Role of HPV in the landscape of oral cancer in India

Oncological sciences have seen a remarkable evolution in the last few years. The last decade or so has seen rapid advancements in technology, leading to a better understanding of cancer biology and the development of newer therapeutics. One of the areas to benefit has been our comprehension of the role of human papillomavirus (HPV) in the development of head and neck cancers. While the association between HPV and cervical cancer is well established, its role in the development of oropharyngeal cancers is becoming increasingly recognized. In India, the consumption of tobacco is high, and as such, it still remains one of the leading causes of head and neck cancers in the country. The relevance of HPV infection in causing head and neck cancers needs further evaluation in the Indian context. In their paper, Frequency and clinical significance of human papilloma virus in oral cancer - A study from Kerala, Divya Raj et al.[1] have tried to document the frequency of HPV in oral cancers and correlate it with p16 expression and treatment outcomes. Although a small study of 183 patients, the prevalence of HPV was found to be 6.6% with all cases being tongue cancer patients. There was no correlation between HPV and p16 expression. Outcomes were better in HPV-positive patients, as well as in those who were p16-positive but negative for HPV. HPV: Understanding the Culprit HPV family consists of more than 200 related viruses, some of which can cause cancer. The high-risk strains, particularly HPV 16 and 18, have been implicated in the development of malignancies like cervical, anal, and oropharyngeal cancers. The mechanisms by which HPV contributes to cancer development are complex, involving the integration of the viral DNA into the host cell’s genome, causing dysregulation of cellular processes and thus leading to uncontrolled cell growth. In oral cancer, HPV primarily affects the oropharynx, which includes tonsils, the base of the tongue, and the soft palate. HPV-positive oropharyngeal cancers often have distinct clinical characteristics like small primary with large cystic nodal masses. They are more likely to be non-keratinizing squamous cell carcinomas, occurring more commonly in younger patients. They seem to exhibit a better prognosis compared to HPV-negative cancers in most studies. Relevance to the Indian Scenario Oral cancer is the leading cause of cancer in men in India and the second most common cause in women, only after breast cancer. This is largely due to the widespread use of tobacco in multiple forms, including smoking, chewing, and other smokeless tobacco products. While tobacco remains the primary etiological factor, the role of HPV in oral cancers in India is becoming increasingly apparent, although its exact prevalence and distribution needs further research. Several factors contribute to the complexity of the situation in India. Firstly, there are a lot of regional variations in tobacco and areca nut use in the country, with diverse cultural practices making it difficult to assess the true impact of HPV. Secondly, access to HPV testing and awareness of HPV-related cancers remain confined predominantly to urban areas. Thirdly, large-scale epidemiological studies specifically focusing on HPV in oral cancer in the Indian population are scarce, limiting our knowledge of the precise role of HPV in this context. HPV Vaccines: Game Changer? The development of HPV vaccines represents a major breakthrough in cancer prevention. These vaccines target some of the high-risk HPV types responsible for the majority of HPV-related cancers, including cervical, anal, and oropharyngeal cancers. There are two types of vaccines available presently: 1. Quadrivalent vaccine, which protects against four strains of HPV (6, 11, 16, and 18), and 2. Nonvalent vaccine, which offers protection against nine of the high-risk HPV types. Both have been shown to be effective in preventing HPV infections and the subsequent development of HPV-related cancers. HPV vaccination has now been widely carried out in many countries. However, its implementation in India has been slow. Various factors are responsible, including the cost of the vaccine, lack of awareness, and cultural sensitivities surrounding vaccination. With the advent of the Indian vaccine, there seems to be a promise of better access to and utilization of this vaccine in the future. Overcoming the Challenges: A Multi-layered Approach To effectively address the issue of HPV-related oral cancers in India, a multistage approach would be required, incorporating scientific research, awareness campaigns, and vaccination programs. Research: Well-conducted large-scale epidemiological studies to determine the exact prevalence and distribution of HPV-positive oral cancers across different parts of India would be key to better understanding the present problem and assessing the true impact that HPV has on the development of oropharyngeal cancers in our country. These studies would be better if they could also investigate the interaction between HPV and other risk factors, such as tobacco and areca nut use, which are so rampant here in the development of oral cancer Awareness Programmes: Public awareness campaigns are essential to educate the population about HPV and its link to oral cavity and other cancers. These programmes can also highlight the importance of vaccination as a preventive measure in the development of HPV-related cancers. They should be conducted for both healthcare professionals and the general population. With the widespread availability of current social media platforms, this information can be easily disseminated among the target population Vaccination Programs: Making HPV vaccines accessible and affordable is vital for their widespread uptake. The integration of HPV vaccination into national immunization programs could be a significant step towards reducing the burden of HPV-related cancers in the country Early Detection and Treatment: Improving access to early detection and treatment of oral cancers is crucial. Regular oral cancer screening in high-risk individuals can help identify cancers at an early stage, when treatment is more likely to be successful. Educating the masses about early signs and symptoms may help people seek medical assistance at an early stage of the disease. Collaboration and commitment are the way forward I believe that the fight against HPV-related oral cancers requires a united effort from all stakeholders, including healthcare professionals, researchers, policymakers, and the public. Collaboration between government agencies, academic institutions, and non-governmental organizations is essential to develop and implementing effective strategies for prevention, early detection, and treatment. I am certain that combining HPV vaccination with regular screening while educating the target population will help reduce the burden of HPV-related cancers in our country.