Bill Klaproth: This is OMS Voices, an AAOMS Podcast. I’m Bill Klaproth, and with me is Dr. Eric Carlson, who is here to discuss oral cancer and the HPV vaccine. Dr. Carlson, thank you for being here.  

Dr. Eric Carlson: Well thank you, Bill. It’s great to be here to talk to you about this very exciting topic in medicine, one that we’re hearing just an awful lot about. 

Bill Klaproth: Absolutely. I’m glad that we’re discussing this for sure. So, first off, let’s set the basis. What is HPV? 

Dr. Eric Carlson: Sure. Well, HPV is human papillomavirus, and it is currently in the United States the most common sexually transmitted infection. It’s estimated that about 43 million Americans in 2018 had HPV. And interestingly, during that time frame, there were about 13 million new infections on an annual basis. This infection, HPV, causes all sorts of different diseases, things such as common warts of the skin. It’s also responsible for genital warts. And most importantly, it’s responsible for quite a few cancers that are present in humans, which we’ll talk about I’m sure here in a moment. 

Bill Klaproth: Can many of us, some of us have this and not even know it? 

Dr. Eric Carlson: Yeah, in fact, most people do have asymptomatic infections. So, it doesn’t cause fever or chills. People don’t get sick from it, they just have it and most commonly don’t know it. And the big concern, of course, is they’re the people who can transmit this infection to others. 

Bill Klaproth: Wow. OK, well, you say it’s the most common sexually transmitted virus? So how many people are infected with HPV? 

Dr. Eric Carlson: Yes, so about 43 million in the United States. And about 13 million new infections on an annual basis. And most of those are in teens and young adults. So let’s put those numbers into perspective for just a moment. When we talk about sexually transmitted infections, not uncommonly, we’re also talking about herpes and HIV, for example, in that conversation. By comparison, here’s the interesting thing, Bill. In 2018, the Centers for Disease Control in Atlanta indicated that about 572,000 new cases of genital herpes were present in the United States. In 2021, there were about 36,000 people during that year who received an HIV diagnosis. So, we can see by comparison that those 13 million new cases annually of HPV, it’s staggering. And it’s something we really need to talk about. 

Bill Klaproth: Almost an epidemic? Sort of? 

Dr. Eric Carlson: I’m not sure we would call it an epidemic, but it’s a public health issue of tremendous magnitude. 

Bill Klaproth: Well, the thing is we have vaccines that can combat that, is it just that our young people aren’t getting it, is that the problem? 

Dr. Eric Carlson: An insufficient number of young people are receiving this vaccine, and so the conversation needs to continue in pediatricians’ offices and the like. 

Bill Klaproth: Absolutely. And you said this causes things that are, you know, it could be genital warts or other types of warts, something that’s not really deadly, but then it can cause cancers, right? 

Dr. Eric Carlson: It sure can.

Bill Klaproth: So, what are the cancers that it causes again? 

Dr. Eric Carlson: Yeah, so cervical cancer is the cancer that was primarily responsible for the development of the vaccines back in 2006, Gardasil, that was marketed and approved by the FDA. Interestingly, Bill, in 2015, oropharyngeal cancer, so throat cancer, the back of the tongue, the back of the throat, etc., became the most common HPV-associated cancer in the United States. It actually overtook cervical cancer, which is why the vaccine was originally developed. 

Bill Klaproth: So, oropharyngeal cancer, what is the percentage at this point? 

Dr. Eric Carlson: Just, by comparison, about 90 percent of cervical cancers are associated with HPV. About 70 percent of oropharyngeal or throat cancers are associated with HPV. So, the numbers on that that we’re aware of is that there are about 12,000 cervical cancers associated with HPV each year. And there are about 20,000 oropharyngeal cancers associated with HPV each year. So, what this represents really is an opportunity to change indications and the marketing for HPV vaccination to not only cervical cancer but also to include oropharyngeal cancer. 

Bill Klaproth: Is this transmitted via sex or oral sex? Just, I mean, if parents are listening to the podcast, they need to know how is this transmitted? 

Dr. Eric Carlson: Yeah, it’s a great question, and this is a sensitive issue, and this is why parents don’t always want to talk about it with pediatricians. So here are the facts. It is a sexually transmitted infection and it’s commonly transmitted through traditional sexual practices, but oral sexual practices as well, which is why those of us who are in the cancer surgery arena, in the head and neck, are seeing more and more of these cases in men with these cancers in the tongue and in the throat. 

Bill Klaproth: Right, okay. So that’s kind of why I asked. Okay, so that’s really important to know. That’s a really, really good thing that you said that, so we can build awareness for this. So, for a parent listening to this, or a young person, is there something that we can do to help prevent our children or loved ones from contracting HPV? 

Dr. Eric Carlson: Well, certainly vaccination strategies are paramount, but there are other things that young people can do, and that is to practice safe sex, for example. So, in addition to vaccination protocols, certainly limiting the number of sexual partners is important. There’s very good data that shows that a larger number of traditional sexual partners and oral sexual partners places people at risk for the development of HPV-related cancers of the head and neck. The other things that are self-evident, of course, are the use of condoms, for example, but they’re not entirely protective. And so, we come to rely on vaccination. And in terms of HPV vaccination, these are conversations that should really begin with parents when their children are about the age of nine. 

Bill Klaproth: Nine? 

Dr. Eric Carlson: Nine. And as you can imagine, these are sensitive and difficult conversations. Because parents will understand that this is a sexually transmitted infection, and they’ll be reticent to undergo vaccination for their children because they’ll say, well, my child is nine. They’re not having sex at this time. 

