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When Is Insurance Not Really Insurance? When You Need Pricey Dental Care.

May 21, 2018
By: David Tuller
Source: https://khn.org

I’m 61 years old and a San Francisco homeowner with an academic position at the University of California-Berkeley, which provides me with comprehensive health insurance. Yet, to afford the more than $50,000 in out-of-pocket expenses required for the restorative dental work I’ve needed in the past 20 years, I’ve had to rely on handouts — from my mom.

This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.

For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.

Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.

In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional pop-up clinics.

Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.

My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. Almost half of Americans 30 and older suffer from mild to severe forms of it.

My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.

At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, states decide themselves on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.

The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.

“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”

A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.

He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”

As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.

Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 did not have medical insurance in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.

Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by Mary Otto in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.

Research has demonstrated links between periodontal infections and chronic conditions like diabetes and cardiovascular disease. Studies have found associations between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.

The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.

In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of the world’s first dental school.

Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.

Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.

With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.

In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.

Meanwhile, the bold line between what is covered or what is not often strikes patients as nonsensical.

Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.

Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.

If only his tumor had placed itself just a few inches away, he thought.

“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

May, 2018|Oral Cancer News|

The Sate of Liquid Biopsy

Author:Pam Harrison
Date: March 5, 2018
Source: Medscape.com

So called “liquid biopsies” — which can detect circulating tumor DNA (ctDNA) in blood samples — are not yet ready for prime time in the diagnosis or management of early-stage or advanced solid tumors, a new expert review concludes.

These assays are also not useful, outside of clinical trials, for monitoring patients for minimal residual disease following definitive treatment of cancer, nor for cancer screening, the expert review concludes.

The review was prepared jointly by the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) and was published online March 5 in the Journal of Clinical Oncology.

“This is an area of great interest to both pathologists and oncologists, [and] it’s also an area where we see a lot of commercial advertisement and a lot of enthusiasm from the public,” Jason Merker, MD, PhD, cochair of the expert panel, who was representing the CAP, said in a statement.

“We thought it was a good time to look at the literature and take an evidence-based approach to various uses for ctDNA assays,” he added.

“Like all new things in medicine, the use of ctDNA assays in routine cancer care requires evidence of clinical utility. At present, there is insufficient evidence of clinical validity and utility for the majority of ctDNA assays in advanced cancer, including those that interrogate a panel of genes,” said Daniel F. Hayes, MD, coauthor of the review, who was representing ASCO.

“What is promising is that this area of research is rapidly evolving, so there should be enough evidence soon to formulate evidence-based guidance for a variety of clinical scenarios,” Hayes suggested.

Review Based on Literature Review

For the review, panel members identified 77 relevant articles in the literature. They limited their analysis to variants in ctDNA for solid tumors and to sequence or copy number variants in DNA.

 

They assessed overall evidence of the ability of a test to reliably detect the variant or variants of interest (analytic validity); whether a test accurately detects the presence or absence of a pathologic state or predicts outcomes for patients (clinical validity); and whether the use of the test improves patient outcomes compared with not using it (clinical utility).

The authors focused largely on the use of ctDNA assays in the setting of metastatic cancer, because that is the area for which there is most evidence. Much less research supports the use of liquid biopsy in other settings.

Advanced Cancer

“Fundamentally, there are two paradigms to demonstrate clinical utility and the adoption of ctDNA as a clinically useful test,” the panel members write.

The most reliable strategy is to conduct a prospective clinical trial designed to evaluate how well the test performs as a stand-alone diagnostic test. However, no such trial has yet been carried out, they write.

The second approach is to assess whether the ctDNA test in question delivers the same information that physicians would seek through tissue genomic evaluation.

“[D]emonstrating that a ctDNA assay has high agreement with tumor tissue genotyping may provide sufficient evidence of utility for ctDNA assays in driving patient treatment decisions,” the panel members explain.

They go on to document how far short ctDNA assays fall with respect to meeting this high level of agreement.

First, only one polymerase chain reactin–based ctDNA test has been approved by the US Food and Drug Administration and the European Medicines Agency. That test is the COBAS assay for the detection of EGFR genetic variants in non–small cell lung cancer (NSCLC).

Another assay is available in Europe for the detection of the KRAS mutation in colorectal cancer (CRC).

“These assays have demonstrated clinical validity but the clinical utility in this setting is based on retrospective analyses,” the panel members point out.

Even in light of these approvals, the panel members note that physicians should continue to rely on tissue sample analysis if nothing is detected on ctDNA testing.

They also point out that ctDNA levels may drop while a tumor is still responding to treatment, and as a result, the sensitivity of the test may be compromised.

As for tumor types other than NSCLC and CRC, there is limited evidence to support the clinical validity of ctDNA analysis, the panel members conclude.

The clinical utility of assays developed for the detection of other potentially targetable variants, such as BRAF in melanoma, is not yet established, they add.

Further confounding the diagnostic potential of ctDNA testing is the fact that advanced cancers may be “genetically heterogeneous.”

Although ctDNA tests may be able to pick up subclonal variants in cancer, these variants may not predict how well patients will respond to treatments that theoretically target the variant.

“[S]ubclonality may undermine the clinical utility of ctDNA assays,” the panel members state.

