Hpv cancer in throat

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HPV and Oropharyngeal Cancer

Diagram of the oral cavity and oropharynx. The oral cavity includes the lips, the labial and buccal mucosa, the front two-thirds of the tongue, the retromolar pad, the floor of the mouth, the gingiva, and the hard palate. The oropharynx includes the palatine and lingual tonsils, the back one-third base of the tongue, the soft palate, and the posterior pharyngeal wall.

Human papillomavirus (HPV) can cause serious health problems, including warts and cancer.

What Is HPV?

HPV is the most common sexually transmitted infection in the United States. Of the more than 100 types of HPV, about 40 types can spread through direct sexual contact to genital areas, as well as the mouth and throat. Oral HPV is transmitted to the mouth by oral sex, or possibly in other ways. Many people are exposed to oral HPV in their life. About 10% of men and 3.6% of women have oral HPV, and oral HPV infection is more common with older age. Most people clear HPV within one to two years, but HPV infection persists in some people.

HPV can infect the mouth and throat and cause cancers of the oropharynx (back of the throat, including the base of the tongue and tonsils). This is called oropharyngeal cancer. HPV is thought to cause 70% of oropharyngeal cancers in the United States.

It usually takes years after being infected with HPV for cancer to develop. It is unclear if having HPV alone is enough to cause oropharyngeal cancers, or if other factors (such as smoking or chewing tobacco) interact with HPV to cause these cancers. HPV is not known to cause other head and neck cancers, including those in the mouth, larynx, lip, nose, or salivary glands.

What Are the Symptoms of Oropharyngeal Cancer?

Symptoms of oropharyngeal cancer may include a long-lasting sore throat, earaches, hoarseness, swollen lymph nodes, pain when swallowing, and unexplained weight loss. Some people have no symptoms. If you have any symptoms that worry you, be sure to see your doctor right away.

Can the HPV Vaccine Prevent Oropharyngeal Cancers?

The HPV vaccine was developed to prevent cervical and other cancers of the reproductive system. The vaccine protects against the types of HPV that can cause oropharyngeal cancers, so it may also prevent oropharyngeal cancers. But studies have not been done to show this.

CDC recommends HPV vaccination for 11- to 12-year-olds. CDC also recommends HPV vaccination for everyone through age 26 years, if not vaccinated already.

Vaccination is not recommended for everyone older than age 26 years. However, some adults age 27 through 45 years who are not already vaccinated may decide to get the HPV vaccine after speaking with their doctor about their risk for new HPV infections and the possible benefits of vaccination. HPV vaccination in this age range provides less benefit, as more people have already been exposed to HPV.

HPV vaccination prevents new HPV infections, but does not treat existing infections or diseases. This is why the HPV vaccine works best when given before any exposure to HPV.

What Are Other Ways to Lower My Risk of Getting HPV or Oropharyngeal Cancer?

Condoms and Dental Dams

When used consistently and correctly, condoms and dental dams can lower the chance that HPV is passed from one person to another.

Alcohol and Tobacco

Alcohol and tobacco products may contribute to oropharyngeal cancers. Don’t smoke or use smokeless tobacco products, and avoid smoke from other people’s cigarettes. Limit the amount of alcohol you drink.

An expert who reviewed the study called the findings “interesting,” but said they should be interpreted with caution.

Larger studies are needed to confirm the results, said Maria Worsham, research director in the department of otolaryngology/head and neck surgery at Henry Ford Hospital, in Detroit.

Plus, Worsham said, the symptoms these study patients reported are not unique to cancer. So people should not assume that a lump in the neck means they have cancer — or oral HPV, she said.

Another expert not involved with the study said that a lump could indeed be an infection that just needs a round of antibiotics.

But if the mass persists, see your doctor again, added Dr. Dennis Kraus, director of the Center for Head and Neck Oncology at Lenox Hill Hospital, in New York City.

According to Kraus, the findings help “codify” what many doctors have noted: that people with HPV-positive oropharyngeal cancer tend to have no symptoms, but instead notice a lump.

The “good news,” Kraus said, is that HPV-positive cancers generally have a better prognosis. Patients with HPV-negative cancers tend to have a more-aggressive disease — and, therefore, obvious symptoms like an irritated throat and difficulty swallowing.

Kraus agreed with Day that the face of oropharyngeal cancer has changed from years ago. HPV-positive tumors are now more common than HPV-negative ones, he said.

According to the CDC, about 7 percent of Americans have oral HPV, though only 1 percent have the particular strain (HPV-16) that’s linked to oropharyngeal cancer.

Usually, the immune system is able to clear HPV from the body, and most people never know they were infected.

But for reasons that aren’t clear, some people harbor chronic HPV infections. Persistent infection with a cancer-linked strain is the big worry: Nearly all cases of cervical cancer, for instance, are caused by HPV.

There are, however, two vaccines against the most common cancer-linked HPV strains — including HPV-16. Experts recommend all children ages 11 and 12 be vaccinated. Older girls and women up to age 26 should get “catch-up” shots if they’ve never been vaccinated. The same advice goes for boys and men ages 13 to 21.

The vaccines — Gardasil and Cervarix — are known to ward off genital and anal HPV infections. Studies on whether the vaccines prevent oral infections are just starting. But, Kraus noted, they do target the major HPV strain linked to oropharyngeal cancer.

Does oral sex cause throat cancer?

Share on PinterestOral sex can spread HPV from people that carry the virus to people that do not.

Although smoking tobacco and drinking alcohol are the primary risk factors for oral cancer, the HPV virus may also be linked to oral cancer.

It is estimated that 35 percent of throat cancers are infected with HPV.

HPV has been demonstrated as one of the leading risk factors for cancer of the mouth and throat, known as oropharyngeal cancer.

