HPV

HPV and mouth cancer

Source: www.hippocraticpost.com
Author: Thea Jourdan

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Mouth cancer kills nearly 2000 people in the UK each year. The Human Papilloma Virus (HPV) of which there are over 100 different types, is more commonly associated with cervical cancer and genital warts, but it can also cause oral cancer, particularly of the back of the tongue and tonsils. The virus incorporates itself into the cell’s DNA and causes the cell to multiply out of control, leading to cancer.

In Britain, the number of mouth and throat cancers have increased by 40 per cent in just a decade, to 6,200 cases a year. According to Cancer Research UK, the HPV virus, which is transmitted to the mouth region from the genitals during oral sex, may be key to the ‘rapid rise’. Statistics also show that the more sexual partners you have the greater your chance of acquiring mouth cancer.

“There is now scientific evidence that a proportion of mouth and throat cancers are linked to HPV infection,” says Hazel Nunn, head of health information at Cancer Research UK. “We know that HPV is found in the mouth but we do not yet know how it gets there – whether through oral sex or otherwise. HPV virus has been found on the fingers and elsewhere on the body. It is possible that oral sex is having an impact but more research needs to be done into the kinds of behaviour that leads to this infection.”

“HPV has been causing mouth cancer for decades but the link is only now becoming clear. HPV is a hardy virus that likes sitting in lymphoid tissue wherever it is in the body,” explains Professor Mark McGurk, a senior consultant ENT surgeon based at London Bridge Hospital in London. That means it thrives in the lymphoid tissue in the mouth, including that of the tonsils and at the base of the tongue. For the same reason, it settles in the cervix, the vulva and around the anus.

For many people, HPV won’t cause any problems at all. “In fact, we know that 80 per cent of women and men will have the HPV infection at some time in their lives and clear it themselves without any symptoms,” explains Mr Mike Bowen, a consultant obstetrician and gynacologist based at St John and St Elizabeth Hospital in London. “But for a few it can cause cellular changes that lead to cancer.”

Professor McGurk says that over the last 30 years, he has seen a rise in oropharyngeal cancer, which typically affects sexually active men in their 50s and 60s. “They may have been infected with the virus for some time and ,” he explains. The cancer reveals itself as growths on the tonsils and back of the tongue.

Many patients are only diagnosed at the late stage of their disease. Michael Douglas, the actor, already had stage 4 cancer when his cancer was recognized. Fortunately, oral cancer caused by HPV is very treatable, even when it is very advanced, using radiotherapy. “We used to do surgery on these cases, but we don’t need to anymore. In many cases, the cancer simply melts away with radiotherapy,” explains Professor McGurk. Patients with stage 1 and 2 Oral cancer caused by HPV have an 85 per cent chance of surviving for 5 years after treatment, and patients with stage 4 disease have a 60 per cent chance of surviving five years – impressive compared to the survival rates for other types of oral cancer where overall survival is 50 per cent over 5 years. [Cancer Research UK]

Cancer research UK is pushing for all mouth tumors to be tested to see if they are HPV positive, to assist with effective treatment of patients. “At the moment, it varies massively depending on what hospital you are in. We think it should be standard,” says Hazel Nunn.

Professor McGurk believes there is a simple explanation why men are more likely to have HPV in their mouths than women. “Women harbor the virus in their genitalia which provides a hospitable environment while the male penile area is a relatively hostile area for the virus to settle.”

One way to try and turn the tide would be to introduce a HPV vaccination for boys and girls before they become sexually active. Girls from the age of 12 in the UK have been offered vaccinations since 2008 against the two most common strains of HPV -16 and 18- which are linked to cervical cancer.

Boys are not offered the vaccine, but this should change, according to Professor Margaret Stanley, a virologist based at Cambridge University who believes that boys must be given the vaccine for HPV too from the age of 12 or 13.

