HPV-associated Oropharyngeal Cancers--Are They Preventable?

HPV-associated oropharyngeal cancer: in search of surrogate biomarkers for early lesions

The incidence of oropharyngeal cancer (OPSCC) has escalated in the past few decades; this has largely been triggered by high-risk human papillomavirus (HPV). Early cancer screening is needed for timely clinical intervention and may reduce mortality and morbidity, but the lack of knowledge about premalignant lesions for OPSCC poses a significant challenge to early detection. Biomarkers that identify individuals at high risk for OPSCC may act as surrogate markers for precancer but these are limited as only a few studies decipher the multistep progression from HPV infection to OPSCC development. Here, we summarize the current literature describing the multistep progression from oral HPV infection, persistence, and tumor development in the oropharynx. We also examine key challenges that hinder the identification of premalignant lesions in the oropharynx and discuss potential biomarkers for oropharyngeal precancer. Finally, we evaluate novel strategies to improve investigations of the biological process that drives oral HPV persistence and OPSCC, highlighting new developments in the establishment of a genetic progression model for HPV + OPSCC and in vivo models that mimic HPV + OPSCC pathogenesis.

PI3K/AKT/mTOR Signaling Pathway in HPV-Driven Head and Neck Carcinogenesis: Therapeutic Implications

High-risk human papillomaviruses (HR-HPVs) are the causal agents of cervical, anogenital and a subset of head and neck carcinomas (HNCs). Indeed, oropharyngeal cancers are a type of HNC highly associated with HR-HPV infections and constitute a specific clinical entity. The oncogenic mechanism of HR-HPV involves E6/E7 oncoprotein overexpression for promoting cell immortalization and transformation, through the downregulation of p53 and pRB tumor suppressor proteins, among other cellular targets. Additionally, E6/E7 proteins are involved in promoting PI3K/AKT/mTOR signaling pathway alterations. In this review, we address the relationship between HR-HPV and PI3K/AKT/mTOR signaling pathway activation in HNC with an emphasis on its therapeutic importance.

The Drivers, Mechanisms, and Consequences of Genome Instability in HPV-Driven Cancers

Human papillomavirus (HPV) is the causative driver of cervical cancer and a contributing risk factor of head and neck cancer and several anogenital cancers. HPV's ability to induce genome instability contributes to its oncogenicity. HPV genes can induce genome instability in several ways, including modulating the cell cycle to favour proliferation, interacting with DNA damage repair pathways to bring high-fidelity repair pathways to viral episomes and away from the host genome, inducing DNA-damaging oxidative stress, and altering the length of telomeres. In addition, the presence of a chronic viral infection can lead to immune responses that also cause genome instability of the infected tissue. The HPV genome can become integrated into the host genome during HPV-induced tumorigenesis. Viral integration requires double-stranded breaks on the DNA; therefore, regions around the integration event are prone to structural alterations and themselves are targets of genome instability. In this review, we present the mechanisms by which HPV-dependent and -independent genome instability is initiated and maintained in HPV-driven cancers, both across the genome and at regions of HPV integration.

The Role of HPV in Determining Treatment, Survival, and Prognosis of Head and Neck Squamous Cell Carcinoma

Human papillomavirus (HPV) infection has been identified as a significant etiological agent in the development of head and neck squamous cell carcinoma (HNSCC). HPV's involvement has alluded to better survival and prognosis in patients and suggests that different treatment strategies may be appropriate for them. Only some data on the epidemiology of HPV infection in the oropharyngeal, oral cavity, and laryngeal SCC exists in Europe. Thus, this study was carried out to investigate HPV's impact on HNSCC patient outcomes in the Irish population, one of the largest studies of its kind using consistent HPV testing techniques. A total of 861 primary oropharyngeal, oral cavity, and laryngeal SCC (OPSCC, OSCC, LSCC) cases diagnosed between 1994 and 2013, identified through the National Cancer Registry of Ireland (NCRI), were obtained from hospitals across Ireland and tested for HPV DNA using Multiplex PCR Luminex technology based in and sanctioned by the International Agency for Research on Cancer (IARC). Both overall and cancer-specific survival were significantly improved amongst all HPV-positive patients together, though HPV status was only a significant predictor of survival in the oropharynx. Amongst HPV-positive patients in the oropharynx, surgery alone was associated with prolonged survival, alluding to the potential for de-escalation of treatment in HPV-related OPSCC in particular. Cumulatively, these findings highlight the need for continued investigation into treatment pathways for HPV-related OPSCC, the relevance of introducing boys into national HPV vaccination programs, and the relevance of the nona-valent Gardasil-9 vaccine to HNSCC prevention.