 

Monitoring Response to Therapy

Ideally, liquid biopsies could help physicians monitor patients’ response to treatment, as some tumor-associated proteins now enable them to do.

This, too, remains a challenge, because quantifying changes in ctDNA over time is not as simple as determining whether or not a variant is present. Nor has the best unit by which to measure DNA burden been established.

“Correlations between changes in ctDNA levels and tumor responses or outcomes have been demonstrated in small proof-of-principle studies in a variety of cancer types,” the panel members acknowledge.

“However, currently there is a lack of rigorous evidence on clinical validity, let alone clinical utility, because few large, prospective validation studies have been performed on ctDNA-based monitoring,” they conclude.

 

Use to Monitor Residual Disease

Researchers expressed hope that after curative treatment of a solid tumor, ctDNA assays could be used to monitor patients for minimal residual disease, much as is done in hematogic malignancies using assays to detect leukemic cells in blood following completion of chemotherapy.

However, there is not enough evidence to support the ability of ctDNA tests to detect low levels of minimal residual disease in a manner similar to assays used in the management of diseases such as leukemia, the panel members conclude.

Moreover, “[t]he false-negative rate of ctDNA analysis in…patients who relapse without ctDNA being detected and the false-positive rate [in] patients who do not relapse despite the ctDNA assay being positive have not been established sufficiently for any assay,” they caution.

There is also no evidence that treatment based on detection of ctDNA improves patient outcomes, a major metric of clinical validity.

Screening for Cancer

In an ideal world, ctDNA tests could be used in the early detection of cancer in patients who have no signs of disease.

However, the feasibility of using ctDNA tests to screen asymptomatic individuals has not been demonstrated.

“[D]iagnosing the presence of cancer in a patient without cancer, and determining tissue of origin, have not been established,” the authors point out.

There is also a risk that such tests might be positive for cancers in cases in which none exists and thus lead to overdiagnosis. Currently, overdiagnosis is a major problem with, for example, mammography in breast cancer and prostate-specific antigen screening for prostate cancer, the panel members observe.

Dr Merker has served as a consultant to or in an advisory role for Bio-Rad Laboratories, Rainbow Genomics, and Genoux and has received patents or royalties or has other intellectual property in the measurement and monitoring of cell clonality. Dr Hayes owns stock or has other ownership interests in OncImmune and InBiomotion and has served as a consultant or as an advisor to Cepheid. He has also received research funding, mostly for his institution, from AstraZeneca, Puma Biotechnology, Pfizer, Eli Lilly, Merrimack Pharmaceuticals, Parexel, and Menarini Silicon Biosystems (aka Veridex/Johnson & Johnson). He also holds a number of patents and receives royalties for some of them.

 

 

March, 2018|Oral Cancer News|

Australia may become the first country to eliminate one form of cancer

Author: Brad Jones
Date: March 8, 2018
Source: flipboard.com

The International Papillomavirus Society has announced that Australia could become the first country to eliminate cervical cancer entirely.

According to a new study, Australia’s efforts to distribute a human papillomavirus (HPV) vaccine for free in schools have been a resounding success. The sexually transmitted infection causes 99.9 percent of cases of cervical cancer.

In 2007, the Australian federal government began offering the vaccine to girls aged 12-13, and in 2013 it was made available to boys, too. Girls and boys outside of that age bracket but under nineteen are also entitled to two free doses of the vaccine.

Between 2005 and 2015, the percentage of Australian women aged between 18 and 24 who had HPV dropped from 22.7 percent to just 1.1 percent. Immunization rates have increased further since 2015, contributing to what’s being described as a “herd protection” effect.

Coupled with a more advanced screening test that was introduced by the Australian government in December 2017, there are hopes that no new cases of cervical cancer will be reported within ten or twenty years.

THE WORLD ISN’T CATCHING UP

In the US, the HPV vaccine is not free. It can cost as much as $450 for the full regimen, according to the Association of Reproductive Health Professionals, although financial assistance is often available. In 2016, 78.6% of 15-year-old Australian girls, and 72.9% of 15-year-old Australian boys were vaccinated – but only 50% of American girls between 13 and 17, and 38% of American boys between 13 and 17 had received the vaccination, as per data published by the Henry J. Kaiser Family Foundation.

The situation is much worse in the developing world, where papillomavirus incidence rate remains high. “Two-thirds of the world’s population of women don’t get access to what Australian women do,” said Joe Tooma, the chief executive of the Australian Cervical Cancer Foundation. “Unless we do something, it will still be one of the major cancer killers in developing countries.”

Administering the HPV vaccine in schools has also proven to be effective in a trial that took place in Bhutan. Offering this kind of free access to the vaccine in other developing countries may seem like an expensive measure, but as the Australian example shows, it could ease the burden of cervical cancer down the line.

 

March, 2018|Oral Cancer News|

Immunotherapy: beyond melanoma and lung cancer treatment

Author: David Crow
Source: www.ft.com
Date: March 4, 2018
In the late 1800s, William Coley, a surgeon in New York, developed what scientists now think was the first cancer immunotherapy.

Coley noticed one of his patients, Fred Stein, had started recovering from cancer after catching a serious infection. The observation made him wonder whether the bacteria had somehow stimulated the patient’s immune system and recruited the body’s natural “resisting powers” in the fight against Mr. Stein’s tumours.

