Lifting the Stigma: The Importance of HPV Vaccination Education in Head and Neck Cancer

Tom Thomas, MD, MPH

Otolaryngologist, Director

Head and Neck Reconstructive Surgery and Transoral Robotic Surgery (TORS)

Leonard B. Kahn Head and Neck Cancer Institute

Morristown Medical Center of Atlantic Health System

Morristown, NJ

Although a stigma has persisted surrounding human papillomavirus (HPV)–associated head and neck cancers, a lot of progress has been made through education efforts within the head and neck surgical oncology community, according to Tom Thomas, MD, MPH, an Otolaryngologist and director of Head and Neck Reconstructive Surgery and Transoral Robotic Surgery (TORS) at the Leonard B. Kahn Head and Neck Cancer Institute at Morristown Medical Center of Atlantic Health System in New Jersey, said in an interview with Cancer Network.

The main reason for stigma to persist is due to lack of public understanding of the science behind HPV infection and disease progression.HPV is a family of over 150 viruses and the leading cause of sexually transmitted diseases (STD) in the world, but a minority can cause cancer. Most of us are often exposed to HPV through intimate contact, but we can fight off the disease and eliminate it.However, in a small minority of us, disease could potentially remain dormant for decades before resurfacing. “We don't know the triggers of this coming back as cancer later, stated Dr. Thomas.

When it comes to HPV associated oropharyngeal cancer, Dr. Thomas is careful in counseling patients and their current partners about the long latency of the virus. Without this premise, there can be misunderstanding and distrust in the relationship, that can affect cancer treatment. If caught early, the disease has a good cure rate.

“HPV associated oropharyngeal cancer is a curable cancer. If caught early and treated appropriately with surgical and non-surgical treatment options allow for normal function. The patient will be able to go back to the productive life that they once had. I wouldn’t think of this diagnosis as anything detrimental. It is completely treatable and curable,” Dr. Thomas stated.

Going forward, he said it’s important to undo the stigma as the incidence of HPV-associated head and neck cancers are on the rise. A systemic review of 31 population-based studies over 50 years identified an increase in overall incidence of HPV-related subsites and either a decrease or stable HPV-unrelated subsites.1 Increases in HPV-related subsites appeared to increase regardless of factors such as age group. The increase in HPV-related disease was also observed globally, with incidence growing in Canada, England, Europe, Hong Kong, Korea, Peru, and Taiwan; this could be indicative of an emerging global epidemic for head and neck cancer associated with HPV. The research further solidifies the need to monitor the incidence of HPV-related head and neck cancer subsites individually.

Oropharyngeal cancer has even surpassed cervical cancer as the most common disease caused by HPV.2 One study assessing trends in oropharyngeal cancer incidence and mortality in the United States from 2001 to 2017 identified 260,182 cases of oropharyngeal cancer. Of these cases, 80% were men, 65% had regional disease, and over half resided in Southeastern and Midwestern regions.

A 2.7% increase in oropharyngeal cancer among men was identified, especially in non-Hispanic White men who were 65 years or older. The rise in incidence was smaller among women at 0.5%. An increase in regional-stage disease at 3.1% per year was reported among men vs 1.0% in women. The increase in oropharyngeal cancer incidence in men was observed across almost all states with the exception of Alaska, the District of Columbia, and Wyoming. Moreover, men experienced an increase in mortality related to oropharyngeal cancer of 2.1% per year while women experienced a decrease in mortality of 1.2% per year.

Investigators concluded that that the incidence of oropharyngeal cancer had increased nationally among men, especially among elderly individuals, with a concurrent rise in mortality within this population. The geographic trends also highlight a potential need for other studies to better understand the etiologic reasons for geographic disparities in this disease.

The increase in incidence highlights the need to redouble the effort for preventative measures such as vaccination to protect individuals from developing HPV–related head and neck cancer, Dr. Thomas said.

