Association of Unsafe Sexual Behavior with Head and Neck Cancer: A Bibliometric Analysis

Abstract

Inappropriate sexual practice like oral sex has been linked with head and neck cancer (HNC). The recent data revealed that about 20% oropharyngeal caner among Indians are associated with oral sex. Thus, we aimed to comprehensively assess the trend of research in oral sex associated with HNC and to predict the research frontiers and potential hotspots in the near future. The publications related to oral sex and HNC were retrieved from Scopus database via systematic search strategy (till 15th July 2023). VOSviewer version 1.6.19 and Biblioshiny software were used to identify the trends and research hotspots. A total of 2,179 original articles has been identified of which United States had the highest number of articles (837) followed by United Kingdom (155) and India (140). The number of articles in the area of oral sex and HNC has been increased significantly over decades (highest in 2022: 169 articles) which suggests the trend of the research. Most of the studies were from the National Cancer Institute and most of the studies were published in oral oncology journal (76) along with the 3231 citations. HNC, Human papilloma virus (HPV), oropharyngeal cancer and oral cancer are the enriched keywords which suggests that the individual practicing oral sex are prone to HPV infection which results into HNC. HPV infection mediated via oral sex might be the reason behind the surge of HNC which needs to be addressed via spreading awareness, proper counseling and integrating sex education in study curriculum.

Introduction

Head and neck cancer (HNC) is a type of epithelial cancer that affects the upper common respiratory/digestive tract (lips, oral cavity, oropharynx, nasal cavity, nasopharynx, hypopharynx, and larynx), the salivary glands, and lymphadenopathy affecting the physical structures required for normal functioning like phonetics, mastication, and deglutition [1–3]. It is the sixth most common malignancy worldwide, with 2,140,131 new cases and 1,555,277 deaths [4]. According to GLOBOCAN 2020, India accounts for 359,629 new cases of HNC and 200,846 deaths [5]. In the past decade, there has been many advances in the treatment modalities which are based on location of the Tumor, node and metastasis status. Generally, patients in early stages are treated with single modality, it may be surgery or radiotherapy and in the advance stages a multimodal approach is implied which includes surgery, radiotherapy and chemotherapy [6]. Despite, these advances in the treatment of HNC patients the 5-year survival rate is found to be 68.5% (2013–2019) [7]. There are various risk factors such as tobacco, alcohol, betel nut chewing, and infection with viral agents such as Human papillomavirus (HPV), and Epstein-bar virus. Apart from these, a few nonspecific risk factors for head and neck cancer have been associated with poor dental hygiene, cigar and pipe smoking, and occupational hazards such as working in the nickel industry [1, 8]. The International Head and Neck Cancer Epidemiology Consortium concluded that cigarette use alone caused 33% of HNC, compared to only 4% when only alcohol was present. Tobacco and alcohol were responsible for 35% of HNC cases [9]. However, a recent survey by Global Adult Tobacco Survey-India GATS-India (2016-17) has shown a 4.5% decline in tobacco consumption, which was majorly seen in 15–24 age group [10]. Despite the decline in smoking trends the prevalence of head and neck cancer still remains to increase every year, previous reports have drawn a strong association between HPV infection and HNC cases [11]. Therefore, increasing incidence of HNC particularly oropharyngeal cancer can be attributed to HPV Infection. HPV is an epitheliotropic virus that can infect the skin and mucous membranes and is commonly transmitted sexually and spreads by close skin-to-skin and mucosal contact [12, 13]. The most predominant HPV type is HPV16, which accounts for 90% of HPV DNA-positive HNSCCs [14]. Oral sex has frequently been identified as a risk factor for oral HPV infections [15]. It refers to sexual activity that involves genital stimulation through the mouth, tongue, teeth, or throat. Individuals who have a history of oral intercourse, multiple partners, and oral HPV 16 infection are more likely to be diagnosed with cancer [16]. Deep kissing and orogenital intercourse have been linked to HPV 16 transmission in HCN. The increased popularity of oral sex and the use of condoms on occasion during fellatio may be linked to HPV infection and other sexually transmitted illnesses [17].

