Head-and-neck cancers in India: Time to acknowledge the human papillomavirus factor

Head-and-neck cancer (HNC) continues to be a major public health issue across India and especially among the Northeastern and Northern states of the country, as reported by Bagal et al.[1] in their analysis of published data of population-based cancer registries. We read with great interest the article published by Bala et al.[2] in the Cancer Research, Statistics and Treatment journal. Bala et al.,[2] in their study from North India, reported a high and rising trend of HNCs with an incidence rate of 30.4% in 2018, 32.9% in 2019, and 34.4% in 2020. Oropharyngeal cancers were the most common site seen in 34.5%, followed by oral cavity cancers in 27.1% of the patients, which is contrary to the national data reporting oral cavity as the most common site of HNCs.[1,2] The editorial by Singh and Shetty also addresses the notably higher number of oropharyngeal cancers with the base of tongue to be the most common primary subsite, constituting 21.7% of all patients analyzed in the study.[3] The probable cause could be an addiction to smoking, seen in 80% of patients, and a history of smoking along with alcohol in 42.5% of the patients, which was much higher than tobacco chewing, seen in only 14.3% of the patients.[2] It has been established that chewing tobacco is the main cause for oral cavity cancer and smoking is more associated with pharyngeal and laryngeal cancer. Furthermore, the cumulative effect of smoking and alcohol is more than multiplicative for HNCs, as shown by Hashibe et al.[4] Another important cause of HNCs could be the presence of human papillomavirus (HPV) infection, which was not evaluated in the study by Bala et al.[2] A recent epidemiological analysis of HPV-related cancers in India by Ramamoorthy et al.[5] showed that cervical (87.6%) and oropharyngeal cancers (63.2%) were the most common HPV-related cancers among females and males, respectively. Farsi et al.[6] studied the etiological heterogeneity of head-and-neck squamous cell carcinomas (HNSCCs) and concluded that the positivity for HPV 16 among heavy smokers and heavy alcohol users was associated with a 30.4-fold [95% confidence interval (CI), 8.94-103.26] and 18.6-fold (95% CI, 5.75-60.13) elevation in risk of OPC relative to participants who were HPV-negative, respectively. More than 60% of the patients in the study group were from lower economic strata, which could have also contributed to other probable etiological factors like poor oral hygiene and low nutritional diet.[2] Whether the data presented by Bala et al.[2] are an isolated finding peculiar to the patient population of the study in the given time frame or it is the breeze that has just ruffled the smooth and settled surface of HNC site distribution seen commonly in our country remains to be seen in further studies. Nonetheless, it brings into focus the hidden prevalence and nuance of HPV beyond cervical cancer and advocates routine testing of HPV in patients with HNC to create a robust database that can guide further policy making. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.