Human papillomavirus (
HPV)-asso-ciated cancers of the oropharynx are a
growing problem in the United States.
The incidence of these cancers is four
times higher among men than women
and tripled between 1988 and 2004.
The President’s Cancer Panel, citing
work published in the Journal of Clinical Oncology, emphasized that the number of new oropharyngeal cancer cases
caused by HPV likely will exceed the
number of cervical cancer cases by 2020.
HPV vaccine has the potential to reduce the morbidity and mortality from
oropharyngeal cancers. The Academy is
among organizations participating in
the American Cancer Society National
HPV Vaccine Roundtable, a network
that is promoting cancer prevention
through HPV vaccination.
Following is a
Q&A with roundtable participant
Terry A. Day, M.D.,
immediate past president of the American Head and Neck
Society, the Wendy
& Keith Wellin Endowed Chair in Head and Neck Surgery, and director of the Head and Neck
Tumor Center in Medical University
of South Carolina’s Hollings Cancer
Why would a head and
neck oncology surgeon get
involved in this effort?
Unfortunately, this constitutes the
majority of patients I see in my practice.
I see patients with oropharyngeal cancer
in almost every clinic. I see firsthand the
shock on their face when they hear the
diagnosis and hear about the need for
The HPV issue? It’s really common
sense: The majority of oropharyngeal
cancers are caused by HPV, and we
have a vaccine approved to prevent
HPV infection. HPV vaccine may have
the highest potential to reduce the morbidity and mortality from a cancer with
rapidly rising incidence in our country
in people who are younger and don’t
smoke. HPV vaccination is definitely
the best tool we have for prevention.
We want to work side by side with the
AAP and other organizations in the
roundtable to increase the number of
young people receiving HPV vaccine.
Prevention is urgent!
What is meant by oropharyngeal cancer?
In many textbooks, peer-re-viewed publications and media, people
have used the terms “oral” and “
oropharyngeal” cancer synonymously. We
now know that oropharyngeal cancers
are distinct from oral cavity or “mouth”
The oropharynx consists of the soft
palate, the posterior third (or base) of
the tongue, tonsils, palatoglossus folds,
valleculae and posterior pharyngeal
wall. The border separating the “mouth”
from the oropharynx is, from above, the
junction of the hard and soft palate, and
from below, the circumvallate papilla —
the really big taste buds toward the back
of the tongue.
How are oropharyngeal
and oral cancers different?
The incidence of oropharyngeal cancers is increasing, but that’s
not true for oral cancers. The risk factors
for the two sites are different, too. In
comparison with patients with oral cancers, oropharyngeal cancer patients are
more likely to be non-smokers, Europe-an-American, in a higher socioeconomic
group and younger.
In addition, oropharyngeal cancer
peaks at age 40-59 years, whereas oral
cancer has a small peak in ages 20-29
and higher peak after age 60 years. Importantly, oropharyngeal cancers are
more likely to be HPV-associated.
Is a large proportion of oropharyngeal cancer HPV-positive?
Yes. Studies have shown that
60%-80% of oropharyngeal cancers are
HPV-positive, but there is no test for the
general population to get oropharyngeal
screening for HPV as there is for women
to get cervical cancer screening. Fortunately, the most common HPV types associated with oropharyngeal cancer are
HPV- 16 and HPV- 18, both of which
are covered by all U.S.-licensed HPV
Among the oropharyngeal
cancers, how are HPV-negative and HPV-positive cancers different?
The table at right summarizes the
differences between HPV-positive and
HPV-negative oropharyngeal cancers.
How would a person discover he/she has oropharyngeal cancer?
Typically, patients with oropharyngeal cancer present with a sore
throat or neck mass. In a recent study,
most HPV-positive patients presented
with symptoms related to a neck mass,
such as a swelling they noticed while
shaving, rather than a symptom related
to the cancer’s originating site like sore
throat, swelling or earache. Occasionally, they present with a neck mass that
appears cystic, confusing the radiologist
and clinician into thinking this is an unimportant benign cyst, but eventually it
can be found to harbor squamous cell
It is recommended that any adult with
a sore throat or neck mass that does not
resolve within two weeks be referred to
a specialist such as an otolaryngologist-
head and neck surgeon (www.entnet.
org) or specialist in head and neck
org). Also, Americans can get a free
oropharyngeal cancer exam at hundreds
of sites nationally during Oral, Head
and Neck Cancer Awareness Week in
April ( www.OHANCAW.com).
How is a patient treated for
Patients often benefit from
multidisciplinary care that
may include specialists in head and neck
surgery, radiation oncology, medical
oncology, dental oncology and speech
pathology among others.
Treatment depends on the stage of
the cancer. For early stage oropharyngeal cancers, either radiation alone or
surgery alone is indicated, while advanced staged oropharyngeal cancers
require combinations of either surgery
followed by radiation or concomitant
chemotherapy and radiation therapy
( www.nccn.org). Families may be faced
with difficult decisions because one cannot predict the functional and curative
outcome prior to treatment. The good
news is that we’ve made real strides, and
cure rates have been rising in the past
Dr. Humiston is a
participant ˜in the
American Cancer Society
National HPV Vaccine
President’s panel warns of rising incidence
of HPV-associated oropharyngeal cancers
“Oral vs. Oropharyngeal Cancer:
Compare and Contrast,” by Benjamin
Murphy and Terry A. Day, M.D.,
September 2014, http://conta.
Most common risk factors Tobacco, alcohol HPV
Most common site Tonsil, soft palate Base of tongue, tonsil
Age Older Younger
Education level Lower Higher
African-American Common Rare
Tobacco use High Low
Survival Poor Good
Joseph D. Tobias, M.D., FAAP, chair of the AAP Section on Anesthesiology and Pain
Medicine, and Constance S. Houck, M.D., FAAP, past chair, were among nearly a
thousand attendees celebrating the section’s 50th anniversary, held during its
annual joint meeting with the Society for Pediatric Anesthesia on March 14 in
Phoenix. Posters honored the section’s previous leaders as well as the section’s
Anesthesiology/pain medicine section marks 50th anniversary