HPV Oropharyngeal Cancer: A Killer Among Us

As I took my seat amidst my family, the chapel began to fill up very quickly. There was a faint playing of favorite songs accompanied by a slide show of treasured family times playing across a large screen. The balcony began to fill and eventually there were more chairs being brought into this setting that had witnessed much happier times.
This was the day of the funeral for my cousin, Bonnie, who lost her life to human papillomavirus (HPV)-oropharyngeal cancer. This was not supposed to happen.

A Cruel Twist of Fate
Bonnie informed the family of her being diagnosed with HPV-16 oropharyngeal cancer on September 26, 2011. This was days before I was to deliver a presentation based on my research in this very area to our National Dental Hygiene Association at the annual meeting. Her diagnosis was a cruel and crushing blow to our entire family. Bonnie dedicated her life to fitness and the pursuit of a healthy lifestyle for herself, family, and all those who she came in contact with.
She fought this insidious disease with everything she had in order to be there for her 3 beautiful daughters and loving husband, Geoff. Her treatment regimen included 35 radiation treatments, chemotherapy, and the insertion of a feeding tube; only to be told weeks later at the conclusion of her treatment that the cancer had recurred. She then entered into a clinical trial that unfortunately never reached completion.
On December 6, 2012, with the heaviest of hearts, I announced the passing of my beautiful cousin at the age of 46 years to my colleagues in the dental community.
The day after Bonnie’s funeral, I received notification of a bittersweet award. The dental editors of PennWell publications had selected an article I’d written for RDH eVillage FOCUS e-newsletter on HPV-related oropharyngeal cancer as the “Most Important Dental Story Published in 2012 for the Dental Profession.” This message was my passion and now has become my personal mission, so that a life may not be in vain and others may be saved.

In loving memory of Bonnie Louise Nugent, fourth from left,
March 4, 1966 – December 6, 2012, shown here with her family.

The Reality
Currently, HPV is the fastest growing sexually transmitted infection. At least 50% of sexually active men and women will acquire a genital HPV infection at some point in their lives. Often the immune system is strong enough to eradicate the virus from our bodies, with little or no apparent symptoms or repercussions. Most people who become infected with HPV are not even aware that they have an infection.
So what’s the connection? The global increase in HPV-oropharyngeal cancer has been tied in with sexual relations, namely oral sex. However, the virus, when active, may be passed on with kissing. The virus may then lay hidden and dormant for many years. The HPV has accounted for a 225% increase in oropharyngeal cancers from 1988 to 2004.1 The same viral strain, HPV-16, that is responsible for 70% to 80% of all cervical cancers, is solely responsible for 85% to 95% of HPV-related oropharyngeal cancers.2 Data projections cite that the number of oropharyngeal cancers that are HPV-positive will surpass the annual number of cervical cancers by the year 2020.3 HPV-oropharyngeal cancer is currently rated the second most common HPV-associated cancer after cervical cancer.

What Can We Do?
The most common sites for HPV-related oropharyngeal cancer are the base of the tongue, the oropharyngeal area, tonsils, and tonsillar pillars. There are a number of subtle symptoms that accompany HPV-related oropharyngeal cancer that we need to be fully acquainted with. These include, however are not limited to, the following:

  • Hoarseness
  • Continuous sore throat
  • Throat infection not responding to antibiotics
  • Pain when swallowing
  • Difficulty swallowing
  • Pain when chewing
  • Continual lymphadenopathy
  • Nonhealing oral lesions
  • Bleeding in the mouth or throat
  • Ear pain
  • A lump in the throat or the feeling that something is stuck in the throat.

To this need, I have developed a medical history update questionnaire to be used at regular intervals. It includes the question: Do you have a persistent sore throat, hoarseness, earache, or feeling of something being caught in your throat? (Answer: Yes/No. If yes, please provide details.)
In contrast, smoking- and alcohol-related oral cancer tend to involve the anterior portion of the tongue, lateral borders, floor of mouth, and the palate.
Optimal visual acuity in these often visually compromised areas is of utmost importance. The use of magnification through customized through-the-lens loupe systems is of great benefit, as well as conducting a thorough and effective extraoral and intraoral examination.
When we do discover a texture or color change, what do we do about it? If the lesion is related to trauma or injury, is it the “golden” rule to appoint back in 14 days to make certain the lesion has resolved, or do we dismiss as being “nothing of clinical significance”? If a leukoplakic, erythroplakic, or mixed lesion is identified with an unknown etiology or clincal cause, it should be sampled and analyzed by a pathology lab to help determine its cause and to rule out dysplasia. A simple brush biopsy such as Oral CDx obtains a complete transepithelial biopsy with minimal discomfort or bleeding. The brush biopsy will provide you with valuable information to guide management and referral, as required. OralCDx is not a replacement for a scalpel biopsy, but because it is a minimally invasive procedure, it is a perfect chairside tool to help you provide optimal care for your patient and to determine when a scalpel biopsy is necessary.

