Leslie Laine: Welcome to Premier Health Now On Air. Today we're talking about a virus you have probably encountered, some 80 million Americans have it and odds are don't even know it. Some doctors say it's more common than the common cold but it has the potential to be much more serious. It's human papillomavirus. The bad news, it can cause cancer. The good news, there's a safe and effective vaccine. Stay with us to learn what you should know and what you can do.
Leslie Laine: I'm your moderator Leslie Laine. with me today are two specialists who are very familiar with the damage human papillomavirus, known as HPV, can do. From Premier ENT Associates, we have Dr. Sameep Kadakia. Thank you so much for joining us.
Sameep Kadakia: Thank you for having me.
Leslie Laine: And from Premier Surgical Oncology, Dr. James Ouellette. Welcome to you.
James Ouellette: Thank you very much.
Leslie Laine: Now, there isn't just one human papillomavirus. There are many. So let's start there. What do we need to know about what this virus is and what it isn't?
James Ouellette: The important thing to know there are definitely subtypes of the virus and we know that there are some of the subtypes that do contribute to the cancer causes that we are here talking about. So all HPV doesn't necessarily imply that it will lead to a cancer of some sort. The specific subtypes are the ones that we try to enhance the vaccination for because those are the ones we know to be dangerous. Most of the people, as you stated earlier, don't know they have the virus and they probably won't be affected through most of their lives. However, it's the ones with the bad actor subtypes that lead to the various cancer causes that we're hoping to impact.
Leslie Laine: There are a lot of questions now, just based on what you've said. Let's start with how it's transmitted. How does the virus get passed?
Sameep Kadakia: Well, the most common ways that it's transmitted is, A, through sexual contact. That's the more common way that we know it to be transmitted, but interestingly, it can also be transmitted by what we call vertical transmission during the birth process actually.
Leslie Laine: Can you explain more about that, because I don't quite follow that.
Sameep Kadakia: Sure. So during the birth process, if a mother has the human papillomavirus, then oftentimes children that are born to that mother can also be inoculated with that virus, and similar to what Dr. Oullette had mentioned, not a lot of those patients are going to have any kind of manifestation of the virus, but one of the things we do find are that there are a number of kind of throat and airway issues that can be as a result of that virus that actually we see even in young children, and for those young children, obviously they haven't participated in sexual contact, so the other way that they had gotten the virus was during the birth process.
Leslie Laine: Do we know if that's a very common transmission route?
Sameep Kadakia: It's very difficult to say because all of those patients are not routinely screened for the virus, as most of us are usually not screened for the virus, but it ends up being a smaller subset of those patients that actually go on to develop different ailments of the head and neck.
Leslie Laine: Well since we're talking about different subtypes and which ones develop into problems, if I can have HPV with no symptoms and no health problems, but that's not always the case, then let's talk about what kind of damage this virus can do when it does cause problems? What happens? What's going on?
James Ouellette: As with other viruses that lead to different types of cancers, this virus essentially kind of implants in really the mucosal surfaces is where we see it, and that's why we see it in the mouth, throat, the cervix, various locations like that, the anus as well. Those are the places where we see a lot of the cancers develop from those kind of bad actor subtypes and it changes the cells, like any type of damage can, but this is more of a virus that is causing damage to the natural cells and the process of developing a cancer is disrupting the normal cycle of cells. So we have cells throughout our body, they routinely die off, the body discards them, they routinely divide. The body checks these cells as they change and gets rid of the bad ones. And what happens with cancers is those cells change and either they're not recognized as bad or they're proliferating or changing so fast that they actually develop into tumors.
Leslie Laine: Are there any signs, any visible signs?
Sameep Kadakia: Do you mean when tumors are beginning?
Leslie Laine: That you have these bad actor cells working? Yes.
Sameep Kadakia: Well, it's a great question because actually before you develop a tumor or before you develop an actual physical manifestation, there may not be signs. And as we alluded to earlier, many of us may be inoculated with one or more of those strains of HPV, but only when you start seeing the physical change in your body is when you'll begin to know. And part of that is because there aren't a lot of routine screening guidelines for those particular types of HPV viruses.
Leslie Laine: So what kind of cancers are you most concerned about with HPV? Because you're an ENT, and you are a-
James Ouellette: Surgical oncologist.
Leslie Laine: Surgical oncologist. So let's talk about which cancers do you see.
Sameep Kadakia: So typically as far as the head and neck goes, we see that HPV, and again, I'm not going to use the word causes because what we find is that it is a risk factor, it is associated, but we can't claim true causality, but what we find is that there is a higher association with the part of the head and neck that we call the oropharynx, and by the oropharynx what we mean is the part of the mouth that basically includes the back of the tongue, what we call the tongue base, the tonsils, and kind of the posterior pharyngeal wall, meaning sort of your throat, quote unquote. That's the area that's the most associated and really the most studied in terms of HPV.
