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Dr. Michael Smith: Welcome to GW Healthcast. I'm Dr. Mike Smith and today’s topic is HPV and throat cancer. My guest is Dr. Punam Thakkar. Dr. Thakkar is an assistant professor of surgery at George Washington University School of Medicine and Health Sciences and a member of the medical staff at the George Washington University Hospital. She is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Welcome to the show.

Dr. Punam Thakkar, MD: Thanks for having me.

Dr. Smith: Why don’t we just start off first with what is HPV?

Dr. Thakkar: HPV is the human papillomavirus. This virus is quite prevalent and there are different types of this virus. There's type 6, 11, 16 and 18. The higher numbers, 16 or 18, are the ones that cause cervical cancer, and that we know, but they can also cause cancer in the base of the tongue or the tonsil – that's the oropharynx. Why it's interesting is because in the last 25 years or so, we've seen a decline in some of the other head and neck cancers, but oropharyngeal cancer rates are rising and that’s because of this virus. We’re seeing this type of cancer in younger healthier patients who've never had a history of smoking and drinking. They're different from our typical head and neck cancer patients that we think about traditionally.

Dr. Smith: HPV is a virus. How is it usually transmitted?

Dr. Thakkar: It can be transmitted sexually or by mucous contact, so theoretically kissing and oral sex. It’s not really known how the transformation happens between just carrying HPV and actually progressing to cancer. That's something we don't quite know exactly why some patients progress to cancers and others are just carriers. It is prevalent in more than 95% of people that at some point in their life have been positive for HPV.

Dr. Smith: It takes some sort of close contact to transmit this virus and you said something interesting. You said that especially those strains that are more linked to cancers, we’re seeing those strains, those HPV strains, increasing in general in the population. Is that true?

Dr. Thakkar: Right. There are different theories for why this is the case. People have changed sexual practices and more sexual partners traditionally in the past, so this may be one of the reasons why we're seeing higher numbers of these cancers.

Dr. Smith: When we look at the large population of people who are a carrier of HPV, who do those people look like? Are they mostly men or women? What's the age group?

Dr. Thakkar: The carriers of the HPV, any age can be carriers. In terms of which of those patients are positive for cancer, usually that age group is 40 years old and above. Right now, it’s a higher proportion of men, but we’re seeing more women with oropharyngeal cancer than we have in past from smoking and drinking.

Dr. Smith: I do think a lot of listeners probably are familiar with HPV and maybe the cervical cancer part of that. I think there's a lot of public service announcements about that, getting the pap smears, and all of that, but I don’t know if a lot of people understand that HPV is also related to cancers of the mouth and throat. When you look at all the different cancers that happen through HPV, what percent are occurring in the oral cavity and in the throat?

Dr. Thakkar: In general or HPV related?

Dr. Smith: HPV related.

Dr. Thakkar: In 2016, there were about 500,000 cases in the country of HPV cancer. It’s predicted that by 2020, the rate of HPV related oropharynx cancer is going to be higher than cervical cancer if it keeps going the rate that it is.

Dr. Smith: Since we’re talking about a viral infection, and you had mentioned that it’s close contacts, most likely sexually transmitted, what are some of the signs and symptoms that we should look for just in case we have HPV infections?

Dr. Thakkar: HPV infection is asymptomatic. HPV infections that are caused by the less virulent strains – that would be HPV 6 and 11 – those will just cause warts. Those are called papillomas. Those can occur in the oral cavity. Having these papillomas or warts in your oral cavity or oropharynx actually does not increase your risk of progressing to cancer. On the other hand, if you have an HPV positive tumor, the signs and symptoms would be the same as a non-HPV positive throat mass. For HPV positive cancers, we've seen that even very small lesions have a propensity to metastasize to the neck nodes, so the first sign would be a mass in the neck. When an adult has a neck mass that's persistent for two weeks, it's highly possible that this is cancer, and so it should be evaluated first by the primary care physician, and if it persists past two weeks, there are recommendations by the American Academy of Otolaryngology and Head and Neck Surgery that the primary care doctor should refer to a specialist and further imaging and biopsy is certainly warranted. The most common sign of a newly diagnosed head and neck cancer that’s HPV positive is a new neck mass.

Dr. Smith: Obviously that’s a good reason to go see your primary care. You mentioned the papilloma, so if somebody has a papilloma or what you said was a wart in the oral cavity, should they still go see their doctor to make sure and get that checked out?

Dr. Thakkar: 100%. If it's a small papilloma and they come and see an otolaryngologist, then most of the time, we can excise the lesion in the office and you can get the biopsy result in a week. When their tumor is at the base of the tongue or the tonsil, they may require a biopsy in the operating room, but small papillomas in the oral cavity are very easy to biopsy. Any new mass or lesion in the oral cavity or the oropharynx should definitely prompt a visit to your primary care doctor and a specialist thereafter.

Dr. Smith: If somebody comes to you with a neck mass, how do you know if it’s HPV related or not? What's the workup for that?

Dr. Thakkar: The first step would be imaging. We can also do an ultrasound in our office and do ultrasound-guided needle biopsies and those are usually small gauge needles just about the size of the needle that you get your blood drawn with. Once we do the needle biopsy, we can send it to our pathologist who can test it for the HPV virus with certain immunostains and that stain is called P16.

Dr. Smith: There's a specific stain that you can do in the laboratory that would tell you if this is HPV related or not. You have a person come in, there's a neck mass, you’ve done the work up, it’s HPV related – tell us about the treatment both from a cancer perspective and then also from the HPV perspective.