The infection does not directly cause oral cancer. The virus triggers changes in the infected cells. The genetic material of the virus becomes part of cancer cells, causing them to grow. This can lead to the detection of HPV in people who have cancers that were caused by other factors.

Later on, these cells can become cancerous. However, few people with an HPV infection will develop cancer. In fact, the body clears around 90 percent of HPV infections within 2 years.

The subtypes of HPV found in the mouth are almost all sexually transmitted, so oral sex is a probable cause.

People who smoke are less likely to be able to clear an HPV infection because smoking damages immune cells in the skin. These normally help protect against viral damage.

In a study published in the New England Journal of Medicine in 2007, researchers suggested that people who have oral sex with at least six different partners have a significantly higher risk of developing throat cancer.

The team recruited 100 patients who had recently been diagnosed with oropharyngeal cancer, as well as a control group of 200 healthy individuals.

They found that people who had at least six oral sex partners during their lifetime were 3.4 times more likely to have throat cancer. Those with 26 or more vaginal sex partners had 3.1 times the risk of developing throat cancer.

The presence of oral HPV that could cause cancer was found in another study to be 14.9 percent in men who smoked tobacco and have had more than five oral sex partners.

Men with one of those risk factors saw a lower risk of throat cancer at 7.3 percent. Prevalence was much lower for both men (1.7 percent) and women (0.7 percent) who have had one lifetime oral sexual partner or less.

Many media outlets have represented this data poorly, framing oral sex as a direct cause of cancer.

However, the conclusions drawn from research to date are that HPV can be transmitted by oral sex and that it is linked to changes in the infected cells.

HPV / Oral Cancer Facts

HPV oral and oropharyngeal cancers are harder to discover than tobacco related cancers because the symptoms are not always obvious to the individual who is developing the disease, or to professionals that are looking for it. They can be very subtle and painless. A dentist or doctor should evaluate any symptoms that you are concerned with, and certainly anything that has persisted for two or more weeks. Although there are many adjunctive oral cancer screening devices and tests, currently none of them can find HPV positive oral and oropharyngeal cancers early. There are oral HPV infection tests on the dental market, and while they will find an oral HPV infection which as many as 26 million Americans have on any given day, (NHANES study, ongoing), that is no indicator that a person will cascade into an oral/oropharyngeal cancer. The foundation feels that while these tests find infections through a well-recognized testing protocol (PCR testing), since only about 1% of individuals that develop a high risk type oral HPV infection ever cascade into cancer, and that most often occurs decades after infection, that the utility of the test is highly in question when in it comes to providing meaningful and actionable information. The best way to screen for HPV related oral and oropharyngeal cancer today is through a visual and tactile exam given by a medical or dental professional, who will also do an oral history taking to ask about signs and symptoms that cover things that are not visible or palpable. Most of the symptoms of a developing HPV positive infection are discovered by asking questions not using a test, a light or other device to do so. Like other cancer screenings you engage in, such as cervical, skin, prostate, colon and breast examinations, opportunistic oral cancer screenings are an effective means of finding cancer at its early, highly curable stages. However like many other cancer screening techniques, this process is not 100% effective, is highly problematic in HPV origin disease, and any screening technique or technology can miss things. This is why it is so important that persistent problems, those which do not resolve in a short period of time like 2-3 weeks, are pursued until a definitive diagnosis of what it is, is established. Most of the time these will be issues that are not cancer, but persistent problems need to be addressed, cancer or not.

HPV Facts:

  • HPV is the most common sexually transmitted virus and infection in the US.
  • There are nearly 200 different strains of HPV, most of which are harmless and do not cancer. Out of all these, 9 are known to cause cancers, and another 6 are suspected of causing cancers as they are commonly found along with one of the nine we know to be oncogenic. In oral cancers, we are primarily concerned with HPV number 16 which is also associated with cervical, anal, and penile cancers besides those of the oropharynx.
  • You can have HPV without ever knowing it because the virus often produces no signs or symptoms that you will notice, and the immune response to clear it is not a process that you will be aware of.
  • Every day in the US, about 12,000 people ages 15 to 24 are infected with HPV. According to data from the ongoing NHANES study, approximately 26 million Americans on any given day have an oral HPV infection. Of those approximately 2600 are HPV16. The vast majority of individuals will clear the virus naturally through their own immune response, and never know that they were exposed or had it.
  • If you test positive for HPV, there is no sure way to know when you were infected with HPV, or who gave it to you. A person can have HPV for many years, even decades, before it is detected or it develops into something serious like a cancer. In the vast majority of infected people, even with a high-risk version of HPV known to cause cancers, they will not develop cancer.
  • Testing positive for an HPV infection does not mean that you or your partner is having sex outside of your relationship. It is believed to have long periods of inactivity or dormancy that may even cover decades; these are periods of time that you will test negative for it.
  • Sexual partners who have been together for a while tend to share all types of sexual infections. Typically if one partner has a fungal infection like Candida, the other partner has it as well, even though they may appear to be asymptomatic. The same is true of other common sexual infections like Chlamydia, a bacterial infection. HPV viral infections also are commonly shared. This means that the partner of someone who tests positive for HPV likely has HPV already, even though they may have no signs or symptoms. Like most Americans, their immune system will customarily clear it in under 2 years.
  • Condoms may lower your chances of contracting or passing the virus to your sexual partners if used all the time and the right way. However, HPV can infect areas that are not covered by a condom- so condoms may not fully protect against HPV.
  • Because of its ubiquitous nature, the CDC says that more than 80% of Americans will have an HPV infection in their lifetimes. For most of us, this occurs late in our teens and twenties when our sexual activity is the highest and the number of partners is likely the greatest.

