Forgotten patients: New guidelines help those with head-and-neck cancers

Author: Diane Mapes and Sabrina Richards

Stigma, isolation and medical complexity may keep patients from getting all the care they need; recommendations aim to change that.

Like many cancer patients, Jennifer Giesel has side effects from treatment.

There’s the neuropathy in her hands, a holdover from chemo. There’s jaw stiffness from her multiple surgeries: an emergency intubation when she couldn’t breathe due to the golf ball-sized tumor on her larynx and two follow-up surgeries to remove the cancer. And then there’s hypothyroidism and xerostomia, or dry mouth, a result of the 35 radiation treatments that beat back the cancer but destroyed her salivary glands and thyroid.

“I went to my primary care doctor a couple of times and mentioned the side effects,” said the 41-year-old laryngeal cancer patient from Cleveland, who was diagnosed two years ago. “She was great but she didn’t seem too knowledgeable about what I was telling her. She was like, ‘Oh really?’ It was more like she was learning from me.”

Patients like Giesel should have an easier time communicating their unique treatment side effects to health care providers with the recent release of new head-and-neck cancer survivorship guidelines. Created by a team of experts in oncology, primary care, dentistry, psychology, speech pathology, physical therapy and rehabilitation (with input from patients and nurses), the guidelines are designed to help primary care physicians and other health practitioners without expertise in head-and-neck cancer better understand the common side effects resulting from its treatment. The goal is that they’ll then be able to better make referrals or offer a holistic plan for patients to get the support they need.

“Head-and-neck cancer survivors can have enormous aftereffects from the disease and treatment by virtue of the location of the primary tumor,” said Dr. Gary Lyman, a public health researcher with Fred Hutchinson Cancer Research Center who helped create the guidelines. “There are functional interruptions, like losing the ability to talk, eat or taste. And some of the surgeries can be disfiguring.

“I’m really glad the American Cancer Society decided to take this on,” he said. “These guidelines are sorely needed, long overdue and will serve cancer patients who are incredibly affected — both physically and emotionally.”

Currently, there are more than 430,000 head-and-neck cancer, or HNC, survivors in the U.S., accounting for around 3 percent of the cancer patient population.

As with many other cancers, HNC is an umbrella term for a number of different malignancies, including cancers that develop in or around the mouth, tongue, throat, nose, sinuses or larynx. Brain, thyroid and esophageal cancer are not considered head-and-neck cancers.

HNC has traditionally been linked to tobacco and alcohol use, and about 75 percent of HNC are related to these risk factors. Increasingly, though, human papillomavirus, or HPV, is causing a significant number of head-and-neck cancers (another reason why the HPV vaccine is such an important prevention tool).

An isolating group of diseases
For some patients with HNC, there can be a certain amount of stigma and isolation, due to its association with drinking and smoking. Treatment can also isolate patients since it sometimes mars a person’s appearance or alters their speech.

Some patients, literally, have no voice.

HNC’s complicated nature — it’s not one disease but several, all of which behave and respond to treatment differently — also results in very small patient populations, which can hinder research.

“Head-and-neck cancer patients have historically been somewhat ignored,” said Lyman, an oncologist with Seattle Cancer Care Alliance, Fred Hutch’s treatment arm. “Many view this as a lifestyle-associated cancer, like lung cancer, heavily influenced by tobacco exposure and [drinking] alcohol to excess. And people may have difficulty dealing with the appearance of some of the more severely affected patients.”

t’s a sentiment echoed by Dr. Eduardo Méndez, a Fred Hutch clinical researcher and head-and-neck cancer surgeon at SCCA.

“It’s in a location that affects your appearance, it affects your ability to speak and to swallow, and those are all things that you need to interact with others,” he said. “It can have an effect of shutting you down from the rest of society. Even the treatment for head-and-neck cancer can have consequences that affect those very same things that the tumor was affecting — swallowing, speech, appearance.”

Not surprisingly, many HNC survivors suffer from depression and/or body image and self-esteem issues after diagnosis and treatment.

“I struggle with body image issues every day,” said Beci Steelman, a 42-year-old court clerk from Bushnell, Illinois, who went through radiation and eight surgeries, including a total right maxillectomy (a surgery of the upper jaw), after being diagnosed with a rare head and neck tumor in 2010.

“You can see that my eye looks like someone’s pulling it halfway down my cheek,” she said. ”My mom and I just call it my googly eye and joke that I have ‘really good face days’ and others that are just ‘face days.’ Clearly something’s not right. When I smile, you can see a bit of metal from the obturator, this weird rubbery dental piece that plugs the hole in the roof of my mouth. Some days I just feel like I’m so ugly.”

Holistic approach benefits patients
There is good news with these cancers: most patients are diagnosed with HNC in its early, most curable stages.

“The majority will be completely functional and normal [after treatment],” said Dr. Christina Rodriguez, the medical oncologist who oversees the majority of HNC patient care at SCCA.

According to the National Comprehensive Cancer Network, around 80 to 90 percent of early stage patients (stage 1 and 2) go into remission after receiving surgery or radiation. Advanced stage patients (stage 3 and 4) receive more aggressive treatment and have lower cure rates, with the exception of patients with HPV-related head-and-neck cancers. Their 5-year cure rates are close to 90 percent.

But even those who go into remission may have to contend with a constellation of difficult side effects.

The head and neck area is “like a fine-tuned machine,” said Dr. Keith Eaton, a medical oncologist at SCCA and Fred Hutch who specializes in lung cancer and HNC. “There are so many dedicated structures that we can’t do without. If you get rid of half your liver, not a problem. If your epiglottis doesn’t work, you aspirate.”

In addition to trouble with swallowing and speech, stiffness in the jaw and problems with shoulder and neck mobility, HNC patients can be left with hypothyroidism, hearing loss, taste issues, periodontitis and lymphedema, the swelling that comes after lymph nodes are surgically removed, a common step in cancer treatment. Because of this complexity, patients need a holistic approach, said Méndez.

Steelman’s cancer extended to the orbital floor of her right eye which meant she had to undergo extensive surgery to her face including the removal of four back teeth, an incision to the roof of her mouth and the shortening of a jaw muscle.

“They got the tumor out and then put me back together,” she said. “I feel like Humpty Dumpty.”

She now wears a prosthetic (which requires daily maintenance) and has had injectable fillers to help with the atrophy around her right eye (an implant in the area became infected and had to be removed). She’s lost hearing in her right ear, her speech is sometimes “a little marble-y,” she has dry mouth from damage to her salivary glands and her jaw will not open as wide as it once did.

Steelman tapped a number of specialists to help her deal with these issues, including an otolaryngologist (ear, nose and throat doctor), speech pathologist, a prosthodontist (an expert in the restoration and replacement of teeth) and a plastic surgeon.

“You have to be your own advocate,” she said. “You learn that very quickly.”

Get help early
Physical therapists, speech pathologists, dietitians and providers with expertise in palliative and pain care (also called supportive care) can improve survivors’ quality of life enormously, especially when therapy is started early.