India is the most populous country in the world ranking number 1 in the list of countries by population with an estimated population of 1,428,627,663. The rise in the overall Indian population is driven by its young population [18]. In 2020, 70% of the population was between the age group of 15 and 64 years old. India has the most millennials and Gen Zs in the world, with over 600 million people between the ages of 18 and 35 [19]. Adolescent sexual and reproductive health in India is among the poorest in the world [20]. In Indian Society, public discussion of sex related topics is considered as taboo. Sex education is still not part of the curriculum in Indian schools, and children and adolescents still have no education or information [21]. Healthcare workers often have little expertise themselves, which has an impact on passing knowledge to the adolescent population who seeks it. India has one of highest rate of sexually transmitted disease and low rates of STD prevention due to less use of contraception [22]. The Human papillomavirus (HPV), which spreads due to oral sex is linked to every fifth case of oropharyngeal cancer in India and about 20% of oropharyngeal cancer cases in India are linked to oral sex [23]. India appears to be the world’s biggest consumer of porn ranking third, with a 95% increase in traffic to pornographic websites [24]. Excessive pornographic viewing has a negative impact on one’s life. It modifies the brain in ways similar to the neurological changes seen in cocaine, alcohol, and methamphetamine addicts. In the aftermath, there is also an increase in sadness, anxiety, self-esteem, anger, and violence against women [25, 26]. India has played an important part in the history of sex, writing the first literature that addressed sexual intercourse as a science. Between the first and sixth centuries, the ancient ‘Kamasutra’ (Aphorisms of love) was written, which comprised of ‘Dharma,’ ‘Arth,’ and ‘Kama’. They symbolized religious duty, the wellbeing of the world, and aspects of life which are sensual. Ajanta cave paintings and Khajuraho statues are only a few instances of Indians’ strong fascination and admiration for sexuality. Ironically, the land of Vatsyayana’s Kamasutra where sexuality was articulated through sculptures of everyday life artistically, is still far behind in providing proper sex education [27].

Herein, we carried out bibliometric analysis to answer the following research questions:

1)What does the published literature reveal about the current worldwide trends in HNC and oral sex research and development?

2) Which countries or regions, institutions, and authors stand out as the most prolific and influential contributors in this particular field of study?

3)Which journals are considered the most popular journals for publishing documents related to HNC and oral sex?

4) What are the primary areas of research focus and current hotspots in this field, and how have they evolved and shifted over time?

5) What Are the Most Concerned Research Frontiers and Potential Hotspots in the Near Future?

Bibliometric analysis is a research method that involves quantitatively analyzing scholarly publications to understand patterns, trends, and connections within the field of study. This approach utilizes various types of analysis, such as bibliographic coupling and co-occurrence, to examine the relationships between authors, co-authors, keywords, institutions, journals, and countries (Fig. 1).

Fig. 1.

Snapshot on bibliometrics

Materials and Methods

Data Sources and Search Strategies

The Scopus database was used for performing the bibliometric analysis and about 2179 articles were found fit for the search strategy applied. Search strategy included “Head and Neck Neoplasms” OR “Mouth Neoplasms” OR “Oropharyngeal Neoplasms” OR “Pharyngeal Neoplasms” OR “Tonsillar Neoplasms” OR “Tongue Neoplasms” OR “Gingival Neoplasms” OR “Lip Neoplasms” OR “palatal neoplasms” OR “oral cancer” OR “Oral squamous cell carcinoma” AND “sexual behavior” OR “sexual partners” OR “sexuality” OR “sexually transmitted diseases” OR “sexual harassment” OR “sex workers” OR “homosexuality” OR “heterosexuality” OR “sexual practices” OR “sexual activity” OR “oral-genital contact” OR “oral sex” OR “cunnilingus” OR “cunnilinctus” OR “analingus” OR “anilingus” OR “fellatio” OR “fellation” without restricting to time range except for retrieval deadline of 15th July 2023 in order to avoid potential bias from frequently updated databases and only included English original articles.

Bibliometrics and Visualization Analysis

To conduct the bibliometric analysis, we utilized VOSviewer (1.6.19), a software tool that identifies and visualizes collaboration networks between authors, co-authors, keywords, institutions, journals, and countries [28]. The data used for analysis were obtained from Scopus and downloaded in CSV format. Different types of analysis and visualizations were performed based on the specific requirements of the study. Some of the visualizations including network maps of country region output, institutions, and journals were performed using bibliographic coupling analysis. Additionally, co-occurrence analysis was used to generate network, density, and overlay visualizations of keywords. We used the Biblioshiny software, which is specifically designed for analyzing scholarly publications and thoroughly investigates the data such as author production over time, institutions, and co-cited references [29].