The surgeon began treating inoperable cancer patients with bacterial injections — known as “Coley’s toxins” — and recorded some success, but his poorly documented findings were dismissed by contemporaries who favoured radiation and chemotherapy.

Mr. Coley died in 1936 and his theories were all but forgotten: it would take almost 80 years for oncologists to take cancer immunotherapy seriously.

Today, immunotherapies are among the world’s best selling drugs and they have dramatically improved the survival prospects for some of the sickest patients, especially those with melanoma and lung cancer.

“Immunotherapy is here to stay,” says Jill O’Donnell-Tormey, chief executive of the Cancer Research Institute. “It’s not just a blip, it’s not overhyped — I think it is going to become the standard of care for many cancer types.”

The most common immunotherapy drugs are known as checkpoint inhibitors, which work by removing brakes in the immune system so the body can attack cancer.

Their discovery was made possible by the research of James Allison, now a professor at the MD Anderson Cancer Center in Texas, who spent the 1990s and early 2000s working on immunotherapy even as many other scientists dismissed it as an intriguing but futile sideshow.

60 percentage of advanced melanoma patients who survive three years when they take a combination of two checkpoint inhibitors Checkpoint inhibitors have proven remarkably effective in people with advanced melanoma, a disease once known as the “cancer that gave cancer a bad name” because it had such a terrible prognosis, with most patients dying within three to 18 months.

Today, almost 60 per cent of advanced melanoma patients survive three years if they take a combination of two checkpoint inhibitors, both made by Bristol-Myers Squibb, the US pharmaceutical group that bought Yervoy, the drug based on Dr Allison’s findings, in 2009.

A rival drug made by Merck, known as Keytruda, can significantly boost survival in lung cancer patients when added to a type of chemotherapy, according to early findings from a trial that is due to be published shortly. Other companies, including Roche and AstraZeneca, make competing versions.

It was not until 2013 that checkpoint inhibitors gained widespread acclaim among oncologists, but the drugs were soon being hailed as the biggest breakthrough in cancer treatment since the advent of chemotherapy.

The hype served to cloud some uneasy truths.

When checkpoint inhibitors work, they are remarkably effective, helping patients live for months or years longer than expected with less severe side-effects than other drugs. However, with the exception of the remarkable impact in melanoma and, to a lesser extent, lung cancer, most patients do not respond.

Although immunotherapies have now been approved in a long list of cancers from bladder and gastric to liver, the response rates in these illnesses is lower, with as many as 4 out of 5 patients deriving no benefit at all.

When the second generation of checkpoints, known as PDL1 inhibitors, were approved in 2014, researchers and pharma executives confidently predicted they would quickly push response rates higher by combining them with newer experimental immunotherapies.

So far no one has come up with the magic combination, despite running hundreds of trials.

Giovanni Caforio, chief executive of Bristol-Myers Squibb, hails “unprecedented progress” with immunotherapies, but concedes the next step, which he describes as finding “intelligent combinations”, has not moved as quickly.

“I think that it is not growing at the same speed, but I wouldn’t call it stalling,” he says. “I think it’s moving at a speed that is probably more typical of the speed of [traditional] cancer research.”

Sean Bohen, chief medical officer of AstraZeneca, says the quick advent of checkpoint inhibitors was all the more remarkable because immunotherapy “had been a disappointment for decades”. Yet he cautions progress might become slower because the “science is going to harder places”.

That is not necessarily a bad thing, says Dr. Bohen, because it encourages companies and researchers to work in a more methodical way rather than making speculative guesses: “I believe it’s a healthier way to do drug development”.

The challenge now is finding new drugs that can be added to checkpoints and boost the immune response to cancer without putting patients at risk or causing intolerable side effects.

One hope is a so-called IDO inhibitor, which suppresses an enzyme that tumours use to hide from the immune system. Both Merck and Bristol-Myers are testing their checkpoints in combination with this type of medicine in a partnership with Incyte, a US biotech group that is developing the most advanced IDO inhibitor. The first trials are due to complete in May.

Regardless of whether drugmakers and scientists find the right combination any time soon, the remarkable progress in recent years means the field is unlikely to languish as it did after Mr. Coley’s early discoveries.

 

March, 2018|Oral Cancer News|

In Memoriam: Jimmie C. Holland, MD

The Oral Cancer Foundation is deeply saddened by the passing of OCF Science Advisory Board member, Dr. Jimmie C. Holland. When our organization was in it’s infancy, Dr. Holland was an early supporter of OCF.  She was one of the first in the profession to focus attention on the mental well being of cancer patients. With OCF being a foundation that is heavily geared to funding the advancement of research, and being very hard science and research oriented,  her compassion for the mental health of cancer patients was a key component in humanizing our efforts, and ensuring that we stayed people centric.  We are tremendously grateful for her advanced work in Psycho-oncology, the good it has done for so many in the oral cancer community, and the guidance she offered us. She will be missed by many.

Author: William Breitbart
Source: https://blog.oup.com
Date: Feb. 23, 2018

Jimmie C. Holland, MD, internationally recognized as the founder of the field of Psycho-oncology, died suddenly on 24 December 2017 at the age of 89. Dr. Holland, who was affectionately known by her first name, “Jimmie,” had a profound global influence on the fields of Psycho-oncology, Psychosomatic Medicine, and Oncology.

