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A 29-year-old patient presents with complaints of sore throat especially with swallowing. Examination reveals only some moderately enlarged lymph nodes. Strep throat? Mononucleosis? Allergy? Viral upper respiratory infection?

Head and neck cancer probably isn’t at the top of your list. Perhaps it should be.

Head and neck cancer incidence has been decreasing for all groups of patients except younger patients with little or no history of tobacco exposure. For the last 70 years, the typical patient with head and neck cancer presented in their 50s or 60s and had an extensive history of tobacco use or abuse alone or in combination with consumption of alcohol. This profile of the typical head and neck cancer patient began to change in the 1990s and early 2000s. Now it is common to diagnose patients with head and neck cancer in their 30s; some cases are discovered in patients in their early 20s or even late teens.

Why has the pattern of head and neck cancer migrated to younger patients without risk factors? Although all factors responsible for the change of head and neck cancer demographics are not known, it is now firmly established that in the majority of young head and neck cancer patients, the human papilloma virus (HPV) is to blame. Mucosal infection with HPV is associated with almost all cases of uterine cervical cancer. There are many types of HPV, but only a few, such as type 16 and 18, cause cancer. These same types are found in more than 90% of head and neck cancers caused by HPV. For unknown reasons, not all sites within the upper aerodigestive tract are equally susceptible to HPV infection. The oropharynx (tonsils, base of tongue, pharyngeal wall, and soft palate) is particularly susceptible, with close to 50% of all oropharyngeal cancers attributable to HPV. HPV-associated head and neck cancer is also found in the oral cavity (tongue, floor of mouth, buccal mucosa) with reports suggesting that up to 15% of oral cancer may be due to HPV infection. HPV is rarely associated with laryngeal, hypopharyngeal, or nasopharyngeal cancers.

HPV-associated head and neck cancer has some clinical and behavioral characteristics that distinguish it from the remainder of head and neck tumors. Histologically, HPV-associated and typical head and neck cancer are indistinguishable with both being squamous cell carcinomas, but HPV-associated head and neck cancer is more likely to present with cystic nodal metastases. It is not uncommon for HPV-associated head and neck cancer to present with nodal neck metastases and few or no other symptoms. In these instances, thorough examination may reveal a small primary tumor of the tongue base or tonsil. HPV-associated head and neck cancer responds better to standard chemotherapy and radiation, which in recent studies translates into an excellent survival rate.

As with uterine cervical cancer, HPV-associated head and neck cancer is a sexually transmitted disease and is associated with risky behaviors such as multiple partners, early onset of sexual activity and oral sex. Safe sex practices that prevent transmission of other sexually transmitted diseases should similarly protect against HPV-associated head and neck cancer. HPV vaccines have recently been developed and approved for use in young females to protect from uterine cervical cancers. Both Guardisil and Cervarix have been developed against HPV types 16 and 18 and therefore should also be effective at preventing head and neck cancer. In fact, since many uterine lesions are often identified before they progress to cancer and because almost all head and neck cancers are due to HPV types included in the vaccines, the numbers of HPV-associated head and neck cancers in the United States that would be prevented by the vaccine may be greater than the number of uterine cervical cancers prevented. For this reason, as well as protection from anogenital cancers, vaccination of young males in addition to young females is being considered.

Conclusion: Head and neck cancer has changed in the last several decades to include a previously unknown variant that is associated with HPV infection of the oral cavity and oropharynx. Young patients without significant tobacco or alcohol exposure who present with symptoms consistent with head and neck cancer should be considered at risk and screened or referred appropriately to a head and neck surgeon.





Presented in Partnership by Nashville Medical News and Vanderbilt University Medical Center



July 2008


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