Purpose: The incidence of human papillomavirus (HPV)–associated head and neck squamous cell carcinoma (HPV + HNSCC) is increasing in the United States. Currently, there are no early detection approaches for HPV + HNSCC. Two blood-based analytes for early detection and diagnosis of HPV + HNSCC, circulating tumor HPV DNA (ctHPVDNA) and HPV early protein antibodies (HPV Ab), show promise, yet current approaches lack adequate diagnostic accuracy for broad clinical utility. Further, performance metrics across various assays for detecting these analytes alone or in combination have not been compared head-to-head. To address these limitations and knowledge gaps, we developed a multifeature HPV whole-genome sequencing (WGS) liquid biopsy for improved low-level ctHPVDNA detection. We defined the performance characteristics of this WGS-based approach and compared it head-to-head with existing blood-based HPV detection approaches to determine the optimal single or combinatorial biomarker strategy for a future prospective study of HPV + HNSCC early detection. Experimental Design: We tested blood samples from 304 participants: 152 patients with untreated incident HPV + HNSCC (77% stage I) and 152 general population control patients. We compared WGS-based ctHPVDNA detection, single-plex Droplet Digital PCR (ddPCR)–based ctHPVDNA detection, multiplex ddPCR-based ctHPVDNA detection, multiplex HPV Ab detection, and clinical standard-of-care tissue biopsy, benchmarked to gold-standard HPV + HNSCC tissue diagnosis. We then modeled the operational feasibility of these approaches as screening biomarkers for HPV + HNSCC. Results: HPV WGS sensitivity and specificity were 98.7% and 98.7%, respectively. Single-plex ddPCR sensitivity and specificity were 94.2% and 98.6%, respectively. Multiplex ddPCR sensitivity and specificity were 90.6% and 96.3%, respectively. HPV Ab sensitivity and specificity were 86.4% and 96.3%, respectively. A combinatorial approach using both HPV WGS and HPV Ab yielded a sensitivity and specificity of 87.4% and 98.8%, respectively. In a head-to-head comparison, HPV WGS demonstrated significantly improved diagnostic accuracy compared with ddPCR (Youden index for HPV WGS, 0.99 vs. ddPCR, 0.90; P < 0.001), HPV Ab (HPV WGS, 0.99 vs. HPV Ab, 0.83; P < 0.001), and clinical workup (HPV WGS, 0.99 vs. clinical workup, 0.82; P < 0.001), which was maintained when evaluating only early-stage disease cases. For men ages 55 to 74, HPV WGS yielded the lowest number needed to screen (2,903 men) and the highest positive predictive value (2.6). Conclusions: HPV WGS–based ctHPVDNA detection demonstrated the highest sensitivity, specificity, and diagnostic accuracy and thus the lowest number needed to screen and highest positive predictive value compared with ddPCR-based ctHPVDNA detection, HPV Ab–based detection, and combinatorial approaches. These results highlight the promise of HPV WGS liquid biopsy for screening and early detection of HPV + HNSCC and the need for modeling and cost-effectiveness studies to evaluate and guide screening implementation.

