By Alyssa Giacobbe, Men's Health
ERIC STATLER'S WISDOM teeth were impacted. Inconvenient, sure, but certainly not life threatening. As general manager of a hotel in Idaho's picturesque Clearwater County, Statler spent his 12-hour days charming and chatting up guests, which meant he couldn't afford a week of bloated cheeks and Percocet. Nor, given his myriad responsibilities at the hotel, did Statler feel he could justify time off for at-home recovery. So he procrastinated until the pain was almost unbearable and eating a turkey sandwich felt like chewing tacks.
Two months after he finally underwent the operation, Statler was still waiting for relief—his molars were gone but the pain remained. Not only did he find it excruciating to chew, but now he was losing weight and beginning to feel emotionally beat down. He decided to return to his dentist, who sent him to a local ear, nose, and throat specialist the same day. The ENT needed just minutes to solve the mystery: He took one look at Statler and said, "Son, I think you have cancer."
Statler couldn't believe it. A former college athlete, he still ran nearly every day, never smoked, and drank only a few beers a week.
"My wife used to say I was the healthiest man she'd ever known," he says. The average oral cancer patient, by contrast, is a lifelong smoker or heavy drinker in his mid-60s.
But the definition of "average" has slowly been changing, as more and more oral cancer diagnoses are being handed down across the country to otherwise healthy young men. Statler soon learned that he was part of this emerging subset of oral cancer patients, a group of guys who all share one unlikely risk factor: HPV, an undetectable and untreatable STD that may act like tinder for tumors.
An Invisible Enemy
You've probably heard of human papillomavirus, or HPV, the rampant sexually transmitted disease most often associated with cervical cancer in women. How rampant? Odds are good that you once had the virus, you have it now, or you will contract it soon. In fact, the CDC estimates that half of all sexually active people become HPV positive at some time in their lives. With 6 million new infections each year, HPV is the most widely spread and overexposed STD we've ever known—the Kim Kardashian of communicable diseases, if you will.
The reason HPV moves around the way it does has to do with its stealth: In 99 percent of cases, the disease is symptom-free. (The remaining 1 percent present as bumpy, cauliflowery warts on the penis or groin area in men and in and around the vagina in women.) Most people infected with HPV have no idea they have it, who they contracted it from, or that they could be infecting others.
Cancer researchers have known about HPV's connection with cervical cancer since the 1970s, but they've only recently discovered a similar link between the virus and oral cancer. For years, the rate of new head and neck cancers had been declining in tandem with falling smoking rates. But then, after noticing a major upswing in the number of young nonsmokers being diagnosed with oropharyngeal cancer—a form of oral cancer found in the tonsils and in the base of the tongue—doctors at Johns Hopkins acted on a hunch and began testing cancerous tissue for HPV. The resulting study, published in the New England Journal of Medicine, revealed that exposure to HPV-16, a high-risk strain known to cause cervical cancer, made patients 32 times as likely to develop oropharyngeal cancer. By comparison, the previous top risk factors—a history of heavy smoking and a history of heavy drinking—were found to increase that risk by just 3 and 2.5 times, respectively.
"HPV is replacing alcohol and smoking as the leading cause of oropharyngeal cancer," says Ted Teknos, M.D., a professor of medicine in the head and neck oncology program at Ohio State University's comprehensive cancer center. HPV fuels cancerous growth in a man's mouth much as it does in a woman's cervix: by integrating into his DNA and hindering the function of proteins that are supposed to reduce cellular stress and suppress tumors.
Figures from the National Cancer Institute reveal that between 1998 and 2008, oropharyngeal cancer rates rose 36 percent in men—or 3.6 percent each year on average. And sometimes its victims are shockingly young, even men in their late 30s, says Robert I. Haddad, M.D., chief of the center for head and neck oncology at the Dana-Farber Cancer Institute. "Many of these cases are missed or diagnosed late because there are no symptoms until it's moved into the lymph nodes; plus, the patient is young and otherwise healthy," he says.
Many doctors view the increase in HPV-related oral cancer as a direct result of a change in sexual practices in the past decade—that is, our orally promiscuous ways. Because HPV is a locally invasive virus, it can spread to your mouth only through direct contact. (In other words, HPV in or around your penis won't "travel" on its own through your body to your mouth.) The most likely way to contract oral HPV is to perform oral sex on an infected partner. However, simply kissing someone who has oral HPV can also lead to infection, according to many researchers who believe that it's possible for HPV to be transmitted through saliva.
It should seem obvious, then, that oral sex is not safer sex—and that your chances of developing oral cancer increase with every type of sexual encounter. According to the same New England Journal of Medicine study, people who have had six or more oral sex partners over the course of their lifetime are nearly nine times as likely to develop oropharyngeal cancer.
"Many people don't think oral sex counts as sex," says Gregory Masters, M.D., an oncologist at the Helen F. Graham Cancer Center in Newark, Delaware, and a spokesman for the American Society of Clinical Oncology. "But oral sex comes with risks. And cancer may be one of them."
Is Abstinence the Answer?
The day before Brian Hill was diagnosed with stage four oral cancer, he was skiing at Lake Tahoe. "I felt perfectly normal," recalls Hill, a nonsmoker then in his 40s. "I had no sores on my mouth as far as I was aware of, and no pain." He'd grown a beard for the winter, which unfortunately had camouflaged an enlarged, though painless, lymph node. "By the time I felt it, it was the size of an almond," he says.
After a course of antibiotics proved ineffective, an ear, nose, and throat doctor near Hill's home in Santa Fe performed a fine-needle biopsy and delivered the diagnosis: The lymph node contained cancerous tissue.
Hill, the owner of a medical-device company who'd sold his dental implant business a few years earlier, says he considered himself better educated in matters of oral health than the average person. And yet the tumor, which had originated in his right tonsil, had probably gone undetected for as long as 2 years.
At Houston's MD Anderson Cancer Center, Hill's doctors told him they'd been seeing a great number of nonsmokers with oral cancer, but didn't know why. Hill was treated, he recalls, with "everything but the kitchen sink," including chemo, radiation, and surgery to remove the right side of his neck. It was a brutal process during which he suffered from radiation sickness, relied on heavy-duty painkillers, ate through a tube for a year, and lost more than 50 pounds.
Hill eventually learned that his tumor tested positive for HPV-16, the subtype linked to oral cancer, although he had no idea that he had been carrying the virus. Nor would he have: Although gynecologists screen sexually active women for cervical HPV as part of routine annual exams, there is no commercially available HPV test for men and no reliable oral-HPV test for either sex.Part of the reason no good screening options have been developed is because researchers and doctors share a "why bother?" mentality: In 90 percent of cases, a person's immune system will clear the virus naturally within 2 years, with no lasting implications. Furthermore, unlike cervical HPV—which can be managed by removing infected cells—there's no way to treat oral HPV.
But screening is also challenging because HPV is so very squirrelly: The virus can lie dormant and undetectable, yet transmissible, for years. This is why most doctors say it's pointless for people in monogamous relationships to change their sexual habits in the aftermath of an HPV-positive determination. Chances are, both partners have already been exposed.
For everyone else, however, most doctors do advise a change in sexual practice to reduce risk, including using protection when giving or receiving oral sex, and limiting your number of partners.
That said, there is one other promising preventive measure, at least for the next generation of men: vaccination. Two vaccines currently on the market—Gardasil and Cervarix—target HPV-16; they're 95 percent effective in girls and young women and 90 percent effective in boys and young men when administered before exposure to the strain. But despite the impressive percentages, vaccination is a controversial issue for many parents, in part because the possible side effects include fever, fainting, and (rarely) severe allergic reaction and blood clots.
Some parents also have trouble with the idea of protecting their prepubescent kids from a virus related to sex, while other parents, mistakenly believing that HPV affects only girls (in the form of cervical cancer), assume that vaccinating boys is irrelevant. The result: Roughly 4 percent of boys have received the shot. In 2010, in a move that may sway hesitant parents, the American Academy of Pediatrics included HPV in its schedule of vaccines for boys.
(UPDATE: In October 2011, the Centers for Disease Control and Prevention recommended that all boys ages 11 to 21 receive the vaccine. The recommendation should pave the way for insurance companies to begin covering the vaccine, which costs around $500. Read more here.)
The Dentist Defense
Before you tick off your girlfriend and tell her you've decided to abstain from oral sex, keep in mind that several things have to go wrong for HPV to leave you DOA. First, you need to contract the dangerous HPV-16 strain of the disease (an estimated 1.5 percent of women have it). Next, your immune system has to come up short in trying to clear the virus. And then, even if these two conditions are met, you still may not develop cancer. But if you do? Doctors point out that compared with tobacco-related oral cancer, those cancers associated with HPV are much more beatable.
"The cure rates are in the 80 to 90 percent range, assuming patients are nonsmokers," says Dr. Haddad. "Part of the reason is that these patients are younger and in good shape and can tolerate aggressive treatment."
Consider Bryan Hill. He's been cancer-free for more than a decade, during which he founded the nonprofit Oral Cancer Foundation, a charity that sponsors research, patient support, and public awareness. Statler is also in remission; however, like Hill, he needed radiation, chemotherapy, and extensive surgery—doctors removed 44 cancerous lymph nodes and half his jaw.
Even though Statler's and Hill's cases are success stories, earlier diagnosis would have made their treatment and recovery less invasive and less physically taxing. In most cases, this means spotting a premalignant lesion or change in mouth tissue. While researchers are looking into the possibility of using DNA samples to detect precancerous changes in oral tissue cells, that technology is still years away. Until then, your dentist may be your best hope.
The American Dental Association recommends that dentists perform regular visual and physical exams to look for changes in and around the mouth and throat. No one else knows their way around this part of your body like they do. Ideally, the dentist will catch a tissue change before it becomes dangerous, or spot an abnormal growth in its early stages.
John C. Comisi, D.D.S., a dentist in private practice in Ithaca, New York, says he's caught dozens of precancerous lesions in the mouths of men as young as their 30s. "Anything that looks abnormal or persists over a period of a few weeks should be tested," says Dr. Comisi.
"Any abnormality should be treated aggressively and removed. You can't be too sure."
Of course, no dentist will catch everything—just ask Statler, who was told his tumor pain was a toothache. That's why every man should be aware of the possible warning signs of oral cancer: persistent sore throat, hoarseness or unexplained cough, painful sores, any swelling in your lymph nodes or neck, or a change in your voice or trouble swallowing. Your dentist or an ENT specialist should vet any suspicious condition present for longer than 2 weeks.
There's one more thing: Keep enjoying your sex life. You may never contract HPV, let alone develop cancer. But if you live in fear of either possibility, you'll be giving in to an affliction that no surgery or chemotherapy can beat. Statler certainly hasn't backed down: "For now, my wife and I haven't changed what we do in the bedroom," he says. "I just try to have as much sex with her as I can."