Concerned About HPV-Related Cancer Rise, Researchers Advocate Boosting HPV Vaccination Rates

By: Anna Azvolinsky
Source: JNCI Journal of the National Cancer Institute Advance Access
Published:  August 29, 2013


Deaths from the major cancers—lung, colorectal, breast, and prostate—continue to decline, a trend that started in the early 1990s. Cancer incidence is also declining, if slightly, for both sexes. That’s the good news from the annual Report to the Nation on the Status of Cancer, a joint research effort by the American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries (J Natl. Cancer Inst. 2013;105:175–201).

But the study also shows an uptick in rates of anal and oropharyngeal cancer, a type of head and neck cancer related to infection with the human papillomavirus (HPV), in the 10-year period ending in 2009. Cancer of the oropharynx increased among white men and women (3.9% and 1.7%, respectively). Anal cancer also increased in both sexes, with the greatest increase among black men (5.6%) and white women (3.7%). Rates of vulvar cancer, another HPV-related cancer, also increased among women despite continued lower rates of cervical cancer.

Researchers attribute this rise in HPV related cancers to more HPV infections. “We think that increases in oral–genital sexual practices and increasing number of sexual partners that occurred some 30 years ago as part of the sexual revolution may be implicated in part of the increase in cancer rates we are seeing today,” said Edgar P. Simard, Ph.D., M.P.H., senior epidemiologist of surveillance research. Although rates of HPV infection from three decades ago were not available in the joint report, a trend exists of men and women now in their 50s and 60s having the highest rates of both oropharyngeal and anal cancers.

To directly relate HPV infection with cancer development later in life, epidemiologists are attempting to understand how HPV, the most common sexually transmitted infection in the U.S., is spread and which populations are most at risk. HPV infection of the cervix increases with number of sexual partners and younger age of first sexual experience. Studies now show similar trends for oral HPV infection rates, which can lead to oropharyngeal cancer.

More than 100 strains of the virus are passed through skin contact. Most cause benign warts on the genitals, hands, or face, but about 15 strains can cause cancer of the cervix, vagina, vulva, penis, anus, and oropharynx (tonsils, back of the throat, and base of the tongue). Most people with HPV clear the infection, but those with persistent infection for many years or decades are at risk for these cancers, depending on the site of viral infection.

Screening for Noncervical HPV-Related Cancers

The Pap smear screening test has drastically reduced both cervical cancer incidence rates and deaths. Screening methods for other HPV-related cancers are not so straightforward. “Right now, it is just cervical cancer screening and some anal cancer screening that is done for certain individuals who are high risk,” said Simard. HPV causes an estimated 90% of anal cancers. Anal cancer screenings are offered to HIV-positive men who have sex with men, but not enough research has yet occurred to adapt this type of screening for other cancer sites.

HPV infection causes approximately 60% of oropharyngeal cancers, but screening remains problematic. “We have a serious problem trying to screen for oropharyngeal cancer because we have not clearly identified a premalignant lesions that can be used for screening,” said Douglas R. Lowy, M.D., chief of the NCI Laboratory of Cellular Oncology, who works on HPV. This type of cancer has been studied for a relatively short time, and more research is needed to fully understand whether premalignant lesions caused by HPV could be identified early.

Oropharyngeal Cancer–HPV Link

Oropharyngeal cancers were seen predominantly in older men who had comorbidities and who tended to have a history of drinking or smoking. “What we see now is still more men than women, but these men are younger, in their 40s and 50s, and they don’t have the comorbidities from smoking and drinking and in general are more healthy,”said Everett E. Vokes, M.D., head and neck expert at the University of Chicago.

Researchers now distinguish two types of oropharyngeal cancers—those related to HPV infection, which generally have a better prognosis, and those related to tobacco and alcohol use. At the molecular level,  HPV-related cancers are not only positive for HPV DNA but also express the human p16 gene, induced by the virus’s oncoproteins. Most HPV-positive patients also have detectable antibodies against HPV.

HPV Vaccine Reaching Broader Population

Current HPV vaccination rates will at least partly influence the cancer statistics that will emerge in 20–30 years as a result of current HPV infection rates. Over time, “prevention is the key, and prevention is either abstinence or vaccination,” said Vokes.

