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Oropharyngeal Cancer, HPV, and Patient Counseling

last modified on: Thu, 04/04/2019 - 06:03

Oropharyngeal Cancer, HPV, and Patient Counseling

return to: Oropharyngeal Cancer Management

It is estimated that approximately 25-25% of all head and neck squamous cell carcinomas are associated with HPV genomic DNA - with the majority occurring in the oropharynx (Kreimer 2005). The more than doubling of HPV-postive head and neck cancer rates between 1970 and 2007 have been attributed to changing trends in sexual activity and increasing oral sex practices (Nasman 2009). Other modes of infection have even proposed, including kissing, other mouth-to-mouth contact, auto infection, and prenatal contact (Gillison 2008)

An increasing body of literature to address common questions patients have about HPV-related disease is coming forward, but is still rudimentary. Fakhry and D'Souza (2013) affirm that discussions with patients about this topic should include the caveat ‘‘we do not know, however, initial evidence suggests that...’’ Concerns and questions about other HPV-related disease such as Recurrent Respiratory Papillomatosis (RRP) warrants a similar approach (Taliercio 2015)

 Chu et al (2013) have provided an excellent review and guide for counseling patients and their family about HPV (human papillomavirus) positive oropharyngeal cancer (OPC) as a sexually transmitted entity. They report that this disorder is increasing in frequency to the point that the annual number of HPV-related (HPV-16) oropharyngeal cancers is expected to exceed the annual number of cervical cancers in the United States in 10 years.  This review article identifies that there are currently few relevant articles to address concerns within this patient group regarding 'self-blame, intimacy, and interpersonal relationships'.  The broader body of literature addressing HPV-infected women and cervical cancer is reviewed by these investigators to offer counseling suggestions to those with HPV-related oropharyngeal cancer. 

A synopsis of the more detailed discussion offered by Chu et al in response to frequently posed questions about HPV - positive oropharyngeal cancer is listed below:

  1. HPV is a sexually transmitted virus; most sexually active people will get HPV in their lifetimes - "it is impossible to know with certainty from whom or when you acquired HPV because most people do not know they have it."
  2. "Lifetime mutual monogamy or abstinence are the best ways to prevent transmission"
  3. "Experts are still determining what risks, if any, sexual partners of patients with HPVOPC have in developing cancer"
  4. The virus is suppressed by a healthy immune system in most people
  5. There is currently no test for early detection of oropharyngeal cancer that would be similar to the Pap test for cervical cancer
  6. HPV is a common virus that does not imply infidelity or promiscuity
  7. Most infected people with HPV do not develop signs or symptoms

As per Fakhry et al (2013), "It is important to remind patients that being diagnosed with HPV-OSCC does not imply that either partner was/is unfaithful. Based upon CDC recommendations for discussion of presence of an oncogenic cervical HPV infection, ‘‘emphasis should be placed on the fact that HPV is a common infection that is often shared between partners and can lie dormant for many years. [citing Dunne et al 2011]’’ "

An invited commentary by Bock (2016) addressing a large dataset analysis of concordant oral and vaginal HPV infection in the U.S. (Kedarisetty 2016) identified that "Data from this study and others indicate that rates of oral and vaginal HPV infection are increased with a greater number of sexual partners and condom use is known to decrease rates of HPV transmission".  Bock (2016) identifies that "discussion of condom use or other barrier method protection during sexual contact for otolaryngologic patients with known oral or cervical HPV is therefore of paramount importance." He concludes with support 'advocating for HPV vaccine administration in all patients, both male and female."

A January 2019 "Triological Society Best Practice" by Rettig et al (Rettig, Fakhry, Nathan 2019) entitled "To Kiss or Not to Kiss in the Era of the Human Papillomavirus- Associated Head and Neck Cancer 'Epidemic'?" reviewed the literature to conclude that although "open-mouth kissing is associated with oral HPV infection transmission based on limited evidence", "there is not enough evidence at this time to recommend that they [referring to HPV-OPC patients and their partners] change their kissing practice." 

Rettig published another article in 2019 (Rettig, Gooi et al 2019) that identified low rates of oral HPV infection and low rates of oropharyngeal squamous cell carcinoma rates in a section of Africa where there is a high incidence of uterine cervical HPV driven cancer. These investigators oncluded that limited oropharyngeal exposure to HPV may in turn limit the HPV-driven carcinogenesis in lymphoid tissues of the palatine and lingual tonsils. This region of Africa has limited data on oral-sexual behavior but that which is available suggests reatively low rates among those surveyed of ever having had oral sex. 




Kreimer AR, Clifford Gm, Boyle P et al Human papillomavirus types in head and neck sqaumous cell carcinomas worldwide: A systematic review. Cancer Epidemiol Biomarkers Prev 2005;14:467-475

Nasman A, Attner P, Hammarstedt L et al. Incidence human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm, Sweden: An epidemic of viral-induced carcinoma? Int J Cancer 2009;125:362-366

Fakhry C and D'Souza G: Discussing the diagnosis of HPV-OSCC: Common questions and answer. Karl Oncology 49 (2013) 863-871

Taliercio S, Cespedes M, Born H, Ruiz R, Roof S, Amin MR and Branski RC: Adult-onset recurrent respiratory papillomatosis: a review of disease pathogenesis and implications for patient counselling. JAMA Otolaryngol Head Neck Surg 2015 Jan 141(1):78-83

Gillison ML. Human papllomavirus-related disease: oropharynx cancers and potential implications for adolescent HPV vaccination. J Adolesc Health 2008;43:552-560

Chu A, Genden E, Posner M, and Sikora A: A Patient-Centered approach to counselling patients with head and neck cancer undergoing human papillomavirus testing: a clinician's guide. Oncologist. 2013;18(2):180-9 Epub 2013 Jan 23

Dunne EF, Friedman A, Datta SD, Markowitz LE, Workowski KA. Updates on human papillomavirus and genital warts and counseling messages from the 2010 sexually transmitted diseases treatment guidelines. Clin Infect Dis Off Public Infect Dis Soc Am 2011;53(Suppl 3):S143–52.

Sedarisetty S, Orosco RK, Hecht AS, Chang DC,Weissbrod PA, Coffey CS. Concordant oral and vaginal human papillomavirus infection in the Univetred STates. JAMA Otolaryngol Head Neck Surg Volume 142, Number 5 published online March 24,2016
Bock J: Expanding the Human Papillomavirus Clinical Conversation in otolaryngology - Risky Business. JAMA Otolaryngology-Head&Neck Surgery May 2016 Volume 142 N0 5 pp465-466
Graham DM, Isaranuwatchai W, Habbous S, et al A cost-effectiveness analysis of human papillomavirus vaccination of boys for the prevention of oropharyngeal cancer. Cancer 2015;121(11):1785-1792
Rettig EM, Fakhry C, and Nathan C-A O: To Kiss or Not to Kiss in the Era of the Human Papillomavirus- Associated Head and Neck Cancer "Epidemic"?   Laryngoscope 129:January 2019 pp 4-5
Rettig, E. M., Gooi, Z., Bardin, R., Bogale, M., Rooper, L., Acha, E., & Koch, W. M. (2019). Oral Human Papillomavirus Infection and Head and Neck Squamous Cell Carcinoma in Rural Northwest Cameroon. OTO Open. https://doi.org/10.1177/2473974X18818415