Mouth, throat cancers caused by HPV on the rise, especially among Canadian men

Source: www.ctvnews.ca
Author: Sonja Puzic, CTVNews.ca Staff

Mouth and throat cancers caused by the human papilloma virus have been rising steadily over the past two decades, with a “dramatic” increase among Canadian men, according to a new report from the Canadian Cancer Society.

The special report on HPV-associated cancers, released Wednesday as part of the 2016 Canadian Cancer Statistics breakdown, says the rate of mouth and throat cancers in men is poised to surpass the rate of cervical cancer diagnoses in women.

Researchers and doctors have known for decades that certain strains of HPV – the most commonly sexually transmitted disease in Canada and the world — cause cervical cancer. But the latest Canadian cancer statistics show that only 35 per cent of HPV cancers are cervical, and that about 33 per cent of HPV cancers occur in males.

The latest data show that about one-third of all HPV cancers in Canada are found in the mouth and throat.

Between 1992 and 2012, the incidence of HPV-related mouth and throat cancers increased 56 per cent in males and 17 per cent in females. In 1992, the age-standardized incidence rate (or ASIR) of those cancers was 4.1 per 100,000 Canadian males. In 2012, it was 6.4 per 100,000 males. In females, the rate was 1.2 in 1992 and 1.4 in 2012.

‘I thought I was done’
Three years ago, Dan Antoniuk noticed a lump on his neck and initially thought that it was just a swollen gland. But when the Edmonton father went to see a doctor, he was diagnosed with Stage 4 throat cancer, caused by HPV.

“I was devastated. I thought I was done,” Antoniuk, 61, told CTV News. “It shattered me, it shattered my family and affected everybody sitting in the waiting room.”

Antoniuk said that until his diagnosis, he had never heard of HPV cancers in men. His doctors told him that, despite the late stage of his cancer, his prognosis was still good with the right treatment. He underwent surgery, radiation and chemotherapy and although the treatments took a toll on his body, he’s now doing well.

“The end result is I am here, I am healthy and I can do most of the same things I have done before,” he said. “The ultimate message is: Be aware of your body and be aware of the fact that this could be something more serious and there is hope now.”

Dr. Hadi Seikaly, a professor and oncology surgeon at the University of Alberta, said doctors are seeing more HPV-related cancers in both men and women.

“The surprising thing is that we’re just seeing the front end of the epidemic,” he told CTV News. “And it is an epidemic … cervical cancer rates are coming down and head, neck cancer rates are going up.”

Doctors say that oropharyngeal cancers (which include the back of the throat, the base of the tongue and the tonsils) and cancers of the mouth used to be mostly found in older patients who smoked, drank heavily or had other health issues. But it’s now more common to see HPV-related throat and mouth cancers in younger, otherwise healthy patients.

“HPV is without question driving the dramatic increase we are seeing in oropharyngeal squamous cell carcinoma (OPSCC),” Dr. Joseph Dort, the chief of otolaryngology head and neck surgery at the Foothills Medical Centre in Calgary, told CTV News.

“Our most recent data shows that about 70 per cent of our new cases of this cancer are HPV positive. Recent studies suggest that oropharyngeal cancer will become the most common HPV-associated malignancy by the year 2020, surpassing cancer of the cervix,” he said in an email.

The changing face of the disease
Jennifer Cicci was shocked to learn that she had oral cancer caused by HPV after a lump appeared on the side of her neck in the fall of 2013.

The dental hygienist and mother of four from Brampton, Ont., said she was an otherwise healthy woman in her 40s who didn’t have any of the typical risk factors associated with head and neck cancers.

Cicci’s surgeon removed a baseball-sized mass of tissue from the back of her throat and a section from the back of her tongue. She also underwent laser surgery and radiation, with painful side effects. Still, she feels she “got off easy,” despite the entire ordeal.

In some cases, mouth and neck cancer treatments can have devastating effects on a patient’s ability to speak and eat. Some patients have had parts of their tongues and even their voice boxes removed.

The good news, doctors say, is that HPV-related cancers seem to be more treatable. More than 80 per cent of patients will survive if the cancer is caught in time.

“I felt like having this gave me an opportunity to raise awareness of something that I felt was becoming an epidemic,” Cicci said.

Dr. Brian O’Sullivan, a head and neck cancer specialist at Princess Margaret Hospital in Toronto, said that HPV infections in the throat and mouth are largely linked to sexual contact, but he has also seen patients who have had very few sexual partners and little experience with oral sex.

Calls for more widespread HPV immunization
The Canadian Cancer Society estimates that nearly 4,400 Canadians will be diagnosed with an HPV-caused cancer (that can include cervical, vaginal, anal and oral) and about 1,200 will die from it in 2016.

The society is focusing its messaging on cancer prevention and informing the public about the HPV vaccine. The two HPV vaccines approved by Health Canada are Gardasil and Cervarix.

HPV immunization is already available through publicly-funded school programs across the country, starting between Grades 4 and 7, up to age 13. But while the vaccine is offered to girls in all provinces and territories, only six provinces — Alberta, Manitoba, Nova Scotia, Ontario, Prince Edward Island and Quebec – also offer it to boys.

The Canadian Cancer Society is calling on the remaining provinces and territories to expand HPV immunization to boys.

Robert Nuttall, the society’s assistant director of health policy, also said that adults should talk to their doctors to see whether they can benefit from the HPV vaccine. However, there is currently no scientific evidence showing the benefits of HPV vaccines in older adults.

In Canada, Gardasil is approved for use in females aged 9 to 45, and males aged 9 to 26. Cervarix is approved for use in females between the ages of 10 and 25, but is currently not approved for boys and young men.

The vaccine works best in people who have not been exposed to HPV. That’s why it is given to school-aged children and teens as a preventative measure.

It will be a while before scientists can conclusively determine whether HPV vaccines can prevent throat and neck cancers, since it can take many years for an HPV infection to cause malignancies.

In the meantime, Dr. Seikaly says it’s important for Canadians to understand this disease could happen to anybody, because the modes of HPV transmission aren’t fully understood.

“They need to understand the signs and symptoms of it. And those include pain in your throat, difficulty swallowing, neck masses, ulcers in your mouth and throat,” he said. “And they need to make sure during their physical that doctors do look in their mouth and their throat.”

Early symptoms of mouth and throat cancers can often be vague, but they also include white or red patches inside the mouth or on the lips, persistent earaches and loose teeth.

As a dental hygienist who was also a cancer patient, Cicci urges regular exams of the mouth and throat during dental visits.

“What I try to do is to break down the stigma that is attached to (HPV),” she said. “The fact of the matter is, while most of the time it is still being sexually transmitted … we don’t know all the modes of transmission.”

October, 2016|Oral Cancer News|

Despite medical backing, HPV vaccine rates remain low amid sexual and moral controversy

Source: www.omaha.com
Author: Rick Ruggles, World-Herald staff writer


The HPV vaccine can reduce the rates of certain cancers, including many cervical and oral cancers, physicians and medical organizations say. But opposition by some individuals is strong, and HPV vaccination rates remain low when compared with other kinds of vaccinations recommended for adolescents.

Because the human papillomavirus is sexually transmitted and seventh grade is considered the ideal time to receive the three-dose vaccine regimen, the issue is rife with sexual and moral implications. Perhaps more potent today, though, are Internet horror stories and concerns about side effects.

A World-Herald Facebook request for views on the HPV vaccine generated far more negatives than positives. “NO NO & NO!! There is NO reason for this vaccine,” one wrote. Another called it a “deadly shot.”

Two Omaha mothers who were interviewed expressed their belief that it’s wise to have children vaccinated, and said their kids suffered no side effects. But an Iowa man described health problems suffered by his daughter, and he and an Ohio physician believe the girl was injured by the HPV vaccinations.

So mediocre are HPV vaccination rates that GSK, the maker of Cervarix, plans to cease distribution of its HPV vaccine in the United States in September. It will continue to supply it in many other nations, such as Great Britain, Germany, France and Mexico. The departure of Cervarix leaves the market to Gardasil, a vaccine produced by Merck.

“GSK has made the decision to stop supplying Cervarix … in the U.S. due to very low market demand,” the company told The World-Herald last week by email.

Many doctors in the Omaha area express disappointment with the low HPV vaccination rates but are optimistic that the situation will improve.

“As pediatricians, we’re trying to change that,” said Dr. Katrena Lacey, a Methodist Physicians Clinic pediatrician in Gretna. “I think we’re on the right track.”