Dr. Holland was the Attending Psychiatrist and Wayne E. Chapman Chair at Memorial Sloan-Kettering Cancer Center (MSK) and Professor of Psychiatry, Weill Medical College of Cornell University in New York. In 1977, she was appointed Chief of the Psychiatry Service in the Department of Neurology at MSK. The Psychiatry Service at MSK was the first such clinical, research, and training service established in any cancer center in the world. In 1996, Dr. Holland was named the inaugural Chairwoman of the Department of Psychiatry and Behavioral Sciences at MSK Cancer Center, also the first such department created in any cancer center in the world. Over 25 years ago, Dr. Holland founded and co-edited the international Psycho-Oncology journal.

Dr. Holland edited the first major textbooks of Psycho-oncology, and in 1989 edited the Handbook of Psychooncology: Psychological care of the patient with cancer. This landmark textbook was notable for several reasons; it established a “new” field, a subspecialty of both Psychosomatics and oncology. I remember being a young faculty member in Dr. Holland’s service and the very real sense that we were creating something that had not existed before. I remember her asking me to write multiple chapters, including several in which I had very little expertise. I expressed my concern, “I’m not an expert on the psychiatric complications of head and neck cancer!” She calmly reassured me, “Well, Bill, no one is. So when you finish researching and writing the chapter I suppose then you’ll be the world’s expert!”

Psycho-oncology was born and named with the publication of this textbook and with Dr. Holland’s founding of the International Psycho-oncology Society (IPOS) in 1984, then the American Psychosocial Oncology Society in 1986. Subsequently, Dr. Holland edited, with a group of co-editors, what became known as the “Bible” of Psycho-oncology; Psycho-oncology was published in 1998, and represented the most comprehensive, multidisciplinary, and international encyclopedia of a field entering its adolescence. 2010 saw the publication of the second edition followed by the third edition in 2015. Every card-carrying “psycho-oncologist” (in 57 countries with national psycho-oncology societies) had to have the latest edition in their library to demonstrate their link to Jimmie Holland. Dr. Holland also co-wrote two well received books for the public: The Human Side of Cancer and Lighter as We Go: Virtues, Character Strengths, and Aging, the latter reflecting her interests in Geriatric Oncology as she approached her 90th birthday.

Dr. Holland was born in the small farming community of Nevada, Texas in 1928. She credits the local family physician in that community for her interest in medicine and caring for those who were suffering. She was one of only three women in her class at Baylor College of Medicine. In 1956, Dr. Holland married the renowned oncology pioneer James Holland, MD, who was then Chief of Medical Oncology at Roswell Park in Buffalo, NY. She would chide James, complaining that cancer patients were asked every conceivable question about their physical functioning but never, “How do you feel emotionally?” Dr. Holland pioneered the inclusion of psychological and emotional well-being patient-reported outcomes in quality of life measures and as a component of clinical outcomes in clinical trials.

Dr. Holland has received too many awards to list, however some notable ones include: The Medal of Honor for Clinical Research from the American Cancer Society, The Marie Curie Award from the Government of France, and the Margaret L. Kripke Legend Award for contributions to the advancement of women in cancer medicine and cancer science from the MD Anderson Cancer Center. She served as President of the Academy of Psychosomatic Medicine (APM) in 1996 and was the recipient of the APM’s Hackett Lifetime Achievement Award in 1994. She was also the inaugural recipient of the Arthur Sutherland Award for Lifetime Achievement from IPOS.

Over a 40-year career at MSK Cancer Center, Dr. Holland created and nurtured the field of Psycho-oncology, established its clinical practice, advanced its clinical research agenda, and through her pioneering efforts, launched the careers of the leaders of a national and worldwide field who mourn her passing and continue to work in what has become a shared mission to emphasize the care in cancer care.

After stepping down as Chairman of the MSK Department of Psychiatry and Behavioral Sciences in 2003, she kept working full time, seeing patients, conducting research, training and supervising fellows, and traveling the world lecturing and teaching. She also helped bring Psycho-oncology to Africa through her work with the African Organization for Cancer Research & Training in Cancer (AORTIC).

Born in a humble farming community with a one room school house, Dr. Holland created a life that led her to New York and the capitals of the world, honored by so many organizations and societies. She was teaching and seeing patients up until two days before her death. I think we’ll all remember her for various reasons. I certainly have many memories from a 34 year career working beside her. But on that list was her generosity and loving attitude towards her family, her patients, her colleagues, trainees, and everyone who crossed her path. Those who worked alongside her in medicine have made her mission our mission. We will continue this mission’s work, always remembering and honoring Dr. Jimmie Holland. Her death is a profound loss for all of Psychiatry, Psychosomatic Medicine, Psycho-oncology, and Oncology. We’ve lost a pioneer, a remarkable woman, a once-in-a-generation influencer.

Suicide Among Cancer Survivors — Highest Risk in HNC

Author: Roxanne Nelson, RN, BSN
Source: MedScape.com
Date: Feb. 20, 2018

ORLANDO, Florida — Head and neck cancer (HNC) accounts for only about 4% of new cancer cases in the United States, but the risk for suicide among survivors is significantly higher than for survivors of all other cancer types, with the exception of pancreatic cancer.

