HPV is a sexually transmitted infection linked to cervical cancer among other malignancies. In most cases, the body will clear HPV within a few years, but strains can cause cancer.
We asked Diana Finkel, DO, an associate professor in the Department of Medicine and the director of the Infectious Disease Fellowship Program at Rutgers New Jersey Medical School, to discuss the strains of HPV, how the vaccine is important in preventing cancer and what screenings are available. She has been a faculty member at the New Jersey Medical School since 2018, and has been a community provider for over 16 years, actively involved in patient care, medical education and clinical research.
New Jersey Family: What are the different strains of HPV and how are they spread?
Dr. Diana Finkel: HPV is a regional disease, so it can be spread even if you’ve never had close, intimate contact. Or, if you’ve had only vaginal intercourse, it can still spread to the surrounding areas. You can get it from very close contact. It could be on skin anywhere on the body, though we are most concerned with types that cause cervical, anal and throat cancers. Those strains are generally in the pelvic area. Unless nobody’s ever touched anybody in their whole entire life before they decide to commit to a relationship, they are probably at risk for HPV. Certain strains of HPV can cause genital warts or other warts; those are not cancerous. If there’s a wart, it doesn’t necessarily mean that the person will have cancer or get cancer. As a matter of fact, most of the warts we see do not cause cancer. There are about 14 cancer-causing strains but the most common ones are HPV 16 and 18 that cause the most cancerous issues. They can cause cervical, pelvic, uterine, vulvar, scrotal or penile cancer. Anal cancer is one of the fastest-growing cancers in America.
NJF: How is HPV diagnosed? What are the screening protocols?
Dr. Finkel: There is no test currently for an asymptomatic person. There are cancer screenings such as an anal or cervical Pap smear. We don’t recommend testing for HPV in women until age 30. They start their Pap smears at 21 but you don’t start HPV testing until 30. A Pap smear looks at cells to see if any of them look precancerous or cancerous while the HPV test is a separate test looking for HPV DNA in the cell sample. If somebody has always been normal and had three negative HPV tests, then you could slow down.
Initially, they do it every year, but then they slow down to every three. Some guidelines say that if the HPV test is negative, they can go to every five years. You should continue until age 65, generally. If there are other circumstances, like somebody is living with a suppressed immune system or has HIV, then you might require more frequent testing. In people who were assigned male at birth or trans women or non-binary folks who are assigned male at birth, we do anal Pap smears. It depends on personal risk factors and the immune system.
We don’t screen the throat in a similar way unless there is a mass. We do a physical exam to see that there’s nothing going on in the mouth. Screening prevents the development of cancer. If you don’t get screened, then you don’t know if you have HPV and then you won’t go through with anal or cervical Pap smears. Then you won’t know if you have it until after it develops into cancer. Other than HPV vaccination, the best prevention for cancer is screening.
NJF: Are you able to pinpoint when you contract HPV and when it turns into cancer?
Dr. Finkel: We are not worried about HPV itself, and it’s not the warts that we worry about – it’s more of the precancerous changes that can develop from HPV. If you have a new partner, we don’t necessarily recommend you get tested and be screened unless there’s something going on. When people say, I never had this before I met this person, there’s really no way to say that. People might shed (HPV DNA on a Pap) or might not shed so I can’t pin it on a particular timeframe. Most of the time you can’t really say this person gave you HPV. It’s not like gonorrhea where it was negative yesterday, and today, you’re positive. It can still been there. Just because you’re now testing positive, I couldn’t prove to you that you never had it before.
I have seen people who identify as heterosexual and are married to one person for 35 years gets HPV throat cancer. I’ve been asked, ‘How did that happen?’ Unless none of you ever touched anybody else in any way, it can happen to anybody.
Even if you have a new partner and you’ve always been fine and now the Pap is positive, it doesn’t mean that you’re going to have cancer. It probably just means you have HPV. But if you don’t have HPV on the one smear we do, it doesn’t mean you don’t have HPV. That’s why it’s important to screen periodically and consistently.
ScreenNJ is a statewide service the provides education about cancer prevention and detection to the community and for professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: Who has the highest risk for contracting HPV and its potentially cancerous strains?
Dr. Finkel: I would say instead that the groups that are at highest risk of progression to cancer are people with a suppressed immune system such as people living with HIV and that is why we test these folks more aggressively. Although new HPV infections are most commonly acquired in adolescence and young adulthood, at any age, having a new sex partner is a risk factor for acquiring a new HPV infection. In addition, some persons have specific behavioral or medical risk factors for HPV infection or disease, including men who have sex with men, transgender persons, and persons with immunocompromising conditions.
