Wednesday, October 8, 2008


One of the unfortunate aspects of letting someone like me loose with a column, is that, every once in a while I’m going to get up on a soap box and start preaching. This is one of those times. Cancer prevention is one of those things I take pretty seriously, because, of all the people I see every day I can be pretty sure that at least forty percent of them will die of the disease that I’m trying to cure them of. Some days that pisses me off. When I see my own colleagues acting like a bunch of nattering old ladies on an issue that has the potential to have a huge effect on reducing the number of young people that may have to walk through the doors of my cancer center, it really pisses me off.

In the August 21, 2008 issue of the New England Journal of Medicine they published a special article by Kim and Goldie titled Health and Economic Implications of HPV vaccinations in the United States that concluded that such a vaccination program may be cost effective. In the same issue there was a dire warning framed as an editorial by Haug that warned of the unknown adverse side effects of such a vaccination program. Unfortunately, I think the pundits from New England missed the boat. What we may unknowingly do by instituting such a vaccination program is that we may inadvertently prevent a whole bunch of cancers in other areas. The discussions that were presented limited themselves to discussing the value of vaccination against human papillomavirus (HPV) for the currently approved indication, the prevention of cervical cancer. This indication alone is a certainly sufficient to merit serious consideration of the benefits of such a program, cost effectiveness be damned, but when the discussion is expanded to include other malignancies associated with HPV the potential benefits are of a significantly larger magnitude.

An association of HPV and oral squamous cell carcinogenesis has been discussed since 1983 . Early studies which included all cases, and included leukoplakia, estimated that between 11 and 15% of these lesions had evidence of HPV DNA . In later studies looking at oral cancers in non-smoking individuals the percentage of those cases associated with HPV jumped to 60-78% . The increase that was seen was largely due to improved methods of detection of HPV DNA. When sub-type analysis was performed, it was shown that 70 % of oral carcinomas contained HPV 16 or 18 . Which are the same strains currently protected against by the commercially available vaccinations for cervical cancer.

In the United States in 2007 there were 11,150 new cases of carcinoma of the uterine cervix diagnosed, while there were 34,360 new cases of carcinoma of the oral cavity and pharynx. Carcinomas of the vagina, vulva, and anus have also been linked to HPV exposure, and when added together would account for another 15,000 cases of cancer that be impacted by a vaccination program. In my mind, the question we should be asking is not should adolescent females be vaccinated against HPV, but shouldn’t all adolescents be so vaccinated. Isn’t it worth considering the 14,507 cases of carcinoma that could be prevented in men by such a vaccination program?

Kim JJ, Goldie SJ. Health and Economic Implications of HPV Vaccination in the United States. N. Engl. J. Med. 359:821 Aug. 21,2008
2 Haug CJ. Human Papilloma Vaccination – Reasons for Caution. N. Engl. J. Med. 359:861 Aug. 21, 2008
3 Syrjanen, et al. Morphologic and Immunohistochemical Evidence Suggesting Human Papillomavirus (HPV) in Oral Squamous Cell Carcinogenesis. Int. J. Oral Surg. (6) 418-24 Dec. 12, 1983
4Gassenmaier A., Hornstein O. Human Papillomavirus DNA in Benign and Precancerous Leukoplakias and Squamous Cell Carcinomas. Dermatologica 176(5) 224-233.1988
5 Syrjanen, et al. Human Papillomavirus (HPV) DNA Sequences in Oral Precancerous Lesions and Squamous Cell Carcinoma Demonstrated by In Situ Hybridization. J. Oral Pathol. 17(6) 273-278 July 1988
6 Honig. Non-Radioactive In Situ Hybridization for Detecting Human Papillomavirus DNA in Squamous Cell Carcimona of the Tongue. Bull. Group Int. Rech. Sci. Stonatol. Odontol. 3-4(35) 107-115 Sept-Dec 1992
7 Woods, et al. Analysis of Human Papillomavirus DNA in Oral Squamous Cell Carcinoma. J. Oral Pathol. 22 (3) 101-108 Mar 1993
8 Barten, et al. [p53 alterations and HPV Status in Oral Squamous Cell Carcinoma]. Verh. Dtsch. Ges. Pathol. 78: 255-259 1994
9 Jemal, et al. Cancer Stastics 2007 . Ca Cancer J. Clin. 2007: (57) 43-66

No comments: