Jou nal o
Clinical Medicine
Re iew
Associa ion o Sali a y Human Papilloma i us
In ec ion and O al and O opha yngeal Cance :
A Me a-Analysis
Ósca Rapado-González 1,2,3, C is ina Ma ínez-Regle o 4,Ángel Salgado-Ba ei a 4,
Almudena Rod íguez-Fe nández 5, San iago Aguín-Losada 6, Luis León-Ma eos 6,
Lau a Muinelo-Romay 2,3 , Ra ael López-López 3,6,* and
Ma ía Me cedes Sua ez-Cunquei o 1,3,7,*
1Depa men o Su ge y and Medical-Su gical Special ies, Medicine and Den is y School, Uni e sidade de
San iago de Compos ela (USC), 15782 San iago de Compos ela, Spain; osca [email p o ec ed]
2Liquid Biopsy Analysis Uni , T ansla ional Medical Oncology (Oncome ), Heal h Resea ch Ins i u e o
San iago (IDIS), 15706 San iago de Compos ela, Spain; [email p o ec ed]
3Cen o de In es igación Biomédica en Red en Cánce (CIBERONC), Ins i u o de Salud Ca los III,
28029 Mad id, Spain
4Me hodology and S a is ics Uni , Galicia Su Heal h Resea ch Ins i u e (IISGS), 36312 Vigo, Spain;
c is ina.ma inez@iisgaliciasu .es (C.M.-R.); angel.salgado.ba ei a@se gas.es (Á.S.-B.)
5Depa men o P e en i e and Public Heal h, Uni e sidade de San iago de Compos ela (USC),
15782 San iago de Compos ela, Spain; almudena. od í[email p o ec ed]
6T ansla ional Medical Oncology (Oncome ), Heal h Resea ch Ins i u e o San iago (IDIS), Complexo
Hospi ala io Uni e si a io de San iago de Compos ela (SERGAS), 15706 San iago de Compos ela, Spain;
[email p o ec ed] (S.A.-L.); [email p o ec ed] (L.L.-M.)
7T ansla ional Medical Oncology (Oncome ), Heal h Resea ch Ins i u e o San iago (IDIS),
15706 San iago de Compos ela, Spain
*Co espondence: [email p o ec ed] (R.L.-L.); ma iame cedes.sua [email p o ec ed] (M.M.S.-C.);
Tel.: +34-981-95-14-70 (R.L-L.); +34-881-812-437 (M.M.S.-C.)
Recei ed: 31 Ma ch 2020; Accep ed: 26 Ap il 2020; Published: 29 Ap il 2020
Abs ac :
Backg ound. Human papilloma i us (HPV) in ec ion has been ecognized as an impo an
isk ac o in cance . The pu pose o his sys ema ic e iew and me a-analysis was o de e mine
he p e alence and e ec size o associa ion be ween sali a y HPV DNA and he isk o de eloping
o al and o opha yngeal cance . Me hods. A sys ema ic li e a u e sea ch o PubMed, EMBASE,
Web o Science, LILACS, Scopus and he Coch ane Lib a y was pe o med, wi hou language
es ic ions o speci ied s a da e. Pooled da a we e analyzed by calcula ing odds a ios (ORs) and
95% con idence in e als (CIs). Quali y assessmen was pe o med using he Newcas le–O awa Scale
(NOS). Resul s. A o al o 1672 s udies we e sc eened and 14 me inclusion c i e ia o he me a-analysis.
The o e all p e alence o sali a y HPV DNA o o al and o opha yngeal ca cinoma was 43.2%, and he
p e alence o sali a y HPV16 geno ype was 27.5%. Pooled esul s showed a signi ican associa ion
be ween sali a y HPV and o al and o opha yngeal cance (OR =4.94; 2.82
−
8.67), o al cance
(
OR =2.58; 1.67−3.99
) and o opha yngeal cance (
OR =17.71; 6.42−48.84
). Signi ican associa ions
we e also ound be ween sali a y HPV16 and o al and o opha yngeal cance (
OR =10.07; 3.65−27.82
),
o al cance (
OR =2.95; 1.23−7.08
) and o opha yngeal cance (
OR =38.50; 22.43−66.07
). Conclusions.
Ou me a-analysis demons a ed he associa ion be ween sali a y HPV in ec ion and he incidence o
o al and o opha yngeal cance indica ing i s alue as a p edic i e indica o .
