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Reducing Radiation Successfully Treats HPV-Positive Oropharynx Cancers and Minimizes Side Effects

Source: Yale Cancer Center, http://www.newswise.com/articles/reducing-radiation-successfully-treats-hpv-positive-oropharynx-cancers-and-minimizes-side-effects

Released: 12/26/2016

Newswise — Human papillomavirus-positive oropharynx cancers (cancers of the tonsils and back of the throat) are on rise. After radiation treatment, patients often experience severe, lifelong swallowing, eating, and nutritional issues. However, new clinical trial research shows reducing radiation for some patients with HPV-associated oropharyngeal squamous cell carcinomas can maintain high cure rates while sparing some of these late toxicities.

“We found there are some patients have very high cure rates with reduced doses of radiation,” said Barbara Burtness, MD, Professor of Medicine (Medical Oncology), Yale Cancer Center, Disease Research Team Leader for the Head and Neck Cancers Program at Smilow Cancer Hospital, and the chair of the ECOG-ACRIN head and neck committee. “Radiation dose reduction resulted in significantly improved swallowing and nutritional status,” she said.

The study, published in the December 26 issue of the Journal of Clinical Oncology, showed that patients treated with reduced radiation had less difficulty swallowing solids (40 percent versus 89 percent of patients treated with standard doses of radiation) or impaired nutrition (10 percent versus 44 percent of patients treated with regular doses of radiation).

“Today, many younger patients are presenting with HPV-associated squamous cell carcinoma of the oropharynx,” said Dr. Burtness. “And while traditional chemoradiation has demonstrated good tumor control and survival rates for patients, too often they encounter unpleasant outcomes that can include difficulty swallowing solid foods, impaired nutrition, aspiration and feeding tube dependence,” said Dr. Burtness. “Younger patients may have to deal with these side effects for decades after cancer treatment. We want to help improve our patients’ quality of life.”

The study included 80 patients from 16 ECOG-ACRIN Cancer Research Group sites who had stage three or four HPV-positive squamous cell carcinoma of the oropharynx, and were candidates for surgery. Eligible patients received three courses of induction chemotherapy with the drugs cisplatin, paclitaxel, and cetuximab. Patients with good clinical response then received reduced radiation.

Study results also showed that patients who had a history of smoking less than 10 packs of cigarettes a year had a very high disease control compared with heavy smokers.

 

Other authors on the paper include: Shanthi Marur (Johns Hopkins Medicine) and Anthony Cmelak (Vanderbilt University).

“This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.”

January, 2017|Oral Cancer News|

Why won’t our doctors face up to the dangers of radiotherapy?

Source: http://www.dailymail.co.uk/health/article-1089091/Why-wont-doctors-face-dangers-radiotherapy.html

Author: Isla Whitcroft

It’s a life-saver for thousands – but the side-effects can be devastating.

A year after he’d undergone treatment for cancer of the tonsils, Richard Wayman felt a painful tingling in his legs. Within weeks, the 59-year- old shopkeeper was struggling to walk. He was admitted to hospital, where doctors carried out scans, X-rays and tests.

‘The scans revealed lesions on my lungs, which raised fears that the cancer had spread, so I was admitted to another hospital for a biopsy and, as a result, contracted MRSA and pneumonia,’ recalls Richard, from Colchester in Essex.

‘From 11-and-a-half stone I went down to eight-and-a-half stone. I thought I was never going to get out of there.’

Finally, the lung lesions were diagnosed as a side-effect of the radiotherapy Richard had undergone for his cancer. However, his problems only got worse: a few weeks after a routine tooth extraction, the bone around the extraction started to crumble and become infected.

Within months he had an open weeping wound, running from his lower cheek through his jaw and into his mouth. The diagnosis: bone necrosis as a direct result of radiotherapy damage to the jaw.

Richard is one of the many thousands of cancer survivors who have developed terrible conditions as a result of the radiotherapy treatment that helped save them.

Around 4 to 5 per cent of all head and neck cancer patients suffer problems with swallowing or breathing, fistulas (open holes) in the jaw and gum, loss of taste and hearing.

But the problem is not unique to these cancers. Up to 10 per cent of breast cancer patients suffer radiation damage to their heart, lungs or the nerves to the arms (leading to loss of circulation and movement).

Every year, another 6,000 patients who’ve had pelvic radiotherapy treatment for conditions such as bowel cancer suffer long-term damage (including incontinence). A thousand of these patients go on to suffer even worse problems, such as intestinal failure or heavy bleeding.

It is clear that radiation damage is a significant health care issue. Yet, to date, there has been no national attempt to collate statistics that would enable any significant research work to begin.

Remarkably, it is not even officially classified as a specific medical condition; nor is there any definitive information on how to deal with it.

As a result, when it comes to treating the problems, patients can be offered a mix of options. Some are treated by a urologist, others are referred to a gastroenterologist, or an ear, nose and throat expert, while women often see a gynaecologist. This means many people will go undiagnosed for months and often years.

‘Until recently, radiotherapy damage has not been a priority in the treatment of cancer,’ says oncologist Paul Cornes, who runs clinics for patients with radiotherapy damage.

‘It is not a deliberate cover up; but in the past, cancer medicine was all about the treatment and giving patients a chance of life. Now we must address quality of life after cancer.’