“The risk of suicide is significantly elevated across cancer sites, and the risk is especially high among HNC and pancreatic cancer survivors,” said Nosayaba Osazuwa-Peters, BDS, MPH, CHES, instructor, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Missouri.

“Cancer survivors are candidates for suicide-related psychosocial surveillance,” he added.

Cancer is the number 2 cause of death in the United States and accounts for 1 of every 4 deaths. Suicide is the tenth cause of death, independent of cancer. “If you add cancer to it, you get the perfect storm,” he said.

“Survivorship does come at a cost, and this is one of the more unfortunate costs of cancer survivorship,” Osazuwa-Peters told delegates here at the Cancer Survivorship Symposium (CSS) Advancing Care and Research.

Currently, there are more than 16 million survivors in the United States. The good news is that more people are surviving cancer, and there is now more focus on competing causes of death and comorbidities, he explained. There is also more focus on the increased risk for acute and late toxicities, which needs to be addressed as the rate of survival increases.

Osazuwa-Peters pointed out that there are “a lot of unmet psychosocial needs and struggles with functionality in this population. The overall risk of suicide among cancer survivors is 50% higher than in the general population.”

Findings from a recent study presented in 2017 at the European Psychiatric Association Congress found that a diagnosis of cancer significantly increases an individual’s risk of dying by suicide by 55% as compared to those without cancer.

“Throughout the lifetime of a survivor, the risk of suicide consistently remains higher,” Osazuwa-Peters pointed out.

Suicide Risk Significantly Higher in HNC

In this study, Osazuwa-Peters and colleagues sought to estimate the incidence of HNC-associated suicide in comparison with other common cancers and to quantify the suicide rate among HNC survivors compared with survivors of cancers other than HNC.

They used data from the Surveillance, Epidemiology and End Results (SEER) database from 2000-2014 to identify all cancer deaths that were confirmed as suicide. The death rates from suicide were estimated for the 21 most common cancers, including HNC.

SEER data revealed that there were 4513 suicides among 4,235,657 cancer survivors during that time frame. This extrapolates to an incidence rate of 23.6 suicides per 100,000 person-years.

For cancers in all other sites combined, the suicide rate was 45% lower than for HNC for both males (mortality rate ratios [MRRs] = 0.55; 95% confidence interval [CI], 0.48 – 0.64) and females (MRR = 0.55; 95% CI, 0.37 – 0.81).

Pancreatic cancer was the only cancer type in which the suicide rate was higher than for HNC (86.4 suicides per 100,000 person-years for pancreatic cancer vs 63.4 suicides per 100,000 person-years for HNC). When stratified by sex, this finding held true only for males; the suicide MRR was significantly higher for male pancreatic cancer survivors compared to that of HNC survivors (MRR = 1.54; 95% CI, 1.23 – 1.90). For females, the suicide MMR was highest with HNC compared with all other cancer types.

“A lot of conversation revolves around depression and fear, but depression does not equate to suicide, and data show that even patients who screen okay for depression still commit suicide,” said Osazuwa-Peters. “There are other factors, such as pain and fear, that may heighten the risk of suicide.”

It is important “that suicide is tackled as a problem” when guidelines are developed by the National Comprehensive Cancer Network and other major players, he said.

“Misery Index”

In a discussion of the paper, Christopher J. Recklitis, PhD, MPH, director of research at the Perini Family Survivors’ Center, Dana-Farber Cancer Institute, Boston, Massachusetts, noted that the suicide risk among cancer survivors has been studied for a while, and it has previously been suggested that HNC survivors are particularly at risk.

 

“This study is important because it focused on head and neck cancers, which isn’t often seen, and we can say that these data are largely confirmatory showing the elevated risk,” he said. “My take on this is that it highlights the need for better integration of mental health care into medical survivorship care.”

Not only does the risk for suicide need to be considered, but in general, the psychosocial needs of this population need to be considered more broadly, because suicide is something of a “misery index,” he commented.

“The number of people who are unfortunately ending their lives through suicide suggests that there is large group of people who are quite miserable and thinking about suicide and suffering in a way that needs attention,” he said.

But the study opens the door to several questions, he noted, namely, what is it about HNC that explains this excess risk?

“HNC survivors face poor prognosis, pain, disfigurement, and functional impairments, but that can be said of other cancer survivors,” he pointed out. He added that this group also has a higher risk for substance abuse and depression, but it is not known whether that risk contributes to risk for suicide.

“We need to understand these risks better so we can identify patients at risk and provide effective interventions, and also support the medical providers caring for this high-risk group,” Recklitis added. “We also need to move beyond registry data and study the risk over the course of survivorship, as it can change over time.”

Dr Osazuwa-Peters and Dr Recklitis have disclosed no relevant financial relationships.

Cancer Survivorship Symposium (CSS) Advancing Care and Research. Abstract 146, presented February 17, 2018.