Sameep Kadakia: The other parts of your mouth and your throat, including parts of your tongue, the mucosa on the inside of your cheek, your voicebox, yes, it can be associated, but it's not a very strong association. It's really only with the back of your mouth.
Leslie Laine: And Dr. Oullette?
James Ouellette: I'm not necessarily involved in all of these types of cancers, but we certainly need to know how they're manifested, and some of the cancers we see are... Anal cancer is probably the one I see the most that's HPV-related, but our gynecologic oncologists see also cervical cancer, vulvar cancer, our urologists will see penile cancer as manifestations of the bad viruses.
Leslie Laine: What do we know about who's most at risk? The American Cancer Society statistics that I've seen suggest about twice as many women as men develop cancers from HPV.
Sameep Kadakia: That may be true for certain subtypes. So for example, for cervical cancers of course, but interestingly in the head and neck, we find that a lot of patients that are developing HPV associated tonsil cancers or HPV associated base of tongue cancers end up being young males actually.
Leslie Laine: When you say young, what kind of age range are you talking?
Sameep Kadakia: I've seen them in their 20s and 30s. I'd say probably 30s to 50s is probably the most common range.
James Ouellette: Some of the reasons we see this more in females is really cervical cancer. Cervical cancer has a high prevalence and even though there's screening like Pap smears, which hopefully can pick up the virus actually before it becomes a problem, it is important to make sure that those things are done, and that's actually one of the very few screening tests that have an impact on HPV.
Leslie Laine: And these are the kinds of screenings that would turn up something that we usually hear as a precancerous condition?
James Ouellette: Correct. The gynecologists will find dysplasia or some type of change in the cells on a Pap smear and that would hopefully prompt then treatment early in that pre-cancerous stage when really then there's no need for any major treatment.
Leslie Laine: So it sounds like there's no treatment for the virus, but there might be or there are treatments for the cancers. Have I got that straight?
Sameep Kadakia: That's correct.
James Ouellette: Correct.
Leslie Laine: Okay. So since 2006 we have had a vaccine for HPV that is expected, according to the American Cancer Society, to prevent 90% of HPV cancers if it's given before the young person is exposed to the virus. So who should get the vaccine and when should they get it?
James Ouellette: So we really promote that young teens, children 11 to 13, should start the process of getting the vaccination and we certainly look to our primary doctors to do this because they are really in control of the vaccination schedule and talking to the parents, because really this is not a child who's going to make this decision, it's their parents. And with the proliferation of vaccines, I actually had someone talk to me the other day, and say, "Well, when I was a kid I got four vaccines," and they brought a young child in who needed six at once and there was a schedule that's pretty extensive.
James Ouellette: I wouldn't even try to speak to all the vaccines that our primary physicians have to discuss with parents as children come in for their well visits, but this is another one, and the hard thing for people to, I think really grasp, is that you're doing a vaccine to a child in order to prevent something from being a problem for them 20 years from now.
Leslie Laine: What do we know about the length of protection? Because 2006 is not that long ago.
James Ouellette: Correct. It's not that far away. So really what we have to date, and this is from the information we have from the CDC, is that when they look at the quality of vaccination, even 10 years out on patients who are vaccinated early, that it does not seem to have diminished their immunity. So that's a positive. Obviously that will need to continue to be evaluated. We don't know if those need boosters or if there's an age where it does sort of start to decrease the effectiveness.
Leslie Laine: So right now, what is the schedule? You mentioned not having a booster. Is it a one time thing, a series?
Sameep Kadakia: For women at least what they recommend is that before the age of 24 to 26 depending on the source you look at, that they've completed I believe a three vaccine cycle. For males, I know now they are also kind of championing them getting the vaccines also, but to my knowledge, there isn't an exact schedule yet.
Leslie Laine: And age wise for men?
Sameep Kadakia: Same thing. They recommend having it completed by the early to mid 20s.
Leslie Laine: So if you didn't get the vaccine during your childhood or teen years, is there any value in getting it later?
James Ouellette: Interestingly, we would recommend that people are vaccinated long before there's any potential transmission and that's why the age ranges is young. It's supposed to be young so that we catch things long before there's any contact, and what we've discovered and what they've worked on over the past several years is how far or how old can a person be before we might still see some effectiveness of the vaccine, and initially it went up to 24, 24 to 26 range and recently, and it was just probably as close as the end of 2018 they extended those recommendations to up to 45 years old.
Leslie Laine: So this is a talk to your primary care doctor about this question?
James Ouellette: Correct.
Sameep Kadakia: Absolutely.
James Ouellette: Yes. Obviously you can make your own decisions at that point. However, we don't necessarily expect the cancer development to be a quick event and we don't know if we're preventing things that may happen five, 10, 15, 20 years down the line. And so we certainly hope to see changes in the incidence of these HPV related cancers, but we may not see those for another 10 to 20 years when those vaccinated reach the age where those cancers potentially develop.
