Malloy KM, Ellender SM, Goldenberg D, Dolan RW. A Survey of Current Practices, Attitudes, and Knowledge Regarding Human Papillomavirus–Related Cancers and Vaccines Among Head and Neck Surgeons. JAMA Otolaryngol Head Neck Surg. 2013;139(10):1037-1042. doi:10.1001/jamaoto.2013.4452
Understanding head and neck surgeons’ current knowledge, practices, and opinions regarding human papillomavirus (HPV) education and prevention will enable efforts to assist surgeons in this important endeavor.
To assess knowledge, attitudes, and beliefs of head and neck surgeons regarding HPV education and vaccination.
Design, Setting, and Participants
Online survey of members of the American Head and Neck Society (AHNS) in late 2011 and early 2012.
Main Outcomes and Measures
Knowledge, attitudes, and current practices regarding HPV education and vaccination.
All 1081 members of the AHNS were approached via e-mail, and 297 members completed the survey, for an overall response rate of 27.5%. Most respondents were male (86.2%) fellowship-trained head and neck surgeons (80.4%), and most practice in an academic setting (77.1%) in the United States (78.1%). More than 90% of respondents discuss risk factors for head and neck cancer and HPV as a specific risk factor with their patients. However, only 49.1% discuss the importance of vaccinating preadolescents for HPV, most commonly citing that they do not do so because their patients are adults (38.7%). Of those respondents with daughters, 68.9% reported that their daughters had received or they intend their daughters to receive the HPV vaccine. Of those respondents with sons, only 55.8% reported that their sons had been vaccinated or they intend for them to be. Respondents reported divergent attitudes toward HPV vaccination safety and efficacy. However, respondents were overwhelmingly supportive of possible future ANHS activities to educate clinicians, increase public awareness, educate patients, and advocate for health policy related to HPV.
Conclusions and Relevance
Head and neck surgeons are knowledgeable about HPV and show generally positive attitudes and beliefs about HPV education and vaccination. They endorse AHNS actions to improve public and patient education, as well as health policy on HPV. These findings support AHNS developing a strategic plan and actions to improve knowledge and reduce HPV infection among the American public.
The relationship of human papillomavirus (HPV) to oropharyngeal carcinogenesis is now well established, with 40% to 80% of cases of oropharyngeal squamous cell carcinoma (OSCC) in the United States estimated to be related to HPV.1 The incidence of OSCC has been increasing over the past 30 years in many parts of the world, a trend now attributed to the HPV epidemic.2- 4 In the United States, the incidence of HPV-positive OSCC increased by 225% between 1988 and 2004, compared with a 50% decline in the incidence of HPV-negative OSCC.4 Recent epidemiologic evidence indicates that the prevalence of oral HPV infection is associated with an increased number of lifetime sexual partners.5
Head and neck surgeons play a critical role in the detection and treatment of HPV-related OSCC, and they are arguably the best poised to educate patients, families, and the public regarding the prevention of the disease. Historically, head and neck surgeons have been active in the education of patients and the general public regarding the association of tobacco and alcohol use with head and neck cancers. With the emerging etiologic shift of OSCC, it is unclear how these experts are addressing education of their patients regarding their HPV-associated disease. Furthermore, with the HPV vaccine now widely available, questions regarding its theoretical efficacy in prevention of HPV-related OSCC emerge. With the emerging preponderance of virally induced cancers within the head and neck, the question arises as to the role of the head and neck surgeon in education and advocacy of HPV vaccination. The Education Committee of the American Head and Neck Society (AHNS), with its mandate of providing education for both the medical community and the public regarding head and neck cancer, sought to discover the current opinions and knowledge of its membership toward HPV-related head and neck cancer and its prevention. Understanding head and neck surgeons’ beliefs, attitudes, and knowledge regarding HPV education and vaccination offers opportunities to develop and implement HPV education within the specialty and the medical community at large.
The Education Committee of the AHNS reviewed recent survey research concerning the willingness of pediatricians and family physicians to support HPV public awareness campaigns and to recommend the HPV vaccine to their patients.6,7 Subsequently, we developed our own 20-question survey to assess clinical practices, attitudes, and knowledge regarding HPV-related cancer of the head and neck among head and neck surgeons. There were also questions concerning whether members of the AHNS would like the organization to become more involved in educating other clinicians and the public regarding HPV as a risk factor for some types of head and neck cancer and regarding the availability of an HPV vaccine. Demographic information was also collected. The survey was made available to members at an online site (Survey Monkey). The study as structured qualified for an institutional review board exemption. The AHNS provided access to all 1081 member e-mail addresses. Members were offered participation in this project through online access to the survey in late 2011 and early 2012. We used χ2 tests for categorical responses or Cochran-Mantel-Haenszel tests for ordered responses to test associations between survey questions and respondent characteristics. We analyzed the data using SAS/STAT software, version 9.3 (SAS Institute).
