In July 2014, Phil Rech, then 59, was diagnosed with tonsil cancer.
"I had got a lump in my neck. I had the tonsils out, and within the next few days, I was having radical neck dissection," he said. "Then I had six weeks of intensive, targeted radiotherapy. The burning effect towards the end of the treatment became very painful."
High-risk types of HPV can develop into things like genital warts and cancer
Girls in the UK are routinely offered the vaccine, but experts have debated whether boys need it
The therapy involved a radiotherapy mask, molded to the shape of his face, that went over his head as radiotherapy was beamed in, targeting the cancer.
The discovery of his cancer not only startled him, it startled everyone who knew him.
Phil is my dad, and to our family, he had always been healthy: He doesn't smoke, he rarely drinks alcohol, and he generally stays fairly fit.
But that's not how cancer works.
At the time of the diagnosis, Phil didn't question how or what could have caused his cancer, as he focused on getting better.
Like many men in the UK and around the world, he wasn't aware of a group of viruses that were a threat, human papillomavirus or HPV, which were eventually connected to his cancer.
"To discover it was linked to HPV was a massive shock," he said. "There was a lot of speculation over what could have caused it. To discover it was that, was certainly a surprise. I didn't really know it was a threat to me."
A cancerous virus
HPV is a group of 150 related viruses that can be transmitted through any form of sexual contact, whether kissing or intercourse. In most cases, the human body will get rid of it naturally, but certain high-risk types can develop into things like genital warts and cancers, including cervical, anal and throat.
But there is a vaccine, and how it works is pretty simple. It's a mimic of the virus particle; when administered into someone's muscle, it creates many more antibodies than a natural infection would, according to John Doorbar, professor of viral pathogenesis at Cambridge University.
According to the US Centers for Disease Control and Prevention, "almost every person who is sexually active will get HPV at some time in their life if they don't get the HPV vaccine."
The vaccine needs to be given before a person is exposed to HPV. Its effectiveness in terms of preventing infections is well-known -- 100% in some studies -- but who gets it is a question of debate around the globe, particularly in the UK.
In the UK, girls ages 12 to 13 are routinely offered the first HPV vaccination. They can get the vaccine for free via the National Health Service from ages 12 to 18. This is encouraged to help combat cervical cancer, which a recent report suggests it has done globally.
In England, between 2010 and 2016, infections with HPV 16 and 18 (two types of the virus responsible for most cervical cancer cases) fell 86% among women 16 to 21 who were eligible for the vaccine during this period, Public Health England found.
But what about men?
Until now, some experts in the UK have argued that men would ultimately be protected against the virus through "herd immunity": As long as girls are well-protected, the male population should be shielded, too.
But according to the Royal Society of Public Health, which supports providing the vaccine to boys, uptake of the vaccine for girls is insufficiently high to ensure herd immunity in several areas of the UK. Men are still at risk of acquiring HPV from sexual contact with women from countries without a vaccination program, the society said.
In April, NHS England and Public Health England, on recommendation from the UK's Joint Committee on Vaccination and Immunisation, decided to introduce the vaccine to men 45 or younger who have sex with other men, often called MSM, after concluding that this group does not benefit from herd immunity.
Historically, heterosexual men and young boys have not been offered it through the NHS but can pay to receive it privately. Pharmacies including Boots, Lloyds and Superdrug in the UK charge about 150 pounds ($196) per dose, with people typically needing two or three doses.
But on Tuesday, the government announced that boys between 12 and 13 in England will be given a vaccine to protect them against HPV-related cancers, according to Public Health Minister Steve Brine. It came just a week after the vaccination committee recommended extending the HPV immunization program to boys after it reviewed the evidence for vaccinating boys since 2013. A recommendation last year concluded it was still not cost-effective to vaccinate this group, but experts and campaigners appealed for the committee to look again -- and their stance changed.
"It is clear that a programme to vaccinate adolescent males would provide those vaccinated with direct protection against HPV infection, and associated disease including anogenital warts, anal, penile and oropharyngeal cancers," the statement says. The committee confirmed that evidence has strengthened on the association of HPV with non-cervical cancers, which affect men as well as women, and that vaccination is efficacious in preventing these other HPV-related cancers.