“Careful — and early — attention to side effects and treatment-related complications can help optimize survivors’ quality of life,” said Eaton, the SCCA oncologist.

Dr. Elisabeth Tomere, a physical therapist at SCCA, said she and her colleagues prescribe exercises that help patients regain strength, range of motion and tissue flexibility that surgery and/or radiation may have diminished. Some patients, for instance, need help building up their trapezius muscle to improve shoulder function they have lost after neck surgery. Others need to learn movements that strengthen the front of their necks and the muscles needed to maintain posture.

Patients with lymphedema in the face and neck — a common side effect from HNC treatments — can also benefit from early intervention by a physical therapist, said Tomere.

“These issues are all helpful to address as quickly as possible so they’re not ongoing,” she said, adding that it may take up to two years for patients to mentally and physically recover from treatment.

“We try to give people a realistic timeline,” she said.

The new ACS guidelines should help providers without expertise in head-and-neck cancers find the right specialists for their patients, she said.

Cancer physical therapy, while new, is becoming more standard. Both the American Physical Therapy Association and the Lymphology Association of North America allow providers or patients to search for specialized physical therapists near them — a boon to primary care providers who are not “connected to that world,” said Tomere.

Dietitians can play a key role, too, since many HNC patients struggle to eat. Treatments can cause dry mouth, taste changes or make chewing difficult. Food can become unappetizing or difficult to ingest.

“There’s an emotional component. Food becomes medicine,” said Linda Kasser, an SCCA dietitian and specialist in oncology nutrition. Patients must eat to keep their weight up, “but it can become exhausting … Sometimes they need to force themselves to eat. They feel pressured, which can contribute to family tensions and even food aversions.”

Dietitians can offer approaches to help patients maintain their weight and strength, from using new cooking strategies to make food more palatable to recommending temporary feeding tubes inserted into the stomach that help patients avoid the pain of chewing and swallowing altogether. They also help alleviate patients’ worries about food and separate “nutrition fallacy from fact,” said Kasser.

Not surprisingly, communication is strongly emphasized in the guidelines.

“We wanted to make sure that there is open communication between the providers and caregivers,” said Lyman. “That there’s a care plan that the patient understands and the caregiver understands. All the different specialists involved in the care should be on the same page.”

The new guidelines also emphasize lifestyle choices that will help to reduce the risk of HNC recurrence and secondary cancers: smoking cessation, limiting use of alcohol, regular exercise and good oral hygiene.

Exciting new research
Chemotherapy, radiation and surgery remain the standard of care for HNC — and drive many of the side effects covered by the new ACS care guidelines — but recent advances are making researchers like Méndez very optimistic for future care.

Thanks to advances in genomics, researchers now know that the mutations found in head and neck tumors vary widely.

“One size will not fit all,” said Méndez. “Treatment will have to be individualized.”

Méndez is leading efforts at Fred Hutch to develop tailored therapies based on the cancer’s genomic mutations, zeroing in on cancer cells’ “Achilles heels” — molecular pathways that tumor cells rely on to survive but that normal cells can do without. The approach is already paying dividends: Méndez is currently leading a clinical trial of a drug he and his team identified that exploits a vulnerability unique to head and neck tumors missing a key gene called p53.

“Once we understand the genotype driving tumor growth, strategies [for treatment] can become more targeted, more effective and less toxic,” he said.

New robotic-assisted surgery has also transformed the procedure for certain patients with tumors in the larynx and at the base of the tongue, allowing surgeons to perform fewer incisions and better preserve functions like swallowing and speech, he said.

Immunotherapy also looks like a very promising path to better HNC treatments.

“New immunotherapy drugs are getting FDA approval for head and neck cancer,” said Méndez. “I think in the next few years we will see it moving to a first-line therapy. It’s a very exciting time for head and neck cancer.”

For patients like Steelman and Giesel, that’s great news.

“I had a social worker who helped me get through the thick of [treatment], but nobody talked about what it would be like when treatment was over,” said Giesel, who had to teach herself how to swallow food a new way (she no longer has an epiglottis). “I thought I’d be returned to myself and I’d be fine, but it was not like that in any way.”

These new guidelines, she said, will help patients like her get the help they truly need.

“Primary care doctors need to know about the physical and emotional effects,” she said. ”I have a lot of good support and know how to ask for help, but I can’t imagine how [patients] who don’t know how to ask for help explain how they’re feeling.”

Do you or someone you love have a head-and-neck cancer? Join the conversation about treatment challenges and how the new guidelines might help on our Facebook page.

About the authors:
Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor and patient advocate, she writes the breast cancer blog and tweets @double_whammied. Reach her at

Sabrina Richards is a staff writer at Fred Hutchinson Cancer Research Center. She has written about scientific research and the environment for The Scientist and OnEarth Magazine. She has a Ph.D. in immunology from the University of Washington, an M.A. in journalism and an advanced certificate from the Science, Health and Environmental Reporting Program at New York University. Reach her at

1. Original article available at:

April, 2016|Oral Cancer News|

A small revolution in cancer treatment by Belarusian and U.S. scientists

Author: Igor Belotserkovsky

Scientists from Belarus and the United States have developed a new method for detecting residual cancer cells. This method also contributes to their destruction. This is done with the help of nanobubbles generated in some cancer cells. The method was successfully tested on laboratory mice with implanted head and neck cancer cells. Although scientists are only at the beginning of the road, they call their discovery a small revolution in the fight against cancer.

The results of the research titled “Intraoperative diagnostics and elimination of residual microtumors with plasmonic nanobubbles” was published in the prestigious science journal Nature Nanotechnology on 15 February. To learn more about the successes of oncologists, BelTA talked to Igor Belotserkovsky, PhD in Medical Sciences, one of the authors of the research, the leader of the head and neck tumor research team at the Aleksandrov National Cancer Center.

Mr Belotserkovsky, what is the share of head and neck tumors in the structure of other localizations?
In the total structure of oncological morbidity, the share of head and neck tumors is 3-4% (excluding skin cancer). Larynx and oral cavity cancer are diagnosed most frequently. For example, in 2014 laryngeal cancer was detected in 604 Belarusians, oro-pharyngo-laryngeal cancer in 1,338 people. Men fall ill ten times more often.

Despite the fact that head and neck cancers are categorized as tumors of outside localization, many patients with cancer have their disease diagnosed when it has already reached an advanced stage. This is due to the social aspect. In most cases cancer patients are alcohol and smoking abusers. In 2014, 50% of laryngeal cancer cases were found at an early stage, as was 30% of cases of oral cavity cancer.

Why has it been decided to test the new method specifically on head and neck tumors?
Head and neck account for 9% of the total body surface area. Yet, this is where many important organs are located. If one of these organs is affected by cancer, oncologists have to work in a small body region. When removing a tumor, a surgeon cannot cut out much of the normal tissue surrounding it. He has to remove the parts affected by cancer and ensure no damage is done to vitally important structures.