A survey of adolescents reported last year by the federal Centers for Disease Control and Prevention found that 39.7 percent of girls ages 13 to 17 had received the three-dose regimen of the HPV vaccine in 2014, and 21.6 percent of boys.

This compares with 87.6 percent of boys and girls who had received the tetanus-diphtheria-pertussis vaccination and 79.3 percent who had received the meningococcal vaccine.

Dr. Megann Sauer, a pediatrician with Boys Town Pediatrics, said parents accept use of the vaccine if it’s explained well and described as a cancer-prevention strategy. “It’s a huge responsibility for us as providers to offer this to our patients,” Sauer said. “My job is to keep my patients healthy.”

Gardasil was approved in the United States 10 years ago. It was met with concern that having a child vaccinated for HPV, which is the most common sexually transmitted infection, would promote promiscuity.

Today, the global Christian ministry Focus on the Family says it “supports universal availability of HPV vaccines,” but it opposes government-mandated HPV vaccinations for public-school enrollment. The mandates are in place in Virginia, Rhode Island and Washington, D.C.

Tom Venzor of the Nebraska Catholic Conference said the vaccine itself isn’t morally problematic. But “the promotion of chastity and parental consent should never be undermined in the promotion of the HPV vaccine,” Venzor said in an email.

The Kaiser Family Foundation estimates that there are more than 14 million new human papillomavirus infections annually in the U.S. Most resolve on their own, but some chronic HPV infections can embed in tissues and lead to cervical cancers and tongue, tonsil, anal, vulvar, vaginal and penile cancers.

The American Cancer Society estimated there will be close to 13,000 new cases of cervical cancer this year and 4,120 deaths. HPV was detected in more than 90 percent of cervical cancers, a 2015 study reported in the Journal of the National Cancer Institute said.

“If you’ve ever seen anyone die of cervical cancer, it will tear you apart, because it’s a nasty, nasty disease,” said Dr. Steve Remmenga, a specialist in gynecologic oncology at the University of Nebraska Medical Center. Remmenga advocates getting the vaccination.

The CDC recommends routine HPV vaccinations beginning at 11 or 12 years of age for girls and boys, but the series can start as early as 9 years of age. The second dose should be given a month or two later and the third at least six months after the first. The vaccinations may be completed by 26 years of age. The recommendations have been adopted by the American Cancer Society and other medical organizations.

The recommendations suggest children receive the vaccinations “so they are protected before ever being exposed to the virus,” the CDC said. The agency said clinical trials indicate the vaccination provides “limited or no protection” against HPV-related diseases for women older than 26.

The CDC says the vaccine has repeatedly been shown to be safe.

Kari Nelson, a biology instructor at the University of Nebraska at Omaha, said two of her daughters, Claire and Emma, have had the full regimen and her third daughter, Gretchen, is about to get her second shot.

“I definitely believe in protecting my kids as much as possible,” Nelson said. “I do always try to weigh the pros and cons of anything. I just feel that the pros far outweigh the cons in this case.”

The Nelsons’ pediatrician, Dr. Tina Scott-Mordhorst, supports children and adolescents receiving the HPV vaccine. Why, she asked, would anyone not get a shot that might prevent cancer? “It works,” said Scott-Mordhorst, a clinical professor in UNMC’s department of pediatrics.

A study reported this year in the journal Pediatrics found that among sexually active females ages 14 to 24, the prevalence of four key HPV types was 16.9 percent among the unvaccinated and 2.1 percent among the vaccinated.

Scientists say it can take many years for chronic HPV to turn cancerous.

Dr. Bill Lydiatt, a head and neck cancer surgeon at Methodist Hospital, said oral sex and the sexual revolution of the late 1960s have contributed to an increase in cancers of the pharynx, or tonsil and back of tongue. The cancer society reported there will be 16,420 cases of cancer of the pharynx this year, most of them in men, compared with 8,950 in 2006. More than 3,000 will die this year from that kind of cancer, the society says.

Lydiatt said scientists only about 10 years ago made the clear link between HPV and cancers of the pharynx and tonsils.

There are more than 150 strains of HPV and more than 40 that can cause cancer, the Kaiser Family Foundation reported. The first form of Gardasil protected against four strains, including the two believed to be most prevalent in cancers. Two years ago the FDA approved a Gardasil vaccine that protected against nine strains. The study in the Journal of the National Cancer Institute says that “current vaccines will reduce most HPV-associated cancers.”

The vaccines are expensive. The Gardasil nine-strain vaccine is close to $250 per dose at Kohll’s Pharmacy if a family pays out of pocket. But many insurers, such as Blue Cross Blue Shield of Nebraska, Aetna/Coventry and UnitedHealthcare, participate in the payment.

A Merck spokeswoman said GSK’s decision to cease supplying Cervarix to the U.S. market hasn’t affected Gardasil prices as of now. An Omaha pharmacist said it wouldn’t be unusual to see prices go up with the departure of a competitor. “The reality is that they can,” Mohamed Jalloh said. “I’m not saying they’re going to.”

Merck has applied to the Food and Drug Administration to market a two-dose regimen of Gardasil, which would reduce the overall price of the series.

Facebook posts and the Internet contain scathing reviews of Gardasil, including stories of children being hurt and families being scared of the vaccination.

Laura Hansen, a cancer researcher at Creighton University, said she wishes she could find the words to persuade people to get their kids vaccinated.

“About all of us have family members impacted by cancer,” said Hansen, a professor of biomedical sciences. By having their kids vaccinated, she said, “Every parent could make an impact on cancer deaths.”

She said it’s hard to fight Internet scare stories and “anecdotal science” as opposed to real science and legitimate studies. The discussion should be “more about facts and less about hysteria,” said Hansen, who saw to it that her two teen-age sons, Charlie and Jack, were vaccinated.

Jeff Weggen of Muscatine, Iowa, has an entirely different view. Weggen said his daughter, Sydney, had the vaccines about four years ago. Soon after, she began to lose weight, suffered back pain and became pale. Over a period of months she was hospitalized and saw specialists in state and out-of-state. She was eventually found to have a fungal infection and a large tissue mass in her chest.

Weggen eventually linked Sydney’s ongoing medical problems to Gardasil, he said. Online groups, other parents and the timeline of her vaccines and her illness helped lead him to this opinion, he said. An anti-Gardasil Facebook post introduced him to a doctor in Ohio who early this year generally confirmed Weggen’s suspicions.

Dr. Phillip DeMio of the Cleveland area said he has several patients he believes were sickened by Gardasil. DeMio, a general practitioner who said his practice focuses on chronically ill people, said some of his patients have been injured by other vaccines, too.

“These are challenging situations, no two ways about it,” he said. Most people have received a variety of vaccinations, he said, and he believes the aluminum in Gardasil and other vaccines can be a problem for some people.

He saw Sydney early this year. Based on the extensive testing that ruled out other diseases, the severity of her illness, the timing of vaccination and other factors, he said he believes “there’s a component of vaccine damage for her and for many of my patients.”

He said there are good reasons to have an adolescent receive Gardasil and mentioned the likelihood that some individuals will be sexually active. But it makes no sense to have a 9-year-old get it, he said. He said parents should be well-informed of the risks and benefits of Gardasil and other vaccines.

“I think people should have a choice,” he said. “I’m not saying I’m against the vaccine.”

The CDC sent a written statement saying that millions of doses of Gardasil have been administered.

Scientific studies have detected no link to “unusual or unexpected adverse reactions,” the CDC said.

Side effects can include pain from the shot and occasionally a patient might faint after any injectable vaccine, the CDC said. But “the benefits of vaccination far outweigh any risks.”

HPV is changing the face of head and neck cancers

Source: www.healio.com
Author: Christine Cona

A drastic increase in the number of HPV-associated oropharynx cancers, particularly those of the tonsil and base of tongue, has captured the attention of head and neck oncologists worldwide.

In February, at the Multidisciplinary Head and Neck Cancer Symposium in Chandler, Ariz., Maura Gillison, MD, PhD, professor and Jeg Coughlin Chair of Cancer Research at The Ohio State University in Columbus, presented data that showed that the proportion of all head and neck squamous cell cancers that were of the oropharynx — which are most commonly HPV-positive cancers — increased from 18% in 1973 to 32% in 2005.

9ea467bbf8646a69da2a432f8fcc5452Maura Gillison, MD, PhD, Jeg Coughlin Chair of Cancer Research at The Ohio State University, said screening for HPV in the head and neck is years behind cervical screening for HPV.