HPV and Oral Cancer:

  • HPV is the leading cause of oropharyngeal cancers; primarily the tonsils, tonsillar crypt, the base of the tongue (the very back of the mouth and part of what in lay terms might be called a part of the throat), and a very small number of front of the mouth, oral cavity cancers. HPV16 is the version most responsible, and affects both males and females.
  • More males than females will develop oropharyngeal cancers. This understanding was elucidated and the reason revealed for it in a published study by Gillison et. al. Through conventional genital sex, females acquire infection early in their sexual experiences, and rapidly within very few partners, seroconvert that infection into a systemic antibody that protects them through life. Males take a far greater number of sexual partners to seroconvert an infection into a systemic protective antibody. This increased number of partners and exposure before the development of a protective antibody against the invading virus is most likely the reason that more males will later in life develop oropharyngeal cancers than females.
  • In public messages for simplicity, OCF frequently speaks about oral cancers in general. Scientifically, this is actually anatomically divided up into the oral cavity and the oropharynx; two distinct anatomical sites though they are one continuous space. Each anatomical site has different statistics, infections, disease etiologies which dominate that location, and outcomes from treatment are different in each location. The fastest growing segment of the oral and oropharyngeal cancer population are otherwise healthy, non-smoking individuals in the 35-55 age range. When you consider both anatomical sites, the growth is in oropharyngeal HPV positive cancers primarily.
  • White, non-smoking males age 35 to 55 are most at risk, 4 to 1 over females.
  • In the oral/oropharyngeal environment, HPV16 manifests itself primarily in the posterior regions (the oropharynx) such as the base of the tongue, the back of the throat, the tonsils, the tonsillar crypts, and tonsillar pillars.

Risk Factors:

  • Number of sexual partners- The greater your number of sexual partners, the more likely you are to contract a genital HPV infection; and when engaging in oral sex, this also holds true for oral infections. Having sex with a partner who has had multiple sex partners also increases your risk.
  • Weakened Immune Systems- People who have weakened immune systems are at greater risk of HPV infections. Immune systems can be weakened by HIV/AIDS or by immune system-suppressing drugs used after organ transplants.

Oral Cancer Signs and Symptoms:

This list considers both oral cancers from HPV and those from tobacco and alcohol

  • An ulcer or sore that does not heal within 2-3 weeks
  • A red, white, or black discoloration on the soft tissues in the mouth
  • Difficult or painful swallowing. A sensation that things are sticking in the throat when swallowing
  • A swollen but painless tonsil. When looking in the mouth, tonsils on both sides should be symmetrical in size
  • Pain when chewing
  • A persistent sore throat or hoarse voice
  • A swelling or lump in the mouth
  • A painless lump felt on the outside of the neck, which has been there for at least two weeks.
  • A numb feeling in the mouth or lips
  • Constant coughing
  • An ear ache on one side (unilateral) which persists for more than a few days.

  • HPV is passed on through skin to skin genital contact, most often during vaginal, anal and oral sex.
  • You are more likely to get HPV if you have many sex partners or a sex partner who has had many partners.
  • Many people don’t have symptoms and are unaware that they have HPV. They will be equally unaware when the clear it through natural immune responses to it.
  • The virus may be inactive for weeks, months and for some people possibly even years after infection.

What does that mean for my health?

Partners usually share HPV. If you have been with your partner for a long time, you probably have HPV already. Although HPV is the most commonly transferred sexual infection, in most people it is cleared by the immune system in under 2 years. Individuals with persistent infections are at risk for several types of cancers depending on the location of the infection. When considering the entire US population of over 300 million people, the incidence rate of oral cancers from it are still relatively rare mathematically, though the media frequently likes to state that this is an epidemic. In terms of oral and oropharyngeal cancers (which in 2017 about 50,000 Americans will get) the rapid increase in them is certainly alarming. The trend line since the early 1970’s has been a steep upward climb. With proper use of the HPV vaccination in our youth, we should see progress against this trend in future generations.

How common is HPV?

HPV is the most commonly sexually transmitted infection. The CDC estimates that there are 6.2 million new infections each year in the United States. The vast majority of Americans will have some form of HPV early in their sexual experiences. Since it is so common, there is nothing to be ashamed about. If you are diagnosed with HPV, talk to your health care provider about it. HPV’s are divided into 9 high risk types and more than 150 others that either cause benign warts, or do nothing at all that we know of at all.

How do I know if I have HPV?

The only way to know if you have an HPV infection is if your health care provider tests you for the virus. For females, in relationship to cervical discovery, this may be done directly from the Pap test cervical exam or by using an additional swab at the time of the Pap test. The CDC now recommends an HPV test for women along with the pap test as a matter of routine. Oral HPV testing in both men and women is problematic. While there have been some commercial tests available in the dental community, the value of this testing is not clear, and testing positive on any given day for an oral HPV does not prove persistence of the infection, which is what we are really concerned about. There are no visible oral signs of an HPV infection. There are no viricides or other drugs to kill it. There are also no established genital tests for men. There are anal brush cytology tests for those that engage in anal sexual practices. Those tests can be early predictors of HPV caused anal cancers.

Is there a cure for HPV?

There is no cure for the virus. Most of the time, HPV goes away by itself within two years and does not cause health problems. It is only when HPV stays in the body for many years, usually decades, that it might cause these oral cancers. Even then, it is a very small number of people that will have an HPV infection cascade all the way into an oral malignancy, though that number is increasing every year by about 10%. It is not known why HPV goes away in most, but not all cases. For unknown reasons there is a small percentage of the population whose immune system does not recognize this as a threat and it is allowed to prosper. Although HPV can increase the risk of developing some types of cancer, most people who have HPV do NOT develop cancer.