For this reason, the radicality of head and neck cancer surgeries is strongly debated. Some reputable specialists believe that many head and neck surgeries are conditionally radical. We remove the visible tumor, and some unnoticed microscopic metastatic cancer cells may remain in the body. These cells cause cancer recurrences that are more difficult to treat, because they are more resistant to drugs, chemotherapy, and radiation therapy.

What is special about this new treatment method?
Its breakthrough nature is seen in our ability to spot and eliminate residual cancer cells during the surgery, right after the removal of the visible tumor. Today there is no fast, accurate and safe method for detection of individual cancer cells and microtumors in the tumor removal zone to be used during the surgery.

The method is based on the utilization of gold nanoparticles and laser radiation to generate nanobubbles inside tumor cells. The nanobubbles, in turn, are detected with an acoustic probe. For this purpose, the gold nanoparticles are decorated with special antibodies that identify cancer cells and gather in clusters only around the tumor, thereby ensuring no damage is done to healthy tissue.

The approach has been successfully tested on lab mice. The animals of the research and control groups underwent the same operations to remove implanted head and neck tumors. With additional minimal surgery conducted after detection of residual cancer cells with plasmonic nanobubbles, the survival rate in the research group was 100%. Meanwhile, the control group mice underwent only a standard surgery and died of progressing tumor. By the way, nanobubbles helped eliminate inoperable microtumors.

The idea is to reduce the frequency of tumor recurrence. The procedure is as follows: a patient gets an injection with gold nanoparticles before the surgery. After the tumor is removed, the tumor bed is treated with laser which activates nanobubbles that quickly expand and burst, ripping apart the residual cancer cells.

We expect that the new method will help reduce the number of local recurrences. It will allow a maximum radical removal of tumors. Oncologists will be able to eliminate cancer cells, which may cause recurrences, at the microlevel.

When do you plan clinical tests?
We are ready to conduct the tests, here in Belarus. Our center has a high level of credibility in research. Foreign companies annually run nearly 30-40 clinical tests in the Aleksandrov National Cancer Center.

However, it is still early to talk about the date for clinical testing of the new method. There is a certain algorithm to follow. It can take up 3 to 4 years from research to the final product.

What are the prospects for the plasmonic nanobubbles technology?
Proceeding from the results of the experiment, we can say it is a small victory over cancer. However, I would like to reiterate that in interpreting our successes we do not go beyond the framework of the experiment. In the future this technology can be used to treat other types of cancer.

How long did the research take? Who financed the studies?
This is a Belarusian-U.S. project launched some three years ago. Dmitry Lapotko, head of laser science at medical nanotechnology group Masimo Corporation, is the leading researcher. The project was financed by Gillson Langenbough Foundation, Houston, TX and the National Science Foundation of the United States.

Thank you for the interview. We wish you every success with this important project.

February, 2016|Oral Cancer News|

Rodeo Insider: Cowboy takes it on himself to ride home a message

Author: Brett Hoffman
0125 rodeoBronc rider Cody Kiser is trying to encourage cowboys to abstain from tobacco. Richard W. Rodriguez Star-Telegram


In a day when rodeo riders are approaching the sport from an athletic standpoint more than ever, there’s a heavier emphasis on physical fitness and many competitors are taking a closer look at abstaining from substances such as alcohol and tobacco.

One cowboy attempting to send a message about abstaining from frequent tobacco consumption is bareback bronc rider Cody Kiser.

“A lot of these cowboys don’t smoke or chew, and if they do, it’s really rare,” Kiser said. “A lot of the guys consider themselves as athletes. So they want to keep their bodies at an optimum performance and they don’t want to do anything that would break them down.”

When the Fort Worth Stock Show conducted the opening performance of its 16-day Professional Rodeo Cowboys Association show on Friday, Kiser turned in a bareback score of 80, the highest marking of the night.

As he competed in the renowned rodeo, Kiser wore a patch on his shirt that said: “Oral Cancer Foundation.”

The foundation’s website lists Kiser and a spokesman and states: “The western/rodeo environment has had a long-term relationship with tobacco, and until 2009 the PRCA had a lengthy history of tobacco sponsorship money. While that has ended, tobacco use, and smokeless/spit tobaccos still thrive in the sport. While adults have the right to make any lifestyle choice, they inadvertently expose impressionable young people to what are sometimes harmful habits though poor examples like the use of tobacco products. This is particularly harmful as kids look up to athletes.”

Kiser, 25, who is from Carson City, Nev., aspires to set a great example.

“My message is for the younger generation, to expand the sport of rodeo and help it become more mainstream,” he said. “Rodeo can be like NASCAR. When NASCAR started getting rid of most of their alcohol and tobacco sponsors and then started bringing in sponsors such as Tide and Kellogg, which are more family oriented, then the sport exploded. Today, there’s so much more money in NASCAR and it can become the same for rodeo.”

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

For the war against oral cancer, what’s in your arsenal?

Author: Dennis M. Abbott, DDS

The face of oral cancer has changed: No longer is oral cancer a disease isolated to men over 60 years of age with a long history of smoking and alcohol consumption. Today, the demographic for the disease includes younger people of both sexes with no history of deleterious social habits who are otherwise healthy and active. It spans all socioeconomic, racial, religious, and societal lines. In other words, oral and oropharyngeal cancer is an equal opportunity killer. Today, as you read this article, 24 people in the US will lose their battles with oral cancer. That is one person for each hour of the day, every day of the year. Each of those lost is someone’s sister, a father’s son, a small child’s mommy, or maybe even a person you hold dear to your heart. The truth is, oral and oropharyngeal cancer has several faces . . . and each of those faces is a human being, just like you and me. So how can we, as dental professionals, be instrumental in the war against oral and head and neck cancer?

Views of the oropharynx, the base of the tongue, and the epiglottis, taken with the Iris HD USB 3.0 intraoral camera using different points of focus. Photos courtesy of the author.

Views of the oropharynx, the base of the tongue, and the epiglottis, taken with the Iris HD USB 3.0 intraoral camera using different points of focus.
Photos courtesy of the author.

The answer, as with most other cancers, lies in early detection. When oral and oropharyngeal cancer is detected early, the five-year survival rate can be as high as 80% to 90%. The harsh reality is that most oral and head and neck cancers are only found at late stages after the cancer has advanced—often to the lymph system. As a result, the chance of the person living for five years after diagnosis falls to approximately 55%.

As dentists and dental hygienists, we—like it or not—are on the front line of this war. We often have the opportunity to see potential cancer patients more frequently than our medical colleagues do, and we are trained to see abnormalities inside the mouth and in the head and neck region. (This is a huge part of the solution!) Many of my medical colleagues tell me that they do not have the training to see what I can see in the mouth. But I do not have the training to practice oncological medicine like they do. The truth is, it takes all of us doing our jobs to care and manage the individual person—not just the teeth, not just the liver, not just the breast, but the whole patient.

