oral cancer

Having written about sexually transmitted HPV (human papillomavirus) for 13 years, I’ve been waiting for the day when  celebrity would lend his or her fame to spotlight the realities of HPV infection, especially of HPV-related oral cancers. My hopes were that big news could bring about big change.  Today is that day, but it remains to be seen if it can be long-needed catalyst for change.

When news first broke, about three years ago, that Michael Douglas had oral cancer, my gut instinct was that it had been caused by HPV, likely one of the same types of HPV that has been causally linked to cervical cancer. The mucus membrane tissue of mouth and throat are similar to those of genital skin, so researchers have known for some time that, like herpes, HPV could be transmitted oral to genital, as well as genital to oral.

Back in 2009, the research findings were already clear: oral transmission of cancer-causing HPV means that almost all of us are more likely at risk than we are safe from risk.  For my 2010 feature article in Ms. Magazine, I focused on the importance of not only educating the public about HPV-related cancers in men but also about the HPV-oral cancer link. In addition, I advocated for the need to destigmatize all STDs: my research and book have shown that STD stigma makes it more likely for at-risk/infected  individuals to put off getting tested and treated. STD stigma also makes it less likely for individuals to disclose their sexual health status to partners, placing those partners at greater risk for infection.  In addition, negative stereotypes about the ‘types’ of women and men likely to be infected distort our ideas of who is at risk.

I’ll wrap up this post with a call: for us to come together, to learn the facts and not be swayed by incomplete media coverage and confusing pharmaceutical claims.  We must support significant funding increases to investigate exactly how we can prevent HPV-related oral/throat cancers, which research shows to be steadily on the rise and more fatal than cervical cancers in the U.S.

Update (6/3/13): I was not surprised to read reports which broke today — that the actor’s rep is correcting one aspect of yesterday’s breaking news: “He did not say cunnilingus was the cause of his cancer.” All any cancer survivor probably knows is that his/her cancer was caused by HPV (viral tests and typing can be done in lab tests of biopsied tissue samples). Researchers have found that cancer-causing HPV can be transmitted to oral/throat area via oral sex. The point remains: Michael Douglas did a good deed by helping raise awareness that serious (often fatal) oral cancers can be caused by sexually-transmitted HPV which is likely contracted by oral sex….

As a sexual health researcher, I have followed the saga of HPV (human papillomavirus) vaccination since the early 2000s. I’m posting this month’s column early to address three news stories that recently caught my attention – both for what they reported and also for what they left out:

March 26, 2012: PRNewswire report on Harold zur Hausen’s remarks at the annual meeting of the Society of Gynecologic Oncology. Having won the 2008 Nobel Prize in Medicine for discovering the link between HPV and cervical cancer, zur Hausen kept the spotlight on cervical cancer when he advocated for HPV vaccination of young females and males in order to “eradicate cervical cancer.” While I advocated for non-sexist HPV vaccination policies back in a 2010 Ms. Magazine article, I was surprised by reports that zur Hausen favored male vaccination: “…if society were to vaccinate just one gender to prevent the spread of cervical-cancer causing HPV, it would be more effective to vaccinate just males.”  I found myself asking two questions: (1) Why base medical recommendations on heterosexist assumptions that girls/women only contract cancer-causing strains of HPV from male partners? (2) Why continue to narrowly focus on HPV as a cause of cervical cancer, when a growing body of research documents its role in a range of genital cancers as well as often fatal oral-throat cancers?

April 2, 2012: The New York Times offers a summary of a study published in the March issue of the British Medical Journal: the findings suggest that HPV vaccination “can significantly cut the likelihood of virus-related disease even among women who have had surgery for cervical cancer caused by HPV.” The strongest prevention effect – 64% reduction in risk – was for women who had the most serious kinds of cervical cancer. The article quotes Dr. Elmar A. Joura, associate professor of gynecology at the Medical University of Vienna: “Regardless of your age or your history, a vaccination can prevent new disease.” Key question not addressed by this article: why does the CDC have an upper-age limit of 26 years old for HPV vaccination? Last year, Canada raised their upper-age limit to 45 – how much longer will ‘older’ Americans have to wait?

April 4, 2012: Forbes article on “The Gardasil Problem” fails to address the full scope of HPV vaccination ‘problems.’ First, the author misleads readers into thinking that HPV-related oral-throat cancers are “a new form” – again, see not only the 2010 Ms. Magazine article but also the Oral Cancer Foundation’s thorough summary of the decades of research linking sexually-transmitted HPV to serious oral cancers.

The author also misstates the focus/bias of Merck’s original years of marketing Gardasil: “When it was introduced in 2006…Merck began an advertising push to raise awareness of the risks of HPV.” What ads did he see? I and other consumers of mainstream media were exposed to a series of commercials that referred to Gardasil as “the cervical cancer vaccine” and strategically obscured message about “HPV-related diseases”, never clarifying for viewers that HPV was, in fact, sexually transmitted.  While I offered a feminist critique of the branding and marketing of Gardasil in my 2008 book and several blog posts – trying to get the public to understand that “You don’t need to have a cervix to benefit from the cervical cancer vaccine” – Merck did not change to a focus on Gardasil as a STD vaccine until it received FDA approval for male vaccination…until profits depended upon bursting the bubble of the mythical cervical cancer vaccine.