Dr Sylvie Delanian, a radiologist and oncologist at the Hospital St Louis in Paris, is one of the few radiologists around the world to research and treat the condition. ‘Long-term radiotherapy damage is a taboo subject,’ she argues.

‘Radiologists are often frightened to discuss the matter with patients in case they refuse treatment. There is also the feeling that “we’ve saved your life, now go away and live with the side-effects”.’

Indeed, some hospitals seem to actively discourage discussion about the subject. While we were investigating this article, one London trust refused to allow Good Health to speak to their specialist, while another major cancer centre barred us from a conference on pelvic radiotherapy damage.

Radiotherapy is an incredibly successful method of treating cancer, increasing survival rates by around 50 per cent. It works by bombarding the tumour or tumour site with X-rays to kill the dividing cancer cells. In doing so, it inevitably affects surrounding healthy cells.

But areas such as the bowel, lung and jaw seem to be more susceptible to long-term damage. The precise reason is not clear, although it is thought that the mucus which lines the bowel and the delicate sacs in the lung are extremely vulnerable.

Long-term damage can appear as fibrosis (an overgrowing of healthy cells as they go into overdrive to repair the radiotherapy damage) or necrosis (the death of the tissue, causing open holes or fistulas).

Radiotherapy can also damage nerves, reducing blood circulation or causing breathing difficulties, with side-effects often not appearing for several years after treatment.

When Alan Warren was diagnosed with rectal cancer four years ago, it was, understandably, very worrying. The taxi driver and father-of-two underwent chemotherapy, then radiotherapy, to shrink the tumour, before it was removed along with several inches of his bowel.

‘My oncologist said I would be back working within four months. Fours years on, I’m still unable to work,’ says Alan, 55.

During those years, Alan, from Christchurch, Dorset, has suffered unimaginable pain. He has also suffered the indignity of urine leaking out through his back passage after he developed an internal fistula 12cm long, running from the top of his bladder to what was left of his lower bowel.

An operation to close the fistula failed. After that, the only option was a permanent catheter.

‘My problems were all blamed on scar tissue from the original cancer surgery, so I was referred to a urologist for treatment.

‘By chance, Alan’s wife Jackie, a nurse, came across an article on radiotherapy damage. ‘My urologist reluctantly admitted that I probably did have it,’ says Alan.

In the UK treatment tends towards cutting out the afflicted area if necessary – which often results in more scar tissue and pain. But there are other options.

Jervoise Andreyev, a gastroenterologist at the Royal Marsden, London, uses anti-diarrhoea medication, pelvic exercises, antibiotics and dietary changes to treat the problem if it’s in the pelvis.

Meanwhile, Dr Delanian uses a combination of three drugs: vitamin E, pentoxifylline (for vascular and circulatory problems) and clodronate (bone disorders).

Her success rates are impressive, with research to back these up going back over a decade. After contacting the radiotherapy damage action group RAGE, Alan and Jackie found out about Dr Delanian, and in October last year they visited her in Paris. Thanks to treatment, by January 2008 Alan’s fistula was gone and he was healed.

Richard Wayman also saw Dr Delanian. Six months later, the hole in his face healed.

The leg weakness and tingling have stabilised, too.

But despite the fact that some UK doctors are quietly following her method, it is not a mainstream treatment, and many of her patients find that in the UK they are refused the drugs she prescribes.

In 2006, the Royal Marsden carried out a trial into Delanian’s treatment on breast cancer patients, but announced that it failed to show any significant improvement.

Paul Cornes says: ‘Newer radiation therapies such as intensity modulated radiation therapy (IMRT) and proton beam therapy deliver more accurate beams with significantly lesser side-effects.

‘Unfortunately, IMRT is not yet widely available in the UK, and proton beam therapy is considered too expensive for the NHS.’

Dr Delanian adds: ‘Radiation is a great tool, but can also be very dangerous. As a profession, we should try to find a way to minimise the risk and deal with the effects.’

 

Originally posted:  

“This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

December, 2016|Oral Cancer News|

US Surgeon General Says Vaping Among Young People is a ‘Major Public Health Concern’

Report calls for higher taxes and stronger regulations on the e-cigarette industry

Author: Amar Toor

Source: http: www.theverge.com

The US surgeon general says that the increased use of e-cigarettes among young people represents a “major public health concern,” The Washington Post reports, and is calling on lawmakers to implement regulations that would curb their use among American youth. In a report to be released on Thursday, Surgeon General Vivek Murthy says that although there is a need for further research on the long-term effects of e-cigarettes, exposure to nicotine through vaping poses serious health risks to young people.

“We know enough right now to say that youth and young adults should not be using e-cigarettes or any other tobacco product, for that matter,” Murthy said in an interview with the Post. “The key bottom line here is that the science tells us the use of nicotine-containing products by youth, including e-cigarettes, is unsafe.”

“Young adults should not be using e-cigarettes or any other tobacco product.”

The report, which focuses on vaping among young people, acknowledges that e-cigarettes are less harmful than traditional cigarettes, as previous research has shown. But the surgeon general says there is not strong evidence that the devices are effective at helping people to quit smoking cigarettes, and concludes that vaping is “strongly associated” to the use of other tobacco products. A report from the Centers for Disease Control and Prevention (CDC) found that 3 million American teenagers used e-cigarettes in 2015, marking a ten-fold increase over four years.

