If you’re under age 30, you’ll probably never need to worry about getting cancer caused by the human papillomavirus (HPV). Incredibly, a vaccine can now prevent all six types of HPV-related cancer. But if you’re a middle-aged man, you’re currently facing an epidemic. Cases of HPV-caused throat cancer are skyrocketing in guys ages 40 and up who were infected pre-vaccine. There is some good news: Throat cancers linked to HPV are proving to be highly curable when caught early. Here’s how to make that happen so you can get back to living your best life.
We went to some of the nation's top experts on head and neck cancers to bring you the most up-to-date information possible.
Salvatore M. Caruana, M.D.Director of the Division of Head and Neck Surgery
Nadia Mohyuddin, M.D.Head and Neck Surgical Oncologist, Associate Professor of Clinical Otolaryngology
J. Kenneth Byrd, M.D.Chief of Head and Neck Surgery, Medical Director and Research Director
What Is HPV, Actually?
We know, we know, this article is supposed to be about throat cancer. But before we can dive into that, we need to understand a bit about its #1 cause: the human papillomavirus (HPV). There are more than 200 related strains of the virus, and if you’ve ever had sex, it’s highly likely you’ve already been exposed to it.
Statistically speaking, nearly all men and women will contract at least one type of HPV, which is spread by having vaginal, oral, or anal sex with someone who has it. Nine out of 10 of these HPV infections will go away on their own within two years, but sometimes they’re stubborn and hang around. If it’s one of the strains that causes cancer, that’s where the trouble starts.
Most strains of HPV are considered low risk—they usually cause no disease and when they do, you’re looking at warts around the genitals, anus, mouth, or throat. Not ideal, but better than cancer. Fourteen types of HPV are high risk, however, and two of them—HPV16 and HPV18—cause most cases of HPV-related cancer. The Centers for Disease Control and Prevention (CDC) estimates that HPV causes about 35,000 cases of cancer annually, including:
cervical, vaginal, and vulvar cancer in women
penile cancer in men
anal and throat cancer in both women and men
Head and neck cancers caused by HPV usually develop in the part of the throat behind the mouth. This area is known as the oropharynx and includes the tonsils, the soft palate, and the base of the tongue.
HPV is now responsible for 70% of these malignancies, known as oropharyngeal cancers, making them the most common form of HPV-related cancer. It's currently thought that HPV does not cause most other forms of head and neck cancer, including those in the mouth, lips, or salivary glands. (There have been very rare cases of potential HPV-related laryngeal cancers, but more research is needed.)
Risk Factors for HPV Throat Cancer
While the vast majority of throat cancers were once caused by tobacco and alcohol use, HPV has flipped that statistic on its head. Nonsmokers and never-drinkers are suddenly getting it, and the average age has dropped from over 60 to between 40 and 55.
The two biggest risk factors: The number of oral sex partners you’ve had and your gender. Men appear to be four to eight times more likely to get it than women, with white men having the highest rates, Asian and Pacific Islanders the lowest, and blacks and Hispanics somewhere in the middle.
So what’s gender got to do with it? It may be all about anatomical makeup. HPV infects the wet, mucous membrane surfaces of the body and the skin. When women contract HPV, the virus lives inside the vagina and its mucosal tissues, where antibodies are more likely to develop. For men, however, HPV is a skin-borne infection, where it’s less likely to trigger an antibody response.
This means that women are likely to build immunity to HPV with fewer sexual partners, whereas men can get repeated infections and may need 10 or more sexual partners before their body develops immunity. As a rule, the longer it takes to develop immunity to the virus, the greater the odds of contracting a strain that causes cancer. For this reason, the risk of HPV-positive throat cancer increases five-fold in people with six or more oral sex partners.
Let’s talk about sex for a minute. Between 1984 and 2004, the number of head and neck cancers caused by HPV quadrupled. Experts believe that’s a direct result of changes in sexual habits that occurred between the 1950s and 1970s, since it can take as many as 30 years for HPV to turn into cancer. To be blunt, experts say a rise in oral sex is the leading contributor to HPV throat cancer.
In 2006, the medical community began recommending the first HPV vaccine for young girls to prevent cervical cancer. Because the vaccine must be given prior to HPV infection in order for it to be effective, the idea was to inoculate tweens (who might become sexually active in their teens). It wasn’t recommended for boys, however, until 2011. For this reason, while cervical cancer numbers are declining, HPV-related throat cancers are still climbing.
As we close in on a decade of vaccine availability for boys, experts hope these numbers will begin to drop as well. One study found that the prevalence of oral HPV infections in young adults, including the two types that cause cancer, was 88% lower in those who received at least one dose of the vaccine (two doses are required before age 15, and three doses after that age).
Do I Have the Symptoms of HPV Throat Cancer?