Years ago, we could almost profile who would or would not be likely to present with oral cancer. It was always the “Marlboro man”—that guy who was older, drank alcohol frequently, and had a smoking pack-year history that was two or three times his age. But those days are long gone. With the recent understanding that the human papillomavirus (HPV), the most common sexually transmitted infection in the United States, is an etiological factor for oral and oropharyngeal cancer, virtually everyone is a potential cancer patient. As such, everyone should be screened. While the individual with classic risk factors still remains at risk for developing oral cancer, many who present with HPV-related oral and head and neck cancers have no other discovered risk factors, other than exposure to HPV and an immune system that, for reasons still unknown, will not adequately clear the virus without repercussions.

It is believed that 80% to 90% of all Americans have been exposed to HPV at least once in their lifetimes. Most people manage to clear the virus through the immune system’s normal defense function within six to seven months; in some patients, however, damage takes place at the cellular level that may take months, years, or even decades to manifest as cancer. The majority of HPV-related oral and head and neck cancers present in areas that are difficult for us as dental professionals to visualize, such as the tonsils, the base of the tongue, the oropharynx, the posterior pharyngeal wall, and the larynx. That, however, does not give us an excuse not to screen in these areas . . . we just have to think outside of the box and get creative about how we screen.

Visual inspection combined with palpation remains the essential foundation of screening for oral and oropharyngeal cancers, but where visualization is difficult—such as with the base of the tongue and the lower oropharynx—knowing and asking the right questions can become critically important for identifying potential concerns:
“Are you noticing any unusual hoarseness?”
“Are you having any difficulty swallowing?”
“Do you ever have a sensation as though something is caught in your throat?”
“How long has that tonsil been inflamed?”
“Have you noticed any sinus or allergy issues since that tonsil has been enlarged?”
While these questions may seem unrelated to teeth, they are not unrelated to oral health. Simply asking the right questions can open a dialogue of discovery that may lead to the detection of an oropharyngeal cancer early. And early detection is the key to beating the disease and maintaining a good quality of life during the survivorship years.

Technology-based adjunctive devices to assist the dental professional in the early detection of oral cancer have existed in the market for the past 10 to 15 years. Much has been written about fluorescence and reflective technologies, which help the examiner to detect subtle changes in tissue through the usage of light in the violet and yellow ranges of visible light, respectively. Examination with these wavelength-specific devices enhances visualization by highlighting changes in the oral mucosa and vasculature. Usage of these adjuncts has also demonstrated value in enabling clinicians to better understand the size of affected tissue surrounding suspected lesions. As such, these may be useful in selecting a field for biopsy that may produce clear, or noncancerous, margins.

Since the completion of the Human Genome Project (HGP) in 2003, there exists a more clearly defined understanding of how diseases such as cancer affect our cells at the nucleic acid level and how genetic mutations can serve as risk factors or catalysts for cancerous changes in cells. Technology used in the HGP has also provided insight into the genotyping of viruses, leading to a sharper picture of how viral interaction with our genetic code can lead to disease. Today, the dentist and dental hygienist have this technology readily available to move their practice into the era of personalized health.

Salivary tests, such as the MOP (Molecular Oral Testing) by PCG Molecular, take advantage of innovative, advanced genetic testing to establish the risk or presence of oral or oropharyngeal squamous cell carcinoma. MOP does this by evaluating cellular abnormalities in the oral cavity and oropharynx, DNA damage associated with oral and oropharyngeal cancer, and the presence of HPV. With this information, the clinician can better determine the appropriate course of action for the patient.

Sometimes striving to provide the best possible patient care means thinking outside of the box to use technology designed for one purpose and discovering a new application to meet an unanswered need. Most of us are at least familiar with intraoral cameras, and many of us have them in our offices. Using the magnified imagery of a quality intraoral camera and a high-resolution monitor, this tool is a favorite device for illustrating the need for proposed treatment and for establishing patient trust. But what if we could use those images to possibly save a life?

The Iris HD USB 3.0 intraoral camera by Digital Doc LLC has catapulted intraoral photography into the high-definition age. Using the Iris HD precision optical lens array and an advanced HD sensor from Sony, the Iris HD USB 3.0 provides unmatched 720p-resolution clarity that is perfect for the magnification and photographic capture of suspicious areas discovered during a thorough head and neck examination/oral cancer screening. Because of the size of the camera head, the device even makes it possible to examine areas of the oropharynx that were previously difficult for dentists and hygienists to visualize.

Of course, the camera cannot substitute for laryngeal endoscopy, especially if cancer inferior to the epiglottis is suspected, but the camera’s ability to see beyond the palatopharyngeal arch is an improvement over an angled dental mirror. Most patients can tolerate the necessary posterior placement of the camera to capture an oropharyngeal image either by breathing through the nose or with placement of a topical anesthetic on the posterior soft palate and uvula to suppress the gag reflex.

Regardless of the power of the technology, the ultimate skill in detecting early-stage oral and oropharyngeal cancer lies in the eyes, hands, and brain of the examiner. Careful inspection, knowledge, discernment, and experience are the real tools of the professional for acquiring and processing all of the available data and for correctly fitting the puzzle pieces into a picture that illustrates either health, concern with reason for reevaluation, or the need to biopsy the area in question. When reevaluation is required, no more than two weeks should elapse between the initial examination and follow-up, as time is of the essence in proceeding to treatment should the suspicious area indeed be cancerous.

Responsibility to the patient does not end with an abnormal screening result. The dental professional should have a plan in place to either biopsy or refer. The dental professional should biopsy only if he or she is well-experienced in the removal of suspected cancerous lesions. Otherwise, the patient should be referred to an oral/maxillofacial surgeon, periodontist, otolaryngologist, or head and neck surgeon who is comfortable with and experienced in the safe and effective biopsy of a potentially cancerous area. It is most often the case that only one opportunity to obtain a diagnostic tissue sample exists, so the skills of the doctor performing the biopsy should be without question. Every effort should be made to ensure that the patient is seen promptly for biopsy and that the pathology results are returned and shared with the patient expeditiously. Delay can be detrimental to the survival of a patient with oral or oropharyngeal cancer.

Should a screening result from your office lead to a diagnosis of oral or oropharyngeal cancer, be prepared to counsel and educate your patient about what to expect in his or her cancer journey. Learn about and be prepared to meet the unique dental and oral health needs of patients with oral and head and neck cancers, and become equipped to continue care for your patients throughout their treatment and into survivorship. For all of the destruction and hardship that cancer brings, it can form unbreakable bonds, between doctor and patient and between dentist and physician.

Don’t be afraid to reach out to your counterparts in the medical community and bridge the gap between medicine and dentistry in your area. Form alliances with head and neck surgeons, radiation oncologists, medical oncologists, and oncology nurses. Let them know about your skills and the services and technology available in your office that place you on the front line of this war on oral cancer. Take time to understand your medical colleagues’ role in treating the disease and become familiar with the technology they are using to save lives and diminish the long-term effects of oral cancer treatment. We are, after all, fighting the same war, and we’re all on the same side. It is all of us against oral and oropharyngeal cancer, with the needs and health of that one patient we’re fighting for leading us in the battle.

