Furthering the Knowledge of HPV Linked Oral Cancer

Abstract

Among the familiar risk factors influencing the development of oropharyngeal cancer, like the use of tobacco or excessive consumption of alcohol, human papillomavirus has also been identified as a leading causal agent. A lack of education is present in terms of the link between these two phenomena, HPV and oropharyngeal cancer. A review of the literature was completed to assess the caliber of knowledge surrounding the correlation between human papillomavirus and oropharyngeal cancer, in reference to those diagnosed and also dental hygienists.

A majority of participating patients who had been diagnosed with HPV related oropharyngeal cancer, reported they were not educated of the cause of their condition at the time of their diagnosis, just as a majority of the surveyed dental hygienists admitted to neglecting initiating such conversations with their patients when conducting oral cancer screenings.

In the United States, approximately 50,000 people were newly diagnosed with a form of cancer of the oral cavity in 2012; of those people, an estimated 9,000 died as a result of their diagnosis (“Oral health conditions,” 2015).

The most common type of head and neck cancer is oropharyngeal squamous cell carcinoma. Familiar causes of oropharyngeal squamous cell carcinoma are tobacco use and the consumption of alcohol, but aside from those, is a newly discovered link between oral cancer and human papillomavirus, or HPV. Human papillomavirus is the most common sexually transmitted disease, with 80% of people contracting an HPV infection in their lifetime, and is primarily known to have the ability to progress to cancer of the reproductive organs (“6 reasons to,” 2018).

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Because of this, the link to oropharyngeal cancer may not be easily perceived. The traditional risk factors have been replaced by those related to sexual activity and increased number of sexual partners. There is a knowledge gap associated with the connection of human papillomavirus and oropharyngeal cancer between the population and healthcare professionals, more than likely due to a lack of research conducted on the topic. Closing this gap is one way to spread awareness of the link between HPV and oropharyngeal cancer; this can be done by implementing appropriate educational requirements for dental hygienists as new information is becoming available.

Review of Literature

A particular study performed through the University of North Carolina by Gallagher, Deal, Ballard, and Mayer, was conducted to understand the knowledge of human papillomavirus of those who had survived HPV related oropharyngeal cancer, and to explore how said survivors learned more about HPV. This study was performed as a cross-sectional study. Thus, meaning it was carried out through a survey, allocated towards a specific group of people at a given point in time. The specific group being survivors of HPV-related oropharyngeal cancer at a National Cancer Institute, the University of North Carolina’s Lineberger Comprehensive Cancer Center (Gallagher, Deal, Ballard, & Mayer, 2017).

The selection process started with 225 total patients diagnosed with oropharyngeal squamous cell carcinoma between the dates of January 2010 and March 2013. The selected participants were deemed eligible for participation in the study based on a set criteria. The parameters included the survivors must have been over 18 years of age, spoke English as their primary language, and have been previously diagnosed with an HPV-linked tumor between the dates of January 1, 2010, and April 1, 2013. The participants also had to have undergone at least three months of treatment under the care of specific oncologists, with at least one of their treatments performed at UNC Lindberger Comprehensive Cancer Center; this could have been radiation treatment, a surgery, or simultaneous radiation and chemotherapy treatment. Current circumstances at the time of the study included no evidence of recurrent cancer at the participants’ most recent oncology appointment; and they could not have been incarcerated in state or federal prison at the time. Using this criteria, the number of qualified participants was greatly reduced from the original 225 to 64. Invitations and informed consent documents to participate in the study were mailed to possible candidates (Gallagher et al., 2017).

The survey could have been filled out online by the participant using Qualtrics, a web-based research software, or completed surveys received by mail were manually entered into the online software by the principle investigator. All responses were anonymous. The survey consisted of three sections: prior knowledge of HPV, education provided, and impact. The knowledge section was a series of 20 true or false statements pertaining to HPV; there was also an “uncertain” answer choice. The impact choice portrayed 4 statements to participants related to the frequency of thoughts about HPV, embarrassment, and harm to relationships, and how the participant felt negatively impacted by these thought rated on a scale of 0 to 3, 3 being the greatest negative impact. Of the 64 surveys sent out, 34 were returned, 20 via the online software and 14 by mail. There were two participants who claimed they were unaware their cancer was related to HPV, so their responses were discarded, bringing the final number to 32 participants (Gallagher et al., 2017).

Deciphering the responses from the knowledge section of true or false statements resulted in a median score of 48% of the questions answered correctly among the 32 participants. The highest score was 79% correct, and the low was only 6% answered correctly (Gallagher et al., 2017).

