I won't claim to have followed the media nor discussions on this site about HPV, oral sex and oral cancer very closely, but I gather that there have been some media items about a possible relationship?

I refer to this article by Dr. Gabe Mirkin, which expresses his take on the state of what is known about the possible relationships between HPV and cancers with a good description of "cofactors". I think it should be okay to post this link, as Mirkin isn't really selling anything, that I'm aware of:

http://drpinna.com/dr-mirkin-and-skin-cancers-19327
****while dr mirkin is not selling anything, dr pinna certainly is. the link in this post takes you to pinna's website not mirkin's and if you look at products, pinna is going to be selling magic mushrooms****(added by OCF admin)

It is clear that current evidence does point to a causative relationship between sexual promiscuity and the rates of certain cancers (cervical being the most discussed).

However, I will suggest (my opinion) that it will turn out that we as human beings are basically bathing in germs and viruses every day, and perhaps more and more so as the world becomes more crowded, and while it seems likely that certain viruses are a contributing factor to cancer, it will turn out that it requires a combination of cofactors to in fact trigger most cancers.

HPV alone seems to not cause cancer in the vast majority of people who become infected. As Dr. Mirkin states, most HPV goes away on its own within 6 months to two years.

However, chronic HPV infection (perhaps some people can't resolve the infection for whatever reason), repeated exposure to HPV, or HPV in combination with other cofactors such as smoking, being overweight, poor diet, lack of exercise, poor Vitamin D status, or genetic predisposition, may be what it takes to trigger cancer.

Perhaps HPV prevalence in the general population is a new thing, but I will suggest that any notion that you can avoid it may be misguided.

While Mirkin does state that most HPV infection is from sex, he also states that, technically, you could get HPV from a handshake. Also, some of the forms of HPV are what causes warts, and how many of us had warts as kids long before sexual activity began? I did, and I can guarantee I didn't get them from sex!

So what's my point? I feel that any attempt to stigmatize oral cancer as a sexually transmitted condition (or to stigmatize oral sex as particularly risky, for that matter) is misguided and unhelpful, that it will turn out that we're all under attack by thousands of viruses and germs at any given time simply by way of living on the planet among other people (and usually our bodies take care of this), that it takes a combination of cofactors to trigger cancer, and that simply living a healthy lifestyle will turn out to be the best defence against cancer.

Thoughts?

Perhaps you should read at least the articles on the OCF HPV page. The mechanism by which HPV16 causes oral cancer is very well understood. It requires no cofactors. It does require an unknown, and that is an individual with a genetic makeup that includes some genetic sequence (yet unidentified) that prevents their immune system from recognizing it as a threat, allowing the progression of infection, expression of onco proteins E6 and E7, which destroy cellular P53 and RB to immortalize a normal cell and begin the process to malignancy, which will be characteristic in all the daughter cells spun off, to take place.

In 99.1% of those infected with HPV16, either cervically or orally, it is destroyed by a healthy immune system. And yes, you can get HPV from a handshake but it is not one of the oncogenic versions of HPV (there are now cataloged more than 130, only 9 of which are proven oncogenic viruses, the rest cause benign warts or do nothing at all that we can determine at this stage of our knowledge.

All cancers require some genetic predisposition, even when the cancer is caused by a known carcinogen like tobacco use. For instance there are lifetime smokers that never develop cancer. You cannot avoid HPV unless you are non sexual, so that means that the vast majority of the population will be exposed. But to most people HPV infection is a non issue. Plenty of individuals who live healthy lives get cancer, perhaps those that do not, get it more often, but evidence based publications do not exist to support that premise. At the end of the day this is only part nurture and a lot nature (genetic predisposition) from the genes you inherited from your grandparents. If you are predisposed genetically to get cancers you will and no diet or lifestyle regime is going to change that. You can do things that keep you immune system healthy, but if you have a genetically inherited strong or weak one there is little you can do to change that aspect of what it controls in you. All anglo Saxon descendants of the original settlers from Europe in the US are descendants of people who survived the black plague. At the time of the plague there was no real medicine, and 2/3rds of the European population were killed off by it. Only those with a genetic predisposition to not become infected survived it. Their descendants also have that same protection, not that black plague will ever be an issue again. This is evolution of the species at the most basic level.

OCF has never attempted to stigmatize any person for a sexual infection, especially one as common and ubiquitous as HPV, actually quite the opposite. Since we know that it cannot be avoided, and we have no way as individuals to know that we have an infection for the most part, and since most of us will naturally clear it, (and those that do not clear it have no way of knowing till it's too late that they will not) all we ask is that individuals get an oral cancer screening annually for something that does not produce symptoms in its early development that a lay person may not recognize.