NJF: What is the treatment for the virus itself?
Dr. Finkel: Currently, there is no treatment for the virus. Most people, once they’re exposed to HPV, will clear it in two years, even the cancer response. Some people, for whatever reason, immunologic or if they have a suppressed immune system, have a harder time clearing it.
The people who persistently have replication and still carry HPV are the ones that go on to have cancer. If a person has either a precancerous or a cancerous lesion, then the precancerous lesions are usually treated through removal or laser treatment, and the cancerous lesions get removal, chemo, radiation, whatever is appropriate for the kind of cancer it is because HPV can cause squamous cell carcinoma of the throat as well and larynx, as well as anal and cervical cancer and vaginal and penile cancers.
NJF: What can be done to reduce the spread of HPV?
Dr. Finkel: Condom use is protective and may decrease the spread, but you could still get HPV on nearby areas not covered by condoms. There is the female condom that could be inserted into any opening. There are also latex panties that have been approved by the FDA for STI prevention – you could use those for any area of the front, back, or mouth and it could decrease contact and spread. Barrier methods are still better than no methods. Still, almost anybody can get HPV through any very close intimate contact. Vaccination remains our biggest tool.
Interested in learning more or getting screened but not sure where to start? Contact ScreenNJ patient navigators for free help scheduling your cancer screening regardless of your income or health insurance status. Email patientnavigation@cinj.rutgers.edu or call (833) 727-3665 or text SCREEN to 43386.
NJF: Can you describe the vaccine that’s available to help prevent the strains of HPV that cause cancer?
Dr. Finkel: The HPV vaccine is recommended for everyone between the ages of 11-26. The series can even be started at age 9. Because HPV can cause cancer, it would be best to protect children while they are still seeing their pediatrician routinely for all other vaccines. The best time to get the vaccine is the same time as the rest of childhood vaccinations since the HPV vaccine is not a special vaccine only associated with intercourse but is an anticancer vaccine which benefits everyone.
If a person starts their series before the age of 15, they only get two shots and they have really good efficacy. If your child is 11 years old, when they come in for their tetanus or whooping cough vaccines, that’s the time they should be getting their HPV vaccine.
Anybody who starts after age 15 needs three shots. Anybody between the ages of 27 and 45 can have 46 risk-based stratifications, an assessment that aids a shared decision made with their primary doctor. Most people would have been already exposed to HPV by that point, but there might be folks who still would benefit from getting The vaccine.
NJF: How effective is the vaccine?
Dr. Finkel: The vaccine is very effective. When given to kids before the age of 18, there are 88 percent protection rates, a decrease in the precancerous strains and a decrease in warts in general. While it won’t cover every strain, it covers most of the ones most associated with cancer. This is not our first STI vaccine and it’s our second anti-cancer vaccine. Children get the hepatitis B vaccine at birth, and hepatitis B can cause cancer. Once that was instituted, we had a tremendous drop in hepatitis B infections among young adults. Before my time, all medical students, because they weren’t vaccinated, had to take time off because they would get hepatitis B; now, that’s unheard of for any healthcare worker unless they decline the vaccine.
With the HPV vaccine, cases have decreased throughout the world, and in every country that’s given it the risk of cervical cancer has decreased. It will, hopefully, also decrease the rates of anal and throat cancer. Anytime we can decrease cancer, it’s a benefit to your child.
NJF: If you were younger when you got the vaccine, is there any evidence a booster is needed?
Dr. Finkel: Right now, we have 10 years’ of information that shows that it seems to be very effective. There’s no data that says a booster is needed. We used to have the 4-valent vaccine before; now there’s the 9-valent vaccine that covers nine different strains of HPV. You don’t need to boost somebody with a nine if they got a four. Technically it’s a one-time deal, so they’ll be protected. They are still collecting more data, but so far it does not look like the vaccine loses its effectiveness.
NJF: What should parents know about the pros and cons of the vaccine?
Dr. Finkel: The pro is it’s very safe. They’ve given over 38 million doses. There’s a registry from the government that files reactions to the vaccine and the vast majority have been very mild: dizziness or a sore arm. It’s a safe vaccine. It hasn’t caused MS. It doesn’t cause infertility. It doesn’t cause any more side effects than any other known vaccine that we’re studying.
