School is back in session, and if your child has had his or her annual checkup, their doctor might have talked to you about the importance of kids and adults obtaining the human papillomavirus (HPV) vaccine.
The HPV vaccine can prevent genital warts and penile cancer in men; cancer of the cervix, vagina and vulva in women; and anal and throat cancer in both men and women.
The HPV vaccine keeps the body from becoming a carrier even if a person is exposed to the virus through sexual contact.
A patient of mine I’ll call Deb recently went through some fairly intense testing to rule out cervical cancer, and it was very stressful for her.
She came to see me for her annual exam and Pap smear, and she had experienced abnormal Paps in the past. She even had to have a colposcopy to make sure she didn’t have cervical cancer. Fortunately, Deb did not have cancer, but she wanted to make sure her kids wouldn’t have to endure the same procedures and worries she endured.
I recommended the HPV vaccine to give her some reassurance for her children.
The HPV vaccine is available in three different brands, each covering two, four or nine different types of the virus. The vaccine is given in three doses within a 24-week period. It can be given to both boys and girls and it has been shown to be safe and effective for females and males between the ages of 11 and 29.
The vaccine can also be given even if the person already has the HPV virus, because it can protect against other types of viruses as well. The optimal range for girls and boys to receive the first shot is between the ages of 11 and 12, because the immune response is better the earlier it is given. In addition, whether or not we like to think about it, kids often have sex before we suspect they do.
In countries where vaccines are more mandated, the HPV vaccine rate is approximately 80 percent. In the U.S. the rate is 54 percent for the first shot and only 33 percent for all three shots. The higher the rate of vaccination, the fewer the women who will develop cervical cancer.
Bottom line: Get your kids vaccinated.
So, why is our vaccination rate so low compared to other countries? In a survey, parents gave the following reasons for choosing not to get their kids vaccinated against HPV:
They think the vaccine is unnecessary.
They think the vaccine is ineffective.
They think the vaccine is unsafe.
They don’t understand the details of the HPV vaccine.
They don’t think their children would have sex that young.
Health care providers know the vaccine is safe, effective and necessary—and they know that parents need to learn more about the vaccine and appreciate the reality that some children will have sex at a young age. There is excellent information available to support the decision to vaccinate kids early.
I am happy that Deb trusted me and was willing to consider the vaccine to reduce her daughter’s chance of having abnormal Pap smears in the future.
Even if the shot has been given, it is still important to screen for HPV and abnormal cells on the cervix. Pap smears should be started at age 21 and performed every three years after that.
I follow the recommended guidelines to start co-testing of the Pap and HPV at age 30; if the results are negative, repeat the test every three years. If there are abnormal cells present, the next step is to do a colposcopy, where we look at the cervix with a telescope and take a biopsy of the cervix.
Of course, there are several other ways to prevent the HPV virus, and I told Deb to give the following advice to her children:
Do not smoke.
Use a condom every time.
Delay sex until after age 15.
Deb appreciated the information I shared with her and scheduled
appointments for her kids to get their vaccines during their checkups.
As a gynecologist who has had to perform hysterectomies on many women because of cervical cancer, I’m very happy that Deb made the choice to have her kids vaccinated.
Rob Buitendorp didn’t worry much about the little lump he found on his neck, behind his right ear.
It didn’t hurt, didn’t get in the way. He had no problems swallowing or speaking.
But he had a doctor’s appointment in three weeks, so he decided to ask about it then.
He is so glad he did.
Buitendorp, a 73-year-old retired insurance adjuster, is one of the growing number of people diagnosed with HPV-related throat cancer. And thanks to his quick reaction, he benefited from early detection and treatment.
“If the cancer is detected early, then patients are more likely to have a choice of effective cancer treatments,” said Thomas O’Toole, MD, a Spectrum Health head and neck surgical oncologist.
It is the most common HPV-associated cancer in the U.S.—more common even than cervical cancer. But the lack of awareness about the disease hampers efforts to combat it.
“This is an epidemic,” Dr. O’Toole said. “It can happen to basically anybody and it’s the scariest thing. It really strikes middle-aged healthy people out of the blue.”