In addition, studies from the United States, Europe, Denmark and Australia indicate that HPV-positive patients have a more than twofold increased cancer survival than HPV-negative patients, according to Gillison.

With the rising incidence of HPV-related oropharynx cancers, it will soon be the predominant type of cancer in the oral or head and neck region, according to Andy Trotti, MD, director of radiation oncology clinical research, H. Lee Moffitt Cancer Center & Research Institute, in Tampa, Fla.

“We should be focusing on HPV-related oropharyngeal cancer because it will dominate the field of head and neck cancers for many years,” he said during an interview with HemOnc Today. “It is certainly an important population for which to continue to conduct research.”

Because HPV-associated oropharyngeal cancer is emerging as a distinct biological entity, the recent rise in incidence will significantly affect treatment, and prevention and screening techniques, essentially reshaping current clinical practice.

Social change driving incidence

In the analysis performed by Gillison and colleagues, trends demonstrated that change in the rates of head and neck cancers was largely due to birth cohort effects, meaning that one of the greatest determinants of risk was the year in which patients were born.

The increased incidence of HPV-related oropharyngeal squamous cell carcinoma started to occur in birth cohorts born after 1935, indicating that people who were aged in their teens and twenties in the 1960s were demonstrating increased incidence, Gillison said.

“Two important and probably related events happened in the 1960s. In 1964, the surgeon general published a report citing smoking as a risk factor for lung cancer, and public health policy began promoting smoking cessation along with encouragement not to start smoking,” she told HemOnc Today.

If you were 40 years old between 2000 and 2005, your risk for having HPV-related cancer is more than someone who was between the age of 40 and 45 years in 1970, according to Gillison. Social changes that occurred among people born after 1935, for example, a reduction in the number of smokers, is consistent with the increasing proportion of oropharyngeal cancers that were HPV-related.

“The rates for HPV-related cancers began to increase and the rates for HPV-unrelated cancers started to decline, consistent with the known decline in tobacco use in the U.S. population,” she said.

Now, most cases of head and neck squamous cell carcinoma in non-smokers are HPV-related; however, oral HPV infection is common and is a cause of oropharyngeal cancer in both smokers and non-smokers, research shows.

In addition to a decrease in tobacco use reducing HPV-unrelated oral cavity cancers, the number of sexual partners may have increased during this time and have helped to increase HPV-related oropharyngeal cancers, according to Gillison.

Determining the cause of the elevated incidence is only a small piece of the puzzle. Screening, establishing who is at risk, and weighing vaccination and treatment options are all relevant issues that must be addressed.

Screening is problematic

A critical area for examination and research is the issue of screening for oral cancers. In contrast to cervical cancer, there is no accepted screening that has been shown to reduce incidence or death from oropharyngeal cancer, according to Gillison.

Not many studies have examined the issue of screening for HPV-unrelated oral cancers, and the few that have, tend to include design flaws.

Gillison said there is a hope that dentists would examine the oral cavity and palpate the lymph nodes in the neck as a front-line screen for oral cancer; however, in her experience, and from her perspective as a scientist, this has never been shown to provide benefit for oral cancer as a whole.

Another caveat with regard to HPV detection is that head and neck HPV screening is about 20 years behind the cervical field.

“Clinicians screening for HPV in the field of gynecology were incredibly fortunate because Pap smear screening was already an accepted cervical cancer screening method before HPV was even identified,” she said. “There was already a treatment algorithm: If there were cytologic abnormalities, patients were referred to the gynecologist, who in turn did a colposcopy and biopsy.”

A similar infrastructure does not exist for oropharyngeal cancer. People with HPV16 oral infection are at a 15-fold higher risk for oropharynx cancer and a 50-fold increased risk for HPV-positive head and neck cancer, yet there is no algorithm for treatment and management of these at-risk individuals, Gillison said.

In 2007, WHO said there was sufficient evidence to conclude that HPV16 was the cause of oropharynx cancer, but with no clinical algorithm already established, progress in this area is much further behind.

Another problematic aspect of HPV-related oropharyngeal cancer screening is that the site where the cancer arises is not accessible to a brush sampling, according to Gillison.

“To try to find this incredibly small lesion in the submucosal area that you cannot see and cannot get access to with a brush, highlights that we need to develop new techniques, new technologies and new approaches,” she said.

The near future consists of establishing the actual rates of infection in the oral cavity and oropharynx, and then screening for early diagnosis, according to Erich Madison Sturgis, MD, MPH, associate professor in the department of head and neck surgery and the department of epidemiology at The University of Texas M.D. Anderson Cancer Center.

“I am not extremely hopeful because the oropharyngeal anatomy makes screening complicated, and these cancers likely begin in small areas within the tonsils and the base of the tongue,” Sturgis told HemOnc Today. “I am hopeful, however, that preventive vaccines will eventually, at a population level, start to prevent these cancers by helping people avoid initial infection by immunity through vaccination earlier in life.”

Much of the currently known information surrounding the issue of HPV-related oral cancers is new, so researchers continue to conduct research in various relevant areas. One key question to answer is who may be at higher risk for HPV-related oropharynx cancers.

Who is at risk?

As mentioned earlier, the number of oral sex partners seems to play a role in the risk for contracting the HPV virus.

In one study published in The New England Journal of Medicine in 2007, findings demonstrated that a high lifetime number of oral sex partners (at least six partners) was associated with an increased risk for oropharyngeal cancer (OR=3.4; 95% CI, 1.3-8.8).

In addition to a higher number of oral sex partners, other still unknown factors may be contributing to risk. This is an area that needs further research, according to Barbara Burtness, MD, chief of head and neck oncology, and professor of medical oncology at Fox Chase Cancer Center in Philadelphia.

The effect of smoking status is another area that needs further research. According to Burtness, smokers with HPV-associated oropharynx cancer have less favorable outcomes.

When discussing the prognosis of HPV-associated cancers, Sturgis said low risk is defined as low or no tobacco exposure and positive HPV status, and intermediate risk is defined as significant tobacco exposure but an HPV-positive tumor, and the highest risk group appears to be the HPV-negative group.

Although HPV-negative cancers are overwhelmingly tobacco-related cancers and tend to have multiple mutations, it appears that HPV-positive cancers, particularly those in patients with low tobacco and alcohol exposure, tend to lack mutations and to have a better prognosis, and this may ultimately help to guide treatment practices, according to Sturgis. Yet, there is still much to learn about HPV-related oropharyngeal cancers on various fronts.

Vaccination a hopeful ally

In HPV-related head and neck cancer, particularly oropharynx cancers, more than 90% of patients who have an HPV-type DNA identified, have type 16, according to Sturgis.

The two current HPV vaccines, Gardasil (Merck) and Cervarix (GlaxoSmithKline), which are approved for cervical cancers, include HPV types 16 and 18; therefore, in theory, they should be protective against the development of infections in the oropharynx and protective at preventing these HPV-associated cancers from occurring.

The presumption is that if there was a population-wide vaccination against HPV, there would be less person-to-person transmission, and this would lead to fewer oropharynx cancers, according to Burtness, who said this theory still needs further research.

There is excitement at the possibility that therapeutic vaccines could be developed, and various groups are investigating this, Burtness added.

“There is reason to think that the vaccines may be helpful; however, when HPV infects the tonsillar tissues, it exerts control in the host cells by making two proteins: E6 and E7; so another potentially exciting therapeutic avenue would be to target those specific viral proteins,” she told HemOnc Today.

Anxiety about protection from the HPV virus is palpable, according to Sturgis. He described the worry that many patients experience about contracting and transmitting HPV infection.

“Many patients are concerned they will put their spouses and/or children at risk in ways such as kissing them; and we need to tone down those worries until we have better data,” he said.

Screening and vaccination are fundamental aspects of current ongoing research, but of equal importance is determining what clinicians should do to treat a population of patients with HPV-related oropharyngeal cancers.

HPV status may influence treatment

With rates of HPV-related cancers escalating, determining the appropriate treatment for these patients is crucial.

During the past 10 years, findings from retrospective studies have shown that patients with HPV-related cancers have a much better prognosis than patients who test negative for HPV. Findings from several retrospective analyses from clinical trials conducted during the past 2 years have come to the same conclusion, according to Gillison: HPV-positive patients have half the risk for death compared with patients negative for HPV.

Therefore, there may be several alternative treatment options, including the possibility of reducing the dose of radiation given to patients after chemotherapy, thereby reducing toxicity.

