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2016 HPV Vaccine Summit: HPV – You are the Key to Cancer Prevention May 12, 2016 MCW Department of Otolaryngology and Communication Sciences MCW Institute for Health and Society (Center for Bioethics and Medical Humanities) HPV-Related Head and Neck Squamous Cancers Bruce H. Campbell, MD FACS Medical College of Wisconsin Financial Relationship Disclosure Statement I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Learning Objectives that Address the Practice Gaps and may Lead to Change • Understand: – Oropharyngeal cancer presentation and basics of treatment – The increasing proportion of oropharynx cancers is related to HPV – HPV vaccination should have an impact on incidence – More men than women are diagnosed with oropharyngeal cancer The Invisible Origins of HPV Infection • Genital HPV infection is common in sexually active adults – Majority will have HPV infection at some point – Most will never know • Natural history of HPV infection is usually benign – Low-risk HPV types (6, 11) • Mild Pap test abnormalities • Genital warts – High-risk types HPV types (16, 18) • Mild to severe Pap test abnormalities • Rarely, cancers of the cervix, vulva, vagina, anus, penis, oropharynx How HPV causes cancer… HPV proteins E6 and E7: • Block cell cycle regulation • Defeat the cell’s surveillance of “bad” cells • Let the cells grow forever Munger K, et al., J Virology 2004; 78(21): 11451-11460 Time Course of HPV infections Up to Decades Within 1 Year 1-5 Years Persistent Infection Initial HPV Infection CIN 1 Cleared HPV Infection CIN 2/3 Cancer Cancers with Rising Incidence 1999-2008 • • • • • • • Pancreas Liver Thyroid Kidney Melanoma Esophageal adenocarcinoma HPV-positive oropharynx Simard, Ca: Cancer J Clinicians (published online: 4 JAN 2012) Pharyngeal Anatomy Natural History and Symptoms of Oropharyngeal Cancer • Early nodal spread • Sore throat • Trouble swallowing • Neck mass Oropharynx Cancer Patients 1881 1996 2010 Per 100,000 HPV-Positive Oropharynx Average Annual Percentage Change (AAPC) White Black Asian Native Hispanic Male 4.4% -0.1% 0.7% -0.1% 0.3% Female 1.9% -0.6% -2.2% NA -0.7% Simard, Ca: Cancer J Clinicians (published online: 4 JAN 2012) Percentage of Oropharyngeal Cancers that are HPV Positive Chaturvedi AK, J Clin Oncol 2011; 29 (32): 4294-4301 Wisconsin Oropharynx Cancer Incidence Cases per 100,000 1995-2011 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1995 1996 1997 1998 1999 2000 2001 2002 Female - incidence 2003 2004 2005 2006 2007 2008 2009 2010 2011 Male - incidence Source: Wisconsin Cancer Reporting System, Office of Health Information Division of Public Health, Department of Health Services, 2014 Association between oral HPV infection and oropharyngeal cancer • OP cancer significantly associated with – Oral HPV-16 infection (OR 14.6) • Sexual activity associated with OP cancer – >25 vaginal partners (OR 3.1) – >5 oral sex partners (OR 3.4) D’Souza NEJM 2007 356:1944-1956 Overall Survival Based on Tumor HPV Status Ang, N Engl J Med 2010;363:24-35 Risk Stratification Based on HPV, Smoking, Tumor Size, and Nodal Size 3-yr OS 93 % 71 % 46 % Ang, N Engl J Med 2010;363:24-35 Management of HPV-Positive Oropharyngeal Cancer • Concurrent Platinum-based chemotherapy and radiation therapy • Concurrent cetuximab and radiation therapy • Surgery with postoperative radiation therapy – Transoral laser microsurgery (TLM) – Transoral Robotic Surgery (TORS) PET Scan: Tumor Response April to October 2011 April 2010 June 2011 May 2006 December 2009 National Immunization Survey Physician Responses on the HPV Vaccine Survey Question 2008 2013 Recommendation for 11- and 12year olds Strong Not strong None or recommendation against Pvalue 52% 39% 7% 59% 33% 6% .05 .05 .05 Major barriers to parent compliance Concern about vaccine safety 5% 18% <.01 Concern about encouraging sexual 4% activity 13% <.01 Lack of insurance coverage 7% <.01 22% Kempe A, Pediatric Academic Societies (PAS) 2015 Annual Meeting: Abstract 3115.2. Presented April 27, 2015 Changes in Practice that Might Narrow the Practice Gaps Head and Neck SCC of the Oropharynx • Share with parents and teens: – Immunize boys and girls – HPV-related cancers are associated with increased exposure to oral sex and increased number of partners – HPV-related cancers are increasing in prevalence – Cancers are most common in males in their 50s and early 60s – Symptoms are often subtle – Treatment is effective Comments or questions [email protected] (414) 805-5583 References: Munger K, et al., J Virology 2004; 78(21): 11451-11460 Simard, Ca: Cancer J Clinicians (published online: 1/4/2012) Chaturvedi AK, J Clin Oncol 2011; 29 (32): 4294-4301 Wisconsin Cancer Reporting System, Office of Health Information Division of Public Health, Wisconsin Department of Health Services, 2014 D’Souza NEJM 2007 356:1944-1956 Ang, N Engl J Med 2010;363:24-35 Kempe A, Pediatric Academic Societies (PAS) 2015 Annual Meeting: Abstract 3115.2. Presented April 27, 2015 Bailey, ASCO Statement: HPV for Cancer Prevention, J Clin Oncol 2016 (Pulished online 4/11/2016)