More on the impact of genetics and cancer and what it all means for the future here http://blogs.forbes.com/matthewherper/2011/06/05/cancers-new-era-of-promise-and-chaos/

This is the most current thinking presented at the ASCO meeting yesterday.

CHICAGO � Human papillomavirus infection was firmly linked to the recent rise in oropharyngeal cancers in the United States, based on data from the National Cancer Institute�s Surveillance, Epidemiology, and End Results program.

If current trends continue, the incidence of HPV-related oral cancers will soon surpass that of cervical cancers, senior author Dr. Maura Gillison reported at the annual meeting of the American Society of Clinical Oncology.

The incidence of HPV-positive oropharyngeal cancers increased 225% � from 0.8 per 100,000 to 2.8 per 100,000 � between 1988 and 2004, the researchers found. At the same time, the incidence rate for HPV-negative oropharyngeal cancers, which are strongly related to tobacco and alcohol use, declined by 50% � from 2.0 per 100,000 to 1.0 per 100,000.

Consequently, the overall incidence of oropharyngeal cancers increased 28%.

Even by the conservative estimate that 70% of oropharyngeal cancers in 2020 will be HPV positive, the annual number of HPV-positive oral squamous cell carcinomas (8,653 cases) is expected to surpass cervical cancers (7,726 cases). Further, the majority will occur among men (7,426 cases), said Dr. Gillison, a medical oncologist and the Jeg Coughlin Chair in Cancer Research at Ohio State University Comprehensive Cancer Center in Columbus.

Changes in sexual behavior among recent birth cohorts and increased oral HPV exposure probably influenced the increases in incidence and prevalence, Dr. Gillison speculated. Having a high lifetime number of sexual partners is a known risk factor for HPV infection.

Although the rise in oral cancers in the United States has been attributed to HPV infection, the empirical evidence to back the contention was uncovered prior to the SEER study. A previous study by Dr. Gillison and her colleagues helped to establish that HPV infection causes an epidemiologically and clinically different form of oral cancer. Their findings documented a major increase in the incidence of HPV-related oral cancers in the United States, particularly among young, white men, and that survival rates are significantly higher in patients with HPV-related oral cancers than in those with HPV-negative cancers (J. Clin. Oncol. 2008;26:612-9).

The evidence surrounding HPV-related oral cancers has been mounting, "but I don�t think there is a lot of awareness in the general medical community," Dr. Gillison said in an interview. Most of her head-and-neck cancer patients who are nonsmokers were referred to her after undergoing months of antibiotic therapy for presumed tonsillitis.

Screening the sexual partners of oropharyngeal cancer patients has been discussed, but there is no evidence to support the practice. The risk for oral cancer is fourfold higher in HPV-positive patients� partners, but the absolute risk is low, Dr. Gillison said. Alternatively, there are now three or four case reports of husband-wife couples with HPV16-positive tonsillar cancer.

"Probably 80% of people have HPV exposures in their life and 99.1% clear the infections without consequence," she said. "So, whatever [stable sexual partners] have swapped in terms of infection, they�ve already swapped. Just because they suddenly found that one of them got cancer from it doesn�t mean the other one will."

The researchers called for more studies to evaluate the efficacy of HPV vaccines in preventing oral HPV infections.

Dr. Gillison worked for 3 years with Merck & Co., the maker of the HPV vaccine Gardasil, and commented that Merck will not likely pursue this indication. Merck was interested in studying the vaccine in prevention of oral cancers but saw the endeavor as too much of an uphill battle in part because oral cancers are not readily accessible visibly or through biopsy. Merck instead successfully opted to seek approval for the prevention of anal cancers, an indication that was approved in December 2010 for male and females 9-26 years old.

It was already approved in the same age groups for the prevention of cervical, vulvar, and vaginal cancer and of genital warts caused by HPV types 6, 11, 16, and 18 in females and for the prevention of genital warts caused by HPV types 6 and 11 in males.

Invited discussant Dr. Lisa Licitra of Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, said that oral cancers are on the rise in Europe in both men and women and that a vaccine should be pursued. Data on oropharyngeal cancer from her institute did not find a greater contribution from men.

"A preventive vaccine is worth considering," she said. "In particular, when we consider the European data, I think that in this direction, action should be taken."

In their study, Dr. Gillison and her colleagues used four different assays to determine the HPV status for 271 oropharyngeal cancer cases collected from 1984 to 2004 by three population-based cancer registries of the National Cancer Institute�s Surveillance, Epidemiology, and End Results program in Hawaii, Iowa, and Los Angeles. Trends in HPV prevalence across four calendar periods were estimated using logistic regression.