The findings of the education portion of this survey were as follows: prior to their diagnosis, 31% of respondents had never heard of HPV, and 53% had previously heard about it, but knew very little. It is important to note that 72% of participants reported they were satisfied with the education they received when diagnosed, but 63% said they were not educated about HPV at that time. Following their diagnosis, 63% of participants researched HPV, with 92% of that group doing so by use of the internet (Gallagher et al., 2017).

The impact section of the survey had a total of 4 scenarios; with the total answers ranging from 0 to 12. Ninety-percent of participants had feeling of optimism because their oropharyngeal cancer was HPV related, while 59% claimed HPV rarely crossed their mind (Gallagher et al., 2017).

Now, shifting to another study focused on a dental hygienist’s role in educating patients of the link between HPV and oropharyngeal cancer by Thompson, Daley, Vamos, Horowitz, Catalanotto, DeBate, Merrell, Griner, Vazquez-Otero, and Kline, which was conducted through the University of South Florida. In July of 2015, at a national dental hygiene conference, licensed dental hygienists of the United States were asked to join focus groups investigating their understanding and promotion of health literacy related to HPV. Participants were recruited via email and the only requirements was they had to hold current U.S. dental hygiene licensure, have graduated from an accredited dental hygiene program, have over one year of clinical experience, and be at least 21 years of age. Forty-eight participants were selected and split amongst four focus groups. Before the study commenced, informed consent was obtained from each individual participant, in written form. In 85 minute audio recorded sessions, each group was asked questions based on their knowledge of HPV, where they received their information, how they used said information, strategies used to facilitate HPV related discussions with their patients, and barriers they faced when doing so. The transcripts from the sessions were then compared and analyzed by two researchers, and logged into data system Atlas-ti version 6.2 (Thompson et al., 2017)

Common sources of information where the participants had become educated of HPV were scholarly journals, continuing education courses, dental hygiene school, and online sources such as the American Dental Hygienists’ Association website and the Centers for Disease Control website. Of the participants, those who had been in practice longer admitted they had not received education on HPV-linked cancers during their schooling and/or training. As a whole, out of 48 participants, the majority proved to be knowledgeable in their understanding of HPV and one of its modes of transmission being oral sex. A lack of knowledge was evident pertaining to the treatment and cure of HPV, and also which specific strains of the virus were associated with oropharyngeal cancer directly.

Another gap in knowledge among a majority of the participants was knowing the appearance of an HPV associated lesion, and the plan of action to be taken in means of treatment or a referral. When asked about initiating conversations with patients about HPV and its link to oropharyngeal cancer, there was a theme across all four focus groups and that was about the age barrier. A majority of the participants felt uncomfortable discussing a matter related to sexual acts with patients who were older and also with adolescents. Because of their discomfort in the situation, some of the participants admitted to omitting the conversation, unless it was first initiated by the patient. Other barrier that were reported were ones posed by religion, and also language differences. From a clinical aspect, a majority of the participating dental hygienist agreed on the importance of regular oral cancer screenings, and added they were willing to have the conversation with their patients about HPV and its risk factors associated with oropharyngeal cancer (Thompson et al., 2017).

Methods and Procedures

Topic Selection

The topic of this literature review was selected after it was mentioned in one of the author’s dental hygiene program courses by an instructor. She explained to the class that there was a newly discovered link between oral cancer and HPV because of oral sex behaviors. This discussion provoked the author to do additional research via google searches to gain additional general information on the correlation. As a topic of interest to the author, it seemed to be the perfect topic to select when the literature review was assigned in a different course.

Resource Search and Selection

A careful review of the significant literature related to the association between human papillomavirus and oral cancer was conducted. The search was narrowed to the importance of human papillomavirus educational in relation to oropharyngeal cancer, limiting the search to 22 articles. Review of the abstracts was accomplished and 4 articles were selected for incorporation into the project.

Libraries/search engines and databases used. One PMI library database, EBSCOhost, was used to search for the sources for this project. The website of the Centers for Disease Control and Prevention was also used for statistical research related to HPV.

Search terms. Several search terms were used to identify sources for this project. The search terms included (a) oral cancer, (b) HPV, (c) human papillomavirus, and (d) oropharyngeal cancer. This search resulted in 22 articles. Filters were used to narrow down the search. Sources resulted from the searches were peer reviewed, had full texts available, and were published after 2008.

Boolean strings. Three Boolean string were used:  HPV AND oral cancer; human papilloma virus AND oropharyngeal cancer; and HPV AND oropharyngeal cancer.

Age of the Sources. The significant literature will be reviewed.  Only sources from the last 10 years were considered for inclusion in the review of literature.

