Human Papilloma Virus- Associated Head and Neck Cancer: A 21st Century Pandemic; Assessing Student Awareness and Knowledge

F.G. Kavanagh1, A.T. McNamara2, O. Fopohunda1,2, I.J. Keogh1,2

1. Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Galway, Newcastle Rd, Galway.
2. Academic Department of Otorhinolaryngology, Head and Neck Surgery, National University of Ireland Galway, University Road, Galway.

Abstract

Background
The Human Papillomavirus (HPV) is a causal agent in a subset of Head and Neck Cancers (HNC) being diagnosed in younger patients without significant tobacco and alcohol use. This survey assessed the awareness level of HNC and HPV vaccinations in university students.
Methods
An anonymous, questionnaire-based survey of registered students of the National University of Ireland, Galway (NUIG) was carried out.
Results
1,550 responded, 1,494 completed the survey; 1,018 female (68.1%), 476 male (31.9%). 63% had never heard the term HNC. 45% had never heard the term HPV. 69% were unaware of how one would be exposed to HPV. 84% were unaware of the association between HNC and HPV.
Conclusions
There are poor levels of awareness of HNC, HPV and HPV vaccination. HPV vaccination needs to be appreciated as a major cancer breakthrough. However the public health benefits of increased awareness of HPV, HNC and HPV vaccination have yet to be realised.

Introduction

Head and neck cancer is a heterogenous group (17 different sites) of neoplasms that affect the upper aerodigestive tract. Although cigarette smoking and alcohol are recognised risk factors evidence suggests that HPV causes a subset of HNC, primarily oropharyngeal squamous cell carcinomas (OPSCC), . The majority of these are due to a single HPV type: HPV 16. The increasing incidence of HPV-related OPSCC, particularly in men (3:1 vs. women), <50 years, with no history of alcohol or tobacco use, has been recorded over the past decade. These cancers have an improved prognosis and survival in comparison to other HNC.

Over 120 different subtypes of HPV have been catalogued to date, with all identified types being epitheliotropic: infecting epithelial cells of the anogenital and oropharyngeal mucosa. Of the 40 subtypes known to infect the epithelial lining of the anal, cervical, genital and oropharyngeal tract, some 13-18 subtypes have been identified as probable or high risk oncogenic risk HPV types. These cause virtually all cases of cervical cancer worldwide and are a likely cause of a substantial proportion of other anogenital neoplasms and oral squamous cell carcinomas. Implicated HPV subtypes include: HPV types 16, 18, 31, 33, 39, 45, 52, 58, and 69.

Human Papillomavirus is the most prevalent sexually transmitted pathogen in the USA. Experts believe that virtually all sexually active adults have been infected given that there are over 40 HPV types that can infect the lower genital tract however the majority of HPV infections are transient. Amongst asymptomatic women in the general population, prevalence ranges from 2-44% but regional and age differences exist.  Peak prevalence of HPV infection occurs within the first decade after sexual debut, between the ages of 15 and 25 years.

In recent decades, as tobacco-associated HNSCC is decreasing there has been a rise in the incidence of HPV related oropharyngeal cancers. HPV is detected in ~25% of all HNSCC; the majority being oropharyngeal (tonsillar and base of tongue) squamous cell cancers. However HPV has been detected in laryngeal and oral cavity cancers,,. Recent evidence demonstrates an annual increase in the rates of HPV associated HNC. HPV-related HNC has surpassed the incidence of cervical cancer in the USA.

Changes in sexual behaviour have been associated with the increasing incidence of HPV infection. The most notable trends to emerge are the decreasing age of sexual debut but also the increase in the lifetime number of sexual partners . Orogenital sex is a risk factor for HPV transmission2. Increase in sexual risk taking is postulated to have led to increased oral HPV exposure and the rise in HPV associated oropharyngeal cancer. The HPV vaccine is a prophylactic vaccine target oncogenic subtypes (16 + 18) of HPV. Despite evidence that HPV vaccination is safe and effectively prevents cancer there have been falling rates of vaccination especially in the Irish population.  The reason why only a small proportion of infected individuals go on to develop HPV-related HNC are currently unknown. However complex interactions between the virus and the host immune system appear to play very important roles5.

Methods

Ethical approval for this research was granted by the Clinical Research Ethics Committee. The survey was conducted in late 2016 in the National University of Ireland in Galway (NUIG). NUIG is Ireland’s fourth largest university.  An anonymous closed question questionnaire was used focusing on three primary areas: general awareness of HNC, general awareness of HPV and attitudes towards HPV vaccines. Questionnaires were distributed using a survey provider platform. Data analysis was qualitative was performed using SPSS statistical software for windows, version 22 (IBM).