HPV Vaccines

Two vaccines known as Gardasil and Cervarix protect against the strains of HPV that cause cervical cancers (HPV16 and 18), Gardasil also protects against other versions that cause genital warts (HPV6 and 11). A new version of the Gardasil vaccine protects against 9 versions of HPV. Millions of young girls in the US and in developed countries around the world have been safely vaccinated with an HPV vaccine. Because the original clinical trials were done only on cervical cancers, the FDA restricts the manufacturers from talking about other potential positive implications of these vaccines in different anatomical sites that HPV is known to infect. Since these vaccines block people from ever getting HPV16, it is not much of a scientific leap to extrapolate that to “if you can’t get the virus, you can’t get things the virus might cause”. Using this logic, many in the science community, including the CDC, and every major cancer treatment center in America, recommend vaccinating to protect people from the various different cancers associated with the virus such as oropharyngeal and anal cancers. The foundation also believes this to be highly worthy of doing, and has advocated at the CDC for vaccination of boys (finally winning their approval for pediatricians and other doctors to do so), not only to more quickly help reach the point of “herd immunity” in our country; protecting our next generation from HPV caused cervical cancers, but also to offer protection from other HPV cancers as well including oropharyngeal.

The National Advisory Committee on Immunization Practices recommends routine HPV vaccination for girls and boys ages 11 and 12, as well as individuals ages 13 to 26 if they haven’t received the vaccine already. While not part of the original approval for use, today the Gardasil vaccine has also been approved for use in boys and men, ages 9 through 26 years old. For adults the age range has been extended from 27 to 45 years old. The value of vaccination at a later stage of life might be higher in those who have had a limited number of sexual partners in their lifetime than others. These vaccines are most effective if given to children before they become sexually active. If you have already been exposed to a particular version of HPV, the vaccines will not work for you in preventing issues from that version, though if you have had few sexual partners there is a chance that one of the versions of HPV that the vaccine covers, you have not been exposed to yet. So vaccination at pre-sexual ages brings the most protection.

Oropharyngeal Human Papilloma Virus (HPV) Infection

What is human papilloma virus (HPV)?

HPV is a sexually transmitted virus. There are more than 150 subtypes of HPV that can infect the genital area and the throat (oropharyngeal HPV).

How common is oropharyngeal human papilloma virus (HPV) infection of the throat?

A recent study found that 7 percent of Americans 14 to 69 years old are infected with oropharyngeal HPV. The same study found that the prevalence has increased significantly over the past three decades, and that more men than women have oropharyngeal HPV infection.

The most frequent subtype of oropharyngeal HPV detected is HPV-16, a high-risk subtype of HPV for oropharyngeal (throat) cancer. About 2/3 of oropharyngeal cancers have HPV DNA in them. Infection with HPV-16 occurs in about 1 percent of men and women.

How is oropharyngeal human papilloma virus (HPV) acquired?

Evidence strongly suggests that oropharyngeal HPV is predominantly transmitted by sexual contact. An increase in oral sex is suspected as the cause of the increase in the prevalence of oropharyngeal HPV infection, although several sexual behaviors seem to be related to HPV prevalence.

The risk of infection increases with an increasing number of lifetime or recent sexual partners for any type of sexual behavior (vaginal sex, oral sex). With 20 or more lifetime sexual partners, the prevalence of oropharyngeal HPV infection reaches 20 percent. Smokers are also at greater risk than nonsmokers, with current heavy smokers at particularly high risk.

What are the signs and symptoms of oropharyngeal human papilloma virus (HPV) infection?

Most people with oropharyngeal HPV infections have no symptoms and therefore do not realize that they are infected and can transmit the virus to a partner.

What are the consequences of oropharyngeal human papilloma virus (HPV) infection?

Tonsillar HPV infection can cause oropharyngeal cancer. An increase in the incidence of oropharyngeal cancer has paralleled the increased prevalence of tonsillar HPV infection. However, the vast majority of people with tonsillar HPV infections do not develop cancer because the subtypes of HPV with which they are infected are not linked to development of cancer. Although millions of Americans have tonsillar HPV, fewer than 15,000 get HPV-positive oropharyngeal cancers annually.

Some oropharyngeal cancers are not related to HPV infection, but rather with tobacco and alcohol use. People with HPV-positive oropharyngeal cancers tend to be younger and are less likely to be smokers and drinkers.

Are there any signs that are specific for human papilloma virus (HPV)-positive oropharyngeal cancer?

The first sign is often having trouble with swallowing. Other signs are:

  • Coughing up blood
  • A lump on the neck or in the cheek
  • Hoarseness that doesn’t go away

Unfortunately, these are late signs of the disease.

Other potential signs and symptoms of oral cancers are:

  • Sore throat
  • A white or red patch on the tonsils
  • Jaw pain or swelling
  • Trouble swallowing that is new

These signs don’t necessarily mean that you have cancer, but if any signs are present for longer than two weeks, you should see your doctor.

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In February, after returning home to Calgary from a family vacation in Mexico, Will Dove and his wife both came down with symptoms of ear infections.

“She had an ear infection,” said Dove. “I had cancer.”

Specifically, Dove had throat cancer caused by a human papillomavirus (HPV) infection. For Dove, the treatment that followed was excruciating. A self-described fitness fanatic, the 51-year-old lost 30 pounds of muscle while undergoing chemotherapy and radiation treatment. On a good day, he could force down 500 calories of food; many days he ate nothing — his throat so sore that even drinking water became impossible. Then there was the constant nausea, the fits of coughing, the mouth sores, the sleepless nights.

“Treatment for HPV throat cancer is hell,” said Dove, who completed his treatment 10 weeks ago and is now in recovery. “Words don’t even come close to describing it. You cannot understand the misery and suffering you will go through.”