Next, the author not only makes a heterosexist assumption but also unnecessarily demonizes oral sex on women as the ‘usual’ mode of transmission: “Usually transmitted when men perform oral sex on women, it can also spread through other forms of contact, perhaps even just kissing.”  If kissing can transmit the virus, the why is he so sure that most of men with HPV-related oral-throat cancers skipped ‘first base’ and went straight to ‘third base’? If, and this is a big ‘if’, clinical studies can verify unprotected oral sex as the primary mode of transmission, then why not offer readers a brief education on the vaccine-free ways to practice safer oral sex? 

Finally, the author unnecessarily dashes readers’ hopes for the near future: “tests that might well prove that [Gardasil] can prevent the new throat cancer strain would take at least 20 years, until the boys sampled actually became sexually active and then contracted the disease.” Why would these tests take 20 years? Does this author think that a boy who is vaccinated at age 12 will not perform oral sex until he’s 20+ years old? Where is the data to show it would take another ten years for HPV-related oral and throat cancers to develop?  In addition, the author fails to point readers towards the likely source of delay: a lack of interest by the makers of the two FDA-approved HPV vaccines.   

A 2010 article in the Journal of the National Cancer Institute not only clarifies the challenges of developing effective screening for oral HPV infections but also reports the truth about Merck’s failure to move forward with testing HPV vaccination as prevention of oral and throat cancers. Maura Gillison, M.D., Ph.D., a leading researcher on HPV-related head and neck cancers at Ohio State University in Columbus, explained why clinical trial plans were derailed in 2010: “We were 6 weeks from enrolling the first patient when I got an e-mail saying it was no longer in the interest of Merck to conduct the trial.” The article also quotes Pam Eisele, a Merck spokeswoman:

“The link between HPV infection and head and neck cancers continues to be an area of scientific interest for Merck; however, we currently do not have any plans to study the potential of Gardasil to prevent HPV-related oropharyngeal cancers. In 2008, we did conduct a small pilot study to assess our ability to obtain adequate and valid oropharyngeal samples. While the results of the pilot study were promising, due to competing research and business priorities we ultimately decided not to move ahead with an efficacy study at this time.”

Why is Forbes not asking for a more complete explanation of those “competing research and business priorities”?  We, the American public, should demand more funding find out how to prevent cancers which research shows to be on the rise and more fatal than cervical cancer in the U.S.

The one section of this Forbes article that some readers might find valuable is its summary of the data on the safety record of HPV vaccination.  However, as I’ve said before, I am not advocating that vaccination is the only way to reduce one’s risk of contracting cancer-causing strains of HPV.  Those who decide not to vaccinate themselves and/or their children need to learn the facts about HPV prevention, testing, diagnosis, and treatment: check out the American Social Health Association’s online HPV and Cervical Cancer Prevention Resource Center.

January is Cervical Health Awareness Month, making it the perfect time to post a follow-up to Part I which featured my concerns about potential unintended consequences of new Pap test guidelines (from ACOG, the American College of Obstetricians and Gynecologists). To recap, it is vital that we do not confuse a recommendation of less frequent Pap tests with the unchanged recommendation of annual pelvic/sexual health exams (see the National Cancer Institute for explanations of both).

So, let’s look back at a letter dated November 20, 2009, in which the President of ACOG clarified:

Cervical cancer screening should begin at age 21 years (regardless of sexual history). Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.

Medically speaking, why should this recommendation disregard an individual woman’s sexual history? His letter continues on to state:

Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years. Evidence shows that screening women every year has little benefit over screening every other year.

Doesn’t this depend on how many new sexual partners a woman has in a given year? Are the revised guidelines assuming monogamy (or at least long-term, serial monogamous relationships) which decrease odds of a woman contracting a new cancer-causing strain of HPV in less than a 2-year period? Where are the conclusive findings of large-scale sexual-behavior surveys to support this assumption?

ACOG’s November 2009 press release featured these quotes from Alan Waxman, M.D.:

Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix. Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.

I agree with GWP reader anniegirl1138 who commented on my previous post that over-treatment is no joke. However, we have not been presented with data that a Pap test — the test, itself, not over-treatment based on test findings — is directly linked to significant increases of any negative health outcome.

Cervical HPV infections can be detected by Pap tests: ACOG acknowledges that, “the rate of HPV infection is high among sexually active adolescents, but counters with, “the large majority of cervical dysplasias in adolescents resolve on their own without treatment.”

Why should that smaller group of girls and young women (whose pre-cancerous lesions do not resolve without treatment) miss the annual opportunity to receive an early diagnosis? Early-stages of cervical HPV infection can often be resolved with less-invasive treatment options.

More-invasive treatment options, such as the “excisional procedures for dysplasia” that have been linked to increased risk of premature births, are one of several medical treatments for cervical HPV.