Leslie Laine: And based on what you're saying, it sounds like even if a baby was exposed during birth, the vaccine could still have some protection. Am I understanding that correctly? Even though they might have been exposed, that there would be some mechanism that the vaccine would create in the body that would lead to some protection against development of cancers?
Sameep Kadakia: Sure, it absolutely could.
James Ouellette: And the reason we want to do that is because, again, there are strains that are carcinogenic and there are strains that are essentially irrelevant to human life, and the problem is we don't know who has which one.
Sameep Kadakia: Right.
Leslie Laine: For people who are concerned about vaccine safety, what do the studies show about the general experience with this vaccine with side effects or the ingredients?
Sameep Kadakia: Like with any vaccine, the actual administration of the vaccine can always be accompanied by some redness of the skin, some swelling. Some people can have some flu like symptoms, but overall it's thought to be a very safe vaccine. Of course, if you were to look at a very, very small minority, and again this could apply to even the vaccine we get for the flu for example, that people could have some very, very rare side effects. But overall it's thought to be a very safe vaccine.
Leslie Laine: So do we know if there are people who should not get the vaccine?
Sameep Kadakia: Well, it seems like anybody who has had a severe reaction, an allergic reaction to a prior vaccine, should probably hold off on getting this vaccine until they've either been treated or they've been desensitized.
Leslie Laine: And I think we said before, but just to confirm, that many of us who were probably exposed to the virus long before the vaccine arrived, there are not very many tests to check for HPV.
James Ouellette: That is correct. The typical kind of well screen exams are really the only things that we have, short of the Pap smear which we mentioned earlier. The Pap smear was developed obviously for cervical cancer many years ago. However, with a regular screening it can pick up these changes early. For many of the other manifestations, you really only have your general physical exam. If you are experiencing any symptoms, you really should have your doctor evaluate those, and I don't want to speak for my ENT colleague, but having a head and neck exam by especially your dentist, which is probably the most likely person to be in your mouth and throat, is a good thing. So it really is important for our communication with our dental colleagues that their exam is extremely important. They know this, but I think patients also should know that that's an important part of actually getting to the dentist and making sure that they don't find anything that's abnormal or something that they can tell needs to be further evaluated.
Leslie Laine: So in terms of HPV, we can consider our dentist another primary care provider helping us to stay well.
Sameep Kadakia: Absolutely. And like Dr. Oullette was mentioning, anytime that a new physical manifestation comes about or if a patient comes in and they've complained about a new lump or bump forming in their mouth, oftentimes before they get to one of us, they'll either have seen their primary care doctor or their dentist, and many times what we also find is that patients are seen by their dentists for a routine oral cavity exam or a cleaning and something is found that the patient may not have even known about, and those types of situations are very, very useful for us because the dentists, again, like Dr. Oullette said, they're the ones that are going to be specifically screening for these things on their general physical exam, and by doing so they can pick up lesions at a very, very early stage.
Sameep Kadakia: One other interesting technology that has come about, and it's not commonplace by any means, but there are some practices that are beginning to experiment with a oral cavity swab now. So similar to a Pap smear, there are some companies that have put out an oral cavity swab, which the accuracy of it is questionable. I don't know if a lot of large scale studies have been performed on it, but the thought being that some of these swabs may be able to test for early cancerous lesions as well.
Leslie Laine: Well, if there is one thing about HPV that you would like our listeners to take away from this discussion today, what would that be?
James Ouellette: So I think the biggest thing to take away is this is really a parent decision for a child, not for today, but really for a generation. And so that's the hardest part. We're communicating not necessarily to the people who need it, though I think any parent out there understands that you do things for kids so that they will be protected and better in the future and this is really just another one of those things.
Sameep Kadakia: And I would also add that I think this also kind of speaks to how important it is for everyone to have regular followup with their primary care physician, if you are a woman, then with your OB/GYN also, and for everyone to have good dental evaluations as well. I think nowadays they recommend that at least dental evaluations should be done every six months or so for cleanings and exams, so I think it's very important for us to at least partner with those colleagues and really for the general public to recognize how important those preventative screenings are.
Sameep Kadakia: At the same time, I think it also speaks to the fact that no matter how healthy you are, whether you eat well, you exercise, if you have medical problems, no medical problems, nobody is really immune to having cancer, and I think being aware of that should push all of us towards getting to our primary care physicians and those individuals that are in charge of the screening process.
Leslie Laine: Well, we have to thank you both for a very enlightening discussion today. Our guests have been Dr. Sameep Kadakia with Premier ENT Associates and Dr. James Oullette Premier Surgical Oncology. If you want to know more, visit premierhealth.com/healthnow. We'll be back and we hope you will. I'm Leslie Laine and thanks for joining us. Watch for our next edition of Premier Health Now On Air.