Unfortunately, there are many men who may have to go through the same ordeal. The number of men in Canada getting throat and mouth cancer from HPV infections has risen dramatically. Between 1992 and 2012, there has been a 56% increase in males, compared to 17% in females, according to Canadian Cancer Statistics 2016, a new report released by the Canadian Cancer Society. Overall, mouth and throat cancers account for a third of all HPV cancers, about the same as cervical cancer. An estimated 4400 Canadians will be diagnosed with an HPV cancer this year, according to the report, and one-third will be male.

The Canadian Cancer Society is urging Canadians to get the HPV vaccine. It is also calling for the expansion of free access to the vaccine for school-aged boys. Currently, it is available to girls across Canada but to boys in only six provinces: Alberta, Manitoba, Nova Scotia, Ontario, Prince Edward Island and Quebec.

Only six provinces have HPV vaccination programs for boys.

Image courtesy of Christopher Futcher/iStock

“I think there are a lot of misconceptions about HPV vaccination,” said Leah Smith, an epidemiologist with the Canadian Cancer Society. “One of our goals with this report is to highlight some of the statistics that have never before been available on the impact HPV is having on cancer in Canada.”

Smith notes that the HPV vaccine has been studied for more than 20 years and approved for use for more than a decade. It has been shown to be safe and effective all over the world, and the benefits far outweigh the risks.

“One thing that is unique about the HPV vaccine is that most cancer-prevention strategies require a lifelong effort in order to reap the benefits, whereas HPV vaccination is relatively easy.”

Still, myths about the vaccine persist, which may explain why coverage rates across the country range from 43% to 91%. The hesitancy of some people to have their children vaccinated can be attributed, in part, to anti-vaccination activism and the media, which often gives them equal voice to that of scientists, according to Dr. Eduardo Franco, chairman of the Department of Oncology at McGill University.

“It’s a very tough battle to win,” said Franco. “In a way I blame the media for that, with this obsessive need for balance, which they say is part of their ethics. They talk to the scientists, who talk about the evidence, and then they say, for balance, let’s go to an activist.”

And these activists are “experts in identifying the infinitesimal proportion of cases” that can be linked to vaccine harm, said Franco. Anti-vaccination activists also come armed with emotionally charged stories of children who have suffered, whether or not the harm was actually caused by vaccines. Prevention of disease, on the other hand, tends to make for far less compelling anecdotes.

“We can never depict the side of protection — which is overwhelmingly more important, even if we assume there are adverse events, which disappear next to the benefits of vaccination — the same way, because what we can never do, on the side of defending, is say here is a case of a disease that never existed.”

For Will Dove, however, there is one story that he will never forget. When he told his 12-year-old son that he had throat cancer, Dove noticed the look of concern on his son’s face. Though Dove still had a tough road ahead, he could at least reassure his son that, because he had been vaccinated, his future would likely be free of an HPV-related cancer.

“I will never forget the look of relief on his face,” said Dove. “My son will never go through what I went through.”

Head and Neck Institute

What is Human Papillomavirus (HPV)?
Human Papillomavirus or HPV is a small sized DNA virus that infects skin and wet surfaces of the body like the mouth, vagina, cervix and anus. There are more than 100 different types of HPV. The most common types are found on the skin and appear as warts seen on the hand. Some HPV types also infect the genital areas of males and females. According to the Centers for Disease Control & Prevention (CDC), genital HPV is the most common sexually transmitted infection in the US and worldwide. There are at least 40 HPV types that can affect the genital areas. Some of these are “low-risk” and cause genital warts while “high-risk” types can cause cervical or other types of genital cancer. The high-risk HPV types may also cause a form of throat cancer, called oropharyngeal cancer, which is becoming more common in the US and Europe.

How prevalent is HPV-positive throat cancer?
Over the past decade there has been at least a four- to five-fold increase in the number of oropharynx cancers in the US. The oropharynx includes the tonsils and the base of the tongue. The increase in these cancers is a result of HPV infection. Almost all of these cancers are caused by HPV16, a subtype of the HPV virus. Research indicates that approximately 70 percent of cases of oropharynx cancer is caused by HPV16. These cancers have the HPV16 virus detectable in the tumor. The number of HPV positive cancers of the tonsil and base of tongue (oropharyngeal cancer) is rising quickly. Several studies evaluating the prevalence of active oral HPV infection have found that three to five percent of adolescents and five to 10 percent of adults have an active HPV infection. More than 3% of adult men and 1% of adult woman have HPV16 detectable in their saliva at any one time. In contrast to active infection, estimates are that 90 percent of adults have been exposed to HPV16 and 70% have evidence of infection as demonstrated by the presence of HPV16 antibodies in their blood.

Why is HPV-positive throat cancer becoming more prevalent?
The epidemiology of oral HPV infection is not well understood. However, HPV viruses have long been known to be present in the genital area and to be a significant cause of cervical, vulvar, penile, and anogenital cancer. It is believed that an increased number of people are engaging in sexual activity with multiple partners and engage in oral sex practices and as a result are contracting HPV in the head and neck region, resulting in a higher rate of oropharynx cancers.

Who is at risk for HPV infection and throat cancer?
HPV is a sexually transmitted infection. The number of lifetime sexual partners is an important risk factor for the development of HPV-positive throat cancer. Research has shown that:

The odds of HPV-positive throat cancer doubled in individuals who reported between one and five lifetime oral sexual partner

The risk increased five-fold in those patients with six or more oral sexual partners compared with those who have not had oral sex

It is important to know that HPV-positive throat cancer also occurs in individuals who report few sexual partners and that this is the largest group that get HPV+ oropharynx cancer. We are not sure what is leads to the development of cancer and whether there are other factors. Almost everyone is infected with HPV16 at some point in their lives so the relationship between HPV16 infection, sexual activity, and getting cancer is more comoplex then simple exposure. We do not know what those additional risk factors are yet. . What we do now is that getting HPV+ oropharynx cancer does not indicate a history of increased sexual activity or multiple partners, Rather, sexual activity with multiple partners increases risk.

