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Published on July 01, 2018

HPV+ Head and Neck Cancer Rates Rapidly Rising

CT Scan of the neck with HPV

CT with contrast of axial and sagittal neck views
show cancer at the base of the tongue.

Historically, alcohol and tobacco use have been the most significant risk factors for head and neck cancers. Yet, the human papilloma virus is rapidly becoming an even more significant risk factor for a specific subset of head and neck cancers: oropharyngeal squamous cell carcinoma. OPSCC is found primarily in the lymphoid tissues of the palatine tonsils or tongue base.

Of the nearly 5,000 cases of OPSCC diagnosed each year, approximately 80% are HPV positive. Of those, 85% are found in men, a disproportionately — and concerning — high rate. In fact, estimates suggest the disease rate for HPV-positive OPSCC will surpass that of HPV-positive cervical cancer by 2020.

“The timing between exposure to HPV and the development of cancer likely exceeds 10 years, so that might be why we’re starting to see more of it,” said Gaurav Prasad, MD, an otolaryngologist and head and neck cancer specialist with Meritas Health ENT.

85% of diagnosed HPV-positive head and neck cancers are seen in men.Equally concerning is that HPV-positive cancers are being diagnosed in a younger demographic. The average age of someone diagnosed with oropharynx HPV-positive cancer is 57, as opposed to 61 years of age in HPV-negative cancers.

The primary risk factor for HPV-positive cancer is sexual behavior. People who have their first encounter at a young age increase their HPV exposure risk. A high number of sexual partners also is linked to significantly increased risk.

Early Detection

“Patients typically present with a painless neck mass or neck swelling,” Dr. Prasad explained. “It’s this mass that spurs people to get medical attention.” Symptoms of HPV-positive head and neck cancer are not always identifiable, meaning many patients are diagnosed after the cancer has spread to the lymph nodes.

Unlike cervical cancer, there is no swab or screening to detect OPSCC. Primary care physicians are often the first line of defense when it comes to early detection and referral, which can lower morbidity and mortality for this population.

“Having a high index of suspicion, even in the absence of risk factors like tobacco or alcohol use, is important,” Dr. Prasad said. “So is keeping the possibility of head and neck cancer in mind and checking the neck lymph nodes for a mass.”

Improved Survival Rates

A recent study placed median survival for HPV-positive tumors at 11 years compared with 1.6 years in HPV-negative tumors. Additionally, the cure rate for a nonsmoker with HPV-positive cancer is 80%-90%, compared with 30%-40% for people with HPV-negative cancer who smoke or drink excessively. The prognosis worsens for smokers with HPV-positive cancer.

Improved survival rates led the American Joint Committee on Cancer to adjust staging criteria for HPV-positive cancer in January 2018. Under the new criteria, HPV-positive tumors that previously may have been staged as an advanced-stage tumor may now be staged lower.

While some patients are candidates for surgery, including robotic surgery, HPV-positive cancers respond better to chemotherapy and radiation.

Treatment

“When we look at surgical options, we consider several different factors, such as tumor size and whether we can expose it properly enough to get clear margins,” Dr. Prasad explained.

Surgeons also consider the post-operative and long-term consequences that could arise, such as difficulty with speech and swallowing.

Improved survival rates also have spurred research into whether aggressive treatment methods are necessary.

“There are trials now that are looking at whether radiation can be intensified or if chemotherapy could potentially be deferred for these advanced-stage cancers because they respond well to radiation,” Dr. Prasad said. “These trials aren’t standard of care yet, but researchers are looking at whether we need to treat these HPV-positive tumors as aggressively as we would HPV-negative tumors.”

Prevention

Vaccines to prevent the HPV strains that cause cervical, oropharynx and other cancers became available for males and females in 2006. They have seen some success among the female population, with HPV infections among girls 14-19 years old decreasing from 11.5% to 4.3% since the vaccine was first released to the United States market. Yet, in 2013, only 14% of males received the recommended dosage.

Last year, the Centers for Disease Control and Prevention altered the recommended vaccination schedule from three doses to two for females 11-26 years of age and males 11-21 years of age. As of 2016, about 60% of young people had received the first dose; however, only 43% had completed the vaccination protocol.

“With increased education, awareness, and discussion between primary care physicians, pediatricians, mid-level providers and parents, an increase in the rate of HPV vaccinations could potentially prevent HPV-related head and neck cancers,” Dr. Prasad said.

Gaurav Prasad, MD

Gaurav Prasad, MD Dr. Prasad earned his medical degree and completed his residency in otolaryngology at the Saint Louis University School of Medicine. He completed a head and neck oncology/ microvascular reconstruction fellowship at Indiana University, Indianapolis.