Exploratory study of an oral screening dysplasia program for HIV-infected men who have sex with men

BACKGROUND

HIV-infected men who have sex with men (MSM) are at high risk to develop human papilloma virus (HPV)-related oropharyngeal cancer. The aim of our study was to assess the usefulness of a pilot oral dysplasia screening program and its correlation with an anal dysplasia screening program.

METHODS

This was a prospective study with HIV-infected MSM. Oral and anal screenings were performed based on HPV determination, liquid cytology, direct and microscopy oral examinations, high-resolution anoscopy and biopsies, if necessary.

RESULTS

A total of 103 patients were included. The mean age of the patients was 44.6 years, 55.3% were smokers, and 57.3% had a history of previous anal high-grade squamous intraepithelial lesions (HSILs).The prevalence of oral HPV infections was 14% (9% HPV-high risk), the prevalence of abnormal cytology was 25.2%, and in 4.8% of the patients, oral examinations showed suspicious HSILs. Oral microscopy did not detect additional lesions that visual inspection. Five oral biopsies were performed and the results were normal. No risk factors for oral HPV infections were identified.The prevalence of anal HPV infections was 88.3% (76.7% HPV-high risk), 52.9% of the patients had altered cytology, and in 45.6% anoscopy showed changes suggestive of HSILs. Seventy-two anal biopsies were performed, detecting 25 cases of HSILs (24.3%).A poor correlation was observed between oral and anal HPV infections (κ = 0.037).

CONCLUSIONS

The prevalence of oral HPV infections, abnormal cytology and lesions in HIV-infected MSM was low, and their correlation with anal HPV-related lesions was slight. These results confirm the current barriers to oral dysplasia screening techniques.

Global burden of oropharyngeal cancer attributable to human papillomavirus by anatomical subsite and geographic region

BACKGROUND

Oropharynx is the anatomical site with the highest human papillomavirus (HPV) infection in head and neck. Many studies on HPV prevalence and p16^INK4a positivity in oropharyngeal cancer have been published in recent years. We aimed to update the global burden estimates of oropharyngeal cancer attributable to HPV with the latest data and estimate global burden of tonsillar cancer and base of tongue cancer attributable to HPV by region and country.

METHODS

We calculated the number of new cancer cases using the Cancer Incidence in Five Continents Volume XI (CI5XI) and country-specific population in 2012 issued by the United Nations. Estimates of HPV prevalence and p16^INK4a positivity were obtained from literature search and pooled analyses where necessary.

RESULTS

Globally the number of oropharyngeal cancer and tonsillar cancer attributable to HPV were 42,000 and 20,000 in 2012, corresponding to AFs of 42.7% and 52.7%. The number of cancer cases attributable to HPV among males was about 4-fold greater than that among females. For both oropharyngeal cancer and tonsillar cancer, AFs were higher in more developed countries. Among HPV positive oropharyngeal cancer cases, 86.7%, 87.8%, and 92.5% could have been prevented by bivalent (2v), quadrivalent (4v), and nonavalent (9v) HPV vaccines.

CONCLUSIONS

It is worth considering the inclusion of HPV immunization in males, especially in the regions where oropharyngeal cancer is highly prevalent.

Summary from an international cancer seminar focused on human papillomavirus (HPV)-positive oropharynx cancer, convened by scientists at IARC and NCI

Cancer of the oropharynx has attracted considerable attention in recent years given: (1) an increasing incidence in selected populations over the past three decades; (2) the discovery of human papillomavirus (HPV) infection as the driver of the increase, as opposed to the traditional risk factors such as tobacco (smoking and chewing) and alcohol; and (3) the promise of new prevention and treatment strategies. As a result of such developments, the International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI), convened the fourth Cancer Seminar meeting in November 2018 to focus on this topic. This report summarizes the proceedings: a review of recent science on the descriptive epidemiology, etiology, biology, genetics, early detection, pathology and treatment of HPV-positive oropharyngeal cancer, and the formulation of key research questions to be addressed.