In response to the recommendation, the same day, the Scottish government announced that it would implement a vaccination program to boys as soon as it practically could, Public Health Minister Joe FitzPatrick said. Wales also opted to roll out the vaccine to boys.
There is some disparity over the number of other countries vaccinating boys against HPV. Shirley Cramer, chief executive of the Royal Society of Public Health, said 20 countries vaccinate boys, while the HPV Action partnership says that about 15 roll it out to boys as well as girls.
The vaccine has been approved for males in the United States for almost 10 years. Italy and Australia are also pioneering gender-neutral vaccination plans.
Lagging behind and increasing rates
In 2017, after being in remission for three years, Phil's cancer surfaced again -- this time, in the brain and the lungs.
"I started to feel some funny fluttery feelings in my chest," he said. "It was only my oncologist, who revealed to me that I had six small lesions on my lungs. An MRI scan also showed three on my brain.
"That's the nature of cancer. It's a crafty disease," he said.
A 2017 study found that one in nine American men is infected with the oral form of HPV. Nationwide, rates for oral HPV infections are 11.5% of men and 3.2% of women: 11 million men, compared with 3.2 million women, the researchers estimated.
Among HPV-related cancers, a type of head and neck cancer called oropharyngeal squamous cell carcinoma was far more likely to strike men in the US, the same study found, with its incidence surpassing cervical cancer among women. Men who have had multiple sex partners, men who reported having sex with men and men with genital HPV infections were found to have the highest rates of oral HPV.
But in the UK, the discussion around vaccinating boys has been ongoing. In less than 10 years, admissions for primary cancerous tumors of the head and neck increased by almost 10,000, according to the NHS, from 29,198 in 2008-09 to 37,417 in 2016-17.
A recent review by the nonprofit medical research group Cochrane acknowledged that HPV was not only linked to cervical cancers, it increases risk of vulval cancers, penile cancers and some head and neck cancers. But the review also said that these cancers were rarer and that ascertaining the effects of vaccination on them may require the evaluation of non-randomized, population-level evidence over many years.
Beyond the price tag
"The problem is cost-effectiveness, and that is why the government hadn't made a decision to vaccinate boys in this country," said Jo Morrison, co-ordinating editor for the Cochrane Gynae, Neuro and Orphan Cancer Group.
However, she added, "doctors and other informed people are looking to get their boys vaccinated."
Giampiero Favato is one of them. "Twenty years from now, we will laugh about this discussion," said the health economics specialist at Kingston University. "It is obvious we should vaccinate boys. HPV is a gender-neutral killer. When my son is 12, I will pay for the vaccination if necessary."
He is skeptical of "herd immunity" and giving the vaccine only to girls: "The current models are not capable of replicating the sexual behavior and preference in the normal population. Most of the models are based on the assumption that sex is only happening between fully heterosexual couples and their partnerships."
This of course would mean more money for the NHS, but Favato says "price is not the issue," and the private cost of the vaccine is unlikely be anywhere near that for the NHS, which is likely to get it at a competitive rate. "In Italy, the vaccination costs about $30 to $32 per vial."
But Helen Bedford, professor of children's health at the UCL Great Ormond Street Institute of Child Health, added that cost-effectiveness still needs to be taken into account and that the method of calculating this is what ultimately needs to change.
"In view of the long interval between infection with HPV and development of disease, [the Joint Committee on Vaccination and Immunisation] are supportive of changing the methods for calculating cost effectiveness to consider HPV vaccine for boys," she said. "A review of cost-effectiveness modeling is soon to be concluded, and this is one of the issues that is being considered as part of that review."
Phil said that if he could have had the vaccine readily available when he was younger, he would have taken it.
He continues to fight his cancer today, but cases like his are increasing amid the discourse on HPV vaccination rollouts in the UK.
"I would urge all boys to be vaccinated as a matter of course," he said. "We have long vaccinated against the likes of polio, measles, mumps and rubella. HPV is just as serious and life-threatening as any of these."