HPV16 E6 Seropositivity and ctHPVDNA for Early Detection of Oropharyngeal Cancer

TECHNICAL ABSTRACT Background: Human papillomavirus-driven oropharyngeal cancer (HPV-OPC), a type of head and neck cancer, is rapidly increasing in the US. There are no methods for early detection. A major barrier to screening is the inability to identify those at high risk -- no precancerous lesion has been identified. Yet, our group has shown that HPV16 E6 antibodies are a promising early marker -- present in ~90% of patients and appearing >10 years prior to diagnosis. A recent modelling study found that HPV16 E6 seropositive men aged 50 have a 50% chance of developing HPV-OPC in their lifetime – making HPV16 E6 antibodies an excellent risk biomarker to identify those for whom screening may be beneficial. Yet, not all seropositives develop HPV-OPC. Early detection biomarkers that indicate the presence of a tumor need to be co-developed with HPV16 E6 testing. Circulating tumor HPV DNA (ctHPVDNA) is a promising method for detecting HPV-OPC cancer cells. We and others have shown that nearly all HPV-OPC patients have detectable ctHPVDNA in their blood at the time of diagnosis and that ctHPVDNA is virtually undetectable in cancer-free controls. We recently demonstrated that ctHPVDNA can be non-invasively assessed in urine with high sensitivity and specificity. While ctHPVDNA is primarily being studied for detection of recurrent HPV-OPC, it may also be a promising tool for screening. Circulating Epstein-Barr Virus (EBV) DNA has been shown to be effective for early detection of EBV-driven nasopharyngeal cancer. Yet, use of ctHPVDNA for screening has not been explored. Objectives/hypothesis: The objective of this study is to evaluate the accuracy of HPV16 E6 seropositivity and urine-based ctHPVDNA for the detection of undiagnosed HPV-OPC using inexpensive, easy to collect methods, which could be rapidly scaled to increase screening accessibility for medically underserved populations. We hypothesize that HPV16 E6 antibodies and ctHPVDNA combined will have an accuracy for detecting HPV-OPC that is comparable to other accepted cancer screening methods. Impact: Regional stage HPV-OPC diagnoses are on the rise, and with them, increasing mortality, particularly among men in the southeast. This highlights the need for earlier detection of HPV-OPC to reduce geographic disparities in survival. This proposal is innovative by using novel biomarkers that can be assessed inexpensively using self-collected specimens. These methods could be rapidly scaled to increase screening accessibility for medically underserved populations, such as those in the southeastern US, who are disproportionately affected by the rising incidence and mortality due to HPV-OPC. The potential near-term impact of this proposed research is that it may lead to methods for early detection of HPV-OPC. Specific Aims: The aims are: (1) Identify factors associated with increased HPV16 E6 seroprevalence; (2) Evaluate the accuracy of HPV16 E6 antibodies and ctHPVDNA for the detection of HPV-OPC. Study Design: We are recruiting 3,000 men aged 45+ from primary care clinics across Kentucky, including rural underserved Appalachia. We are focusing on men in Kentucky given that ~80% of OPCs occur in males and Kentucky has one of the highest and most rapidly increasing rates of OPC in the country. At enrollment, a finger prick and blood spot card are collected for HPV16 E6 testing along with an oral rinse for HPV testing and basic demographic and smoking data. All HPV16 E6 seropositives and a random subset of seronegatives will be invited for a one-time head and neck cancer screening exam to include urine-based ctHPVDNA testing, visual inspection of the oral cavity and neck, laryngoscope exam, and a risk factor questionnaire. Assuming 2% are HPV16 E6 seropositive and 90% consent, 54 seropositive men will undergo the exam along with 79 seronegative controls. Based on prior studies, we anticipate diagnosing 8 HPV-OPCs among the 54 seropositives. In exploratory analyses, seropositive men not diagnosed with cancer (N=46) will be monitored yearly for HPV-OPC using urine-based ctHPVDNA testing; all ctHPVDNA positives will be offered a repeat exam. All 3,000 men will also be monitored for HPV-OPC development via the Kentucky Cancer Registry. Relevance to Military Health: Veterans are more likely to be diagnosed with and die from HPV-OPC than the general population. Veterans with HPV-OPC experience 10 times the number of annual hospitalizations and incur 8 times greater healthcare costs compared to veterans without cancer. Compared to early stage disease, late stage HPV-OPC has poorer survival, requires more prolonged and aggressive treatments and is associated with severe and often permanent side effects. Thus, early detection has the potential to improve survival, reduce total treatment time and treatment-related side effects and support a more rapid return to mission readiness.