‘Obviously cervical cancer is the big one but the other cancers – cancers of the anus and increasingly the tonsil and tongue – there is no screening for them and no way of detecting them until they are proper cancers and they are more common in men than in women.’

Hazel Nunn of Cancer Research UK points out that there is no evidence that vaccinating boys will help protect them from oral cancer. “It is theoretically possible but there have been no trials that had this as an end point. There is a danger that we get too far ahead of ourselves without evidence-based medicine.”

She insists that although HPV is a worrying factor, by far the most significant risks associated with mouth and throat cancers of all types are smoking and alcohol. “

November, 2016|Oral Cancer News|

GlaxoSmithKline pulls Cervarix from U.S. market

Source: www.managedcaremag.com
Author: staff

In response to “a very low market demand,” GlaxoSmithKline has decided to stop selling its human papillomavirus (HPV) vaccine Cervarix in the United States, according to FiercePharma. The move gives Merck’s Gardasil unchallenged dominance of the HPV vaccine market in this country.

Last year, Cervarix earned only about $3.7 million in the U.S. out of a $107 million worldwide total. In contrast, the global total for Merck’s Gardasil franchise was $1.9 billion.

Figures from the Centers for Disease Control and Prevention (CDC) last year placed HPV vaccination rates at 42% of girls and 28% of boys ages 13 to 17 years––far short of the U.S. Department of Health and Human Services’ goal of 80% for both boys and girls by 2020.

To combat the public’s lukewarm response, the CDC and other cancer organizations are urging health care providers to promote the cancer-prevention benefits of HPV vaccines rather than stressing that they protect against sexually transmitted infections, which puts off some parents who worry the vaccine will promote promiscuity or who feel that their preteens are too young to need the shots, according to the Wall Street Journal.

HPV, which is transmitted sexually, can cause at least six types of cancer as well as genital warts. The vaccine is recommended for boy and girls at age 11 or 12 and is also given at other ages.

Experts are urging pediatricians to present the vaccine as routine, rather than different from other preteen shots. They are also stressing completion of the vaccine series by age 13.

Merck, the maker of Gardasil, is currently airing an ad on national television that puts the onus on parents to get their children vaccinated.

Sources: FiercePharma; October 21, 2016; and Wall Street Journal; October 17, 2016.

October, 2016|Oral Cancer News|

The startling rise in oral cancer in men, and what it says about our changing sexual habits

Source: www.washingtonpost.com
Author: Ariana Eunjung Cha

Oral cancer is on the rise in American men, with health insurance claims for the condition jumping 61 percent from 2011 to 2015, according to a new analysis.

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The most dramatic increases were in throat cancer and tongue cancer, and the data show that claims were nearly three times as common in men as in women during that same period with a split of 74 percent to 26 percent.

The startling numbers — published in a report on Tuesday by FAIR Health an independent nonprofit — are based on a database of more than 21 billion privately billed medical and dental claims. They illustrate both the cascading effect of human papillomavirus (HPV) in the United States and our changing sexual practices.

The American Cancer Society estimates that nearly 50,000 Americans will be infected this year, with 9,500 dying from the disease. In past generations, oral cancer was mostly linked to smoking, alcohol use or a combination of the two. But even as smoking rates have fallen, oral cancer rates have remained about the same, and researchers have documented in recent studies that this may be caused by HPV.

HPV infects cells of the skin and the membranes that lines areas such as the mouth, throat, tongue, tonsils, rectum and sexual organs. Transmission can occur when these areas come into contact with the virus. HPV is a leading cause of cervical, vaginal and penile cancers.

Surveys have shown that younger men are more likely to perform oral sex than their older counterparts and have a tendency to engage with more partners.

“These differences in sexual behavior across age cohorts explain the differences that we see in oral HPV prevalence and in HPV-related oropharyngeal cancer across the generations and why the rate of this cancer is increasing,” Gypsyamber D’Souza, an associate professor in the Viral Oncology and Cancer Prevention and Control Program at the Johns Hopkins Bloomberg School of Public Health, said at the time. The work was published in the Journal of Infectious Diseases.

