, and media sensationalism. Medicaid reimburses HPV vaccination for both girls and boys, but not all private payors cover it for boys. Some parents believe that consenting to the HPV vaccine is tantamount to giving their children a license to have sex. Not so, says Dr. Roberts: “Recommending vaccination is in no way giving permission to have sex. The vaccine should be given early because the younger you are, the greater the protective antibody response.”

The issue became further sensationalized when actor Michael Douglas revealed in a tabloid interview that he believed his throat cancer was due to HPV acquired during oral sex. The myth that only the sexually promiscuous are at risk is a dangerous one in the opinion of Fred Dings, an English professor in Columbia, SC, who was treated for HPV-positive OPSCC at MUSC: “I am a 61-year-old man who has been monogamous since 1987. This virus somehow did genetic damage over a quarter century ago that only recently manifested as cancer.” By dispelling such misperceptions, physicians can lessen the stigma associated with the disease and overcome parents’ reluctance to have their children vaccinated.

For those who were exposed to the virus before the advent of the HPV vaccine and developed HPV-related OPSCC, the news is not all bad. “I had that sort of jaw-dropping conversation where you never think it’s going to be you,” remembers 57-year-old David Freeman, a business owner in Greenville, SC, about the day he was diagnosed with OPSCC. “Learning later that my cancer was HPV16-positive was oddly enough the first bit of good news I had had.”

Why good news? According to Terry A. Day, M.D., Director of the Division of Head and Neck Oncologic Surgery at MUSC, “HPV-related OPSCC, when treated early, has a much better cure rate (around 80%) than smoking-related OPSCC (around 60%).” Too often, however, these HPV-related cancers are misdiagnosed as strep throat or tonsillitis. Dr. Day, who recently reported the results of a retrospective study identifying the telltale symptoms of HPV-related OPSCC,2 advises “that any white, male nonsmoker aged 40 to 60 years with a neck mass or a sore throat that does not resolve within two weeks should be evaluated by a specialist for this disease.” Earlier diagnosis and treatment usually means better outcomes for these patients.

References

1 Luque JS, et al. Recommendations and administration of the HPV vaccine to 11- to 12-year-old girls and boys: a statewide survey of Georgia vaccines for children provider practices. J Low Genit Tract Dis. 2014 Mar 13. [Epub ahead of print]

2 Wesley R, McIlwain WR, Sood AJ, Nguyen SA, Day TA. Initial symptoms in patients with HPV-positive and HPV-negative oropharyngeal cancer.JAMA Otolaryngol Head Neck Surg. 2014 Mar 20 [Epub ahead of print]