Keywo ds: human papilloma i us; o al cance ; o opha yngeal cance ; sali a; me a-analysis
J. Clin. Med. 2020,9, 1305; doi:10.3390/jcm9051305 www.mdpi.com/jou nal/jcm
J. Clin. Med. 2020,9, 1305 2 o 18
1. In oduc ion
Human papilloma i us (HPV) in ec ion has been ecognized as an impo an isk ac o in a subse
o head and neck squamous cell ca cinomas, independen ly o adi ional isk ac o s such as obacco
o alcohol use [
1
,
2
]. Globally, a ound 38,000 cases o head and neck cance a e a ibu ed o he HPV
in ec ion. O hese, a ound 76% a e cases o o opha ynx cance , 12% o o al ca i y cance and 10% o
la ynx cance [
3
]. Cu en ly, i is well known ha HPV-s a us de e mines he molecula landscape o
hese umo s and hei clinical e olu ion, wi h a be e p ognosis and esponse o he apy being ound
in HPV-posi i e pa ien s [4,5].
HPVs a e small, non-en eloped, close-ci cula , double-s anded DNA i uses o app oxima ely
8000 base-pai s which p esen a speci ic issue opism in ec ing epi helial cells o he skin and mucosae
o he anogeni al and uppe ae o-diges i e ac [
6
]. Mo e han 200 di e en HPV ypes ha e been
iden i ied and classi ied in o low- isk and high- isk acco ding o hei oncogenic po en ial. In his sense,
high- isk HPV (HR-HPV) can p omo e he malignan ans o ma ion o HPV-in ec ed cells h ough
E6 and E7 i al oncop o eins, esponsible o inac i a ing he TP53 and Rb ( e inoblas oma umo
supp esso gene) [
7
]. A subse o 12 alpha HR-HPV (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59)
has been classi ied as ca cinogenic o humans acco ding o he In e na ional Agency o Resea ch in
Cance [
8
]. HR-HPV is conside ed he main cause o ce ical cance , geno ypes 16 and 18 being
esponsible o 70% o cases [
9
]. In addi ion, se e al s udies ha e also demons a ed he pa hogenic
ole o HPV in o he anogeni al cance s [
10
–
12
] as well as in head and neck cance s [
13
]. Cu en ly,
HPV16 is widely ecognized as an e iological ac o in o opha ynx umo s [
14
], howe e , no enough
e idence exis s ega ding he HPV ela ionship and he ana omic subsi es o head and neck squamous
cell ca cinoma [15].
Nowadays, a a ie y o molecula biological me hods ha e been de eloped o he de ec ion and
geno yping o HPV a DNA, mRNA, and p o ein le els by polyme ase chain eac ion (PCR), eal- ime
PCR, in si u hyb idiza ion, immunohis ochemis y and se um an ibody assays [
16
]. In addi ion,
nex -gene a ion HPV sequencing app oaches p o ide accu a e in o ma ion on geno ype composi ion
and pa hways o be e unde s and unc ional consequences [
17
]. Ce ain collec ion app oaches p esen
di icul ies. Fo example, umo al issue biopsy is in asi e and umo s may be inaccessible. Fo i s
pa , he collec ion o o al ex olia ed cells wi h co on swabs o cy ob ush is es ic ed o a speci ic and
accessible o al a ea, making collec ion di icul o non- isual umo s and ea ly molecula al e a ions.
To o e come hese d awbacks, he de ec ion o HPV in o al ex olia ed cells om sali a (wi h o wi hou
o al inses) ep esen s a quick and easy non-in asi e al e na i e o o al and o opha yngeal cance
sc eening in high- isk popula ions. In his sense, se e al esea che s ha e analyzed he p e alence o
sali a y HPV DNA om head and neck cance , howe e , o ou knowledge, no p e ious sys ema ic
e iew has elucida ed e idence o his ela ionship. The e o e, he aim o he p esen sys ema ic e iew
and me a-analysis was o de e mine he p e alence and e ec size o associa ion be ween sali a y HPV
DNA and he isk o de eloping o al and o opha yngeal cance .
2. Ma e ials and Me hods
2.1. P o ocol and Regis a ion
This s udy was conduc ed acco ding o P e e ed Repo ing I ems o Sys ema ic Re iews and
Me a-Analysis (PRISMA) guidelines [
18
] and he p o ocol was egis e ed wi h he In e na ional
P ospec i e Regis e o Sys ema ic Re iews ( e e ence No. CRD42020161345).