In February, researchers at the American Association for the Advancement of Science meeting reported that men are not only more likely to be infected with oral HPV than women but are less likely to clear the infection. It’s not known why oral HPV is more aggressive in men.

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HPV is an extremely common virus that has infected nearly 80 million, or one in four, people in the United States. Fortunately, the risk of contracting HPV can be greatly reduced by a vaccine. HPV has become a public health priority in recent years with dozens of countries recommending universal vaccination. The Centers for Disease Control and Prevention recommends that children get it at the age of 11 or 12, although they may get vaccinated as early as 9 years old. The CDC said earlier this month that young people who get it before the age of 15 need two doses rather than the typical three.

A CDC study has found that although fewer teenagers and young adults are having sex than in previous years, more are engaging in oral sex than vaginal intercourse under the assumption that it’s safer.

“However, young people, particularly those who have oral sex before their first vaginal intercourse, may still be placing themselves at risk of STIs or HIV before they are ever at risk of pregnancy,” the researchers wrote in the 2012 report.

October, 2016|Oral Cancer News|

Pre-Teens need just two doses of HPV vaccine, not three: Feds

Source: www.nbcnews.com/health
Author: Maggie Fox

There’s good news for kids who haven’t received all their HPV vaccines yet – they only need two doses of the vaccine instead of three, federal government advisers said Wednesday. The new recommendations should make it easier to get more children vaccinated against the human papillomavirus (HPV), which causes a range of cancers including cervical cancer, throat cancer and mouth cancer, officials said.

“It’s not often you get a recommendation simplifying vaccine schedules,” said Dr. Nancy Messonnier, Director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention.

The CDC immediately accepted the recommendations from its Advisory Committee on Immunization Practices.

“Safe, effective, and long-lasting protection against HPV cancers with two visits instead of three means more Americans will be protected from cancer,” said CDC Director Dr. Tom Frieden. “This recommendation will make it simpler for parents to get their children protected in time.”

The CDC says every pre-teen boy and girl should get the vaccine, but fewer than a third have received all three doses.

Messonnier says the three-dose schedule was based on the earliest studies of the vaccine. New studies show that two doses protect people for decades from the cancer-causing virus. And studies also suggest that spacing the two doses a year apart is at least as effective, if not more effective than giving them more closely together – something that could also make it easier to get kids fully vaccinated.

Older teens who have not been vaccinated at all before age 15 should still get three doses, because there’s not enough evidence to show whether two doses fully protect them, ACIP said.

Adults can also get the HPV vaccine. “Young women can get HPV vaccine through age 26, and young men can get vaccinated through age 21,” the CDC says.

“The vaccine is also recommended for any man who has sex with men through age 26, and for men with compromised immune systems (including HIV) through age 26, if they did not get HPV vaccine when they were younger.”

HPV is extremely common, but rates of HPV-related disease have fallen among vaccinated people.

“About 14 million people, including teens, become infected with HPV each year. HPV infection can cause cervical,vaginal, and vulvar cancers in women; penile cancer in men; and anal cancer, cancer of the back of the throat (oropharynx), and genital warts in both men and women,” the CDC says.

The original two vaccines on the market protected against either two or four of the strains of HPV known to cause cancer. Now the only vaccine available in the U.S. is Merck’s Gardasil 9, which protect against 9 strains of HPV.

Messonnier says it’s too soon to say whether teens vaccinated with the older vaccines should get a top-up dose with the new formulation.

October, 2016|Oral Cancer News|

Mouth, throat cancers caused by HPV on the rise, especially among Canadian men

Source: www.ctvnews.ca
Author: Sonja Puzic, CTVNews.ca Staff

Mouth and throat cancers caused by the human papilloma virus have been rising steadily over the past two decades, with a “dramatic” increase among Canadian men, according to a new report from the Canadian Cancer Society.

