While HPV is the leading cause of cervical cancer, there are also several other HPV-related cancers. If you’ve had cervical cancer, it’s essential to understand your potential risk for these other cancers and what you can do. Join us and Dr. Keith Sigel, Associate Professor in the Division of Internal Medicine and Infectious Diseases at Mount Sinai, to learn more about the other cancers HPV can lead to and how you can take control of your health.

1. Beyond Cervical Cancer: What
You Need to Know About HPV
Keith Sigel, MD, PhD, MPH
Division of General Internal Medicine / Infectious Diseases
Icahn School of Medicine at Mount Sinai

2. My reasons
for giving this
talk
Infection / cancer specialist
I take care of many HIV+ persons, HPV is a
major issue
We are working to improve the detection of
second HPV tumors, particularly women who
have had cervical cancer and precancer

3. What we are going to talk about
• HPV
• Why it causes problems
• What happens with HPV
• Development of cancer
• Types of cancers related to HPV
• What is happening with those cancers
• Risk of a second HPV cancer
• What to do after you’ve had an HPV precancer or cancer

4. What is HPV
• HPV is a group of viruses
• Spread through vaginal, anal and oral sex
• Low risk and high risk
• Cause genital warts
• The vast majority of people will be infected with HPV, half with a high
risk type
• Most HPV infections DO NOT cause cancer – the immune system
controls them
• High risk HPV infections that persist can cause cancer

5. HPV in the United States
HPV infection in US women, 2004
High risk HPV in US, 2014
CDC

6. How does HPV cause problems
HPV integrates into your genetic
material (DNA) to support itself
This leads to inflammation and
fights off your immune system in
the area
These genetic disturbances
eventually lead to cancer

7. HPV Infection Dynamics
Normal cervix,
oropharynx, anus
HPV infected tissue Precancer
infection
clearance
progression
regression
The majority of women will clear high-risk HPV (>50%)
Why do some women not clear high-risk HPV?
Suppressed immune system
Smoking
Genetic predisposition

8. HPV types and risk
40% of women will be infected with high-risk at some point

9. Warts
Are my body warts from HPV? (yes)
Is it high-risk HPV? (no)
• High-risk types are most frequently associated with genital warts
Are all genital warts high-risk? (no)
• Many are not high-risk
Can genital warts be high-risk HPV? (yes)
If I do not have warts can I have high-risk HPV? (yes)

10. The development of an HPV cancer

11. How do we prevent HPV cancer with
screening?
Cervical pap +/- HPV
testing
Colposcopy
Treatment with removal
of precancer
If abnormal
If “high-grade” precancer
Example = cervix

12. Nearly everyone gets HPV – why do some get
cancer and others do not?
• HPV clearance
• Precancer clearance
• Screening
• Vaccination

13. HPV cancers
in the United
States
• The main HPV associated cancers
in women are:
• Cervical (~11,000 per year)
• Vulvar (4,000 per year)
• Anal (4,500 per year)
• Oropharyngeal (i.e., tonsil/throat;
3,400 per year)
• Vaginal
HPV cancers are going up –
nearly doubled over last 20 years

14. HPV cancers
in the United
States
HPV causes nearly all cervical and
anal cancers, 70% of vulvar and
throat cancers
HPV cancers are going up –
nearly doubled over last 20 years

15. Cervical cancer is going down

16. Others are not going down

17. Hundreds of thousands of survivors / Millions
of precancer patients
>250,000 cervical
cancer survivors
in US
>20 million
women with high
grade precancer

18. Having had
a first HPV
cancer
puts you at
higher risk
of a
second
HPV
cancer
British J Cancer. 2008

19. Second HPV
cancers

20. Increased
HPV
cancers
after
precancer

21. Anal cancer is rising in incidence
Deshmukh, Gaisa, Liu, Sigel et al. JNCI 2019
US general population 2000-
2015
2.7% increase annually in
incidence
Distant stage at diagnosis
tripled (7.5% per year)
Anal cancer mortality rates
increased 3% per year
Most prominent among older
women

22. Overtaking Cervical cancer among women
Deshmukh, Sigel et al. JNCI 2020

23. What can we do to prevent second cancers?
HPV Vaccine
Protects against 9 high risk types
(6,11,16,18,31,33,45,52)
2 doses: first, then 6-12 months later
Very strong immune response against
HPV types in vaccine