The HPV prevalence in oropharyngeal cancer significantly increased across the time period, regardless of the assay used, and remained statistically significant, even after correcting for potential loss in assay sensitivity, Dr. Gillison reported. Genotyping with the Inno-LiPA assay appeared to be the most precise, detecting more than a fourfold increase in HPV prevalence from 16.3% in 1984-1989 to 72.7% in 2000-2004.

Median survival was significantly better for patients with HPV-positive cancer at 131 months vs. 20 months for HPV-negative patients (log rank P value less than .001). HPV-positive cases on all assays had a significant reduction in hazard of death compared with HPV-negative cases after adjustment for age, sex, race, registry, calendar period, stage, surgery, chemotherapy, and radiotherapy.

Survival of HPV-positive cases increased over the study period but remained unchanged for HPV-negative cases. Consequently, survival of all oropharyngeal cancer cases improved over time, according to the results of the study, which was led by Dr. Amil Chaturvedi, an investigator with the division of cancer epidemiology and genetics at the National Cancer Institute, Rockville, Md.

I only have two comments
Firstly, I question the veracity of "dr mirkin" and "dr pinna" as this website just doesn't ring true. To try to put my finger on it, I looked around the website and stopped when I got to Dr Pinna's biography which just sounds ... wrong. A BA in economics??? In Mexico? After which he becomes a purser on a ship?? Then a Masters in Philosophy before his medical degree?? I wonder if these doctors, if in fact they ARE medical doctors are better suited to the "quacksite"

My second comment is around the use of the word promiscuity. If we don't want to stigmatise HPV and oral cancer then we need to watch our language. I remember reading the trial last year that quantified risk against the number of sexual partners we have, (the number 6 springs to mind but don't quote me) and I do not recall thinking that the number was particularly promiscuous.

As a still single 50 year old (although heavily committed to one man), I think I may have hit that number before I was 25. Maybe people DO interpret that as promiscuous but I think some of us were just slow learners:). I wonder how I would have been labelled by my 35th birthday?

We only just DE-stigmatised oral sex during my generation and I know at least half the population would be devastated if we were forced to return to the 50s way of thinking.

Karen

My thoughts are that the link (which I have notified the moderators about) goes not to gabe mirkin's article but rather to dr pinna's website where pinna is indeed selling "products".
Pinna's website is a mismash of health, economics, etc but I agree with Klo that this website link borders on meriting quackwatch listing since dr pinna is touting "magic mushrooms" and not the psychedelic kind I took back in college but instead another "miracle" cure from China that is a combination of a worm and a fungus and of course not available from any recognized medical source but soon to be sold by pinna.

I will say that Trends in Microbiology article on HPV was excellent but of course neither Mirkin nor Pinna discussed it. Brian actually did but in plain english compared to the actual article. Here is a link that I think will go to the pdf version of the article but since it's a redirect, I don't know HPV malignant progression If it does not, here is a link to that issue of the journal Trends in microbiology where you can scroll down for the HPV article

Last but not least, thanks Stily for posting this as I had actinic keratosis three times and had it burned off but the first time was ten years ago and according to my ENT, that was approximately when my cancer tumor started . Of course it wasn't discovered until almost four years ago. So I;ll buy the theory that HPV is involved in actinic keratosis.
Charm

Oops, I certainly did not mean to involve this "Dr. Pinna" person and have no idea who that is. I also certainly did not mean to suggest that OCF has in any way stigmatized anything! If anything I had posted here trying to promote the opposite.

Thank you, Brian, for all the information and certain clarifications.

It certainly is reassuring to read that "The risk for oral cancer is fourfold higher in HPV-positive patients� partners, but the absolute risk is low".

-Seth

not oops Seth, you just scored comments from 3 "tell it how it is" posters. 'Tis the nature of the beast that the written word is often more to the point (and consequently reads as blunt) than our spoken word.

I was mainly agreeing with you but just wanted to add to your important point about ensuring that HPV infection is not stigmatised by reminding people to avoid words such as promiscuous.

Your last paragraph made your point eloquently.

Unfortunate about the link - the problem wasn't the article but where it ended up.