About the author:
Dennis M. Abbott, DDS, is the founder and CEO of Dental Oncology Professionals, an oral medicine-based practice dedicated to meeting the unique dental and oral health needs of patients battling cancer. In addition to private practice, he is a member of the dental oncology medical staff at Charles A. Sammons Cancer Center at Baylor University Medical Center in Dallas. Dr. Abbott is also the founder of the American Academy of Dental Oncology and serves as a consultant to the national American Cancer Society in the development of oral monitoring guidelines for post-treatment cancer survivors. Dr. Abbott lectures internationally on the topics of dental oncology and oral cancer.

DNA shed from head and neck tumors detected in blood and saliva

Author: Wang et al., Science Translational Medicine (2015)
Schematic showing the shedding of tumor DNA from head and neck cancers into the saliva or plasma. Tumors from various anatomic locations shed DNA fragments containing tumor-specific mutations and human papillomavirus DNA into the saliva or the circulation. The detectability of tumor DNA in the saliva varied with anatomic location of the tumor, with the highest sensitivity for oral cavity cancers. The detectability in plasma varied much less in regard to the tumor’s anatomic location. Credit: Wang et al., Science Translational Medicine (2015)


On the hunt for better cancer screening tests, Johns Hopkins scientists led a proof of principle study that successfully identified tumor DNA shed into the blood and saliva of 93 patients with head and neck cancer. A report on the findings is published in the June 24 issue of Science Translational Medicine.

“We have shown that tumor DNA in the blood or saliva can successfully be measured for these cancers,” says Nishant Agrawal, M.D., associate professor of otolaryngology—head and neck surgery—and of oncology at the Johns Hopkins University School of Medicine. “In our study, testing saliva seemed to be the best way to detect cancers in the oral cavity, and blood tests appeared to find more cancers in the larynx, hypopharynx and oropharynx. However, combining blood and saliva tests may offer the best chance of finding cancer in any of those regions.”

Agrawal explains that inborn genetic predispositions for most head and neck cancers are rare, but other mutations that don’t generally occur in normal cells have long been considered good targets for screening tests.

In the case of head and neck cancers associated with HPV—tumors on the rise among Americans—Agrawal and his colleagues searched patients’ blood and saliva samples for certain tumor-promoting, HPV-related DNA. For non-HPV-related cancers, which account for the worldwide majority of head and neck tumors, they looked for mutations in cancer-related genes that included TP53, PIK3CA, CDKN2A, FBXW7, HRAS and NRAS.

The major risk factors for head and neck cancers are alcohol, tobacco—including chewing tobacco—and HPV infection.

For the study, 93 patients with newly diagnosed and recurrent head and neck cancer gave saliva samples, and 47 of them also donated blood samples before their treatment at The Johns Hopkins Hospital and MD Anderson Cancer Center in Texas. The scientists detected tumor DNA in the saliva of 71 of the 93 patients (76 percent) and in the blood of 41 of the 47 (87 percent). In the 47 who gave blood and saliva samples, scientists were able to detect tumor DNA in at least one of the body fluids in 45 of them (96 percent).

When the scientists analyzed how well their tumor DNA tests found cancers in certain regions of the head and neck, they found that saliva tests fared better than blood tests for oral cavity cancers. All 46 oral cavity cancers were correctly identified through saliva tests, compared with 16 of 34 oropharynx cancers (47 percent), seven of 10 larynx cancers (70 percent) and two of three hypopharynx cancers (67 percent).

The oral cavity refers to areas within the mouth, including the lips, front of the tongue, cheeks and gums. The oropharynx and hypopharynx are located in the back of the throat. The larynx, also in the throat, is typically known as the voice box.

“One reason that saliva tests may not have been as effective for cancer sites in the back of the throat is because we didn’t ask patients to gargle; we only asked them to rinse their mouths to provide the samples,” says Agrawal, a member of Johns Hopkins’ Kimmel Cancer Center and Ludwig Center.

Blood tests correctly identified tumor DNA more often in 20 of 22 oropharynx cancers (91 percent), six of seven larynx cancers (86 percent) and all three hypopharynx cancers. Taken together, blood and saliva tests correctly identified all oral cavity, larynx and hypopharynx cancers and 20 of 22 oropharynx cancers (91 percent).

Agrawal says the sensitivity of the tests overall depended on the cancer site, stage and HPV status, ranging between 86 to 100 percent. He also reports that saliva tests performed better for early-stage cancers, finding all 20 cancers, compared with blood tests that correctly identified seven of 10. He and his team found the opposite was true for late-stage cancers: Blood tests found more late-stage cancers (34 of 37), compared with saliva tests (51 of 73). Blood tests also correctly identified HPV-related tumors, occurring in 30 of the 93 patients, more often than saliva tests, probably because HPV-related tumors tend to occur in the back of the throat, which may not have been reached with the saliva rinse.

“Our ultimate goal is to develop better screening tests to find head and neck cancers among the general population and improve how we monitor patients with cancer for recurrence of their disease,” says Bert Vogelstein, M.D., the Clayton Professor of Oncology at the Johns Hopkins Kimmel Cancer Center, co-director of the Ludwig Center at Johns Hopkins and a co-author of the study.

The scientists caution that further study of their tumor DNA detection method in larger groups of patients and healthy people is needed before clinical effectiveness can be determined, and that refinements also may be needed in methods of collecting saliva and the range of cancer-specific genes in the gene test panel.

In addition, Agrawal says: “We don’t yet have definitive data on false positive rates, and won’t until there are more studies of the tests in healthy people.” However, he notes, the formulas used to analyze their blood and saliva tests are designed to weed out questionable results.

False results in gene tests arise when DNA are copied many times, sequenced and analyzed. The scientists used a method they developed and tested previously in cervical fluid to find ovarian and cervical cancers. Specifically, they attach a kind of genetic bar code—a random set of 14 DNA base pairs—to trace each copied DNA fragment to its original one. DNA copies lacking the bar code are suspected to be an artifact of the process, and any mutation found in it is disregarded.

Agrawal says that tests like the one his team used, if used commercially, likely would cost several hundred dollars, and “our long-term goal is to create a test that costs less than $50 so it can be administered by physicians or dentists.”

To screen for head and neck cancers, which occur in more than 50,000 people in the U.S. each year, doctors conduct physical examinations. Biopsies are taken of suspicious-looking lesions, but “this method is not ideal, as evidenced by the fact that most head and neck cancers are rarely found at very early stages, when they are most curable,” says Agrawal.

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

Researchers ID potential prognostic marker for recurrence of head and neck squamous cell carcinoma

Author: press release

A new study provides the first evidence that the mediator complex subunit 15 (MED15) may play a crucial role in the pathophysiology of head and neck squamous cell carcinoma (HNSCC). MED15 overexpression was found to be associated with higher mortality rates in HNSCC patients with cancer recurrence, particularly in oral cavity/oropharyngeal tumors, according to the study published in The American Journal of Pathology. MED15 overexpression was also associated with heavy alcohol consumption, which is an HNSCC risk factor.

