A sexually transmitted virus that’s long been known to cause cervical cancer is now being blamed for a growing list of other cancers that are hitting Kentucky hard. HPV, short for human papillomavirus, is linked to cancers of the vulva, vagina, penis, anus and lung, and most recently to a rising number of head and neck cancers that strike in the prime of life. “It’s turning out to be a pretty bad actor ... an extensive health problem,” said Dr. Daniel Metzinger, a gynecological oncologist with University of Louisville Physicians and one of several local doctors who say they’re seeing more HPV-related disease than ever before.
One of his patients is Marcy Sarnecki, who had a precancerous, HPV-related lesion on her vulva surgically removed in February. She said it was very close to turning into cancer, and if she’d let it go any longer, it could have affected her fertility, or even killed her. “I’ve never been so scared in my life,” said Sarnecki, 36, of Louisville. “Everyone I know realizes HPV is related to cervical cancer. But no one knows it can cause other types of cancers. It’s frightening.” The U.S. Centers for Disease Control and Prevention has found that Kentucky’s cancer rates are among the nation’s highest for several types of HPV-related cancer, including cervical, penile, vaginal, vulvar and oropharyngeal, which are head and neck cancers affecting the back of the throat, base of the tongue and tonsils. Smoking is also a risk factor for many of these cancers, such as cervical, vulvar and penile cancers, and Kentucky has the nation’s highest smoking rate. “I’m seeing more of it for sure,” said Metzinger, who treats women for gynecological cancers. “It used to be a disease we’d see in older people. Now, we see it in younger and younger people.” Doctors said one way people can protect themselves is to be immunized with a relatively new vaccine against HPV, which can be transmitted through sexual contact. In 2006, the federal Advisory Committee on Immunization Practices recommended vaccinating 11- and 12-year-old girls and young women through age 26. Last October, the group widened its recommendation to include 11- and 12-year-old boys through 21-year-old men. And this year, the Kentucky House of Representatives passed a resolution encouraging young adults to be vaccinated and urging parents to have their sons and daughters immunized. But the idea of requiring the vaccine is controversial. When the Kentucky legislature proposed mandating the vaccination of middle school girls in 2007, opponents expressed concerns about possible side effects and contended that such a requirement would undercut parental authority and send a tacit message to teens that it’s all right to have sex. The bill failed.
Rachel Burgess of Jeffersonville, Ind., a marketing professional who has followed the issue, said adults should do their research and decide for themselves whether to get the shots. But she’s opposed to mandatory vaccination of children. “I think my main concern is: What is the long-term effect?” said Burgess, 30. “And morally and ethically, I don’t agree with 10- and 13-year-olds going out and living promiscuous lives.”
Connections to disease
According to the National Cancer Institute, more than half of sexually active people are infected with HPV at some point in their lives. More than 40 types are passed through sexual contact. “It’s a widespread virus,” said Dr. Jeffrey Bumpous, a professor of head and neck surgery at U of L. “It’s all over the place.” Most of the time, experts said, it goes away by itself within a couple of years. Sometimes, it causes genital warts. But it can also set the stage for cancer. Across the nation, about 26,000 new cancers attributed to HPV occur each year, with 18,000 in women and 8,000 in men, the CDC says.
A 2008 study in the journal Lung Cancer said HPV was found in almost a quarter of lung cancer cases reviewed, and “the data suggest that HPV is the second most important cause of lung cancer after cigarette smoking.” The CDC says virtually all cervical cancers are caused by the virus, as are 95 percent of anal cancers, 65 percent of vaginal cancers, half of vulvar cancers and 35 percent of penile cancers. HPV-related head and neck cancers are also arising in patients much younger than the once-typical heavy smoker and drinker over 60. The CDC says up to 60 percent of oropharyngeal cancers — and about a third of all head and neck cancers — are linked to HPV, although some of these may also be related to tobacco and alcohol use.
Doctors said an increase in oral sex over the past few decades most likely contributes to the rise in HPV-related head and neck cancers, which may take 15 years or more to develop after an exposure. Multiple exposures through oral sex increase the risk, Bumpous said, but kissing doesn’t seem to transmit the virus. “It’s sort of a taboo subject. But it’s out there,” said Dr. A. Bennett Jenson, a U of L researcher who helped invent the vaccine against HPV. “And these (cancers) are happening in younger people who don’t smoke and seem to be at low risk otherwise.” Dr. John Hamm, a medical oncologist and associate medical director for the Norton Cancer Institute, said that’s what he’s seen, too — “a younger population, people in their 30s and 40s ... people who are not big smokers or drinkers.” Doctors said one silver lining about HPV-associated head and neck cancers is that they are more treatable than other cancers in the same area. They “have slightly better prognoses,” Hamm said, “particularly if they are caught early.”
Vaccines and other preventions
Doctors said patients should stay vigilant about changes in their bodies and raise the possibility of HPV if they notice something suspicious such as a sore that doesn’t heal. Doctors also suggest people take steps to prevent HPV from taking hold in the first place — such as practicing safe sex, limiting the number of sexual partners, using condoms and getting vaccinated. “In addition to cervical cancer, the HPV vaccine also protects against increases in HPV-related head and neck cancers, anal cancers, penile cancers,” Hamm said.
But statistics show that many people are not heeding the advice on vaccines.
CDC data for 2010, the latest year available, show that 49 percent of girls ages 13-17 were covered with one dose of HPV vaccine, 32 percent with the recommended three doses. These statistics were gathered before the advisory committee recommended boys be vaccinated, but Bumpous said “precious few” boys are getting the vaccine.
Metzinger said he recommends vaccination but doesn’t think it should be mandatory. He also pointed out that it doesn’t protect against all types of the virus; Merck’s Gardasil vaccine protects against four types, and GlaxoSmithKline’s Cervarix protects against two. Still, federal officials said people who forgo vaccination are losing out on protection. Besides preventing genital warts and certain cancers, they said, the vaccine could reduce the spread of HPV from men to women.
Drug makers said the vaccine has not been studied in all HPV-related cancers. Gardasil is indicated for the prevention of cervical, vulvar and vaginal cancer in females, and anal cancer, precancerous lesions and genital warts in females and males. The newer Cervarix is indicated for the prevention of cervical cancer in females. But Dr. Alfred Saah, director of clinical research at Merck, said Gardasil should “in theory” protect against cancers such as those in the head and neck, and his company supports other scientists’ research in this area. Rob Perry, director of U.S. communications for GlaxoSmithKline, said while his company doesn’t plan to study the effectiveness of its vaccine against noncervical cancers, “we could reassess this at some point as knowledge about other HPV diseases increases.” Jenson said he suspects that the HPV-cancer connection may be a harbinger of future findings linking all sorts of viruses to cancer. “There’s thousands and thousands of viruses,” he said. “I think the next generation is gonna find that more and more cancers are at least associated with viruses if not caused by them.”