The survey had an overall response rate of 27.5%, with 297 AHNS members completing the substantive questions. Among the 331 members who started the survey, approximately 90% completed it. The response counts for each question are listed in the tables. A total of 297 members answered all questions regarding their practice patterns, attitudes, and knowledge of HPV-related head and neck cancers and the HPV vaccine; 297 also completed the section on potential future actions by the AHNS. However, 22 of the 297 declined to complete the demographic questions in which respondents provided their sex, age, training, time in practice, and practice setting.
Demographic information for respondents, including practice setting and years of experience, is provided in Table 1. The majority of respondents (80.4%) were fellowship-trained head and neck surgeons; most respondents practice in the United States (78.1%). Among that group, approximately 35.0% of their patients pay through Medicare, and 36.6% pay through private insurance. The 59 respondents from outside the United States (21.9%) came from 25 different countries. Given the small number of respondents per country, we did not analyze responses in relation to the country where the respondents practiced.
Most respondents (94.9%) stated that they routinely discuss the risk factors for head and neck cancer with their patients (Table 2). Most (90.9%) also specifically mention HPV as a risk factor. However, only 160 respondents (49.1%) discuss the importance of current efforts to provide HPV vaccine to preadolescents. When asked to provide 1 or 2 reasons why they do not discuss the HPV vaccine with their patients, respondents gave a variety of answers. The most common reason, cited 86 times (38.7%), was that the vaccine “is not appropriate for most adults so my patients are not interested.” The next 2 most commonly cited reasons were “safety and effectiveness of vaccine are not yet proven,” cited 37 times (16.7%), and “discussing this vaccine is not part of my health care role,” cited 30 times (13.5%). Additional responses are given in Table 2.
Of the 228 respondents with daughters, 68.9% reported that their daughters had received or would receive the HPV vaccine. Of the 231 respondents with sons, 55.8% reported that their sons had received or would receive the vaccination. Respondents with children answered “yes” to questions 1, 2, and 3 in proportions almost identical to those of the group as a whole; approximately 95% routinely discuss the risk factors for head and neck cancer with their patients, roughly 85% specifically discuss HPV, and 49% discuss the HPV vaccine. There was no statistically significant association between having sons or daughters and any answers to these questions. Respondents with children were asked to list the children’s ages in an open-ended response field, but 16% declined to do so or gave answers that were unclear. Therefore, we did not determine whether respondents’ answers to questions about the HPV vaccine had an association with the ages of the respondents’ children.
The survey questions concerning attitudes are listed in Table 3. As indicated, 68.4% of respondents disagreed (including 43.8% who disagreed strongly) with the statement, “Pediatricians should remain the sole appropriate source of information regarding the HPV vaccine.” As expected, there was an association between agreeing or disagreeing with this statement and routinely discussing HPV as a risk factor in head and neck cancer (χ2P < .01). There was also an association between agreeing or disagreeing with that statement and routinely discussing the HPV vaccine with patients (χ2P < .001). A χ2 test also indicated that there was a statistically significant association between the practice setting (academic vs nonacademic) of respondents and their attitudes about the role of pediatricians in HPV awareness (χ2P = .01). Practitioners in an academic setting were more likely to strongly disagree that pediatricians should remain the sole source of information on the HPV vaccines than practitioners in nonacademic settings, 49% compared with 27%, respectively. However, using a Cochran-Mantel-Haenszel test, we also determined that there was not a statistically significant association between respondents’ time in practice and their responses to the same statement about the role of pediatricians (χ2P = .30).
The statement, “It is necessary to discuss issues of sexuality before recommending HPV vaccines to patients” was agreed on by 56.2% of respondents. A majority (59.6%) agreed that “The efficacy and safety of new vaccines can only be sufficiently established after the vaccine has been on the market for 5 to 10 years.” There was an association between agreeing or disagreeing with the latter statement and a willingness to routinely discuss both HPV as a risk factor in head and neck cancer (χ2P < .05) and the HPV vaccine (χ2P < .01) with patients. A majority (68.7%) disagreed with the statement, “My patients are sufficiently informed of the risks of becoming infected with HPV and the potential consequences of such an infection.” There was an association between agreeing or disagreeing with this statement and whether the respondent routinely discussed the HPV vaccine with his or her patients (χ2P < .01).
