Dear Doctors,

Thank you for providing this valuable service.

I am a 33-year-old man living in Europe. Over the course of my life, I have performed oral sex with approximately 10 partners, around 20 times in total.

About 10 years ago, I developed genital warts (condylomas) following a single instance of unprotected intercourse.

I am now increasingly concerned about the potential risk of HPV-related oral cancer due to my past sexual activity, particularly oral sex. I understand that HPV-related oropharyngeal cancers have been discussed more frequently in recent years, and I was not fully aware of these risks when I was younger.

Given my history, should I be worried about a significant long-term risk of oral cancer? Would you recommend HPV vaccination at my age?

I would greatly appreciate your guidance on how concerned I should be and whether there are any preventive steps or screenings I should consider.

Thank you very much for your time and help.

There are no data on the risk of oral/pharyngeal HPV by oral sex. Although oral HPV probably is often acquired by oral sex, the association with specific sexual practices is not as strong as you might think. Many people with oral HPV have never performed oral sex. In other words, the risk likely is present even without oral sex, perhaps due to auto-inoculation (i.e. self transfer) from genital HPV. In any case, oral cancer in general is not strongly associated with HPV except for pharyngeal squamous cell carcinoma (SCC), for which most cases are caused by a single HPV type, HPV16. In any case, this is not a very common malignancy. While I don't know the data in Europe, in the United States the estimated frequency of pharyngeal SCC is among the least common cancers, around 15,000-18,000 cases per year. That's a small number in a population ~340 million. (By contrast, according to CDC and the American Cancer Association the five most common cancers in the US are 1) breast 320,000 per year, 2) prostate 314K, lung/bronchial 220K, colorectal 154K and malignant melanoma 104K. I imagine the relative frequencies are similar in Western Europe.)

Prevention strategies are beyond the expertise of most STI experts; this academic field is covered primarily by otolaryngologists (ear-nose-throat or ENT). Oral or pharyngeal HPV tests may have a role but in general are not routinely recommended at this time by most experts. One possibly useful strategy is for concerned persons to simply ask their dentists to pay attention to the appearance of the pharynx during routine visits -- but most dentists probably do this routinely anyway. For those who are especially concerned, perhaps a visit to an ENT specialist every few years would be comforting.

All persons should be vaccinated against HPV, there is no reason you should not do so. The vaccines are highly effective against HPV16 and are believed to reduce the risk of pharyngeal SCC. However, HPV 16 is one of the most common genital HPV types; if previously exposed, vaccination has little role in prevention. On the other hand, given your concerns I suggest you discuss vaccination with your doctor.

All in all, your sexual history is not especially unusual or at all alarming -- my guess is that your risk of pharyngeal SCC due to HPV is about average. Beyond vaccination, I would advise you to not worry about this -- your risk of other cancers is a lot higher. Or, taking a broad view of health risks, I would advise using your seat belt, keeping firearms out of the house, having working fire alarms, proper diet and exercise -- and as you age, consider suitable screening for prostate and colorectal cancers.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

Dear Dr. Handsfield,

Thank you very much for your response. 

Just to make sure I understand you correctly: based on what I told you, you do not think I should live with the fear that I have harmed my future health by not getting vaccinated earlier. Is that correct? If you were in my position, would you be worried?

I generally live a healthy lifestyle, but I still worry that my past sexual practices may affect my future health. 

When you say my risk is about average, do you mean that many people are exposed to HPV or HSV, but in most cases the body clears or controls these infections without serious long-term consequences? Would you be able to estimate the risk I already acquired HPV16, but this will never develop into something serious?

More broadly, I often worry that possible STI exposures could have a major impact on my life, and I am trying to understand whether these fears are medically justified.

Thank you again for your time and guidance.

My comment about your "average risk" simply means I think you are no more likely than the average person to have a serious health problem due to HPV or any STI. In my view, your fears are not medically justified.