Results

Data Collection

The findings of the bibliometric analysis revealed that the United States had the highest number of original articles in the respective field, with 837 documents. It was also observed that India had a substantial number of studies in this field, ranking among the top three countries. The significant increase in the number of published articles occurred in 2022, with a total of 169 articles, and as of the mentioned date in 2023, there have been 73 articles published (Fig. 2). D’souza G. and Fakhry C. are the authors who published the most documents (45 and 30, respectively), raised awareness, and disseminated knowledge in this field (Fig. 3).

Fig. 2.

Number of published articles by year

Fig. 3.

Most relevant authors based on the number of documents

Analysis of Country and Region Output

In the field of oral sex and HNC, a total of 89 countries have made contributions. The United States stands out as a prominent presence in the scientific community, having produced the highest number of publications, totaling 837, and establishing significant collaborative connections (Fig. 4). Following closely is the United Kingdom, with 155 documents and 38 citations, while India follows with 140 documents and 449 citations. Germany, with 136 documents, and China with 133, also hold significant positions among the top contributors. These three countries Germany, China, and India make up the top tier in terms of research output.

Fig. 4.

Analysis of country and region output based on number of articles published

The link between countries, such as Germany and China, signify collaborations where these nations have jointly authored publications (as indicated by bibliographic coupling links). The strength of these links reflects the extent of their collaboration, with stronger links suggesting more collaborative efforts. Table 1. clearly illustrates that the United States has the most extensive collaborative network with other countries in this research field. The data in Table 1 represents, top 10 countries and their respective contributions to the research landscape.

Table 1.

Top 10 countries publishing research articles on HNC and oral sex

S. No	Countries	Documents	Citations	Link strength
1	United states	837	810	117,507
2	United Kingdom	155	38	31,817
3	India	140	449	14,906
4	Germany	136	530	38,135
5	China	133	835	15,822
6	Italy	129	1	29,515
7	France	120	5	38,608
8	Brazil	114	46	22,037
9	Australia	90	11	18,492
10	Canada	89	7	15,783

Analysis of Institutions that Publish Clinical Research Papers on HNC and Oral Sex

Among the 8483 organizations analyzed, approximately 1000 of them exhibited the most significant linkages, as depicted in Fig. 5. This analysis was conducted based on the number of documents published by each institution. Notably, the National Cancer Institute is among the top 10 institutions (Fig. 6) having contributed 173 documents. Following closely is Johns Hopkins University with 156 publications. It’s important to mention that VOSviewer specifically visualized the strongest linkages out of the 8483 organizations, with 1000 organizations meeting the established threshold for inclusion in this visualization.

Fig. 5.

Most relevant affiliations based on the number of articles published

Fig. 6.

Network of institutions involved in HNC and oral sex research

Analysis of Academic Journals

Among the 898 academic journals that have made significant contributions by publishing relevant articles, the top ten journals have played a crucial role in advancing knowledge and understanding in this field.

Leading the way is “Oral Oncology” with an impressive 76 published documents and 3231 citations. “PLOS ONE” has also made a significant impact, presented 61 documents and received 1781 citations. “The International Journal of Cancer” closely follows with 55 published documents and a remarkable 6456 citations. “Head and Neck” is also notable, with 49 published documents and 1505 citations (Fig. 7). It’s noteworthy that the majority of these top 10 journals are from the United States, with England being the next most prominent source.

Fig. 7.

Network of journals involved in HNC and oral sex research

Bibliometric analysis frequently serves as a valuable guide for selecting journals to publish in. Among the 2179 articles published, they span across 898 different academic journals. Information regarding the journals with the highest number of published articles (top 10) and their respective Impact Factors (IFs) are presented in Table 2.

Table 2.

Top 10 journals based on number of publications and citations

S. No	Journal	Documents	Country	IF (2022)	Quartiles	Citations
1	Oral oncology	76	England	5.97	Q1	3231
2	Plos one	61	United states	3.7	Q1	1781
3	International journal of cancer	55	United states	6.4	Q1	6456
4	Head and neck	49	England	2.9	Q1	1505
5	Cancers	36	Switzerland	6.5	Q1	2727
6	Oral diseases	28	Denmark	3.8	Q1	726
7	The laryngoscope	27	United states	2.6	Q1	1197
8	Asian pacific journal of cancer prevention	26	Thailand	2.52 (2014)	Q2	386
9	sexually transmitted diseases	25	Australia	3.1	Q2	1014
10	cancer epidemiology biomarkers and prevention	23	United states	4.344	Q1	1663

Analysis of Co Cited References (Co-Citation)

In the realm of research on HNC and oral sex, a total of 84,108 cited references have been identified. Among these, VOSviewer has visualized the reference with the highest link strength, which happens to be reference number 897.