Photo by Chris Clark, Spectrum Health Beat
Early detection is key to surviving—or suffering fewer physical effects. But the earliest signs often go unrecognized by patients and, sometimes, even by doctors, Dr. O’Toole said.
The most common early symptom patients notice is a painless bump on the neck. A sore throat is the second most common sign. Too often, people wait months, hoping the problem will go away, before they seek medical care.
“If you have a bump on your neck and it’s been there for more than two weeks, you should go to your doctor, even if you don’t feel any other symptoms,” Dr. O’Toole said. “The quicker we get a diagnosis, the quicker you can get treatment, which is important in terms of improving patients’ survival.”
He recommends the HPV vaccine to prevent the cancer from occurring.
The Food and Drug Administration initially approved the vaccine for youths age 9 to 26 years. But in October 2018, it expanded the approved use of the vaccine to include men and women age 27 to 45 years.
“Because HPV-related cancers may develop decades after exposure to the virus, it may be a while before we see the impact of the vaccine on the incidence of oropharynx cancer,” Dr. O’Toole said.
Cancer rates on the rise
In the 1980s, the medical community began identifying problems with throat cancers related to the human papillomavirus, or HPV.
As smoking became less popular, the incidence of most head and neck cancers declined, as expected. But one form began to show up more often—cancer of the oropharynx.
If you open your mouth and look in a mirror, you see much of oropharynx at the back of your throat. It includes the tonsils, the base of the tongue, soft palate and the back wall of the swallowing passage.
Long before Buitendorp’s diagnosis, lab analysis of oropharynx cancers began to find evidence of a virus in the tumors. They identified HPV in 15 to 20 percent of tumors in the 1980s, and in 80 percent of tumors by 2004.
Photo by Chris Clark, Spectrum Health Beat
HPV viruses, which can be sexually transmitted, are common and doctors believe many people have been exposed to them.
“It’s only rare that people end up with cancer from it. It’s something we don’t fully understand—who’s going to develop cancer,” Dr. O’Toole said.
Treatments for cancer of the oropharynx include surgery, chemotherapy and radiation.
“We try to identify what we think is going to be the most effective treatment for the patient with the fewest side effects,” Dr. O’Toole said.
To reduce delays in diagnosis of throat cancer, the American Academy of Otolaryngology-Head and Neck Surgery has developed a clinical practice guideline for evaluation of adult patients with a neck mass, Dr. O’Toole said.
“They recommend that when adult patients have a neck mass for more than two weeks or of uncertain duration without signs of infection, there should be an examination of the upper aerodigestive tract, including the oropharynx and larynx,” he said. “This usually will require referral to an otolaryngologist.
“Dr. O’Toole’s office called and said this is something that should be seen immediately.”
Bob Buitendorp
When Buitendorp’s internist looked at the lump on his neck in February 2018, he recommended seeing an otolaryngologist. He gave him the phone number for Dr. O’Toole.
When he arrived home, Buitendorp discussed it with his wife, Ruth. He figured he would follow up on the advice—eventually—but he wasn’t worried. The bump was painless.
“In my family, we have a problem with procrastination,” he added.
Fifteen minutes later, a phone call surprised him.
“Dr. O’Toole’s office called and said this is something that should be seen immediately,” he said.
Photo by Chris Clark, Spectrum Health Beat
At the first appointment, Dr. O’Toole examined Buitendorp’s throat and showed pictures of a suspicious area on the right tonsil.
“He showed me a growth on the inside that was directly related to the external growth,” Buitendorp said.
Dr. O’Toole performed a fine needle aspiration biopsy in the office. Later, in an operating room, he performed a biopsy of the tonsil, which confirmed an HPV-related cancer.
Dr. O’Toole performed the operation with the use of the da Vinci robot. The minimally invasive procedure is performed through the mouth. He made only one incision a few inches long in the neck to remove lymph nodes.
The minimally invasive approach makes recovery easier, he said.
A more traditional approach could involve cutting the jaw in half and opening the face like a book. Or a surgeon might make an incision across the neck and take apart the muscles that attach the voice box to the jaw.
“All those things disrupt the muscular attachments,” he said.