The surgeon general’s warnings contrast with a report published earlier this year by the Royal College of Physicians in the UK, which said that e-cigarette use should be encouraged as a healthier substitute for tobacco cigarettes. That report, released in April, concluded that e-cigarette use in the UK is “limited almost entirely to those who are already using, or have used, tobacco,” and said that the products can be seen “as a gateway from smoking.” The long-term effects of e-cigarette use remain unclear, though a study released in July identified two cancer-causing chemicals in the vapor that the products release.

The US Food and Drug Administration (FDA) banned the sale of e-cigarettes to people under 18 earlier this year, and now require manufacturers to submit their ingredients for approval. The surgeon general’s report recommends stronger regulations, including a sales ban for people under the age of 21, higher taxes, and restrictions on marketing that targets young people.

 

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

December, 2016|Oral Cancer News|

Controversies in Treatment Deintensification of Human Papillomavirus–Associated Oropharyngeal Carcinomas: Should We, How Should We, and for Whom?

Source: Journal of Clinical Oncology
Published: 2013
By: American Society of Clinical Oncology 
       (Harry Quon and Arlene A. Forastiere)
       Corresponding author: Arlene A. Forastiere, MD, Department of Oncology and the Sydney Kimmel Comprehensive        Cancer Center, Johns Hopkins University School of Medicine, 1650 Orleans St, Rm G90, Baltimore, MD 21231-1000; e-mail: af@jhmi.edu.

 

It has been little more than a decade since the recognition of the epidemiology, distinct molecular biology, and profile of risk factors, patient demographics, and tumor characteristics of human papillomavirus (HPV) –associated oropharyngeal squamous cell carcinoma (OPSCC). From prospective and retrospective studies, we know that patients with locally advanced, stage III/IV, HPV-associated OPSCC who are treated with standard cisplatin-based concurrent chemoradiotherapy have significantly better overall survival and reduced risk of recurrence compared with patients with HPV-negative OPSCC. More than 80% will likely be cured of their cancer. That said, it is also evident that a subset of patients demonstrate an aggressive phenotype with the development of distant spread and death as a result of their cancer.

Given that the typical patient with HPV-associated OPSCC is younger (age 40 to 60 years) and without major comorbidities, increasing discussion has been focused on deintensification of treatment in the hopes of minimizing treatment-related morbidity without compromising the current cure rates. In particular, attention has been focused on reducing the morbidity of severe late swallowing complications that result in the need for enteral nutritional support, because this has been shown to substantially affect patient quality of life.

Historically, typical rates of long-term gastrostomy-tube dependence were reported to be 15% to 20%. However, with advances in radiation technology (such as intensity-modulated radiation therapy), target delineation has become more complex, with steeper dose gradients and shifting of dose away from organs at risk, such that the current frequency of severe swallowing dysfunction needs to be reestablished. Nonetheless, maximizing quality of life by not overtreating patients is a uniformly supported goal.

Deintensification strategies have to date been based on an understanding of the treatment-related risk factors that are independently associated with late and severe swallowing complications, for example, radiotherapy dose, the volume of the pharynx irradiated, and use of concurrent chemotherapy.With the focus largely on ways to modify treatment components, it has been hypothesized that radiotherapy dose reduction and/or alterations in concurrent chemotherapy may result in the same locoregional control rates with reduced late toxicities. The ability to identify patients with HPV-associated OPSCC who are appropriate for participation in the investigation of less intense therapies is now coming into play with risk stratification modeling. It is within this context that O’Sullivan et al, in the article that accompanies this editorial, report predictors of low risk of distant metastases for potentially safe deintensification of chemotherapy.

Recent studies have explored the significance of tobacco exposure history as a variable, along with tumor (T) and regional node (N) stage as predictors of risk of recurrence and death in the patient with HPV-associated OPSCC who is treated with radiation therapy. O’Sullivan et al report the results of a large, retrospective, institutional review of 505 patients treated uniformly by stage with radiotherapy alone or concurrent cisplatin and radiotherapy, and demonstrate with recursive partitioning analysis that advanced T and N stage can significantly influence the risk of distant relapse in both HPV-positive and HPV-negative OPSCC. The HPV-positive cohort could be segregated into low-risk (T1-3, N0-2C, 7%) and high-risk (T4, N3, 24%) groups for distant metastases. O’Sullivan et al also demonstrate that the proportion of relapses is predominantly distant (given the high locoregional control rates achieved), with T4 and/or N3 stages associated with an increased risk of distant relapse. Among the low-risk HPV-positive cohort, subgroups of patients with N2b (particularly those with > 10-pack-year tobacco exposure) and N2c were found to have a higher rate of distant relapse when treated with radiotherapy alone (the majority with accelerated radiotherapy schedules) compared with patients treated with concurrent chemoradiotherapy. Thus, modifying or eliminating chemotherapy as a deintensification strategy may be most reasonably tested in patients with HPV-positive T1-3 and N0-2a stage disease, which would encompass all stage III cancers and most stage IV cancers with low-volume regional nodes. By implication, it could be that today’s treatment paradigms result in the overtreatment of many patients (and the consequent late effects on swallowing function) and undertreatment of a smaller subset. Rigorous prospective study is needed.