Comparing HPV-negative and HPV-positive patients may not be enough to determine proper treatment, researchers said. Data between different cohorts of HPV-positive patients also needs to be examined. Smoking, for example, may play a role in patient outcome.

In a prospective Radiation Therapy Oncology Group clinical trial (RTOG 0129), presented by Gillison at the 2009 ASCO Annual Meeting and recently published in The New England Journal of Medicine (see page 53), researchers conducted a subanalysis of the effect of smoking on outcome in uniformly staged and treated HPV-positive and HPV-negative patients while accounting for a number of potential confounders. HPV-positive patients who were never smokers had a 3-year OS of 93% compared with heavy smoking HPV-negative patients who had an OS of 46%.

The study found that smoking was independently associated with OS and PFS. Patients had a 1% increased risk for death and cancer relapse for each additional pack-year of smoking. This risk was evident in both HPV-positive and HPV-negative patients. Gillison said smoking data must be paid attention to, and she encouraged cooperative group research on the topic.

Most of the findings demonstrate improved outcomes for patients with HPV-positive oropharyngeal cancers vs. patients with HPV-negative oropharyngeal cancers, according to the experts interviewed by HemOnc Today.

Dose de-intensification for less toxicity

To date, there is no evidence that HPV-related cancers should be managed differently than HPV-unrelated cancers, but it is a hot topic among clinicians in the field, according to Burtness.

The superior outcomes for HPV-associated oropharynx cancer have suggested the possibility of treatment de-intensification. The use of effective induction chemotherapy may permit definitive treatment with a lower total radiation dose. In theory, this would reduce the severity of late toxic effects of radiation, such as swallowing dysfunction. Such a trial is being conducted by the Eastern Cooperative Oncology Group. Burtness said this is currently pure research question.

“There is still much research that needs to be done before clinicians can safely reduce the dose of radiation administered to HPV-positive patients,” Burtness said.

Currently, she and colleagues in the ECOG are conducting a study of patients with HPV-associated stage III or IV oropharynx cancers to examine the possibility of tailoring therapy to these patients. Patients are assigned to one of two groups: low-dose intensity-modulated radiotherapy 5 days per week for 5 weeks (27 fractions) plus IV cetuximab (Erbitux, ImClone) once weekly for 6 weeks, or standard-dose intensity-modulated radiotherapy 5 days per week for 6 weeks (33 fractions) plus IV cetuximab once weekly for 7 weeks.

If patients have a very good clinical response to chemotherapy, which is likely to happen with HPV-associated cancers, they are eligible to receive a reduced dose of radiation, and hopefully, they would experience less adverse effects, Burtness said.

“Patients who are treated with the full course of radiation for head and neck cancer are now getting 70 Gy, and they are often left with dry mouth, and speech and swallowing difficulty,” she said. “We are hopeful that if these particular cancers are treatment responsive to chemotherapy, we may be able to spare the patient the last 14 Gy of radiation.”

Immunotherapy a viable treatment

Another possible treatment technique that may benefit patients with HPV-related cancers is immunotherapy. One form of immunotherapy uses lymphocytes collected from the patient, and training the cells in the laboratory to recognize in this case a virus that is associated with a tumor and consequently attack it. This approach potentially may be used to treat HPV-related oropharynx cancers, according to Carlos A. Ramos, MD, assistant professor at the Center for Cell and Gene Therapy at Baylor College of Medicine, Houston.

“With some infections that lead to cancer, even though the virus is present in the tumor cells, the proteins shown to the immune system are limited; therefore, they do not drive a very strong immune response,” Ramos told HemOnc Today. “Training the immune system cells, T lymphocytes, may make them respond better to antigens.”

Data from ongoing trials that are taking T lymphocytes from patients and educating them to recognize antigens in patients with the Epstein-Barr virus associated tumors have shown some activity against them, according to Ramos. This adoptive transfer appears to be safe and may have the same effect on the HPV virus associated tumors. Immunotherapy does not cause the usual toxicities associated with chemotherapy, he said.

“There are currently no trials showing whether we can prevent more recurrences with this approach, but the results of trials examining viruses such as Epstein-Barr are good so far, in both patients who have no evidence of disease and in those who still have disease,” he said.

Even patients with active disease who have not responded to other therapies have responded to this therapy, Ramos said. He and colleagues are working toward compiling preclinical data to study the possibility of using immunotherapy to treat patients with HPV-related cancers.

Journey is just beginning

Much of what is known about risk, screening, prevention and treatment of HPV-related oropharynx cancers is in the early stages of discovery and much is still theoretical, according to Sturgis.

“As far as we can tell, these infections are transmitted sexually; the hope is that as we have better vaccines for prevention of cervical dysplasia, the downstream effect will help prevent other HPV-related cancers, such as anal cancers and penile cancers and oropharyngeal cancers,” he said.

Several recent studies examining new therapies that may reduce the intensity of traditional treatments while maintaining survival rates would have a major effect on the field, according to Sturgis.

Gillison said the rise in the number of cases of HPV-related cancers is changing the patient population considered to be at risk, and more research is vital.

“The most important thing for clinicians to do is be aware that trials are being developed and strongly encourage their patients to participate,” she said.  Christen Cona

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

June, 2016|Oral Cancer News|

Frontline Cancer: vaccines for HPV near guarantee

Source: www.lajollalight.com
Author: Dr. Scott Lippman

Dear Scott: “Our son, who is 25, went to the GP yesterday and his doc wasn’t sure about giving the Gardasil I had been bugging him to get. Didn’t you tell me about the benefits of the HPV vaccination?”

The note was from a friend. It was personal, but also a topic of wide public interest and one that remains much discussed among cancer researchers and physicians. That’s why I’m answering my friend here.

Roughly 12 percent of all human cancers worldwide — more than 1 million cases per year — are caused by viral infections (called oncoviruses) and attributed to a relatively small number of pathogens: human papilloma virus (HPV), hepatitis B virus (HBV), hepatitis C virus (HCV) and Epstein-Barr virus (EBV). Given the emphasis upon other causal factors of cancer, such as genetic mutations or environmental sources, it’s a statistic that’s not well known nor, I would argue, fully appreciated.

Human viral oncogenesis is complex, and only a small percentage of the infected individuals develop cancer, but that 12 percent translates into more than 500,000 lives lost each year to virus-caused malignancies. Many of those deaths are preventable because effective vaccines already exist for HPV and HBV. Right now. No future discoveries required.

I want to specifically talk about the HPV vaccine. Controversy has constrained its proven effectiveness as a public health tool, but if used as prescribed, the HPV vaccine could essentially eliminate cervical and other HPV-caused cancers. Infection with HPV is very common. It’s estimated that at least 80 million Americans are affected. HPV is actually a group of more than 200 related viruses. There is no cure for HPV, but the infection typically clears on its own without lingering effect.

Forty types of HPV are easily spread through direct sexual contact. They fall into two categories: Low-risk HPVs that do not cause cancer, but can cause skin warts on or around the genitals, anus, mouth or throat. And high-risk HPVs (mostly two strains, type 16 and type 18) that cause approximately 5 percent of all human cancers worldwide. High-risk HPV strains drive the rates of cervical (the leading cause of cancer deaths in women in many developing countries), anal and a dramatically increasing subset of oropharyngeal (the tonsil and parts of the throat and tongue) cancers among men in the United States and other developed countries.

The Food and Drug Administration has approved three vaccines for preventing HPV infection: Gardasil, Garadsil-9 and Cervarix. They have strong safety records and a near-guarantee of dramatically reducing the risk of infection. But they are not widely used. The HPV vaccination rate in the U.S. is just 36 percent for girls and 14 percent for boys (and even lower for Hispanics, blacks and the poor).

The chief reason, it has been argued, relates to the recommended age of vaccination: 11-12 years. Because cancer-causing HPV viruses are transmitted through sexual contact, the idea of vaccinating a young girl or boy as a preventive measure strikes many people (i.e. parents) as premature, unsettling or enabling. My friend and colleague, Howard Bailey, M.D., director of the University of Wisconsin Carbone Cancer Center and a national leader on this topic, believes this attitude costs lives. “We need to shift focus from behavior associated with infection to preventing major cancers,” he says.

There are other factors as well. For example, full vaccination requires three doses, so persistence is required. Safety concerns continue about the vaccine (perhaps part of a larger misplaced mistrust of vaccines in general). And there remains limited public understanding of HPV or HPV-related diseases, especially in men.