Discussion

After analyzing these studies related to oral cancer and HPV, it should be made known that there are both strengths and weaknesses associated with every study. Both of the studies previously mentioned, made note that “HPV 16 is linked to up to 70 percent of oropharyngeal squamous cell carcinoma,” (Clark, 2013). This finding proves that the research is definitely being done to uncover the root causes and specific roles that HPV plays in the cause and prognosis of oropharyngeal cancer. However, it’s the quantity of studies and cases that are going to reinforce the findings. For example, the study performed at UNC Lineberger Comprehensive Cancer Center was definitely conclusive, but even though it was the largest of its kind, it was confined to only a single cancer center in a single state. By broadening these studies and conducting them more frequently, more accurate and valid findings will arise. Furthermore, by acquiring more recent and proven data, the education that is given to the public through healthcare professionals will improve as well.

Educating the public is crucial to aid in prevention of ailments and diseases. Dental hygienists specialize in oral health through educational, therapeutic, and preventative services. In the health literacy study mentioned earlier, which was conducted at a national conference, it was stated that, “dental hygienists possess the baseline knowledge of oral cancers and they clearly expressed a desire to learn more and have accurate information before they begin to educate patients,” (Thompson et al., 2017). The hygienists in this study admitted to more often than not omitting the conversation of HPV with their patients when performing oral cancer screenings. This in part was since, “recent evidence found oropharyngeal cancer (associated with oral HPV 16) to be associated with a high life-time number of oral sex partners,” hygienist claimed to be uncomfortable initiating this conversation with their patients (Crosby et al., 2012).

With the dental hygiene profession on the rise, employment, “is expected to increase by 20% in the next ten years, and the number of dental hygiene education programs is expected to increase to meet those needs,” (Thompson et al., 2017). This is an opportunity to implement HPV education into dental hygiene program curriculum. By educating dental hygienists of HPV and its link to oropharyngeal cancer, they can better promote prevention of the virus by recommending oral cancer screenings and the HPV vaccine to their patients. Along with the factual education, hygienist would also benefit from being taught the communication skills needed to initiate these conversations with patients. Another option would be to make HPV education a topic of required continuing education courses. With the research on the topic evolving quite regularly, and with frequent new findings, this would ensure that all dental hygienists, those with minimal experience and those who are veterans of the occupation, have the adequate knowledge they need to better educate their patients.

Conclusion

Because it is a recent finding, there is a lack of knowledge surrounding the connection of human papillomavirus and oropharyngeal cancer due to the absence of research performed on the topic. This inevitably leads to the lack of knowledge dental hygienists are able to relay to educate their patients. As was described from the studies conducted, a majority of patients diagnosed with oropharyngeal cancer related to HPV were not educated about HPV when diagnosed. To further this finding about the lack of education, the second study revealed that a majority of dental hygienists omitted discussing the relationship of HPV and oropharyngeal cancer with their patients because of the discomfort associated with the private nature of such conversation. Because of this, patients are left uneducated about the risk factors associated with their oral health and possibly even their current oral health situations. Adding HPV education to dental hygiene programs will better inform future hygienists on how to initiate such conversations with patients, and adding HPV related courses to continuing education requirements for currently licensed hygienists will educate those who did not receive the information through their school program. Staying educated is not for a hygienist’s own benefit, but for the benefit if his or her patients.

References

1. Clark, D. (2013). Beyond cervical cancer: Human papillomavirus (HPV) and its role in oropharyngeal squamous cell carcinoma. Canadian Journal of Dental Hygiene, 47(3), 135–138. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107929897&site=eho t-live
2. Crosby, R. A., DiClemente, R. J., Salazar, L. F., Nash, R., Younge, S., & Head, S. (2012). Human papillomavirus vaccine intention among college men: What’s oral sex got to do with it? Journal of American College Health, 60(1), 8–12. https://doi.org/10.1080/07448481.2011.552538
3. Gallagher, S. T., Deal, A. M., Ballard, D., & Mayer, D. K. (2017). Oropharyngeal cancer and HPV: Measuring knowledge and impact among survivors of head and neck cancer. Clinical Journal of Oncology Nursing, 21(3), 321–330. https://doi.org/10.1188/17.CJON.321-330
4. Oral health conditions. (2015, October 13). Retrieved January 16, 2019, from https://www.cdc.gov/oralhealth/conditions/index.html
5. 6 Reasons to Get HPV Vaccine for Your Child. (2018, May 1). Retrieved January 16, 2019, from https://www.cdc.gov/hpv/infographics/vacc-six-reasons.html
6. Thompson, E. L., Daley, E. M., Vamos, C. A., Horowitz, A. M., Catalanotto, F. A., DeBate, R. D., … Kline, N. S. (2017). Health literacy approaches to improving communication between dental hygienists and patients for HPV-related oral cancer prevention. Journal of Dental Hygiene, 91(4), 37–45. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=125017225&site=eho -live