Case of an Incidentally Found Squamous Cell Carcinoma of the Tonsil: Are We Underestimating Its Incidence?

A 65-year-old male was incidentally found to have a human papillomavirus-16 (HPV)-associated squamous cell carcinoma of the tonsil. His only major risk factor was chronic and heavy alcohol and smoking history. Fortunately, surgery, followed by chemoradiation led to clinical remission. HPV is a common and known cause of oro- and anogenital squamous cell carcinoma (SCC). However, unlike anogenital SCC, there is no screening method available for the detection of oro-genital SCC. HPV vaccination is known to prevent a majority of these cancers. However, rates of HPV vaccination have been declining in the United States, thus causing an increase in these preventable cancers. This case report highlights the need for increased HPV vaccination rates, which can only be made through adequate physician recommendations and patient education.

Oral HPV Infection Is Common Worldwide, but Risk of Infection Differs by Sex, Continent, Population at Infection, and Year

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

The epidemiology of oral human papillomavirus infection in healthy populations: A systematic review and meta-analysis. Tam S, Fu S, Xu L, Krause KJ, Lairson DR, Miao H, Sturgis EM, Dahlstrom KR. Oral Oncol 2018;82:91-9.

SOURCE OF FUNDING

The University of Texas MD Anderson, Christopher and Susan Damico chair in Viral Associated Malignancies, Lyda Hill Foundation, HPV-Related Cancers Moonshot program, Steifel Oropharyngeal Research Fund.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

Disparities in HPV vaccination rates and HPV prevalence in the United States: a review of the literature

Human papillomavirus (HPV) is a common sexually transmitted infection which is the cause of several cancers, including cervical cancer, and genital warts. Although cervical cancer can be prevented through screening, this cancer persists in the US. More recently, HPV vaccination has the potential to decrease the burden of HPV-related disease among young HPV-unexposed adolescents. Several initiatives aimed to encourage HPV vaccination have been adopted. Unfortunately, uptake of the HPV vaccine remains modest, despite evidence that vaccine-type HPV prevalence is decreasing as a result of HPV vaccination. Further, geographic disparities in vaccination uptake across different US regions and by race/ethnicity may contribute to continuing disparities in HPV-related cancers. More data are needed to evaluate impact of HPV vaccination on HPV prevalence in smaller geographic areas. Further, more information is needed on the impact of individual vaccination programs and policy on population level vaccination and HPV prevalence.

Prevalence of current oral HPV infection among 100 betel nut chewers or cigarette smokers in Northern Taiwan

BACKGROUND

The incidence of HPV positive oropharyngeal cancer is increasing in Taiwan. Given this, it is critical to understand the prevalence of oral HPV infection since this cancer is potentially preventable. A community-based study was conducted to evaluate the prevalence of oral HPV infection and sexual behavior changes.

METHODS

Between January and December 2016, 100 subjects between 20 and 70 years-old with current/ever betel nut chewing or current cigarette smoking visited the Department of Health, New Taipei City. Subjects with cancer history or known HIV/AIDS were excluded. Sexual behavior information was collected through a questionnaire. Oral rinse samples and oropharyngeal swabs were obtained for HPV genotyping using the EasyChip HPV genotyping array (King-Car, Taiwan).

RESULTS

92 men and 8 women were recruited. The prevalence of oral HPV infection was 3%, present between 60 and 70 (11%) and between 30 and 40 years old (4%). The prevalence of the first sexual contact at younger than 20 years old were 71.4%, 53.6%, 15.4% and 44% in <40, 40-49, 50-59 and 60+ years old, respectively (p for trend = 0.0036). The prevalence of 3 or more lifetime sexual partners were 60.7%, 57.1%, 23.1% and 16.7%, respectively for <40, 40-49, 50-59 and 60+ years old (p for trend = 0.0005).

CONCLUSION

The prevalence of oral HPV infection is 3%, in current/ever betel nut chewers or current cigarette smokers in Northern Taiwan. Younger generation have more lifetime sexual partners and younger first sexual contact. This could explain the rising incidence of HPV positive oropharyngeal cancer in Taiwan.

