By LAURA LANDRO
A sharp rise in a type of throat cancer among men is increasingly being linked to HPV, the sexually transmitted human papillomavirus that can cause cervical cancer in women.
A new study from the National Cancer Institute warns that if recent trends continue, the number of HPV-positive oral cancers among men could rise by nearly 30% by 2020. At that rate, it could surpass that of cervical cancers among women, which are expected to decline as a result of better screening.
The study is to be presented this week at the annual American Society of Clinical Oncology meeting.
Between 1988 and 2004, the researchers found, the incidence of HPV-positive oropharynx cancers—those that affect the back of the tongue and tonsil area—increased by 225%. Anil Chaturvedi, a National Cancer Institute investigator who led the research, estimates there were approximately 6,700 cases of HPV-positive oropharynx cancers in 2010, up from 4,000 to 4,500 in 2004, and cases are projected to increase 27% to 8,500 in 2020.
Find out more about HPV Currently, Merck markets the vaccine Gardisil
Human papillomavirus is the most common sexually transmitted virus in the U.S.
More than half of sexually active men and women are infected with HPV at some time in their lives.
About 20 million Americans are currently infected and about six million more get infected each year.
HPV can cause cervical cancer in women, which is the second-leading cause of cancer deaths in women world-wide.
HPV is linked to a four- to five-fold increase in certain oral cancers, especially in men; about 25% of mouth and 35% of throat cancers are caused by HPV.
There are more than 100 different types of HPV virus. Some are low-risk while highrisk types can cause several cancers, including head and neck cancer, which is becoming more prevalent.
Source: Centers for Disease Control and Prevention; American Academy of Pediatrics
Recent studies show about 25% of mouth and 35% of throat cancers are caused by HPV, according to the Centers for Disease Control and Prevention.
Men account for the majority of cases, and currently the highest prevalence is in men 40 to 55, says Eric Genden, chief of head and neck oncology at Mount Sinai Medical Center in New York. Studies have shown that the cancer can show up 10 years after exposure to HPV, which has become the most common sexually transmitted virus in the U.S.
"We are sitting at the cusp of a pandemic," says Dr. Genden.
Dr. Chaturvedi says more studies are needed to evaluate whether a vaccine now used to prevent HPV for genital warts and genital and anal cancers can prevent oral HPV infections.
The HPV vaccine, Gardasil, made by Merck & Co., was approved in 2006 for girls and young women up to age 26, but while it is routinely recommended, only about 27% of girls have received all three doses needed to confer protection.
The FDA in 2009 approved the vaccine for males ages 9 through 26 to reduce the risk of genital warts, and in 2010 approved it for both sexes for the prevention of anal cancers. However, the CDC has only a "permissive" recommendation for boys, rather than a routine recommendation, meaning doctors generally will only administer it if parents or patients ask for it, says Michael Brady, chairman of the American Academy of Pediatrics infectious disease committee.
Lauri Markowitz, a CDC medical epidemiologist, says the CDC advisory committee that sets vaccine recommendations will review new data related to the issue at a meeting next month. However, at present there aren't any clinical-trial data showing the effectiveness of the vaccine against oral infections, she says.
A Merck spokeswoman says the company has no plans to study the potential of Gardasil to prevent these cancers.
Researchers say it isn't clear why men are at higher risk for HPV-positive oral cancers. But for both men and women a high lifetime number of sex partners is associated with the cancer.
Changes in sexual behaviors that include increased practice of oral sex are associated with the increase, but a 2007 New England Journal of Medicine article also said engagement in casual sex, early age at first intercourse, and infrequent use of condoms each were associated with HPV-positive oropharyngeal cancer. Mouth-to-mouth contact through kissing can't be ruled out as a transmission route.
Most infections don't cause symptoms and go away on their own. But HPV can cause genital warts and warts in the throat, and has been associated with vaginal, vulvar and anal cancers.
Anna Giuliano, chairwoman of the department of cancer epidemiology at the Moffitt Cancer Center in Tampa, Fla., who studies oral HPV infections of men in several countries, says the rise in cancers among men shows it is important for males, as well as girls, to be vaccinated.
Doctors typically don't test for HPV-positive oral cancers. But Jonathan Aviv, director of the voice and swallowing center at New York's ENT and Allergy Associates, says his group looks through a miniature camera inserted through the nose at the back of the throat and tongue, and can biopsy suspicious warts or tumors.
In addition to being asked about symptoms such as hoarseness, difficulty swallowing, a neck mass or mouth sore that won't heal, patients are asked to fill out a risk-assessment sheet that includes the number of lifetime oral-sex partners. "People do get upset sometimes, but if your sexual history puts you at an increased risk for HPV, you should go and see an ear, nose and throat doctor," says Dr. Aviv.
