Why more men are getting throat cancer like Michael Douglas
It’s more than a decade since the Hollywood star blamed oral sex for his illness. Here’s how the human papillomavirus became a male problem.
In 2013 a reporter asked Michael Douglas, the Hollywood actor, if drinking and smoking had led to his throat cancer. No, Douglas replied, it was oral sex (he used the vocabulary of his generation, “cunnilingus”).
The reporter was so shocked he thought he had misheard. The news cycle blew up in sheer disbelief: oral sex can cause cancer? This was followed by shame: Douglas quickly said he “so regretted any embarrassment it caused Catherine”, his wife, the actor Catherine Zeta-Jones.
The world – and men – need to get a lot less embarrassed. Douglas was simply ahead of his time. You probably know that the human papillomavirus (HPV) is responsible for cervical cancer in women, who are bombarded with public health advice and invitations to screenings.
However, HPV is now responsible for more cancers of the throat than cancers of the cervix in the United Kingdom. Most of them are in men: men are uniquely vulnerable, for reasons still unknown. The more partners men have oral sex with, the more likely they are to acquire HPV, and the more likely they are to get HPV-related throat cancer.
One study in the Scientific Dental Journal in 2022 showed that men who have had more than five oral sex partners are 68 per cent more likely to get throat cancer. The risk is only increasing because research shows almost all younger men under 40 have given oral sex, far more than the boomer generation.
Just two years after the mass embarrassment caused by the Douglas bombshell, a quiet milestone was reached in the UK. The type of throat cancer affected by HPV is called “oropharyngeal”, which means the part of the throat at the back of the mouth. Most cases of oropharyngeal cancer are now linked to HPV. In 2015 the number of new cases of oropharyngeal cancer in men exceeded the number of cervical cancer in women, according to the Office for National Statistics.
Men have roughly double the cases of HPV-related throat cancer than women, and rising. The overall numbers are relatively low compared with cancers such as breast and prostate: a study published in 2021 in Clinical Infectious Diseases stated there were almost 4000 new cases of oropharyngeal cancer in 2019 in England. However, that had risen 47 per cent from 2013.
While cervical cancer rates are falling in women, the baton of HPV-related cancers has been passed to men. According to National Health Service data, head and neck cancer is the fifth most common cancer in men, and a study in Nature in 2022 predicted that in the next two decades HPV will account for most of those head and neck cancers in the UK, as smoking falls and HPV continues to spread. But every researcher I spoke to wished there was far more awareness among men and their doctors, the kind of awareness, in fact, that women have achieved for cervical cancer.
My interest in this story began when I interviewed the comedian Mark Steel, who has just recovered from throat cancer. His doctor told him that it was caused by the HPV virus that he acquired at some point through oral sex. Steel reflected on the hidden dangers of the generous sex life of his youth in his memoir, The Leopard in My House. “Honestly,” Steel wrote, “you just try to be nice and look at all the trouble it causes you.”
Margaret Stanley is a virologist with an OBE for her services to HPV understanding, after a career at the vanguard of life-saving research. Now emeritus professor at Cambridge, Stanley is also fond of a punchy turn of phrase. At the outset she explained how other types of head and neck cancers are not related to HPV, but rather to alcohol, smoking and poor oral hygiene.
“But as I always say,” Stanley says, “if you stink of cigarettes and booze and you’ve got rotten breath, nobody wants to have oral sex with you.”
HPV-related throat cancer occurs in two places: the tonsils and the base of the tongue. Like the cervix, these are “junctional” sites between inside and outside the body.
“When HPV was first being really intensively studied in the 1980s and 1990s, we all thought the only thing it did was cause cancer of the cervix,” Stanley says. The idea of men having their own version in their mouths seemed far-fetched. This all changed with substantial research in the early 2000s, she says. “It made it clear that HPV was actually a big and important risk factor for cancer of the head and neck.”
Why men are so vulnerable to HPV in the throat is still not understood. More than 80 per cent of us catch HPV at some point. It is, says Stanley, “an inevitable part of a normal sex life”: both men and women often carry it in their genitals.
It is, says Stanley, easier for a woman to catch HPV than to get pregnant. Most of us clear the infection naturally in a couple of years. Some researchers compare HPV to the common cold for this reason. But for a fraction of us the HPV virus we acquired through oral sex will lie hidden in the folds of our tonsils.
Years or decades later, typically in our 50s and 60s, this can lead to cancer. Men are far less able to fight HPV off in their throat. One study in PLOS One in 2014 found that men were five to seven times more likely to have oral HPV.
