STDs...The Latest is...Head and Neck Cancer

Apr 29, 2011 | The HWN Team | Cutting Edge
STDs...The Latest is...Head and Neck Cancer


The incidence of head and neck cancer is going down. The bad news is another type of head and neck cancer is on the rise and is related to a common STI...HPV the same virus implicated in cervical cancer. Could oral sex play a role?

One of the first reports that suggest the involvement of HPV in head and neck cancer dates back nearly two decades ago and it was “greeted with incredulity.” Although there have been more scientific papers reporting that head and neck cancer, especially around the oral cavity is linked to HPV, there has been little information available to the public mainly due to the sensitivity of the issue. This is because the HPV-head and neck cancer connection would surely touch on the topic of oral sex.1-4

HPV infection is one of the most common sexually transmitted diseases in the world. It is estimated that 550,000 new infections occur each year in Canada, about 220,000 in the UK and around 6 million in the United States. At least 50% of the sexually active population get HPV at some stage. 

There was a time when the disease was simply called HPV. Nowadays, distinction has to be made between genital HPV and HPV infecting other parts of the body. Genital HPV is caused by more than 40 HP virus types. The most prevalent are types 6, 11, 16, and 18. The most common sign of HPV is the development of warts in the genital areas. Ninety percent of HPV infections clear naturally within a couple of years. The remaining 10% can cause cancer involving the sexual organs and the head and neck.5-7

Worldwide, head and neck cancer is the 6th most common malignancy. 

Due to smoking bans and stricter environmental guidelines in the workplace, the overall incidence of head and neck cancers is going down. Most of these develop in the mucosal surfaces in the head area such as the mouth, throat, tonsils, base of the tongue and nostrils and are usually classified as squamous cell carcinoma.8-10

Annually there are over 400.000 new cases diagnosed each year with about two thirds occurring in developing countries. 100,000 new cases occur in Europe, 30,000 in the U.S. and in Canada about 4300. In the U.S. it accounts for 3 to 5% of all cancer cases.11-13   

The incidence of oropharyngeal cancer is higher in males than in females with ratios ranging from 2:1 to 5:1. Exceptions are the Philippines and Vietnam where incidence is higher among women. For tonsillar cancer the U.S. Surveillance Epidemiology and End Results (SEER) reported the following rates per 100,000 person-years.14-16

  • 1.4 for white males
  • 0.4 for white females
  • 2.9 for black males
  • 0.6 for black females

Several environmental factors have been linked to head and neck cancers.

Use of tobacco products, which include smoking, chewing tobacco or snuff and other “smokeless” ways of using tobacco. 85% of head and neck cancers are due to tobacco use.

Use of alcohol. The combination of tobacco and alcohol use is a very strong risk factor for head and neck cancer. Michael Douglas had this cancer, linked to both smoking and alcohol consumption.

Other factors such as sun exposure, radiation exposure and exposure to occupational hazards such as asbestos and wood and nickel dust.

HPV infection – this was discovered when It became apparent that  15-20% of carcinomas involving  the tonsils and the throat were not linked to said risk factors, in fact they occurred among non-smokers and non-drinkers. This led to epidemiological investigations that found the link between HPV and these carcinomas.17,18

So, why is HPV related Head and Neck cancer so newsworthy?

While everyone by now knows the relationship between HPV and cervical cancer, most of the world is unaware of the increasing incidence of HPV related head and neck cancer. 60 to 70% of all tonsil cancers in the U.S. are linked to HPV whereas other studies report that 45 to 95% of oropharyngeal tumours are HPV-positive. In Central and Latin America, the International Agency for Research on Cancer (IARC) tested for HPV 16 in the following cancers and reported the positive cases:19-21

  • 4.4% in the oropharynx
  • 3.8% in the hypopharynx/larynx

In Australia, data from 2000 to 2005 reported 219 cases of tonsil cancer, 159 cases of tumors at the base of the tongue, and 110 cases in other oropharyngeal site, with the trend of increasing.22

HPV related head and neck cancer represents “a distinct subset of head and neck squamous cell carcinoma, independent of the traditional risk factors and with different clinical presentation and outcome."HPV related cancers are usually located in tonsils (tonsillar cancer) or back of the throat or at the base of the tongue. 