Background: Early detection of HPV-associated oropharyngeal squamous cell carcinoma, the most common HPV cancer in the United States, could reduce disease-related morbidity and mortality, yet currently, there are no early detection tests. HPV circulating tumor DNA (ctDNA) is a sensitive and specific biomarker for HPV–associated oropharyngeal squamous cell carcinoma at diagnosis. It is unknown if ctDNA HPV is detectable prior to diagnosis, and thus its potential as an early detection test is also unknown. Methods: Plasma samples from the Mass General Brigham Biobank collected 1.3-10.8 years prior to diagnosis from HPV–associated oropharyngeal squamous cell carcinoma patients (n = 28) and age- and sex-matched controls (n = 28) were blinded and run on a newly developed and validated multifeature HPV whole genome sequencing liquid biopsy assay and a validated HPV antibody assay. Results: HPV ctDNA results were positive in 22 of 28 prediagnostic samples from HPV–associated oropharyngeal squamous cell carcinoma cases (sensitivity 79%) with a maximum lead time of 7.8 years. HPV ctDNA results were negative in all controls (0 of 28, 100% specificity). Diagnostic accuracy was highest within 4 years of cancer diagnosis and was higher than HPV Ab detection within the same timeframe (P = .004). Application of a machine-learning model trained and tested on an independent cohort of 306 cases and controls increased the sensitivity of detection to 27 of 28 cases (overall sensitivity 96%) and the maximum lead time to 10.3 years. Conclusions: HPV ctDNA can be detected in the blood years prior to diagnosis with HPV–associated oropharyngeal squamous cell carcinoma, with high specificity, in a case-control cohort of 56 participants. HPV ctDNA detection alone, or in combination with previously identified serological biomarkers, may be a feasible approach to early detection of HPV–associated oropharyngeal squamous cell carcinoma.

Surgery is a standard treatment for early-stage human papillomavirus–associated head and neck cancer (HPV+HNC), yet adjuvant therapy decisions rely on clinicopathologic features with limited prognostic accuracy. Circulating tumor HPV DNA is a promising biomarker, but current assays lack the sensitivity needed for detecting minimal residual disease after surgery. This study evaluated the prognostic value of an HPV whole-genome sequencing assay, HPV-DeepSeek, and compared this with existing methods and clinical standards. One hundred three patients with stage I to IV HPV+HNC treated with surgery were prospectively enrolled (NCT06730412). Blood samples were collected before surgery, postoperatively, and during surveillance and were analyzed using HPV-DeepSeek and droplet digital polymerase chain reaction (PCR) assays. After a median follow-up of 27 months, patients with circulating tumor HPV DNA detected after surgery had worse 2-year disease-free and overall survival than those without detection. Detection after completion of all treatment was also associated with poorer outcomes. Minimal residual disease status was a stronger predictor of recurrence than standard clinicopathologic criteria. Molecular recurrence was identified up to 17.5 months earlier than clinical recurrence and nearly twice as early as with droplet digital PCR. These findings demonstrate that sensitive HPV whole-genome sequencing enables accurate detection of minimal residual disease, early identification of recurrence, and improved postoperative risk stratification, supporting its potential as a tool for guiding personalized adjuvant therapy in HPV+HNC.

Legislative moves to legalise assisted dying in the UK have renewed discussion on future clinicians’ preparedness for new potential responsibilities. This study examined medical students’ ethical attitudes, legal understanding and curricular exposure. VOICE was a national cross-sectional survey of UK and Ireland medical students in 2025 (n = 896). The questionnaire assessed ethical views, confidence, legal knowledge and teaching exposure. Descriptive statistics, thematic analysis and multivariable logistic regression explored predictors of ethical agreement, curriculum coverage and legal knowledge. Most students (64.5%) believed that assisted dying can be ethically justified, yet legal knowledge was limited; only 7.6% correctly identified all eligibility criteria. Nearly 70% reported minimal curricular coverage. Formal teaching was associated with higher confidence and greater ethical agreement. Regional variation and concerns about coercion and inequalities were common. Students show broad ethical support but have very limited confidence, legal understanding and curricular preparation, highlighting the need for structured education.