2.2. Sea ch S a egy and S udy Selec ion
The sys ema ic li e a u e sea ch was pe o med in PubMed, EMBASE, Web o Science, LILACS,
Scopus and he Coch ane Lib a y h ough 9 Janua y 2020, wi hou language es ic ions o speci ied
s a da e. The ollowing combina ions o keywo ds and medical subjec headings we e used: (human
papilloma i us OR HPV) AND (sali a OR o al inses OR mou hwash) AND (o al squamous
J. Clin. Med. 2020,9, 1305 3 o 18
cell ca cinoma OR OSCC OR o opha yngeal squamous cell ca cinoma OR OPSCC OR o al cance
OR o opha yngeal cance ). All s udies we e sc eened based on he i le and abs ac , and eligible
manusc ip s we e e ie ed o ull- ex e iew. Addi ionally, we manually sea ched he e e ence lis s
in each o iginal and e iew a icle in o de o a oid missing po en ial s udies. The li e a u e sea ch
was pe o med independen ly by wo esea che s (ORG and MMSC), and any disag eemen s we e
esol ed by consensus. The s udies selec ed h ough he sea ch s a egy and o he e e ences we e
managed using Re Wo ks so wa e, and duplica ed i ems we e emo ed using he associa ed ools.
2.3. Eligibili y C i e ia
We included he s udies ha me he ollowing c i e ia: (1) case-con ol s udies o pa ien s wi h
o al and/o o opha yngeal cance and heal hy con ols, (2) HPV DNA p e alence de e mined in
sali a y samples (whole sali a o o al inses), and (3) su icien da a o calcula e odds a ios (ORs)
wi h 95% con idence in e als (CIs). The exclusion c i e ia we e as ollows: (1)
in i o
o animal
s udy, (2) e iews, le e s, pe sonal opinions, book chap e s, case epo s, and con e ence abs ac s,
and (3) duplica e a icles o suspicion o da a o e lap.
2.4. P o ocol and Regis a ion
Two esea che s (ORG and MMSC) independen ly assessed each eligible manusc ip , ex ac ed
da a using a p e-es ablished o m, and colla ed he da a in o a Mic oso Excel sp eadshee (Mic oso
Co p. Redmond, WA, USA). Any disag eemen among e iewe s was esol ed by consensus.
The ollowing in o ma ion was ex ac ed om each s udy: au ho , publica ion yea , coun y, ype o
sample, me hod o collec ion, umo loca ion, sample size, HPV de ec ion me hod, numbe o cases
and HPV-posi i e cases, numbe o con ols and HPV-posi i e con ols, HPV-posi i e geno ypes,
o e all HPV DNA p e alence (numbe o subjec s es ing posi i e o any HPV ype) and ype-speci ic
HPV DNA p e alence (numbe o subjec s es ing posi i e o speci ic HPV ypes: HPV16 o HPV18,
HR-HPV and LR-HPV). I he equi ed da a we e incomple e, a emp s we e made o con ac he
au ho s o ob ain he missing in o ma ion.
2.5. Assessmen o Risk Bias
The Newcas le-O awa Scale (NOS) [
19
] was used o e alua e he indi idual quali y o he selec ed
s udies by h ee independen esea che s (ORG, ARF, and MMSC), and disc epancies we e esol ed
by consensus. The NOS assesses he quali y o non- andomized s udies based on design, con en
and ease o use di ec ed o he ask o inco po a ing he quali y assessmen s in he in e p e a ion o
me a-analy ic esul s. This ‘s a sys em’ consis s o 8 i ems classi ied in o h ee b oad pe spec i es:
he selec ion o s udy g oups; he compa abili y o he g oups; and he asce ainmen o ei he he
exposu e o ou come o in e es o case-con ol o coho s udies. The highes quali y s udies we e
allo ed a maximum o one s a o each i em, excep o , he i em ela ed o compa abili y, which was
allowed he assignmen o a maximum o wo s a s. The NOS sco e anged om 0 o 9 s a s and
alidi y c i e ia we e as ollows: 8–9, high quali y; 6–7, medium quali y; <5 low quali y.
2.6. S a is ical Analysis
S a is ical analysis was conduc ed using he me a package o ee R so wa e ( .3.6.2; h ps:
//www. -p ojec .o g). Fi s ly, o e alua e he s a is ical model applied o he me a analy ic da abase,
he e ogenei y was assessed using he Coch an’s Q s a is ic es -based Chi-squa ed es and I2 s a is ics.
He e ogenei y was conside ed signi ican when I2 >50% and/o p esence o a p<0.10 o he Coch an’s
Q es . The p e alence o HPV DNA and HPV geno ypes in o al and/o o opha yngeal cance was
calcula ed using ixed o andom e ec s depending on he he e ogenei y. The ela ionship be ween
sali a HPV DNA in ec ion and o al and/o opha yngeal cance isk was e alua ed by pooled odds a io
(OR) and 95% con idence in e als (CIs) compa ing cases o con ols. I signi ican he e ogenei y was
de ec ed, he De Simonian and Lai d andom-e ec s model was applied o calcula e he pooled OR
J. Clin. Med. 2020,9, 1305 4 o 18
wi h 95% CIs; o he wise, he Man el–Haenszel ixed-e ec s model was used. Then, subg oup analyses
we e pe o med o explo e he po en ial sou ces o he e ogenei y among s udies acco ding o he
ana omic umo loca ion and HPV geno ypes. Addi ionally, publica ion bias was checked wi h Begg’s
and Egge ’s es s and by isual inspec ion in unnel plo s demons a ing he ela ionship be ween he
indi idual log ORs and hei s anda d e o s [
20
,
21
]. p- alues o <0.05 we e conside ed o indica e
s a is ical signi icance.
3. Resul s
3.1. S udy Selec ion
A o al o 1669 a icles we e iden i ied ac oss he six elec onic da abases and h ee addi ional
epo s om he e e ence lis s. A e emo ing duplica es, a o al o 1542 a icles we e sc eened based on
he i le and abs ac , and 1494 we e excluded o lack o adhe ence o ou inclusion c i e ia. The e o e,
ull- ex a icles we e e ie ed o he emaining 48 a icles. A e a ull- ex e iew, 34 a icles we e
excluded o he ollowing easons: non case-con ol s udies (22); con ols unde isk condi ions (2);
suspicious o da a o e lap (3); insu icien da a (3); and e iews, le e s, and me a-analysis (4). Finally,
14 a icles me all he inclusion c i e ia and we e included in he inal analysis. A de ailed lowcha
showing he selec ion p ocess is shown in Figu e 1.
J. Clin. Med. 2020, 9, x FOR PEER REVIEW 4 o 19
he e ogenei y was de ec ed, he De Simonian and Lai d andom-e ec s model was applied o
calcula e he pooled OR wi h 95% CIs; o he wise, he Man el–Haenszel ixed-e ec s model was used.
Then, subg oup analyses we e pe o med o explo e he po en ial sou ces o he e ogenei y among
s udies acco ding o he ana omic umo loca ion and HPV geno ypes. Addi ionally, publica ion bias
was checked wi h Begg’s and Egge ’s es s and by isual inspec ion in unnel plo s demons a ing
he ela ionship be ween he indi idual log ORs and hei s anda d e o s [20,21]. p- alues o < 0.05
we e conside ed o indica e s a is ical signi icance.
3. Resul s
3.1. S udy Selec ion
A o al o 1669 a icles we e iden i ied ac oss he six elec onic da abases and h ee addi ional
epo s om he e e ence lis s. A e emo ing duplica es, a o al o 1542 a icles we e sc eened based
on he i le and abs ac , and 1494 we e excluded o lack o adhe ence o ou inclusion c i e ia.
The e o e, ull- ex a icles we e e ie ed o he emaining 48 a icles. A e a ull- ex e iew, 34
a icles we e excluded o he ollowing easons: non case-con ol s udies (22); con ols unde isk
condi ions (2); suspicious o da a o e lap (3); insu icien da a (3); and e iews, le e s, and me a-
analysis (4). Finally, 14 a icles me all he inclusion c i e ia and we e included in he inal analysis.
A de ailed lowcha showing he selec ion p ocess is shown in Figu e 1.
Figu e 1. P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analysis (PRISMA) low
diag am o he li e a u e selec ion p ocess, including iden i ica ion, sc eening, eligibili y and o al
s udies included in quali a i e and quan i a i e syn hesis.
Figu e 1.
P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analysis (PRISMA) low
diag am o he li e a u e selec ion p ocess, including iden i ica ion, sc eening, eligibili y and o al
s udies included in quali a i e and quan i a i e syn hesis.
3.2. S udy Cha ac e is ics
Indi idual cha ac e is ics o he included s udies a e summa ized in Table 1. A o al o 14 a icles
e alua ing HPV p e alence in o al and/o o opha yngeal cance we e included in his me a-analysis,
and hese s udies we e ca ied ou om 2005 o 2019. S udy sample sizes anged om 42 o 677 subjec s.
J. Clin. Med. 2020,9, 1305 5 o 18
The s udy uni s in his me a-analysis comp ised a o al o 2320 cases (658 om he o al ca i y, 1160 om
he o al ca i y plus o opha ynx and 502 om he o opha ynx), and 5868 con ols (2210 om he o al
ca i y, 2304 om he o al ca i y plus o opha ynx and 1354 om he o opha ynx). As epo ed in Table 1,
ou s udies we e conduc ed in India [
22
–
25
], h ee in he USA [
26
–
28
], and wo in Sweden [
29
,
30
],
whe eas he emaining s udies we e ca ied ou in he ollowing coun ies: Canada [
31
], F ance [
32
],
Hunga y [
33
], Pakis an [
34
], and I an [
35
]. In e ms o sampling, o al inses and sali a (
n=7, 50%
,
espec i ely) we e analyzed o HPV posi i i y and geno yping. The me hods mos used o sali a
HPV-DNA de e mina ion we e con en ional PCR, nes ed PCR and quan i a i e PCR. Howe e ,
o he analy ical s a egies such as nex gene a ion sequencing o immunoassays we e also employed
o sali a y HPV geno yping (Table 1).
3.3. S udy Quali y
Assessmen o isk o bias and quali y was pe o med acco ding o NOS (Table S1). Rega ding
he selec ion domain, adequa e desc ip ion abou cha ac e is ics and selec ion c i e ia o cases and
con ols we e p o ided by all o he included s udies. Rega ding he compa abili y domain, six ou
o he 14 s udies ma ched o age and a leas one addi ional ac o . Inso a as he exposu e domain,
ew s udies epo ed he blinding o analyses o non- esponse a es. The mean NOS sco e in ou
me a-analysis was six.
3.4. Me a-Analysis
3.4.1. Sali a y HPV Associa ion wi h O al and O opha yngeal Cance
O e all, he p e alence o sali a y HPV o o al and o opha yngeal ca cinoma was o 43.2%
(
n=1160
) while he in ec ion a e in he heal hy con ol g oup was o 8.9% (n=2304). Sali a y HPV16
was he mos common ype o HPV DNA posi i e cases (n=1116), ep esen ing 27.5% (Figu e 2).
J. Clin. Med. 2020, 9, x; doi: FOR PEER REVIEW www.mdpi.com/jou nal/jcm
3.3. S udy Quali y
Assessmen o isk o bias and quali y was pe o med acco ding o NOS (Table S1). Rega ding
he selec ion domain, adequa e desc ip ion abou cha ac e is ics and selec ion c i e ia o cases and
con ols we e p o ided by all o he included s udies. Rega ding he compa abili y domain, six ou
o he 14 s udies ma ched o age and a leas one addi ional ac o . Inso a as he exposu e domain,
ew s udies epo ed he blinding o analyses o non- esponse a es. The mean NOS sco e in ou
me a-analysis was six.
3.4. Me a-Analysis
3.4.1. Sali a y HPV Associa ion wi h O al and O opha yngeal Cance
O e all, he p e alence o sali a y HPV o o al and o opha yngeal ca cinoma was o 43.2% (n
= 1160) while he in ec ion a e in he heal hy con ol g oup was o 8.9% (n = 2304). Sali a y HPV16
was he mos common ype o HPV DNA posi i e cases (n = 1116), ep esen ing 27.5% (Figu e 2).
Figu e 2. Schema ic d awing o sali a y HPV and p e alence o o al and/o o opha yngeal cance .
O al issue sheds pa hogen-in ec ed cells con aining di e en HPV DNA geno ypes (HPV16, HPV18,
HR-HPV, and LR-HPV) in o sali a (wi h o wi hou o al inses). The p e alence o sali a y HPV DNA
a ied acco ding o ana omic umo loca ion, showing he highes in ec ion a e in o opha yngeal
ca cinomas. In addi ion, he ype-speci ic p e alence in sali a was also di e en acco ding o he
ana omic umo loca ion.