HPV-positive oral carcinomas have a different pathology than non-HPV oral cancers. “HPV-positive tumours are usually poorly differentiated and nonkeratinizing and have a basaloid appearance in contrast to the HPV-negative that is more moderately differentiated and keratinizing.” 70% of non-typical tumours contain HPV DNA, usually the E7 gene of HPV 16 subtype  indicating that this subset of carcinomas are the so-called HPV-positive oral tumours. HPV antibodies may also be detected in individuals with HPV-positive tumours.23

So, who is getting HPV related head and neck cancer?

Generally it’s the healthy and well-off segment of the population - in other words, people who are not your typical chain smoking alcoholics or junkies.  A study by Johns Hopkins scientists showed that patients with HPV-positive tumors are:

  • Younger, especially those with tonsillar cancer
  • more likely to be white
  • more likely to be male
  • married
  • college-educated
  • no history of smoking or excessive alcohol consumption24,25

Not surprisingly, this topic has become quite popular thruout the general media.

Although not well-publicized until recently, the risks for developing HPV-positive head and neck cancer is closely linked to sexual behaviour and practices such as having multiple sexual partners and oral sex. This may be attributed to the widespread practice of oral sex among the younger generation, which can be traced back to the early 70’s. Of interest marijuana use has also be studied as a risk factor, but so far its role remains unclear.26-29

One of the world’s leading pioneers on exposing the relationship of sexual practices and head and neck cancer, Maura Gillison MD, PhD, has published extensively on this subject, as well as others. Sexual behaviours associated with HPV-positive cancers included increasing numbers of lifetime vaginal or oral sex partners, participating in casual sex at least once, infrequent use of barriers during vaginal or oral sex, and having had at least one sexually transmitted disease.  People… who reported having a history of six or more oral sex partners were three times as likely to develop the cancer as people who reported that they had never had oral sex. Six or more oral sex partners increased risk for throat cancer by eightfold.'

Dr. Greg Hartig, professor of otolaryngology and head and neck surgery at the University of Wisconsin School of Medicine and Public Health in Madison summarizes it well: “The general consensus on the street is that because people's (sexual) practices have changed over time, we're seeing an increase in these cancers. I don't know why they're having more oral sex (but) the concept of having oral sex is something that seems less obscure to you than it did to your parents or grandparents".30

What about the current HPV vaccines?

Gardasil is quadrivalent and targets HPV types 6, 11, 16, 18 and Cervarix is bivalent and targets HPV 16 and 18. These vaccines were designed to prevent HPV infection that can lead to cervical cancer in women.31

Recently, Gardasil has also been approved for the prevention of anal cancer in men. However, there is currently no data to show whether these vaccines are also effective against HPV-positive oral tumours but studies are ongoing.

The Bottom Line

The silver lining behind the cloud is that the prognosis for most HPV-positive oral tumors is generally better than those that are HPV-negative. Clinical outcomes and survival are usually positive regardless of treatment strategies. This may be partly due to the fact that patients with HPV-positive tumors tend to be young and in good health. However, recently, a subgroup of highly aggressive HPV-positive oropharyngeal cancers has also been identified that needs to be studied closely.32

The take home message is…Modifying sexual behaviour is the key in preventing HPV and HPV-related cancers. Oral sex seems to be the main mode of transmission of oral HPV that leads to cancer although transmission by mouth to mouth contact through French kissing cannot be ruled out.

Staying in a strictly monogamous relationship and avoiding risky sexual behavior can probably prevent HPV infection and transmission. However, refraining from oral sex will probably significantly lower your risk.