Seth

Considering Dr. Pinna's lack of credibility (BTW, if you look at the link you posted you will see that the very first words are drpinna), I began to wondering if this is even a Gabe Mirkin article at all. I could not find it on the real Dr. Mirkin's website and a google search didn't turn it up either. Finally blogspot did the trick. There was never any such article.
Well, it turns out Dr. Pinna simply cut and pasted excerpts from three different different Dr. Mirkin blog posts and gave the impression that it was one article. Pinna took parts of Mirin's April 5, 2011 blog on HPV/cancer, Mirkin's blog entry a full year ago on June 19,2010 which was the one on HPV/ skin cancer and a Mirkin blog on March 10, 2010 about Cofactors for cancer.

That's why I objected to your linking directly to Pinna's page; he's just not credible plus hawks fraudlent products.
Like most quacks, he puts in just enough real stuff to trick readers. Technically his composite of three blog entries spanning a full year is "Dr. Mirkin on skin cancer", but it's hardly a Dr. Mirkin article. Pinna also left out some of Mirkin's cautions and common sense.

I know I'm a bit of nag on this, but I have always like Dr. Mirkin and this "article" seemed too loose with the facts to be truly his. At least Pinna left in Dr. Mirkin's cites to a real medical article.

Charm

Related to changing sexual behaviors as a solution. I have read several articles in the last week that do however, from a very conservative viewpoint, wish to alter American's and teenagers sexual behaviors. My observations are two things about this that have a history of not working. The first is prohibition of ANYTHING. I don't care what you pick, alcohol, prostitution, illegal drugs etc. it has never worked. You can make it illegal, you can stigmatize those that engage in it, but at the end of the day you can't eliminate it.

So using OCF tobacco policy as an example, we are proponents of "harm reduction" vs. prohibition. Essentially this means acceptance of the behavior, but offering alternatives that in some way reduce the harm. Clearly in tobacco use this would be replacement of the addictive portion of the product, nicotine with a strong enough supplement to have an equal effect to what was currently being used. The gums and patches do not, and OCF is an advocate for a controlled availability of nicotine inhalers and nasal sprays as higher dose delivery systems that do little harm, but reduce the incidence of inhaled combustion products from burning tobacco. It's not a perfect solution, people are still addicted and some will have higher blood pressure (not more than tobacco use but more than a non smoker), but cancer incidence particularly lung and oral will go down.

Since there is some argument about what constitutes "good" harm reduction, here are a couple of examples. In heroin use, we have FREE methadone to anyone that wants it without too many questions associated with getting it. They are still addicts, but the element of crime to generate capital to buy their habit is eliminated. Some harm reduction (particularly to others, some less revenues going into organized crime) but not a perfect solution. The key is there is no introduction of any new harm in the process. Another good harm reduction strategy are needle exchange programs. They do not stop people from being addicts, but they do stop the spread of HIV, hepatitis and other deadly diseases through their use.

Right now the idea of harm reduction in sex is limited to condom use (partially helpful in HPV, certainly helpful in the AIDS paradigm) and education (whatever is left after our current politics eliminate most of it from our schools for reasons I won't go into here). After that there are no real behavior changes that we can really count on - anyone that remembers their early years when hormones were raging and the opposite sex took a disproportionate amount of your thought process, understands why. Really what we have now is a chance to help the next generation through vaccination, and early discovery of disease stages in HPV+ oral cancers to reduce treatment related morbidity and death.

In an effort to be responsible but realistic parents, some of us parents of teens think about condom use this way: Abstinence is what we want and expect. But, we know it isn't always that simple nor is it safe and/or healthy not to advocate the use of condoms. So, we find we're saying, "we don't want you to have sex but if you do, use a condom."

Personally, I keep the lines of communication open with my sons all the time, seize upon "teachable moments", and have made it a part of family life to talk about things we see or hear about in the media or even in our community. It surprises me how many people are still very shy and won't talk to their children about sex. I handle talking about illegal drug use and alcohol abuse in the same way.

When we had the Gardisil vaccination series started for our sons, we talked very openly with them about the reasons for them to have the vaccine. Also, I sat with my 17 year old son and his pediatrician and discussed it. Although he's a shy kid, he didn't get embarassed, and didn't complain about what we were talking about.

As parents, it's not that were advocating a particular behavior...we're just aware we can't prevent it from happening. So, it's best to protect them and educate them.

My daughter recently took her two boys for their check-ups. She and the two boys were together in the same exam room as the doctor who examined both boys (the oldest just entering puberty) at the same time, which I thought really helped to eliminate any possibly embarrassing moments. Everything was discussed including the Gardasil shots due to be given next year to the oldest. Then the doctor gave each boy the opportunity to talk with him privately w/o their Mom there . I'm all for "teachable moments" starting very young which provides for later situations to be that much easier. Sandy, I agree, it's best to protect and educate. There are unforeseen circumstances that arise where even the best intentions or personal beliefs go awry.