Ou me a-analysis included a o al o 1160 cases and 2304 con ols. The pooled analysis showed
a signi ican associa ion be ween posi i e sali a y HPV DNA s a us and o al and o opha yngeal
cance wi h a pooled OR o 4.94 (95% CI = 2.82−8.67; p < 0.01) (Figu e 3).
Figu e 2.
Schema ic d awing o sali a y HPV and p e alence o o al and/o o opha yngeal cance .
O al issue sheds pa hogen-in ec ed cells con aining di e en HPV DNA geno ypes (HPV16, HPV18,
HR-HPV, and LR-HPV) in o sali a (wi h o wi hou o al inses). The p e alence o sali a y HPV DNA
a ied acco ding o ana omic umo loca ion, showing he highes in ec ion a e in o opha yngeal
ca cinomas. In addi ion, he ype-speci ic p e alence in sali a was also di e en acco ding o he
ana omic umo loca ion.
J. Clin. Med. 2020,9, 1305 6 o 18
Table 1. Cha ac e is ics o he 14 case-con ol s udies included in his me a-analysis.
Coun y Tumo
Loca ion (n)
Type o Sample/
Me hod o Collec ion
HPV-Posi i e
Cases (n/N)
HPV-Posi i e
Case Types
HPV-Posi i e
Con ols (n/N)
HPV-Posi i e
Con ol Types
HPV De ec ion
Me hod
Hansson e al.;
2005
Sweden
OC (85)
OPC (46)
O al inse/7 mL o 0.9%
NaCl solu ion o 30s 39/131
16, 18, 33, 45,
58, 59, 13, 32,
62, 10, 76
14/320
16, 67, 54, 55, 62,
87, 75, 76,
RTRX9
Nes ed PCR (MY09/
MY11 and GP5+/6+
p ime s)
DNA sequencing
SahebJamee e al.;
2009 I an OC (22) O al inse/10 mL o
no mal saline 9/22 16, 18, 6/11 5/20 16, 6/11
PCR (GP5+/ 6+p ime s
o L1 egion)
Kulka ni e al.;
2011 India OC (34) Sali a 24/34 16, 18 255/396 16, 18 PCR (16 and 18 speci ic
p ime s)
Goo -Heah e al.;
2012 India OC (14) Sali a 0/14 - 0/30 -
Nes ed PCR (MY09/11
and GP5+/6+p ime s
o L1 egion)
Chen e al.; 2013 USA OC (32)
OPC (52)
Sali a/O agene DNA
ki s (DNA Geno ek) 38/84 16 1/19 16
qPCR (speci ic p ime s
and p obe o E6 egion
o HPV16)
No d o s e al.;
2014
Sweden
OPC (47)
O al inse/15 mL 50%
Lis e ine®(Johnson
and Johnson) o 30s
25/47
16, 18, 67, 6, 51
0/37 -
Bead-based mul iplex
assay on a MagPix
ins umen (Luminex
Co po a ion), GP5+/6+
p ime s o he L1
egion and speci ic
p ime s and p obe o
E6 egion o HPV16
Khyani e al.; 2015
Pakis an
OC (35) Sali a 15/35 16, 18 3/35 16
qPCR using Real- ime
PCR Ki HPV16/18
Real-TM Quan (Sacace
Bio echnologies)
Modak e al.; 2016 India OC (235) Sali a 149/235 16 193/409 16 PCR (HPV 16 speci ic
p ime )
J. Clin. Med. 2020,9, 1305 7 o 18
Table 1. Con .