 

 

February, 2018|Oral Cancer News|

Bareback Rider Cody Kiser Uses Tucson Rodeo Role to Rail Against Oral Cancer

Author: Norma Gonzalez
Source: Arizona Daily Star
Date: Feb. 23, 2018

Prior to Friday’s first event, Cody Kiser stretched and danced around the dressing room behind the chutes. Kiser was nothing but smiles as he loosened up for bareback riding at the 93rd annual La Fiesta de los Vaqueros.

While in high school in 2006, Kiser suffered an injury competing in bull riding. The bull stepped on his face, breaking all the bones in its left side. Kiser’s jaw was broken in two places and had to be wired shut. Through plastic surgery, Kiser had his face put back together.

Now, Kiser’s smile is more than just a gruesome injury story. The 27-year-old from Carson City became a spokesperson and role model with the Oral Cancer Foundation in 2014, and is the first spokesman to be affiliated with the rodeo.

“My side of it isn’t giving out a lot of facts,” he said. “Everyone knows smoking and chewing is bad. If you do it long enough, it’ll kill you.”

Kiser has never smoked or chewed. He simply doesn’t like it.

“I was never part of that,” Kiser said. “I just like to lead a healthy lifestyle and it just worked out so perfect to get involved with the foundation.”

So now, the bareback rider lends his voice to the foundation and helps in the prevention of tobacco use. According to oralcancer.org, as many as 15 percent of high school boys use smokeless tobacco in the United States. The nicotine content in a can of dip equals approximately 80 cigarettes, the website says.

The foundation’s slogan “Be smart — don’t start” could be seen embroidered down Kiser’s right sleeve.

“My part is the anti-tobacco, chewing or smoking, for the kids,” he said. “So I go around and represent the Oral Cancer Foundation and try to spread the word to these youngsters coming out to the rodeo that you don’t need to smoke or chew to be cool or to be a cowboy.”

At rodeos, Kiser hangs out with children and will have autograph sessions at times. Even if he finds kids hanging out nearby, he’ll reach out to the children.

Kiser said he knows plenty of cowboys who started using tobacco at a young age, so talking to children is important.

“It’s not so much smoking, but everyone’s chewing. It’s so prevalent (in the rodeo community),” Kiser said. “You talk to guys and they say they started chewing at 13 because their dad would do it.”

Kiser’s rodeo career has taken him all over the United States. He worked as Bradley Cooper’s stunt double in “American Sniper.” When Kiser stops to think about everything he’s been able to do at such a young age, he says he knows he’s been able to live an amazing life.

“So when I talk to younger people, I tell them not to smoke or chew, but I also tell them they need to travel — even if it’s just in the United States,” Kiser said. “I’m just the luckiest guy to be able to do all that, and rodeo has been the gateway to that.”

La Fiesta de los Vaqueros

  • Meili Chuinard Hepner, a 12-year-old student at Miles-Exploratory Learning Center, was honored after the bareback riding event. Meili, who came out to the Tucson Rodeo through the Children’s Western Wish Foundation, was named an honorary princess and was presented with a sash, buckle and cowboy hat signed by contestants. Meili, who was accompanied by her mother, Lisa, and siblings Noah and Amira, has neurofibromatosis (NF2), which causes tumors to grow on nerve endings. Lisa Chuinard said Meili was already suffering from hearing loss when she was adopted from China, but wasn’t diagnosed with NF2 until 2016. The 12-year-old said she was happy to be able to come out to the rodeo.
  • Evan Jayne made his seventh appearance at the Tucson Rodeo when he competed in bareback riding on Friday. Jayne was inspired by Louise Serpa’s book of rodeo photographs as a kid and eventually moved to the United States from France to pursue rodeo. The 35-year-old met Serpa 10 years ago and was photographed by the Tucson icon.

Jayne finished Friday’s run with a 73.00 score.

  • Riker Carter was the first bull rider to compete Friday, and the only one to have a qualifying run. Carter was awarded an 86.50.
  • The Tucson Rodeo announced a crowd of 9,000.

 

 

 

February, 2018|Oral Cancer News|

New cancer test isn’t ready for prime time

Author: H Gilbert Welch
Date: February 14, 2018
Source: http://www.cnn.com/2018/02/13/opinions/liquid-biopsy-opinion-welch/index.html

(CNN)- A simple blood test to detect cancer early. How great is that?

There has been enthusiasm about the so-called “liquid biopsy” for years. In mid-January, however, doctors learned more — both about this vision and its problems.

A widely reported study in the journal Science described a liquid biopsy test — CancerSEEK — which combined measuring eight tumor biomarkers with testing for pieces of DNA with cancer associated mutations in 16 genes.

It’s not one test; it’s a battery of tests. And while collecting the blood may be simple, the subsequent analysis is extraordinarily complex.

The task at hand is particularly challenging. We all have pieces of DNA in our blood. Distinguishing the tumor DNA from the background DNA requires finding the mutations specifically associated with cancer.

Adding to the complexity, healthy individuals can have mutations. To avoid labeling innocuous mutations as cancerous requires a bunch of statistical fine-tuning.

In other words, there are a lot of steps in a liquid biopsy and much potential for things to go awry.

To their credit, the CancerSEEK investigators were very forthright that the study conditions were ideal for the test to accurately detect cancer. The liquid biopsy simply had to discriminate between patients with known cancer (the majority of whom had symptoms) and healthy individuals. And the statistical fine-tuning was tailored to the study participants — with the knowledge of who had, and who did not have, cancer.

