Human papillomavirus status in head and neck cancer

Abstract

Human papillomavirus (HPV) is an emerging causative factor for squamous carcinoma of the oropharynx and perhaps other head and neck cancers. There is a great deal of uncertainty regarding the clinical significance and implications of HPV status in this patient population. As a result, there is no established protocol for informing patients of the potential link between viral infection and their cancer. This paper discusses some of the ethical issues involved with informing head and neck cancer patients of their HPV status, recognizing the dilemma posed by unresolved clinical questions and the need to respect the autonomy of patients by disclosing relevant information. Cancer 2010;116:4221-6. V C 2010 American Cancer Society.KEYWORDS: human papillomavirus, head and neck cancer, oropharynx, disclosure, patient autonomy.An increasing volume of data have linked infection with human papillomavirus (HPV), a sexually transmitted pathogen, with head and neck cancer. 1,2 HPV infection may explain the increasing incidence and changing demographics of these cancers, particularly squamous cell carcinomas of the oropharynx. 3,4 Patients with HPV-related tumors often lack the classic risk factors for these malignancies, such as a history of tobacco or alcohol abuse, and often present at younger ages. 5 Currently, there are no conclusive data suggesting that treatment modalities or other aspects of care should differ for head and neck cancer patients based on their HPV status.The issue of discussing the relationship of HPV status and the development of head and neck cancer poses a dilemma. Clinicians aspire to keep their patients duly informed, but may not know which patients might have HPVrelated infections, nor can they make further definitive statements regarding etiology or outcome based on the limited knowledge of this clinical entity. In general, we know that the association of HPV infection in a nonsmoking head and neck cancer patient is a favorable prognostic factor; however, the literature addressing HPV-related head and neck cancers is growing exponentially. This paper does not attempt to provide a comprehensive review of the topic, but will discuss the ethical issues surrounding the disclosure and discussion of HPV status among head and neck cancer patients. Ethical Tenets of Honesty and TransparencyContemporary medical ethics is based on a foundation in which patients and their healthcare providers are partners. Patients and their designated decision-makers are charged with using the expertise and recommendations of their physicians to make informed and reasoned decisions. Rather than make paternalistic judgments concerning what patients should know or must do, physicians are obligated to present all relevant and pertinent information in a way that is accurate and honest, and allow their patients to act autonomously. One model of this process involves the implementation of both informal conversational ethics and formal deliberative ethics. 6 The former process centers on the creation of a partnership between physic...

Psychosocial impact of human papillomavirus-related head and neck cancer on patients and their partners: A qualitative interview study

“…Previous research in the USA has confirmed that less than half of oncologists discuss HPV with their patients (Milbury et al, 2013) and this study showed just over half of patients were aware of their HPV diagnosis. As it is becoming more recognised that patients should be informed that HPV is the cause of their cancer (Shuman & Wolf, 2010), health professionals need to decide on the best time to discuss this with patients, with patients in this study suggesting the earlier the better.…”

“…The potential for psychosocial distress and fear of recurrence in HNC patients is high (Badr, Gupta, Sikora, & Posner, ; Humphris & Ozakinci, ), due in part to the potential for disfigurement of the head and neck region, and dysfunction (e.g., problems with swallowing, eating) after treatment (Singer et al, ). However, identifying a sexually transmitted infection as a causal factor may lead to additional distress in patients with HPV‐oropharyngeal squamous cell carcinoma (HPV‐OSCC) and their partners (Gold, ; Longacre, Ridge, Burtness, Galloway, & Fang, ; Shuman & Wolf, ). Common patient concerns related to HPV in HNC have been documented to be how, when and why they got their cancer (Fakhry & D'Souza, ).…”

Sharing a diagnosis of HPV-related head and neck cancer: The emotions, the confusion, and what patients want to know

“…Currently, HPV status does not affect treatment decisions, but physicians should discuss the role of HPV, like other risk factors such as tobacco and alcohol, in the development of HNSCC in the spirit of full disclosure. (6) Yet, HPV infection is a complicated concept that requires a substantial time investment on the part of physicians for a detailed explanation that results in adequate patient comprehension. Given the gravity of a HNSCC diagnosis, questions about HPV may be overshadowed by conversations about cancer and its treatment.…”

Sexual health in oral oncology: Breaking the news to patients with human papillomavirus–positive oropharyngeal cancer

“…20 Evidence suggests that even primary healthcare professionals involved in taking cervical smears may avoid talking to patients about HPV, 21 but head and neck clinics must make such conversations part of routine practice, 22 despite the fact that patients and clinical teams may be unused to discussing matters relating to sexual health. A systematic review identified a range of responses to HPV infection, including concerns regarding disclosure of a sexually transmitted infection, impact on relationships, and fear of stigmatization.…”

“…A systematic review identified a range of responses to HPV infection, including concerns regarding disclosure of a sexually transmitted infection, impact on relationships, and fear of stigmatization. 20 Evidence suggests that even primary healthcare professionals involved in taking cervical smears may avoid talking to patients about HPV, 21 but head and neck clinics must make such conversations part of routine practice, 22 despite the fact that patients and clinical teams may be unused to discussing matters relating to sexual health. The following key messages may help address some common patient concerns.…”