Coun y Tumo
Loca ion (n)
Type o Sample/
Me hod o Collec ion
HPV-Posi i e
Cases (n/N)
HPV-Posi i e
Case Types
HPV-Posi i e
Con ols (n/N)
HPV-Posi i e
Con ol Types
HPV De ec ion
Me hod
Rosen hal e al.;
2017 USA OC (61)
OPC (45)
O al inse/10 mL o
0.9% NaCl solu ion o
30s
44/106
16, 18, *
HR-HPV
o he
3/81 16, * HR-HPV
o he
qPCR om he HPV L1
egion (Cobas®HPV
Tes -Roche Diagnos ics)
Augus e e al.;
2017 F ance OC (22)
OPC (41)
Sali a/O agene
OG-500 ki (DNA
Geno ek)
21/63 16, 33, 51 80/308 16
PCR (SPF10 p ime
sys em o L1 egion,
INNO-LiPA®HPV
Geno yping Ex a;
Innogene ics)
Lap ise e al.; 2017
Canada
OC (72)
OPC (183)
O al
inse/alcohol-based
solu ion o 15–30s
125/255
16, 18, ** HPV
α-9 o he han
HPV16, ***
HPV o he
61/422
16, 18, ** HPV
α-9 o he han
HPV16, *** HPV
o he
PCR (MY09/11 p ime s
o HPV) and
geno yping by Linea
A ay assay (Roche
Molecula diagnos ics)
He man e al.;
2018
Hunga y
OPC (12) Uns imula ed sali a 4/12 16, 13 2/57 13, 11
PCR (MY09/11 p ime s
o L1 egion)
Nes ed PCR (MY09/11
and GP5+/6+p ime s
o L1 egion),
sequencing o
geno yping
Ramesh e al.;
2018 India OC (30)
O al inse/10mL o 0.9%
no mal saline 13/30 16, 18 18/60 16, 18 Nes ed PCR (MY09/11
p ime s o L1 egion)
Dang e al.; 2019 USA OC (16)
OPC (76)
O al inse/O iginal
Min
Scope®mou hwash o
C es ®Alcohol- ee
mou hwash (P oc o
and Gamble) o 30s
37/92 16, NV14.4,
NV69.1, NV95 1/110 18
qPCR (HPV16
E7/HPV18 E7 p ime s
and p obe)
FAP-PCR om he L1
egion
NGS and Sange
sequencing
Abb e ia ions: OC, o al cance ; OPC, o opha ynx cance ; PCR, polyme ase chain eac ion; qPCR, quan i a i e PCR; FAP-PCR, luo escen a bi a ily p imed PCR; NGS, nex -gene a ion
sequencing; * HR-HPV o he : 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68; ** HPV
α
-9 o he han HPV16: 31,33,35,52,58, and 67; *** HPV o he : 6, 11, 18, 26, 34, 39, 40, 42, 44, 45, 51, 53, 54,
56, 59, 61, 62, 66, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, and 89.
J. Clin. Med. 2020,9, 1305 8 o 18
Ou me a-analysis included a o al o 1160 cases and 2304 con ols. The pooled analysis showed
a signi ican associa ion be ween posi i e sali a y HPV DNA s a us and o al and o opha yngeal cance
wi h a pooled OR o 4.94 (95% CI =2.82−8.67; p<0.01) (Figu e 3).
J. Clin. Med. 2020, 9, x FOR PEER REVIEW 2 o 19
Figu e 3. Fo es plo o he s udies on he associa ion be ween sali a y HPV and o al and
o opha yngeal cance . The squa es indica e he ORs (odds a ios) in each s udy, wi h squa e sizes
in e sely p opo ional o he s anda d e o o he OR. The diamond shape indica es he pooled ORs.
Ho izon al lines ep esen 95% CIs (con idence in e als), I2 > 50% indica es se e e he e ogenei y.
A andom-e ec s model was used because he e ogenei y was iden i ied among he 14 s udies
(I2 = 82%). Visual inspec ion o he unnel plo e ealed a symme ical (Egge ’s es , p = 0.159; Begg’s
es , p = 0.298) dis ibu ion o he s udies, indica ing no e idence o publica ion bias (Figu e 4).
Figu e 4. Funnel plo o s udies (o 14 s udies) on he associa ion be ween sali a y HPV and o al and
o opha yngeal cance . The e ical line ep esen s he pooled OR using andom-e ec me a-analysis.
Two diagonal lines ep esen (pseudo) 95% con idence limi s a ound he OR o each s anda d e o
on he e ical axis. In he absence o he e ogenei y, 95% o he s udies should lie wi hin he unnel
de ined by hese diagonal lines. Abb e ia ions: se OR, s anda d e o o odds a io.
Figu e 3.
Fo es plo o he s udies on he associa ion be ween sali a y HPV and o al and o opha yngeal
cance . The squa es indica e he ORs (odds a ios) in each s udy, wi h squa e sizes in e sely p opo ional
o he s anda d e o o he OR. The diamond shape indica es he pooled ORs. Ho izon al lines ep esen
95% CIs (con idence in e als), I2 >50% indica es se e e he e ogenei y.
A andom-e ec s model was used because he e ogenei y was iden i ied among he 14 s udies
(
I2 =82%
). Visual inspec ion o he unnel plo e ealed a symme ical (Egge ’s es , p=0.159; Begg’s
es , p=0.298) dis ibu ion o he s udies, indica ing no e idence o publica ion bias (Figu e 4).
