Abstract & Commentary

HPV-related Oral Cancers Increase by 225% in U.S. from 1988 to 2004

By Stan Deresinski, MD, FACP, FIDSA, Clinical Professor of Medicine, Stanford University, Hopistal Epidemiologits, Sequoia Hospital, Redwood City, CA, is Editor for Infectious Disease Alert.

Synopsis: HPV infection is associated with 26,000 new cancers a year in the U.S.

Source: Centers for Disease Control and Prevention. Human papillomavirus-associated cancers – United States, 2004-2008. MMWR 2012; 61:258-61.

Based on an analysis of data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results programs, CDC determined that there was an average annual occurrence of 33,369 cancers at sites frequently associated with human papillomavirus (HPV) infection during 2004-2008. Using published data indicating the proportion at each of these sites associated with HPV, they were able to estimate that approximately 26,000 new cancers attributable to HPV infection, including 18,000 in females and 8000 in males, occurred annually. These included 11,500 cervical and 7400 oropharyngeal cancers; 5900 (79.7%) of the latter occurred in men and 1500 in women.

Commentary

Cancers of the cervix, vulva, vagina, penis, anus, and oropharynx (especially at the tongue base and tonsils) are frequently associated with HPV infection. HPV 16 and 18 account for approximately 70% of cervical cancers and HPV 16 is responsible for the majority of noncervical cancers caused by HPV. The two commercially available HPV vaccines each protect against both HPV 16 and 18. Both vaccines protect against cervical precancers; the quadrivalent vaccine has also been demonstrated to prevent vaginal, vulvar, and anal precancers. Vaccination for prevention of HPV-associated genital warts and anogenital malignancies is recommended in the U.S. for females aged 9 – 26 years and males 9 -21 years of age.

Screening for cervical cancer continues to also be a critical element of prevention. The guidelines have recently been updated (see box below) and they now recommend screening intervals of 3 years for women aged ≥21 years if screening with a Papanicolaou (Pap) test alone, or, as an acceptable alternative for women >30 years of age, every 5 years if screening with both a Pap test and an HPV DNA test.1

U.S. Preventive Services Task Force Screening for Cervical Cancer Current Recommendation (Release Date: March 2012)

These recommendations apply to women who have a cervix, regardless of sexual history. These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).

  • The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval. Grade: A Recommendation.
  • The USPSTF recommends against screening for cervical cancer in women younger than age 21 years. Grade: D Recommendation.
  • The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors. Grade: D Recommendation.
  • The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. Grade: D Recommendation.
  • The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years Grade: D Recommendation.

The increased risk of anal cancer in HIV infected men has led some to recommend routine screening for this malignancy, but no consensus appears to have been reached. In additiion, the incidence of non-HPV associated oral malignancies, which are instead associated with tobacco and alcohol use, has decreased. In contrast, the incidence of HPV-related oral cancers increased by 225% in the U.S. between 1988 and 2004. Oral inspection remains the currently utilized means for detection of oropharyngeal malignancies.

The prevalence of oral infection with HPV 16 in individuals 14 to 69 years of age is 1%.2 HPV infection is detected in 25% of head and neck squamous cell cancers and 90% of these are associated with HPV16. There is thus reason to believe that the available vaccines will protect against HPV related malignancies of the oropharynx. The cornerstones of prevention of HPV related malignancies are behavioral change, screening for premalignant lesions, and full utilization of the available vaccines.

References

  1. Screening for Cervical Cancer, Topic Page. April 2012. U.S. Preventive Services Task Force: http://bit.ly/cyDcWj
  2. Gillison ML, et al. Prevalence of oral HPV infection in the United States, 2009-2010. JAMA 2012; 307:693-703.