Results

Questionnaires were circulated to circa 14,000 students. 1,550 responded. 1,494 questionnaires were complete; 1,018 female and 476 male. The average age of respondent was 24 years. The median age was 21 years. Age range 16-63 years.  70% of participants were undergraduates, 7% were mature undergraduates and 23% were postgraduate students.

63% of respondents had never heard the term Head and Neck Cancer. Only 33% of male respondents were familiar with the term HNC and 39% of female respondents were familiar with the term HNC. 69% of health science students were aware of HNC, compared to 26% of all other students. Engineering/IT students were the least informed, with only 22% having heard of HNC, Arts/Humanities 24%, Commerce/Law at 25%.

Only 55% of participants were aware of HPV. More females were aware of the existence of HPV at 61% compared to 43% of males. 78% of health science students were more likely to have heard of HPV compared to 47% of non-health science counterparts (p-value <0.05). 69% of respondents were not aware of how HPV is transmitted. 57% of health science students were aware of how they might be exposed to HPV, compared to only 16% of Commerce/Law students.

94% of females were aware of the vaccine, compared to 79% of males. 57% of the cohort were unaware that the vaccine protects against HPV. 50% of females knew HPV was being vaccinated against, compared to 30% of males. 78% of participants were not aware that the vaccine would be of benefit to males. 84% of male respondents would be open to being vaccinated. And 89% of female respondents think that males should be vaccinated.

84% were unaware of the association between HPV and HNC. 49% of respondents were not aware of the association between oral sex and HPV associated HNC.

Discussion

This survey highlights the large knowledge deficit that exists in this cohort of university students. Respondents had a basic knowledge of HNC and HPV disease. This is surprising given that a majority of the female participants are of an age where they should have been vaccinated. The majority of females in our cohort would have been offered the HPV vaccine in school, with a minimum of 60% of the older female students receiving it in the catch-up programme. Since the vaccine was introduced in Ireland in 2010 uptake rates have gradually declined. It is of concern to consider that participants may have been vaccinated and know very little about the virus and the diseases they are being vaccinated against. This is a challenge for the Irish vaccination service. New strategies are required to educate parents and children about the benefits of the vaccine. Education, awareness and early detection are fundamentals that can be applied to all cancers. One interesting aspect of this survey is the limited knowledge that students studying health sciences had in relation to HPV.

In all aspects of this study, males had a lesser knowledge than females. In Ireland we do not vaccinate males for HPV, it is hardly surprising that males are not getting the message that the vaccine is also for them. The incidence of both HPV-associated HNSCC is greater than two fold higher among men than women. It is unclear why the incidence of HPV-associated HNSCC is higher amongst men than women. One theory is that HPV burden is higher in the vagina and cervix than the penis, and individuals are more likely to acquire an oral HPV infection when performing oral sex on a woman than on a man. Greater engagement of men in the discussion around HPV and its consequences needs to occur. Currently the HPV vaccine is tied to sex and unproven questions about safety. Gain frame messaging, co-ordinated communication, intergrated social media campaigns, need to be used to firmly tie the vaccine to cancer prevention for girls and boys.

Head and neck cancer is the 6th most common cancer worldwide. HPV associated HNC is affecting a younger cohort of patients who often do not smoke or take alcohol. The possibility of preventing and eradicating a cancer through vaccination deserves a vigorous public awareness campaign. Awareness amongst medical students and health care professionals was surprisingly low raising awareness and interest in this cohort should occur in parallel to public health awareness campaigns.

This survey highlights that public awareness and knowledge of HPV, HPV vaccination and head and neck cancer is poor. A clear co-ordinated and direct message needs to be delivered to the public. HPV vaccination is for males and females. Vaccination offers the possibility to eradicate HPV associated cancers and to prevent so many patients and families taking that ‘terrifying cancer journey’.

Conflicts of Interest
The authors have no conflicts of interest to declare.

