Steve Holzer rings a bell in the radiation department at Cedars Sinai to mark the end of his six-week treatment for oral cancer. The Los Angeles-based television producer celebrated his 51st birthday during his treatment, and appears triumphant, if not a bit tired, by the end. Before Holzer's cancer diagnosis, he had hit a stride with boot camp and kettle bell classes. He lost some of his muscle mass during treatment, but that was a trade-off for trooping through it successfully.
"The doctors who saw me all commented about my physical fitness and my relatively young age and how those were going to be a huge asset in the battle I was about to undertake. Of course, as a single gay man living in West Hollywood, I was just pissed that I was going to have to take a break from the momentum I'd been gathering," Holzer wrote in a blog post.
Perhaps the most noticeable difference in Holzer is his prominent salt-and-pepper beard, which thinned out during radiation. The radiation beams targeted at Holzer's neck means that the stubble on the lowest part of his neck will never grow back, but the other parts will eventually return. During treatment, Holzer wore a specially designed mask that protected his vocal cords. He is an accomplished singer, and hopes to return to performing with the Gay Men's Chorus of Los Angeles soon. Next week, Holzer plans to take a yoga class and move into the next part of his life.
The cancer in Holzer's throat was squamous cell carcinoma, an HPV-related cancer. In Holzer's case, HPV-16 specifically was the cause. As a gay man, he is considered at higher risk for HPV infection. HPV now causes the bulk of head and neck cancers—even more so than smoking. Fortunately for Holzer, HPV cancers respond very well to treatment, and patients with this form of cancer live longer than those with non-HPV head and neck cancers.
"We caught mine early because I was not about to let a lump on the side of my neck go unchecked," Holzer says. "Men—gay or straight—have a tendency to avoid doctors."
There are currently around 200 types of HPV identified, with perhaps more undiscovered strains still lurking. Human papilloma viruses tend to be highly specialized, which means they prefer places like hands or feet or mucosal skin. A few dozen strains of HPV infect the genitals. About 90 percent of cases of genital warts are caused by HPV-6 and 11, which like warm, wet areas of the body—such as the genitals, throat, anus, and cervix. There are about a dozen high-risk HPV strains, with types 16 and 18 causing the bulk of HPV-related cancers.
Joel Palefsky, professor of medicine at University of California San Francisco, and founder of the International Papilloma Society, has seen a profound shift in understanding about HPV-related cancers in the past three decades. And only in the last decade has male (gay and straight) risk been more clearly understood. "We have the tools to eliminate HPV-caused cancers over time. It won't be tomorrow, but we can do it if we have the will," Palefsky says.
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Palefsky says the link between HPV and cervical cancer was discovered in the late 80s, and after that researchers discovered which specific strains were causing cancer. This lead to the development of the HPV vaccine (trade name: Gardasil) for girls to prevent cervical cancer, which came out in 2006. Palefsky says it was soon discovered that the same strains of HPV causing cervical cancer were also causing almost all cases of anal cancer, primarily in gay men and straight women. Oral cancers caused by HPV, like in Holzer, were showing up in gay and straight, male and female populations. In 2009, Gardasil was approved for males by the FDA, and in 2011 became a suggested vaccination for all males between ages 11 and 21. The CDC raised the suggested age of vaccination for gay men to 26, because they are at such high risk for infection and HPV cancers.
But what about that age, 26? Is it safe, or even possible, to get the vaccine later in life? Many gay men, myself included, were sexually active before the vaccine was approved for use in men. Could we still benefit? "The number 26 is based on mathematical modeling. [Insurers] had to pick a number to decide at what age the vaccine stops being cost-effective and beneficial," Palefsky tells me.
Essentially, by age 26, everyone has likely been exposed to HPV enough that the vaccine may provide limited protection. And at approximately $600 for the three-shot regimen, insurers view Gardasil as a waste of money past that age. Despite this, it's possible to get Gardasil at any age—if you're willing to pay for it.
"This really comes down to a cost-benefit analysis. If you can afford it and plan on having more sex partners, the HPV vaccine may be worth it to you as a gay man over age 26," says Palefsky. "But the vaccine does nothing to treat existing infections."
I am 31 years old and I paid out of pocket to get Gardasil. I've likely been exposed to HPV, but I don't know if I've been exposed to types 16 or 18. Since these are rarer, it was worth the $600 to possibly protect myself from the most dangerous strains of HPV. I did learn a few things in the process of getting vaccinated for HPV over the cutoff age:
First, no matter what your insurer or doctor says, expect to pay for it out of pocket. Even if your doctor recommends you get the shot, and your insurer says they will cover it—if you are over age 26, expect to pay retail price. Second: Bargain shop, and know that your local pharmacy may be the cheapest option. Yep, your pharmacist can very likely give vaccinations (with a doctor's order), and may charge the least for the vaccine. My pharmacy charged $175 for the vaccine, and $25 to administer it. My doctor's office charged $200 for the vaccine and $100 to administer it. Receiving the vaccine at the pharmacy was also faster and more convenient for my schedule.
HPV remains the most common STI in the US, and we only recently started understanding how these viruses work. As doctors find more cases of HPV-caused cancers, it becomes clear that we don't fully know the impact these infections have on our populace. Risk is hard to assess with HPV, especially because condoms don't fully prevent its spread (unlike, for example, HIV, which spreads through semen). And with certain strains jumping from orifice to orifice, containing its spread even in one person can be a challenge.
Vigilance stands as the best solution for HPV. Men don't have the same protocol, such as a pap smear for women, to test for HPV. This is why it's vital for men, both gay and straight, to look for unusual growths, lumps, or lesions and to check with a doctor if they find something unusual. And while more of the medical community is recognizing the benefits of boys getting the HPV vaccine, many adult men may find it worthwhile to shell out the money for it, too. The prognosis for HPV is quite good. We can contain it, treat it, and eradicate it if we all put in the effort to fight it.
Update: A previous version this article states that Joel Palefsky is the president of the International Papilloma Society. He has since moved out of that role.
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