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

Source: www.dentistryiq.com
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

Source: www.medicalexpress.com
Author: Wang et al., Science Translational Medicine (2015)
 
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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

Source: medicalxpress.com
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

Source: www.healthcanal.com
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

Source: www.bbc.com
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

betel-stained

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

Source: www.medscape.com
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%)

table1

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.

table2

“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.”

Note:

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

Source: www.drbicuspid.com
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.

Conclusion

“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|

New model proposed for predicting outcomes more accurately in HPV-related throat cancer patients

Source: www.news-medical.net
Author: staff

Researchers at the Princess Margaret Cancer Centre are proposing a new model to enable doctors to predict outcomes more accurately for patients with throat cancers specifically caused by Human Papillomavirus (HPV).

The findings are published online today in the Journal of Clinical Oncology. Study investigators, Dr. Brian O’Sullivan, Lead, Head and Neck Cancer Site Group and Shao-Hui Huang, Research and Clinical Radiation Therapist at Princess Margaret Cancer Centre, have determined that a new model for classifying the most frequently seen throat cancers in our geographic location is needed. This classification incorporates individual patient factors including age and their smoking status with the traditional classification of the extent of disease, to offer a more personalized approach to predict outcomes and guide treatment.

“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,” says Huang.

“This is the future of tumour staging. We need to consider the patient as a whole. Both individual factors, how extensive the disease is in the patient, and tumour biology should play a role in determining the best course of treatment.”

The purpose of a tumour staging system is to classify the disease into early, intermediate or advanced stage cancer. This classification helps determine treatment plans and can suggest what is likely to be the outcome. In recent years, it’s been discovered that throat cancer caused by HPV behaves differently than throat cancer caused by smoking and alcohol, yet both cancers use the same tumour classification model. Therefore, regardless of whether the cancer was caused by HPV or smoking, the treatment and perceived prognosis based on tumour staging has remained the same – even though patient outcomes, as this study demonstrates, vary considerably.

For example, a stage IV patient with HPV-related cancer has an 80 per cent survival rate while a stage IV smoking-related cancer patient has a 50-60 percent survival rate, but both are presently considered advanced stage – 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,” says Huang. “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 throat cancer patients are over-treated due to the stage IV tumour classification. High dose chemotherapy combined with high dose radiation is often given to this patient population when radiation therapy alone or other less intensive strategies can probably cure many of them.

Clinical trials have now begun to address these questions but their descriptions and design are hindered by inadequacies of the current stage classification. A new tumour staging model will help to separate patients with promising prognoses from those with negative prognoses to design the most appropriate treatment strategies for each group.

“This work has several interesting characteristics, and not just relating to the management of head and neck cancer. 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,” says Dr. O’Sullivan.

“The structure used for the classification follows a template we developed at the Union for International Cancer Control (UICC) and is relevant to all cancers. Important factors that are emerging throughout oncology are not currently included in the international classifications. This needs to change to facilitate our goal of providing personalized approaches to patients with cancer.”

The Princess Margaret is collaborating with six major cancer centres across the world to validate these findings, which will provide solid evidence for a new tumour staging system that offers a personalized approach to medicine.

Source:
Princess Margaret Cancer Centre, University Health Network

February, 2015|Oral Cancer News|

Inherited factors linked to head and neck cancers in young adults

Source: www.news-medical.net
Author: Oxford University Press

An article published online today in the International Journal of Epidemiology pools data from 25 case-control studies and conducts separate analyses to show that head and neck cancers (HNC) in young adults are more likely to be as a result of inherited factors, rather than lifestyle factors such as smoking or drinking alcohol.

Approximately 550,000 new cases of HNC are diagnosed worldwide annually, with an increased incidence in young adults (YA) also being reported. In particular, reports indicate an increase in tumours affecting the tongue and oropharynx among young adults in Europe, the United States, India, and China.

Dr Tatiana Natasha Toporcov and colleagues pooled data from 25 studies from the International Head and Neck Cancer Epidemiology (INHANCE) consortium to compare the role of major risk factors and family history in HNC for YA (45 years of age or younger) and older adults (over 45 years of age). Participants were surveyed about their history of cigarette smoking, alcohol drinking, and diet, as well as family history of cancer. In total, there were 2,010 cases and 4,042 controls in YA, and 17,700 cases and 22,704 controls in older adults.

