Oral HPV and cancer risk

[alahue]

Dear H. Hunter Handfield.

I have been following posts about HPV and particularly the oral risk, and read most reports, but am now ready to ask some questions that might shed some light on my last thoughts, my language is not English so excuse me if it sounds a little weird, I choose to numbers the questions to try to keep some order.
1
  Your last response to a parent was that HPV16 is only transmitted through sex, previously has always been your answers in the oral hpv, "that it is not even certain that the person became infected through sex (oral sex), then one can interpret this to mean that the are other modes of transmission? but deviates from the last answer.?
2
HPV has always existed, and oral sex performed well already in Roman times? why increase oral cancer by HPV right now? the last 10-15 years? must be some other factor? HIV can be one of these
4
To return to the last oral hpv report mentioned above, this report found that oral HPV is most common in the age just after 30 and elderly over 65, how does this with the assertion that only six rubs, I mean a sexually transmitted disease is most common in older, it sounds very strange, probably has fewer partners at that age and the partner who is older that the risk of genital HPV at the time gives oral sex is very low, it should not oral HPV to be most common among teenagers? where is the genital HPV is most common, what does this say about transmission risk or sexual habits of people over 65
5
Have you read this report can be reassuring to who are concerned about oral caner, is in this report with your opinion? I bought all the article but the link sums up pretty well, maybe you can use this article in your answer to the troubled on this forum? http://vitals.msnbc.msn.com/_news/2012/03/23/10832041-can-oral-sex-really-give-you-cancer?lite

[Edward W Hook, MD]

It is standard procedure, and totally appropriate, for authors of published material to disclose if they have received payment as consultants, as investigators or for other other activities which might be considered to be potentially relevant to statements they make.  For instance, when Dr. Handsfield or I refer MedHelp clients to the American Social Helath Association, we always mention that we have each served on the Board of irectors of the organization.  That way the reader can decide if they think our advice has been influenced through our association with ASHA  EWH

[alahue]

I agree, this substance shall be terminated and I have received value for money :)
I found the letter, copy into then maybe other readers will find this interesting and have a small final question, I do not really understand, some scientists such as Gillison been hired by the company that sells the vaccine?

Letters

Prevention of Oral Human Papillomavirus Infection
H. Hunter Handsfield, MD
[+] Author Affiliations
JAMA. 2012;307(20):2147-2148. doi:10.1001/jama.2012.3566
Text Size: A A A
Article
References
Letters (1)

To the Editor: Dr Schlecht's Editorial1 adds context to the report on the epidemiology of oral human papillomavirus (HPV) infection based on the National Health and Nutrition Examination Survey (NHANES).2 However, the subtitle undercuts some reassuring observations, such as the relatively low prevalence of oral HPV infection (6.9%) compared with anogenital infection and the 1% prevalence of oral HPV-16, the main type associated with oropharyngeal squamous cell carcinoma.2

The suggestion that barrier protection would prevent oral HPV is unsupported. Orogenital exposure was not independently associated with oral HPV in the NHANES sample,2 and other transmission mechanisms are likely to contribute to oral HPV infection, such as autoinoculation from genital infection and indirect exposure to genital secretions during other sexual practices. Condoms reduce HPV transmission to women by vaginal intercourse, but even a modest lapse in consistent use ablates the protective effect.3 It is difficult enough to influence sexually active persons to adopt evidence-based prevention strategies, and promoting strategies with inherently low acceptability and little likelihood of success risks undermining those efforts. There are cogent arguments for barriers for oral sex in some settings, but clinicians should not tell their patients it would reduce their risk of oral HPV or throat cancer.
AUTHOR INFORMATION

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a member of the board of directors of the American Social Health Association; receiving payment from the American Social Health Association for developing educational materials on HPV prevention through an unrestricted grant to the association from Merck; recently completing a term as a member of Merck's Gardasil Male Population Advisory Committee; and receiving royalties from McGraw-Hill for his book, Color Atlas and Synopsis of Sexually Transmitted Diseases, 2nd and 3rd editions.

[Edward W Hook, MD]

For most people, including you, risk of oral cancer from oral sex is negligible.  Here in the U.S. where such things are monitored rather closely there are less than 10,000 new oral cancers occurring each year in a population of over 350 million people and not all of those cancers are due to HPV 16.   Further, dentists are now on the lookout for oral cancers.  If you receive regular dental care, I would not worry about oral cancer.  

Further, with regard to HPV and oral cancer, three further comments
1. Dr. Handsfield indicates to me that the question you asked reflected a statement taken out of context and that the comment he made was related to risk for HPV transmission form kissing.
2. He likewise adds to your lists of reading his rather extensive response to another HPV related question ..    The link is  http://www.medhelp.org/posts/STDs/Oral-HPV-Cancer-Risk/show/1512873  ;
3. Finally, his own letter to the editor relating to the article in JAMA you refer to has recently been published.  You might wish to see this as well as it reflects our thoughts on the matter.