Purpose:The incidence of human papillomavirus (HPV)–associated head and neck squamous cell carcinoma (HPV + HNSCC) is increasing in the United States. Currently, there are no early detection approaches for HPV + HNSCC. Two blood-based analytes for early detection and diagnosis of HPV + HNSCC, circulating tumor HPV DNA (ctHPVDNA) and HPV early protein antibodies (HPV Ab), show promise, yet current approaches lack adequate diagnostic accuracy for broad clinical utility. Further, performance metrics across various assays for detecting these analytes alone or in combination have not been compared head-to-head. To address these limitations and knowledge gaps, we developed a multifeature HPV whole-genome sequencing (WGS) liquid biopsy for improved low-level ctHPVDNA detection. We defined the performance characteristics of this WGS-based approach and compared it head-to-head with existing blood-based HPV detection approaches to determine the optimal single or combinatorial biomarker strategy for a future prospective study of HPV + HNSCC early detection.Experimental Design:We tested blood samples from 304 participants: 152 patients with untreated incident HPV + HNSCC (77% stage I) and 152 general population control patients. We compared WGS-based ctHPVDNA detection, single-plex Droplet Digital PCR (ddPCR)–based ctHPVDNA detection, multiplex ddPCR-based ctHPVDNA detection, multiplex HPV Ab detection, and clinical standard-of-care tissue biopsy, benchmarked to gold-standard HPV + HNSCC tissue diagnosis. We then modeled the operational feasibility of these approaches as screening biomarkers for HPV + HNSCC.Results:HPV WGS sensitivity and specificity were 98.7% and 98.7%, respectively. Single-plex ddPCR sensitivity and specificity were 94.2% and 98.6%, respectively. Multiplex ddPCR sensitivity and specificity were 90.6% and 96.3%, respectively. HPV Ab sensitivity and specificity were 86.4% and 96.3%, respectively. A combinatorial approach using both HPV WGS and HPV Ab yielded a sensitivity and specificity of 87.4% and 98.8%, respectively. In a head-to-head comparison, HPV WGS demonstrated significantly improved diagnostic accuracy compared with ddPCR (Youden index for HPV WGS, 0.99 vs. ddPCR, 0.90; P < 0.001), HPV Ab (HPV WGS, 0.99 vs. HPV Ab, 0.83; P < 0.001), and clinical workup (HPV WGS, 0.99 vs. clinical workup, 0.82; P < 0.001), which was maintained when evaluating only early-stage disease cases. For men ages 55 to 74, HPV WGS yielded the lowest number needed to screen (2,903 men) and the highest positive predictive value (2.6).Conclusions:HPV WGS–based ctHPVDNA detection demonstrated the highest sensitivity, specificity, and diagnostic accuracy and thus the lowest number needed to screen and highest positive predictive value compared with ddPCR-based ctHPVDNA detection, HPV Ab–based detection, and combinatorial approaches. These results highlight the promise of HPV WGS liquid biopsy for screening and early detection of HPV + HNSCC and the need for modeling and cost-effectiveness studies to evaluate and guide screening implementation.See related commentary by Haring et al., p. 3359See related article by Sim et al., p. 3494

Sinonasal squamous cell carcinoma (SNSCC) is an aggressive head and neck cancer of the sinonasal cavity which has not benefitted from therapeutic advances over decades ¹ . Though historically attributed to inhaled carcinogens such as hardwood dust and tobacco smoking ² , SNSCC is incidentally associated with human papillomavirus (HPV) ^3,4 . Importantly, HPV is the primary oncogenic driver of >80% of anatomically adjacent oropharyngeal cancers ⁵ . While viral status drives clinical staging and treatment guidelines in these malignancies ^6,7 , the potentially oncogenic consequences and prognostic value of host–virus interactions in SNSCC remain incompletely defined. Here, through paired host and viral whole-genome sequencing (WGS), we map the genomic footprint of HPV in SNSCC. Strikingly, lesser studied strains such as HPV45, 51, and 39 constitute driver infections in this rare but clinically credentialed cancer, where extrachromosomal DNA (ecDNA)-associated viral integration and APOBEC mutagenesis are shown to underpin somatic tumor evolution. Statement of Significance: Paired host viral and whole-genome sequencing of SNSCC nominates HPV as a primary oncogenic driver of SNSCC. HPV–human ecDNA amplicons harboring noncanonical strains such as HPV45, 51 mediate viral carcinogenesis. Routine clinical diagnostic HPV panels should be expanded to capture the activity of lesser studied strains.