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Counseling an Important Part of HPV Treatment

Carole Fakhry, MD, MPH, (left) and and Christine Gourin, MD, discuss the importance of counseling for patients with HPV-positive head and neck cancers.

Carole Fakhry, MD, MPH, (left) and and Christine Gourin, MD, discuss the importance of counseling for patients with HPV-positive head and neck cancers.

The drastic increase in HPV-positive head and neck cancers means that otolaryngologists find themselves not only treating more infections and cancers but counseling patients about the sensitive topic of sexually transmitted infections. A Monday Miniseminar offered physicians answers to the uncomfortable questions they may face when talking to patients.

“These are questions that have come up for us over the years. We want to help educate people in how to answer these questions,” said Carole Fakhry, MD, MPH, lead instructor for “Discussing HPV-Head and Neck Cancer: Diagnosis and Beyond.”

“None of us went into this thinking we would be talking about sexually transmitted infection, but here we are. It is not something we usually think about, so it helps to have some evidence-based construct for everyone.

“We as physicians have had to make an adjustment on how to answer these questions. It is hard for us to ask these questions, but the patients don’t mind talking about these things.”

After a diagnosis, some patients may have anger, shock, confusion, distress, anxiety, embarrassment, and stigma, Dr. Fakhry said. This can lead to two questions: Who transmitted the disease to the patient, and how can it be transmitted to others?

The sexual behaviors most associated with HPV transmission are an increase in vaginal and oral sex partners, infrequent use of condoms, a history of sexually transmitted infections, early age for intercourse, and marijuana use, she said. HPV cannot be transmitted casually, such as by sharing drinks or a kiss on the cheek.

Although the median age for diagnosis of HPV-associated cancers is 54, in recent years more people in their 30s and 40s are being diagnosed, and more non-whites and women are being diagnosed.

After transmission is discussed, the focus shifts to treatment and mortality.

“If you see an oropharynx cancer in a non-white or in a woman in this day and age, odds are it is going to be HPV-associated,” Dr. Fakhry said, adding that survival rates are good. After five years, about 80 percent of HPV-positive patients have survived, compared with about 50 percent of HPV-negative patients.

How HPV infections are acquired also is a common question. It is important for otolaryngologists to present evidence, including written materials, to educate patients, and to take a non-judgmental approach. HPV is a sexually transmitted infection affecting the oropharynx, anus, and genitals, with genital HPV the most common.

Oral HPV is usually transmitted to the mouth through oral sex or kissing. In the United States, about 10 percent of men and 4 percent of women have an oral HPV infection, and it is most common in older age groups. Oral HPV infections are associated with sore throats, sores and bumps in the mouth and throat, and swollen and bleeding gums. In most patients, the infection clears in one to two years and only a small proportion of patients ever develop cancer, Dr. Fakhry said.

Patients also want to know when they became infected, but that is unclear. It can take years or decades for oral HPV to develop into cancer. Exposure to HPV does not mean a patient has cancer.

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