24. What can we do to prevent second cancers?
▸Vaccination
▸Women up to age 45 can be vaccinated
▸Even if you have high risk HPV types
vaccine can still have some benefit
▸Vaccine has other benefits:
▸Lowers risk of precancer recurrence after
treatment
Meta-analysis of vaccination after CIN treatment
Should women who have had cervical cancer or precancer get vaccinated?
YES

25. What can we
do to prevent
second
cancers?
• Vaccination
• Does vaccination help clear existing
HPV infection?
• Unfortunately it does not appear to

26. What can we
do to prevent
second
cancers?
• Quit smoking
• Smoking makes it harder to clear HPV
• Is associated with increased risk of most
HPV cancers
• Is particularly associated with throat
cancer
• There are very good smoking
medications available (varenicline,
buproprion) that can be used with
nicotine replacement
• Talk with your doctor

27. Screening

28. Cervical
cancer
screening
For women who have
not had precancer
USPSTF Guidelines

29. Cervical
cancer
screening
For women who have
had a “high-grade”
precancer
HPV testing or HPV testing + pap
smear every 3 years

30. What else for other HPV cancers
What are the chances of
having HPV in one of the
other important body sites
if you have it in your cervix?
Up to 50% in the anus
About 7% in the throat
These are often spread from
one body part to another
from sex, but do not
necessarily have to be from
sex

31. What if I no longer have
HPV in my cervix
▸2,000 women in
China – anal HPV
testing
▸Substantially lower
clearance at 12
months in women
compared to
1,000+ men
Wei et al. Int J Cancer 2019

32. Anal cancer
screening
• WOMEN WITH PREVIOUS HPV CANCER OR
PRECANCER ARE AT HIGHER RISK OF ANAL CANCER
• ANAL CANCER IS ONE OF THE FASTEST GROWING
CANCERS IN US
• ANAL CANCER SCREENING EXISTS AND IT WORKS
TO PREVENT ANAL CANCER

33. The MSSM anal cancer screening program
▸In ~2009 we began an anal cancer
screening program
▸initial screening with anal cytology
and hrHPV testing
Michael Gaisa MD, PhD
anal cytology
Benign Low-grade Lesion Anal Carcinoma
High-grade Lesion
Screening process similar to cervix

34. Anal cancer
screening
• ASK YOUR GYNECOLOGIST ABOUT ANAL CANCER
SCREENING WITH AN ANAL PAP SMEAR OR ANAL
HPV TEST
• IF YOU ARE IN THE NYC AREA, YOU CAN CONSIDER
PARTICIPATING OUR SWAN STUDY – WE OFFER A
FREE COMPREHENSIVE SCREENING TO WOMEN
WHO HAVE HAD GENITAL PRECANCERS, CONTACT
ME FOR MORE INFORMATION

35. Vulvar cancer
• HPV CAN ALSO INFECT THE VULVA, THE
OUTER SKIN AREAS OF THE GENITALS
• WOMEN WHO HAVE HAD HPV
ASSOCIATED PRECANCERS OR CANCERS
ARE AT INCREASED RISK AND SO ANY SKIN
ABNORMALITIES THAT MAY BE NOTICED
IN THIS AREA SHOULD BE CHECKED BY A
GYNECOLOGIST

36. What about oropharynx (throat) cancer?
Unfortunately there is no screening
test for oropharynx cancer
But vaccination can protect against
HPV infection in this area – and so it
is still highly recommended and is
the best tool we have available

37. To summarize
HPV is a virus that infects
nearly everyone
Many people clear the
infection but those who
do not can develop
precancers and cancers
People with weakened
immune systems and
those that smoke have a
harder time clearing HPV
These include cervix,
vagina, vulva, anus and
oropharynx
Vaccination is a good idea
for anyone and still likely
has value after being
diagnosed with a
precancer or cancer
Screening for anal cancer
may be appropriate for
women who have had
cervix or vulva precancers
or cancers
There is no screening test
for throat cancer

38. Questions?
▸Feel free to email me: Keith.Sigel@mssm.edu
▸If you are in the New York metro area and want to hear more about
our screening study, please email or go to swan-study.org
▸Thanks to SHARE for the opportunity to present