The CDC's Advisory Committee on Immunization Practices (ACIP) issued a recommendation for the human papillomavirus (HPV) vaccine for males ages 11 to 12 years and the HPV vaccine for men who have sex with men (MSM) through age 26.1 As of 2017, HPV vaccine coverage with one or more dose of the HPV vaccine in adolescents ages 13 to 17 years was 65%.2 This is an increase of 5.1% compared with the 2016 numbers but falls short of the target goal established by Healthy People 2020. Reasons why the Healthy People 2020 goal was not achieved are multifaceted, and therefore, require a multipronged strategic intervention to meet the Healthy People 2020 goal of 80% vaccination rate of the current ACIP recommendation of a 2-dose, 9-valent HPV vaccine.3 Negative patient outcomes may result from failure to vaccinate, such as the diagnosis of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC).
HPV is the most common sexually transmitted infection in the US.4,5 According to the CDC, there are more than 100 different strains of HPV, and HPV 16 and 18 are linked to the etiology of carcinomas of the vagina, vulva, cervix, anus, penis, and oropharynx.5 The CDC reported that an average of 18,300 HPV-associated cancers were diagnosed in men annually, and 24,000 cases were diagnosed among women annually between 2011 and 2015.4 Of those diagnosed, an average of 14,814 HPV-associated squamous cell oropharyngeal carcinomas in males and 3,412 in females were reported annually.4 MSM and MSM who are HIV-seropositive in the US continue to experience disproportionate HPV disease.6,7 MSM and MSM who are HIV-seropositive have a higher burden of HPV infections and higher rates of certain cancers, such as anal cancer, than heterosexual males.7,8
This case presentation illustrates patient outcomes associated with reduced HPV vaccine uptake. Closing the gap on missed opportunities to immunize young males with the HPV vaccine is a strategy to improve the health outcomes in this population. The authors interviewed a survivor of head and neck cancer to illustrate the poor health outcomes patients may encounter when diagnosed with HPV-related OPSCC.
Mr. T is a 31-year-old White male who presented to his NP with a complaint of a lump in his left neck and nasal congestion. The history of present illness illustrated that 2 months earlier, he developed an upper respiratory tract infection associated with a scratchy throat, nasal congestion, small lump on the left side of his neck, and fatigue; these symptoms all resolved with the exception of lingering nasal congestion and a lump on the left side of the neck, which had increased in size. On his second visit, he denied any tenderness in the lump or other areas of his neck, sore throat, oral lesions, difficulty swallowing, any unusual sensation in throat, ear pain, fatigue, weight loss, fever, or chills.
The patient's medical history indicates a diagnosis of gonorrhea 12 years ago. Mr. T is HIV-negative and does not take any medications. His sexual history includes unprotected sex with both men and women involving oral, vaginal, and anal sex with 20 or more partners over his lifetime. Over the last 4 years, he has been in a monogamous relationship with his wife.
Mr. T is a nonsmoker, has two alcoholic beverages per week, and does not use illegal drugs; however, in his teens and early 20s, he admits to having used cocaine, marijuana, and drinking 3 to 4 nights per week, consuming anywhere from 4 to 5 alcoholic drinks each night. He has had the flu vaccine annually but denies ever having received the HPV vaccine. The patient's social history includes being married for 2 years with one child who is 12 months old. He graduated from college 3 years ago and is employed as an engineer at a local engineering firm.
Physical exam revealed a 3- to 4-cm mass that is palpable and mobile with no overlying skin irritation or lesions. The oral exam was unremarkable for erythema, lesions, enlarged tonsils, or inflammation. The remainder of his head, ears, eyes, nose, and throat exam was normal. The diagnosis on this visit was cystic neck mass, but the possibility of an oral carcinoma, given the patient's history, warranted patient referral to an ear, nose, and throat (ENT) specialist.
The ENT specialists performed a nasopharyngoscopy 2 weeks after the initial visit to the NP, which showed a visible mass on the left tonsil. A computed tomography scan followed revealing a probable cystic malignant mass. Lastly, a fine needle aspiration biopsy confirmed OPSCC of the left tonsil and base of the tongue with local lymph node involvement that was positive for HPV genotype 16 using the in-situ hybridization and the polymerase chain reaction based methods to detect HPV DNA in the tumor tissue; the mass size was 4.4 cm with lymph node involvement. A positron emission tomography scan also indicated a “hot spot” on the right side of the neck. The therapeutic intervention was surgical resection of the tumor, chemotherapy, and radiation; stage III was determined (T3, N2, M0).
Within 6 weeks of the OPSCC diagnosis, Mr. T had a left tonsillectomy to remove the mass followed by chemotherapy for 3 weeks using the combination drug therapy of docetaxel, cisplatin, and fluorouracil, and lastly, targeted radiation that lasted for 7 weeks. He then experienced extreme fatigue, which resulted in the need to take time away from work and a medical leave of absence to maintain health insurance coverage. Pain in his neck has recently developed (7/10 on the 0 to 10 pain scale) postradiation for which the oncologist prescribed oxycodone 5 mg orally every 4 to 6 hours as needed. Mr. T was hesitant to use the oxycodone with the current opioid crisis and has been trying to use acetaminophen to manage his pain.
