What Do We Really Know About Human Papillomavirus (HPV)?

HPV CONCEPT Virus vaccine with syringe HPV criteria for pap smear slide cytology.

Introduction

One of the challenges in discussing sexually transmitted diseases with patients is the timing. However, with the pervasive infection rates of Human Papillomavirus (HPV), the timing has never been better. Whether reviewing the eventual risk of cancer with adult men and women or initiating the subject of HPV prevention with parents of teens, the topic has never been more essential.

Each year, about 44,000 new cases of HPV-attributable cancers are diagnosed. An HPV-attributable cancer is a cancer that is presumed to be caused by HPV because it is diagnosed in an area of the body where the Human Papillomavirus (HPV) would be found.

Background Information

Human Papillomavirus (HPV) is a group of more than 200 related types of viruses that can cause warts or specific types of cancer once a human is exposed. Approximately 40 of these viruses are spread via sexual contact with a human who has been infected with the virus. They can also spread through direct, skin to skin contact. There are two categories: low-risk viruses and high-risk viruses. Low-risk viruses can lead to warts around the anus, genitals, throat, or mouth. High-risk HPV can cause pre-cancerous conditions or actual cancer. Nearly all sexually active males and females are exposed to HPV once they begin having sex; some may know they are infected by the development of symptoms such as external warts.

Others may not be so lucky. They may be exposed, have a high-risk infection that appears to go resolve on its own, but the virus could linger, producing cellular changes that go unnoticed. If these changes are not detected over time, cancerous conditions may develop.

Cervical cancer is the most widely known form of cancer caused by HPV, but there are several other forms of cancerous and precancerous conditions caused by HPV. Unfortunately, even with aggressive screening, 10,900 cases of cervical cancer are diagnosed each year. 4,000 of these women will die. Equally as unfortunate are the 196,000 cases of cervical precancers diagnosed every year. Treatment for this precancerous condition may be successful but may also limit a woman’s ability to bear children.

Further Information

Additional HPV cancers may include oropharyngeal cancer, anal cancer, vulvar and vaginal cancer, as well as penile cancer. Currently, there are no specific screenings for these types of cancer, although they are typically detected as health problems occur, such as a sore or lesion in the mouth that doesn’t heal, or a lump or thickening in the cheek (common symptoms with oropharyngeal carcinomas). Symptoms of anal cancer, lamentably, are often brushed aside as those normally attributed to hemorrhoids: rectal bleeding or itching, lumps or masses in the anal area. Although anal cancer has been rare, the numbers are rising. HPV places adults at higher risk of anal cancer due to compromising the immune system overall.

Diagnosing HPV

Other than observing external warts on physical exam, there is no specific protocol for diagnosing HPV infection. Women who undergo regular Pap smears and cervical cancer screening may be diagnosed with tissue abnormalities, precancerous conditions, or cell anomalies. “An HPV infection itself cannot be treated.” The best treatment for HPV is prevention via consistent use of latex condoms for sexually active adults, or with vaccines for teens who have not yet become sexually active.

HPV Prevention

One of the biggest game changers for HPV infection is to educate parents of teens about the opportunity to vaccinate their children against the infection before teens become sexually active, thus guaranteeing they remain free from the dangers of most HPV-attributable cancers as they enter their twenties, thirties and hopefully, for years beyond. Family physicians currently estimate that approximately 50% of adults in the U.S. have active HPV, possibly more if you consider the ones who were exposed but cleared the infection. Regrettably, physicians believe no one knows what type of HPV they might get. You might get a minimal infection, you might notice a few genital warts, or you could get cancer. But, without a vaccination to protect against HPV, all children who become sexually active adults will inevitably draw one of the above possibilities.

Children ages 11-12 may receive two doses of the HPV vaccine (Gardasil 9, Gardasil, Cervarix) at least six months apart, instead of the previously recommended three doses. It is important for children to be started at this age because they have the most robust response to the vaccine, and they have generally not become sexually active. If parents are uncomfortable discussing sex regarding a child of this age, AAFP (American Academy of Family Physicians) liaison Margot Savoy, M.D., M.P.H. of Wilmington, Delaware uses the analogy of vaccinating a child prior to sexual activity like placing a helmet on a child prior to allowing a child on a bicycle: it’s necessary prevention. You would not place a seat belt on your child after a vehicular trauma; that would be negligence. Missing the opportunity to provide your child with a lifesaving vaccine could be pictured in the same light.

Adolescents aged 13-14 are also able to receive the Gardasil vaccine on the two-dose schedule. Dr. Savoy reminds parents of teens that even without the concern of cancer later in life, genital warts are “stigmatizing, disfiguring, and often difficult to treat.” The HPV vaccine reduces the incidence of warts as well.

Prevention for Older Females

HPV vaccination can also be given to girls and women aged 13 to 26 years of age who have not yet been vaccinated or who might not have completed their vaccination cycle. Ideally, females should get the vaccine before they become sexually active, but even if they have become active, and have been exposed to one or more of the viruses, it is unlikely they will have been exposed to all the Human Papillomavirus types, so they will still receive partial benefit from vaccination. The vaccine is not, however, recommended for pregnant women, as more testing needs to be completed before it is determined to be safe for mother and baby.

Conclusion

HPV infections and cervical precancers have dropped 86% in teen girls since the vaccinations have been initiated, as well as another 40% decline among vaccinated young women. While women still need to continue with Pap smears and cervical screenings (as the vaccine does not eliminate the risk of other sexually transmitted disease nor does it protect against all HPV types), risk reduction with vaccination has been significant. The hope is that effective vaccination could prevent up to 90% of all cancers caused by HPV in the future: from cervical cancer and precancer, to oropharyngeal cancer, anal cancer, vulvar and vaginal cancer, as well as penile cancer. The Human Papillomavirus has caused devastating, and sometimes terminal disease for adults, with warning signs unrecognized until far too late in the illness. 

With early vaccination, children can grow into adults who have no need to fear this insidious killer; that’s progress.

FYI: HPV vaccination is also recommended for use in boys and men, and can be started as early as age 9, although routine vaccination is typically initiated with a series of two doses age 11-12 years. The vaccine has been shown to be safe and effective in males ages 9-26.

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