Although the test was able to detect most of the late-stage cancers, it detected less than half of the stage 1 cancers.

But doctors don’t screen to find advanced cancer, we screen to find early cancer. And we don’t screen people with symptoms of cancer, we screen people who don’t have symptoms of cancer.

There’s no doubt that there would be more detection errors in the less controlled environment of the real world.

Just how often was made clear in a recent JAMA-Oncology study. Forty patients with metastatic prostate cancer received liquid biopsies to tailor therapy in real time to the genetics of their spreading tumors. That’s the vision for precision medicine.

But the investigators added a little twist. They wanted to know whether it mattered which lab the liquid biopsies were sent to. So they sent each patient’s blood for two different commercial liquid biopsies: Guardant360 and PlasmaSELECT. Both tests were designed to detect mutations in the same genes.

Yet in over half of the 40 patients, the tests gave different answers about which mutations were present. Different liquid biopsy tests give different answers in a majority of patients? That’s not precision, that’s awful.

Sure, the analyses of liquid biopsies will improve. But if this much confusion exists about what mutations are present in the blood of patients with metastatic cancer (who have a lot of tumor DNA), imagine the uncertainty that will exist for asymptomatic individuals not known to have cancer — the very people who would be screened.

And then there is the question of what to do with a positive result. This is very different than detecting a concerning lung nodule on a screening chest CT scan or a concerning breast mass on a screening mammogram. In these cases, it’s clear what to do to get a definitive answer: surgically biopsy the nodule or the mass. But with a liquid biopsy, the anatomic location of a cancer can be a mystery. It may not even be clear what organ the cancer is in.

Imagine what this might mean for a patient: A doctor says, “It looks like you have cancer, but we are not sure where.”

Even if there is certainty that the cancer is in, say, the liver, doctors may not know where in the organ. What to do then? Randomly biopsy different parts of the liver?

This is doubly concerning when screening average-risk individuals, because most positive results are expected to be false alarms. We typically learn that a screening test is falsely positive because a surgical biopsy is normal. But absent the knowledge of where to biopsy, how can we ever be sure a positive liquid biopsy is wrong?

Doctors won’t know where to look, but we will keep looking. Liquid biopsies are a recipe for more health anxiety, more procedures, more complications and more overdiagnoses. Not to mention, more out-of-pocket costs for our patients.

Of course, we should continue to study liquid biopsies. The detection of circulating tumor DNA may ultimately prove useful in selected settings, such as tailoring therapy for aggressive cancers that are rapidly mutating. But the real enthusiasm is for screening average-risk individuals.

One reason is obvious: there is a lot of money to be made. A Goldman Sachs video estimated the potential liquid biopsy market to be $14 billion annually, adding “and we’re just at the beginning.” That kind of money doesn’t come from testing the few patients with aggressive cancer, that comes from screening millions of people.

And there is a less obvious reason: it is easier for a new test to pass regulatory muster than it is for a new drug. While the FDA has a longstanding mandate to protect us from snake oil treatments, this often doesn’t extend to snake oil testing.

The enthusiasm for finding things that might benefit people in the future ignores the fact that doing so can cause people to have problems now. In short, a bad test can do as much damage as a bad drug. Worrisome liquid biopsies will start a cascade of subsequent, not-so-simple tests and procedures. People will be hurt in the process.

February, 2018|Oral Cancer News|

CDHA Urges Hygienists to Remind Patients of Oral Cancer Screening

Author: Canadian Dental Hygienists Association
Date: January 29, 2018
Source: https://www.oralhealthgroup.com

World Cancer Day (February 4) is a perfect time for dental hygienists across Canada to remind the public of the importance of regular oral cancer screenings, not only during dental appointments, but also now at home.

The Canadian Cancer Society projected in 2017 that 4,700 Canadians would be diagnosed with oral cavity cancer, and that 1,250 Canadians would die.  In hopes of improving the long-term outcomes for people diagnosed with oral cancer, the Canadian Dental Hygienists Association (CDHA) has partnered with the Oral Cancer Foundation and the American Dental Hygienists Association on a “Check Your Mouth™” initiative to help individuals identify the early signs and symptoms of oral cavity cancers.  “Dental hygienists recognize that early detection has great potential to reduce the oral cancer burden in Canada,” states Sophia Baltzis, CDHA president. “Between dental visits, which usually include an oral cancer screening, our clients can and should examine their mouths for suspicious tissue changes.”

The Check Your Mouth™ campaign features an interactive website (www.checkyourmouth.org) that offers easy-to-use tools and tips for a quick visual and tactile examination of the oral cavity.  Individuals can learn to self-discover the early symptoms of disease and then seek further evaluation from a dental professional if necessary.  “Dental hygienists are your partners in prevention,” adds Baltzis. “We encourage all Canadians to maintain a healthy lifestyle, practice good oral hygiene habits, and spot the early signs of oral cancer. The Check Your Mouth™ website is a valuable resource that everyone should explore.”  By raising public awareness of oral cancer and its early signs and symptoms, dental hygienists are helping to meet the global challenge of saving lives. Together, we can make a difference!