The HPV vaccine can reduce the risk of HPV-related cancers that in 10–30 years could affect people who are now teenagers. The vaccine, a series of three shots, is recommended for girls aged 11 or 12 years (with catch-up until age 26 years) and boys aged 11 or 12 years (with catch-up until age 21 years), to protect against HPV infection and HPV related diseases, including cancer. Researchers initially developed the vaccine to protect against cervical cancer and genital warts, and the U.S. Food and Drug Administration has now approved it to protect against anal, vaginal, and vulvar cancers. In principle, the vaccine should also protect against HPV-positive oropharyngeal cancer because as many as 90% of cases are attributed to the two HPV strains that the vaccine targets.

“A critical aspect of the HPV vaccine is that it should reduce the risk of all cancers caused by the HPV types targeted by the vaccine, not just cervical cancer, for which we don’t have another public-health intervention,” said Lowy.

Yet uptake of the vaccine in the U.S. remains low: Only 35% of girls aged 13–17 years were fully vaccinated as of 2011, compared with 18% in 2008—considerably short of the 80% goal of the Healthy People 2020 program.

Studies indicate that physician recommendation is a main determinant of whether a teen will receive the vaccine. Susan T. Vadaparampil, Ph.D., associate member of the Health Outcomes and Behavior Program at the Moffitt Cancer Center in Tampa, Fla., who studies trends in HPV vaccination, said that pediatricians are more likely than family physicians to offer the vaccine (Cancer 2013;119:621–8). Her study also showed that physicians who care primarily for minority groups are more likely to administer the vaccine to these patients. Cost is not necessarily a deterrent because children from families who cannot pay can receive the vaccine free through Medicaid or the Vaccines for Children program.

These findings are consistent with results of a national survey that Vadaparampil conducted to compare rates of physicians’ HPV vaccine recommendations for girls aged 11–12 years from 2010 and 2011. Recommendation rates increased little, and another study focusing on low-income families showed that despite free programs and recommendations, vaccination rates for girls remained low.

“There has been very poor and slow uptake compared with the meningococcal and Tdap [combined tetanus–diphtheria– pertussis] vaccines given to teens,” said Robert M. Jacobson, M.D., a pediatrician at the Mayo Clinic. Jacobson recently found that the number of parents who opt out of vaccinating their teens against HPV is increasing nationally despite recommendations (Pediatrics 2013;131:645–51). “The most alarming finding, frankly more disturbing than the poor uptake, is the increasing concern of parents regarding safety issues and the decreasing number of parents who say they will vaccinate their daughters,” said Jacobson.

To better understand how to improve physician–parent communication, Jacobson and colleagues will, as part of a large national study, go directly to physicians’ offices to analyze the conversations physicians are having with parents and teens. “We need to find out what is being said and, perhaps more important, what is not being said.”

CDC and other organizations are leading campaigns to increase HPV vaccination rates. According to Simard, the campaigns underscore the vaccine’s anticancer function. As for the scientifically unfounded safety concerns, “we need to continue to communicate the scientific rationale for HPV vaccines to the public and underscore that all of the data support the conclusions that the vaccines are safe and efficacious,” said Simard. “We are confident in that, but we do need additional ways to combat people’s misperceptions about the HPV vaccine.”

© Oxford University Press 2013. DOI:10.1093/jnci/djt260

*This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

September, 2013|Oral Cancer News|

Alcohol withdrawal syndrome worsens cancer surgery outcomes

Source: www.oncologyreport.com/
Author: Damian McNamara

Patients with head and neck cancers who develop alcohol withdrawal syndrome perioperatively experience significantly more complications after undergoing surgery, a large database analysis indicates.

The presence of withdrawal symptoms was associated with a 25% incidence of postoperative complications, compared with 14% among patients who abused alcohol and 7% among those without alcohol abuse, Dr. Dane J. Genther said at the Triological Society’s Combined Sections Meeting. The risk for wound complications was nearly double in this population (odds ratio, 1.9).

