Transcript Wisconsin HPV Vaccine Summit HPV-Related Head and

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)