Dr. Thakkar: From the HPV perspective, it doesn't really change the management. It does change the prognosis. For early-stage oropharynx cancers in the tonsils or the base of the tongue, there are two options. One is nonsurgical and the other is surgical. One option, if the patient does not want surgery would be chemo and radiation and that's given concurrently for about six weeks depending on the stage of the disease. It'll depend whether they need just radiation or chemo and radiation. The other option is surgery and for early-stage cancers of the base of the tongue and tonsil, there is the advent of the transoral robotic surgery. There are two systems that are used here at GW. One is the Da Vinci robotic system and the other is the Med-robotic system. Both are approved for early-stage tumors of the base of the tongue or oropharynx. The reason these new robotic surgeries are helpful is because in the past, in order to get access to the base of the tongue, we would have to split the mandible, and that could be quite morbid for the patient as you can imagine. With access to these robotic surgical techniques, we can get access in those hard to reach areas and patients are out of the hospital in about 48 hours and eating and drinking just as they were, swallowing is fine and their speech is fine and they avoid a big incision.

Dr. Smith: Let me ask you a question about those robots and I want you to explain this and use this to educate the audience about robotic surgery because when you say robotic or robot, people have certain things in their minds. I want you to clear that up for us. Tell us exactly what robotic surgery is.

Dr. Thakkar: One question that I get asked all the time when I mention robotic surgery is ‘will you be there in the operation room?’ 100%, your surgeon will be in the operating room. What the robotic machinery does for us in the operating room is it’s set up so that the instruments are in correct positions and then the surgeon is at a console. In the console, we have complete control of whatever movement those instruments have in the throat. The arms of the instruments are obviously smaller than any of the instruments by hand that we would use and the magnification is much more than what we can get with our eyes. That’s the benefit. One is the access, two is the magnification. We also see in 3D with the robots, so that’s actually very helpful when performing these operations.

Dr. Smith: I think the important point is the surgeon is still doing the surgery. You're controlling these arms that are just allowing you to get access to tough spots, the magnification is better, it makes the surgery and as you said, the outcomes are a lot better. I thank you for clearing that up for us. When somebody goes through this kind of treatment for an oral or throat cancer that is HPV related, you had mentioned that prognosis is different than somebody who does not have HPV and has a throat cancer. Tell us a little bit about the difference in the outcome.

Dr. Thakkar: Oropharyngeal cancers caused by the human papillomavirus have a definitely favorable survival. This was first found in a landmark study that was in the New England Journal of Medicine in 2010 which demonstrated that patients who had HPV positive tumors had significantly better overall survival. When you looked at their three-year overall survival, and this was back in 2010, it was 82.4% versus 57%. Much better survival curves. Patients do better whether they go with the traditional nonsurgical routes of chemoradiation or surgery. These studies regarding survival benefits and treatment options with tours are just now being published and there's a large clinical trial that was just closed in July 2017, which is going to answer some questions that have come up. We know that HPV patients have overall survival which is better, so can we de-escalate their therapy, meaning in the past, someone who had a significantly sized tumor that was stage three would need multiple modes of treatment, surgery and radiation or chemo and radiation. The question is ‘can we de-escalate their therapy so we can do surgery, a lone surgery with a lower dose of radiation, surgery with standard-dose radiation and then surgery with chemoradiation?' They're going to look at all these four groups and see if there's any benefit to decreasing the treatment they receive because long-term higher doses of radiation and chemo can have an effect on swallowing and fibrosis and that’s the next step. We should get that information in the next couple of years hopefully.

Dr. Smith: That's very exciting. I always like to end in a summary. What would you like people to know about HPV related throat cancers?

Dr. Thakkar: As far as we know, the cancer is not contagious. It shouldn’t be a reason to frighten people to change any habits that they have because there's no evidence that kissing causes cancer. I think that’s really important. We don’t know why certain patients progress to cancer and others don’t. There's more than just the virus; it’s genetics and other things that we don’t understand. Number two, any adult with a new neck mass, it’s important not to just assume that it’s infectious or it’s going to go away. Just go and see a physician whether it’s your primary care doctor or an ENT preferably who can evaluate this right away. 40 years ago, studies showed that there was about a five- to six-month delay between a new neck mass and getting their diagnosis. Even today, studies show that there's still a three- to six-month lag. Despite better imaging with MRI, CAT scan, and PET scan, we’re still not identifying patients right away and that’s something we see all the time, just delayed diagnosis or patients being treated with multiple courses of antibiotics for a neck mass because it’s presumed to be infectious and in fact it’s not – it’s cancer – that’s why it’s not going away with antibiotics. Thirdly, it’s important to know if you have the new diagnosis that there are options for your treatment and you should definitely go to a center which explains all these options to you to make sure you're getting the treatment that makes the most sense for you. If you're young and healthier and can tolerate surgery and it’s an early stage cancer, you may do fine with just having robotic surgery and perhaps some low dose radiation, but you have to go to centers that are treating these tumors so that an informed decision can be made with multidisciplinary teams to treat your cancer in a way that makes sense for you and that’s the standard of care.

Dr. Smith: Go to the specialist and go quickly. Don’t waste time. Thank you so much for the work that you're doing at George Washington University and our George Washington Hospital and thank you so much for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Punam or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.

This is Dr. Mike Smith. Thanks for listening.