HNSCC is the sixth most common  worldwide and has a high rate of recurrence and early metastatic disease, resulting in approximately 350,000 deaths each year. “Our findings suggest that MED15 may serve as a prognostic marker for HNSCC recurrence and as a therapeutic target in HNSCC patients suffering from recurrences,” said lead investigator Sven Perner, MD, PhD, of the Department of Prostate Cancer Research, Institute of Pathology, and the Department of Otorhinolaryngology at the University Hospital of Bonn (Germany).

Mediator is a multiprotein complex that regulates many signaling pathways. In humans, it consists of 30 subunits including MED15, which has been implicated in breast and , with particular attention being given to its link to transforming growth factor-β (TGF-β) signaling. “The evidence that multiple aberrant pathways account for the progression of HNSCC calls for a much deeper understanding of the effect of molecules involved in these signaling pathways upon HNSCC progression,” noted Dr. Perner.

To investigate the role of MED15 in HNSCC, the researchers analyzed tissues from 113 patients with primary tumors, 30 recurrent tumor tissues, 85 , and 20 control samples of normal squamous epithelial tissue. Using immunohistochemical staining, expression scores were calculated by multiplying staining intensity by the index of immunoreactive cells and categorized as no expression (<0.07), low expression (0.07<0.2), or overexpression (0.2). They found that MED15 was overexpressed in 35% of primary tumors, 30% of lymph node metastases, and 70% of recurrences, in contrast to no or low expression in control samples.

To determine the extent to which MED15 levels correlated with mortality, the investigators performed immunohistochemical analysis of primary tumor tissues from the 108 patients who developed recurrent tumors. They found that the mortality rate (defined as death within 1 to 12 years after first diagnosis) increased from 58% overall to 78% in the subset of patients whose tumors showed MED15 overexpression, with a significant association found between MED15 overexpression and high mortality.

Further investigation revealed that the mortality rate of patients with tumors in the oropharynx or oral cavity was significantly higher than that of patients with tumors in the hypopharynx or larynx. Likewise, the expression of MED15 was found to be higher in oral cavity/oropharyngeal tumors compared with tumors from the hypopharynx or larynx.

The study also investigated whether MED15 levels were associated with any of the risk factors for HNSCC, such as tobacco use, alcohol consumption, or chronic oncogenic human papillomavirus infections. Only heavy alcohol consumption was found to be significantly associated with MED15 overexpression, shedding light on the possible mechanism of action of alcohol’s adverse influence.

Dr. Perner and his co-investigators believe MED15 may be a molecular marker that can be used to predict the risk for development of tumor recurrence or metastases that can help clinicians make early diagnosis and treatment decisions. Support for this hypothesis comes from their observations that in 74% of cases, there was a concordance for the presence or absence of MED15 overexpression in samples from a patient’s primary tumor and corresponding lymph node metastasis. In addition, MED15 expression correlated with high proliferative activity in HNSCC tissues and genetic inhibition of MED15 reduced both cell proliferation and migration. They also found that MED15 was highly expressed in the HNSCC malignant cell lines HSC-3 and SCC-25.

“Such observations indicate that MED15 overexpression is likely to be a clonal event in the progression of HNSCC,” explained Dr. Perner. (A clonal event is a mutation, deletion, or translocation that occurs within a tumor and recurs in a significant proportion of patients.) “These findings regarding MED15 overexpression are particularly significant, as genetic alterations that provide cells with growth advantages and metastatic potential may be present only in subpopulations of cells in the primary tumor, but increase in tissue from metastases and relapsed HNSCC tumors.” He suggests that a MED15 inhibitor may be a future therapeutic option, especially for patients with advanced disease and tumor recurrence.

March, 2015|Oral Cancer News|

Head and neck cancer on rise in young men

Author: staff

“The head and neck cancers we have found in younger men with no known risk factors such as smoking are very frequently associated with the same HPV virus that causes cervical cancer in women.” said Kerstin Stenson, MD, a head and neck cancer surgeon at Rush and a professor of otolaryngology at Rush University. The cancer develops from an HPV infection, likely acquired several years earlier from oral sex.

“Men are more susceptible to these cancers because they don’t seem to have the same immune response as women and do not shed the virus like women do,” Stenson said.

‘Epidemic proportions’
According to the Centers for Disease Control and Prevention, cancers of the oropharynx (back of the throat, including the base of the tongue and tonsils) are usually caused by tobacco and alcohol, but recent studies show that about 72 percent of oropharyngeal cancers are caused by HPV.

“There has been significant change in the last decade. Overall, head and neck cancers account for approximately 3 to 5 percent of all cancers, but what’s changed in the past decade is the HPV-associated oropharyngeal cancer. It has reached epidemic proportions,” said Stenson.

The American Cancer Society estimates that 45,780 Americans will be diagnosed with cancer of the oral cavity and oropharynx in 2015. If this trend continues, the number of cases of HPV-positive oropharyngeal cancer will surpass the number of cervical cancer cases.

Early detection is key
The current vaccine has been shown to decrease the incidence of HPV-associated cervical infections and cancer. While the same result is anticipated for HPV-associated head and neck cancer, the impact of vaccines on incidence of persistent oral HPV infection and/or HPV associated oropharyngeal cancer has not yet been investigated. We will need about 10-30 more years to see the anticipated effect of the vaccine on HPV-related cancers that could affect people who are now teenagers. Still, head and neck surgeons, medical oncologists and other researchers strongly advocate vaccination of both girls and boys to help prevent all HPV-associated cancers.

“For all individuals, the key is in early detection, as with any cancer,” Stenson said.

In addition to being vaccinated, Stenson stresses the importance of regular visits to the dentist. “Dentists play a key role in detecting oral cancer. You might not see a primary care physician even once a year, but most people see their dentist twice a year. Having regular dental visits can help catch cancers early to help ensure the best outcome.”

The American Dental Association states that 60 percent of the U.S. population sees a dentist every year.

Oral cancer warning signs
The Oral Cancer Foundation presumes that cancer screenings of the existing patient population would yield tens of thousands of opportunities to catch oral cancer in its early stages.

“There is much that can be done for those who are diagnosed with head and neck cancer. Since early detection and treatment is critical, it’s important to see your dentist regularly and to promptly see a medical professional if there are any warnings signs,” Stenson advised. Strategies to improve public awareness and knowledge of signs, symptoms, and risk factors are critical topics for study and may decrease the disease burden of head and neck cancers.

Possible warning signs of oral cancer may include difficulty swallowing, pain when chewing, a white patch anywhere on the inside of your mouth, a lump or sore in the mouth or on the lip that does not heal.

If you notice any of these symptoms, ask your dentist or doctor about it.

Treatment includes surgery for early or low-volume late stage lesions and radiation or chemoradiation for more advanced cancers.