Primary, secondary and tertiary prevention of human papillomavirus-driven head and neck cancers

Human papillomavirus (HPV)-driven oropharyngeal cancers (OPCs) represent an increasing proportion of head and neck cancers that could become, in the next few decades, a public health problem in certain western countries. This significant epidemiological change strongly calls for preventive measures. Prophylactic HPV vaccination and screening programmes for early identification and treatment of premalignant lesions are currently being used to reduce the incidence of uterine cervical cancer, which is the paradigm of HPV-driven malignancy. These strategies have proven to be efficient as the incidence of cervical cancer has dramatically dropped since the 1960s in most countries where they are properly applied. The success of cervical cancer prevention encourages the development of similar approaches to prevent HPV-driven OPCs. However, a number of important limitations impede their application to HPV-driven OPCs, and the development of innovative and specific strategies dedicated to this disease are urgently needed. This article provides an overview on primary, secondary and tertiary prevention of HPV-driven OPC and discusses some directions for future research.

The Expanded Impact of Human Papillomavirus Vaccine

Human papilloma virus (HPV) infection is the most common sexually transmitted infection in the United States. Some infections will result in anogenital warts and anogenital or oropharyngeal cancers. Preventing HPV infection is a public health priority to reduce cancer and HPV-associated complications. Prevention through vaccination is the most cost-effective and lifesaving intervention to decrease the burden of HPV-related cancers and other HPV-associated diseases. It is critical for pediatricians to make a strong recommendation for early and timely vaccination and completion of the 3-dose series. The goal of early vaccination is to immunize before first exposure to HPV virus.

Detection of hypermutated human papillomavirus type 16 genome by Next-Generation Sequencing

Human papillomavirus type 16 (HPV16) is a major cause of cervical cancer. We previously demonstrated that C-to-T and G-to-A hypermutations accumulated in the HPV16 genome by APOBEC3 expression in vitro. To investigate in vivo characteristics of hypermutation, differential DNA denaturation-PCR (3D-PCR) was performed using three clinical specimens obtained from HPV16-positive cervical dysplasia, and detected hypermutation from two out of three specimens. One sample accumulating hypermutations in both E2 and the long control region (LCR) was further subjected to Next-Generation Sequencing, revealing that hypermutations spread across the LCR and all early genes. Notably, hypermutation was more frequently observed in the LCR, which contains a viral replication origin and the early promoter. APOBEC3 expressed abundantly in an HPV16-positive cervix, suggesting that single-stranded DNA exposed during viral replication and transcription may be efficient targets for deamination. The results further strengthen a role of APOBEC3 in introducing HPV16 hypermutation in vivo.

Role of Prophylactic Bilateral Tonsillectomy as a Cancer Preventive Strategy

The rate of vaccination against human papillomavirus (HPV) among adolescent girls and boys over the past few years has been stagnant in spite of the increase in incidence of HPV-positive oropharyngeal (OPX) squamous cell carcinoma (SCC). The indirect relationship between HPV cancer incidence and preventive vaccination poses a public health concern and has caused clinicians to search for other methods toward eradicating the ongoing oropharyngeal carcinoma epidemic. This alarming increase in OPX is motivating a search for therapeutic prevention strategies, including biomarker discovery, risk assessment, therapeutic vaccines, immunotherapy, and surgery. The current Danish Cancer Registry study by Fakhry and colleagues (in this issue) is the first to investigate the impact of prior tonsillectomy on the development of HPV OPX. They report that remote tonsillectomy resulted in a decreased incidence of tonsillar SCC. While thought-provoking, this study has a small sample size. Also, tonsillectomy does not address all anatomic sites at risk; there is lack of well-defined precancerous lesions or biomarkers to identify high-risk patients, and cost and morbidity make it impractical to justify prophylactic tonsillectomy as a cancer preventive strategy at present. The provocative clinical signal reported in this study supports further research and strategies that employ surgery when the technology and epidemiology can reliably be used to identify high-risk subjects.