These findings provocatively suggest that there is a limit to the favorable biology of HPV-associated OPSCC. Advanced tumor progression resulting in T4 and N2b-N3 disease and possibly enhanced by tobacco exposure may lead to sufficient tumor heterogeneity, increasing the risk of distant relapse, although still sufficiently sensitive to concurrent chemoradiotherapy. In patients with more advanced nodal presentations and/or heavy tobacco exposure history (≥ 10 pack-years), omitting concurrent chemotherapy may increase the risk of distant relapse. In multivariable analysis, heavy tobacco exposure was a strong negative predictor for overall survival but did not predict for relapse-free survival (in both the HPV-positive and -negative cohorts), which supports the known increased risk of noncancer-related deaths from tobacco-related comorbidities. Conflicting data regarding the relationship between tobacco exposure and locoregional control has been reported.

These findings may also help to define a beneficial role for induction chemotherapy on the basis of risk of distant metastases. It is noteworthy that although phase III, controlled trials have not shown benefit for induction chemotherapy added to concurrent chemoradiotherapy, induction is frequently administered outside of a clinical trial to patients considered to have stage III/IV disease.

O’Sullivan et al appropriately highlight the limitations of their observations and recommend further validation in prospective clinical trials. Given our current knowledge, treatment of HPV-associated, locoregionally advanced cancers with anything less than the standard full doses of radiotherapy and concurrent cisplatin should only occur in the context of a clinical trial. To modify treatment components at this juncture may jeopardize a high probability of cure. The recently closed phase II Eastern Cooperative Oncology Group (ECOG) trial E1308 for stage III/IV HPV-associated OPSCC tested whether induction chemotherapy (combination paclitaxel, cisplatin, and cetuximab followed by concurrent cetuximab and radiotherapy) may allow for safe reduction in radiotherapy dose to the primary site and involved neck nodes. Those patients with complete response to induction had modification of the prescribed radiation therapy dose from 69.3 Gy (given for incomplete response) to 54 Gy, which represents a substantial reduction in dose delivered to the pharyngeal constrictor muscles, with the expectation of reducing late swallowing complications. Outcome data on toxicity, quality of life, and disease control are awaited. The Radiation Therapy Oncology Group (RTOG) is actively accruing patients to a phase III noninferiority trial, R1016, that randomly assigns patients with stage III/IV HPV-associated OPSCC to standard-dose radiotherapy and either concurrent cisplatin or concurrent cetuximab. This study is powered to demonstrate a comparable 5-year overall survival rate, with secondary objectives to demonstrate differences in acute and late treatment toxicities. The question of whether radiotherapy alone is sufficient for patients with low-volume nodal disease remains on the table. Other institutional studies are in progress.

It is interesting to note several surgical series reporting similar correlations between advanced nodal features and a higher proportion of distant relapses than expected in the patient with HPV-associated OPSCC. Advanced T stage, N stage, and the presence of extracapsular extension (ECE), including the pathologic extent of any ECE (soft tissue infiltration), have been observed to be associated with an increased distant relapse pattern. Whether or not the association between advanced clinical N stage and distant relapse is solely a result of the presence of ECE or its extent is not clear at this time. However, the observations by O’Sullivan et al should draw caution to the omission of concurrent adjuvant chemotherapy with postoperative radiation for the HPV-associated OPSCC that demonstrates microscopic ECE, despite the favorable prognosis that has been reported. Transoral surgery in appropriately selected patients may serve as a platform for deintensification in the patient with HPV-associated disease, although three treatment modalities may be indicated. This is based on the fact that the range of postoperative doses of radiotherapy (60-66 Gy) is closer to the threshold of injury for the pharyngeal constrictors, and the lower risk of late swallowing complications at these doses may allow for a larger volume of the pharyngeal constrictor muscles to be safely irradiated. Studies of transoral surgery are being planned to test this hypothesis.

Lastly, O’Sullivan et al also observed a difference in the temporal pattern of distant relapse on the basis of HPV status. Their observations suggest that patients with HPV-positive disease may be at risk of distant relapses for up to 5 years of follow-up. In contrast, the rate of distant relapses in patients with HPV-negative disease remained relatively stable beyond 2 years. These observations suggest not only a difference in the tumor biology, but may have implications regarding surveillance imaging and long-term follow-up.

In summary, ongoing research efforts to better define the patient with high-risk HPV-associated OPSCC have broad implications. Clinical, pathologic, and molecular definitions are needed. Future deintensification protocols should consider not only the risk level but the pattern of relapse for the HPV-associated OPSCC, as well as how deintensification is achieved. Future longitudinal studies to further characterize the natural history of this high-risk cohort are needed to define a more strategic and cost-effective long-term surveillance plan.

 

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

 

* This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

 

 

January, 2014|Oral Cancer News|

How do you conquer the main difficulties to accomplish a proper oral cancer screening?

Source: DentistryIQ.com

From coast to coast the same answer complete

As I tour this country presenting programs on early oral cancer detection, I ask the same question of all my attendees: What do you think is the main reason that dentists give for not doing a complete oral cancer examination?

The unanimous response in more than 25 states and close to 50 locations is, “Time!” … Yes, time!

My next question is always the same: How much time does it take to do a complete extraoral and intraoral cancer examination?

The answer is always the same: “One to one-and-a-half minutes.”

