What is Human Papillomavirus (HPV)?
Human Papillomavirus or HPV is a small sized DNA virus that infects skin and wet surfaces of the body like the mouth, vagina, cervix and anus. There are more than 100 different types of HPV. The most common types are found on the skin and appear as warts seen on the hand. Some HPV types also infect the genital areas of males and females. According to the Centers for Disease Control & Prevention (CDC), genital HPV is the most common sexually transmitted infection in the US and worldwide. There are at least 40 HPV types that can affect the genital areas. Some of these are “low-risk” and cause genital warts while “high-risk” types can cause cervical or other types of genital cancer. The high-risk HPV types may also cause a form of throat cancer, called oropharyngeal cancer, which is becoming more common in the US and Europe.

How prevalent is HPV-positive throat cancer?
Over the past decade there has been at least a four- to five-fold increase in the number of oropharynx cancers in the US. The oropharynx includes the tonsils and the base of the tongue. The increase in these cancers is a result of HPV infection. Almost all of these cancers are caused by HPV16, a subtype of the HPV virus. Research indicates that approximately 70 percent of cases of oropharynx cancer is caused by HPV16. These cancers have the HPV16 virus detectable in the tumor. The number of HPV positive cancers of the tonsil and base of tongue (oropharyngeal cancer) is rising quickly. Several studies evaluating the prevalence of active oral HPV infection have found that three to five percent of adolescents and five to 10 percent of adults have an active HPV infection. More than 3% of adult men and 1% of adult woman have HPV16 detectable in their saliva at any one time. In contrast to active infection, estimates are that 90 percent of adults have been exposed to HPV16 and 70% have evidence of infection as demonstrated by the presence of HPV16 antibodies in their blood.

Why is HPV-positive throat cancer becoming more prevalent?
The epidemiology of oral HPV infection is not well understood. However, HPV viruses have long been known to be present in the genital area and to be a significant cause of cervical, vulvar, penile, and anogenital cancer. It is believed that an increased number of people are engaging in sexual activity with multiple partners and engage in oral sex practices and as a result are contracting HPV in the head and neck region, resulting in a higher rate of oropharynx cancers.

Who is at risk for HPV infection and throat cancer?
HPV is a sexually transmitted infection. The number of lifetime sexual partners is an important risk factor for the development of HPV-positive throat cancer. Research has shown that:

The odds of HPV-positive throat cancer doubled in individuals who reported between one and five lifetime oral sexual partner

The risk increased five-fold in those patients with six or more oral sexual partners compared with those who have not had oral sex

It is important to know that HPV-positive throat cancer also occurs in individuals who report few sexual partners and that this is the largest group that get HPV+ oropharynx cancer. We are not sure what is leads to the development of cancer and whether there are other factors. Almost everyone is infected with HPV16 at some point in their lives so the relationship between HPV16 infection, sexual activity, and getting cancer is more comoplex then simple exposure. We do not know what those additional risk factors are yet. . What we do now is that getting HPV+ oropharynx cancer does not indicate a history of increased sexual activity or multiple partners, Rather, sexual activity with multiple partners increases risk.

What are the symptoms of HPV-positive throat cancer?
Symptoms include hoarseness, pain or difficulty swallowing, pain while chewing, a lump in the neck, a feeling of apersistent lump in the throat, change in voice, or non-healing sores on the neck. If you have any of these symptoms, speak with your doctor or visit the Ear, Nose, and Throat/Head and Neck Surgery Service Area to schedule an appointment.

If HPV is a sexually transmitted infection, are there other ways to contract the virus?

Researchers are still evaluating the various ways HPV can be transmitted. There have been reports of HPV transmission through what is referred to as “deep french kissing.” It may also be possible for the virus to be transmitted to an infant through the infected mother’s cervical canal. Virus could also be transmitted by hand to mouth contact in the context of sexual activity.

Should I get vaccinated?
All cases of cervical cancer are derived from HPV. Two vaccines, Gardasil and Cervarix, have been developed to protect against high risk HPV infection. The vaccine is administered in three doses over a six-month period. Currently, the vaccine is approved for males and females ages nine-26. There is no evidence that vaccinating adults, most of whom have had infection, will be protected from the development of cancer. This vaccine prevents infection, it does not treat adults who are already infected.