Fortunately, says Mount Sinai's Dr. Genden, those with HPV-positive oral cancers have a disease survival rate of 85% to 90% over five years, higher than those with oral cancers that aren't linked to HPV, but are more commonly linked to alcohol use, tobacco, and radiation exposure.
Philip Keane, a 52-year-old photographer and partner in a marketing firm, found a lump on his neck while shaving, which was initially misdiagnosed as an infection. A scope of his throat showed it was HPV-positive throat cancer. Dr. Genden removed it last July using minimally invasive robotic surgery, and Mr. Keane had 6½ weeks of daily radiation after that, which left him cancer-free.
At first surprised and embarrassed, Mr. Keane says he has no reason to think he was at high risk; while he has young daughters who have been immunized, "I didn't know about HPV in men." He plans to have his 12-year-old son immunized as well.
May 31, 2011, 12:30 PM ET
With HPV-Related Head and Neck Cancers Rising, Focus on Treatment and VaccinationBy Laura Landro
A form of head and neck cancer associated with the sexually transmitted human papillomavirus is on the rise, especially in men, the WSJ reports.
Fast-rising rates of oropharyngeal cancer — tumors in the tonsil and back-of-the-tongue area — have been linked to changes in sexual behavior that include the increased practice of oral sex and a greater number of sexual partners.
But HPV-positive cancer has also been reported in individuals who report few or no sexual partners. It may also be possible for the virus to be transmitted to an infant via an infected mother’s birth canal. An HPV vaccine is routinely recommended for girls because the virus can cause cervical cancer.
The rise in HPV-positive head and neck cancers is leading to a new focus both on treatment of the disease, and whether recommending routine vaccination for boys could prevent oral infections and cancers. (A CDC advisory panel said in 2009 that it was fine for boys to get the vaccine, but recommended against routine administration.)
Eric Genden, chief of head and neck oncology at Mt. Sinai Medical Center, tells the Health Blog that when treated appropriately, patients with HPV-positive cancers have an 85% to 90% disease-free survival rate over five years. By contrast, patients with HPV-negative head and neck cancers, which are often associated with smoking and drinking, typically have more advanced disease when the cancer is detected and face a five-year survival rate of only 25% to 40%, Genden says.
HPV-induced head and neck cancer responds well to almost all forms of cancer therapy including surgery, external beam radiotherapy and chemotherapy. At Mount Sinai, the use of robotic surgery and radiation –with no chemotherapy required — resulted in three-year survival rates of 90% and significantly improved quality of life for patients, its studies show. Robotic surgery is less invasive than non-robotic tumor surgeries, minimizing complications and recover time.
Philip Keane, a 52-year old photographer and father of three (pictured at upper right), had the surgery last July at Mount Sinai, followed by a six-and-a-half week course of radiation at Memorial Sloan-Kettering Cancer Center. Keane says he’s switched to a healthier diet, and didn’t develop many of the symptoms of radiation he was warned about, such as mouth or neck sores. He says that during his therapy, he was able to continue working and doing everything he did before he got sick, and is now cancer-free.
On the vaccine front, at a meeting next month the CDC plans to review data on the issue of the cost and benefits of routinely recommending HPV vaccination for boys.
Michael Brady, chair of the department of pediatrics at Nationwide Children’s Hospital in Columbus, Ohio and chairman of the infectious disease committee for the American Academy of Pediatrics, says the AAP is awaiting any updates before changing its own policies: routine recommendation for girls at age 11 to 12 (with catch-up for teens and young women who have not received the vaccine, up to age 26 years) and a permissive recommendation for boys — meaning families or teens can get it if they ask for it.
Brady explains that the gender discrepancy for HPV vaccine occurred because initial studies for safety and effectiveness were done in females and the idea was a high coverage rate in females would result in protection of heterosexual males via herd immunity.
But low coverage of females by the vaccine means that there is minimal protection of heterosexual males, and there’s increasing evidence of the impact of HPV-related genital, oral and anal cancers in men. There is also no value in a female vaccine program for homosexual men. “All [this leads] to a realization that males would benefit from the HPV vaccine,” Brady says.
The CDC’s own permissive recommendation for young men allowed for payment through the Vaccines for Children program, and a Merck spokeswoman says more commercial insurers are paying for the vaccine for males. But Brady says vaccines with that level of recommendation tend to not be discussed at physician visits, and administration of HPV vaccine to males has been very low.
Moreover, while clear evidence of a cost benefit in girls was shown prior to the release of the vaccine, cost/benefit data for males are still being determined. “The more that people look; the more that it is clear that males would benefit by receiving the HPV vaccine,” Brady says. “The discussion is [over] whether it merits a routine recommendation.”
Oral sex, HPV puts non-smoking men at highest risk for oral cancer: What are the facts?