Early Discovery and Diagnosis Are Critical
Are we discovering oral lesions early enough? A recent study based on searches of PubMed, Web of Knowledge, and the Cochrane Library from 1966 through 2010 was published in the Journal of the American Dental Association on December 1, 2012.4 The study was based on a systematic review to assess the effectivelness of the clinical oral examination (COE) in predicting histologic diagnosis of dysplasia and oral squamous cell carcinoma (OSCC). On the basis of the available literature, the authors4 determined that a COE of mucosal lesions generally is not predictive of histologic diagnosis. The authors conclude, “The fact that OSCCs often are diagnosed at an advanced stage emphasizes the need for improving the COE and the need to develop adjuncts to assist in oral mucosal lesion detection and diagnosis.”4
By the time we discover the lesion and its clinical manifestation, it is often too late or in the more advanced stages. Direct fluorescence visualization (VELscope [DenMat]), also referred to as narrow band (light) imaging, has been well studied. A clinical study published in the July/August 2011 issue General Dentistry, by Truelove et al,5 examined 620 low-risk patients with loss of fluorescence suggestive of pathology in 69 subjects, or 11.1%. After a second immediate evaluation, 28 of the 69 subjects were scheduled for follow-up. None of the lesions discovered in these 28 subjects, which included 5 dysplasias, had been detected using standard white light examination. Thus adjunctive use of this technique led to the earlier discovery of histologic changes. The conclusive statement was that adding an adjunctive diagnostic procedure such as VELscope improved the quality and outcome of the examination process.
The most common misunderstanding is the reported occurence of “false positives.” This notion typically arises when an adjunctive device is incorrectly treated as if it were a diagnostic test with a well-defined “positive” or “negative” outcome. This is no more true of the adjunctive procedure than it is of the COE itself. The gold standard for histologic diagnosis is excisional biopsy. It is critical to recognize that adjunctive devices such as VELscope are not diagnostic devices or tests. They are simply screening tools to enhance our ability to discover oral abnormalities at the earliest stage possible.

Closing Comments
As dental professionals, we can and should do much more in the fight against oral cancer. We are trained to be keenly aware of abnormal versus normal tissue. The application of critical thinking is what we base our decision making and treatment planning on. Why do we continually “watch and wait,” or dismiss abnormal tissue as “nothing of clinical importance”? Also, with the omission of a regular oral cancer screening examination, we place the onus of discovery on our dental patient to bring an abnmormality to our attention. By then, it can be, and is too often, much too late. The increase in HPV-related oropharyngeal cancer is a wake-up call for our profession and a strong call to action.
So many of us take for granted that we will see our children graduate from high school, go on their first date, get dressed for their first prom, get that first coveted kiss from a grandchild…others will not have that joy. Our profession is strategically positioned to play an integral role in earlier discovery of abnormal lesions, making a huge impact on better treatment outcomes, improved survival rates, and enhanced quality of life for our dental patients. After all, isn’t the highest calling in life being able to serve others?
I learned many life lessons through the journey of oral cancer with my cousin. My world and our world are both a better place after having been graced with her presence. We need to change our game.
“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.”—Charles Darwin


References
1. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29:4294-4301.
2. Dayyani F, Etzel CJ, Liu M, et al. Meta-analysis of the impact of human papillomavirus (HPV) on cancer risk and overall survival in head and neck squamous cell carcinomas (HNSCC). Head Neck Oncol. 2010;2:15.
3. Cleveland JL, Junger ML, Saraiya M, et al. The connection between human papillomavirus and oropharyngeal squamous cell carcinomas in the United States: implications for dentistry. J Am Dent Assoc. 2011;142:915-924.
4. Epstein JB, Güneri P, Boyacioglu H, et al. The limitations of the clinical oral examination in detecting dysplastic oral lesions and oral squamous cell carcinoma. J Am Dent Assoc. 2012;143:1332-1342.
5. Truelove EL, Dean D, Maltby S, et al. Narrow band (light) imaging of oral mucosa in routine dental patients. Part 1: Assessment of value in detection of mucosal changes. Gen Dent. 2011;59:281-289.


Resources
Medical History Update Form, available from info@rdhconnection.com.

Ms. Jones has become a well-recognized international speaker, bringing life, energy, and inspiration to her presentations. She is the president of RDH CONNECTION Inc, an educational and training company dedicated to excellence in quality dental hygiene education and dental team training. She has been appointed to serve on the advisory board for Dentistry Today and joins the 2013 Leaders in Continuing Education. She was nominated for a 2012 Dental Excellence Award for the Most Effective Dental Hygiene Educator by her peers and was PennWell’s Dental Editor’s award recipient for writing “The Most Important Dental Story Published in 2012.” She can be reached at jjones@rdhconnection.com.

Disclosure: Ms. Jones is a key opinion leader for VELscope and received no compensation for writing this article.