Ten years ago, oral cancer among women was practically unheard of. Patients were nearly always male and over 50, heavy smokers or drinkers, or both. (When actor Michael Douglas was diagnosed with the illness, the media pointed to his longtime half-a-pack-a-day habit.)
But according to the Journal of Clinical Oncology, there has been a major upswing in HPV-related oropharyngeal cancer, a deadly disease often found in the base of the tongue and the tonsils.
In fact, up to 20% of all oral cancers are now HPV-related, according to the World Health Organization (WHO), and about 25% of cases occur in women, some as young as 19, says oncologist Dr Gregory Masters.
But how could HPV be causing so many mouth problems? It’s something doctors and health experts have long feared, thanks to the rampant spread of the virus.
You’ve probably heard the stats: one in 35 women in South Africa will develop cervical cancer, predominantly caused by HPV. About 21% of SA women are estimated to harbour a cervical HPV infection at any time. What’s more, the virus – which can have zero symptoms or bloom into visible warts – will affect up to 80% of sexually active women.
In the majority of cases, the body’s immune system will clear up the HPV within two years (there is some debate over whether the same HPV infection can return to cause cervical lesions later, but research is in the early stages).
However, some infected SA women – around 6 000 per year – will not clear and may develop cervical cancer. This has prompted the WHO to recommend that girls be vaccinated for HPV by age 12.
To date, safe-sex campaigns have blamed the spread of HPV on unprotected vaginal sex. But it’s now clear that the disease can be contracted orally too. Thousands of women’s mouths were infected with HPV-16, the strain that most doctors believe is responsible for the majority of HPV-related oral cancers.
How long HPV-16 lingers in the mouth before turning into cancer is uncertain. But what is evident is that more than 14% of cases aren’t caught until the very late stages, possibly because some doctors are slow to consider the cancer in young female patients.
Since HPV-related oral cancers don’t affect the traditional group of those at risk for mouth cancer, a lot of these cases are missed or diagnosed late. Usually, the patient is healthy, exercises and eats well. She doesn’t fit the old oral cancer profile.
Healthy or not?
Lydia Miner definitely didn’t fit the profile. She had a healthy diet, worked out and didn’t smoke or drink much. But she had a strange sensation in her throat that felt like a pill, stuck midway. Or, she thought, it was skin irritated by one of the times she’d hurriedly choked down lunch during her hectic job. “I thought I was just imagining it,” says Lydia, now in her forties. But after two months, she knew better.
She got a scan, which showed something alarming. “The doctor stared at the results, then turned to me and said, ‘I think you have oral cancer,’” she recalls. Her small malignant tumour, which was surgically removed, tested positive for HPV. Lydia was incredulous. She hadn’t thought about the virus in over a decade.
In her twenties, Lydia had had a series of abnormal Pap smears, but by her thirties, her results continuously came back normal and she’d forgotten about any irregularities. But HPV is nothing if not sneaky; it can lie dormant and undetectable in the body for years, making it incredibly difficult to know if you’re infected and unknowingly passing it along to others.
This can also make it nearly impossible to pinpoint the partner responsible for giving it to you. (Meaning, that one-night stand you had in your teens or the guy you dated seriously in varsity can come back to haunt you well into your thirties and beyond.)
Though between 40 and 60% of guys have HPV at any given time, less than 1% will have visible symptoms. What all this means is that oral sex puts you at risk of picking up a cancer-causing virus, not just the host of venereal diseases such as HIV.
The most obvious HPV-related oral-cancer risk factors have to do with the kind of sex you have, how often you have it and the number of partners you’ve tangled sheets with.
According to a study in the New England Journal of Medicine, people who have had six or more sex partners are more than twice as likely to develop oral cancer. But those who’ve had six or more oral sex partners increase their chances by a whopping 340%. As such, says Dr Masters, HPV-related oropharyngeal cancer should be considered a sexually communicable disease.
“From cases I see, I get the sense that many younger people don’t think oral sex counts as sex,” he says. “But oral sex has risks too.”
As is the case with most STIs, the best way to protect yourself from HPV-related oral cancer is abstinence, which isn’t realistic for most people.
“Honesty about your sexual history and having an HPV vaccination should also be considered,” says Dr Di Marais, a virologist at the University of Cape Town, who is working on research in South African communities to determine the factors affecting oral transmission of HPV.
Using condoms for any sexual contact, including oral sex – and even with a committed partner – can also help thwart the genital-to-mouth spread of HPV, though it’s naive to think couples will commit to a lifetime of wrapped-up oral sex.
(For their part, men or women can get oral HPV by performing oral sex on a woman with vaginal HPV, with or without using a dental dam.)
Michael Douglas reportedly tested positive for HPV, and while there’s no concrete link between his cancer and the STD, cases of HPV-related oral cancer are also rising among men.
If this advice sounds thin, that’s because it is. A lot of HPV research still needs to be done. For one thing, determining how STIs spread depends in part on the truthfulness of patients and test subjects. “It’s tough to get figures on sexual habits, because you’re relying on people’s memories and forthrightness,” says Dr Masters.
The good news
If detected early, this type of cancer is treatable. Compared with other forms of mouth malignancies, HPV-related oropharyngeal cancers have significantly higher survival rates, especially among non-smokers. “For reasons we’re not sure of, HPV-related cancers respond better to chemo and radiation,” says Dr Masters.
“The majority of patients are cured not only because they are generally younger and more tolerant of treatment, but also because the cancer behaves differently.” The problem, says Dr Carlos Fernandes, an ENT surgeon based in Durban, is that oral cancers, in particular tonsil carcinoma, are frequently diagnosed late because they are silent in the early stages.
“Stage at diagnosis has not changed much over the past 50 years,” he says. “The major causes in South Africa are still HIV, alcohol abuse and smoking, but I have noticed an increase in oral cancer in patients who don’t smoke or gave up smoking decades ago. I think HPV is a more common cause of oral cancer than we think.”
So the key is to catch it early, which in most cases means spotting a lesion or a change in mouth tissue colour or texture. It also means seeing your dentist regularly, says Dr Fernandes.
Tests using rinses, dyes and different types of light can be used by oral specialists to administer comprehensive oral-cancer screenings, but many dentists are already actively peering into patients’ mouths, on red alert for cancerous signs. (While all dentists are educated in cancer screenings, not all perform them, so it’s crucial to ask.)
Dr Howard Gluckman, a periodontist, says that while HPV can increase your risk of contracting oropharyngeal cancer (those that develop from the soft palate, base of the tongue, tonsil area and pharyngeal wall), there is a smaller risk linked to squamous cell cancers of the mouth which are commonly associated with the base of the tongue and floor of the mouth.
A good oral-cancer screening, says Dr Gluckman, includes a head, neck and lower-jaw examination, as well as checks of the lymph nodes, the front of the ears (where tumours can develop) and the back of the neck. And your tongue should be examined from every angle.
“We’re looking for subtle changes in colouration,” he says. “A white or black lesion, anything that causes pain and ulcers that won’t heal after 10 days should be investigated. White lesions in the mouth usually don’t cause pain but could be precancerous,” he warns.
In fact, the biggest problem with these types of cancers is that people typically don’t have many symptoms, and if you can’t see it or feel it, your dentist might not either.
“It’s important to see your dentist, not your doctor, if you have any concerns,” says Dr Gluckman. “Your doctor will probably offer you antibiotics or antifungals, but will not be trained to diagnose diseases of your mouth.” That reclining chair in your dentist’s room should still be your first stop.