Something changed somewhere along the way

Within this past year, I was made aware of a statewide study evaluating outcomes of dental school education at one particular state-supported dental school. Among the topic areas evaluated was the percent of graduates who are doing a complete extra-/intraoral cancer screening examination in their current practice setting. About 30% of respondents replied in the affirmative. Only one-third! And that was within the first five years out of dental school. Nationwide, the percent of dental offices doing a complete screening examination is only about 20%!

My question is what happened that stopped dental professionals from doing a complete extra-/intraoral cancer screening?

What are the barriers stopping us from doing what we all know we should be doing?

Brief overview of Parts 1 and 2

In Part 1, I discussed that, in my opinion, there is a four-part “system of early oral cancer detection” for any dental office to be maximally effective:

  1. The target population: Who do we examine and why?
  2. The basic examination: How do we perform and record it?
  3. The delivery of a difficult message: Verbal skills and seamless referrals
  4. The new tools available for screening: What are they, how do they work, and when are they used?

Part 1: the first resistance factor

  • Overall lack of confidence in doing the complete oral cancer screening examination. The rationale: “Not doing the exam at all puts me at less risk than doing it and missing something.”

Part 2: the second resistance factor

  • Being unclear about who to examine: The changing target population.

Now, in Part 3: the third resistance factor

  • Uncertainty about the complete extraoral and intraoral screening examination itself.

When every dental health-care provider had his or her respective training, the “parts and pieces” of the extraoral and intraoral oral cancer screening examination were:

  • Discussed at length in the classroom setting
  • Practiced (usually one student on another)
  • Required to be performed and recorded for every patient evaluated as a new patient
  • Required to be performed and recorded in the preventive recare clinical areas

The critical nature of this examination, the doing of it, and the recording of it were all stressed. So what happened?

It’s all there inside our heads

Besides our own books from our training, there are many books and online materials available that can serve as a refresher on how our cancer screening should be done. This “cancer screening exam” has not changed in more than 30 years.

As a prominent oral pathologist who attended a recent program of mine agreed, a squamous cell carcinoma looks the same now as it did 30, 40, or more years ago. So the majority of pathology has not changed either. To refresh what is already in our heads, we just need to take a few minutes, break out our books or our computer, and do a review. Simple, huh? So why is there resistance? Is it ego?What do you think?

Here are the facts:

  1. We were taught how to do an effective cancer screening examination.
  2. We have the tools at our fingertips to review what we were taught at any time we would like to do so.

If the barrier to doing a complete cancer screening examination is not being sure of what one should be doing, voila! Here is a way to easily get unstuck.

If your ego does not allow you to admit that you are rusty or unclear about what you need to be doing when performing the cancer screening exam, then you can quietly review what you need to know privately.

What about when the patient asks, “Why are you doing this cancer screening exam now when you did not do it before?”

Now that you are committed and have clarified and sharpened your skills about the complete cancer screening exam, what is your next step?

Involve the entire team!

  1. Have a discussion with your team about the mission of your office as it relates to the complete cancer screening exam (see Dental Economics article by this author, December 2008. Complete buy-in is critical.
  2. Write down the questions that might arise when patients experience this exam.
  3. Role-play and practice the communication skills with each other that will make it comfortable and effortless to answer these questions that we all know will arise.

I am often asked to provide a scripted reply to the patient question: “Why are you doing this now?” The process of working through a response for yourself is critical to the ownership and buy-in that is required for maximum team success. So I encourage you to create your own scripts in your own words.

Work through this challenge of what the “complete cancer exam” entails and how to reply to your patients’ questions about why you are doing it. Once accomplished, you will overcome another common barrier that stands in the way of performing the routine extra-/intraoral cancer screening exam that we all were taught to do and know we should be doing!

In Part 4, I will be discussing the critical aspect of recordkeeping that is a key adjunct to the cancer screening exam. The confusion/lack of clarity about what this recordkeeping must entail, as well as how it must be done medicolegally, is a barrier for many dentists that is directly connected with the uncertainty about exactly how the cancer screening exam should be performed.

 

Jonathan A. Bregman, DDS, FAGD, is a clinician, speaker, author, and trainer who led successful dental practices for more than 30 years. While dedicated to improving the dentist, team, and patient experience, he has a passion for educating dental professionals about early oral cancer detection and laser-assisted dentistry. You may contact Dr. Bregman by e-mail at info@bregmandentistry.com or visit www.bregmandentistry.com. Also be sure to check out his blog at www.oralcanceraware.com.


April, 2011|Oral Cancer News|

Patient who loses jaw to oral cancer from smoking tells her story

Source: Los Angeles Times

By: Milton D. Carrero, The Morning Call

 

Look at Christine Brader’s deep, amber eyes and you will see her beauty. Look beyond her contorted lips, and the jaw she lost as a three-time oral cancer survivor. Radiation took away her teeth, but she smiles.

“I still feel like I’ve lost a great deal, she says, “but I’m still alive. And as long as I am alive, I am going to do what I can to help other people.”

Brader, 48, is sharing her face, her story and her time to tell the world about the dangers of smoking. The South Whitehall woman, who smoked about half-a-pack a day for 28 years, is featured in the national Truth campaign. Sponsored by the American Legacy Foundation, the series of ads present the unsweetened reality of those living with a serious illness caused by smoking.

