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Chancellor JA, Ioannides SJ et al. Community Dent Oral Epidemiol 2017; 45: 20–34

Primary prevention may have a major impact on that minority of tumours classified as D-tumours (D for deterministic such as HPV-16 head and neck – Science 2015;347: 78–81). But what is the evidence that sexual behaviour is a risk factor for oropharyngeal cancer. From a pool of 513 papers, 20 met the inclusion criteria; only two papers were rated as moderate quality and 18 as weak. The investigators used the Effective Public Health Practice Project Quality Assessment Tool. This has been used in areas such as the promotion of sexual health and substance misuse. Of note, two studies found a significant negative association with oral cavity cancers and oral sex. But when taken in the round, five studies reported that oral sex was associated with oral cancer and nine studies reported that a 'high number of lifetime sexual partners' was associated with oral cancer. After adjusting for confounders, never or rare use of a condom was associated with a risk of oropharygeal cancer, but then those who had sex with a person who had genital warts were not associated with oropharyngeal cancer. They concede that due to the sensitivity of this subject there may underreporting in some, but then again overreporting in other groups.