The most frequently cited article in this area of research is “D’Souza G., Kreimer A.R., Viscidi R., et al., Case-control study of human papillomavirus and oropharyngeal cancer, N Engl J Med, 356, pp. 1944–1956, (2007)”. This pivotal article was authored by D’Souza and published in the New England Journal of Medicine. It has been cited an impressive 94 times, underscoring its significant influence in the field.

The literature with a total co-citation number of more than 90 (n = 4) was published in the New England Journal of Medicine, Cancer Epidemiology Biomarkers and Prevention, Journal of Clinical Oncology, and Journal of National Cancer Institute (Table 3).

Table 3.

Frequently cited references in HNC and oral sex

Cited references	Citations
D’souza g., kreimer a.r., viscidi r., et al., case-control study of human papillomavirus and oropharyngeal cancer, n engl j med, 356, pp. 1944–1956, (2007)	94
Kreimer a.r., clifford g.m., boyle p., franceschi s., human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review, cancer epidemiol biomarkers prev, 14, pp. 467–475, (2005)	93
Chaturvedi a.k., engels e.a., pfeiffer r.m., et al., human papillomavirus and rising oropharyngeal cancer incidence in the United States, j clin oncol, 29, pp. 4294–4301, (2011)	90
Gillison m.l., koch w.m., capone r.b., et al., evidence for a causal association between human papillomavirus and a subset of head and neck cancers, j natl cancer inst, 92, pp. 709–720, (2000)	90
Ang k.k., harris j., wheeler r., et al., human papillomavirus and survival of patients with oropharyngeal cancer, n engl j med, 363, pp. 24–35, (2010)	79
D’souza g., agrawal y., halpern j., bodison s., gillison m.l., oral sexual behaviors associated with prevalent oral human papillomavirus infection, j infect dis, 199, pp. 1263–1269, (2009)	75
Gillison m.l., d’souza g., westra w., et al., distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers, j natl cancer inst, 100, pp. 407–420, (2008)	65
Chaturvedi a.k., engels e.a., anderson w.f., gillison m.l., incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States, j clin oncol, 26, pp. 612–619, (2008)	63
Herrero r., castellsague x., pawlita m., et al., human papillomavirus and oral cancer: the international agency for research on cancer multicenter study, j natl cancer inst, 95, pp. 1772–1783, (2003)	60
Fakhry c., westra w.h., li s., et al., improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial, j natl cancer inst, 100, pp. 261–269, (2008)	57

VOSviewer has proven to be a valuable tool for visualizing collaborations and has depicted various clusters in Fig. 8. These clusters signify groups of researchers or institutions that have worked in similar areas or shared similar research ideas, further contributing to the advancement of knowledge in the field of HNC and oral sex.

Fig. 8.

Network Analysis of co-cited references

Authors Production over Time

The most active authors in the last two years have been Dsouza G and Fakhry C with the main areas of concentration in HNC and oral sex. Figure 9 clearly portrayed the number of articles and total citations per year of an author. The most cited sources were Gillison ML, Dsouza G, Chaturvedi A K. with 1298, 888, 825 local citations respectively (Fig. 10). With three field plot (Fig. 11) illustration which involves the parameters like cited source (left field), authors (middle field) and keywords (right field), each outflow from left field is the cited sources by the authors in the middle field and keywords used frequently by the authors in the right field. Table 4 shows the highest sources cited by the authors in the middle field. D’Souza G, Fakhry C, Gillison ML, and Kreimer AR are widely acknowledged as eminent figures in this field, recognized for their substantial contributions.

Fig. 9.

Authors production overtime based on number of articles and total citations

Fig. 10.

Most local cited sources according to number of citations

Fig. 11.

Three field plot for cited source(left field), authors(middle field) and keywords(right field)

Table 4.