BY LINDSAY GOLDWERT
DAILY NEWS STAFF WRITER
Monday, April 18, 2011
HPV, otherwise known as the human papillomavirus, is a leading cause of cervical cancer for women but the nasty virus is now causing a spike in oral cancer and ravaging an entirely different group: men.
Cases of oral cancer resulting from exposure to the HPV-16 strain of the virus are hitting epidemic proportions in the U.S., doctors say.
Though the mention of oral cancer evokes images of gravely-voiced chain-smokers, the disease now has a new face: mostly white, male, non-smokers in their late 30s and early 40s.
The tumors forming on the back of their tongues and tonsils have nothing to do with nicotine - they are directly linked to engaging in oral sex with multiple female partners.
"If you've had more than five or six sexual partners, you are at a higher risk," Dr. Eric M. Genden, professor and chair of head and neck surgery at Mount Sinai Medical center told the Daily News. "We're only now beginning to see the beginning of a bell curve."
Women can get it from men as well although their chances are lower, according to doctors.
The human papillomavirus (HPV), a nasty bug with strains that causes genital warts and cervical cancer in women, is now the top cause of oral cancer in men, beating out smoking and drinking, according to reports from the New England Journal of Medicine and the Journal of Oncology as well as other research and treating institutions.
The number of smokers in the U.S. has steadily declined in the past 50 years, yet the rate of oral cancer has remained relatively steady and recently been on the increase.
The reason is an increase in HPV-16 in the U.S. population.
If detected early, the chance for surviving oral cancer from HPV is high, between 85 to 90%. Treatments - localized radiation, chemotherapy and sometimes surgery - are effective when used in the early stages. When surgery is part of the solution, the options can be conventional surgery or a new robotic surgical technique, which reduces scarring and side effects in some patients.
Brian Hill, a medical device manufacturer, was in his mid-forties when found a hard spot on his neck 14 years ago. He went to his ear, nose and throat doctor, who dismissed the bump as an infection and prescribed antibiotics.
But a biopsy later found the lump was cancerous.
Though he had never smoked a cigarette, Hill was told he had a low chance of survival as the node in his neck was positive for squamous cell carcinoma, the most common oral cancer.
Hill has since founded the Oral Cancer Foundation and spends his time working with patients, doctors and dentists, as well as campaigning in Washington to raise awareness about the danger of oral cancer and the links to HPV.
"Anyone old enough to have engaged in sexual behaviors known to transmit this virus needs to be screened annually for oral cancer," said Hill. "It's the only way to catch this disease at its early stages."
Hill believes many doctors and researchers are still in the dark about the ties between HPV-16 and oral cancer, despite the rise in diagnoses in the past decade.
"We don't know exactly if or how long HPV-16 may lay dormant, or why it strikes certain people and not others," he said. "What we don't know exceeds what we do know."
Nearly all sexually active Americans will come in contact with HPV, according to the Oral Cancer Foundation and the National Institutes of Health.
Young women are encouraged to get the HPV vaccine, but doctors say there is little point in vaccinating patients past the age of 26 since the likelihood of prior exposure to cancer-causing strains is so high.
Young people now are having a lot more oral sex with many more partners so exposure rates are higher.
HPV is the most common STD in the U.S. About 20 million Americans are currently infected with HPV. Another 6 million people become newly infected each year, according to the Centers for Disease Control and Prevention.
HPV is passed through skin-to-skin contact, not fluids. Besides conventional sex, oral sex and even deep French kissing may spread the virus.
Doctors are sounding the alarm, but have stopped short of advising men to abstain.
"This is not a call to stop having oral sex," said Dr. Mark D. DeLacure, a head and neck surgeon at NYU's Langone Medical Center. "People have to continue living their lives, however we make the best choices when we know all the risks."
DeLacure said using condoms and dental dams during oral sex could reduce transmission, but acknowledges the idea is hardly appealing or practical.
"Limiting your sexual partners is a way to reduce your risk," said DeLacure. "But still, there are no guarantees."
Doctors also have this advice: Don't panic.
Patients with HPV - even the cancer-causing strain - may never develop cancer and may never transmit the virus to a partner.
The vast majority of individuals have immune systems that recognize the virus as a threat and easily defeat it.
Doctors instead recommend vigilance.
The important issue is persistence - meaning attention to how long an unusual symptom like a lump has lasted. When an abnormality persists for longer than 14 to 21 days, it's time to see an expert.
"If you've got a sore tonsil that is still a problem after a couple of weeks and particularly if it's localized to one side, I would say that's sign it's time to talk to a doctor," said DeLacure.
And talk to the person who sees your mouth the most: Your dentist.
Dentists, too, are becoming more aware of HPV and its role in the development of oral cancer.
A good dentist will know what to look for and where to look for it.