What are the symptoms of HPV-positive throat cancer?
Symptoms include hoarseness, pain or difficulty swallowing, pain while chewing, a lump in the neck, a feeling of apersistent lump in the throat, change in voice, or non-healing sores on the neck. If you have any of these symptoms, speak with your doctor or visit the Ear, Nose, and Throat/Head and Neck Surgery Service Area to schedule an appointment.

If HPV is a sexually transmitted infection, are there other ways to contract the virus?

Researchers are still evaluating the various ways HPV can be transmitted. There have been reports of HPV transmission through what is referred to as “deep french kissing.” It may also be possible for the virus to be transmitted to an infant through the infected mother’s cervical canal. Virus could also be transmitted by hand to mouth contact in the context of sexual activity.

Should I get vaccinated?
All cases of cervical cancer are derived from HPV. Two vaccines, Gardasil and Cervarix, have been developed to protect against high risk HPV infection. The vaccine is administered in three doses over a six-month period. Currently, the vaccine is approved for males and females ages nine-26. There is no evidence that vaccinating adults, most of whom have had infection, will be protected from the development of cancer. This vaccine prevents infection, it does not treat adults who are already infected.

How are HPV-positive cancers treated?
HPV-positive throat cancer has been demonstrated to respond very well to almost all forms of therapy, including surgery, external beam radiotherapy, and chemotherapy. New technologies have been developed that greatly improve treatment, survival and side effects. For early cancers, the use of robotic surgery followed by a course of radiation treatment has had positive outcomes. At Mount Sinai, the use of robotic surgery and radiation, with no chemotherapy required, resulted in three-year survival rates of 90 percent, and significantly improve patient quality of life. In more advanced cases combinations of chemotherapy and radiation have lead to more than 80% cure rates. Mount Sinai is currently testing ways to reduce radiation therapy to patients with this diagnosis to improve side effects.

How does the robotic procedure work? What are the benefits?
Mount Sinai is one of very few centers in the country that use a robot to safely remove tumors, especially those growing in challenging locations. Robotic surgery is far less invasive than non-robotic tumor surgeries, greatly minimizing complications and recovery time—and maximizing quality of life after surgery. Quality of life data and the data produced by others demonstrates that patients treated with transoral robotic surgery and deescalated adjuvant therapy have a significantly improved quality of life, oral function, diet, and less long-term toxicity. As a result, Mount Sinai is dedicated to treating patients with HPV-positive throat cancer using this protocol in an effort to improve survival outcomes and decrease short-term and long-term toxicity. Studies to determine if early stage patients can avoid radiotherapy after surgery are being developed.

What is the long-term prognosis for people with HPV-positive throat cancer?
While the prevalence of throat cancer derived from HPV is steadily increasing, data suggest that it is easily treated. Patients with HPV-positive throat cancer have a disease-free survival rate of 85-90 percent over five years. This is in contrast to the traditional patient population of excessive smokers and drinkers with advanced disease who have a five- year survival rate of approximately 25- 40 percent.

My significant other is genital HPV positive yet has no history of cervical cancer, can I get throat cancer by kissing her or having oral sex with her?

Transmission occurs through sexual contact and partners have routinely exchanged virus early in their relationship. Hence it is unlikely that changing your sexual behavior with your partner will change your risk of HPV related cancer.

Do men or women get this more frequently?
Cases of this cancer are much more frequent in men. At Mount Sinai the ratio between men with this and women is roughly six or seven to one. The average age of a patient with this is 40-55, a decade younger than the traditional “smoker/drinker” patient with throat cancer.

Why are men at higher risk for this cancer?
The prevalence and manifestation of this virus is much higher in the genitalia of women because of their anatomical make-up. Pap smears have changed the risk of cervical cancer and transmission to the oropharynx in women because of the earlier exposure in the cervix.

Is there a way to determine if I am oral HPV-positive?
Not yet. Scientists are working on a diagnostic test, but there is nothing commercially available. These tests are very difficult, expensive and unreliable. Currently they are only useful for research purposes.

Who should get screened?
People with a history of tobacco or alcohol use, a history of oral lesions or exposure to radiation therapy, and those with symptoms should be screened. Symptoms to be aware of include hoarseness, pain on swallowing, difficulty swallowing, pain on chewing, a sense of a lump in the throat, a change in voice, a lump in the neck, or non-healing sores.

How do I get screened for HPV- positive throat cancer?
Getting screened is quick and painless. After a physical examination of the mouth, Doctors place a very thin, flexible telescope, the size of a piece of spaghetti, with a miniature camera on its tip, into the nose to examine the back of the throat and base of tongue, the larynx and the vocal cords.

Where did I get HPV from?
It is difficult without specific DNA viral typing to determine who transmitted the virus or where the virus was acquired.

Can the vaccine be used as treatment if I already have HPV-positive throat cancer?
No. Patients with known HPV-positive throat cancer do not appear to benefit from vaccination as the vaccination is used for prevention, not treatment.

What new research is ongoing to better understand and prevent HPV-positive throat cancer?
The Mount Sinai Health System is studying the immune response to the virus and transmission through the HOTSPOT study and the Immune Monitoring Study. We are developing a screening test and vaccine strategies to test HPV vaccines. We are opening two trials, the Quarterback Trial (for patients with advanced oropharynx cancer, to study how to reduce radiotherapy for patients) and the SIRS trials (to investigate whether radiotherapy is necessary after surgery for early oropharynx cancers).

