Prof Chris Nutting on the HPV vaccination programme for boys

Following on from the announcement that the HPV vaccine will now be available to boys aged 12-13, Prof Chris Nutting talks about the crucial work he has done to ensure that HPV vaccination is available to both boys and girls in the UK as part of the NHS vaccination programme. Throat cancer is the fastest-growing cancer in the UK right now and this expanded programme is estimated to prevent 64,000 cervical cancers and 50,000 other HPV-related cancers by 2058.

The Ticking Time Bomb of HPV

As the new vaccination programme for boys begins in the UK in September, Professor Chris Nutting speaks about the urgent need to vaccinate against the HPV virus.

Since 2008 girls aged 12 and 13 in the UK have been offered the human papillomavirus (HPV) vaccine to protect them against cervical cancer. Now new research in Scotland shows that those vaccinated have a significantly reduced risk of developing the disease, which is nearly always caused by an infection with a high-risk type of HPV.

A University of Edinburgh research programme looked at 138,692 women born between 1988 and 1996 who had a cervical cancer screening test at the age of 20. Examining the abnormal cells the team discovered that, compared to unvaccinated women born in 1988, there was an 89 per cent reduction in the high-risk CIN3 cells. There was also an 88 per cent reduction in the lower risk CIN2 cells and a 79 per cent in the CIN1 low-risk group.

But a lesser-known associated risk has been steadily increasing alongside this success. HPV is a commonly occurring group of viruses affecting up to 95 per cent of the population causing minor complaints such as warts, verrucas and, as a result of sexual contact, genital warts. “It’s a transient virus that causes minor respiratory tract symptoms and clears within a few months of infection”, says Professor Nutting, consultant head and neck oncologist at the Royal Marsden Hospital in Chelsea. “But in less than half a per cent the virus persists and creates the risk of a cancer 30-40 years later.”

Professor Nutting and other head and neck specialists are seeing a 40 per cent increase in cases of HPV-related throat cancer among much younger men than the previously accepted demographic.

“Throat cancer is the single fastest-growing cancer and the patients are getting younger, with 75 per cent of the total HPV throat cancer patients being men. The average age of development of a head and neck cancer from smoking and drinking is 70, but from the virus is about 55-60. For the past five years, we have been able to test the tumour and we can see which ones are caused by HPV and these are largely among middle class, healthy, educated non-smokers. It doesn’t seem to be genetic – we are not seeing fathers and sons – so the cause is more likely to be environmental, such as poor immunity or nutrition.”

PROFESSOR NUTTING

Most of the patients with tonsil cancer are around 45-65 and were probably infected as teenagers or young adults with the greater risk associated with a higher number of sexual partners. “The virus infects the person and some of the virus’s genetic material gets incorporated into the lining of the cervix or throat and eventually leads to cervical or throat cancer, as well as penile and anal cancers,” says Professor Nutting.

Treatment options and education

The risk of cervical cancer from HPV infection for women has been known for many years and has resulted in a successful screening programme. Cervical cancer has a long premalignant phase before it turns into cancer and it can be treated before it becomes malignant, which is almost unique. “After 2000 we looked at a vaccine to prevent cervical cancer in girls; the school based programme began in 2008 with the aim to vaccinate girls before they become sexually active,” Professor Nutting says.

Along with colleagues Professor Nutting then began to press for a vaccination for 12-13 year old boys, a programme that was agreed by the UK government in June last year. Like the girls’ programme, it will be free but, unlike the girls, the boys will not be offered a catch-up option for those outside the age bracket. However, high street pharmacies are already offering the vaccine for parents who wish to immunise their sons. Originally conceived as a course of three injections, it is now a two shot programme which is being offered by chemists at the price charged by the pharmaceutical companies. There have been no health concerns around the use of the HPV vaccine.

“Initially the Joint Committee on Vaccination and Immunisation didn’t agree to the boys’ vaccination plan and they claimed that the boys would be protected by herd immunity,” Professor Nutting observes. “But in the UK we are not a fixed population and we cannot assume herd protection will fully protect boys”.

“The challenge will be to maintain high vaccination rates in our young people to keep the protection high. Current UK vaccination levels vary from about 60 to 85 per cent. The lower uptake regions generally follow social demographics, but some wealthy areas also have low vaccination rates. This is due to vaccine hesitancy, where some parents feel their child doesn’t need to be vaccinated if everyone else is, relying on the herd immunity. I am worried about this going forward. You only need a big scare such as the one in Japan around HPV vaccination risk where a big social media-generated scare said the vaccine could cause neurological damage in children. This was completely unjustified as the HPV vaccine is very safe, but as a result, the programme dropped from 80 per cent take up to near zero and is only going recovering slowly.”

Screening and vaccination programmes

In the UK there are 2500 cases of throat cancer a year and the associated costs for treatment now and in the future are high. The most common presentation is a lump in the neck, and at that stage, the cancer is still treatable. “Often primary care practitioners such as GPs think it is a dental infection,” Professor Nutting says. “Patients have a cure rate of nearly 90 per cent if they have never smoked and if they have smoked for 10 years then they still have a 70 per cent cure rate, so it is very good.”

“The treatment is heavy going – six weeks of radiation and chemotherapy. The patients are never quite the same again with resulting effects on their swallowing, speech and taste for the rest of their lives,” he continues. “So we are keen to inform GPs and we have a programme at the Royal Marsden where we invite them to the hospital for an education day.”

Other countries that have an HPV vaccination programme include Australia, Sweden and Denmark. In the United States where the number of sexual contacts per adult is greater than Europe, 70-80 per cent of new throat cancer cases in the big cities are now down to HPV infection. “As some teenagers will never be vaccinated, the incidence of cancer will go up in the short term. 40 years down the line they will start to drop,” he considers. “The lag period between infection and the cancer is for women for pre-cancer is 10-15 years and for throat cancer in men is 30-40 years and we don’t know why this is. But until it is under control, HPV is a ticking time bomb.”