Serving the profession since 1963, CDHA is the collective national voice of more than 28,495 registered dental hygienists working in Canada, directly representing 19,000 individual members including dental hygienists and students. Dental hygiene is the 6th largest registered health profession in Canada with professionals working in a variety of settings, including independent dental hygiene practice, with people of all ages, addressing issues related to oral health. For more information on oral health,

January, 2018|Oral Cancer News|

Study Identifies Potential Cause of Hearing Loss from Cisplatin

Author: NCI Staff
Date: January 26, 2018
Source: National Cancer Institute (https://www.cancer.gov/news-events)

Results from a new study may explain why many patients treated with the chemotherapy drug cisplatin develop lasting hearing loss.

Researchers found that, in both mice and humans, cisplatin can be found in the cochlea—the part of the inner ear that enables hearing—months and even years after treatment. By contrast, the drug is eliminated from most organs in the body within days to weeks after being administered.

The study, led by researchers from the National Institute on Deafness and other Communication Disorders (NIDCD), part of the National Institutes of Health, was published November 21 in Nature Communications.

Cisplatin, a platinum-based chemotherapy drug, is commonly used for the treatment of many cancers, including bladder, ovarian, and testicular cancers. But cisplatin and other similar platinum-containing drugs can damage the cochlea, leaving 40%–80% of adults, and at least 50% of children, with significant permanent hearing loss, a condition that can greatly affect quality of life.

“This study starts to explain why patients who receive the drug sustain hearing loss,” said Percy Ivy, M.D., associate chief of NCI’s Investigational Drug Branch, who was not involved in the study. “This is very important, because as we come to understand how cisplatin-related hearing loss occurs, over time we may figure out a way to block it, or at least diminish its effects.”

A New Approach to Researching Cisplatin-Induced Hearing Loss

The new study differs from previous research because it is a comprehensive look at the pharmacokinetics, or concentration, of the drug in the inner ear, explained study investigator Andrew Breglio, of NIDCD.

The research team primarily used a technique called inductively coupled plasma mass spectrometry (ICP-MS) to quantify the amount of platinum left in inner ear tissue following cisplatin treatment in mice.

Lisa Cunningham, Ph.D., of NIDCD, who led the research team, noted that instead of using one high dose of cisplatin with mice as other studies have, they developed a treatment protocol like those used in everyday care, in which the drug is given in cycles.

Testing done following each cisplatin cycle showed increasingly progressive hearing loss in the mice. The researchers also measured platinum levels in various organs throughout the drug cycles and found that, whereas other organs eliminated the drug relatively quickly, the cochlea retained the cisplatin, showing no significant loss of platinum 60 days after the last administration of the drug.

The researchers also conducted postmortem analysis of inner ear tissue of human patients who had received cisplatin, and found that platinum was retained in cochleae at least 18 months after the last treatment. In addition, they found that in the cochlea of one pediatric patient (the only one available for study), significantly more platinum was retained than in adult patients, consistent with the fact that children’s ears are known to be more susceptible to cisplatin-induced hearing loss.

In both the mouse model and in studies of human tissue, the researchers determined that the platinum accumulates in a part of the cochlea called the stria vascularis, which, Breglio explained, regulates the makeup of the fluid that bathes the sensory hair cells in the ear “and is critical to their proper function.”

This lengthy retention in the cochlea could explain why this drug is damaging the inner ear, Breglio said. Furthermore, these findings, demonstrating the accumulation of the drug and identifying where it is retained, mean that future studies need to “look beyond hair cells” to explain cisplatin-induced hearing loss, the researchers wrote.

Findings That Could Lead to Hearing Loss Treatment and Prevention

The finding that cisplatin is retained in the cochlea indefinitely is important for patient care, Dr. Ivy said.

Hearing loss from cisplatin “is not a static injury, it doesn’t stay the same. It can progress over time and it can occur late,” she added. “That suggests that a long-term survivor needs ongoing monitoring of their hearing.”

She said it will be up to practitioners to continue this monitoring and to rapidly intervene with devices that assist in hearing, such as hearing aids.

Hearing loss can have a particularly negative impact on children, she said.

“If adults develop hearing loss, they’re more acutely aware of it, and are more likely to seek assistance, whereas younger children who develop hearing loss might not notice it as much or be unable to explain the problem,” she explained. “Since they can’t hear very well, they may have trouble paying attention and that could be misconceived as a learning disability or a behavior problem. And yet, if they get the appropriate intervention, they perform at the same level they did prior to receiving platinum.”

This is why researchers on Dr. Cunningham’s team are trying to find ways to block cisplatin from entering the inner ear. They are looking at the cellular mechanism by which cisplatin is taken up by the cells of the stria vascularis to find ways to block uptake, as well as identify drugs that might “target cisplatin itself, and bind it or sequester it” before it can get into the inner ear, Breglio said.

“[Cisplatin] is one of the most widely used anticancer drugs on the planet, and it’s saving a lot of lives,” Dr. Cunningham said. But the hearing loss is permanent. “So these patients are surviving and they have this hearing loss for the rest of their lives. What we’d like to be able to do is develop a therapy that will allow patients to take the life-saving drug, but preserve their hearing.”

 

January, 2018|Oral Cancer News|