Steel describes this HPV lurking in his mouth as “an unexploded bomb that goes off for no apparent reason after sitting under a bush since 1944”. While Douglas felt that somehow his HPV cancer reflected badly on his wife, he quite probably acquired it decades before he met her. Why does Stanley think men are vulnerable?
“I can’t answer that question with evidence, but I could speculate,” Stanley says. “Women get infected with HPV from a sexual partner and, with time, women will make a good immune response. Most of them don’t get reinfected. Now men, in contrast to women, have a lousy immune response to HPV. They struggle to prevent reinfection. So if people have a lot of oral sex, for men the likelihood of getting infected is high, for a woman it’s less.”
Over the past quarter of a century, those that care about HPV cancer in men have faced a huge barrier: embarrassment. That battle has largely been won with women and cervical cancer. But there seems to be a snigger factor about oral sex.
After what happened to Douglas, few celebrities have been willing to be the face of HPV throat cancer. Rhod Gilbert, the comedian, had HPV-throat cancer and of course referenced Douglas in his recent post-cancer stand-up. Bruce Dickinson, the lead singer of Iron Maiden, was another rare exception in being upfront about his HPV throat cancer.
Everybody makes the jokes about Michael Douglas, because he was having oral sex,” Dickinson told Billboard magazine, “and it’s just, like, ‘OK, we need to get over that one, guys, because this is kind of serious’. There’s hundreds of thousands of people at risk for this. And guys should know if you get a lump here and you’re over 40 don’t just assume antibiotics will get rid of it. Probably go and get it checked out.”
Stanley advocated for the HPV vaccine, which the NHS has offered to girls since 2008 and boys since 2019. Boys’ uptake has lagged behind girls, despite there being a plausible argument they need it more. In 2023 only 68 per cent of Year 8 boys had the vaccine, compared with 73 per cent of girls.
“It’s a tricky one,” Stanley says. From a public relations point of view, “the fact that this is a sexually transmitted infection is the kiss of death. People won’t admit to being infected. They won’t admit to the behaviours that increase the risk. So public health messaging for this is very difficult.”
No one needs to be embarrassed, she says. “Oral sex is a pleasurable activity, you don’t need to stop that.” She says that “changes to sexual behaviour have been dramatic”, compared with the early part of the 20th century. One study in the Journal of Clinical Oncology in 2015 stated that the risk of these HPV-related throat tumours has increased for every generation born after 1940.
The study in PLOS One in 2014 also found that both sexes were equally likely to perform oral sex. However, 72 per cent of those in their 60s had performed oral sex. This compared with 84 per cent of those aged 45 to 59, and over 90 per cent of those aged 30 to 44.
Hisham Mehanna is a throat cancer surgeon and professor at the University of Birmingham leading research into HPV-related throat cancer in men. “HPV throat cancer has overtaken cervical cancer, which is actually striking because we talk about cervical cancer a lot more,” Mehanna says. “I think that is remiss and I think the problem is the link to oral sex.”
Mehanna’s study, via an anonymous questionnaire of 1000 adults, found that the vast majority of them had had oral sex. “It’s normal behaviour.” Any idea of asking men to refrain is disproportionate, he says, given the small numbers of cases relative to the general population. “That’s a difficult thing to say … I’d be very careful about that.”
Instead, the focus is on positive steps. The single easiest and most effective is to make sure your teenage son gets the HPV vaccine. Stanley gives a tip on this: informing teenagers that the HPV vaccine also protects against genital warts usually has uptake climbing. “Teenagers don’t think they’ll ever get cancer,” Stanley says, “but they do know what genital warts are.”
Next is raising awareness among dentists and doctors. “It’s important to talk about, because the message hasn’t got out there that there’s been a rise,” Mehanna says. “The rise is linked to the HPV virus. Even many GPs don’t know that. What we see in our clinic is people who have gone to their GP multiple times, they’ve got a lump, or a sore throat, and it doesn’t go away. But they might have been delayed months and had multiple courses of antibiotics before they see us. That’s not good for them.
“The message is, if you have a lump around your head or neck that lasts more than two weeks, or if you have a sore throat that lasts more than three weeks and doesn’t clear with a course of antibiotics, then you need to talk to your GP and ask about throat cancer.” Another symptom, first noticed by Gilbert, is difficulty swallowing.
Finally, the good news. If you are going to have throat cancer, the HPV kind should be rebranded as the “lucky”, rather than embarrassing, one to get. The prognosis is far better than it is for the old-fashioned cancers, as Douglas, still acting aged 80, can attest. As can Steel, Dickinson and Gilbert, all well and working. Cure rates are 80 to 90 per cent – it is not the kiss of death.
The Times
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