Bill Klaproth: So you’re saying the recommendation is nine years of age for the first HPV vaccination. 

Dr. Eric Carlson: Nine years of age to 26 is the recommended time frame for HPV vaccination. The good thing is, if vaccination occurs at ages 11 to 12, for example, and certainly before 15, then only two doses are required and they should be administered six to 12 months apart. If we’re beyond the age of 15, then those individuals require three doses. 

Bill Klaproth: Okay, so nine to 26 is the window, so what if someone’s 27? Now what? 

Dr. Eric Carlson: Yeah, well, it’s not absolutely contraindicated, and in fact, there are people who request HPV vaccination after the age of 26, and they’re granted such vaccination. I think the cutoff currently is believed to be 45 years of age. So ideally nine to 26, but there are some patients between the age of 26 and 45 who are good candidates for vaccination. 

Bill Klaproth: Okay, so if you’ve contracted HPV at a young age, say you were promiscuous, and you didn’t practice safe sex, and you had a lot of safe partners, and now you’re 40, and like, oh boy, in my younger years, I really fooled around a lot, does the vaccine help at that point, or is it too late? 

Dr. Eric Carlson: No, it’s not too late as long as it’s administered before the age of 45. So those patients are considered to be good candidates for vaccination at that age. 

Bill Klaproth: So, if someone is worried about it, they can go in and get the vaccine at that point. 

Dr. Eric Carlson: Absolutely. 

Bill Klaproth: Wow, are there any other strategies, or any other things we should know about this, so, a parent listening, a mom is, like, saying, oh, my God, I missed the window, you’re still okay, up until, really, 45, is that right? 

Dr. Eric Carlson: Yeah, that’s correct. And what we know is that the vaccine is about 90 percent effective. And good studies show that there’s been about an 88 percent decrease in HPV-related sexually transmitted infections in patients who have up-to-date vaccination. So, just a great opportunity. 

Bill Klaproth: Absolutely. And you certainly don’t want to get cervical cancer or cancer of the tongue or the throat. So, this is really important, the discussion we’re having today. Absolutely. 

Dr. Eric Carlson: And, you know, it’s cervical cancer, again, the primary indication for the development of these vaccines along with benign genital warts, and it’s been very successful. But there are other cancers, and oropharyngeal is the big one. Again, the most common HPV-associated cancer in humans. In the genital area, there are vaginal cancers caused by HPV. Anal cancer is the third most common HPV-associated cancer. And, can certainly be prevented as well by proper vaccination strategies. 

Bill Klaproth: Absolutely. So, vaccines recently have kind of taken a hit with, certainly with COVID and the way they’ve been maligned by certain people. For a parent going, oh gosh, another vaccine, now, is this safe? Well, it’s been around since 2005, you said. What would you say to a parent going, oh gosh, another vaccine? 

Dr. Eric Carlson: So, interestingly, COVID was a big part of strategies taking a downturn in terms of HPV vaccination. There’s an initiative known as NIS-Teen, which is the National Immunization Survey in Teens. And the two vaccinations that are looked at as benchmarks, if you will, are tetanus, Tdap as we call it, tetanus and acellular pertussis, and also meningococcus. The national benchmarks for those are about 80 percent, which means that about 80 percent of kids are getting vaccinated successfully and up to date for Tdap and meningococcus. What we’ve found in the United States in the NIS-Teen study is that the up-to-date rates of HPV vaccination in eligible kids is somewhere just shy of 60 percent. So there’s a lot of work to do. Now, at the national level, there are three states and Washington, D.C., where there are mandatory HPV vaccination strategies before kids enter middle school, for example. And they are the Commonwealth of Virginia, Rhode Island, Hawaii and Washington, D.C. So, I think what’s important from the perspective of health care providers is to have those conversations with their local legislatures and attempt to make mandatory protocols come to the forefront. So, it’s one thing to talk to our patients’ parents, for example, our young patients in terms of getting their kids vaccinated. But it’s another thing to take it to the next level and talk to the people who are making those laws and see if we can make a difference here. 

Bill Klaproth: Yeah, that’s very, very well said. And the old adage, preventative medicine is the best medicine. Especially for something as serious as this. If you can help prevent these types of cancers that you were talking about, it’s definitely worth it. 

Dr. Eric Carlson: True. From the perspective of oropharyngeal cancer, Bill, it’s on the rise. And there are a lot of different reasons for that. So, we have available to us really a cancer vaccine, like you appropriately said a moment ago, that we can prevent these. So great public health concern, a significant magnitude, and we have an opportunity to really make a difference here by having these conversations. 

Bill Klaproth: Absolutely, well we thank you for your work and raising awareness for this, Dr. Carlson. Anything else you want to add? 

Dr. Eric Carlson: I think there’ll be more to come here and I look forward to continuing to participate in these conversations. You know, medicine has changed over the last decade. We have a large number of nurse practitioners and physicians’ assistants. So, these conversations can be had by people other than pediatricians and adolescent medicine doctors and primary care doctors, for example. So, nurse practitioners, physician assistants, I mean, just a large number of healthcare providers who can enter into these dialogues with patients and with parents. And in doing so, we will make a difference. 

Bill Klaproth: Yeah, we all need to be sending this message. 

Dr. Eric Carlson: Absolutely true. 

Bill Klaproth: Dr. Carlson, thank you so much for your time. I appreciate it. 

Dr. Eric Carlson: Thank you very much. 

Bill Klaproth: And once again, that is Dr. Eric Carlson. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, and hopefully you did, please share this on social media as we were just talking with Dr. Carlson, we really do need to raise awareness for this. And please make sure you subscribe so you get every episode. Thanks for listening.