The special report on HPV-associated cancers, released Wednesday as part of the 2016 Canadian Cancer Statistics breakdown, says the rate of mouth and throat cancers in men is poised to surpass the rate of cervical cancer diagnoses in women.

Researchers and doctors have known for decades that certain strains of HPV – the most commonly sexually transmitted disease in Canada and the world — cause cervical cancer. But the latest Canadian cancer statistics show that only 35 per cent of HPV cancers are cervical, and that about 33 per cent of HPV cancers occur in males.

The latest data show that about one-third of all HPV cancers in Canada are found in the mouth and throat.

Between 1992 and 2012, the incidence of HPV-related mouth and throat cancers increased 56 per cent in males and 17 per cent in females. In 1992, the age-standardized incidence rate (or ASIR) of those cancers was 4.1 per 100,000 Canadian males. In 2012, it was 6.4 per 100,000 males. In females, the rate was 1.2 in 1992 and 1.4 in 2012.

‘I thought I was done’
Three years ago, Dan Antoniuk noticed a lump on his neck and initially thought that it was just a swollen gland. But when the Edmonton father went to see a doctor, he was diagnosed with Stage 4 throat cancer, caused by HPV.

“I was devastated. I thought I was done,” Antoniuk, 61, told CTV News. “It shattered me, it shattered my family and affected everybody sitting in the waiting room.”

Antoniuk said that until his diagnosis, he had never heard of HPV cancers in men. His doctors told him that, despite the late stage of his cancer, his prognosis was still good with the right treatment. He underwent surgery, radiation and chemotherapy and although the treatments took a toll on his body, he’s now doing well.

“The end result is I am here, I am healthy and I can do most of the same things I have done before,” he said. “The ultimate message is: Be aware of your body and be aware of the fact that this could be something more serious and there is hope now.”

Dr. Hadi Seikaly, a professor and oncology surgeon at the University of Alberta, said doctors are seeing more HPV-related cancers in both men and women.

“The surprising thing is that we’re just seeing the front end of the epidemic,” he told CTV News. “And it is an epidemic … cervical cancer rates are coming down and head, neck cancer rates are going up.”

Doctors say that oropharyngeal cancers (which include the back of the throat, the base of the tongue and the tonsils) and cancers of the mouth used to be mostly found in older patients who smoked, drank heavily or had other health issues. But it’s now more common to see HPV-related throat and mouth cancers in younger, otherwise healthy patients.

“HPV is without question driving the dramatic increase we are seeing in oropharyngeal squamous cell carcinoma (OPSCC),” Dr. Joseph Dort, the chief of otolaryngology head and neck surgery at the Foothills Medical Centre in Calgary, told CTV News.

“Our most recent data shows that about 70 per cent of our new cases of this cancer are HPV positive. Recent studies suggest that oropharyngeal cancer will become the most common HPV-associated malignancy by the year 2020, surpassing cancer of the cervix,” he said in an email.

The changing face of the disease
Jennifer Cicci was shocked to learn that she had oral cancer caused by HPV after a lump appeared on the side of her neck in the fall of 2013.

The dental hygienist and mother of four from Brampton, Ont., said she was an otherwise healthy woman in her 40s who didn’t have any of the typical risk factors associated with head and neck cancers.

Cicci’s surgeon removed a baseball-sized mass of tissue from the back of her throat and a section from the back of her tongue. She also underwent laser surgery and radiation, with painful side effects. Still, she feels she “got off easy,” despite the entire ordeal.

In some cases, mouth and neck cancer treatments can have devastating effects on a patient’s ability to speak and eat. Some patients have had parts of their tongues and even their voice boxes removed.

The good news, doctors say, is that HPV-related cancers seem to be more treatable. More than 80 per cent of patients will survive if the cancer is caught in time.

“I felt like having this gave me an opportunity to raise awareness of something that I felt was becoming an epidemic,” Cicci said.