Where should I go if I want to learn more about HPV-positive throat cancer?
If you would like to learn more or think you or a loved one may be at risk, visit the Ear, Nose, and Throat/Head and Neck Surgery Service Area.

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June 1, 2011 — — Philip and Joanne Keane, of Newtown, Conn., never thought twice about having their daughters immunized against strains of the human papillomavirus that could cause cervical cancer.

“I thought it was a women-only disease, a virus only they should worry about,” said Philip Keane. But when Keane, 52, was diagnosed with stage 4 HPV-related throat cancer, the Keane’s decided their 12-year-old son should be vaccinated too.

“You don’t want them waking up in 20 or 30 years and finding out they have stage 4 throat cancer. That’s where I am now,” said Keane.

HPV appears to be linked to a rare but treatable form of throat cancer in men that’s on an uptick. If the trend continues, the annual occurrence of HPV-related oropharyngeal cancer among men will surpass that of cervical cancer among women by the year 2020, according to a study that will be presented this week at the American Society of Clinical Oncology’s annual scientific meeting.

According to researchers, in 2004 there were nearly 4,000 to 4,500 cases of HPV-related oropharynx cancer in men and women. The number of cases is expected to double to 8,500 by 2020, with the increase occurring primarily in men.

“I think it’s safe to say that we are on the cusp here of a pandemic. An epidemic that’s about to begin,” said Dr. Eric Genden, chairman of the department of otolaryngology at Mount Sinai Medical Center in New York, who’s treating Keane.

HPV, a common virus whose strains are believed to be the primary cause of most cervical cancer, has been linked to some head and neck cancers too.

It’s unclear why some who carry the virus overcome it naturally while others develop cancer. Doctors believe it is most commonly spread through sexual contact and some doctors believe an increase in unprotected oral sex is the cause for the rise in throat cancer. But can it be transmitted through saliva by kissing, even sharing a spoon? Doctors still don’t know.

In 2009, the U.S. Food and Drug Administration approved the HPV vaccine Gardasil for males between the ages of 9 and 26, to reduce the risk of genital warts, and was approved in December 2010 to prevent anal cancers in males and females. Gardasil was first approved in 2006 for females, beginning at age 9, to prevent strains of HPV that could cause cervical cancer.

However, it’s unclear whether the vaccine can prevent oral HPV infections. But many experts say it’s likely, since the vaccine protects against some of the same strains found in HPV-related throat cancer.

According to Dr. Chris Sullivan, assistant professor of otolaryngology at Wake Forest Baptist Medical Center, the increasing instances of throat cancer “emphasize the need for head and neck screening even in patients without traditional risk factors of tobacco and alcohol use.”

Previous studies suggest that head and neck cancer patients whose tumors test positive for HPV tend to survive longer and respond better to chemotherapy and radiation than those who test negative for the virus. As for Keane, he did not undergo chemotherapy, though he did have radiation treatment.

“This is preventable, there are clear signs and symptoms and it’s curable if treated early,” said Genden. Genden said that 85 to 90 percent of HPV-related cancer is curable.

Keane’s cancer was removed last July through robotic surgery, and he’s showed no sign of cancer since.

While the rise in HPV-related oropharyngeal cancer is mostly found among older adults who were not offered a vaccine and now do not qualify for it, Genden said immunizing against HPV would prevent younger adults — both men and women — from later developing HPV-related cancers.

“There’s a good chance that if Phil got the vaccine earlier, he probably would not have developed the cancer,” said Genden.

Mayo Clinic Q and A: Increasing incidence of throat cancer related to HPV

DEAR MAYO CLINIC: I know HPV can cause cervical cancer, but recently I’ve heard it also can lead to throat cancer. How common is throat cancer caused by HPV? How effective is treatment for it?

ANSWER: HPV can cause a form of cancer in the back of the throat. Currently, the number of cases of this type of throat cancer is growing rapidly. Because it usually doesn’t cause symptoms right away, the cancer typically isn’t detected until it has spread to nearby lymph nodes. When it’s found at that point, it often can be cured. And, fortunately, this cancer can be prevented with the HPV vaccine.

HPV is the most common sexually transmitted infection in the U.S. Although most cases of HPV don’t cause symptoms or lead to problems, certain strains of HPV can cause cancer. Two strains of HPV cause 70% of all cervical cancer. HPV infections also can lead to other genital and anal cancers in females, as well as penile and anal cancer in males. In addition, HPV can cause throat cancer.

The increasing incidence of throat cancer related to HPV is turning it into one of the fastest growing types of cancer being diagnosed today. The reason for the increase is unclear, but both men and women are at risk. This cancer tends to appear most often in two age groups: first in people in their 30s and 40s, and then again in people in their 60s and 70s.

Early symptoms of HPV throat cancer are uncommon. Most people don’t get an evaluation until the disease has spread to lymph nodes, and they find a lump just below the jawline in the upper neck. Occasionally, people may have the sensation of something stuck in their throat or a lump in their throat that doesn’t go away, and that triggers an evaluation and leads to diagnosis.

As awareness of HPV-related throat cancer rises, it’s becoming more common for it to be detected during a dental visit. Many dentists now look and feel for tumors when they do their exams. Because these tumors tend to be under the surface of the skin, they can’t be seen easily. But if a dentist feels the back of the tongue and the floor of the mouth, the tumors usually can be detected because they have a distinctive acorn-like feel to them.

Throat cancer caused by HPV is highly treatable, even when it’s spread to nearby lymph nodes. Typically, the first step in treatment is removing the tumor and any affected lymph nodes. That often can be accomplished with a minimally invasive procedure called transoral robotic surgery that’s performed through the mouth.

