Alberta Cancer Foundation

The ABCs of HPV

Before leaving the room, the nurse turned to Janae and said, “Just a small warning, the video is very comprehensive.” After the door shut, Janae got into her saggy hospital gown and I pressed play. It could have been called, “So You’ve Had an Irregular Pap Smear” or “So You’re Getting a Colposcopy.” I don’t remember, but comprehensive it was. I sat squinting at what looked like a wet, outward belly button. “What is that?”


Sweet Life: Omar and Janae have armed themselves with knowledge to cope with HPV.
Photographed by Aaron Pedersen

“A cervix,” said Janae, who has taken enough sexual health courses in university to recognize a cervix, or a genital wart, when she sees one. Which is how we ended up at the Misericordia Hospital in Edmonton last June: a tiny, insidious pebble-shaped mark that she discovered on herself 15 months prior. Again, Janae was knowledgeable enough about it to say, “You better not have given me HPV!”
I likely had, because my fiancée hadn’t had any sexual partners before me. Although the human papilloma virus (HPV) requires sexual contact and can pass with or without intercourse or a condom, it was pretty much an open-and-shut case.

But hold on. When I got tested for sexually transmitted infections early into our relationship I’d heard the clinician correctly, “all negative.”

What gives?

HPV is not part of the standard screening tests for sexually transmitted infections because it’s so common. “If you looked at a group of individuals, people under 30, you’d find a lot of HPV,” says Dr. Barbara Romanowski, an infectious diseases expert at the University of Alberta and former director of Alberta’s Sexually Transmitted Disease program. “No one in the world is recommending routine screening for HPV.”

In fact, most of us will be exposed to one of the 200-plus strains in our lifetime and, if you’re sexually active and under 30, a quarter to a half of you have one right now. “The majority will never develop symptoms and virtually all of them will clear the virus,” Romanowski says. In fact, most people will never know HPV was there.

In other words, Janae and I – actually, just Janae – was the exception. Her first appointment for a colposcopy was preceded by two irregular pap smears showing low-grade cervical dysplasia, basically abnormal cells. From the sexual health experts to her general physician to the Misercordia’s OBGYN, they all assured her that this was common and there probably wouldn’t be a next step. And yet, there always was. So far, her two colposcopies, the last in January, have been the only bearers of good news because they were followed by no news at all. That doesn’t mean her cervix cells have returned to normal; they just haven’t displayed any further changes.

Though I should have felt relieved that I was unaffected, I felt guilty for clearing the virus like the vast majority of people who have contracted it without ever knowing. I wanted to play a bigger role in helping Janae, but all there was for me was to be Chief of Emotional Support, and driver. It was perverse – even sexist! – that I could unknowingly transmit this commonplace virus without personal consequences, while my partner is left to bear them all, and possibly for the rest of her life. That, and the general knowledge I had about its relationship to cervical cancer and a contentious vaccination programs for girls, only validated my misconception that HPV is a woman’s disease.

In men, HPV has been linked to some cancers of the penis, anus and head-and-neck region, but the proportion of incidences pales in comparison to abnormal cervical cells and cervical cancer, the vast majority of which is caused by the virus. However, a landmark study from Ohio State University contradicts many experts’ opinions, that it either attacks quickly or not at all, and that it generally afflicts women.

Dr. Ted Teknos’s colleagues at OSU examined more than 250 samples of throat tumours collected between 1984 and 2004 and found an upsurge in HPV-positivity in the more recent the samples. Not only that, but in the division of head and neck surgery at the Arthur James Cancer Hospital, where he is the leading otolaryngologist, incidences have more than tripled.

“What the data are showing is the numbers of these patients has gone up exponentially,” Teknos says. “We used to see 60-year-old smokers of lower socioeconomic status,” he says. “Now we’re seeing young, higher-educated people of higher socioeconomic status who’ve never smoked.”

The OSU study received an unrestricted grant from Merck, makers of Gardasil, one of two HPV vaccines on the market. But Teknos points to an independent 2009 Swedish study from Karolinska Institute showing that 93 per cent of recent tonsil tumours tested positive for HPV, up from 20 per cent in the 1970s. And men, it seems, are three-to-one more likely to develop these illnesses, perhaps because they have more sexual partners and are infected at rates three times higher.

Teknos says HPV has already surpassed smoking as the leading cause of throat cancer and, in men, this disease will soon outnumber cervical cancer cases in women. “It’s an epidemic,” Teknos says.
That’s a pretty big claim and Romanowski is more guarded in her predictions. She cautions that it’s just one study, in a field of research still in its infancy.


Photographed by Aaron Pedersen

But, closer to home, Dr. Nigel Brockton is also studying changes in the occurrences of HPV-related head-and-neck cancers in Alberta since 1998. “There is substantial literature on the increasing incidence of oropharyngeal cancer,” says Brockton, a research scientist with Alberta Health Services. He estimates that half to two-thirds of oropharyngeal tumours (including the tonsils and base of tongue, in which HPV-related tumours most commonly occur) are caused by HPV, and men account for the vast majority of those cases.