The attributable fraction (an estimate of the proportion of cases which could be avoided if the exposures were eliminated) for smoking on the risk of HNC was 20% in young women, 49% in older women, 46% in young men, and 64% in older men. The attributable fraction for drinking alcohol on the risk of HNC was 5% in young women, 20% in older women, 22% in young men, and 50% in older men. Eating a diet rich in fruits and vegetables was shown to be inversely associated with the risk of HNC in both age groups.

Dr Toporcov says: “To our knowledge, this is the largest study to evaluate the role of the major risk factors for HNC in young adults as well as to compare risks in younger and older patients. The large sample size allowed us to elucidate any differences in the role of risk factors in HNC in YA according to age group, sex and cancer sub sites.

“Although they were less likely to be drinkers and/or smokers, alcohol consumption was a risk factor for HNC in YA. However, a stronger association with heavy drinking was observed for the older group. Our results also indicate that the inverse association with fruit and vegetable intake is similar among young and older populations. YA were more likely to have been diagnosed with oral and oropharynx cancer than older adults. Also, early onset cancer in the family was associated with HNC risk only among YA.

“Our results support public health efforts to decrease exposure to major risk factors for HNC in the population regardless of age. However, investigations of the role of other risk factors, such as human papilloma virus and inherited characteristics, on HNC in the younger age group are warranted.”

January, 2015|Oral Cancer News|

Coupling head and neck cancer screening and lung cancer scans could improve early detection, survival

Source: www.medicalnewstoday.com
Author: staff

Adding head and neck cancer screenings to recommended lung cancer screenings would likely improve early detection and survival, according to a multidisciplinary team led by scientists affiliated with the University of Pittsburgh Cancer Institute (UPCI), a partner with UPMC CancerCenter.

In an analysis published in the journal Cancer and funded by the National Institutes of Health (NIH), the team provides a rationale for a national clinical trial to assess the effectiveness of adding examination of the head and neck to lung cancer screening programs. People most at risk for lung cancer are also those most at risk for head and neck cancer.

“When caught early, the five-year survival rate for head and neck cancer is over 83 percent,” said senior author Brenda Diergaarde, Ph.D., assistant professor of epidemiology at Pitt’s Graduate School of Public Health and member of the UPCI. “However, the majority of cases are diagnosed later when survival rates generally shrink below 50 percent. There is a strong need to develop strategies that will result in identification of the cancer when it can still be successfully treated.”

Screening patients for head and neck cancer and lung cancer could improve early detection and survival.

Screening patients for head and neck cancer and lung cancer could improve early detection and survival.

Head and neck cancer is the world’s sixth-most common type of cancer. Worldwide every year, 600,000 people are diagnosed with it and about 350,000 die. Tobacco use and alcohol consumption are the major risk factors for developing the cancer.

The early symptoms are typically a lump or sore in the mouth or throat, trouble swallowing or a voice change, which are often brushed off as a cold or something that will heal. Treatment, particularly in later stages, can be disfiguring and can change the way a person talks or eats.

Dr. Diergaarde and her team analyzed the records of 3,587 people enrolled in the Pittsburgh Lung Screening Study (PLuSS), which consists of current and ex-smokers aged 50 and older, to see if they had a higher chance of developing head and neck cancer.

In the general U.S. population, fewer than 43 per 100,000 people would be expected to develop head and neck cancer annually among those 50 and older. Among the PLuSS participants, the rate was 71.4 cases annually per 100,000 people.

Recently, the U.S. Preventive Services Task Force*, as well as the American Cancer Society and several other organizations, recommended annual screening for lung cancer with low-dose computed tomography in people 55 to 74 years old with a smoking history averaging at least a pack a day for a total of 30 years. The recommendation came after a national clinical trial showed that such screening reduces lung cancer mortality.

“Head and neck cancer is relatively rare, and screening the general population would be impractical,” said co-author David O. Wilson, M.D., M.P.H., associate director of UPMC’s Lung Cancer Center. “However, the patients at risk for lung cancer whom we would refer for the newly recommended annual screening are the same patients that our study shows also likely would benefit from regular head and neck cancer screenings. If such screening reduces mortality in these at-risk patients, that would be a convenient way to increase early detection and save lives.”

Dr. Diergaarde’s team is collaborating with otolaryngologists to design a national trial that would determine if regular head and neck cancer screenings for people referred for lung cancer screenings would indeed reduce mortality.

January, 2015|Oral Cancer News|