The rising prevalence of oropharyngeal cancers in primary care

Callum Higgins is a 4th year medical student at the University of Glasgow
Paul McNamara (PM) is an honorary clinical lecturer at the University of Glasgow and a Principal GP

In the past 18 months, I (PM) have seen multiple cases of confirmed throat cancer in young people in my general practice clinic in the “Deep end” of Glasgow. The seemingly benign, persistent and common blocked nose and sore throat is not always what it seems!

The most common symptom of throat cancer, specifically oropharyngeal squamous cell carcinoma (OPSCC), is a persistent sore throat. The challenge, as we all know, is that sore throats are an extremely common presentation. In the UK up to 10% of patients consult their GP every year with a sore throat as their primary symptom, mostly being due to self-limiting illness¹ and seldom associated with cancer.

Nevertheless, the prevalence of OPSCC is rising internationally despite the reduction of active smokers in the population,^2,3 which is a well-documented risk factor for OPSCC. A particular concern is that this increasing incidence includes more and more young people who are non-smokers.⁴ There has been a steady increase in OPSCC prevalence in young adults aged 18-45 in most countries over the past two decades but unfortunately, there is limited or conflicting research that establishes a concrete explanation for this.^4,5

Although the proportion of people who smoke tobacco products has seen a global reduction in recent years, as shown in statistics released by the WHO,⁶ we have seen a dramatic increase in the number of people who vape, and this number is still increasing. Across Great Britain, from 2021 to 2022 the percentage of young adults who were actively using disposable e-cigarettes increased 18-fold, and the proportion of teenagers aged 11-17 who vaped more than doubled from 3.3% to 7.0%. ^7,8 Some studies have shown that high levels of specific carcinogens have been measured in the saliva and oral cells of people who actively vape, however the true risk of OPSCC from vaping has limited conclusive evidence.⁹

One plausible explanation for the increase in worldwide OPSCC prevalence is the increase in human papilloma virus (HPV) infection, particularly HPV 16. This has been documented as a potential risk factor for OPSCC since the late 1990s.¹⁰ and today we recognise HPV as causative agent in as many as 72% of OPSCC cases.² It is recognised that the transmission of HPV to the oral cavity is linked with oral sex,¹¹ therefore “the recent increased incidence of this disease may thus reflect societal changes in sexual behaviour.”^2,12,13

The uptake of vaccination against HPV plays a crucial role in eliminating the virus’s potential to cause cancer,¹⁴ yet statistics show that in the United Kingdom in the academic year 2022/2023 the uptake in year 8 and year 9 boys and girls decreased by as much as 7.9%.¹⁵ Although this particular statistic is unlikely to play a role in the current increase in OPSCC incidence in the UK, this likely post-covid effect on vaccination uptake may be of concern for primary care doctors in the future, as it may contribute to an exponential increase in cancers for which HPV infection has been described as a risk factor.

A significant problem that comes with the increasing incidence of throat cancer in younger people is the challenge of diagnosis. Since age is the largest risk factor, GPs may be less likely to suspect cancer in younger patients, ^16,17,18 and diagnosis and subsequent treatment may therefore be delayed. Observing this documented increase in malignancy prevalence among younger generations highlights the importance of discussing opportunities to improve cancer diagnosis and referral in a primary care setting.

In summary, it is important, now more than ever, to be increasingly vigilant when dealing with the presentation of seemingly generic ENT symptoms. The incidence of throat cancer, particularly OPSCCs, is rising, with a worrying prevalence in the younger population, a significant proportion of which may be in part due to HPV 16 infection. Regular vaccination of both girls and boys against HPV should be encouraged at a public health and primary care level, in order to decrease transmission of HPV. Furthermore, although the evidence of malignant potential from vaping is so far inconclusive, the upcoming ban on single use e-cigarettes in the UK is likely a positive starting point while we await further research results. Ultimately, as throat cancer incidence is rising in younger patients, we should be vigilant and mindful of recurrent, seemingly benign symptoms which may harbour serious causes.

References

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15. UK Health Security Agency, Human Papilloma Virus (HPV) vaccination coverage in adolescents in England: 2022 to 2023. Published January 2024. Available at: Human papillomavirus (HPV) vaccination coverage in adolescents in England: 2022 to 2023 – GOV.UK (www.gov.uk) .
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