“Preventing a cancer from occurring is always better than dealing with cancer, period,” he explained. “HPV vaccination started over 15 years ago, started [with] cervical cancer as the reason for the immunization but now oropharyngeal cancer is the most common HPV associated cancer. Vaccination has proven [to be] safe [and] efficacious over the last 15 years, [which] should give public enough of an incentive to get the vaccination.” In general, 2 doses of vaccine are given over a 6 to 12 months period to boys and girls ages 9 to 14 years.These vaccination recommendations are purposeful to promote immunization when the vaccine is most effective, prior to initiation of sexual activity and exposure HPV.Recently FDA expanded is HPV vaccine approval to include adults up-to-age 45.

The HPV vaccination has demonstrated long-term clinical efficacy in studies, including 1 that assessed the impact of inoculation against HPV over the course of 10 years in Australia.3 Vaccine-eligible women experienced notable decreases in high-grade cervical disease and genital warts. In particular, based on findings from the study, the 9VHPV vaccine was thought to prevent up to 90% of cervical cancer and 96% of anal cancer cases. Of an estimated 1544 cases of HPV–associated cancer that were estimated to have occurred in 2012, investigators concluded that 1242 could have been prevented with the 4VHPV vaccine. Moreover, 187 cases of anogenital cancer could have been prevented with the 9VHPV vaccine.

Another systematic review examined the impact of prophylactic HPV vaccination in preventing oropharyngeal HPV infection leading to cancer.4 The review included a total of 48,777 patients across 9 studies, in which investigators identified a mean relative prevention percentage of 82.4% in one randomized community study and 83% in one longitudinal cohort study. Two additional case control studies identified that 100% and 93.2% of patients who were vaccinated developed HPV-16 immunoglobulin G antibodies.

For those who develop HPV–associated head and neck cancer, several cutting-edge treatment options are available through Dr. Thomas’ organization, Atlantic Health System Cancer Care, including transoral robotic surgery (TORS), transoral laser microsurgery (TLM) advanced plastic and microvascular reconstructive surgery, image-guided radiation therapy, chemotherapy, and immunotherapy. In addition, treating this disease requires careful multi-disciplinary team approach, according to Dr. Thomas.

“Here at Atlantic Health System, we are able to treat and cure majority of the Head and neck cancers with surgery.However, radiation treatment is used as a primary modality of treatment in patients who desires nonsurgical treatment or who is unable to undergo surgery or as an adjunct to surgery.We decide on the best treatment for a particular patient in our Head and neck tumor Board, that follows National treatment guidelines.We have a team of professionals besides our physicians and mid-level providers such as head and neck nurse navigator, nutritionist, speech and swallow therapist, prosthodontist, physical therapist,who are dedicated to caring for our head and neck cancer patients. It takes a village to give the best care to our head and neck cancer patients, stated Dr. Thomas.

References

1. dos Santos Menezes F, Fernandes GA, Ferreira Antunes JL, et al. Global incidence trends in head and neck cancer for HPV-related and -unrelated subsites: A systematic review of population-based studies. Oral Oncol. 2021;115. doi:10.1016/j.oraloncology.2020.105177
2. Damgacioglu H, Sonawane K, Zhu Y, et al. Oropharyngeal cancer incidence and mortality trends in all 50 states in the US, 2001-2017. JAMA Otol–Head & Neck Surg. 2022;148(2):155-165. doi:10.1001/jamaoto.2021.3567
3. Patel C, Brotherton JML, Pillsbury A, et al. The impact of 10 years of human papillomavirus (HPV) vaccination in Australia: what additional disease burden will a nonavalent vaccine prevent? Euro Surveill. 2018;23(41). doi:10.2807/1560-7917.ES.2018.23.41.1700737
4. Nielsen KJ, Jakobsen KK, Jensen JS, et al. The effect of prophylactic HPV vaccines on oral and oropharyngeal HPV infection—a systematic review. Viruses. 2021;13(7):1339. doi:10.3390/v13071339
5. HPV-releated head and neck cancer. Atlantic Health System. Accessed May 24, 2022. https://bit.ly/3GnEm2E