Of note, 70.1% disagreed with the statement, “Discussing the HPV vaccination is not appropriate in my practice because it cannot help my patients.” Of that number, 40.1% disagreed strongly. As would be expected, there was a significant association between agreeing or disagreeing with this statement and routinely discussing the HPV vaccine with patients (χ2P < .001).
The survey questions concerning knowledge are listed in Table 4. In 5 of 7 questions regarding respondents’ knowledge of the types, sites, prevalence, prognosis, and presentation of HPV-related cancer of the head and neck, more than 92% of the responses were correct. For a question asking whether males or females were more associated with HPV-related cancers of the head and neck, 88.2% answered correctly. The statement “Patients with a history of HPV infection should not be offered the HPV vaccine” had the most disagreement: 57.6% answered “true,” and 42.4% answered “false.” The correct answer is “false.”
As indicated in Table 5, respondents were overwhelmingly supportive of a range of potential ANHS activities, including efforts to educate clinicians (96.6%), increase public awareness (92.3%), endorse Centers for Disease Control and Prevention (CDC) recommendations (83.5%), educate patients (92.6%), and distribute printed material on the HPV vaccine (97.6%).
A burgeoning body of evidence indicates that HPV-associated OSCC is a novel clinical disease, distinct in behavior and biological characteristics from HPV-negative OSCC.7,8 Furthermore, there is mounting evidence that the incidence of HPV-related OSCC continues to increase in many parts of the world,2- 4 with some studies projecting that nearly all OSCC will be HPV related in the near future.2 There are 2 US Food and Drug Administration–licensed HPV vaccines on the market, Gardasil and Cervarix, approved in 2006 and 2009, respectively. Gardasil is a quadrivalent HPV vaccine effective against HPV types 6, 11, 16, and 18 and has shown efficacy in prevention of cervical, anal, and vaginal and/or vulvar cancers, as well as genital warts; it is also the only HPV vaccine approved for males. Cervarix is a bivalent vaccine against HPV 16 and 18. Both vaccines are considered safe, with few adverse effects other than pain at the injection site, fever, headache, and syncope at the time of injection; although deaths have been reported following vaccination, none have been causally linked to the vaccine itself.9,10 The CDC currently recommends routine HPV vaccination for both girls and boys aged 11 to 12 years, although the series of 3 shots can be started as young as 9 years. Furthermore, catch-up immunization is recommended to age 26 years for women and age 21 years for men. With more than 90% of HPV-positive OSCC attributable to HPV 16, it is possible that the HPV vaccination will have an impact on OSCC prevention; currently, however, there is no evidence that HPV vaccines are effective against oral HPV infection.5 Clinical investigations of the HPV vaccines continue, including studies in adults aged 26 to 45 years and with regard to OSCC prevention.10
Head and neck surgeons are on the front lines of diagnosing and treating HPV-related OSCC, and as such they are the main source of information for patients regarding the etiology of their disease. Patients and families have important questions regarding HPV infection and prevention and may look to their head and neck surgeon for information and advice regarding vaccination. The present study was designed to assess head and neck surgeons’ knowledge of HPV-related head and neck cancer and its prevention, as well as their current practices and attitudes toward vaccination.
Overall, our data indicate that head and neck surgeons are knowledgeable regarding HPV infection and its relationship with OSCC and that the large majority do include HPV in their discussion of risk factors with patients. That said, fewer than half of the respondents routinely discuss HPV vaccination with their patients. The reasons cited by those who do not discuss vaccination indicate their concerns with vaccination safety and with appropriateness for the adult population. Indeed, with most head and neck surgical practices comprising an adult patient population, vaccination in general may be an area that head and neck surgeons feel less comfortable with, even when knowledgeable about HPV itself. We did not ask specifically whether surgeons discuss vaccination more or less frequently with adult patients of different ages, and we assume that they are not routinely discussing vaccination as part of treatment of patients with HPV-related OSCC because to date there are no data supporting the use of the vaccine in this fashion. Moreover, the available HPV vaccines do not currently carry a specific indication for prevention of oral HPV infection; this may be a barrier to head and neck surgeons advocating for vaccination because prevention of HPV-related OSCC via vaccination has not yet been established. Overall, the survey results do impart the sense that head and neck surgeons do not currently consider it part of their role to discuss HPV vaccination. Time constraints, discomfort with a discussion of sexually transmitted disease, and lack of support for HPV vaccination fortunately do not seem to be major factors preventing head and neck surgeons from discussing the HPV vaccine with their patients. That said, it is interesting that only 68.9% of head and neck surgeons with daughters and 55.8% with sons indicated that they intend to or have had their children vaccinated. This is in spite of the young average age of the respondents’ children, which would indicate that for many, vaccination would still be possible.
