Page 8 • DNA Reporter May, June, July 2017 HPV and Cancer in Men: Something We All Need to Understand Jennifer F. Cormier, MSN, RN, OCN, AGPCNP–BC Jennifer Cormier earned her BSN from the University of Delaware in 1995, and her MSN from Wilmington University in 2013. Jen is a certified oncology nurse and board certified as an Adult Geriatric Nurse Practitioner. She has worked in radiation oncology for nearly 18 years as both an RN and now an NP and presently works at the Helen F Graham Cancer Center. She enjoys working with head and neck cancer patients and their families. Jen can be reached by email at email@example.com or at her office 302-623-4800. Jennifer F. Cormier When thinking of human papillomavirus (HPV), we usually associate this virus with women and cervical cancer. However, HPV linked cancer in men is occurring with increasing frequency in certain head and neck cancers. What is HPV? HPV is a DNA virus that affects the skin of the mouth, vagina, cervix, and anus and can be spread through skin to skin contact or anal, vaginal, or oral sexual activity. The Centers for Disease Control and Prevention (CDC) stated that “nearly all sexually active people” will contract HPV at some point but most infections will clear without causing symptoms (Prevention, 2017). While there are more than 100 different types of HPV, more than 40 types affect the genitals and are classified as “low risk” and “high risk.” For example, low risk HPV types 6 and 11 cause genital warts, but high risk HPV types 16 and 18 are associated with cervical cancer and some oropharyngeal cancers (“Icahn School of Medicine at Mount Sinai,” 2016; “Institute,” 2015). Since we are discussing men’s health in this DNA Reporter issue, I will focus on HPV and head and neck cancer in men. Are all head and neck cancers linked to HPV? When high risk HPV 16 enters the epithelial cells that line our mouth and throat, the oncoprotein E6 and E7 are produced. These proteins cause mutation of two suppressor genes (p53 and RB) that are critical for normal programed cell death. Without these suppressor genes, multiplication of the cell continues out of control, leading to cancer (Lie & Kristensen, 2008; “UniProt,” 2017). Most cancers of the head and neck involve the squamous cells that line the mouth, nose, and throat. These are referred to as squamous cell carcinoma and are classified further by the area from which they originate. The area classified as “oral cavity” includes lips (inner lining and outer), front portion of the tongue, gums, cheeks, floor of mouth, and hard palate. The area classified as the “pharynx” includes 3 sections: the nasopharynx, which is behind the nose or upper pharynx; the oropharynx which is the middle/soft palate area including base of tongue and tonsils; and the hypopharynx which is the lower part of the pharynx and includes the larynx/vocal cords and epiglottis which sits above the larynx. Cancers of the head and neck can also affect the paranasal sinuses, nasal cavity, and salivary glands. Alcohol and tobacco use has been shown to be contributing factors to cancers of the head and neck. The good news to report is that as tobacco use has declined, head and neck cancers associated with tobacco are also declining. The bad news is the incidence of oropharyngeal cancer (those involving the tongue and tonsils) has escalated. It is estimated that the prevalence of HPV driven oropharyngeal tumors has risen from approximately 16% in the mid to late 1980s to nearly 73% in the early 2000s (McKiernan, 2016). These HPV driven cancers are shifting the patient demographic to younger men who may not have any tobacco history. The prevalence is increasing fastest in Caucasian men, but is also seen in non-Caucasians as well (D’Souza et al., 2016). What does a diagnosis with HPV driven head and neck cancer mean to my patient? Treatment recommendations can include surgery, chemotherapy/ biologic modifiers, and radiation therapy, or a combination of these. Recommendations are made with the goal of best chance for cure while minimizing long term negative effects. Research has shown that patients with HPV positive tumors have a better response to therapies including chemotherapy and radiation therapy when compared to patients with HPV negative tumors. Some data shows survival rates over 90% even in advanced-stage disease (Miller & Shuman, 2016). Because of this improved response, ongoing research has demonstrated that even when there is a reduction in the total dose of radiation therapy, the outcomes are the same when compared to “standard” higher doses. In some cases, chemotherapy is replaced with a line of therapy called biological response modifiers that sensitize cells to radiation therapy (Reang, 2006). While those with HPV driven cancers have improved overall survival, patients are still at high risk for recurrence and second primary tumors, and therefore will need close follow up after therapy has been completed (Goon et al, 2009). While patients and their loved ones hear the positive message that they have been diagnosed with a type of head and neck cancer that has a better prognosis, they still face the challenges that any head and neck cancer patient faces, and some additional challenges as well. A multidisciplinary team approach is critical in the care of these patients as all patients receiving treatment to the oropharyngeal area will have some level of alteration in nutrition and comfort. Some will have swallowing dysfunction, difficulty with range of motion (including trismus), or general loss of strength due to weight loss or changes in nutrition. The severity of side effects varies depending on treatment modalities. In addition to these issues, patients also carry emotional and psychological stress. Depression and anxiety are common in patients with head and neck cancer, not only after diagnosis and during treatment
May, June, July 2017 DNA Reporter • Page 9 but even after treatment has been completed (McKiernan, 2016). In discussing with patients that they have an HPV driven cancer, some express guilt that they “caught” this virus. Spouses or significant others may feel sadness or anger thinking that their partner has been unfaithful. It is important to inform and support patients and their partners that the majority of adults that are sexually active have been exposed to HPV, and that researchers believe the time from initial HPV infection until tumor formation can be between 10 and 30 years (“Institute,” 2015). It is not yet understood why the virus can lay dormant for such a long period of time before causing cancer, and in some, may never lead to cancer. What can we do for patients? There is no cure for HPV, so the focus needs to be on prevention. Proper and consistent use of condoms is an important message for all patients that are sexually active. However, HPV can be transmitted from skin that is not covered by condoms, and patients need to be aware of this. The FDA has approved vaccines to prevent HPV infection, and the CDC recently updated their recommendations for the vaccine to “protect against cancers caused by HPV.” Boys and girls 9 to 14 years old should get two doses of the vaccine given at least 6 months apart, and those 15 to 26 years old still need three doses for adequate protection (Prevention, 2016). Regardless of the focus of care, an open, honest discussion with patients regarding HPV risk factors and prevention is necessary. HPV prevention needs to be discussed in the pediatrics/adolescent populations as well. Hopefully with the increase in vaccinations, we will eventually see a decline in these HPV driven cancers and we stay optimistic for a cure. References D’Souza, G. P., Westra, W. H., Wang, S. J., vanZante, A. M., Wentz, A. M., Kluz, N. M., . . . Klie, A. P. (2016, December 8). Differences in the Prevalence of HumanPapillomavirus (HPV) in Head and Neck Squamous Cell Cancers by Sex, Race, Anatomic Tumor Site, and HPV Detection Method. Retrieved from JAMA Oncology: doi:10.1001/ jamaoncol.20163067 Goon, P. K., Stanley, M. A., Ebmeyer, J., Steinstrasser, L., Upile, T., Jerjes, W., . . . and Sudhoff, H. H. (2009, October 14). HPV & head and neck cancer: a descriptive update. Retrieved from National Center for Biotechnology Information (NCBI): https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2770444 Icahn School of Medicine at Mount Sinai. (2016). Head and Neck Instisute - Oral Cancer. Retrieved from Mount Sinai Hospital: http://www. mountsinai.org/patient-care/service-areas/ent/ areas-of-care/head-and-neck-cancer/oral-cancer/ hpv-faq Institute, N. C. (2015, February 9). HPV and Cancer. Retrieved from Cancer.gov: https://www.cancer. gov/about-cancer/causes-prevention/risk/ infectious-agents/hpv-fact-sheet Lie, A. K., & Kristensen, G. M. (2008). Human Papillomavirus E6/E7 mRNA Testing as a Predictive Marker for Cervical Carcinoma. Expert Review of Molecular Diagnostics, 405-415. Retrieved from Medscape. McKiernan, J. N. (2016). Human Papillomavirus– Related Oropharyngeal Cancer: A Review of Nursing Considerations. AJN, 34-43. Miller, M. C., & Shuman, A. G. (2016). Survivorship in Head and Neck Cancer: A Primer. JAMA Otolaryngolgy- Head & Neck Surgery, 1002-1008. Prevention, C. f. (2016, October 19). CDC recommends only two HPV shots for younger adolescents. Retrieved from CDC Newsroom: https://www.cdc. gov/media/releases/2016/p1020-hpv-shots.html Prevention, C. f. (2017, January 3). Genital HPV Infection - Fact Sheet. Retrieved from CDC.gov: https://www.cdc.gov/std/hpv/stdfact-hpv.htm Reang, P. M. (2006, November 14). Biological Response Modifiers in Cancer. Retrieved from Medscape General Medicine: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1868326/ UniProt. (2017, January 29). Protein E6- Human papillomavirus type 16- E6 gene. Retrieved from UniProt: http://www.uniprot.org/uniprot/P03126
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