When veteran Hollywood actor Michael Douglas revealed that his throat cancer was due to oral sex and not smoking, the interviewing journalist went into a shocked and nervous giggle — as did the rest of the world, with Twitter going hyper on the subject. Though Douglas’ publicist now denies his client ever meant what he said, and the actor’s ex-wife felt the compulsion to clarify it was not because of her, SHAlINI SAKSENA finds out that oral cancer due to HPV is, indeed, a fast-growing disease
When Hollywood actor Michael Douglas told the world through a newspaper interview that his cancer was not caused by smoking or alcohol but by HPV (human papilloma virus) transmitted through oral sex, it amazed the world — not because of his candid confession but because very few knew of this possibility. “Without wanting to get too specific, this particular cancer is caused by HPV which actually comes about from cunnilingus,” the 68-year-old actor said. Another matter that his outraged publicist Allen Burry denied Douglas had ever blamed oral sex for his cancer.
When contacted by this correspondent, Burry was not willing to elaborate. “Thank you very much for reaching out but we’ve no additional comment,” was all he would say. Contacted again, he insisted: “We’re going to kindly pass.” Douglas’ revelation may have created a huge controversy, but it also propelled a fact that cannot be denied — that oral sex can lead to mouth/throat cancer.
A study published in 2012 in the journal of the American Medical Association says that 10 per cent of men between ages 14 and 69 had an oral HPV infection, compared to 3.6 per cent of women. The study also said that the HPV infection is more common in men than in women. But it isn’t just in the US that this type of cancer is on the rise. A 2010 Swedish study showed a correlation between oral cancer and oral sex. “In addition to the known oral cancer risk factors — smoking, drinking alcohol and chewing betel nuts — HPV has been added to the list,” the study published in the Centre for Disease Control and Prevention’s (CDC) Emerging Infectious Diseases report says. The report, that looked at 542 US students, also said that oral sex has become more commonplace and people have more sex partners and have sex earlier in life — all behaviours linked to HPV-related oral cancers. It has also been reported that open-mouthed kissing was associated with the development of oral HPV infection too.
Dr Ullas Batra, medical oncologist at Rajeev Gandhi Cancer Institute, New Delhi, agrees. “There has been an increase in the number of cases in India where the person has got throat and mouth cancer caused due to sexual transmission. Usually, cancers of the mouth and throat are caused due to smoking and tobacco. But recently, there has been a rise in the number of people coming to us for treatment of mouth cancer with no history of smoking or chewing tobacco. Though there is no conclusive proof that HPV is the only causative, the possibility can’t be ruled out. This is because, unlike the West, where studies are conducted, no such research or data is available in India,” he says.
He also tells you that the viral infection usually surfaces in men and women during adolescence. In 80 per cent cases, the infection gets cured on its own. In the remaining 20 per cent, may be 10 per cent leads to cancer. “Bad hygiene, multiple partners and multiple pregnancies are some of the reasons for HPV cancer. During oral sex, this virus is transmitted to the other person when the man kisses the woman on the mouth, the virus gets lodged in the mouth. It works in a similar fashion the other way round. It starts with a small boil in the man’s mouth and grows from there,” Dr Batra explains.
This view is shared by US-based Dr Kevin J Cullen, director of the University of Maryland Medical Centre and University of Maryland School of Medicine, who says that there has been an increase in malignancies directly or indirectly related to the viral infection. “HPV, at present, is one of the most common sexually transmitted infections worldwide, with a majority of individuals who engage in sexual activity becoming infected at some point in their lifetime. There are more than 130 HPV types identified and these have been classified into low or high-risk groups according to their potential for oncogenesis based on persistent infection,” Dr Cullen says, adding that the association between HPV and genital cancers has been well established with evidence suggesting an infectious etiology dating as far back as 1842, when Italian physician Dr Rigoni-Stern noted a positive association between sexual activity and the cervical cancer mortality rate.
Recently, non-genital cancers (including head and neck malignancies) were associated with HPV infection. Through the integration of viral DNA into the human gene, expression of onco-proteins and inactivation of the tumour suppressor genes, HPV evolves to transform its site of infection with damaging unchecked growth and oncogenesis.
In the US, it is estimated that approximately 25,000 HPV-associated cancers occur annually and the virus is responsible for up to 90 per cent anal cancers, 65 per cent vaginal cancers, 50 per cent vulvar cancers, 35 per cent penile cancers, and 45 to 90 per cent oropharyngeal cancers. Even the CDC says that up to 80 per cent Americans have HPV infections.