The reality is that these vaccines work best if they are given at an early age before exposure to HPV. However, as Howard explained, if this window is missed, the FDA includes indications where the recommendation rises to age 26, to get vaccinated for at least some cancer-causing strains of HPV. Howard recommends every young, unvaccinated adult receive at least the 9-valent HPV vaccine, “which can provide protection against five additional HPV types that cause cancer and are less common than types 16 and 18.” There is the potential for protection against HPV types that a person hasn’t yet been exposed to and if a person hasn’t been exposed to the common HPV types (6, 11, 16 and 18), it can provide protection against them as well.

In a recently published statement paper, the American Society of Clinical Oncology called for a broad, concerted effort by health care professionals and policymakers to increase awareness of the evidence and effectiveness of HPV vaccination. It should be routine. The public health benefit is obvious and indisputable. I completely agree.

Here’s a corollary to consider: Vaccines for HBV have been available for many years and are a routine part of pediatric immunizations in the United States. In the past, countries like Taiwan and Korea suffered endemic HBV infections and high rates of hepatocellular carcinoma (HCC) or liver cancer. In the 1980s, these countries implemented universal infant HBV vaccination policies that have resulted in a dramatic 80 percent decline in HBV infections, cases of hepatitis and, more importantly, reductions in HCC incidence and mortality.

Every day, you can read headlines about research to find new treatments and cures for the many diseases called cancer. Progress is painfully slow and uneven. We’ve been fighting this war for decades. Preventing cancer altogether is a better approach and with cancers caused by HPV, we have the right weapon already at hand. We just need to use it.

ASCO Urges Aggressive Efforts to Increase HPV Vaccination

Source: www.medscape.com
Author: Zosia Chustecka

Human papillomavirus (HPV) vaccines have now been available for 10 years, but despite many medical professional bodies strongly recommending the vaccine, uptake in the United States remains low.

Data from a national survey show that about 36% of girls and 14% of boys have received the full schedule of HPV vaccines needed to provide protection (Vaccine. 2013;31:1673-1679).

Now the American Society of Clinical Oncology (ASCO) has become involved, and in a position statement issued today the organization calls for aggressive efforts to increase uptake of the HPV vaccines to “protect young people from life-threatening cancers.”

“With safe and effective vaccines readily available, no young person today should have to face the devastating diagnosis of a preventable cancer like cervical cancer. But unless we rapidly increase vaccination rates for boys and girls, many of them will,” ASCO President Julie M. Vose, MD, said in a statement.

“As oncologists, we see the terrible effects of these cancers first hand, and we have to contribute to improving today’s alarmingly low vaccination rates,” she added.

The new policy statement is published online April 11 in the Journal of Clinical Oncology.

The statement notes that HPV vaccination has been previously recommended by many US medical societies, including the American Cancer Society, the American College of Obstetrics and Gynecology Committee, the American Dental Association, the American Head and Neck Society, the American Nurses Association, the American Pharmacists Association, the Association of Immunization Managers, the Society for Adolescent Medicine, and the Society of Gynecologic Oncology.

In addition, a joint letter was sent out to all physicians urging them to give a strong recommendation from the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, the Centers for Disease Control and Prevention, and the Immunization Action Coalition.

Now oncologists are specifically being asked by their professional body, ASCO, to join in with the push toward greater uptake of the HPV vaccines.

“ASCO believes oncologists can play a vital role in increasing the uptake of HPV vaccines,” the new policy statement says. “Although most oncologists will not be direct providers of these preventive measures, this does not abrogate us from contributing to this process. Our unassailable role in the mission to lessen the burden of cancer…places us in a position of influence. We should use interactions with our patients, primary care colleagues, and health care systems to raise awareness of HPV-related cancers and the role of vaccination in preventing them.”

Oncology providers have a responsibility to serve as community educators.

“Oncology providers have a responsibility to serve as community educators, disseminating evidence-based information to combat misconceptions concerning the safety and effectiveness of the HPV vaccine,” it continues.

“ASCO encourages oncologists to advocate for and actively promote policy change to increase vaccination uptake,” the statement concludes.

Issues With the Statement

However, there are a few issues with the statement, says a prominent researcher in the field of HPV and cervical cancer, Diane Harper MD, professor and chair of the department of Family and Geriatric Medicine, University of Louisville, Kentucky. Dr Harper, who was approached for comment, was involved in early clinical trials with both HPV vaccines (Gardasil, Merck & Co, and Cervarix, GlaxoSmithKline), and has emphasized the need for ongoing screening with Pap tests to prevent cervical cancer.

This is also one of the issues she raises about the ASCO statement, which does not mention screening. “All messages about HPV vaccination must be couched in terms of continued lifetime screening for cervical cancer,” Dr Harper told Medscape Medical News.

The ASCO statement highlights the potential that HPV vaccination has for preventing cancer. (Both vaccines protect against HPV types 16 and 18, and Gardasil offers additional protection against several other types). The statement notes that HPV is the cause of nearly all cervical cancer cases and that HPV genotypes 16 and 18 are responsible for 70% of cervical cancers. In the United States, HPV is responsible for 60% of oropharyngeal cancers, 90% of which are caused by HPV 16. HPV is also the cause of 91% of anal cancers, 75% of vaginal cancers, 69% of vulvar cancers, and 63% of penile cancers, again with HPV 16 as the predominant oncogenic genotype.

However, the statement also notes that “because of the long latency and the prolonged preinvasive phase after infection with HPV, many years of follow-up are needed for the ongoing trials to demonstrate a significant reduction in HPV-related cancers.”

Therefore, intermediate outcomes are being used as surrogate endpoints, it continues. HPV vaccines have been shown to prevent new cancer-causing HPV genotype-specific infections and resultant diseases, such as grades 2 and 3 cervical intraepithelial neoplasias (CIN), vaginal, vulvar, and anal intraepithelial neoplasias (as precursor lesions to cancer).

There is “almost certainty that cancers caused by oncogenic HPV genotypes will be dramatically reduced,” according to the statement.

Dr Harper told Medscape Medical News that the studies conducted to date have shown that “Cervarix has a 93% efficacy against CIN 3 regardless of HPV type; Gardasil has a 47% efficacy against CIN 3 regardless of HPV type, and Gardasil 9 is equivalent to Gardasil in the prevention of CIN 3 disease regardless of HPV type. None of these vaccines can prevent all CIN 3 or potentially all cancers.”

“Hence, the most important take home point is that screening is absolutely necessary as a prevention tool for preventing cancer by early detection of disease that when found, is curable,” Dr Harper emphasized.

Also, Dr Harper noted that the studies ended at prevention of CIN 2/3 disease as a clinical outcome. CIN 3 on average progresses to cancer in 20% of women within 5 years, and to 40% of women in 30 years. But, she points out, “there are no long-term follow-up studies that show that cancers will be averted.”

“The modeling exercises indicate that we have to wait at least 40 years before we will have a detectable decrease in cervical cancers from vaccination, assuming that at least 70% of the population being surveyed is vaccinated,” she added.

In its statement, ASCO cites the success of widespread vaccination against hepatitis B virus in reducing the incidence of liver cirrhosis and liver cancer as “an exemplary health model that supports more widespread HPV vaccination.”

But Dr Harper argues that “the prevention of liver cancer was an unexpected highlight of HBV vaccination. The primary purpose was to relieve the symptoms of chronic HBV sufferers. The continual re-infection with HBV seems to allow a natural infection to act as a booster in this population, which may not be the same for HPV.”

There also remains a question of how long the protection offered by HPV vaccination will last.

The ASCO statement says, “Both vaccines have a known duration of protection of at least 5 years, with ongoing study of the full duration of their effect,” and it notes that “additional research is needed to evaluate duration of protection to determine if booster doses are required.”

Dr Harper said, “Estimates of long-term effectiveness are based on antibody titers, yet there is no surrogate of protection defined by antibody titers.”

She added: “I agree that observational studies will inform the public health authorities about when a booster will be needed and whether it is needed sooner if only 2 doses are received vs later if 3 doses​ are received.”

Last, but not least, there is the issue of safety.

The ASCO statement notes that both Gardasil and Cervarix “reported excellent short- and long-term safety results in clinical trials. The most common adverse effects were mild and included injection site pain (approximately nine in 10 people) and swelling (approximately one in three), fever (approximately one in eight), headache, and fatigue (approximately one in two). These symptoms were transient and resolved spontaneously. The incidence of serious adverse effects was low and was similar to those who received placebo (aluminum-containing placebo or hepatitis A vaccine).”

