While head and neck cancers have historically been associated with patients in their 60s to 80s with a strong smoking history and a low socioeconomic profile, there has been a significant shift in demographics due to the rise in human papillomavirus (HPV) related cancers, explains Dr Julia Crawford, a Sydney-based ENT specialist and head and neck surgeon.

“We’re seeing a complete shift in the people that present with head and neck cancers. And so those that are caused with smoking as an epidemiological risk factor, laryngeal cancers, are decreasing, whereas the most commonly diagnosed cancer now in the head and neck region is a tonsil or lingual tonsil tumour, which is an oropharynx related to HPV,” Dr Crawford says.

Though still rare overall, incidence of HPV-related oropharyngeal carcinoma is rising, especially in men aged 40 – 60, with 78% of cases occurring in males.

“Now we’re seeing patients who are much younger, have no smoking history, and who have no other presenting feature other than a neck node, presenting with a human papillomavirus-related cancer which has originated in their oropharynx,” Dr Crawford says.

“The youngest patient I’ve treated with this cancer is 32.”

Latent for decades

The shift reflects the natural history of HPV infection, where exposure typically occurs during early sexual activity but may not present as cancer for 10 to 30 years.

The palatine and lingual tonsils are the most commonly affected sites, serving as a “safe harbor” for the virus. This allows it to evade immune system detection and remain dormant for decades, Dr Crawford says. 

Typically, these cancers are caused by HPV 16 subtype, which is included in the preventative vaccine.

“Thankfully this will be a disease of the past, but not for about 40 to 50 years once we get through that latency period,” Dr Crawford says.

Early recognition improves outcomes

In the meantime, early recognition is important.

Unlike other head and neck cancers that have around 50% five-year survival rate, HPV-related oropharyngeal cancers have a much better prognosis, particularly if caught early. A retrospective Australian study co-authored by Dr Crawford found that five year-survival for HPV-associated oropharyngeal cancers was greater than >90%.

“You want to catch it early if possible, because they’ve got such a good outcome from treatment if it’s caught early,” Dr Crawford says.

While symptoms such as a foreign body sensation in the throat should prompt investigation, it’s important to know they are not usually present until later stages.

“The local symptoms that we’d often think about in head and neck cancers are really not there as much in these forms until they get much more advanced,” Dr Crawford says.

“The clinical presentation in these patients is typically an enlarged lymph node in the neck, often with no other features,” Dr Crawfords says.

People can sometimes get persistent sore throat or unilateral throat pain, dysphagia, odynophagia, or referred otalgia, but that’s usually only when the tumour is large enough to cause those symptoms, she notes.

To investigate, request an ultrasound-guided fine needle biopsy with flow cytometry (to rule out a lymphoma or lymphoproliferative process) and P16, an inexpensive and easily reproducible immunohistochemistry stain. P16 a breakdown product of HPV; if a tumour stains more than 70% of p16, it is an HPV-related tumour.

Treatment

While both surgery and radiation therapy offer equivalent cure rates, radiation is “the gift that keeps on giving” in terms of side effects, Dr Crawford says.

“If you have treatment in your 40s, by the time you get to 80, you’re going to have more significant side effects related to radiation and the added risk of a second primary within the upper aerodigestive tract.”

“So in the right patients, we really should be at least offering them surgery if that’s applicable for their particular tumour.”

With robotic assistance, surgeons can now get to previously inaccessible sites without large facial incisions, making surgical resection a viable option for many oropharyngeal cancers.