Dr. Brian O’Sullivan, a head and neck cancer specialist at Princess Margaret Hospital in Toronto, said that HPV infections in the throat and mouth are largely linked to sexual contact, but he has also seen patients who have had very few sexual partners and little experience with oral sex.

Calls for more widespread HPV immunization
The Canadian Cancer Society estimates that nearly 4,400 Canadians will be diagnosed with an HPV-caused cancer (that can include cervical, vaginal, anal and oral) and about 1,200 will die from it in 2016.

The society is focusing its messaging on cancer prevention and informing the public about the HPV vaccine. The two HPV vaccines approved by Health Canada are Gardasil and Cervarix.

HPV immunization is already available through publicly-funded school programs across the country, starting between Grades 4 and 7, up to age 13. But while the vaccine is offered to girls in all provinces and territories, only six provinces — Alberta, Manitoba, Nova Scotia, Ontario, Prince Edward Island and Quebec – also offer it to boys.

The Canadian Cancer Society is calling on the remaining provinces and territories to expand HPV immunization to boys.

Robert Nuttall, the society’s assistant director of health policy, also said that adults should talk to their doctors to see whether they can benefit from the HPV vaccine. However, there is currently no scientific evidence showing the benefits of HPV vaccines in older adults.

In Canada, Gardasil is approved for use in females aged 9 to 45, and males aged 9 to 26. Cervarix is approved for use in females between the ages of 10 and 25, but is currently not approved for boys and young men.

The vaccine works best in people who have not been exposed to HPV. That’s why it is given to school-aged children and teens as a preventative measure.

It will be a while before scientists can conclusively determine whether HPV vaccines can prevent throat and neck cancers, since it can take many years for an HPV infection to cause malignancies.

In the meantime, Dr. Seikaly says it’s important for Canadians to understand this disease could happen to anybody, because the modes of HPV transmission aren’t fully understood.

“They need to understand the signs and symptoms of it. And those include pain in your throat, difficulty swallowing, neck masses, ulcers in your mouth and throat,” he said. “And they need to make sure during their physical that doctors do look in their mouth and their throat.”

Early symptoms of mouth and throat cancers can often be vague, but they also include white or red patches inside the mouth or on the lips, persistent earaches and loose teeth.

As a dental hygienist who was also a cancer patient, Cicci urges regular exams of the mouth and throat during dental visits.

“What I try to do is to break down the stigma that is attached to (HPV),” she said. “The fact of the matter is, while most of the time it is still being sexually transmitted … we don’t know all the modes of transmission.”

October, 2016|Oral Cancer News|

Merck KGaA, Pfizer and Transgene team up on cancer vaccine

Source: www.biopharmadive.com
Author: Joe Cantlupe

Dive Brief:

  • Transgene announced Tuesday it is teaming up with Merck KGaA of Darmstadt, Germany, and Pfizer to evaluate the possibilities of the combination of its human papillomavirus (HPV)-positive head and neck cancer vaccine TG40001 with big pharma’s avalumab in a Phase 1/2 study.
  • The incidence of HPV-related head and neck cancers has increased significantly, with one variation, HPV-16 accounting for 90% of all HPV-related head and neck cancers. HPV-16 is a subset of head and neck squamous cell carcinoma (HNSCC), a group of cancers that can affect the mouth and throat. Global spending on head and neck cancer indications amounted to $1 billion in 2010, according to the companies’ recent estimates.
  • Current treatments for the disease include surgical resection with radiotherapy or chemo-radiotherapy; the companies say they are exploring better options for advanced and metastatic HPV and HNSCC.

Dive Insight:
The current deal between the big pharma partners and Transgene highlights the industry’s efforts to create combination therapies to treat cancer. Virtually every company in the space has embraced the idea that using multiple modes of attack could be the only way to eventually find cures for the many forms of cancer; companies have been teaming up in hopes of finding that crucial pairing.