Tonsillectomy and Risk of Oropharyngeal Cancer: Implications for Research and Prevention

The association of tonsillectomy, a common surgical procedure involving the removal of a majority of the palatine tonsillar tissue, with risk of tonsil cancer specifically or oropharyngeal cancers overall is not known. In this issue of Cancer Prevention Research, Fakhry and colleagues conduct an analysis within the Danish Cancer Registry and show that tonsillectomies were associated with significantly reduced risk of tonsil cancer, but were unrelated to risk of base of tongue cancers. This editorial discusses the implications of the results by Fakhry and colleagues for key prevailing questions in the field related to risk, rising incidence, secondary prevention, and treatment of oropharyngeal cancers.

Human Papillomavirus 16 E6 Antibodies in Individuals without Diagnosed Cancer: A Pooled Analysis

BACKGROUND

The increasing incidence of oropharyngeal cancer in many developed countries has been attributed to human papillomavirus type 16 (HPV16) infections. Recently, HPV16 E6 serology has been identified as a promising early marker for oropharyngeal cancer. Therefore, characterization of HPV16 E6 seropositivity among individuals without cancer is warranted.

METHODS

A total of 4,666 controls were pooled from several studies of cancer and HPV seropositivity, all tested within the same laboratory. HPV16 E6 seropositive controls were classified as having (i) moderate [mean fluorescent intensity (MFI) ≥ 484 and <1,000] or (ii) high seroreactivity (MFI ≥ 1,000). Associations of moderate and high HPV16 E6 seroreactivity with (i) demographic risk factors; and seropositivity for (ii) other HPV16 proteins (E1, E2, E4, E7, and L1), and (iii) E6 proteins from non-HPV16 types (HPV6, 11, 18, 31, 33, 45, and 52) were evaluated.

RESULTS

Thirty-two (0.7%) HPV16 E6 seropositive controls were identified; 17 (0.4%) with moderate and 15 (0.3%) with high seroreactivity. High HPV16 E6 seroreactivity was associated with former smoking [odds ratio (OR), 5.5; 95% confidence interval (CI), 1.2-51.8], and seropositivity against HPV16 L1 (OR, 4.8; 95% CI, 1.3-15.4); E2 (OR, 7.7; 95% CI, 1.4-29.1); multiple HPV16 proteins (OR, 25.3; 95% CI, 2.6-119.6 for three HPV16 proteins beside E6) and HPV33 E6 (OR, 17.7; 95% CI, 1.9-81.8). No associations were observed with moderate HPV16 E6 seroreactivity.

CONCLUSIONS

High HPV16 E6 seroreactivity is rare among individuals without diagnosed cancer and was not explained by demographic factors.

IMPACT

Some HPV16 E6 seropositive individuals without diagnosed HPV-driven cancer, especially those with seropositivity against other HPV16 proteins, may harbor a biologically relevant HPV16 infection.

Attitudes toward Human Papilloma Virus Vaccination and Head and Neck Cancer Prevention in a Diverse, Urban Population

OBJECTIVE

(1) To understand if awareness of the human papilloma virus (HPV) vaccination's potential to prevent head and neck cancer improves acceptability of the vaccine in a large urban population and (2) to identify characteristics of those in whom such discussions would have the greatest impact.

STUDY DESIGN

In-person, anonymous survey.

SETTING

Academic public hospital between March 2014 and June 2014.

SUBJECTS

Patients aged 12 to 24 years and their parents or guardians awaiting scheduled outpatient pediatric appointments.

METHODS

Demographics and modified Carolina HPV Immunization Attitudes and Beliefs Scales data were cross-analyzed, followed by univariate binomial logistic regression to identify predictors for major outcomes of interest.

RESULTS

More than 78% of those surveyed indicated they would be more receptive to the HPV vaccine if given strong evidence that it prevented head and neck cancer. Respondents were more likely to increase receptivity to HPV vaccination if they held the belief that they did not have enough information about the vaccine or indicated they preferred to wait because the vaccine was too new.

CONCLUSION

Increasing public awareness of head and neck cancer prevention with HPV vaccination could increase HPV vaccination acceptance.