J. Clin. Med. 2020, 9, x FOR PEER REVIEW 2 o 19
Figu e 3. Fo es plo o he s udies on he associa ion be ween sali a y HPV and o al and
o opha yngeal cance . The squa es indica e he ORs (odds a ios) in each s udy, wi h squa e sizes
in e sely p opo ional o he s anda d e o o he OR. The diamond shape indica es he pooled ORs.
Ho izon al lines ep esen 95% CIs (con idence in e als), I2 > 50% indica es se e e he e ogenei y.
A andom-e ec s model was used because he e ogenei y was iden i ied among he 14 s udies
(I2 = 82%). Visual inspec ion o he unnel plo e ealed a symme ical (Egge ’s es , p = 0.159; Begg’s
es , p = 0.298) dis ibu ion o he s udies, indica ing no e idence o publica ion bias (Figu e 4).
Figu e 4. Funnel plo o s udies (o 14 s udies) on he associa ion be ween sali a y HPV and o al and
o opha yngeal cance . The e ical line ep esen s he pooled OR using andom-e ec me a-analysis.
Two diagonal lines ep esen (pseudo) 95% con idence limi s a ound he OR o each s anda d e o
on he e ical axis. In he absence o he e ogenei y, 95% o he s udies should lie wi hin he unnel
de ined by hese diagonal lines. Abb e ia ions: se OR, s anda d e o o odds a io.
Figu e 4.
Funnel plo o s udies (o 14 s udies) on he associa ion be ween sali a y HPV and o al and
o opha yngeal cance . The e ical line ep esen s he pooled OR using andom-e ec me a-analysis.
Two diagonal lines ep esen (pseudo) 95% con idence limi s a ound he OR o each s anda d e o
on he e ical axis. In he absence o he e ogenei y, 95% o he s udies should lie wi hin he unnel
de ined by hese diagonal lines. Abb e ia ions: se OR, s anda d e o o odds a io.
J. Clin. Med. 2020,9, 1305 9 o 18
Fo he ype-speci ic analysis (Figu e 5), sali a y HPV16 showed a signi ican associa ion wi h
a pooled OR o 10.07 (95% CI =3.65
−
27.82; p<0.01). Howe e , sali a y HPV18 did no show
any signi ican inc eased isk o o al and o opha yngeal cance wi h a pooled OR o 1.80 (95%
CI =0.66−4.90
). In addi ion, a signi ican associa ion was ound o sali a y HR-HPV wi h OR o 5.94
(95%
CI =2.78−12.69
;
p<0.01
), whe eas sali a y LR-HPV did no show any signi ican inc eased isk
wi h OR o 1.45 (95% CI =0.70−2.98). The espec i e unnel plo s a e ep esen ed in Figu es S1–S4.
J. Clin. Med. 2020, 9, x FOR PEER REVIEW 3 o 19
Fo he ype-speci ic analysis (Figu e 5), sali a y HPV16 showed a signi ican associa ion wi h a
pooled OR o 10.07 (95% CI = 3.65−27.82; p < 0.01). Howe e , sali a y HPV18 did no show any
signi ican inc eased isk o o al and o opha yngeal cance wi h a pooled OR o 1.80 (95% CI =
0.66−4.90). In addi ion, a signi ican associa ion was ound o sali a y HR-HPV wi h OR o 5.94 (95%
CI = 2.78−12.69; p < 0.01), whe eas sali a y LR-HPV did no show any signi ican inc eased isk wi h
OR o 1.45 (95% CI = 0.70−2.98). The espec i e unnel plo s a e ep esen ed in Figu es S1–4.
Figu e 5. Fo es plo o he s udies on he associa ion be ween sali a y HPV and o al and
o opha yngeal cance . The squa es indica e he ORs in each s udy, wi h squa e sizes in e sely
p opo ional o he s anda d e o o he OR. The diamond shape indica es he pooled ORs.
Figu e 5.
Fo es plo o he s udies on he associa ion be ween sali a y HPV and o al and o opha yngeal
cance . The squa es indica e he ORs in each s udy, wi h squa e sizes in e sely p opo ional o he
s anda d e o o he OR. The diamond shape indica es he pooled ORs. Ho izon al lines ep esen 95%
CIs. I2 >50% indica es se e e he e ogenei y. (a) HPV16, (b) HPV18, (c) HR-HPV, and (d) LR-HPV.
J. Clin. Med. 2020,9, 1305 16 o 18
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