March, 2015|Oral Cancer News|

Asia’s deadly secret: the scourge of the betel nut

Author: staff

It is used by almost a tenth of the world’s population. It gives people a buzz equivalent to six cups of coffee and is used variously as a symbol of love, marriage and a cure for indigestion and impotence.

But it is also leading tens of thousands to an early grave.

The culprit? The humble betel nut.

Found across Asia, these nuts are harvested from the Areca palm and are chewed for their warming glow and stimulating properties.

Such is its effectiveness, that alongside nicotine, alcohol and caffeine, betel nuts are believed to be one of the most popular mind-altering substances in the world.

Although used by women and children, the nuts are especially popular among working-age men, who chew to stay awake through long hours of driving, fishing or working on construction sites.

But the short-lived benefits come at a terrible cost.

High rates of oral cancer are destroying the lives of many who buy betel nuts, often decades after their first taste.

Now in Taiwan, where the nuts are affectionately known as ‘Taiwan’s chewing gum’, the government is taking action to curb this centuries-old habit and reduce the thousands of lives lost each year.

Dangerous combination


Regular betel nut chewers stand out from the crowd with their red-stained lips and teeth

The betel nut is a key part of many Asian cultures and can be consumed dried, fresh or wrapped up in a package known as a quid.

Although the exact preparation varies across countries and cultures, the quid is usually a mixture of slaked lime, a betel leaf and flavourings such as cardamom, cinnamon and tobacco.

Worryingly, the International Agency for Research on Cancer lists each ingredient, with the exception of cardamom and cinnamon, as a known carcinogen – or cancer-causing agent.

The slaked lime is seen as a particular problem as it causes hundreds of tiny abrasions to form in the mouth. This is thought to be a possible entry point for many of the cancer-causing chemicals.

“About half of the men here still don’t know that betel nuts can cause oral cancer,” says Prof Hahn Liang-jiunn, an oral cancer specialist at the National Taiwan University Hospital.

“[This is despite] Taiwan’s incidence or mortality rates for oral cancer ranking among the top two or three in the world.”

‘I started chewing because everyone else did’

Like most people, Qiu Zhen-huang, 54, was completely unaware of the risks.

A former gravel company worker, he chewed for ten years. Twenty years after quitting, he developed the disease.

“I started chewing betel nut because everyone at work did it,” says Mr Qiu.
“We shared it with each other to build good relations.”

Three years ago, a small hole developed in his left cheek and in just three months, the tumour grew to the size of a golf ball and completely changed his life.

“Whatever I ate flowed out. I had a gauze pad over it. It hurt,” he said.

“It affected me a lot. I was so ashamed I avoided going out.”

Each year, 5,400 Taiwanese men like Mr Qiu are diagnosed with oral cancer or pre-cancerous lesions and an estimated 80 to 90% of those also chew betel nuts.

An early symptom includes white or red lesions inside the mouth, but this can rapidly progress to grotesque flesh-eating tumours.

Unlike other cancers, these are difficult to hide, leaving sufferers physically and psychologically devastated.

“It’s miserable for them,” says Prof Hahn.

“Sometimes, even after surgery, they still can’t perform basic functions, including expressing emotions through their face because the lower jaw also has to be cut depending on the scale of the cancer.”

Tackling the scourge

The Taiwanese government is offering subsidies in return for cutting down betel nut palms

The Taiwanese government is offering subsidies in return for cutting down betel nut palms

Luckily for Qiu Zhen-huang, his cancer was treated and his cheek reconstructed.

But the Taiwanese government is helping people detect the disease much sooner by providing around one million free screenings and funding programs to help people quit betel nuts for good.

In 2013, these measures helped cut the usage rate among men by nearly half.

The government is also trying to reduce the domestic supply of betel nuts by offering subsidies to farmers to cut down their trees and plant alternative crops.

Other countries such as India and Thailand have also launched campaigns to discourage betel nut chewing.

But there is still a way to go. At a recent presentation to elementary school children of fishing industry workers, nearly all raised their hands when asked whether their parents or relatives chewed betel nuts.

And as the cancer can take up to 20 years to appear, the current changes will have come too late for many people – a fact that Mr Qiu keeps close to his heart.

“I’m one of the luckier ones.”

March, 2015|Oral Cancer News|

Cure Possible for Some HPV-Positive Oropharyngeal Cancers

Author: Fran Lowry

In a subset of patients with human papillomavirus (HPV)-related oropharyngeal cancer, the goal of achieving a “cure” is a realistic one, even in patients who have limited distant metastases, a prospective study has shown.

Of the patients with HPV-positive oropharyngeal cancer and distant metastases, 10% survived more than 2 years after intensive treatment, which the researchers defined as a cure.

The study was presented at the 5th International Conference on Innovative Approaches in Head and Neck Oncology (ICHNO) in Nice, France.

The research was praised by Jean Bourhis, MD, head of the Department of Radiation Oncology at Centre Hospitalier Université Vaudois in Lucerne, Switzerland, and cochair of the ICHNO conference scientific committee.

“This important piece of research adds substantially to what we know about the role and the importance of the human papillomavirus in oropharyngeal cancers and gives real hope of improvement in both diagnosis and treatment to those who are affected by the condition,” he said in a statement.

This study, from a world-leading group of head and neck cancer experts, is very interesting, and related to relevant clinical and interdisciplinary questions,” said Daniel Zips, MD, professor of radiation oncology at the University of Tübingen in Germany.

“HPV status is also important for the management of metastatic disease,” he told Medscape Medical News.

He agrees that for some patients with HPV-positive oropharyngeal cancer, using the researchers’ definition, a cure is possible.

“I also agree that the results from this study might begin to change the view of this disease and provide some hope for patients and their families,” Dr Zips explained.

Distant Metastases Are Main Form of Failure
“The majority of patients with HPV-related oropharyngeal cancer can be cured, but distant metastasis can occur in about 15% of patients. In fact, distant metastasis has become the main form of failure for this patient population,” lead author Sophie Huang, a radiation therapist and assistant professor at the University of Toronto. Dr Huang was a physician in China but is an MRT(T) — a radiation therapist — in Canada.

“When distant metastasis occurs, it is generally viewed as incurable disease. However, long-term survival after distant metastasis has been observed in nasopharyngeal cancer patients, which is another viral-related head and neck cancer, associated with the Epstein–Barr virus. Also, long-term survival in HPV-related OPC patients with distant metastasis has also been reported, but anecdotally,” Dr Huang told Medscape Medical News. “Are these just miracles? And would more miracles be found if we were able to understand how they happen?”

Dr Huang and her colleagues established a prospective database in which they collected data on enough patients to allow them to study how distant metastasis is manifested, how the cancer behaves after distant metastasis, and whether there are any factors that influence survival after distant metastasis.

“We felt that the answers to these questions would help us tailor surveillance strategies for the early detection of distant metastasis and explore optimal management algorithms to improve outcomes,” she explained.