APOBEC3A and 3C decrease human papillomavirus 16 pseudovirion infectivity

Apolipoprotein B mRNA editing enzyme, catalytic polypeptide-like (APOBEC) proteins are cellular DNA/RNA-editing enzymes that play pivotal roles in the innate immune response to viral infection. APOBEC3 (A3) proteins were reported to hypermutate the genome of human papillomavirus 16 (HPV16), the causative agent of cervical cancer. However, hypermutation did not affect viral DNA maintenance, leaving the exact role of A3 against HPV infection elusive. Here we examine whether A3 proteins affect the virion assembly using an HPV16 pseudovirion (PsV) production system, in which PsVs are assembled from its capsid proteins L1/L2 encapsidating a reporter plasmid in 293FT cells. We found that co-expression of A3A or A3C in 293FT cells greatly reduced the infectivity of PsV. The reduced infectivity of PsV assembled in the presence of A3A, but not A3C, was attributed to the decreased copy number of the encapsidated reporter plasmid. On the other hand, A3C, but not A3A, efficiently bound to L1 in co-immunoprecipitation assays, which suggests that this physical interaction may lead to reduced infectivity of PsV assembled in the presence of A3C. These results provide mechanistic insights into A3s' inhibitory effects on the assembly phase of the HPV16 virion.

Optical coherence tomography and autofluorescence imaging of human tonsil

For the first time, we present co-registered autofluorescence imaging and optical coherence tomography (AF/OCT) of excised human palatine tonsils to evaluate the capabilities of OCT to visualize tonsil tissue components. Despite limited penetration depth, OCT can provide detailed structural information about tonsil tissue with much higher resolution than that of computed tomography, magnetic resonance imaging, and Ultrasound. Different tonsil tissue components such as epithelium, dense connective tissue, lymphoid nodules, and crypts can be visualized by OCT. The co-registered AF imaging can provide matching biochemical information. AF/OCT scans may provide a non-invasive tool for detecting tonsillar cancers and for studying the natural history of their development.

Role of human papillomavirus in oropharyngeal squamous cell carcinoma: A review

Human papillomavirus (HPV) has been implicated in the pathogenesis of a subset of oropharyngeal squamous cell carcinoma. As a result, traditional paradigms in relation to the management of head and neck squamous cell carcinoma have been changing. Research into HPV-related oropharyngeal squamous cell carcinoma is rapidly expanding, however many molecular pathological and clinical aspects of the role of HPV remain uncertain and are the subject of ongoing investigation. A detailed search of the literature pertaining to HPV-related oropharyngeal squamous cell carcinoma was performed and information on the topic was gathered. In this article, we present an extensive review of the current literature on the role of HPV in oropharyngeal squamous cell carcinoma, particularly in relation to epidemiology, risk factors, carcinogenesis, biomarkers and clinical implications. HPV has been established as a causative agent in oropharyngeal squamous cell carcinoma and biologically active HPV can act as a prognosticator with better overall survival than HPV-negative tumours. A distinct group of younger patients with limited tobacco and alcohol exposure have emerged as characteristic of this HPV-related subset of squamous cell carcinoma of the head and neck. However, the exact molecular mechanisms of carcinogenesis are not completely understood and further studies are needed to assist development of optimal prevention and treatment modalities.

HPV positive tonsillar cancer in two laser surgeons: case reports

A 53 year-old male gynecologist presented with human papillomavirus (HPV) 16 positive tonsillar squamous cell carcinoma. He had no identifiable risk factors with the exception of long term occupational exposure to laser plumes, having performed laser ablations and loop electrosurgical excision procedures (LEEP) on greater than 3000 dysplastic cervical and vulvar lesions over 20 years of practice. The second patient is a 62 year old male gynecologist with a 30 year history of laser ablation and LEEP who subsequently developed HPV 16 positive base of tongue cancer. He also had very few other risk factors for oropharyngeal cancer or HPV infection. HPV is a probable causative agent for oropharyngeal squamous cell carcinoma and has been reported as being transmittable through laser plume. This paper suggests that HPV transmitted through laser plume can result in subsequent squamous cell carcinoma.