However, worldwide there continue to be reports of adolescents who report chronic side effects and pain syndromes after being vaccinated against HPV. Some of these have been documented in the medical literature, with physicians reporting instances of previously healthy athletic girls becoming incapacitated with pain, fatigue, and autonomic dysfunction, and some remaining permanently disabled.

The US Food and Drug Administration and the Centers for Disease Control and Prevention have repeatedly said that HPV vaccines have an excellent safety record and that no causal associations have been found with atypical or unusual pain syndromes or autonomic dysfunction. The European authorities have investigated two chronic syndromes reported with HPV vaccination, and have said that there is no evidence to show causation.

However, Danish researchers who were among the first to report these syndromes criticized the investigation and are conducting their own study. There have also been lawsuits filed in several countries, and a class action lawsuit is now planned in Japan against the government and the vaccine manufacturers.

In an interview with Medscape Medical News, lead author on the ASCO statement, Howard H. Bailey, MD, from the University of Wisconsin Carbone Cancer Center, Madison, said that the concerns over safety should not be dismissed and should be studied further.

These issues need to be studied further, even if the authorities say that the vaccines are safe, he emphasized. These reports of girls becoming very ill, having pain syndrome and weakness, should not be diminished, he said, adding: “We can’t just ignore these reports…if there is risk involved, then that needs to be sorted out better.”

However, there is always a possibility that the syndromes and side effects that have been reported “have nothing to do with the vaccine,” Dr Bailey commented, citing the case of now-discredited theory linking autism to the pediatric vaccine for measles, mumps, and rubella.

There may be other explanations for the symptoms that are reported, or it could be that the symptoms/syndrome would have developed in the individual, anyway, but the vaccination precipitated it sooner, he suggested.

Dr Bailey noted that across the United States physicians are very sensitive to the fact that rates of pediatric vaccination have gone down because of the link that had been made to autism, subsequently shown to be false. Even though science eventually showed no link between the vaccine and autism, public confidence in the vaccine was damaged.

“When a person’s life has been devastated by an illness, that is very important, but if it turns out that the illness is not related to the vaccine, and in the meantime, the concerns over safety have stopped thousands of young people from being vaccinated….”well, eventually this will mean that there are more people who die from cancer, he said.

“I would be very reluctant right now to shut down the goals of vaccination over what has been reported, because the bottom line is that we have a tremendous problem with the rising incidence of HPV related cancers including in men as well as women when it comes to oropharyngeal cancers here in the States,” he added.

“The data, at least in my opinion, are so strong that HPV vaccination if it’s done in a [systematic] way will reduce the incidence of these cancers…I don’t want to stop whatever progress we are making when there is at best disagreement over whether these things are associated,” he said, although he also added that “maybe if it was my daughter, I would feel differently.”

Dr Bailey also addressed some of the other issues that had been raised about the ASCO statement, and said he agreed about the importance of screening.

“Even if vaccination does all the things we expect it to do, there is no doubt that cervical cancer screening needs to continue, and that’s a pretty standard recommendation across all of the groups,” he said. “We do not mean to diminish the importance of continued screening,” he said, but he added that screening lies in the domain of other physicians, such as primary care and gynecology, whereas this statement was targeted specifically at oncologists. “To take a step back, we are taking the view of cancer physicians, who take care of women, who are unfortunately too often dying of cervical cancer, and…we wanted to remind people that HPV vaccination can prevent this…as well as other associated cancers,” he said.

“The audience in North America has not been paying attention to this vaccination issue very much,” he continued, and “we wanted to remind oncologists and the public that at the heart of the issue is cancer prevention.

“We have this relatively easy way of preventing cancers over and above the ways that we already use,” he added.

“We wanted to remind people, especially in the oncology community, that there is this intervention out there that we think is highly, highly likely — if applied and used in a population format — will significantly reduce the number of women dying of cervical cancer, the number of men and women dying from oropharyngeal cancer, which is increasing in the US…and that was the main focus of the article,” Dr Bailey commented.

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

April, 2016|Oral Cancer News|

Study: HPV vaccine reduces HPV incidence in teenage girls

Source: www.upi.com
Author: Stephen Feller
Study-HPV-vaccine-reduces-HPV-incidence-in-teenage-girlsJust over half of girls have received the HPV vaccination, but a new CDC study shows it has significantly reduced prevalence of the cancer-causing STI among females who have received the vaccine when compared with those who have not. Photo by Adam Gregor/Shutterstock


WASHINGTON, Feb. 22 (UPI) — The prevalence of human papillomavirus infection among teenage and young adult women is down nearly two-thirds since the U.S. Centers for Disease Control and Prevention started recommending vaccine in 2006, according to a new study.

The study is the first to show a drop in prevalence among women in their 20s, and continues to show decreases seen in smaller studies during the last few years, but researchers say the effect could be much stronger.

The vaccine is recommended by the CDC and other organizations for girls and boys starting at age 11, experts say, in order to protect children from HPV before they become sexually active and can become infected.

Concerns that the vaccine would influence teens’ sexual practices have also been unfounded, as research has shown the vaccine does not make children more likely to engage in risky sexual behavior, based on a the lack of an increase in other STI incidence among vaccinated girls.

“It’s just like putting on your seatbelt before turning on the car,” Dr. Alix Casler, medical director of pediatrics for Orlando Health, told UPI. She suggests separating the adolescents’ eventual discovery of sex from the effort to prevent life-threatening diseases.

Recommendations for the HPV vaccine — Cervarix, Gardasil and Gardasil 9 — have been expanded to boys, because of the wide range of cancers for which HPV increases risk, including cervical, anal, head and neck cancer, though a 2015 study showed vaccination rates remain relatively low, with just 57 percent of eligible girls and 35 percent of boys vaccinated.

“We are continuing to see decreases in the HPV types that are targeted by the vaccine,” Dr. Lauri Markowitz, a medical epidemiologist at the CDC, told CBS News. “We have seen declines in genital warts [caused by HPV] already. The next thing we expect to see is a decline in pre-cancers, then later on declines in cancer.”

For the study, published in the journal Pediatrics, used survey information collected as part of the National Health and Nutrition Examination Survey between 2003 and 2006 and between 2009 and 2012 on females between the ages of 14 and 34.

The researchers compared prevalence of HPV between the pre-vaccine group before 2006 and post-vaccine group after the vaccine was introduced, finding HPV prevalence declined by 64 percent, from 11.5 percent to 4.3 percent, in girls between age 14 and 19, and by 34 percent, from 18.5 percent to 12.1 percent, among women age 20 to 24.

Among women aged 14 to 24, the prevalence of HPV among vaccinated women, at 2.1 percent, was also significantly lower than the 16.9 percent of unvaccinated women with the STI.

The research is based on the 4vHPV vaccine, which protects against the four most common forms, though the 9vHPV vaccine was approved by the FDA for use to prevent more forms of HPV.

Casler said data in the next several years is likely to show continuing decreases in HPV prevalence as more adolescents receive the vaccine, however some pediatricians are hesitant because of personal bias. Many parents also are nervous the vaccine will act as a message to teens that sex is OK, making some parents want to delay vaccination until their adolescents are sexually active — by which time it may be too late.

“The infection is sexually transmitted, but that doesn’t need to be part of the conversation,” Dr. Joseph A. Bocchini, a pediatric infectious disease specialist at Louisiana State University, told the New York Times. “If a parent is concerned, physicians should be prepared to talk about it. But we don’t really discuss how people become infected with every vaccine-preventable disease.”

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

February, 2016|Oral Cancer News|

Cancer Centers urge increase in HPV vaccinations

Source: www.wsj.com
Author: Ron Winslow

The top cancer centers in the U.S. jointly called for an increase in vaccination against the human papilloma virus, or HPV, saying low uptake of the three-shot regimens amounts to a “public health threat” and a major missed opportunity to prevent a variety of potentially lethal malignancies.

In a statement issued Wednesday, all 69 of the nation’s National Cancer Institute-designated centers urged parents and health-care providers to “protect the health of our children” by taking steps to have all boys and girls complete the three-dose vaccination by their 13th birthdays, as recommended by federal guidelines, or as soon as possible in children between 13 and 17 years old.

Currently, just 40% of girls and 21% of boys in the U.S. have received the vaccine, according to a report last year by the U.S. Centers for Disease Control and Prevention. The U.S. Department of Health and Human Services Healthy People 2020 initiative has set the goal for HPV vaccination for both boys and girls at 80%.