He advises patients considering surgery to get an evaluation by a surgeon who can perform a minimally invasive operation.
Dr. O’Toole removed the tumor, which affected the back of the tongue, tonsil and throat. And he removed 66 lymph nodes.
Buitendorp spent five days in the hospital recovering.
“Everything went better than I ever expected,” he said. “I was talking the first day.”
After the surgery, Buitendorp didn’t eat for a week. He lost 25 pounds.
Photo by Chris Clark, Spectrum Health Beat
In the year since then, he has worked with speech therapists to regain the ability to eat a variety of foods. He takes small bites and eats slowly.
“I’m also getting my taste buds back slowly,” he said.
The post-surgery weight loss is common, Dr. O’Toole said.
“Most people can expect to lose 10 to 20 percent of their body weight,” he said.
Buitendorp knows the cancer or the treatment could have taken a far greater toll without quick treatment.
“This could have been serious if I had not said something to (my doctor),” he said. “That is the key. If you see something wrong, talk to your doctor.”
If your child is headed to college for the first time, you can allay some of your worries by ensuring they’re up to date on vaccinations. (Courtesy Spectrum Health Beat)
If you’re looking to help your burgeoning thinker prepare for the first year of college, you could do worse than start with a simple science lesson.
Think of the higher learning universe as a giant petri dish.
Your youngster will dive headlong into that glorious environment, seizing opportunities to broaden the intellect and test new ideas that challenge the status quo.
College is, however, a life-sized cauldron of cellular chaos, swimming with a frightening array of potentially deadly germs.
What important steps can parents take to ensure their college student is prepared for life on campus?
Above all else, make sure your child is properly vaccinated, said Mary Zimmerman, immunization program manager at Spectrum Health.
Does this mean you can’t spend this last month of summer scouting out the best deals on futons, bed sheets and mini refrigerators? No. It just means immunizations need to maintain their proper place at the top of the to-do list.
Teens headed to college should be current on six vaccinations in particular—meningococcal serogroup B, meningococcal conjugate vaccine (serogroups ACWY), hepatitis A, Tdap, HPV and influenza.
Meningococcal serogroup B vaccine
Given their bustling social lives and close-quarter living, college students are uniquely prone to exposure of meningococcal disease, Zimmerman said.
And if there’s just one thing to remember about meningitis, it’s this: It is deadly serious.
“People who have had meningitis had flu-like symptoms and then they were dead within 24 hours,” Zimmerman said. “If you survive, it’s a long-term stay in the hospital.”
The disease kills 10 percent of its victims, she said. Of those who survive, 20 percent will suffer long-term consequences from infection, including brain damage, amputation or loss of hearing.
When the bacteria infect the brain and spinal cord, it’s known as meningitis. When it infects the bloodstream, it becomes septicemia. There are two different vaccinations for meningococcus—serogroup B vaccine and serogroup ACWY vaccine, also known as the conjugate vaccine—and they immunize against different groups of the disease.
The CDC requires children to receive the conjugate vaccination by age 12, with a recommended follow-up conjugate booster at age 16. It’s also recommended that children receive the serogroup B vaccine at age 16, when they get the conjugate booster, but it’s not required, Zimmerman said.
Only recently has there been growth in awareness about the serogroup B vaccine.
In Michigan, the family of Emily Stillman, a Kalamazoo College sophomore who died of meningitis in 2013 at age 19, has emerged as the vanguard in pushing for awareness about meningococcal serogroup B.
Stillman died within 36 hours of contracting bacterial meningitis. She had received the meningococcal conjugate vaccine in her youth and also the recommended conjugate booster at age 16.
She did not receive the serogroup B vaccine.
Why? In 2013, the serogroup B vaccine hadn’t been available in the U.S. Not until 2015 did it become available.
Zimmerman cautioned that parents may encounter circumstances, even today, in which a primary care provider doesn’t have immediate access to the serogroup B vaccination.
This should not discourage them from pursuing it further.
“Check first with your primary care provider,” Zimmerman said. “If they don’t carry the B shot, you can check with the local health department — they do have it.”