In previous clinical trials, TG4001 has demonstrated promising activity in terms of HPV viral clearance and was well tolerated, according to Transgene. TG4001 is one of the few drugs targeting HPV-associated cancers that can be combined with an immune checkpoint inhibitor such as avelumab.

TG4001 is an active immunotherapeutic designed by Transgene to express the coding sequences of the E6 and E7 tumor associate antigens of HPV-16, and the cytokine, L IL-2. Avelumab is an investigational fully human antibody specific for a protein found on tumor cells called PD-L1. It is considered to have a mechanism that may enable an immune system to locate an attack cancer cells. In 2014, Merck KGaA and Pfizer signed a strategic alliance to co-develop and commercialize avelumab.

“The preclinical and clinical data that have been generated with both TG4001 and avelumab individually suggest this combination could potentially demonstrate a synergistic effect, delivering a step up in therapy for HPV- positive HNSCC patients,” said Philippe Archinard, chairman and CEO of Transgene, in a statement.

Christophe Le Tourneau, the principal investigator of the study, said HPV-induced head and neck cancers are now treated with the same regimen as non-HPV-positive HNSCC tumors, and that is not enough. “Their different etiology clearly suggests that differentiated treatment approaches are needed for HPV-positive patients,” he said in a statement. “Targeting two distinct steps in the immune response could deliver improved efficacy for patients who have not responded to or have progressed after a first line of treatment,” added Le Tourneau, who is also head of the Early Phase Program at Institut Curie.

This trial is expected to begin in France, with the first patients expected to be recruited in the beginning of 2017, said Le Tourneau. The companies will seek to recruit patients with recurrent and/or metastatic virus-positive oropharyngeal squamous cell carcinoma that have progressed after definitive local treatment or chemotherapy, and cannot be treated with surgical resection and/or re-irradiation.

October, 2016|Oral Cancer News|

Recognizing oral carcinoma

Source: nurse-practitioners-and-physician-assistants.advanceweb.com
Author: Amber Crossley, MSN, ARNP, FNP-BC

Oral carcinoma is identified as one of the top ten cancers worldwide, accounting for nearly 2% to 5% of all cancer cases.1, 2 In 2014, there were an estimated 42,440 new cases of oral and pharyngeal carcinoma.

Males have a greater risk of developing the disease compared to females.2 Black males in particular are amongst the highest at-risk group for developing oral carcinoma.2 Oral carcinoma typically develops after the age of 50, with the majority of cases occurring between the ages of 60 and 70.2 When initially diagnosed with oral carcinoma, more than 50% of people will have metastases.3

The most common causes of oral carcinoma are related to tobacco use and alcohol consumption.4 In fact, 75% of all cases of oral carcinoma may be caused by the combination of tobacco and alcohol use.4

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However, it has also been extrapolated that chronic trauma to the oral mucosa, such as in the case of ill-fitting dentures or the consumption of high-temperature foods, is a leading modifiable risk factor for oral carcinoma.1,5 Dietary deficiencies of vitamins A, C, E, selenium, and folates may also contribute to the development of malignant cancerous lesions in the oral cavity.6

While cases of oral carcinoma have decreased over the last few years in the United States, oropharyngeal cancer is increasing in incidence.4 The rise in cases of oropharyngeal cancer may be related to viral and infectious diseases; however, the mechanisms are largely unclear. Some of these infections and viruses include human papilloma virus (HPV), periodontitis, candida albicans, syphilis and herpes simplex virus.7 However, for the purposes of this case presentation, only oral cavity cancer will be discussed.

A Non-Healing Oral Lesion
MC is an 82-year-old white female who visited her primary care provider’s office complaining of a mouth sore. The sore was present for approximately six months, and grew increasingly painful.

She has worn dentures for more than 10 years, and was accustomed to the typical soreness with irritation sometimes associated with everyday denture use. With this particular occurrence, the soreness lingered in the same area and lasted longer than any previous experience.