So what exactly is HPVIJ According to the Oral Cancer Foundation, US: “The human papilloma virus (HPV) is a double-stranded DNA virus that infects the epithelial cells of skin and mucosa. The moist epithelial surfaces (squamous cells) include all areas covered by skin and/or mucosa such as the mouth interior, throat, tongue, tonsils, vagina, cervix, vulva, penis (the urethra — the opening) and the anus. Transmission of the virus occurs when these areas come into contact with a virus, allowing it to transfer between epithelial cells. While it’s established now that sexual contacts, both conventional and oral, are means of transferring the HPV virus through direct skin to skin contact, it is still poorly understood what other transfer pathways may exist. It is highly unlikely that the virus can live for long on inanimate objects outside of a cell.”
The HPV family contains almost 200 strains but it’s important to understand that of all these, only nine are carcinogenic. Of the nine that are high risk, only one is strongly associated with oropharyngeal cancer — the HPV 16.
Oncologists tell you that in such a situation, people should look out for certain signs. “An ulcer or boil in the mouth that doesn’t heal within a few weeks, problem in swallowing, pain while chewing food, a swelling in the mouth, a lump is the neck and constant coughing are signs to watch out for. And though smoking is still the main cause of mouth cancer — 15 per cent of all cancers in the country are because of this — there has been an increase in oral sex related HPV cancer. Of this 15 per cent, around 10 per cent is caused due to oral sex. Seeing the number of other cancers, this percentage is not that high. And since it’s in our DNA, if one went for a test, the chances of the tests coming back positive are high,” Dr SK Das, senior consultant gynae-oncology with Action Cancer Hospital in Delhi, tells you.
Dr Das is, however, quick to point out that though there is no cure for the virus, most of the time, HPV goes away by itself within two years and doesn’t cause health problems. It’s only when HPV stays in the body for many years that it may lead to oral cancers. And though researchers are not clear why the virus goes away in most cases and remains in others, one reason could be that in some people, the immune system doesn’t recognise the infection as a threat and it’s allowed to stay in the body. Although HPV can increase the risk of developing some types of cancer, most people who have HPV don’t get cancer even though the HPV oral and oropharyngeal cancers are harder to discover than tobacco-related cancers because the symptoms aren’t always obvious to the individual who is developing the disease, or to professionals that are looking for it.
Of course, it goes without saying that it’s extremely difficult for the doctors and oncologists to say with certainty what caused the cancer in an individual. There are other reasons as well that raise the risk of head and neck cancer. But between 1988 and 2004 (in the US), head, neck and throat cancers that tested positive for the HPV rose to 225 per cent, according to one study in the journal of Clinical Oncology.
In India, the threat may not be so alarming but doctors opine that approximately 30-40 per cent of all cancers in males and a substantial percentage in women are HPV-related. “Both smoking and oral sex are on the rise in our country. Once the HPV gets lodged in the oral cavity, it’s very difficult to eliminate the virus. Even a kiss may spread the virus to a woman’s oral cavity. Therefore, the country is likely to see a rise with people aping the West and lifestyle becoming more like theirs. The rise in HPV infection may be due to the wider acceptance of oral sex among teenagers and adults as this is viewed to be a form of safe sex,” Dr Ravi Mehrotra, director with the Institute of Cytology and Preventive Oncology, explains.
Dr Mehrotra, who has been a part of part of three research projects on oral cancer, warns Indians. “These infections are common and rarely cause symptoms. Although HPV infection is linked to oropharyngeal cancer, most people with HPV infections of the mouth and throat don’t go on to develop this cancer. However, the good news is that HPV-related oral cancers have a higher cure rate than those caused by tobacco. While the line of treatment remains the same, people who have HPV caused cancers respond better to treatment and the cure rate is higher too, adding that one should maintain proper hygiene before and after having sex. “Use condoms correctly and consistently to reduce transmission of HPV between sexual partners. The most important thing to keep in mind: Avoid sex with multiple partners,” Dr Mehrotra advises.
Doctors at the Oral Cancer Foundation share the viewpoint. “The symptoms can be subtle and painless. A dentist or doctor should, therefore, evaluate symptoms and analyse anything that has persisted for two or more weeks. Although there are many oral cancer screening devices and tests, not all of them can find HPV positive oral and oropharyngeal cancers. The best way to screen HPV-related oral cancer is through a visual and tactile exam given by a medical or dental professional, who will also do an oral history taking to ask about symptoms that cover things that aren’t visible or palpable.
“like other cancer screenings one engages in, like cervical, skin, prostate, colon and breast examinations, opportunistic oral cancer screenings are an effective means of finding cancer at its early an highly curable stages. However, like many other cancer screening techniques, this process is not 100 per cent effective and any screening technique or technology can miss things. This is why it’s so important that persistent problems are pursued until a definitive diagnosis of what it is established. Most of the time these will be issues that are not cancer, but persistent problems need to be addressed, cancer or not,” Brian Hill, executive director of the foundation says.