Corresponding Author
Fergal Kavanagh.
Department of Otorhinolaryngology,
Head and Neck Surgery,
Galway University Hospital,
Newcastle Road,
Galway
Email: fergalkavanagh@rcsi.ie

 

References

1. Keogh I., O'Connor T., Coughlan D.. HPV and Head and Neck Cancer. Cancer Professional: Autumn 2013; Vol 7, (3)
2. Marur S, D’Souza G, Westra WH, Forastiere AA. HPV-associated head and neck cancer: a virus-related cancer epidemic. Lancet Oncol. 2010 Aug;11(8):781–9.
3. O’Rorke MA, Ellison MV, Murray LJ, Moran M, James J, Anderson LA. Human papillomavirus related head and neck cancer survival: A systematic review and meta-analysis. Oral Oncol. 2012; 48(12): 1191–201.
4. Doorbar J. Molecular biology of human papillomavirus infection and cervical cancer. Clin Sci (Lond) 2006; 110:525.
5. Harald zur Hausen; Papillomaviruses Causing Cancer: Evasion From Host-Cell Control in Early Events in Carcinogenesis, JNCI: Journal of the National Cancer Institute, Volume 92, Issue 9, 3 May 2000, Pages 690–698
6. Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MCB, Su J, Xu F, Weinstock H. Sexually Transmitted Infections Among US Women and Men: Prevalence and Incidence Estimates, 2008. Sex. Transm. Dis. 2013;40:187–93..
7. Schiffman M. A 2-Year Prospective Study of Human Papillomavirus Persistence among Women with a Cytological Diagnosis of Atypical Squamous Cells of Undetermined Significance or Low-Grade Squamous Intraepithelial Lesion. The Journal of Infectious Diseases, Volume 195, Issue 11, 1 June 2007, Pages 1582–1589
8. Trottier H, Franco EL. The epidemiology of genital human papillomavirus infection. Vaccine 2006;24:S4–S15.
9. Ryerson AB, Peters ES, Coughlin SS, Chen VW, Gillison ML, Reichman ME, Wu X, Chaturvedi AK, Kawaoka K.. Burden of potentially human papillomavirus-associated cancers of the oropharynx and oral cavity in the US, 1998–2003. Cancer. 2008;113:2901–2909
10. Nasman A, Attner P, Hammarstedt L, Du J, Eriksson M, Giraud G, Ahrlund-Richter S, Marklund L, Romanitan M, Lindquist D, Ramqvist T, Lindholm J, Sparén P, Ye W, Dahlstrand H, Munck-Wikland E, Dalianis T.. Incidence of human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm, Sweden: an epidemic of viral-induced carcinoma? Int J Cancer. 2009;125:362–366.
11. Coughlan, D., O'Connor, T., Pai, S. I., Westra, W. H., Frick, K. D., O'Neill, C., & Keogh, I. J. (2013). Oncopolicy in high-income countries can make a difference in HPV-related Head and Neck Cancer. Journal of Cancer Policy, 1(3-4), e49-e51.
12. Kreimer AR, Clifford GM, Boyle P, Franceschi S.. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomarkers Prev. 2005;14:467–475.
13. Frisch M, Hjalgrim H, Jaeger AB, Biggar RJ. Changing patterns of tonsillar squamous cell carcinoma in the United States. Cancer Causes Control. 2000;11:489–495.
14. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26:612–619.
15. Jemal A, Simard EP, Dorell C, Noone AM, Markowitz LE, Kohler B, Eheman C, Saraiya M, Bandi P, Saslow D, Cronin KA, Watson M, Schiffman M, Henley SJ, Schymura MJ, Anderson RN, Yankey D, Edwards BK.. Annual Report to the Nation on the Status of Cancer, 1975–2009, Featuring the Burden and Trends in Human Papillomavirus (HPV)–Associated Cancers and HPV Vaccination Coverage Levels. J. Natl, Cancer Inst. 2013; 105 (3): 175-201
16. Turner CF, Danella RD, Rogers SM. Sexual behavior in the United States 1930–1990: trends and methodological problems. Sex Transm Dis. 1995;22:173–190.
17. D’Souza G, Kreimer AR, Viscidi R, Pawlita M, Fakhry C, Koch WM, Westra WH, Gillison ML. Case-control study of human papillomavirus and oropharyngeal cancer. N. Engl. J. Med. 2007; 356(19): 1944–56. 
18. HPV vaccine uptake in Ireland: 2016/2017. Department of Health. Publication Date: 11 January 2018.
19. MacDonald S, Macleod U, Mitchell E. Factors Influencing Patient and Primary Care Delay in the Diagnosis of Cancer. Final report to the Department of Health.
20. Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB, Kamemoto LE, Killeen J, Ning L, Goodman MT.. Transmission of human papillomavirus in heterosexual couples. Emerg Infect Dis. 2008;14:888–894.
21. Coughlan D., Keogh I., O’Connor T.. The Jade Goody Legacy Has Undoubtedly Saved Lives, But What Will be the Michael Douglas Effect? Ir Med J. 2013 Jul-Aug;106(7):197-8

 

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