HPV-induced "throat cancer" and the difficult questions

January 27, 2016 Namou Kim, MD, FACS

Head and neck cancers commonly refer to malignant tumors originating in the tongue and throat region.  Traditionally, those cancers were caused by long-term tobacco use and high alcohol consumption.  As such, there was a fairly strong male predominance between the fifth and seventh decade of life.

As a whole, head and neck cancers comprise 3 percent of all cancers in the US.  In 2015, there were an estimated 59,340 new head and neck cancers (43,390 in men, and 15,950 in women) with 2,290 deaths.  The overall cost of care was estimated at $3.6 billion (2014 NCI estimate).

However, there is a very distinct decreasing trend of new head and neck cancers diagnosed each year since the early 1990’s.  Despite this, a subset of head and neck cancers has seen an explosive growth during the past three decades.  This subset of cancers is the HPV-induced tonsil and base-of-tongue cancers.  These cancers are informally referred to as “throat cancer,” but are more accurately called oro-pharyngeal squamous cell cancer (OPSCC).

Unlike conventional tobacco-induced head and neck cancers, this new breed of cancer is strongly linked to HPV (human papillomavirus) Type 16 and 18.  The demographics for these patients also are distinct.  Afflicted patients tend to be younger men (median age 54), healthier, non-smoking, Caucasian and hail from a higher socio-economic environment.

A social behavioral risk for HPV OPSCC is a high number of lifetime sexual contacts.  In essence, we are seeing a rise in the incidence of HPV OPSCC as a reflection of change in the social and sexual behavior of the second half of the 20th century.

HPV OPSCC patients tend to present to their doctors with a higher initial stage.  They are very often symptom-free.  No pain, no difficulty swallowing, no voice change, no weight loss, etc.

The usual reason they present to their doctors is because of a seemingly innocuous neck mass.  The neck mass in this cancer represents lymph node metastasis, which in turn, upstages those patients automatically to a Stage III or Stage IV (out of IV).

Despite the initial high stage of these patients, they have a distinct survival edge compared to the conventional tobacco-induced OPSCC.  Compared to tobacco OPSCC, the HPV OPSCC patients have a 28 percent reduction in death risk, and a 49 percent reduction in cancer recurrence.  The three-year survival rate is estimated to be between 71 percent and 93 percent, depending on whether these patients also have the additional risk factor of tobacco. 

During the initial consultation and throughout the treatment of these patients, doctors often face challenging questions from patients and family members.  Those are questions that we were not trained to adequately answer, and those questions often carry difficult socially negative stigma.

Some of the most common questions we face are:

Is my (my husband’s) cancer caused by a sexually transmitted disease?
The answer is yes.  For these patients, laboratory testing can predict the likelihood of a high-risk HPV cause of their cancer.  There is just no other way to answer this question.

Am I contagious?  Can I transmit this cancer to my wife/partner/children?
No.  Casual contact does not carry a palpable risk of HPV transmission.  Cancer itself is not contagious.  The wife/partner of the patient very likely has already had transmission of HPV from prior sexual contact, which does not mean that the wife/partner has a higher risk of developing OPSCC.

Is the HPV vaccine useful for HPV OPSCC patients?
There is no role for the HPV vaccine for patients diagnosed with HPV OPSCC.  The vaccine has no impact on preventing OPSCC in sexually active adults.

“But Doctor, I have been faithful to my wife for the past 25 years. How did I get this cancer?”
This is sometimes the trickiest question to answer. It is highly likely that the patient had been exposed to HPV before the current wife/partner.  Or it is also entirely possible that the current wife/partner served as the HPV reservoir from prior sexual contacts.  Again, typically, HPV infection does not cause many symptoms, and the body’s immune response will eradicate the infection.

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