MC attempted to alleviate the soreness with an existing prescription for hydrocodone. This treatment proved unsuccessful. MC scheduled an appointment with her primary care provider, as she assumed the pain was the result of ill-fitting dentures.

At MC’s initial appointment, the provider noticed a 7mm erythematous lesion on the lower interior aspect of her right molar, and suggested it could be the result of her ill-fitting dentures. Because MC had exhausted her hydrocodone, the provider prescribed tramadol and a viscous lidocaine suspension for pain. She was told to follow-up with her dentist once the sore completely healed in order to be fitted with new dentures. She was instructed to refrain from denture use until the sore had resolved. There were no further follow-up instructions given.

One week after the initial visit, MC returned to the primary care provider’s office because of increasing pain and discomfort. During this visit, the provider noted the sore had ulcerated edges that were friable and showed little improvement. She was referred immediately to an otolaryngologist for the suspicion of carcinoma of the oral cavity.

Patient History
MC is an 82-year-old widow. She is a Medicare recipient living in government-subsidized housing for the elderly. MC smoked tobacco between the ages of 17 and 52 at a rate of 1.5 packs per day, or 53 pack years. During the same 35 year time frame, she drank 1 to 2 alcoholic beverages daily.

Over the past 10 years, she lost a total of 40 pounds without any lifestyle modifications to justify the weight loss. At the time of MC’s initial primary care visit, she weighed 91 pounds. Additional patient history included hypothyroidism, mitral stenosis, gastroesophageal reflux disease, coronary artery disease, arthritis and hypertension.

Clinical Features
Oral carcinoma is defined as cancer involving the floor of the mouth, hard palate, buccal mucosa, interior tongue, retromolar trigone, or alveolar ridge.8 Premalignant oral carcinoma may present as a painless white patch known as leukoplakia, or a painful reddened patch identified as erythroplakia.9 In addition to the aforementioned signs, the cervical lymph nodes may be enlarged.10 Any erythroplakia or leukoplakia lesions that appear to be non-healing in an older individual should be deemed suspicious.10

Differential Diagnosis

Refer to the table below to help you rule out other conditions.

table

Diagnosis
Early identification of oral carcinoma offers patients the greatest chance for successful treatment and survival following diagnosis.5

An initial patient history that includes tobacco use, alcohol consumption, sexual practices, denture use, oral trauma, infections of the oral cavity and a history of present illness should be obtained.8 It is important to understand that patients complaining of ill-fitting dentures are four times more likely to develop an oral lesion that is cancerous.5

Oral lesions caused by trauma increase the likelihood of carcinogen absorption from tobacco and alcohol in the oral mucosa. This absorption may disrupt the deoxyribonucleic acid of the mucosal cells.1

Following a thorough history, the provider can perform a complete head and neck examination. During oral cavity inspection, a mirror and fiberoptic exam should also be performed.8 A combination of inspection and palpation for lumps or abnormalities within the tissue of the oral mucosa is the definitive mechanism used to screen for oral cancer as identified by the U.S. Preventive Services Task Force.4 In the presence of a potentially cancerous oral lesion, a surgical biopsy should be completed to confirm a diagnosis of oral carcinoma.9

Imaging studies can be used to detect and identify metastases of oral carcinoma. Computed tomography is the preferred imaging study performed at the site of the primary tumor.11 This study can identify the extent of the tumor, as well as lymph node involvement.10,12 Additionally, a chest x-ray is recommended in order to determine whether or not the oral carcinoma originated in the lungs or metastasized to the lungs. The lungs are the primary site for metastases of oral carcinoma.12 More than 90% of oral cavity cancers are considered to be squamous cell carcinoma.11

Laboratory studies should also be considered in addition to imaging studies. Serum ferritin, alpha anti-trypsin, and alpha-antiglycoprotein levels can be elevated in patients with advanced cancer of the head or neck region.12 Laboratory studies alone cannot determine the presence of oral carcinoma. However, they can aide in identifying the extent and progression of the cancer.12

Case Outcome
A surgical biopsy was performed in order to identify the causative organism. MC was diagnosed with stage IV malignant squamous cell carcinoma of the right retromolar trigone, as well as squamous cell carcinoma of the right middle and lower lobe of the lung. The patient had no lymph node involvement.