Don’t assume the serogroup B vaccination isn’t important simply because the CDC made it a recommended vaccination, as opposed to a requirement, said Mary Wisinski, immunization program supervisor at Kent County Health Department.
“Absolutely get the vaccine,” Wisinski said. “It’s a deadly disease.”
Meningococcal conjugate vaccine
All strains of meningitis are spread through secretions from the throat and respiratory system—coughing, kissing, sneezing, sharing cups and so forth. Simply living in the same environment as someone with the disease could put you at risk.
About 10 percent of people who carry the bacteria in their nose or throat won’t show symptoms of the disease. But they can spread it.
“That’s why it’s so scary,” Zimmerman said. “There’s no rhyme or reason as to who might get the disease and who might just be a carrier.”
This is why vaccinations are so critical, she said, especially for the age 16-to-24 group headed into socially rich environments such as universities.
While the CDC requires the conjugate vaccination by age 12, there are of course children whose parents may have opted them out of vaccines.
College is a great time to reconsider such views.
“A college student will think they’re just run-down, and then they have to be rushed off to the hospital,” Wisinski said. “There’s nothing they can do.
“People do survive it, but the infection can cause them to lose their arms or legs, or cause them to be deaf,” Wisinski added. “It’s not a pleasant thought. Especially when there’s a shot to protect against it.”
The Kent County Health Department follows the mantra, “Vaccinate before you graduate.”
“(Parents) are sending these kids off to college very unprepared and unprotected,” she said.
In recent years, there has been a grassroots push among certain parents to opt out of vaccinations, but that has only led to spikes in diseases that had virtually fallen off the threat radar.
In 2016 and 2017, for example, the CDC logged outsized jumps in the number of mumps cases—directly traced to university campuses. The two largest cases were in Iowa and Illinois.
A Michigan college hit with a recent mumps outbreak didn’t have the data they needed to tackle it, Wisinski said.
“They didn’t know the vaccination status of any of their students,” she said.
In respect to the meningitis conjugate vaccination, nearly half of all teens fail to get the follow-up booster shot recommended at age 16, Wisinski said.
“(In Michigan), 80 percent of our kids get the first meningococcal vaccine at age 12,” she said. “But they don’t come back. In Kent County, only 50 percent of the teens that are immunized with the first vaccine will get that second one. Nationally, it’s 30 percent.”
For about the past decade, the CDC has recommended children receive two HPV vaccinations starting at about age 11.
HPV is a sexually transmitted virus, with some strains causing various types of cancer. Much like other series of vaccinations, it’s important to have the complete series before any exposure, Zimmerman said.
HPV is a two-dose series if the first dose is administered before a child’s 15th birthday. If administered after the 15th birthday, three shots are required, Zimmerman said.
It’s important to remember the follow-up.
“Obviously, you get your best protection by completing the series,” she said.
“So many college students are traveling abroad,” Zimmerman said. “It’s good just to be protected.”
Hepatitis A is a liver disease spread through contaminated food and water. The vaccination is a routine recommendation for children starting at age 1, but there are adults and older children who have never had it.
The hepatitis A disease rate has declined 95 percent since the vaccine became available in 1995, but don’t imagine for a second that it has magically disappeared in this country.
The disease incubates in the body anywhere from 15 to 50 days before manifesting itself, Zimmerman said. Adults who get the disease can be ill for up to six months, with symptoms including nausea, vomiting and jaundice.
“It’s a virus,” Zimmerman said. “You clear it from your system. If you have the disease, you then have immunity. But that’s the hard way to get it.”
The easiest route is vaccination.
Tdap vaccine
Babies and small children receive a series of shots called DTaP, which protect against diphtheria, tetanus and pertussis, also known as whooping cough.
As a child ages, the effectiveness of this vaccination wears off. Consequently, at about age 11 the CDC recommends children receive a Tdap vaccination, Zimmerman said.
It’s effectively a booster for the original shot.
“They get the maximum benefit from (receiving) doses at the proper time,” Zimmerman said.
Tetanus is caused by toxins from bacteria in the soil. Diphtheria and pertussis are spread through coughing and sneezing. According to the CDC, about 1 in 5 people who get tetanus will die and 1 in 10 who get diphtheria will die.