Turns out, being infected with a high-risk strain of HPV itself does not cause any symptoms, so unfortunately, most people don’t suspect anything until the cancer begin to develop. Signs and symptoms to watch for may include:
A lump in the back of the mouth, throat, or neck
A sore throat that does not go away
A swollen tonsil
A white patch or sores in the back of the mouth that does not go away
Making a diagnosis requires several steps: A physical exam of the head and neck, followed by procedures that give your doctor a better look at what’s going on inside your throat, and a biopsy for official confirmation of cancer (or not). These are some of the tests your doc might give you:
In this procedure, a tube with an attached light and lens (endoscope), is placed in the back of the mouth or through the nose to examine your throat in more detail. The lens magnifies the area being examined so the doctor can better detect changes. Usually, you’ll be given an anesthetic spray to locally numb the area if you’re in the doctor’s office, but sometimes an endoscopy is done in an operating room while you’re under general anesthesia. If an area looks suspicious, your doctor can do a biopsy (see below) during the procedure.
Other tests can suggest the presence of cancer, but only a biopsy can confirm it. During this procedure, your doctor will remove some of the suspicious tissue for analysis by a pathologist. This can be done during an endoscopy or separately. The type of biopsy performed will depend on the location of the cancer.
Your pathologist will test the malignant tissue sample for the presence of HPV. This helps determine the cancer’s stage and the most effective treatment options.
Using a small amount of radiation, your doctor can get a picture of the inside of the throat.
This test checks your swallowing ability, which can be impeded by throat cancer. You’ll be given liquid barium to drink, along with an x-ray. Your doctor can view the liquid passing through your mouth and throat on a computer screen, revealing any irregularities in the throat.
CT (or CAT) Scan
This test takes pictures of the affected area from different angles, which are then combined into a detailed, three-dimensional image that can be used to measure tumor size, show spread to lymph nodes, and help your doctor decide if the cancer can be surgically removed.
Magnetic Resonance Imaging (MRI)
Instead of x-rays, an MRI uses magnetic fields, to produce detailed images of soft tissue such as the tonsils and the base of the tongue. There is no radiation involved in an MRI.
This test uses sound waves to create a picture of your internal organs.
Positron Emission Tomography (PET) Scan
This test helps determine if the cancer has spread. A small amount of a radioactive sugar substance is injected into your body and is visible via a computer. Areas of cancer will absorb more of the sugar, lighting up on the scan.
Determining Your HPV Throat Cancer Stage
The next step after diagnosis is called staging. Your doctor will take the results of all your tests and categorize your cancer as either Stage 1 (the earliest), 2, 3, or 4. To determine this, they use the TNM method:
Tumor (how big it is)
Node (has the cancer spread to your lymph nodes)
Metastases (has the cancer spread elsewhere in your body)
Cancer caused by HPV is also evaluated depending on whether any lymph nodes were removed during surgery. If lymph nodes weren’t removed (sometimes they can’t be or don’t need to be), you’d get what’s known as clinical staging. If they were, it gets a pathological staging—that’s why you see the little “p” before the “N” (node) ranking below. Here’s the breakdown.
HPV Throat Cancer Clinical Staging
Stage I: The tumor is 4 cm or smaller. If cancer has spread to lymph nodes, none of the cancer is larger than 6 cm and it only affects lymph nodes on the same side of the body as the primary tumor. Cancer has not spread to other parts of the body (T0 to T2, N0 or N1, M0).
Stage II: Either of the following applies:
The tumor is 4 cm or smaller. Cancer has spread to 1 or more lymph nodes on either side of the body, and none is larger than 6 cm. Cancer has not spread to other parts of the body (T0 to T2, N2, M0).
The tumor is larger than 4 cm or has spread to the epiglottis. If lymph nodes are involved, none of the cancer is larger than 6 cm. Cancer has not spread to other parts of the body (T3, N0 to N2, M0).
Stage III: Either of the following applies:
The tumor is any size. Cancer has spread to lymph nodes, and it is larger than 6 cm. There is no spread to other parts of the body (any T, N3, M0).
The tumor has invaded the larynx, muscle of the tongue, muscles in the jaw, roof of the mouth, or jawbone. Lymph nodes may or may not be involved. There is no spread to other parts of the body (T4, any N, M0).
Stage IV: Cancer has spread to other parts of the body (any T, any N, M1).
HPV Throat Cancer Pathological Staging
Stage I: The tumor is 4 cm or smaller. The cancer involves 4 or fewer lymph nodes. Cancer has not spread to other parts of the body (T0 to T2, pN0 or pN1, M0).
Stage II: Either of the following applies:
The tumor is 4 cm or smaller. Cancer has spread to more than 4 lymph nodes. There is no spread to other parts of the body (T0 to T2, pN2, M0).
The tumor is larger than 4 cm or it invades nearby structures. The cancer involves 4 or fewer lymph nodes. Cancer has not spread to other parts of the body (T3 or T4, pN0 or pN1, M0).
