Leaderboard Ad

HPV Making More Otolaryngologists Act as Counselors

0920-HPVOtolaryngologists increasingly are treating and counseling patients on the ticklish subject of HPV-associated head and neck cancers. A Monday Miniseminar reviewed treatment, clarified how HPV infection is transmitted, and explored typical patient questions and how to address them.

“HPV-associated head and neck cancer is growing in incidence and our role as otolaryngologists in counseling patients about sexually transmitted disease is becoming more important,” Andrew G. Shuman, MD, said in an interview about HPV infections. “There are some potentially stigmatizing implications of an HPV diagnosis in the setting of a cancer diagnosis that shift the way we approach those patients.”

Dr. Shuman, assistant professor in the Department of Otolaryngology—Head and Neck Surgery at the University of Michigan Medical School, Ann Arbor, was moderator of “Sex, Drugs, and Cancer: Talking to Patients about HPV.”

Speakers addressed how to discuss diagnosis and treatment of HPV associated cancer with patients, its effect on intimacy, the ethics of disclosure to sexual partners, and the role of HPV vaccination.

The presentation of oropharyngeal squamous cell carcinoma (OPSCCA) has changed in recent years because it is more frequently associated with HPV, said Jason Showmaker, MD, Capital Region Medical Center, University of Missouri Health Care. In 2000, 40 percent of OPSCCA cases were tied to HPV, but that number grew to 70 percent by 2009 and is even higher today in many populations.

Those at highest risk for HPV associated SCCA include Caucasian men who do not use barrier protection during sexual activity and have a higher number of sexual partners over a lifetime. A study reports that 77 percent of cases first present as a neck mass and/or sore throat. Imaging studies show that primary sites of disease are typically smaller and less invasive than primary tumors among patients with HPV negative SCCA, which may explain a lack of symptoms at presentation, he said.

“We’ve established that HPV positive SCCA is different in the types of people it affects, the way it presents, and the way it looks on imaging,” Dr. Showmaker said. “It also needs to be discussed with patients in a different manner than typical SCCA caused by smoking and drinking.”

Because of the link to sexually transmitted infections (STIs), physicians managing head and neck cancer often are uncomfortable with counseling patients about the stigma associated with STIs. Resources to supplement physician counseling include professional counseling and patient-focused literature that is available from several groups, including the American Cancer Society.

After diagnosis, making treatment decisions can be a challenge, Dr. Shuman said. Patients can struggle with understanding the role of HPV when they have greater concerns about the cancer, and how HPV impacts treatment choices remains unresolved.

Treatment factors to consider include the stage, location, and size of the tumor, patient comorbidities and priorities, and the clinician’s experience, bias, and equipment access. Another factor involves opportunities to participate in clinical research trials, which can add even more complexity to treatment-related decision making, he said.

“In general, institutional and practitioner preference, and the availability of resources coupled with clinical factors and patient preference continue to dictate treatment decision-making,” Dr. Shuman said.

Physicians need to be prepared to answer questions about transmissibility of the disease, said Alexander Langerman, MD, assistant professor in the Department of Otolaryngology at Vanderbilt University Medical Center, Nashville, TN.

HPV is often perceived to be linked to sexual promiscuity because it is an STI, but studies show that the latency between initial HPV infection and clinical presentation of head and neck cancer is measured in decades.

“There is no indication to modify behaviors in long-term monogamous relationships,” Dr. Langerman said. “The risk of cancer in your partner, even if they have been exposed to the same HPV serotype, is exceedingly low. It is not a sign of infidelity.”

HPV may be associated with a persistent oral infection in one partner that can be transmitted to a partner. There is no evidence of casual HPV transmission by hands, towels, or utensils. In addition, exposure among sexually active adults exceeds 80 percent.

“In the absence of evidence that there is substantial risk of harm to partner, there is no justification to violate patient confidentiality,” Dr. Langerman said when discussing the ethical dilemma of informing a partner of the disease.

Prevention of HPV is a good option because vaccines are proven to be effective, said Jason Goodwin, MD, Eglin Air Force Base. Vaccines are given in a three-dose series over six months and are shown to have a 96 percent success rate at inducing a host immune response. However, there is insufficient public acceptance of vaccines, and vaccinations rates to date are not high enough to achieve the necessary herd immunity.

Screening as a prevention tool is not a good option because there are a lack of precancerous lesions or biomarkers. “It is currently impractical to justify this as a cancer prevention strategy,” Dr. Goodwin said.

Return to index page