If a patient has other factors that complicate the diagnosis, such as a tumor that has spread along nerves or outside the capsule of the lymph nodes, focused radiation therapy may be recommended. In some cases, a less-toxic form of chemotherapy can be used to destroy cancer cells left behind after surgery. Using a carefully targeted approach can help eliminate the cancer while minimizing the long-term side effects that can accompany treatment of head and neck cancers, such as difficulty with swallowing, eating and speaking; dry mouth; and neck stiffness and pain.

After treatment, the outlook for people with HPV-related throat cancer is excellent. More than 95% of these tumors are cured with early detection and treatment.

It’s important to recognize, too, that this cancer can be prevented with the HPV vaccine. The HPV vaccine has proven to be a safe and effective way to prevent HPV infection. That, in turn, protects against cancers caused by HPV, including HPV-related throat cancer. The vaccine has been shown to be most effective when it’s given to children between the ages of 9 and 14, but adults also can get the vaccine for some protection from HPV infection. The Food and Drug Administration recently approved the use of the HPV vaccine for males and females through age 45. — Dr. Eric Moore, Otorhinolaryngology — Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota

****************************

  • Mayo Clinic Minute: Why your preteen needs the HPV vaccine published 8/19/19
  • Living With Cancer: HPV and cancer in men published 7/19/19
  • Why you need to get the HPV vaccine now: Mayo Clinic Radio Health Minute published 7/2/19
  • Rise of HPV-related throat and mouth cancer: Mayo Clinic Radio Health Minute published 3/27/19
  • Living With Cancer: How does HPV cause cervical cancer? published 2/22/19
  • Mayo Clinic Minute: Why you need to get the HPV vaccine now published 2/7/19
  • Living With Cancer: Throat cancer — risk factors and prevention published 8/31/18
  • Mayo Clinic Minute: The rise of HPV-related throat cancer published 7/18/18
  • Living With Cancer: Understanding throat cancer published 12/22/17
  • Halving radiation therapy for HPV-related throat cancer offers fewer side effects and similar outcomes, Mayo study finds published 9/25/17
  • Mayo Clinic Q and A: Throat cancer symptoms published 6/20/17

HPV and Head & Neck Cancer

Johns Hopkins head and neck surgeon Carole Fakhry answers questions about oral HPV, the HPV vaccine and recommendations for the vaccine’s use.

Common questions & answers about HPV-positive oropharyngeal squamous cell cancer (HPV-OSCC)
Download HPV Informative Brochure

What is Human Papillomavirus (HPV)?

  • HPV is a sexually transmitted infection that can infect the oropharynx (tonsils and back of throat), anus, and genitals.
  • There are many types of HPV. HPV can cause cancer, warts or have no effect.
  • HPV is very common in the U.S. Over 20 million Americans have some type of genital or oral HPV infection.
  • In some people, oral HPV infection leads to HPV-OSCC (HPV-positive oropharyngeal squamous cell cancer) after many years.

What causes oropharyngeal cancer?

  • HPV now causes most oropharyngeal cancers in the U.S.
  • It is recommended that oropharyngeal tumors be tested for HPV.
  • Smoking and alcohol use can also cause oropharyngeal cancer.

How did I get an oral HPV infection?

  • HPV is transmitted to your mouth by oral sex. It may also be possible to get oral HPV by other ways.
  • Performing oral sex and having many oral sex partners can increase your chances of oral HPV infection.
  • Having an oral HPV infection does not mean your partner was/is unfaithful and does not suggest promiscuity.
  • Many people with HPV-OSCC have only had a few oral sex partners in their life.

Who has oral HPV infection?

  • Many people will likely be exposed to oral HPV in their life.
  • Around 10% of men and 3.6% of women in the U.S. have HPV in their mouths and HPV infection is more commonly nfound with older age.
  • Most people clear the infections on their own within a year or two, but in some people HPV infection persists.

Can I transmit oral HPV infection to others?

Family and Friends:

  • Oral HPV is not casually transmitted by sharing drinks or kissing on the cheek.
  • We do not know if open mouth kissing can transmit HPV.

Partners of people with HPV-OSCC:

  • You have already likely shared whatever infections you have.
  • You do not need to change your sexual behavior.
  • Female partners should have regular cervical Pap screening.

New sexual partners in the future:

  • Many patients with HPV-OSCC no longer have HPV detectable in their mouth after treatment, while others do.
  • With new partners, discuss protection methods (e.g. condoms and barrier protection).

When did I get this infection?

  • We do not know the time from first oral HPV infection to cancer but it takes many years.
  • We know that some people have infection 15 years or more before cancer.

What does having HPV in my tumor mean?

  • Oropharyngeal cancer patients with HPV in their tumor live longer, on average, than people without HPV (i.e. HPV-positive tumors usually respond well to therapy).
  • However, patients who currently smoke tobacco or have smoked for a long time in the past do not live as long as patients who never smoked. Patients who are current smokers should consider quitting.

Will the HPV vaccine help me?

  • The HPV vaccine prevents people from getting new HPV infections.
  • The vaccine will not help you clear an infection you already have.
  • The vaccine is recommended for people ages 9 to 26 years old.

Will my spouse/partner also get Oropharyngeal Cancer?

  • The risk of HPV-OSCC (HPV-positive oropharyngeal squamous cell cancer) may be slightly higher among spouses of HPV-OSCC but this cancer remains rare among spouses.
  • There are no recommended screening tests for HPV-OSCC in clinical care. There are available research studies to explore possible screening tests. Find more information on the MOUTH Study.

**Modified from Fakhry C, D’Souza G. Discussing the diagnosis of HPV-OSCC: Common Questions and Answers, Oral Oncol (2013), with permission from Elsevier

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