Published April 29, 2011, updated July 25, 2012


  1. Scully S, Oral squamous cell carcinoma; from an hypothesis about a virus, to concern about possible sexual transmission, Oral Oncol. 2002 Apr;38(3):227-34
  2. Gillison M, Evidence for a Causal Association Between Human Papillomavirus and a Subset of Head and Neck Cancers, JNCI J Natl Cancer Inst (2000)  92 (9):709-720                                                                   
  3. Chaturvedi A, Incidence Trends for Human Papillomavirus–Related and –Unrelated Oral Squamous Cell Carcinomas in the United States, JCO February 1, 2008 vol. 26 no. 4 612-619
  4. D'Souza G et al, Case–Control Study of Human Papillomavirus and Oropharyngeal Cancer, N Engl J Med 2007;  356:1944-1956
  5. Facts about HPV, McGill University
  6. HPV in Canada, HPV 2010
  8. Head and Neck Cancers, We are MacMillan Cancer Support
  9. Head and Neck Malignancies Part1: Overview, CD
  10. 50 Facts about Oral, Head and Neck Cancer, Head and Neck Alliance
  11. Head and Neck Cancer, Canadian Society of Otolaryngology
  12. Mouth Cancer Foundation
  13. Marklund L et al, Impact of HPV in Oropharyngeal Cancer, J Oncol. 2011; 2011: 509036
  14. Head and Neck Cancers: Fact Sheet, National Cancer Institute
  15. SEER Stat Fact Sheets: Oral Cavity and Pharynx, National Cancer Institute
  16. HPV Infection May Be Linked to Poor Head and Neck Cancer  Survival Rates in African Americans, American Association for Cancer Research, July 29, 2009
  17. Genetic and Environmental Factors in Head and Neck Cancer Genesis, Journal of Environmental Science and Health, Part C: Environmental Carcinogenesis and Ecotoxicology Reviews, Volume 26 Issue 2 2008, Taylor & Francis Online
  18. Mannarini L et al, Human Papilloma Virus (HPV) in head and neck region: review of literature, Acta Otorhinolaryngologica Italica 2009;29:119-126
  19. Chaturvedi A, HPV and incidence trends for head and neck cancer, the Lancet Conferences
  20. Shedding New Light – HPV and oropharyngeal cancer, Frontiers Online, The Ohio State University
  21. Kreimer AR et al, Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review, Cancer Epidemiol Biomarkers Prev. 2005 Feb;14(2):467-75
  22. Hocking et al, Head and neck cancer in Australia between 1982 and 2005 show increasing incidence of potentially HPV-associated oropharyngeal cancers, Br J Cancer. 2011 Feb 1
  23. Ribeiro KB et al, Low human papillomavirus prevalence in head and neck cancer: results from two large case-control studies in high-incidence regions, Int J Epidemiol. 2011 Jan 1
  24. Sexual Activity and Marijuana Use Associated With HPV-Positive Head and Neck Cancer, Study Shows, ScienceDaily, 13 March 2008.
  25. Researchers ID Behavioral Risk Factors for Head and Neck Cancer, Johns Hopkins Medicine, March 11, 2008
  26. Donaldson James S, Oral Sex Linked to Rise in Men's Throat Cancer, abcNews, October 20, 2010
  27. Masters C, Oral Sex Can Add to HPV Cancer Risk, Time Health, May 11, 2007
  28. Halpern-Felsher BL et al, Oral versus vaginal sex among adolescents: perceptions, attitudes, and behavior, Pediatrics.2005 Apr;115(4):845-51.
  29. Liang C, A Population-Based Case-Control Study of Marijuana Use and Head and Neck Squamous Cell Carcinoma, Cancer Prev Res August 2009 2; 759
  30. Gardner A. Study: Rise in some cancers linked to oral sex, HealthDay, USA Today, 29 Jan 2011
  31. Cervical Cancer / HPV Vaccine News, Medical NewsToday
  32. HPV is changing the face of head and neck cancers, HemOnc Today, June 25, 2010

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