Authors based on highest publication and cited sources by them

Authors	Highest cited sources	Numbers
Dsouza G	Dsouza G	70
Fakhry C	Dsouza G	63
Gillison ML	Gillison ML	63
Eisele DW	Fakhry C	43
Sturgis EM	Gillison ML	30
Pawlita M	Kreimer A R	28
Franchesi S	Gillison ML	17
Waterboer T	Kreimer A R	27
Kreimer A R	Kreimer A R	28
Westra W H	Gillison ML	30

High Frequency Keywords Analysis

Keywords are the core of the article. Through the analysis of the article’s keywords, we can peep into the theme of the article. By analyzing keywords, hotspots in specific research fields can be found. The VOSviewer is used to see the network of keywords, as illustrated in Fig. 12 four study directions are indicated by the clustering of blue, orange, yellow and purple. Orange Cluster: This cluster likely centers around research related to the HPV and its association with squamous cell carcinoma, specifically p16-positive cases. The inclusion of terms like HNSCC (Head and Neck Squamous Cell Carcinoma), oral cancer, and HIV suggests a focus on HPV’s impact on oral health and its connection to immune health. Blue Cluster: The terms in the blue cluster seem to converge on topics related to the psychological and social aspects of patients with head and neck cancer. This might include examining the impact of cancer on quality of life, sexuality, intimacy, and body image. Additionally, the terms nursing and breast cancer could hint at studies exploring the support and care for patients during their cancer journey. Purple Cluster: This cluster could revolve around studies investigating the role of alcohol consumption and its potential link to pharyngeal neoplasms, especially concerning the biomarker HPV 16. The case-control study approach may be explored to understand the relationship between these factors. Yellow Cluster: The yellow cluster seems to encompass research focusing on awareness and knowledge related to the HPV vaccine, particularly among adolescents. This could involve studies aiming to improve understanding and uptake of the vaccine for preventive purposes. As illustrated in Fig. 13, the VOSviewer displays that purple signifies a very early appearance of the word, while yellow indicates a more recent appearance, depending on the period in which each word appears. Figure 14 also illustrates the annual frequency of keyword appearances. In Fig. 15, the VOSviewer colors all keywords according to their average number of occurrences. For instance, awareness, knowledge, HPV vaccine, adolescents, oral sex are often used as key terms, which shows the shift in focus and direction of future research to some extent.

Fig. 12.

Bibliometric analysis of keywords in research papers in HNC and oral sex

Fig. 13.

Pattern of keywords according to years

Fig. 14.

Most frequently used keywords from 1971–2023

Fig. 15.

Overlay density map based on keywords

Discussion

General Information

This study involves analyzing trends and the prevalence of HNC in relation to oral sex. We used VOSviewer (version 1.6.19) to perform a bibliometric analysis and looked at the records from Scopus database. The results are represented as tables and network diagrams.

Out of the 2,179 articles in English, we found contributions from 898 different journals, 157 affiliations, and 122 countries. The United States had the highest number of articles published in this field. When it comes to the number of publications, institutions with strong scientific research focus primarily on higher education research institutes, which plays a key role in medical research and education. The various departments of John Hopkins University contributed the most articles in this field. The links between institutions in our analysis represent collaborations among them. The higher the value of the link, the stronger the collaboration between the institutions. As per our analysis encompassing the foremost journals within the domain (ranked 1–10), it becomes apparent that researchers predominantly direct their efforts towards the realm of oral oncology, as indicated by the noteworthy impact factor of 5. This proclivity towards such journals supersedes their preference for journals specifically focused on sexually transmitted diseases.

Delving into the distribution of contributions, the spotlight falls on the top three nations driving advancements in HNC research in conjunction with oral sex. These countries, namely the United States, United Kingdom, and India, consistently emerge as the primary sources of noteworthy research output.

Frontiers and Hotspots

The current analysis conducted using VOSviewer has cast a spotlight on the conspicuous appearance of specific terms such as “human papilloma virus” and “head and neck cancer” in the landscape of scholarly literature. Notably, the prevalence of head and neck cancers, particularly in regions undergoing developmental transitions like Southeast Asia, has garnered significant attention due to its intricate association with habitual tobacco smoking and the consumption of alcoholic beverages [30, 31]. It’s worth noting that the patterns of tobacco usage between genders and across nations showcase variations, with a remarkable finding that about 40% of female patients are devoid of any tobacco addiction and exhibit a markedly higher statistical prevalence of oropharyngeal cancer when contrasted with their male counterparts [32, 33].