Prospective Follow-up of Patients
The team evaluated 1238 consecutive oropharyngeal cancer patients treated at the Princess Margaret Cancer Centre in Toronto from 2000 to 2011. They identified 88 patients with HPV-related cancer and 54 with smoking-related cancer who were HPV-negative, all with distant metastases.

They assessed the pace of the manifestation of the distant metastases, characteristics, and patient survival, and identified factors that might predict longer survival.

The proportion of patients with distant metastases was similar in the two groups. However, metastases associated with HPV-positive oropharyngeal cancer had a later onset, different characteristics, and longer survival than those associated with HPV-negative oropharyngeal cancer.

Specifically, more than 94% of metastases occurred in the first 2 years after treatment in HPV-negative patients, whereas only a quarter occurred in HPV-positive cancers. In the HPV-positive group, some occurred after 5 years.

“This observation indicates that HPV-related OPC patients who are disease-free for 2 years are not out of the woods. A longer surveillance period for HPV-related OPC patients is needed to detect, and hopefully cure, distant metastases,” Dr Huang said.

Additionally, the researchers found two phenotypes of distant metastases in HPV-positive patients.

The disseminating phenotype is aggressive and spreads to multiple organs in a short period of time. This phenotype was found in 55% of the HPV-positive group but in 0% of the HPV-negative group.

The indolent phenotype is characterized by a few lesions growing at a slow pace, and manifesting as oligometastasis, with five or fewer lesions. In patients with metastases in a single organ, this phenotype was found in 24% of the HPV-positive group and in 26% of the HPV-negative group.

The lung was the most common site for distant metastasis in both groups.

“This indolent phenotype has longer survival and might be curable,” Dr Huang reported.

More HPV-positive than HPV-negative patients were specifically treated for distant metastasis (60% vs 31%)


More HPV-positive patients with distant metastases than HPV-negative patients survived to 3 years (25% vs 15%; P = .01).

“The survival advantage in HPV-positive patients is due to a number of factors. The cancer is more sensitive to radiotherapy and chemotherapy, patients tend to be younger by about 10 years, and they have fewer other health problems, including those caused by smoking. This allows them to receive the more aggressive treatment necessary to eradicate metastatic disease,” Dr Huang explained.


“This research shows that metastatic HPV-positive patients who receive active treatment can survive considerably longer. One of the reasons patients with metastatic disease fail to receive aggressive treatment is due to the physician and patient perception that this is an incurable state. We hope these results will motivate researchers to optimize management strategies for these patients,” Dr Huang said.

“The first distant metastasis site is mostly in the chest region,” she noted. In fact, most of the cured patients had lung metastasis. “Computed tomography of the thorax for the early detection of distant metastases” might enhance the cure rate for this disease, she added.

Future studies should look for ways to identify patients at initial presentation who are at high risk for distant metastasis, and which type of distant metastasis will develop.

“We know there is a degree of correlation between the initial stage and the risk of distant metastasis, but we did not find a strong relationship between this stage and the type of metastasis,” Dr Huang reported. “The intensity of cigarette smoking in the years prior to the time of diagnosis is a possible factor. Being able to identify such relationships could be a huge help in deciding appropriate treatment at an early stage.”


1. Dr Bourhis, Dr Zips, Dr Huang, have disclosed no relevant financial relationships.
2. 5th International Conference on Innovative Approaches in Head and Neck Oncology (ICHNO): Abstract OC-044. Presented February 13, 2015.

March, 2015|Oral Cancer News|

Researchers propose new staging model for HPV+ oropharyngeal cancer

Author: Donna Domino

Researchers are proposing a new tumor-staging model for predicting the outcomes and guiding treatments for patients with human papillomavirus (HPV)-related oropharyngeal cancer (OPC), according to a new study in the Journal of Clinical Oncology. Since HPV-related cancer differs significantly from smoking-related cancer, less intensive treatment strategies may be more appropriate, the study authors concluded.

Treatment regimens for oropharyngeal cancer have intensified over time and carry a toxicity burden, the Canadian researchers noted.

In the last few years, research has found that oropharyngeal cancer caused by HPV behaves differently than OPC caused by smoking and alcohol, yet both cancers use the same tumor classification model. Therefore, regardless of whether the OPC was caused by HPV or smoking, the treatment and perceived prognosis based on tumor staging has remained the same, even though patient outcomes vary considerably, the study authors noted (Journal of Clinical Oncology, February 10, 2015, Vol. 31:5, pp. 543-550).

A new tumor-staging model will help separate patients with promising prognoses from those with negative ones to design the most appropriate treatment strategies for each group, according to the researchers from Toronto’s Princess Margaret Cancer Centre.

The researchers analyzed 899 oropharyngeal cancer patients, including 505 (56%) patients with HPV who had been treated with radiotherapy or chemoradiotherapy from 2001 to 2009. The HPV-positive patients (382) had higher recurrence-free survival rates after about four years compared with HPV-negative patients (123). Disease recurrence was 16.7% (64) among HPV-positive patients; 38.2% among HPV-negative patients (47).

The tumor staging system classifies the disease into early, intermediate, or advanced stages of cancer. It helps determine treatment plans and can suggest likely outcomes.

For example, a stage IV patient with HPV-related cancer has an 80% survival rate, while a stage IV patient with smoking-related cancer has a 50% to 60% survival rate. But both are currently considered to have advanced-stage disease, which is recognized as a life-threatening prognosis.

“When you tell a patient they have stage IV cancer, it’s an indication of advanced disease, and they don’t expect it to be curable,” Huang said in a statement. “We need a staging system that more accurately reflects a patient’s prognosis, which in a case caused by HPV is highly curable.”

The study also highlights the fact that many HPV-related OPC patients are overtreated because of the stage IV tumor classification. High-dose chemotherapy combined with high-dose radiation is often given to such patients when radiation therapy alone or other less-intensive strategies can probably cure many of them, the researchers said.


“Our study shows that the current model derived for smoking- and alcohol-related cancers is not suited for throat cancer caused by HPV, a burgeoning throat cancer population in the Western world, including Canada,” Huang concluded.

A new tumor staging model will help separate patients with promising prognoses from those with negative prognoses to design the most appropriate strategies for each group, the study authors concluded.

Clinical trials have now begun to address these questions, but their descriptions and designs are hindered by inadequacies of the current stage classification, they stated.

“Providing a relevant stage classification for a rapidly emerging disease is important, but the additional feature of the classification is that it provides the opportunity to include factors beyond just the traditional description of disease extent into the prognostic classification we are trying to develop to assist in treating patients,” he said.

The structure used for disease classification follows a template that was developed at the Union for International Cancer Control in Geneva and is relevant to all cancers, according to Dr. O’Sullivan.

“Important factors that are emerging throughout oncology are not currently included in the international classifications,” he concluded. “This needs to change to facilitate our goal of providing personalized approaches to patients with cancer.”

The Princess Margaret Hospital is collaborating with six major cancer centers worldwide to validate the findings.

February, 2015|Oral Cancer News|