If your child gets it earlier, then there will be one less dose needed, then they’ll probably be more protected than if they started with the three-dose series after the age of 15.
With the advent of vaccination pushed among boys, I was one of the first people who wanted it. I have five kids and I was one of the first people who wanted their boys vaccinated when it wasn’t recommended. I had an argument with my pediatrician because I so strongly wanted them vaccinated. It’s now a recommended vaccine for boys as well.
NJF: Is there a disparity among genders, races or sexual orientations for the vaccine and its distribution, especially when we speak about different vulnerable populations and its effectiveness?
Dr. Finkel: There’s about 28 percent of boys and young men under the age of 25 who’ve been vaccinated, and it’s lower than in women. There’s distrust and sometimes poor access that may get in the way of vaccination. There are disparities, and men who have sex with men are under-vaccinated. Racially, we need to increase the offering of our vaccine and build improved relationships with communities that we work with to make sure that they trust us, and accept the vaccine.
I think one of the main issues is that we have to move away from the vaccine being associated with sex – it’s associated with cancer. We want to make sure that we vaccinate kids so that they don’t get cancer.
NJF: What are the current treatments if HPV seems it will become cancerous?
Dr. Finkel: If somebody has anal HPV we try to get it before it gets too advanced. Those with precancerous changes, which look like they might become cancerous, will have an anoscopy. They can visualize the cervix as well through a colposcopy. They do key treatment on the areas that have cancer or precancerous changes and remove them, and then they follow up to make sure it’s gone. If something does develop into anal or throat or cervical cancer, then depending on the extent it gets removed, and then if it requires chemo or radiation, they proceed with it.
We currently don’t have an anti-HPV drug treatment. The topical meds we have are for warts, not necessarily cancer.
NJF: Are you involved in any clinical trials for new treatments in terms of HPV becoming cancer?
Dr. Finkel: We were part of the ANCHOR study, which looked at HPV progression to cancer and people living with HIV—men, women, transwomen, cis women and everybody who was living with HIV. They screened and randomized people who had moderate to severe changes but not cancer yet anally from HPV. What they found was that people with suppressed immune systems living with HIV, who had HPV and precancerous changes, progressed to cancer faster. Because of that study, they recommended now that everybody who does have precancerous changes and is living with HIV be treated more aggressively.
Thinking about screening for yourself or someone you love? Start by talking to your primary care doctor about screening options or contact ScreenNJ, a cancer prevention, screening, and early detection program brought to you by Rutgers Cancer Institute of New Jersey, the NJ Department of Health, and healthcare and community organizations statewide.Â
NJF: Are there any last words of advice you have?
Dr. Finkel: Get your vaccine for your child. For yourself, if you missed the recommended cutoff or if you’re in your 40s or 50s, then screening is your way to go. If you miss the vaccine cutoff, it doesn’t mean there’s nothing to do.
Talk to your primary healthcare provider to understand your specific risks and what screening options are best for you. For more info go to The Rutgers Infectious Disease Practice site.
As a community provider and clinical educator in the Greater Newark area, Dr. Finkel has been privileged to provide care for diverse populations at risk, including immigration detainees, LGBQT marginally housed youth, and persons who use drugs (PWUD) for almost two decades. Through partnerships with other community providers and organizations, she is deeply committed to ensuring access to state-of-the-art, highest-quality medical care for all individuals right here in Newark, NJ. Her passion for providing inclusive, complete care to the Transgender community led her to develop a comprehensive, urban community health center-based clinic that provides primary care, HIV care, PrEP and gender affirmative hormonal care. She is fortunate to serve as the Clinical Director of the Transgender Health Care Program at NJCRI, a comprehensive community-based organization.
She has continued to maintain and expand the clinic while being an integral part of the NJMS clinical and educational programs. Her main clinical practice site is the Infectious Disease Practice where she treats persons living with HIV and those who are at increased risk. As part of her ongoing effort to treat the whole person, she also provides gender-affirming hormone therapy integrated into her practice. She also serves as an investigator in NIH-sponsored HIV treatment and prevention trials. Currently, she is focusing on expanding access in the community to PrEP and gender-affirming care and on improving retention in care for PLWH who use drugs by providing access to medication-assisted addiction care services in her practice. She is honored to be mentoring medical and graduate health professions students as well as residents and fellows, and serves as the NJMS ID Fellowship Program Director, training the next, multidisciplinary generation of community HIV treaters.
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