With this, probably time for this exchange to come to a close.  Take care.  - EWH

[alahue]

Many thanks for your answer! I understand and have to resort to me that the risk is almost negligible?

The study I was referring to is the great report as Gillison came up with this year
Prevalence of Oral HPV Infection in the United States, 2009-2010 ... jama.ama-assn.org/.../2012/.../jama.2012.101.f
It can be seen in what ages oral HPV is most common.

The second report is from http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2012.02684.x/abstract

[Edward W Hook, MD]

.
Welcome to our Forum.  As you know, Dr. Handsfield and I share the forum.  You got me this time.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

In preparing to answer your question I reviewed some of your other interactions on other MedHelp Community sites and can see that, indeed, you have spent a lot of time on our site, reviewing answers we have provided to others.  As a result, I think that before I work to briefly address your questions it is appropriate for me to remind you that the topic of HPV and its relationship to cancers is a relatively new area of scientific research and that our understanding of this topic is evolving on a virtually daily basis.  In at least some cases, what we “know” today is different from what we understood a year ago and may change further over time.  In addition, please understand that the nature of many commercial news sites that I see you have also visited is one in which the media sources are competing with other sites for attention and as a result, sometimes sensationalism takes the place of judgment and perspective.  As a result, the combination of researchers who are very enthusiastic about their own research and its importance along with news media who are not expert in the field but are competing for your attention results in statements which lead to concerns which are far out of proportion than the risks they really represent for most people.  When you consider these facts along with that HPV is an infection that nearly everyone has and/or will get which clearly contributes to risk for cancer in just a tiny fraction of people who get infected, you have a situation in which anxieties can be fueled unnecessarily.  On this Forum we try to truthfully reflect this perspective.  

With this introductory comment, let's work through your comments, realizing that this cannot be a prolonged or overly detailed exchange.

1
  Your last response to a parent was that HPV16 is only transmitted through sex, previously has always been your answers in the oral hpv, "that it is not even certain that the person became infected through sex (oral sex), then one can interpret this to mean that the are other modes of transmission? but deviates from the last answer.?

Many of our clients get hung up on small variations in wording.  On the other hand, there are almost no questions we received (including this one) that we have not received before – I urge you to look for the larger message, not to get hung up on small subtlies.  In scientific discussions we acknowledge that one can "never say never".  Just because something has never been observed to occur does not mean that it won't occur tomorrow...or the next day.  On the other hand, some of our readers would like to have information given in absolutes.  While HPV 16 is nearly always transmitted by sex and it is through sex that nearly all infected persons acquire infections, there are studies that show the potential for very rare transmission of HPV through other means and in all studies there are a small proportion of cases in which it is unclear how infections occurred.  I think that to make a statement that HPV is ONLY transmitted by sex is a bit of an overstatement but not much of one.  Our answers are individualized to the clients but are posted so that others can learn.  I am sure the Dr. Handsfield felt that this was the right answer for this client, even if it was a very slight over simplification when considered in a more general sense.  

2
HPV has always existed, and oral sex performed well already in Roman times? why increase oral cancer by HPV right now? the last 10-15 years? must be some other factor? HIV can be one of these.

Certainly there are other factors involved, some which we are beginning to understand, others which we do not. We know for instance that tobacco use greatly amplifies risk that HPV will cause cancers but please also understand that, as mentioned above, this is a VERY active field of study with new information emerging on a daily basis.  Further, worldwide, people now live longer and thus have a longer opportunity for things like cancer to occur when 20 or 100 years ago they would be far more likely to die from some other cause at an earlier age

4 .
To return to the last oral hpv report mentioned above, this report found that oral HPV is most common in the age just after 30 and elderly over 65, how does this with the assertion that only six rubs, I mean a sexually transmitted disease is most common in older, it sounds very strange, probably has fewer partners at that age and the partner who is older that the risk of genital HPV at the time gives oral sex is very low, it should not oral HPV to be most common among teenagers? where is the genital HPV is most common, what does this say about transmission risk or sexual habits of people over 65

Sorry, I am not familiar with the report you mention and likely will not get to it soon.  As you point out, the figures you mention do not correspond with either logical extension of what we already know at this time and multiple other studies on the topic.

5
Have you read this report can be reassuring to who are concerned about oral caner, is in this report with your opinion? I bought all the article but the link sums up pretty well, maybe you can use this article in your answer to the troubled on this forum? http://vitals.msnbc.msn.com/_news/2012/03/23/10832041-can-oral-sex-really-give-you-cancer?lite
The link you provided did not take me to the article.  Further, with all due respect, we cannot evaluate every report that a client has as there are many such reports every day.  

I hope my comments are helpful to you.  Take care.  EWH