Mr. T has lost his sense of taste and has a constant metallic taste in his mouth, resulting in an 18-lb (8 kg) weight loss over the last 6 weeks. Mr. T's current body mass index is at 20. A nutrition consult was requested. He denied any difficulty with swallowing or communication and “hopes this doesn't change.” Mr. T is monitored by his dental provider for oral hygiene, his oncologist, radiologist, and NP.
The demographics of a patient with HPV-positive OPSCC are typically White, 40 to 59 years of age with higher socioeconomic status, multiple sexual partners, engagement in oral and genital sex, MSM, and HIV-positive (see Clinical features of HPV-positive and HPV-negative OPSCC).9,10 The most common clinical presentation of HPV-positive OPSCC is a mass in the neck.9,11 Other presenting features may include throat pain, pain with swallowing, or an abnormal sensation in the throat.9
The radiologic features of HPV-positive OPSCC include small primary lesions with well-defined borders and cystic nodal metastases.11 This appearance can sometimes lead to misdiagnosis of a benign cyst if healthcare providers are not familiar with the disease progression.11 A fine needle biopsy from the cystic mass is important to determine the HPV status.9 The prognosis of HPV-positive OPSCC is more favorable than HPV-negative OPSCC.9,12 The overall survival rate for HPV-positive OPSCC after 5 years is 79% compared with the 46% for HPV-negative OPSCC.10
Currently, treatment of HPV-positive OPSCC does not differ significantly from HPV-negative OPSCC. In both cases, treatment choices are based on the tumor stage and location of the lesion. The staging system for oropharyngeal cancer has recently encountered changes in an effort to differentiate high-risk HPV-associated oropharyngeal cancers from those oropharyngeal cancers linked with other causes.13 The therapeutic treatment approaches for patients with high-risk HPV oropharyngeal cancers have not changed. The optimal treatment for high-risk HPV oropharyngeal cancer is not explicit. The treatment protocol varies and depends on clinical presentation (for example, stage and anatomical location of the lesion).14
Early-stage HPV-related OPSCC (T1-T2, N0) is often treated with either surgery, radiation therapy, or a combination thereof depending on the risk of recurrence. Advanced disease (stage III/IV) usually requires a combined modality of surgery, radiation therapy, and/or chemotherapy.9-11,14
Prevention and vaccination
Three HPV vaccines have been licensed for use in the US. Recently, the bivalent vaccine was removed from the US market following a decrease in market demand.1 In 2011, the CDC and the ACIP issued a routine recommendation for the HPV vaccine for males ages 11 to 12 years with a catch-up vaccination for males ages 13 to 21 years.1 The ACIP extended that recommendation to include MSM through the age of 26 years.1 The HPV 9-valent vaccine, recombinant (9-valent vaccine) protects against HPV types 6 and 11 as well as oncogenic HPV types 16, 18, 31, 33, 45, 52, and 58 and is currently available in a 2-dose and 3-dose regimen.1,15 In 2018, the FDA expanded the use of the 9-valent vaccine to include individuals ages 27 through 45 years. The 9-valent vaccine currently provides protection from certain cancers and diseases caused by the nine HPV types covered by the vaccine for boys and men and girls and women ages 9 through 45 years.15
The HPV vaccine is a primary prevention strategy aimed at reducing the burden of oropharyngeal cancers in men and women. However, there is a significant lack of uptake in the MSM population.
This case presentation illustrates the need for the primary care provider (PCP) to address sexual health history and initiate conversations about sexual behaviors. Although Mr. T no longer identifies as MSM, he did identify as such in his past. Based on the 2011 CDC recommendations, Mr. T was eligible for the HPV vaccination because it was recommended through age 26 years for males who are bisexual, and MSM. Education about sexual health related to MSM along with a recommendation for the HPV vaccine could have been made much earlier for Mr. T.
There are a host of barriers to the low rate of uptake of the HPV vaccine; they include parental attitude, financial concerns, low perceived risk of HPV infection, patient and family education, provider education and recommendation, and system underutilization of the electronic health record (EHR) clinical reminder functions by healthcare providers. Prominently, lack of provider recommendation is cited as the leading reason for not vaccinating.16-21 All visits to the PCP are opportunities to engage in education and make recommendations for the HPV vaccine. Proper strategies must be employed to avoid missed opportunities to provide the HPV vaccine to improve the quality of primary care for young men.
The primary care setting provides an optimal setting to recommend HPV vaccination regardless of the purpose of the visit. The National Vaccine Advisory Committee updated the Standards for Adult Immunization Practices in 2014.21 These recommendations include incorporating immunization assessment into every visit, strongly recommending needed vaccines at every visit, as well as having provider reminder recall systems in place to inform providers which vaccines are needed and whether the series has been completed.
Additionally, multistrategy intervention, such as implementation of an adolescent HPV vaccine protocol that permits vaccination, per schedule, with only a protocol order, use of support staff to promote vaccine uptake, scheduling and reminder systems, and quality improvement projects that assess monthly HPV vaccine uptake are examples of a variety of interventions. The multipronged strategic approach has reportedly increased rates of HPV vaccine uptake in both adolescents and young MSM.20,22 Additional systems-level approaches to increase the HPV vaccine uptake may be achieved through the use of the EHRs.18,21,23 If these approaches had been in place for Mr. T, perhaps his health outcome and disease burden could have been avoided.
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