Brader’s life is testament of resilience against oral cancer — a disease that, in five years, kills more than half of the 37,000 Americans diagnosed with it yearly, according to the Oral Cancer Foundation.

“I still may not make it,” she says, “and I don’t have another chance in me. If I get it again, I’m done.”

Brader’s life seemed idyllic until she discovered she had cancer. She had a stable job, a beautiful house in the woods and two teenage children who inspired her. But in 2007, she went to her family doctor, believing that she had a sinus infection. Her situation was much more serious than she imagined.

“I can’t be sick,” she thought as soon as she heard the diagnosis. “I am a single mother with no one to help me. Nobody. I had my teenage children and I was busy, you know, it didn’t fit into my life. It really didn’t.”

But cancer made room for itself in her life, displacing those things she cherished the most.

“My life had always been about taking care of my children first,” she says. “Always, they came first. Not anymore. I had to survive to take care of my family. They have no one else.”

A week after her diagnosis, Brader took a decision that might have saved her. She was riding in the car with her son on the way to the hospital. They stopped at a gas station and Brader was upset. She took out her anger by crumpling her cigarette pack in her hands and throwing it out the window. She never smoked again.

“The damage may have already been done,” she realized, “but you don’t need to make it worse.”

It would get worse, however. The surgery and radiation treatments would only contain the disease for a year before another cancerous sore would arise in her mouth. This time the treatment would be more complicated because the radiation sessions she had endured to the wound in her mouth encumbered her ability to heal. She underwent 85 sessions of hyperbaric oxygen treatment to facilitate her healing.

It worked and she began feeling better. She even completed a 25-mile bike ride with her son in the Poconos.

Her journey was far from over. She didn’t tell her son, but all throughout the bicycle outing, she had a feeling that she was sick again.

“Most people don’t get through it, twice, and here I have it a third time in three years.”

Doctors confirmed her premonition. Her cancer was now stage 4. She needed her jaw removed to save her life.

If cancer had been a priority earlier, it would now take over her life. Brader was forced to eat through a feeding tube. She wasn’t strong enough to care for her dogs. She eventually decided to leave her house in Lehighton and move closer to her oral surgeon, Dr. Robert Laski.

“Because I smoked, I got sick,” she says. “My doctor is the best doctor in the world. He said: ‘It doesn’t matter how you got it, we are going to take care of it.'”

He did, and she is extremely grateful for it. She also feels in debt to the Oral Cancer Foundation, whose support proved invaluable in her recovery. Brader now volunteers daily on the foundation’s website, reaching out to those experiencing what she went through.

But she is placing most of her energy in promoting early detection and prevention.

“Imagine the humiliation of walking around and people staring at you every time you walk out the door,” she says. “If I could spare anybody that, I’ve done my job.”


April, 2011|OCF In The News, Oral Cancer News|

My dog saved my life, says Sunderland man

Source: Sunderland Echo

By: Katy Wheeler

John and Pauline Douglas were devastated when their dog Diesel had to be put down after developing cancer of the neck.

But it was the late bull mastiff’s symptoms which helped John, 39, realise that he too had the disease.

The dad-of-four, of Tunstall Bank, noticed a lump in his neck in February.

And despite the fact he was told by doctors to rule out cancer, John’s experience with Diesel’s disease convinced him something was seriously wrong – and he pushed for further tests.

His instincts were proved correct and John was diagnosed with cancer, which had spread to his neck, in April – just a week before his wedding day to wife Pauline, 41.

John said: “Because of my age, the fact I don’t smoke and because I am a moderate drinker, I was told not to worry about cancer and that it was just an infection.

“But what happened to Diesel set alarm bells ringing.

“He had the same kind of lump in his neck that would swell up and down. We were told his wasn’t cancer to start with and it was only found late on.

“Even though I was told by a specialist that I didn’t fit the criteria for cancer, the doubt was still niggling and I made such a song and dance that more tests were done.”

As a result of John’s persistence, one of his tonsils was removed and a biopsy revealed the cancer, which had spread to his lymph glands.

After six weeks of radiotherapy and chemotherapy, followed by surgery at Sunderland Royal Hospital, John is now getting his life back to normal.

He is back at work for Vauxhall technical support section.

He said: “I am pushing for normality. The cancer took six months off me. I have my good days and I have my bad days, but I visited the hospital today and they say they don’t need to see me for two months. So today is a good day.”

Such is John’s gratitude to five-year-oldDiesel, who was put down in August last year, he even has a tattoo of him on his leg.

“I owe my life to Diesel. If it wasn’t for him I wouldn’t have been so sure something was seriously wrong. I would urge anyone who is concerned about their mouth and neck to get checked out,” he explained.

As part of Mouth Cancer Action Month, John is backing a campaign to raise awareness of the disease.

Events have been held across the region to promote early detection which improves survival chances.

December, 2010|Oral Cancer News|

Actor’s diagnosis puts spotlight on oral cancer

By: Donna Domino, Associate Editor
Source: DrBicuspid.com

Actor Michael Douglas’ recent revelation that he has stage IV oropharyngeal cancer has highlighted the growing incidence of oral cancer, and experts say dentists can help stem the alarming increase of the disease by checking for it during routine examinations.