The first HPV vaccine, Merck & Co.’s Gardasil, was approved by the U.S. Food and Drug Administration in 2006. A second version of Gardasil and GlaxoSmithKline PLC’s Cervarix are now on the market. Neither company was involved in development of the cancer centers’ statement, those involved in the effort said.

The CDC estimates that 79 million Americans are infected with HPV, a sexually transmitted virus that causes 14 million new infections each year. While the body’s immune system fights off the virus in most cases, certain high-risk strains are responsible for cancers of the cervix, anus, and various genital sites as well as a growing rate of oropharyngeal or throat cancers, all told affecting about 27,000 patients a year in the U.S.

“We have everything we need to eliminate at least cervix cancer and many other HPV-related cancers and we haven’t taken advantage in this country,” said Lois Ramondetta, professor of gynecologic oncology at University of Texas MD Anderson Cancer Center, Houston. She said she is already seeing patients in their 20s and 30s who have developed precursors to cancer that she says could have been prevented had they been vaccinated.

The U.S. rates stand in contrast to those in some other countries, including Australia, where 75% of boys and girls are fully vaccinated; the U.K., with a rate between 84% and 92%;, and Rwanda, where 93% of children are in compliance with World Health Organization recommendations for HPV shots.

When the first vaccine hit the market a decade ago, it was targeted at girls in hopes of preventing cervix cancer. But the rising incidence of HPV-related head and neck cancers, especially among men, in recent years, led to including boys in the prevention effort as well.

Factors responsible for the low U.S. rates include resistance among antivaccination groups, a “misunderstanding” that vaccination might promote sexual activity and a reluctance of pediatricians to discuss prevention of a sexually transmitted virus for children, said Sarah Krobin, acting chief of health systems and interventions research at the NCI. Research shows no link between the vaccine and sexual activity, she said. Early administration is required because “for the vaccine to work, the child shouldn’t have yet had sex,” she said.

The three-dose vaccine can cost around $500, including doctor fees, according to the American Cancer Society, though it is often covered by insurance. It is available free to beneficiaries of the Medicaid program, a key reason why children in low-income families are more likely to have been fully vaccinated than those from wealthier families, Dr. Krobin said.

The statement emerged from a meeting of HPV experts from many of the cancer centers at MD Anderson in November, which in turn resulted from a special NCI initiative among 18 designated centers to study factors affecting HPV vaccination rates in their local markets. NCI designation recognizes centers for excellence in cancer research and care. The NCI wasn’t involved in drafting the document.

The statement urges physicians and other providers “to be advocates for cancer prevention by strongly recommending the vaccine for children. It encourages men up to age 21 and women up to 26 to get vaccinated if they missed the younger age targets.

“This is really a sentinel event to have all the centers get together and say we’re really not doing the best for our kids,” said Dr. Ramondetta, who is also co-director of MD Anderson’s HPV-related Moon Shot initiative. “We feel this is an effective, safe and long-lasting vaccine that we’re not taking advantage of.”

January, 2016|Oral Cancer News|

Single Dose of HPV-16/18 Vaccine Looks to Be Sufficient

Source: www.medscape.com
Author: Jenni Laidman

A single dose of a vaccine against human papillomavirus (HPV) may prevent cervical cancer as effectively as the standard three-dose regimen, researchers concluded after analyzing the combined results of two large vaccine trials. The HPV vaccine in these studies was Cervarix (GlaxoSmithKline), which is effective against HPV strains 16/18.

If randomized controlled trials ultimately support the result of this post hoc analysis, it could broaden protection against cervical cancer in areas of the world where vaccination programs are hardest to administer and where cervical cancer is disproportionately burdensome, the study authors say.

“Even if you ignore the expense, the feasibility of implementing and getting back to individuals for a second and third dose is quite challenging, especially in places where there is no infrastructure,” coauthor Cosette Wheeler, PhD, Regents Professor, Pathology and Obstetrics and Gynecology, University of New Mexico Health Sciences Center in Albuquerque, told Medscape Medical News.

The studies are published online June 10 in the Lancet Oncology.

The possibility of a single-dose HPV vaccine is “a huge public health win,” coauthor Aimée R. Kreimer, PhD, Investigator, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, Maryland, told Medscape Medical News. “Even if one dose protects only against HPV types included in the vaccine formulation, if we vaccinated most girls, we would have the chance to reduce cervical cancer by around 75%.”

That’s the exciting part, Dr Wheeler added. “If we’re able to achieve success with one dose, or frankly even with two doses, that makes the possibility for worldwide prevention much greater.”

HPV type 16 is the leading cause of cervical cancer, responsible for about 50% of all cases, and HPV 18 is the second-largest cause, at 20%.The authors note that this research was carried out with Cervarix, and it is unclear whether the results would also apply to the other HPV vaccine that is available, Gardasil (Merck & Co.), which is active against several more HPV strains and is the product that is commonly used in the United States. Whether results of this trial have any bearing on Gardasil will depend on what’s driving the strong immune response to Cervarix, the authors suggest. Cervarix carries a proprietary adjuvant, which may be responsible for the immune response.

Surprise Over Efficacy Findings

The idea of the current post hoc analysis arose from results in the large randomized controlled Costa Rica Vaccine Trial, in which about 20% of participants received fewer than three doses of HPV-16/18 vaccine. “We were surprised to observe that efficacy was the same regardless of the number of doses received,” Dr Kreimer told Medscape Medical News.

That led to the post hoc analysis of the immunization results from the Costa Rica Vaccine Trial combined with results from the only other large phase 3, double-blind, randomized trial of HPV-16/18, for a total of more than 14,000 participants, ages 15 to 25 years, including about 7000 control subjects. The second trial, called PATRICIA (Papilloma Trial Against Cancer in Young Adults), took place in 14 countries. The analysis found that 4 years after vaccination, women who received the required three vaccine doses and women who received fewer than three doses — usually due to pregnancy or a colposcopy referral — were equally protected against HPV-16/18. Further, the analysis showed a potential benefit of cross-protection against closely related HPV strains 31/35/45 among women whose two doses were 6 months apart — a benefit previously seen only with three doses.

Four-year vaccine efficacy against HPV-16/18 in the combined analysis was 77% for the 13,296 (6634 case, 6662 control) women in the three-dose group, 76% for the 549 (273 case, 276 control) women in the two-dose group, and 85.7% for the 238 (138 case, 100 control) women in the single-dose group. Efficacy against the closely related HPV-31/33/35 was 59.7% for three doses, 37.7% for two doses, and 36.6% for one dose. When data for the two doses were analyzed according to dosing regimen, the cross-protective efficacy was 10.1% for those who received their second dose 1 month after the first and 68.1% for those who received the second dose at 6 months.

Antibody concentrations for two doses given 6 months apart were very close to concentrations for three doses, the research showed. One-dose vaccination titers at 6 to 48 months were lower than those for two or three doses, “but the titers were stable and several times higher than those identified for natural immunity,” the researchers write. “We can now infer that these lower, vaccine-induced antibody titers provide as strong HPV prevention as the titers from two or three doses, at least in the short term.”

Just how long these vaccines will provide protection still needs to be determined. “We know with three doses we can see the protection going out toward 10 years, and we hope that maybe the protection is lifelong,” commented Dr Wheeler. “That does not mean that we know we will never need a booster. And that doesn’t mean if we give less than three doses that we know about the longevity or durability of that protection. So that’s another piece of the puzzle.”

Although these results cannot be applied to Gardasil, Dr Wheeler notes that studies looking at Gardisil antibody titers after two doses look promising.

In an accompanying comment, Julia M.L. Brotherton, Medical Director, National HPV Vaccination Program Register, VCS Registries, East Melbourne, Victoria, Australia, commented: “These data suggest that one dose of bivalent HPV vaccine might be adequate to protect against HPV-16 and HPV-18 persistent infections and, therefore, probably disease. HPV-16 and HPV-18 cause more than 70% of cervical cancers and the vast majority of HPV-related cancers at other anatomic sites. If this finding is confirmed, it opens up a great opportunity to extend the reach of protection using HPV vaccines to more people than we would have previously thought possible.”

Four authors of the study are GSK employees and own shares and stock options in the company. Other researchers had financial or advisory relationships GSK, Roche Molecular Systems, Merck, and Sanofi Pasteur MSD. Dr Brotherton notes that she has been an investigator for investigator-initiated HPV epidemiology research grants partially funded by bioCSL/Merck, but this did not involve financial compensation.