Pertussis is most dangerous for babies. They contract the disease from children or adults who haven’t been vaccinated.
“Pertussis won’t kill adults, but it does kill infants,” Zimmerman said.
Here again, the anti-vaccination crowd has given rise to pertussis outbreaks at levels not seen since the 1950s, according to CDC data. In 2012, more than 48,000 pertussis cases were reported—the most since 1955.
Researchers have blamed these developments on a reduction in herd immunity.
Influenza vaccine
A list of recommended vaccinations for any age group, infant to elderly, would be incomplete without the addition of the influenza vaccination.
“The annual flu vaccine is always recommended,” Zimmerman said.
Children from eligible families can receive free vaccinations through the Vaccines for Children program, Wisinski said. This applies to all vaccines, from birth to age 19. Children with medical insurance that does not cover certain vaccines can also receive vaccines, but they must get them at the health department or a qualified facility.
“If they have Medicaid or no insurance, or even insurance that doesn’t cover shots, they can get free shots,” Wisinski said. “It’s part of the VFC program.
“If someone from birth through age 18 has no insurance, or insurance that does not cover vaccines, the vaccine is free—but we do charge an administration fee on a sliding scale fee, from $0 to $23,” Wisinski said.
HPV—one of the most common sexually transmitted diseases—has been linked to increased risk of cardiovascular disease and stroke. (Courtesy Spectrum Health Beat)
Human papillomavirus, or HPV, is the most common sexually transmitted infection in the country.
In several studies, it’s also linked to the nation’s leading cause of death—cardiovascular disease.
There are more than 150 strains of HPV, including the ones responsible for cancers of the cervix, penis, anus and the back of the throat.
In a study published earlier this year in Circulation Research, researchers found that Korean women infected with these “high-risk” strains of HPV were 22 percent more likely to develop heart disease or have a stroke than women not infected with the virus.
The risk was calculated after adjusting for other common cardiovascular risk factors, including smoking, physical activity and body mass index.
A 2011 study also connected HPV with heart attacks and strokes in women.
“But at this stage, we’re not completely clear on what the link is,” said Dr. Christine Jellis, a cardiologist at The Cleveland Clinic.
Jellis said HPV may encourage chronic inflammation in the body, which can contribute to atherosclerosis, or the hardening of fatty plaque along the lining of arteries.
“But there may be some other social factors that make people both more prone to developing coronary artery disease—atherosclerosis—and also HPV,” she said. “At the moment, we don’t have that information but this … definitely warrants further evaluation.”
The link between HPV and cardiovascular risk is not restricted to women.
A 2017 study of mostly men tied HPV to an increased risk of stroke in people who received radiation therapy for head and neck cancer.
Dr. Tomas Neilan, the lead author of that study published in the Journal of the American Heart Association, said the results show HPV infection has consequences beyond the cervical lesions and cervical cancer typically associated with the virus.
“Specifically, and importantly, this also has implications for men beyond transmission” of the virus, said Neilan, director of the cardio-oncology program at Massachusetts General Hospital in Boston.
HPV is such a common virus that an estimated 80 percent of the population will be infected at some point in their life, according to the Centers for Disease Control and Prevention. About 14 million Americans, including teens, become infected with HPV each year. Most infections go away on their own, but those that don’t can lead to certain types of cancer.
That’s where prevention can help, Neilan said.
HPV vaccines, which have been available for females since 2006 and for males since 2009, have proven effective in decreasing HPV incidence and preventing precancerous growths or infections.
The CDC recommends all girls and boys get two doses of the vaccine before they turn 13. Children who start the vaccine series on or after their 15th birthday need a third dose for complete protection.
Jellis hopes to see more research about the HPV connection to cardiovascular disease, as well as other types of studies that look beyond the factors already known to contribute to heart attacks and strokes.
“We certainly see patients who don’t have any of the traditional cardiovascular risks, but they still have atherosclerotic disease,” she said. “So, whether they have additional genetic factors or additional lifestyle factors, for those patients, maybe these other things like a presence of HPV will end up being the reason why they are at higher risk.”
