Since her article on the relationship between HPV and oral cancers, published in 2000 in the Journal of The National Cancer Institute, the work done and published by Dr. Maura Gillison and her colleagues at Johns Hopkins has redefined the demographics of the oral cancer world in the US. While I have read many researcher’s work, I am really impressed by the series of publications from Dr. Gillison that have elucidated the oral cancer – HPV relationship in ways which are not just interesting, but which have direct applications in reducing the death rate from the disease today. What I am referring to is early detection.
The first rule in solving a problem is defining reality, that is, “what is the situation right now”? If professionals are to be effective in finding disease at the earliest possible stages when outcomes are the best, we have to understand WHO is at risk, and by doing so, who needs to be screened as a matter of routine. Her work has revealed a sub population of young, non-smoking individuals that no one was considering to be at risk, and by doing so changed everything. Being a non-smoker is no longer enough to allow you to dodge this disease. A virus is increasingly becoming a major factor in young people who develop oral cancer. Dr. Gillison’s epiphanies turned into proof of principal studies, and finally peer reviewed published articles that reveal how, with little control over the circumstances related to exposure available to us, we can do little to ensure that we are not at risk for developing this cancer. HPV is a ubiquitous virus, plentiful in the world around us, and easily contracted. For that matter, the CDC says that likely 80% of the US population will have at least one of the more than a hundred versions of HPV at some point in their lifetime. What we do not know is how many will get an oncogenic version of it, and of those, how many will go on to develop cancers.
Determining who was at risk used to be easy in the world of dentistry (doctors of general medicine have never been educated well in finding early stage oral disease). There were historical models that dentists were taught in school about the “typical” oral cancer patient. They were in their sixth and seventh decade of life, they had been tobacco users for at least a decade of their lives, used alcohol, were more frequently men, and more frequently black. But for the last several decades major treatment centers all around the US have anecdotally reported that they were seeing more and more young, non-smoking, white, under 50 year old patients with oral cancer. These people didn’t fit the historical demographic. Of course for the most part, with the exception of dentists working inside the cancer treatment centers, this information was not on the radar of most dental professionals. When they did screen, they thought of the older smokers. Notice that I said, when they did screen. Articles published by Horowitz et. al. from the NIH/NIDCR clearly showed that dentists have not been doing a very good job of engaging in actively screening their patients and finding disease at early stages. While there has been some improvement, things in the dental screening world are just starting to turn around in regard to screenings being done with any regularity. The quality of the screenings still remains to be evaluated. Medicine is even further behind the curve in all this.
Along comes Gillison and her articles. This really throws a wrench in what dentistry has considered the typical patient. Now they have to screen just about everyone that comes into their practice; because HPV16 has been shown through these articles to be a significant and unique (from tobacco and alcohol) pathway to oral cancer. She has defined the anatomical locations in the mouth it has a preference for (no excuses about where to look), she has defined in additional articles that it is easily transferred through oral and conventional sex, and she is telling us who the new demographic is – that is completely unlike the historical stereotype.
My question is – why is dentistry so far behind the curve over the last 7 years as this data has been revealed? Actually, I am being kind to the profession here, since their lack of interest in OC screening and early detection goes back decades, as does that of their professional society, the ADA. One excuse would be that these articles have been published in medical and oncology journals, and the general population of dentists seldom read these. But it is time that the work of this researcher becomes mandatory reading for the dental professional population. She has changed the understanding of the etiology of OC, and with it, who must be screened. My guess is that we will see HPV become THE dominant cause in young oral cancer patients, and the old 75% from tobacco cause is grossly out of date when considering this group.
Read the New England Journal of Medicine article that broke through the usual “research isn’t big news” apathy of major media because oral sex was part of the description… gillison_nejom_2007.pdf.