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

HPV Vaccine Linked to Less-Risky Behavior

Source: torontosun.com
Author: Roxanne Nelson, Reuters

Contrary to concerns that getting vaccinated against human papilloma virus (HPV) will lead young people to have more or riskier sex, a new study in England finds less risky behaviour among young women who got the HPV vaccine.

“To my knowledge no studies have shown that HPV vaccination increases risky sexual behavior among young women and some of these studies have shown this (less risky behaviour) is also the case outside of the UK,” said Dr. Laura Sadler of the University of Manchester, who led the study.

It’s possible that getting vaccinated led to better education about sexual health, Sadler and her colleagues write in the Journal of Family Planning and Reproductive Health Care.

Sadler and other experts say it’s also possible that young women who are already less likely to take risks are the ones who are more likely to get vaccinated.

HPV is one of the most common sexually transmitted infections and causes the majority of cervical cancers. The virus has also been linked to anal and throat cancers. Two vaccines, Cervarix and Gardasil, are now available that protect against strains of HPV that cause most cervical cancers.

Even though public health officials recommend that girls and young women be vaccinated against HPV, some parents have hesitated, fearing that it could encourage sexual activity or unsafe sex.

For their study, Sadler’s team reviewed the medical records of 363 women born in 1990 or later who attended an English clinic. Almost two-thirds of the young women in the group had received at least one dose of the vaccine. Full vaccination requires three vaccine shots.

The researchers compared the womens’ histories of behaviours that are risky in themselves or tend to be linked to risky sexual behaviour, such as not using condoms, having sex for the first time when they were 15 or younger, having six or more sexual partners and drinking alcohol two or more times a week.

They found five variables related to sexual behaviour that were significantly different between women who had been vaccinated and those who hadn’t.

Women who were not vaccinated were more likely to have had three sex partners in the last six months, to have attended the clinic with symptoms of a sexually transmitted disease, to have had anal intercourse with their last sexual contact and to have tested positive for Chlamydia (a common sexually transmitted infection) at their clinic visit.

Being vaccinated, in contrast, was associated with less-risky behaviours, such as using condoms.

“In this study, the lower prevalence of some risk outcomes among vaccinated women relative to unvaccinated women may be related to underlying differences in preventive care seeking and preventive health behaviors,” said Robert A. Bednarczyk, an assistant professor at the Rollins School of Public Health at Emory University, and who was not involved in the study.

“The women in our study were mainly from the catch-up vaccine program – older teens – and as in the other studies, it shows that among this group, vaccination was taken up by those demonstrating other types of preventive or less risky behaviors,” Sadler told Reuters Health by email.

While the findings are encouraging, and consistent with other research demonstrating that HPV vaccination does not lead to riskier behaviors, the study does not demonstrate that vaccination causes less risky behaviors, said Dr. Jessica Kahn, a professor of pediatrics at Cincinnati Children’s Hospital Medical Center.

“One explanation for the findings is that girls who are vaccinated receive education about sexual health and prevention which decreases riskier behaviors,” Kahn said in an email.

Another explanation is that girls who practice healthier and less risky behaviors are more likely to receive the vaccine, she noted. “Preventive health behaviors tend to cluster, so it makes sense that girls who practice safer behaviors are more likely to be vaccinated.”


*This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.
February, 2015|Oral Cancer News|

Federal goal is set to increase the amount of boys and girls vaccinated against HPV by 2020

Source: www. wsj.com (Wall Street Journal.com)
Author: Caitlin McCabe

Public-health officials are pushing for higher HPV vaccination rates amid growing evidence that cancers linked to the virus are afflicting more men.

The National Cancer Institute announced recently it is pouring nearly $2.7 million into 18 U.S. cancer centers to boost HPV vaccinations among boys and girls. The cancer centers will work with local health clinics to set recommendations for vaccinating against the sexually transmitted infection, which in some cases can cause cancers in men and women later in life.

HPV, or human papillomavirus, was considered a women’s-only issue, after researchers discovered a link between it and cervical cancer in the 1980s. 

Now, as cervical-cancer rates are falling and oral-cancer rates in men steadily rise, “the burden of HPV cancer is shifting to men,” said Maura Gillison, a professor in the College of Medicine at Ohio State University Comprehensive Cancer Center.

Vaccination rates remain stifled, despite the availability of two vaccines that experts say provide effective coverage against cancer. 

The Department of Health and Human Services’ goal is to boost HPV-vaccination rates to 80% by 2020—which is far higher than the 38% of girls and 14% of boys who completed the three-dose HPV vaccine last year, according to data from the National Immunization Survey of teenagers.

Pediatricians say boosting those rates can be difficult. Pediatricians may feel uneasy talking to parents of young children about sexually transmitted infections, health experts say, while parents may resist the vaccine because they believe their child isn’t at risk.

“Discussing this vaccination is difficult because there’s an implication of sexual activity,” said Carrie Byington, a practicing pediatrician in Salt Lake City and chairwoman of the Committee on Infectious Diseases for the American Academy of Pediatrics. “It can make some pediatricians uncomfortable with the topic.”

A study conducted in 2011 by the Moffitt Cancer Center in Tampa, Fla., found fewer than 15% of physicians always recommended the vaccine to boys, and no more than 55% always recommended it to girls. Susan Vadaparampil, a professor in the department of oncologic services at Moffitt who helped lead the study, said she thinks recommendation rates have risen today but there’s a long way to go.

To ease difficult conversations, Dr. Vadaparampil said resources on the Centers for Disease Control and Prevention website suggests that pediatricians should emphasize the vaccine is ultimately a protection against cancer and explain why children should receive the shots at such a young age. 

Experts recommend the vaccine at age 11 or 12, but it can be given to girls up to age 26 and boys up to age 21. It is important for children to receive all three doses of the vaccine before they become sexually active.

“There’s science behind giving it at age 11—it’s not just about moral or family choices, or a child’s choice for sexual debut,” said Wendy Sue Swanson, a pediatrician and executive director of digital health at Seattle Children’s Hospital. “The immune response is better if you give it to an 11-year-old.”

Administering the vaccine at a young age doesn’t encourage sexual activity, Dr. Swanson said, citing a concern some parents have. A 2012 study comparing girls who had been vaccinated at ages 11 and 12 to nonvaccinated girls showed the vaccine made no difference in sexual behavior for at least three years after receiving the doses.

Not all cases of HPV are cancerous. Experts estimate nearly 79 million Americans are currently infected with one of the 100 different strains of HPV, which is passed via sex. 

Typically, a body’s immune system fights off HPV naturally within two years of exposure. Complications, such as genital warts or cancer, arise when the virus lingers. 

About 26,800 Americans are diagnosed with HPV-related cancers each year, about two-thirds of whom are women, according to 2010 data, the latest available, from the CDC.

The largest HPV-related threat to men is throat cancer, which has grown sharply in the past decade, Dr. Gillison said. 

Today, more than 90% of all oral cancers are HPV-related, according to trends Dr. Gillison has observed in clinical settings in developed countries. That is up from about 72% between 2000 and 2004 and 16% between 1984 and 1989, she said, referencing a study she conducted that analyzed throat tumors in the U.S.

Most of that growth has been in men: Each year, about 7,200 American men are diagnosed with HPV-related oral cancer, versus 1,800 cases in women, according to 2010 CDC data. 

Dr. Gillison said researchers estimate that around 2020, HPV-related oral cancers in men will eclipse cervical cancer, which afflicts some 12,000 new women each year, according to 2014 data from the American Cancer Society.

It’s unclear why men are more at risk for oral cancer than women, though some researchers suggest a person’s number of sexual partners may be related. The rise is problematic, Dr. Gillison said, because no preventive screening against throat cancer exists. 

“The problem with HPV-positive oral cancer is that premalignant lesions are not clinically detectable. They’re deep within the tonsils that are in the base of the tongue,” Dr. Gillison said. “By the time HPV-infection is detected, they usually already have Stage 3 or 4 cancer.”

That is why doctors and experts are relying so heavily on vaccination as prevention.

Two vaccines—Cervarix, manufactured by GlaxoSmithKline Inc., and Gardasil, manufactured by Merck & Co.—are currently available, though only Gardasil is usually recommended for boys.

Cervarix offers protection against two strains of HPV; Gardasil against four. A third vaccination from Merck currently awaiting approval from the Food and Drug Administration would offer protection against an additional five strains of HPV—nine in total. Doctors expect approval within in the next several months.


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

November, 2014|Oral Cancer News|