If the projections of Brockton and Teknos are true, and HPV becomes as much of a men’s health issue as prostate cancer, what’s behind the upsurge? Teknos guesses that, just as smoking has gone from commonplace to taboo, oral sex has gone from fetish to routine. And he says that HPV acts mysteriously in the throat. Whereas genital tissue reacts quickly, if at all, to the viral infection, the related throat cancers Teknos is seeing occur possibly decades after infection.

Fortunately, head-and-neck cancers respond well to treatment unless the patient smokes, in which case outcomes are not as good. The answer to this epidemic, Teknos says, is to start vaccinating boys. Though Health Canada stopped short of recommending the vaccine for males, it approved the use of Gardasil for boys and young men. So far only PEI has considered offering it freely to boys.
Brockton’s research supports Teknos’s claims. “The numbers of Albertan males developing cancer due to HPV infection are significant,” Brockton says. “At the current rate of vaccination, a cohort of Albertan males will continue to be ‘at risk’ for a long time.”

Yet even with evidence that HPV doesn’t discriminate, that men carry the virus and are increasingly carrying the related diseases, HPV immunization programs currently only give girls the pinch. “The way it’s been sold,” says Teknos, “is as a way to prevent cancer of the cervix and warts in women. To then turn around and talk about oral sex and cancer in men is a big leap.” It’s like trying to sell bras to boys.

Romanowski, however, doesn’t see the need for a school-wide male vaccination program like those offered to girls in every province and territory. She says that herd immunity – the immunization of one part of the population to protect everyone else – will protect the bulk of the population. She says a vaccination rate of 80 per cent, meaning four out of five women, would achieve herd immunity. “You’re not going to gain anything by also vaccinating boys,” she says. “It’s not cost-effective.” Romanowski would rather see focus on increasing female immunization.

But herd immunity can be fragile. Large populations are not amorphous, but comprise a series of smaller networks. There are a variety of reasons people in certain networks opt out of immunization, weakening the case for herd immunity.

Only 10 per cent of women age 18 to 25 received the three-step vaccine, the rest citing cost as the primary reason against it. For school-aged girls in Alberta with access to free vaccines, the rate is three in five publicly educated girls and one in five girls attending Catholic schools, Romanowski says. She says that Catholic schools won’t let the vaccine through their doors because they fear it’s a tacit approval of premarital sex, so the Alberta government offers to vaccinate these girls elsewhere for free.

Religious beliefs are not the only obstacle to herd immunity. After a televised debate in September, would-be presidential candidate Michele Bachmann told NBC news about a woman whose daughter “suffered from mental retardation” after being administered Gardasil.

Her claims, that “it can have very dangerous side-effects,” went unchallenged on live TV and were quickly adopted by tepid parents and conspiracy theorists. “When you have people like Michele Bachmann standing up and saying, ‘Thou shall not vaccinate the child for HPV because it’s dangerous’ – people listen to that nonsense,” says Romanowski.

Romanowski’s view, that immunizing boys is not cost-effective, is widely supported by research including a study in the British Medical Journal. But it ignores men who have sex with men. They carry HPV at rates 17 times higher than heterosexuals and more frequently get its associated illnesses. She says, “I think they should be vaccinated for HPV, because they’re not going to benefit from the herd immunity.” But it’s crucial that people are vaccinated before they’re sexually active and few parents will have their 10-year-old boy injected on the off chance he might grow up gay or bisexual.
I am of the mind that young men should be included in government-funded vaccine programs, not just for their safety, but because it shouldn’t just be up to women to clear the proverbial table. Current health measures all but validate HPV as a women’s health issue and leave sexually active men unaccountable and about as educated on the topic as they are about menstruation. Boys and men should be likewise empowered to care for their own their health and sexuality.

In June, Janae and I will exchange vows, promising fidelity in good times, bad times, sickness and health, before we fly across the Atlantic for our honeymoon. After that, we’ll return for her third colposcopy. If her cells are still low-grade, or have worsened, she’ll get a more invasive electro-surgical treatment called LEEP (loop electrical excision procedure). If they return to normal, she’ll need two more good-news colposcopies over the next year before she can return to regular pap smear screening, recommended for all women in Alberta. So, even if her body clears the HPV, it will be years before her mind does.

And me – have I’ve cleared the virus? Teknos tells me to be vigilant, look for changes in my neck and face, look for lumps, sore throat, ear pains. And, of course, not to smoke.

Janae and I look now toward the next step in our relationship, having children. Whether they’re girls or boys, we can only protect them through immunization – it’s the least we can do. Actually, it’s the best we can do.

Vaccine Facts for Women:

  • About 20 million women have received the vaccine safely.
  • The vaccine has also been approved for use in boys but there’s no province-wide vaccination program.
  • The HPV vaccine is effective in preventing two types of HPV, which cause 70 per cent of cervical cancers.
  • Vaccinating school-age girls against HPV will dramatically reduce cervical cancer for future generations of women.
  • Girls who’ve been vaccinated still need to have regular pap smears starting in their teens.

Source: www.health.alberta.ca/health-info/imm-HPV.html