And, what about the possibility that an increased risk of premature births may not be the paramount concern for every female patient? Not all women want to or can biologically become mothers. What if an individual female patient would rather seek medical treatment for a HPV infection that has resulted in cervical dysplasia so that she has greater peace of mind in knowing that she has reduced her risk of cervical cancer and reduced the likelihood of transmitting HPV to her sexual partner(s) and/or future babies?

Call me a feminist, but I still believe that knowledge is power and that every sexually-active girl and woman should be encouraged to consider the benefits of annual Pap tests. When Pap smear results show “abnormal” cellular changs, then healthcare practitioners should explain the potential for false-positives and discuss the pro’s and con’s of moving forward with different diagnostic and treatment options.  

ACOG acknowledges that, “HPV also causes genital and anal warts, as well as oral and anal cancer.” A Pap test may be a girl/woman’s first chance to learn of a cervical HPV infection, which can result in her having a colposcopy exam. This procedure helps a practitioner find HPV-infected cells not only on the cervix but also in other anogenital areas (the vaginal canal, the labia, the perineum). Beyond the cervix, a Pap test that is positive for HPV may be a wake-up call to get a thorough oral screening for serious oral cancers which have been linked to sexually transmitted HPV.

In addition, my research and others’ studies have found that STI diagnoses can lead to attitudinal and behavioral changes which can decrease risks of contracting other STIs, including HIV. For all of these reasons, a Pap test that leads to a diagnosis of a sexually transmitted cervical HPV infection can bring unintended positive consequences.

In light of the new Pap smear guidelines, I hope that U.S. girls and women who get less frequent Pap tests will more frequently ask their healthcare practitioners to educate them about cervical cancer, about the full range of STIs, and about FDA-approved vaccines against viruses that can be sexually transmitted (HPV and Hepatitis B).

For the medical facts about HPV and HPV vaccines, check out the book The HPV Vaccine Controversy by Shobha Krishnan, M.D., a member of the Medical Advisory Board of the National Cervical Cancer Coalition. 

The Bottom Line: a recommendation for less frequent Pap tests does not mean you should forgo your annual pelvic exam. In our busy lives, e-reminders can make the difference:  PromiseToMe.com allows you to schedule an annual email reminder. [Note for boys/men: make sure to get an annual sexual health exam, too!]

Welcome to the first official post for Bedside Manners. As a sexual health researcher and book author, I receive a lot of emails from women and men who are dealing with sexually transmitted diseases. Yesterday, I replied to Liza, a 25 year-old married, monogamous woman who had just been diagnosed with a serious cervical HPV infection and treated via LEEP. She could not understand how this had happened, since she had been getting pap smears during her annual gynecological exams for the past 10 years, and her husband had never been diagnosed with genital warts. Her doctor told her it was “bad luck,” and now she is worried about the possibility of having an oral HPV infection, wondering whether her cervical infection is cured, and trying to figure out how to this will affect her marriage.

By getting annual pap smear exams, Liza has been doing the right thing. Unfortunately, most medical practitioners don’t explain that pap smears only sample a small area of a woman’s cervix. So, it is possible to receive a “normal” pap smear result when there are HPV-infected/abnormal cell changes in other portions of the cervix.

With Liza’s husband as her only sexual partner, it’s key for him to get thoroughly examined for HPV/genital warts. If HPV-infected cells are found, then he should have them removed via one of several treatment options. Once both of their bodies have healed from treatments, the couple should strongly consider using condoms during sex (note: condoms reduce but do not eliminate the risk of HPV transmission).

Given Liza’s concern about oral HPV, a ‘HPV test’ can determine the specific strain of the virus. HPV 16 has been linked to cervical cancer and to oral/head/neck cancers. So, an important follow-up exam after receiving a genital HPV diagnosis is to see a dentist: I encouraged her to share that she’s been exposed to HPV orally and request a thorough exam.

As I concluded my reply to Liza, I realized that I needed to address the stress that she was clearly experiencing. Medical sociologists have often written about how disease can cause dis-ease, an illness often causes a patient to lose her sense of wellbeing. In the case of socially stigmatizing and medically incurable infections, like HPV, stress is almost unavoidable for newly diagnosed patients. In my book, Damaged Goods?, I detail specific strategies for handling the variety of stressors that come with a genital HPV or herpes infection, but I’ve decided to wrap up today’s post with a general note about stress.

I was fortunate to attend a talk last night by the authors of a new book, The Inner Game of Stress. Tim Gallwey has teamed up with two physicians, who practice a patient-centered approach to integrative medicine, to combine medical research with his executive coaching techniques. The result is a thoughtful self-help approach to stress management that encourages readers to be assertive patients. As a medical sociologist, I have written about the health impacts of practitioner-patient interactions and was familiar with the body of research showing how stress can weaken a person’s immune system.

For people, like Liza, who are battling a virus, it is important to not only empower yourself with knowledge about your particular illness but also to strategize how to strengthen your immune system. In addition to the obvious recommendations of decreasing unhealthy behaviors and increasing healthy ones, I encouraged her to find sources of emotional and social support. Some who are facing a stigmatizing illness may find comfort by talking with trusted friends, while others may prefer the neutrality of a therapist, and many may find empowerment in a book.