Dr. Genther, a resident in otolaryngologyhead and neck surgery at Johns Hopkins Hospital in Baltimore, and his associates used ICD-9 codes in the Nationwide Inpatient Sample discharge database to identify more than 92,000 patients who underwent an ablative procedure for head and neck cancer in 2003-2008. The retrospective, cross-sectional study included patients with malignant oral cavity, laryngeal, hypopharyngeal, and oropharyngeal neoplasms.

In a multivariate analysis, alcohol withdrawal syndrome was significantly more likely for patients undergoing a major procedure (OR, 2.0) and was significantly associated with Medicare payer status and a need for additional health care following discharge, Dr. Genther said.

The researchers found no significant association between alcohol withdrawal syndrome and increased risk for postoperative infections or in-hospital mortality, but there was a significant increase in hospital stay and related costs associated with the syndrome.

Having a major procedure and experiencing alcohol withdrawal contributed approximately $15,000 per admission in 2011 U.S. dollars, Dr. Genther said.

The findings point to a need for alternatives to current alcohol withdrawal prevention therapies, Dr. Genther said. “Despite prophylaxis, which is our current treatment to attempt to stem the onset of alcohol withdrawal syndrome, complications do occur and they are no less severe or frequent than in the absence of prophylaxis.”

Abstinence from alcohol for at least 4 weeks is another strategy proposed to minimize risk of alcohol withdrawal syndrome for any at-risk surgical patient, said Dr. Genther. However, he added, “for many cancer patients, especially those with more advanced disease, waiting a prolonged period of time to possibly gain that benefit from abstinence is not necessarily a viable option.”

Another aim of the study was to assess factors contributing to alcohol abuse. Patients aged 40-64 years had the highest proportion of alcohol abuse, and this age range was a significant factor (OR, 2.37). Those who abused alcohol were more often male and more often underwent major procedures, Dr. Genther said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. In addition, alcohol abuse was significantly associated with pneumonia and need for additional postdischarge health care.

Dr. Genther received a G. Slaughter Fitz-Hugh Resident Research Award for this study from the Triological Society. He reported having no financial disclosures.

February, 2012|Oral Cancer News|

Mouth cancer expert calls for booze abstinence

Source: www.dentistry.co.uk
Author: staff

A mouth cancer expert is calling for an abstinence from alcohol to stem the rise in mouth cancer in the UK. New figures suggest that booze is largely to blame for an ‘alarming’ rise in the rate of oral cancers among men and women in their forties.

The figures, released by Cancer Research UK, show that since the mid-1990s, rates of oral cancers have gone up by 28% for men in their forties and 24% for women. Alcohol consumption has doubled since the 1950s and is the most likely culprit alongside smoking, says Cancer Research UK.

Now Dr Vinod Joshi, founder of the Mouth Cancer Foundation is suggesting people should ‘avoid drinking alcohol altogether’.

The Department of Health’s current advice is that men should not regularly drink more than 3-4 units of alcohol per day, and women should not regularly drink more than 2-3 units of alcohol per day.

He says: ‘In view of the latest reports from Cancer Research UK, the current alcohol guidelines that we’ve got are actually very high.

‘To reduce the risk of mouth cancer risk, the Mouth Cancer Foundation recommends that people should limit or avoid drinking alcohol altogether.’

For men, the Mouth Cancer Foundation recommends no more than occasional drinking of two standard drinks a day and for women no more than one standard drink a day.

Experts suggest that increased alcohol consumption is to blame as they say cancers caused by smoking often take 30 years to develop, and smoking rates have gone down while drinking has gone up.

Hazel Nunn, health information manager at Cancer Research UK, says: ‘These latest figures are really alarming. Alcohol consumption has doubled since the 1950s and the trend we are now seeing is likely to be linked to Britain’s continually rising drinking levels.

‘It’s possible that HPV and diet are also playing a role, and the evidence – particularly for the role of HPV – is growing.’

Each year in the UK, around 1,800 people die from the disease and there are 5,000 newly diagnosed cases per year.

Other risk factors that may be involved include a diet low in fruit and vegetables, and the sexually transmitted human papillomavirus (HPV), which also causes cervical cancer.

August, 2009|Oral Cancer News|