Demographics are important to physicians.
Demographics help guide us toward more-likely and less-likely diagnoses in patients.In their most basic form, they mean we are surprised when we learn that the 90-year-old woman with hand pain suffered the injury while boxing. On the other hand, demographics are why a doctor tells the overweight man with a history of hypertension that he is “a heart attack waiting to happen.”Most disease processes can be characterized by a typical patient and are based on age, gender and sometimes ethnicity or socio-economic class.
This has long been the case with oral-cancer cases. Most physicians have an idea of a typical oral-cancer patient. We envision an older, male patient with few teeth following a lifetime of poor oral health. They generally have lower income and are lifelong smokers.
That’s why the tonsillar-cancer patient was such a surprise to me. He was 34, upper-middle class and did not smoke or drink. He had recently undergone surgery to remove his tonsils and a good portion of the back of his throat.
He had come into the emergency department that day because he was having difficulty breathing and swallowing. When I walked into the room, he was sitting on a gurney and drooling into a garbage can that he kept between his knees. The skin around his neck looked swollen and tight, leaving me to imagine how much swelling there was in the back of his throat.His surgery had been six days earlier, and he had been doing well at home until that day.
The possibilities ran through my head. Was it an infection in the soft tissue of his neck? Was it an abscess? Or was it normal post-operative changes, including inflammation? Swelling in that area heightens our level of concern for having to secure an airway. Surgically creating an airway always is a consideration.Fortunately, my patient was able to lie flat without feeling that his airway was closing.
A CT scan of his head and neck showed narrowing around his airway, but no discrete area of pus to drain. The soft-tissue swelling around the neck looked bad, but he felt comfortable as long as he sat up. We treated him with steroids and antibiotics and gave him aerosolized adrenaline to constrict the blood vessels of the airway and decrease the swelling. Within an hour, he looked much better. This patient spurred my interest. Was he a fluke?Here was a young, otherwise healthy man without risk factors for oral cancer, yet he had developed such a horrible disease. He didn’t fit any of the demographics I knew for a patient with a head and neck cancer.
The answer is that my patient is the new face of head and neck cancer. Human papillomavirus, or HPV — the same virus linked to cervical cancer in women — is being linked to oral cancers in men.Typically, 10 percent to 15 percent of the population is infected with HPV, and the incidence increases if a sexual partner is infected or the patient is HIV-positive.
HPV causes cancer in humans, monkeys, cats, dogs, cattle, mice, turtles and many other species. The literature is replete with example after example.
The incidence of HPV in humans has increased significantly. Since the 1970s, there has been roughly a threefold increase in incidence of HPV associated with tonsillar cancers.
There really is no cure for HPV once a patient is infected. We can generally live with the virus, but we are stuck with the bug and the increased risk of cancer. This is why there is such a push to prevent the infection; doing so essentially gets as close as we can to preventing cancer. There is a vaccine for the most-common causative strains of HPV associated with cervical cancer. Preventing tonsillar and oral cancers might be the next step.
Remembering my patient, I can’t help but wonder if we couldn’t have prevented some of this. More funding for research? More preventive measures? Better patient education? Yes, yes and yes.