“Tobacco is no longer the only bad guy.”
— Brian Hill, executive director,
Oral Cancer Foundation
The actor’s cancer includes a walnut-sized tumor at the base of his tongue, and he will require radiation therapy, chemotherapy, and surgery. Douglas says his doctors told him he has an 80% survival rate if it hasn’t spread to his lymph nodes.

While tobacco was the prime cause of oral cancer in the past, recent studies have attributed the steady increase of the disease to the human papillomavirus (HPV). There are approximately 130 versions of HPV but only nine cause cancers, and the HPV16 version causes almost half of the oral cancers in the U.S., said Brian Hill, executive director of the Oral Cancer Foundation.

“Tobacco is no longer the only bad guy,” he told DrBicuspid.com. “HPV16 is increasing in incidence as the causative etiology, and if it continues on this trend line, it will replace tobacco as the primary cause of oral cancers.”

Dentists can play a key role in catching the disease in its early stages if they check for it during examinations, Hill pointed out. “But many dentists think it’s such a rare disease that they don’t bother to screen for it,” he said. “Most Americans have never even heard of oral cancer, but it’s not as rare or uncommon as people would like to think it is. This is why an opportunistic screening by the dental community is so important.”

Hill, a nonsmoker, got the same diagnosis as Douglas in 1998 and underwent radiation therapy, chemotherapy, and surgery. Since Hill’s oral cancer had metastasized to both sides of his neck by the time it was discovered, surgeons removed the right side of his neck to remove the lymph nodes there. He has been cancer-free for 10 years and said there are a lot of stage IV survivors out there.

“I’m on this side of the grass and that’s all that’s important,” he said, adding with a laugh, “I’m not pretty, but I’m still here.”

Changing demographics

Oral cancer screening tips

According to the Oral Cancer Foundation, an oral cancer screening includes a systematic visual examination of all the soft tissues of the mouth, including manual extension of the tongue to examine its base, a bimanual palpation of the floor of the mouth, and a digital examination of the borders of the tongue, and examination of the lymph nodes surrounding the oral cavity and in the neck.

“Any sore, discoloration, induration, prominent tissue, irritation, or hoarseness that does not resolve within a two-week period on its own, with or without treatment, should be considered suspect and worthy of further examination or referral,” the foundation’s website states.

The website also offers a more complete oral cancer screening protocol and a photo gallery showing various forms oral cancer can take.

In the last decade, the demographics of oral cancer have changed dramatically, according to Hill and other experts, pointing to the sexual revolution and accompanying increase in the prevalence of oral sex. Today almost half of those diagnosed with the disease are younger than 50 years old — with some as young as 20, according to Hill — and they are usually nonsmokers. According to the American Cancer Society, oral cancer occurs almost as frequently as leukemia and claims more lives than melanoma or cervical cancer. The incidence in oral cancer patients younger than age 40 has increased nearly fivefold, with many patients with no known risk factors, according to the ADA.

“Social and sexual behaviors have changed,” Hill said. “Oral sex is more common. The virus is spreading, especially among young people because sexual contact is more common, and this virus is not only ubiquitous in our society, but the mechanism of transfer is very simple.”

Until 2000, scientists were unsure if HPV caused oral cancer, Hill said, but definitive research in 2000 revealed it as a distinct etiology for the disease, and more recent studies have supported this finding.

The disease is dangerous because often there are no symptoms in the early stages that a person might notice. “It’s a very insidious disease,” Hill explained. He recalled that it was not until a lymph node became swollen that Hill realized something was wrong. Even then, it was not painful, he said.

But an alert dentist will notice subtle signs and symptoms in a simple three to five minute visual and tactile exam, Hill noted. “There will be things he’ll pick up on, and that’s why we’re urging that the dental community to become more involved in oral cancer screening,” he said.

Approximately 36,000 new cases of oral cancer are diagnosed each year in the U.S., according to the ADA, and some 25% of those people will die of the disease. Only 57% of all diagnosed oral cancer patients will be alive five years after their diagnosis, Hill said. Approximately 100 people in the U.S. will be diagnosed with oral cancer every day, he added, and one person will die every hour from it.

And when celebrities get oral cancer, it helps bring about much needed public awareness about the disease, said Hill, noting that, in addition to Michael Douglas, such luminaries as Sigmund Freud and Ulysses S. Grant have been among its victims.

“When somebody famous gets the disease, it finally gets the world’s attention,” he noted.

September, 2010|OCF In The News, Oral Cancer News|

Decreases in adolescent tobacco use leveling off

Source: HemOncToday.com

Declines in rates of adolescent tobacco use have stagnated in the past few years, prompting the CDC to call for better prevention efforts, according to a recent report.

