Head and neck cancers used to be primarily associated with tobacco and alcohol consumption, but there’s been a notable surge in new head and neck cancers related to the human papillomavirus (HPV), particularly among younger individuals. This demographic shift is attributed to changes in sexual behaviors and an increase in HPV infections.
“There are 150-200 subtypes of HPV,” said Dr. Brian Burkey, ENT-Otolaryngologist with Cleveland Clinic Indian River Hospital. “Only about five are carcinogenic and only three subtypes lead to head and neck cancers. Those are the same three subtypes that cause cervical cancer in women. Back in 2015 cervical cancer in women was the highest rate of HPV cancer, but today the No. 1 site of HPV-related cancer is in the head and neck.”
While the overall incidence of head and neck cancers has stabilized in recent years, the proportion of cases linked to HPV has been steadily increasing, presenting new challenges in prevention and treatment.
According to Dr. Burkey, head and neck cancers occur between the clavicle and the base of the skull, so brain cancer is not in the category. While things like carotid cancer, thyroid cancer and skin cancer can occur in that area, generally head and neck cancer refers to cancer of the upper airway and digestive track that runs from the lips down to the beginning of the esophagus, including cancers of the voice box, cancers of the oral cavity, primarily the tongue, and cancers of the oropharynx, which is the part of the throat behind the mouth from the soft palate down to the beginning of the larynx.
“Ninety percent of cancers in the upper digestive tract are squamous cell carcinoma, which are now classified as either non-viral or virally related,” Dr. Burkey said. “Those that are virally related come from the human papillomavirus string of cell carcinoma. HPV-related head and neck cancers are of the oropharynx only – meaning they only manifest in the back of the tongue and the tonsils. They are completely different in terms of how they present, their etiology, their presentation in the patient and their prognosis. It’s a completely different disease that was first recognized in 2000 and widely accepted around 2005.”
Oropharyngeal cancers usually present with a bump on the neck under the jaw. They look different than other cancers because they tend to be small primary cancers in general, with very early big cystic lymph nodes. Other cancers are big primary cancers with late, smaller lymph node manifestations. Usually, they can be diagnosed visually, but a biopsy will confirm whether the cancer is viral or non-viral.
Treatment for both HPV-related and non-HPV-related head and neck cancers are basically the same, using surgery, radiation or chemotherapy. But the prognosis is highly different. The cure rate for HPV-related cancers is in the 80 percent to 90 percent range. In contrast, the cure rate for non-HPV-related cancer is in the 30 percent to 50 percent range.
“The disparity in cure rates comes from the cancer itself and its host,” Dr. Burkey explained. “The HPV cancer is a more sensitive tumor. It responds more readily to radiation and because it’s more localized it is much more surgery sensitive so we can treat it more aggressively, usually with robotic surgery. It’s also in a healthier population that isn’t burdened with high blood pressure or lung or heart disease.”
The Centers for Disease Control states that nearly everyone will get HPV at some point in their lives. HPV is very common, affecting more than 42 million Americans, with about 13 million, including teens, becoming infected each year. The virus is spread through intimate skin to skin contact during vaginal, anal or oral sex with someone who has the virus even if they don’t have signs or symptoms. Nine out 10 HPV infections will go away by themselves within two years, but some HPV infections can cause cancers of the cervix, vagina, vulva, penis, anus and oropharyngeal cancer. HPV causes about 36,000 cases of cancer in the United States each year.
“Before 2009 my patients were primarily presenting with larynx or tongue cancer linked to tobacco usage. Now, two thirds of my patients are here for HPV-related oropharyngeal cancer. They are generally younger, in their 40s and 50s, and live healthy lifestyles. The primary risk factors for HPV related head and neck cancer are multiple sexual partners, oral sex, marijuana usage and not being vaccinated.”
Fortunately, there is a very effective vaccination that can protect both male and females from HPV cancers. The CDC recommends that everyone through the age of 26 years should get the HPV vaccine starting at age 9. Early protection works best, long before a child is ever exposed to the virus through sexual contact. Some adults up to age 45 may choose to get vaccinated as well, although more people in this range have been exposed to HPV already.
Thanks to the vaccine, HPV infections and cervical precancers have dropped dramatically since 2006 when the vaccines were first used in the United States. Infections with HPV types that cause most HPV cancers have dropped 88 percent in teen girls, 81 percent in young adult women and 40 percent among women overall.
“Theoretically, the HPV vaccine provides lifetime protection,” Dr. Burkey said. “It’s been shown to prevent or decrease the incidence of cervical cancer and it’s assumed it will do the same for head and neck cancer. About 60 percent of women in the United States are vaccinated but only about 30 percent of men. That means 70 percent of the men are unvaccinated and there’s a whole population out there who have never been vaccinated and potentially carrying the virus so you can understand the surge in HPV-related head and neck cancers.”
HPV vaccination rates, particularly in adolescents, are crucial in reducing the incidence of HPV-related cancers including those affecting the head and neck, according to doctors and researchers.
Dr. Brian Burkey, M.D., MEd, FACS, is Division Chief of Otolaryngology-Head and Neck Surgery at Cleveland Clinic Indian River Hospital. In addition to seeing patients, he also serves as vice-chief of the Integrated Surgical Institute for Cleveland Clinic Florida. He earned his medical degree at the University of Virginia School of Medicine, completed his otolaryngology residency training at the University of Michigan, and his fellowship in head and neck oncologic and reconstructive surgery at Ohio State University. His office is located at the Scully-Welsh Cancer Center at Cleveland Clinic Indian River Hospital, 3555 10th Court, Vero Beach. The phone number is 772-563-4673.