Practice Alert

Taking steps to slow the upswing in oral and pharyngeal cancers

The CDC estimates that 70% of these cancers are caused by HPV. And yet, in 2018, only about two-thirds of adolescents had received 1 or more doses of HPV vaccine.


 

References

A recent report by the Centers for Disease Control and Prevention (CDC) documents the trends in oral and pharyngeal cancers (OPC) in the United States over a 10-year period, 2007-2016.1 The rate of OPC began to increase in 1999 and has been increasing ever since. The age-adjusted rate in 2007 was 10.89/100,000 compared with 11.7/100,000 in 2016 (TABLE 11). This is an annual relative increase of about 6% per year. In absolute numbers, there were 35,076 cases in 2007 and 44,419 in 2016.1 The trends in ­incidence of OPC vary by anatomical site, with some increasing and others declining.

Number and rate of HPV-associated oral and pharyngeal cancers by anatomic site, 2007 and 2016

There are 3 known causal factors related to OPC: tobacco use, alcohol use, and human papillomavirus (HPV) infection. The CDC estimates that, overall, 70% of OPCs are caused by HPV.2 However, while cancers at some oropharyngeal sites are likely related to HPV infection, cancers at other sites are not. The rising overall incidence of OPC is being driven by increases in HPV-related cancers at an average rate of 2.1% per year, while the rates at non-HPV-associated sites have been declining by 0.4% per year.1 It is also important to appreciate that HPV causes cancer at other anatomical sites (TABLE 22) and is responsible for an estimated 35,000 cancers per year.2

Number of HPV-associated and estimated number of HPV-attributable cancer cases per year

There is some evidence that if clinicians actively engage with parents about their vaccination concerns and address them head on, same-day vaccination rates can improve.

Other trends of note in all OPCs combined are increasing rates among non-­Hispanic whites and Asian-Pacific Islanders; decreasing rates among Hispanics and African Americans; increasing rates among males with no real change in rates among females; increasing rates in those 50 to 79 years of age; decreasing rates among those 40 to 49 years of age; and unchanged rates in other age groups.1

The role of the family physician

Preventing OPC and all HPV-related cancers begins by encouraging patients to reduce alcohol and tobacco use and by emphasizing the importance of HPV vaccination. Educate teens and parents/guardians about HPV vaccine and its safety. Screen for tobacco and alcohol use, and offer brief clinical interventions as needed to decrease usage.

Recommendations by the US Preventive Services Task Force regarding screening for, and reducing use of, tobacco and alcohol, as well as screening for cervical cancer, are listed in TABLE 3.3-6 Remember that cervical cancer screening is both a primary and secondary intervention: It can reduce mortality by preventing cervical cancer (via treatment of precancerous lesions) and by detecting cervical cancer early at more treatable stages.

Consider these USPSTF steps to reduce rates of oral, pharyngeal cancers

HPV vaccination essentials. CDC recommendations for the use of HPV vaccine and the vaccine dosing schedule appear in TABLE 4.7 While it is true that the best evidence for HPV vaccine’s prevention of cancer comes from the study of cervical and anal cancers, it is reasonable to expect that it will also be proven over time to prevent other HPV-caused cancers as the rate of HPV infections declines.

ACIP recommendations for the use of HPV vaccine

HPV vaccine is underused. In a 2018 survey, only 68.1% of adolescents had received 1 or more doses of HPV vaccine, and only 51.1% were up to date.8 In contrast, 86.6% had received 1 or more doses of quadrivalent meningococcal vaccine; 88.9% had received 1 or more doses of tetanus, diphtheria & acellular pertussis vaccine; 91.9% were up to date with 2 or more doses of measles, mumps & rubella vaccine; and 92.1% were up to date with hepatitis B vaccine, with 3 or more doses.8

Continue to: Address parental concerns, including these 5 false beliefs

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