BOSTON – Human papillomavirus-associated oropharyngeal cancers are becoming more prevalent, and primary care providers should be prepared to discuss oral HPV risks with patients, according to presenters at the American Academy of Physician Assistants IMPACT 2014 meeting.
“We have been counseling patients for years about HPV and the risk for cervical cancer. Now we also need to educate patients on the risk factors for oral HPV as well,” Denise Rizzolo, PA-C, PhD, an associate professor in the PA program at Seton Hall University in South Orange, N.J., told Clinical Advisor.
Only one-third of patients visit their dentist on an annual basis, and often for emergent versus preventative needs, results of a 2013 Gallup poll indicate. “Typically the dentist will discuss brushing, flossing and maybe tobacco cessation – sexual activity and HPV are probably not discussed,” Rizzolo said.
The oropharynx is now the second most common site for HPV-associated cancers in the United States, behind the cervix, and projections based on current trends suggest prevalence of HPV-positive oropharyngeal cancers in U.S. men could surpass HPV-associated cervical cancer in women by 2020.
Recognizing oral HPV is no simple task — little is known about the natural progression of oral HPV and there are currently no FDA-approved oral HPV screening tests, according to Rizzolo.
What can primary care clinicians do?
Know the risk factors. Current research indicates between 45% and 90% of head and neck squamous cell carcinomas test positive for HPV, with the most common sites being the lingual and palatine tonsils and the base of the tongue versus the lateral borders and underside of the tongue for HPV-negative oral squamous cell carcinomas (OSCC).
Scientists have determined that the high risk HPV-16 strain is responsible for the majority of HPV-positive OSCC. Results from one study that stratified risk factors by HPV-16 tumor type, showed specific sexual behaviors (sexual activity at a young age, multiple sex partners, history of oral and anal sexual contact, history of genital warts and history of HIV), along with marijuana use, were associated with these tumors.
A separate Danish study found a five-fold increased risk for cancer of the tonsils and a four-fold increased for oral cancer among men in registered homosexual partnerships, suggesting homosexuality may also be a risk factor.
Recognize high-risk clinical presentations. Many patients with HPV-positive OSCC will have no signs or symptoms, according to Rizzolo. But patients with the following clinical presentation who do not respond to treatment after two weeks should be referred out to a specialist for further evaluation:
- Persistent sore throat
- Nonhealing sore in the mouth
- Enlarged lymph nodes
- Pain with swallowing
- Unexplained weight loss
Certain lesions may also help signify high-risk patients, including sharply defined leukoplakic lesions greater than 1cm in diameter; nonhomogenous or mixed red-white lesions; erythroplakic lesions; and persistently ulcerated or indurated lesions.
“Since we are only now learning more about HPV-positive oral cancer, the counseling remains the same as we have been offering. If a patient smokes, advise them to quit. Tell them to see a clinician for any nonhealing ulcers, and be sure to see a dentist for routine cleaning and exams,” Rizzolo said.
The two FDA-approved HPV vaccines – quadrivalent (Gardasil, Merck) and bivalent (Cervarix, GlaxoSmithKline) – both protect against HPV-16, but are indicated for prevention not treatment, according to Rizzolo.
Current guidelines from the CDCs Advisor Committee on Immunization Practices recommend vaccinating girls from age 11 to 12 years and boys as early as age 9 years to confer protection before sexual debut. However, it will take decades to determine the efficacy of these vaccines against oral HPV, Rizzolo noted.