The four steps in the prevention of human papillomavirus-associated neoplasia: considerations for preventive measures, screening, disease impact, and potential overtreatments in HPV-related pathology

There is no cure currently available for HPV infections, although ablative and excisional treatments of some dysplasias often result in a clinical and virological cure. Effective control measures of HPV-associated cancers rely on the prevention at four different levels. Apart from sexual abstinence, primary prevention is realized through vaccines targeting the most frequent HPV types: negative attitudes towards HPV vaccination and high costs are the main obstacles. The aim of secondary prevention is to detect precancerous changes before they develop into invasive cancer, while tertiary prevention involves actual treatment of high-grade lesions: in many countries routine screening with cytology is being challenged with HPV DNA testing. Quaternary prevention comprehends those actions adopted to mitigate or avoid unnecessary or excessive medical interventions, and may well be addressed in avoiding treatments for low-grade intraepithelial neoplasia. Though some gynecologists commonly recommend treatment for low-grade disease and women tend to prefer active management if not properly informed, harms arising from unnecessary treatments, increased costs, work overload for second-level health services, and induced psychosocial distress are causing on-going problems. Prevention efforts of genital HPV-associated cancers should concentrate in: (1) enhancing primary prevention through vaccination of all eligible subjects, (2) achieving high levels of adherence to routine screening programs, (3) treating precancerous lesions, and (4) monitoring current guidelines recommendations to avoid overtreatments. Novel research projects should be designed to study the delicate mechanisms of immune response to HPV.

A patient-centered approach to counseling patients with head and neck cancer undergoing human papillomavirus testing: a clinician's guide

The International Agency for Research on Cancer and the National Cancer Institute have acknowledged human papillomavirus (HPV)-16 as an independent risk factor for oropharyngeal cancer (OPC). HPV-positive oropharyngeal cancer (HPVOPC) is a sexually transmitted entity that is on the rise; within the next 10 years, the annual number of HPV-associated OPC cases is projected to exceed the annual number of cervical cancer cases in the United States. Recognition of HPV status in OPC has broad implications beyond the traditional oncological concerns of timely diagnosis, accurate staging, and appropriate treatment of cancer patients. The National Comprehensive Cancer Network recommends testing the tumor site for HPV-status during OPC management; it is likely this will become a standard component of care for patients with high-probability tumors of the oropharynx. As the practice of HPV testing becomes more common, it behooves providers to be able to adequately address the concerns of patients with HPVOPC. Although there are currently few relevant studies focusing on this population, existing literature on HPV-infected women and patients with cervical cancer strongly supports the concept that patients with HPVOPC need education to optimally address concerns such as self-blame, guilt, intimacy, and interpersonal relationships. When HPV testing is done, it should be accompanied by evidence-driven and patient-centered counseling to best minimize negative psychosocial outcomes and ensure optimum health promotion. Based on the current state of the literature, this article is intended to be a reference for physicians to effectively manage psychosocial outcomes when diagnosing patients with HPV-associated OPC.

Economic impact of human papillomavirus-associated head and neck cancers in the United States

Cases of human papillomavirus (HPV)-associated head and neck cancers are rapidly increasing in the United States. Little is known about the economic burden of these cancers. A literature review identified 7 studies that characterized aspects of the overall economic burden of HPV-associated head and neck cancers in the United States. Other cost studies are detailed to highlight the clinical reality in treating these patients. As the clinical awareness of the role of HPV in head and neck cancers continues, the economic impact of cancers caused by this virus will have implications for the role of various preventive measures.

Epidemiology and clinical aspects of HPV in head and neck cancers

Human papillomavirus (HPV) infection is now established as a major etiologic factor for oropharyngeal cancers. Case-control studies conducted around the world show strong and consistent associations of markers of HPV exposure with risk of oropharyngeal cancers (range of odds ratios [OR] for oral oncogenic HPV infections = 3.6-230.0, ORs for HPV16 L1 antibodies = 2.3-182.0, and ORs for HPV16 E6/E7 antibodies = 9.2-231.0. HPV-positive oropharyngeal cancers are epidemiologically distinct from HPV-negative ones, and are characterized by younger age at onset, male predominance, and strong association with sexual behaviors. Importantly, HPV-positive oropharyngeal cancer patients have substantially improved outcomes (28-80 % reductions in the risk of death) than HPV-negative patients. Given the superior survival, younger age, and good performance status of HPV-positive oropharyngeal cancer patients, de-intensified therapies are currently being considered for this group of patients. Recent analyses of cancer registry data show dramatic increases in incidence of oropharyngeal cancers during the past 15-20 years in several parts of the world, highlighting the need for prevention strategies. If proven efficacious, currently available prophylactic HPV vaccines hold great promise for primary prevention of HPV-associated oropharyngeal cancers.