Stage III: The tumor is larger than 4 cm or it invades nearby structures. Cancer has spread to more than 4 lymph nodes. There is no spread to other parts of the body (T3 or T4, pN2, M0).
Stage IV: Cancer has spread to other parts of the body (any T, any pN, M1).
How Is HPV Throat Cancer Treated?
If your oropharyngeal cancer is caused by HPV, you’re lucky in one respect: Your cancer is more likely to be cured and treatment may be less intense than throat cancers caused by something else. Often, surgery and a course of radiation are all that’s needed.
Increasingly, removing a tumor in your throat is done via a less-invasive procedure called transoral surgery—performed robotically or as laser microsurgery—that has become the preferred method over the last decade. Larger tumors, however, may require a more traditional open surgery with an incision in the neck, or a mandibulotomy (a procedure that splits the jawbone to reach the tumor).
Depending on the extent of the cancer, these procedures might also involve a neck dissection, during which the affected lymph nodes are removed, followed by reconstructive plastic surgery to repair any damage that occurred as a result of removing the tumor.
Depending on whether your surgeon was able to remove all the cancer, radiation may not be necessary afterward. If it is recommended, the method of choice is a type of external-beam radiation therapy known as intensity-modulated radiation therapy (IMRT). This delivers more effective doses of radiation while reducing side effects and damage to healthy cells.
Usually, high-energy particles from radiation are aimed at the cancer’s location five days a week for six or seven weeks. In more advanced cases, research has shown that smaller, more frequent dose treatments can be most effective, so lower doses may be given twice a day, or the treatment may be done on an accelerated scheduled that includes two or more doses daily over three weeks instead of six.
These therapies involve cancer-killing medications that travel throughout the body via the bloodstream. They may be given intravenously or in pill form. Usually reserved for more advanced cases, these treatments include:
Chemotherapy: Chemo works by targeting cells that are rapidly dividing and growing—which is what cancer cells do—but the death of normal cells can occur, too, causing chemo’s notorious side effects like hair loss and nausea.
Targeted therapy: This is a new generation of more personalized medication that only attacks the cancer’s specific genes, proteins, and tissue that keep it growing.
Immunotherapy: These drugs boost the body’s natural defenses by teaching the immune system to recognize and attack cancer cells.
Living With HPV Throat Cancer
It’s not easy and treatment won’t be much fun, but if there’s a positive you can take away from an HPV-related throat cancer diagnosis, it’s knowing that your odds of a full recovery are significantly better than someone with throat cancer caused by smoking cigarettes. In fact, 85% to 95% of people with HPV-caused throat cancer will live five or more years after diagnosis, which is about as good as it gets with any type of cancer.
There’s not a ton you can do to alter the course of the disease once you receive this diagnosis, so your best bet is to closely follow the treatment plan your doctor lays out and stick with your regularly scheduled appointments. Committing to a healthy lifestyle is always a good thing, including eating fresh, whole foods (to the degree you throat pain will allow) and find time in your day for some form of physical activity, whether that’s walking, running, or hitting the gym.
You’ll probably have questions about your HPV throat cancer as time goes on, and that’s totally normal. Talk with your doctor and don’t be afraid to get a second opinion if treatment isn't working. The more you know, the smarter you can be about taking charge of your health.
People with HPV-positive throat cancers have a five-year survival rate of 85% to 90%, which is a stark contrast to the 25% to 40% survival rate of smokers and drinkers with advanced throat cancer. Experts believe this is because tobacco significantly damages cell DNA and also weakens the immune system, making it harder to fight the cancer. Alcohol use further compounds these problems.
Is HPV an STD?
Yes, HPV is the most common sexually transmitted virus in the U.S. HPV is spread through vaginal intercourse, anal and oral sex, and other skin-to-skin contact. It’s estimated that nearly all sexually active people will have an HPV infection at some point. When used correctly and consistently, condoms and dental dams can reduce your risk, but won’t completely prevent an HPV infection.
How long does an HPV infection last?
An infection usually clears in one to two years. There are no symptoms with the HPV strains that can cause cancer, so most people don’t even realize they have it. Sometimes, an HPV infection stays dormant in the body and then reactivates after many years. So if your partner suddenly tests positive for HPV, it may be due to reactivation rather than cheating (whew!).
Are my oral warts going to turn to cancer?
Not likely. The strains of HPV that cause warts in the mouth, as well as the genital area, are considered low-risk and don’t lead to cancer. In fact, the term “oral HPV cancer” is a misnomer. HPV only causes cancer in the back of the mouth, which is part of your throat. Cancers that develop in the front part of the mouth, known as the oral cavity, are not HPV-mediated.
Lower Dose Treatment for HPV Cancers:Frontiers in Oncology. (2019). “Deintensification of Adjuvant Treatment After Transoral Surgery in Patients With Human Papillomavirus-Positive Oropharyngeal Cancer: The Conception of the PATHOS Study and Its Development.” ncbi.nlm.nih.gov/pmc/articles/PMC6779788/