Recent scientific investigations have unfurled compelling evidence establishing a robust link between specific strains of HPV infection and the escalating incidence of head and neck squamous cell carcinomas (HNSCC), notably accentuated within the oropharyngeal subsite. Concurrently, the number of sexual partners a person accumulates over their lifetime has surfaced as a pivotal factor correlated with an augmented risk of cancer development [34]. Notably, the limelight fell upon the potential role of HPV infection in oropharyngeal cancer via oral sexual practices, following a widely publicized incident involving an American actor who initially attributed his throat cancer to oral sex, later retracting the statement [35]. Despite initial skepticism, the recognition of oral sex as a potential vector for HPV transmission has gained momentum, signifying an essential advancement in the discourse [36–38]. This is particularly relevant given the prevailing lack of awareness, with less than one-third of sexually active individuals infected with the virus being familiar with it. The latest data from the World Cancer Report underscore this point by attributing 30.8% of oropharyngeal cancers to HPV infection, in stark contrast to mere 2.2% and 2.4% for oral cavity and laryngeal cancers, respectively [39]. Consequently, HPV infection emerges as a plausible etiological agent, especially in non-tobacco users. Additionally, various other factors, including subpar oral hygiene, lichen planus, iron-deficiency anemia, inadequate dietary habits, gastrointestinal reflux, and genetic predisposition, collectively contribute to the onset of HNC, particularly within the non-tobacco user cohort [40].

Media reports, such as those from the Times of India, have drawn attention to a surge in throat cancer cases in Western nations over the past two decades, with some terming it an “epidemic”. This phenomenon has largely been attributed to heightened awareness and reporting, a facet that could play a pivotal role in curbing HNC cases related to oral sex [41].

Within the methodology of the bibliometric study, a selection of the top 10 co-referenced references has been employed, signifying pivotal research touchpoints within the field. For instance, D’Souza et al., established a correlation between sexual behaviors, oropharyngeal cancer, and HPV-16-positive HNSCC, with a particularly intensified link within the HPV-16–positive tumor subset [42]. In another study, Kreimer et al., identified HPV16 as the dominant strain in oropharyngeal cancers, highlighting potential virus-tissue interactions [43].

The evolution of research keywords provides an insightful glimpse into the evolving landscape, where terms such as “oral sex,” “oral rinse,” “awareness,” “knowledge,” and “HPV vaccine” have not only gained traction but have also become integral to ongoing discussions [13, 36, 44]. In parallel, the continued prevalence of keywords like “head and neck cancer,” “oral cancer,” and “human papilloma virus” underscores their critical roles within this discourse.

However, it is important to acknowledge the limitations of this study. The data collection was confined to a single source, Scopus, which might result in the omission of relevant publications from other platforms. Additionally, the study exclusively considered English-language papers, potentially introducing source bias. It is noteworthy that employing advanced visualization tools like Citespace could have further enriched the analytical process.

With this study being the pioneering bibliometric analysis of the intricate interplay between HNC and oral sex, the observed exponential growth in publications speaks volumes about the burgeoning global interest in this intersection. Notably, the United States has emerged as a vanguard, contributing significantly to the advancement of this field by publishing seminal articles of high quality and impact. Moreover, international collaborations between diverse countries and institutions have fostered a climate of collective progress. Presently, the focal points of attention encompass educational initiatives and heightened awareness campaigns surrounding oral sex and its implications. Summarily, the domain of HNC research at the nexus of oral sex exhibits promising trajectories, both in terms of fundamental research and its translation into clinical practice.

Conclusion

HPV infection mediated via oral sex might be the reason behind the surge of HNC primarily among the sexually active population. The research in this field has been found to be trending over decades. However, lack of awareness regarding safe sexual practices and sex education is the key element in the surge of HNC mostly in middle income countries like India. The important domains of high-quality healthcare are accessibility, affordability, timely, efficient and respect towards own socio-cultural context. Policy makers can take small steps and introduce safe sexual practices by integrating sex education at an early age itself.

Author Contributions

Conceptualization: [Raushan Kumar Chaudhary, Pukar Khanal], Literature search: [Burnis Raju, Prakash Patil, Deepthi Avvaru], Literature Review: [Burnis Raju, Deepthi Avvaru, Vijith Shetty], Writing original draft: [Raushan Kumar Chaudhary, Burnis Raju, Revathi Raghunath Peecee, Pukar Khanal], Supervision: [Uday Venkat Mateti, Prakash Patil]. Raushan Kumar Chaudhary holds the final responsibility of the manuscript.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Declarations

Ethical Approval

Not Applicable.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.