How are HPV-positive cancers treated?
HPV-positive throat cancer has been demonstrated to respond very well to almost all forms of therapy, including surgery, external beam radiotherapy, and chemotherapy. New technologies have been developed that greatly improve treatment, survival and side effects. For early cancers, the use of robotic surgery followed by a course of radiation treatment has had positive outcomes. At Mount Sinai, the use of robotic surgery and radiation, with no chemotherapy required, resulted in three-year survival rates of 90 percent, and significantly improve patient quality of life. In more advanced cases combinations of chemotherapy and radiation have lead to more than 80% cure rates. Mount Sinai is currently testing ways to reduce radiation therapy to patients with this diagnosis to improve side effects.

How does the robotic procedure work? What are the benefits?
Mount Sinai is one of very few centers in the country that use a robot to safely remove tumors, especially those growing in challenging locations. Robotic surgery is far less invasive than non-robotic tumor surgeries, greatly minimizing complications and recovery time—and maximizing quality of life after surgery. Quality of life data and the data produced by others demonstrates that patients treated with transoral robotic surgery and deescalated adjuvant therapy have a significantly improved quality of life, oral function, diet, and less long-term toxicity. As a result, Mount Sinai is dedicated to treating patients with HPV-positive throat cancer using this protocol in an effort to improve survival outcomes and decrease short-term and long-term toxicity. Studies to determine if early stage patients can avoid radiotherapy after surgery are being developed.

What is the long-term prognosis for people with HPV-positive throat cancer?
While the prevalence of throat cancer derived from HPV is steadily increasing, data suggest that it is easily treated. Patients with HPV-positive throat cancer have a disease-free survival rate of 85-90 percent over five years. This is in contrast to the traditional patient population of excessive smokers and drinkers with advanced disease who have a five- year survival rate of approximately 25- 40 percent.

My significant other is genital HPV positive yet has no history of cervical cancer, can I get throat cancer by kissing her or having oral sex with her?

Transmission occurs through sexual contact and partners have routinely exchanged virus early in their relationship. Hence it is unlikely that changing your sexual behavior with your partner will change your risk of HPV related cancer.

Do men or women get this more frequently?
Cases of this cancer are much more frequent in men. At Mount Sinai the ratio between men with this and women is roughly six or seven to one. The average age of a patient with this is 40-55, a decade younger than the traditional “smoker/drinker” patient with throat cancer.

Why are men at higher risk for this cancer?
The prevalence and manifestation of this virus is much higher in the genitalia of women because of their anatomical make-up. Pap smears have changed the risk of cervical cancer and transmission to the oropharynx in women because of the earlier exposure in the cervix.

Is there a way to determine if I am oral HPV-positive?
Not yet. Scientists are working on a diagnostic test, but there is nothing commercially available. These tests are very difficult, expensive and unreliable. Currently they are only useful for research purposes.

Who should get screened?
People with a history of tobacco or alcohol use, a history of oral lesions or exposure to radiation therapy, and those with symptoms should be screened. Symptoms to be aware of include hoarseness, pain on swallowing, difficulty swallowing, pain on chewing, a sense of a lump in the throat, a change in voice, a lump in the neck, or non-healing sores.

How do I get screened for HPV- positive throat cancer?
Getting screened is quick and painless. After a physical examination of the mouth, Doctors place a very thin, flexible telescope, the size of a piece of spaghetti, with a miniature camera on its tip, into the nose to examine the back of the throat and base of tongue, the larynx and the vocal cords.

Where did I get HPV from?
It is difficult without specific DNA viral typing to determine who transmitted the virus or where the virus was acquired.

Can the vaccine be used as treatment if I already have HPV-positive throat cancer?
No. Patients with known HPV-positive throat cancer do not appear to benefit from vaccination as the vaccination is used for prevention, not treatment.

What new research is ongoing to better understand and prevent HPV-positive throat cancer?
The Mount Sinai Health System is studying the immune response to the virus and transmission through the HOTSPOT study and the Immune Monitoring Study. We are developing a screening test and vaccine strategies to test HPV vaccines. We are opening two trials, the Quarterback Trial (for patients with advanced oropharynx cancer, to study how to reduce radiotherapy for patients) and the SIRS trials (to investigate whether radiotherapy is necessary after surgery for early oropharynx cancers).

Where should I go if I want to learn more about HPV-positive throat cancer?
If you would like to learn more or think you or a loved one may be at risk, visit the Ear, Nose, and Throat/Head and Neck Surgery Service Area.