Our results also show that a majority of head and neck surgeons believe that it is not solely the domain of pediatricians to discuss HPV vaccination and that they recognize a knowledge gap in their patients regarding HPV infection. The statistically significant association between these beliefs and a tendency to discuss HPV as a risk factor and HPV vaccination indicates a desire among head and neck surgeons to educate their patients and patient families about OSCC prevention. Our data also suggest that for those who do not routinely discuss HPV vaccination, the safety and effectiveness of the vaccine may be concerns. With 70.1% disagreeing with the statement “Discussing the HPV vaccination is not appropriate in my practice because it cannot help my patients,” there is an indication that head and neck surgeons recognize that HPV vaccination information might be helpful to their patients. Overall, these results indicate that head and neck surgeons recognize a potentially wider role for themselves as a source of education regarding vaccination but that barriers remain preventing some from fully assuming such a role.
One such barrier may be uncertainty regarding indications and contraindications for HPV vaccination. Whereas respondents generally scored well on the knowledge-based questions of the survey, there was marked disagreement on the correctness of the statement “Patients with a history of HPV infection should not be offered the HPV vaccine.” The CDC guidelines are designed so that individuals can be vaccinated prior to the onset of sexual activity, thus immunizing them before they may be exposed to HPV. That said, the CDC states that individuals with a history of HPV infection may be vaccinated because the vaccine may afford them protection from the serotypes to which they have not yet been exposed.5 As we have noted, it remains undetermined whether HPV vaccination will be effective in prevention of HPV-related OSCC; however, as the HPV epidemic unfolds, patients will likely look to their head and neck surgeons for information about prevention and vaccination. There is an opportunity for the AHNS to help its membership better educate their patients and patient families, their peers, and the public at large regarding HPV and its prevention. Indeed, the overwhelming majority of responding head and neck surgeons support AHNS efforts to educate clinicians of all specialties, as well as to increase media coverage and public awareness of the HPV epidemic and its link to OSCC. Most would follow an AHNS recommendation to discuss HPV infection and immunization with patients, and most would provide additional printed information to patients if it were made available. Finally, a majority of surveyed head and neck surgeons support an official AHNS statement advocating for routine HPV vaccination of all preadolescents.
In conclusion, this study reveals tremendous opportunity for the AHNS and other organizations to better educate clinicians, patients, and the public regarding HPV-related OSCC and the importance of HPV vaccination. Head and neck surgeons are overwhelmingly supportive of such educational efforts, including media coverage, and in fact desire up-to-date, detailed information to review with patients. The results of this survey may serve as an impetus to the AHNS to develop educational materials and to engage the public on this important public health issue. The AHNS may also wish to consider engaging other organizations, both within and external to otolaryngology, to collaborate on such educational efforts; such societies include the American Academy of Otolaryngology–Head and Neck Surgery, the American Society of Pediatric Otolaryngology, the American Academy of Pediatrics, and the American Academy of Family Physicians. Future surveys of HPV knowledge, attitudes, and current practice patterns of some of these important groups of physicians may provide important data to support such collaborative efforts.
Corresponding Author: Kelly M. Malloy, MD, Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, 1904 Taubman Center, 1500 E Medical Center Dr, SPC 5312, Ann Arbor, MI 48109-5312 (email@example.com).
Submitted for Publication: April 6, 2013; final revision received June 7, 2013; accepted July 11, 2013.
Published Online: August 29, 2013. doi:10.1001/jamaoto.2013.4452.
Author Contributions: Drs Malloy and Ellender had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition of data: All authors.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Malloy, Ellender, Goldenberg.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Ellender, Goldenberg.
Administrative, technical, or material support: Malloy, Ellender, Goldenberg.
Study supervision: Malloy, Goldenberg.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented as an oral presentation at the AHNS Eighth International Conference on Head and Neck Cancer; July 23, 2012; Toronto, Ontario, Canada.
Additional Contributions: Jason Nelson, MPH, of the Tufts Clinical and Translational Science Research Institute at Tufts University, Boston, Massachusetts, provided statistical analysis of the survey data. The authors acknowledge the AHNS and its staff for allowing access to membership e-mails for distribution of the survey and for their assistance in data collection. The authors also acknowledge the Education Committee of the AHNS for their support.