Position Statement: Human Papillomavirus (HPV) Vaccination for Prevention of HPV-Related Oropharyngeal Cancer
Over the past three decades, there has been a clear decrease in the prevalence of tobacco use in the United States and an associated decline in tobacco‐related head and neck cancers.1 The incidence of Human Papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC), however, has been increasing at a dramatic rate, with HPV now being observed in over 70% of these tumors.2,3 Recent data suggests that the incidence of HPV‐related OPSCC in men exceeds the incidence HPV‐related cervical cancer. 4 Despite these statistics, public awareness of HPV‐related OPSCC remains low.5 Since 2006, the Food and Drug Administration (FDA) has approved three commercially available vaccines aimed at preventing HPV infection, Gardisil‐4 (Merck & Co.), Cervarix (GlaxoSmithKline), and recently, Gardisil‐9 (Merck & Co.). Gardisil‐4 is currently recommended by the Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) for use in females between 9 to 26 years of age and males between 9 to 21 years of age, with the option to vaccinate up to age 26 for certain high‐risk individuals.6
These HPV vaccines have been shown to be safe, with no serious adverse events being reported in numerous large studies with over 10 years of follow‐up. 7,8,9,10,11 Moreover, vaccine efficacy of over 93% was observed for preventing oral HPV infection when compared to control, suggesting the potential to prevent HPV‐related OPSCC. 12 While these vaccines have clearly demonstrated their ability to prevent anogenital HPV infection and premalignant lesions, as well as genital warts, a trial proving prevention of HPV‐related OPSCC or even a precursor lesion will be prohibitively difficult. This is primarily due to the inability to reliably screen for oropharyngeal premalignancy, the relative rarity of OPSCC, and the extended latent period between HPV infection and clinical cancer development.
Despite the safety of these vaccines and their potential benefit, uptake in the United States, especially in males, has been poor, 13, 14, 15 with lack of physician recommendation and low public awareness being primarily to blame. This is particularly relevant since males make up the majority of patients who develop HPV‐related OPSCC. 2,16 Moreover, since prevention of OPSCC is not currently a FDA‐approved indication for HPV vaccination, advertising this association is difficult.
It is clear that, without a definitive change to current HPV immunization practices, the HPV‐related OPSCC epidemic will continue. Therefore, based on the observed link between HPV infection and the majority of OPSCC and the safety and efficacy shown of the currently available HPV vaccines in preventing HPV infection, the American Academy of Otolaryngology‐ Head and Neck Surgery and the American Head and Neck Society strongly encourage HPV vaccination of both boys and girls for prevention of OPSCC and anogenital cancers. We hope that this endorsement will encourage more widespread implementation of these vaccines, especially in boys, and thus decrease the future burden of HPV infection and HPV‐related OPSCC.
- Sturgis, E. M. & Cinciripini, P. M. Trends in head and neck cancer incidence in relation to smoking prevalence: an emerging epidemic of human papillomavirus‐associated cancers? Cancer 110, 1429‐1435 (2007).
- Chaturvedi, A. K. et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol 29, 4294‐4301 (2011).
- Saraiya, M. et al. US Assessment of HPV Types in Cancers: Implications for Current and 9‐Valent HPV Vaccines. J Natl Cancer Inst 107, (2015).
- Siegel, R. L., Miller, K. D. & Jemal, A. Cancer statistics, 2015. CA Cancer J Clin 65, 5‐29 (2015).
- Luryi, A. L. et al. Public awareness of head and neck cancers: a cross‐sectional survey. JAMA Otolaryngol Head Neck Surg 140, 639‐646 (2014).
- Markowitz, L. E. et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 63, 1‐30 (2014).
- Stokley, S. et al. Human papillomavirus vaccination coverage among adolescents, 2007‐2013, and postlicensure vaccine safety monitoring, 2006‐2014‐‐United States. MMWR Morb Mortal Wkly Rep 63, 620‐624 (2014).
- Naud, P. S. et al. Sustained efficacy, immunogenicity, and safety of the HPV‐16/18 AS04‐adjuvanted vaccine: final analysis of a long‐term follow‐up study up to 9.4 years post‐vaccination. Hum Vaccin Immunother 10, 2147‐2162 (2014).
- Joura, E. A. et al. A 9‐valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med 372, 711‐723 (2015).
- Scheller, N. M. et al. Quadrivalent HPV vaccination and risk of multiple sclerosis and other demyelinating diseases of the central nervous system. JAMA 313, 54‐61 (2015).
- Scheller, N. M., Pasternak, B., Svanstrom, H. & Hviid, A. Quadrivalent human papillomavirus vaccine and the risk of venous thromboembolism. JAMA 312, 187‐ 188 (2014).
- Herrero, R. et al. Reduced prevalence of oral human papillomavirus (HPV) 4 years after bivalent HPV vaccination in a randomized clinical trial in Costa Rica. PLoS One 8, e68329 (2013).
- Elam‐Evans, L. D. et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13‐17 years‐‐United States, 2013. MMWR Morb Mortal Wkly Rep 63, 625‐633 (2014).
- Lu, P. J. et al. Human papillomavirus vaccine initiation and awareness: U.S. young men in the 2010 National Health Interview Survey. Am J Prev Med 44, 330‐338 (2013).
- Jemal, A. et al. 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 105, 175‐201 (2013).
- O’Rorke, M. A. et al. Human papillomavirus related head and neck cancer survival: a systematic review and meta‐analysis. Oral Oncol 48, 1191‐1201 (2012).