Fighting a Cancer Epidemic With a Vaccine

John Deeken, MD, is president of the Inova Schar Cancer Institute. He is board-certified in medical oncology and specializes in head and neck cancers.

Quitting smoking. Eating better. Wearing sunscreen. These are all well-known behaviors that can lower cancer risk.

But there’s another, less-heralded way to reduce cancer odds: get vaccinated.

Specifically, vaccination against the human papillomavirus (HPV) has been shown to reduce the risk of several cancers.  It’s been known for decades that cervical cancer is caused by HPV, but as a cause of Head and Neck cancer is a relatively new discovery.  Head and neck cancer as an HPV-caused cancer was first identified about 20 years ago. Over those 20 years, it’s become apparent that one area where HPV vaccination could have the greatest impact is in cancers of the head and neck.

“Over the last 10 years there’s been about a 50 percent increase in the total cases of head and neck cancer in the U.S.,” said Dr. John Deeken, president of the Inova Schar Cancer Institute, “all driven by the HPV epidemic.”

Stopping the rise of head and neck cancers is one of the primary focuses at the Inova Saville Cancer Screening & Prevention Center. Deeken, a key player in the creation of the Saville Center, says there’s plenty of room for improvement in preventing HPV-caused head and neck cancers — but there’s also reason for optimism.

The State of HPV-Caused Head and Neck Cancer

Among American men, head and neck cancer is the sixth-most common cancer, with 48,200 estimated new cases in 2020. For American women, it’s the 12th-most common, with 17,430 estimated new cases that year.

Head and neck cancer had been on the decline from the 1970s to the 1990s. As tobacco and alcohol use fell in the U.S., so did incidences of head and neck cancer. But the HPV epidemic changed that trend.

HPV-caused head and neck cancer is typically found in the oropharynx — the tonsils and the area around the tonsils. Those who get this cancer are generally non-smokers, and so far, there is no clear explanation for how HPV causes the cancer.

Men account for more than 90 percent of the cases of HPV-caused head and neck cancer, and they are generally middle-aged or older. Dr. Deeken notes that their exposure to HPV is likely to have happened at an earlier age, and the cancer arrives decades later.

Compared to tobacco-caused head and neck cancer, HPV-caused head and neck cancer has a higher cure rate — but there are still too many cases, Dr. Deeken says.

“We could do much better in terms of detecting early and, ideally, preventing with the vaccine against HPV,” he said.

‘The Big Thing We have Is Prevention’

In the U.S., Gardasil-9 is the approved vaccine for HPV. 

The primary focus of HPV vaccination efforts has been teenagers. Many school districts (including Fairfax County Public Schools) require it. But even though teens are the focus, since 2020, eligibility for the vaccine now extends to age 45.

“That’s thought to be the age range when exposure and especially chronic infection can occur, and that’s the biggest risk factor for getting this cancer,” Dr. Deeken said.

Physicians like Deeken urge vaccination at all eligible ages because, among other reasons, oropharyngeal cancer is hard to detect. Like many other head and neck cancers, it doesn’t cause noticeable symptoms until it’s advanced.

HPV can also cause anal and cervical cancer, making vaccination even more valuable.

The first symptom of head and neck cancer that most patients notice is a mass in their neck, Deeken said. That is often a sign that a tumor has spread to the lymph nodes.

“We can still cure those patients, but it’s already what we call ‘locally advanced’ by that time,” Deeken said. “So it’s already a more advanced tumor with a lower cure rate than if we could catch it early.”

In the United States, there are no national standards or guidelines on how to screen – or detect early – Head and Neck cancers.

“There’s not great screening,” Dr. Deeken said. “We ask primary care doctors and dentists to look in people’s mouths and feel their lymph nodes and their neck as a way of early detection. … The big thing we have is prevention.”

Increasing Cases for 30 to 40 Years?

HPV vaccination rates are high among teens: around 70 percent in Virginia and in the high-60-percent range nationwide. That level of Gardasil uptake will reduce head and neck cancer rates — eventually.

The problem is that many eligible adults aren’t getting the HPV vaccine. That shows up in epidemiology models, which predict that head and neck cancer rates will continue to climb quickly until about 2045 or 2050, Deeken said.

As the teenagers getting vaccinated now reach middle age, the rate will slow and then decline, the models predict.

“So we do see this declining,” Deeken said, “but the problem is it’s not going to decline for three to four decades.”

If more adults get the vaccine, however, the outlook will change.

“If you’re under 45, talk to your doctor about getting the vaccine,” Dr. Deeken said. “Insurance will pay for it. … There’s good evidence that it helps at any age.”

Ready Access, Research and Outreach

Crises like the epidemic of HPV-caused head and neck cancer is exactly why Saville Center exists. The Center working to prevent it in three ways:

1. “Ready access” to the HPV vaccine.

“You would be surprised,” Dr. Deeken said, “a lot of primary care offices aren’t offering this, and aren’t giving it to adults like they should.”

But now, primary care doctors in Northern Virginia can send their patients to Saville Center for vaccination.

2. Research.

Saville Center has started research into HPV-caused head and neck cancer and has more planned. One area of concentration is screening. A saliva test could be an answer, Dr. Deeken said.

“Just like we have stool tests for colon cancer, can we develop spit tests for head and neck cancer?” he asked. 

3. Education and advocacy.

Not enough primary care physicians and patients know about HPV vaccine eligibility. Saville Center’s outreach efforts aim to change that.

This is an epidemic that is growing. But there is optimism that the vaccine can change the trajectory.  “It’s not that everyone who gets exposed to HPV gets cancer,” Dr. Deeken said. “But a subset do, and this is a virus that we could literally get rid of if everyone got the vaccine.”