“Smoking continues to be the leading preventable cause of death and disability in the United States; and among adult established smokers in the United States, more than 80% began smoking before age 18 years,” CDC researchers wrote.
To evaluate behaviors and attitudes toward tobacco use during the critical period of adolescence, the researchers used National Youth Tobacco Survey (NYTS) data collected from 2000 to 2009.
The NYTS, which presents school-based survey responses from a cross-sectional, nationally representative sample of middle school and high school students, gleans information on youth tobacco use; smoking cessation; tobacco-related knowledge and attitudes; access to tobacco; media and advertising and secondhand smoke exposure. The study has been conducted every 2 years since 2000.
From the 205 participating schools, 22,679 students responded. They were polled about any use of, current use of and experimentation with certain tobacco products, including cigarettes, cigars, smokeless tobacco, pipes, bidis and kreteks. Survey questions also investigated students’ willingness to initiate tobacco use.
Results indicated that 8.2% of middle school students and 23.9% of high school students reported current tobacco use in 2009, the researchers said, with 5.2% of middle school and 17.2% of high school students reporting current cigarette use. The researchers also noted that 21.2% of middle school and 24% of high school students were willing to start smoking cigarettes.
Data from 2009 also suggested that, among middle school students, 3.9% currently used cigars; 2.6%, smokeless tobacco; 2.3%, pipes; 1.6%, bidis; and 1.2%, kreteks. A similar distribution of use of these products was noted among high school students, with 10.9% currently using cigars; 6.7%, smokeless tobacco; 3.9%, pipes; 2.4%, kreteks; and 2.4%, bidis.
From 2000 to 2009, decreases occurred among middle school students for current tobacco use, 15.1% to 8.2%; current cigarette use, 11% to 5.2%; and cigarette smoking experimentation, 29.8% to 15%. Overall rates for susceptibility to smoking, however, did not decline. Analysis also indicated that rates of decreases demonstrated no change during this time.
Among high school students, current tobacco use decreased from 34.5% to 23.9% from 2000 to 2009, according to the researchers, with current cigarette use also declining from 28% to 17.2% and rates of experimentation falling from 39.4% to 30.1%. Again, rates of decline did not change.
Prevalence of susceptibility to smoking remained steady for middle school and high school students throughout the study period.
Between 2006 and 2009, however, the willingness to start using tobacco products and current use of cigarettes, cigars, smokeless tobacco, pipes, bidis and kreteks did not change among middle school or high school students. For middle school students, the researchers only noted declines in two subpopulations, with rates of current cigarette use falling from 6.4% to 4.7% among girls and decreasing from 6.5% to 4.3% among white students.
Similarly, from 2006 to 2009, prevalence among high school students only declined in girls for current tobacco use, decreasing from 21.3% to 18.2%, and current cigarette use, with rates falling from 18.4% to 14.8%. Prevalence for current bidi use also declined among white students (2.6% to 1.7%).
“The findings in this report indicate that, from 2000 to 2009, prevalences of current tobacco and cigarette use and experimentation with smoking cigarettes declined for middle school and high school students, but no overall declines were noted for the 2006-2009 period,” the researchers wrote. “The general lack of significant change during the shorter period indicates that the current rate of decline in tobacco use is relatively slow.”
Researchers noted that prevention programs are effective, but they do not receive adequate financial support. “Comprehensive tobacco control programs should be fully funded and implemented, as recommended by the CDC,” they wrote.
The researchers also said better control of cigarette advertisements and more graphic warnings on cigarette packs may help deter adolescents from smoking by altering the general public’s attitudes toward tobacco use.
“Changes in social norms might help reduce youth susceptibility to try cigarettes and other tobacco products and accelerate the decline in tobacco use among youths,” the researchers wrote.

August, 2010|Oral Cancer News|

Scientists Use Salmonella Bug to Kill Cancer Cells

Source: Reuters Health Information via Medscape Today

LONDON (Reuters) Aug 12 – Treating tumors with salmonella bacteria can induce an immune response that kills cancer cells, scientists have found — a discovery that may help them create tumor-killing immune cells to inject into patients.

Researchers from Italy and the United States who worked with mouse and human cancer cells said their work might help in developing new therapeutic vaccines.

“We did experiments first in mice and then in cancer cells and immune cells from human patients, and found that the salmonella was doing exactly the same job,” Dr. Maria Rescigno of European Institute of Oncology in Milan, who worked on the study, said in a telephone interview. “Now we are ready to go into (testing on) humans, but we are waiting for authorization.”

The scientists said they thought the salmonella bacteria helped to flag up cancer cells to the body’s immune system, which was then able to find and kill them.

In the very earliest stages of cancer, patrolling immune cells often recognize cancer cells as abnormal and destroy them, they explained in their study, which was published online in Science Translational Medicine on Wednesday.

This process relies on connexin 43, a protein that forms tiny communication channels between different types of cells. Tumor peptides escape through these channels, enter immune cells, and act as “red flags,” triggering a specific immune response against the disease.

But as cancer cells grow and proliferate, they can become invisible to immune cells because not enough connexin 43 is made to keep the “red flag” process going.

In this study, the scientists looked mainly at melanoma cells,

Dr. Rescigno and colleagues found that injecting salmonella into melanoma cells increased the amount of connexin 43. As a result, new communication channels formed, and immune cells were activated and went on to kill the tumor cells.

The technique also protected mice from cancer spreading to other parts of the body, Dr. Rescigno said, suggesting a potential “vaccination-style” preventative strategy.

Immunotherapy is a relatively new approach. In April, the U.S. Food and Drug Administration regulators approved Dendreon Corp’s Provenge, a therapeutic vaccine designed to stimulate the immune system to attack prostate cancer, as the first vaccine to treat tumors.

An experimental immunotherapy drug called ipilimumab being developed by Bristol-Myers Squibb showed promise in fighting melanoma in trial data released in June.

Dr. Rescigno said the team used melanoma cells in the study because this disease is one of the deadliest forms of cancer, same technique could also be tested in other types of cancer.


August, 2010|Oral Cancer News|