Hot Topic

Should Dermatologic Surgeons Get the HPV vaccine?

by Mariam Mafee, MD, FACMS

In the March 2022 issue of the Dermatologic Surgery journal, survey data was published in regard to the adoption of the HPV vaccination amongst Mohs surgeons.¹  Eighty percent of participants believe that HPV can be transmitted to humans through surgical smoke, but only 45% of respondents had received the HPV vaccine. The American Society for Colposcopy and Cervical Pathology recommends that health care workers who may be routinely exposed to HPV receive the HPV vaccination.²  Of note, in 2010, oropharyngeal SCC surpassed cervical cancer as the most common HPV-associated cancer.³ Given the frequent exposure to surgical plume in our profession, should we be getting vaccinated and encouraging early trainees to get it?

The questions that really matter here are: is the HPV virus present in plume, can that virus enter our bodies through the plume, and can it then cause cancer? Multiple studies have found HPV in smoke and laser plume.^4-6  In addition, studies have found HPV in nares of individuals exposed during surgery.^6-8  The largest study included 134 patients with cervical intraepithelial neoplasia undergoing electrosurgical excision. Samples collected from the cervix, surgical smoke, and clinicians' nares were tested for HPV DNA. Thirty percent of surgical smoke samples and 2 nasal samples contained HPV DNA. The HPV type detected in smoke samples and nares corresponded to the type detected from cervical samples in all cases.⁶  Although HPV is not present 100% of the time, the evidence does show that HPV can be transmitted through plume and to the clinician. As to the question of causation, this is unfortunately not quantifiable. However, there have been multiple case reports in the otolaryngology literature of clinicians contracting HPV-related head and neck cancers.^9-11  The association and prevalence of HPV in head and neck cancer has been increasing in recent years. Therefore, the paucity in data is likely due to the lack of reporting and difficulty in proving the direct association.

If we are at risk of contracting HPV and possibly developing HPV-related cancer in our line of work, ultimately the question is: will the vaccine prevent us from getting that cancer? Efficacy of the vaccine in decreasing cervical cancer has been well documented. Although data is more limited for anal disease, the data suggests it is also efficacious in men. However, there are no studies as to whether HPV vaccination prevents the development of HPV-related oropharyngeal cancer. Given the experience with cervical and anal cancer prevention, the vaccine may be promising for head and neck cancers as well. Hopefully there will be more studies on this in the future.

Although the answer to get the vaccine is not entirely clear, it deserves some discussion especially with our young residents and fellows.  Not surprisingly in the survey in Dermatologic Surgery, younger female surgeons were more likely to have been vaccinated. The assumption is that younger women are more likely to be encouraged to vaccinate during routine gynecologic visits. Therefore, young male surgeons may be less likely to be vaccinated and therefore more vulnerable. This is ultimately a personal decision, but one that should be considered in routine discussion with our trainees.

References:

1. Pearlman R , Condie D, Nahar V, Black W. Adoption of Human Papillomavirus Vaccination Among Dermatologic Surgeons: A Survey Study of American College of Mohs Surgery Members. Dermatol Surg. 2022 Mar 1;48(3):373-376.

2. American Society for Colposcopy and Cervical Pathology. ASCCP Recommends HPV Vaccination for Providers. https://www.asccp.org/hpv-vaccination. (Accessed on April 15, 2022).

3. Van Dyne EA, Henley SJ, Saraiya M, Thomas CC, Markowitz LE, Benard VB. Trends in human papillomavirus-associated cancers—United States, 1999–2015. MMWR Morb Mortal Wkly Rep 2018;67:918–24.

4. Garden JM, O'Banion MK, Shelnitz LS, Pinski KS, Bakus AD, Reichmann ME, et al. Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. JAMA 1988;259:1199–202.

5. Neumann K, Cavalar M, Rody A, Friemert L, Beyer DA. Is surgical plume developing during routine LEEPs contaminated with high-risk HPV? A pilot series of experiments. Arch Gynecol Obstet 2018;297:421–4.

6. Zhou Q, Hu X, Zhou J, Zhao M, Zhu X, Zhu X. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Cancer Manag Res 2019;11:3643–54.

7. Bergbrant IM, Samuelsson L, Olofsson S, Jonassen F, Ricksten A. Polymerase chain reaction for monitoring human papillomavirus contamination of medical personnel during treatment of genital warts with CO2 laser and electrocoagulation. Acta Derm Venereol 1994;74:393–5.

8. Ilmarinen T, Auvinen E, Hiltunen-Back E, Ranki A, Aaltonen LM, Pitkaranta A. Transmission of human papillomavirus DNA from patient to surgical masks, gloves and oral mucosa of medical personnel during treatment of laryngeal papillomas and genital warts. Eur Arch Otorhinolaryngol 2012;269:2367–71.

9. Rioux M, Garland A, Webster D, Reardon E. HPV positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg 2013;42:54.

10. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991;248:425–7.

11. Calero L, Brusis T. Laryngeal papillomatosis—first recognition in Germany as an occupational disease in an operating room nurse [in German]. Laryngorhinootologie 2003;82:790–3.