Because of her increased age and nutritional status, MC did not qualify for multimodal treatment. Instead, she is being treated with aggressive radiation therapy over a period of 12 weeks.

Understanding key factors related to MC’s case — increased age, history of tobacco and alcohol use, and ill-fitting dentures — is paramount when identifying the painful, non-healing, 7 mm lesion in her oral cavity as a potential diagnosis of oral carcinoma.

Implications for Practice
Due to the increase in oral health disparities, the Institute of Medicine released a report revealing a new demand for non-dental health care providers to perform screenings for oral diseases as well as offering prevention advice and referral to preventative services.13

Increasing interprofessional collaboration amongst dentists, nurse practitioners, physician assistants, physicians and medical students has shown to be effective in implementing the head, ears, eyes, nose, oral cavity, and throat (HEENOT) assessment into practice.14 While this is similar to the head, ears, eyes, nose and throat assessment, it allows for the integration of the oral cavity into the evaluation of the head and neck exam.

One study, conducted between 2008 and 2014 at New York University, revealed that the result of HEENOT implementation led to 500 patient referrals to dental clinics for suspicious oral lesions.14 Preventative measures at the primary care level should focus on the greatest risk factors (tobacco use, alcohol consumption and ill-fitting dentures).

Research has shown that due to the sometimes vague and misleading symptoms of early-onset oral carcinoma, a diagnosis may be prolonged by up to 6 months.12 Although screening for oral cancer in healthy individuals without risk factors may not be beneficial, evidence supports oral screenings by primary care providers for high-risk patients.3, 4, 15

Given the fact that only 30% of patients ages 65 years and older have dental insurance coverage, the primary care provider must screen patients who present with many risk factors for oral carcinoma.14,16 Because there are a greater number of primary care providers in comparison to dentists, they have the potential to increase awareness and detection of oral carcinoma.16

While the leading cause for oral carcinoma is tobacco use, it is recommended that the primary care provider encourage patients who use tobacco to employ smoking cessation products.4 Second, the primary care provider should educate patients on the harmful effects of daily alcohol use.12 Third, providers should stress to patients the importance of regular dental check-ups and denture fittings as an essential tool for maintaining good oral health.5

Note:
Amber Crossley practices as an advanced registered nurse practitioner in Jacksonville, Florida.

References
1. Piemonte ED, et al. Relationship between chronic trauma or the oral mucosa, oral potentially malignant disorders and oral cancer. J Oral Pathol Med. 2010;39(7):513-517.

2. National Cancer Institute. Stat fact sheets: oral cavity and pharynx cancer. http://seer.cancer.gov/statfacts/html/oralcav.html.

3. Rethman MP, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinoma. JADA. 2010;141(5):509-520.

4. U.S. Preventative Services Task Force. Oral cancer: screening. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/oral-cancer-screening1

5. Manoharan S, et al. Ill-fitting dentures and oral cancer: a meta-analysis. Oral Oncol. 2014;50(11):1058-1061.

6. Freedman ND, et al. Fruit and vegetable intake and head and neck cancer risk in a large United States prospective cohort study. Int J Cancer. 2008;122(1):2330-2336.

7. Meurman JH. Infectious and dietary risk factors of oral cancer. Oral Oncol. 2010;46(6):411-413.

8. National Comprehensive Cancer Network. Head and neck cancers. http://oralcancerfoundation.org/treatment/pdf/head-and-neck.pdf

9. Jefferson GD. Adult with oral cavity lesion. AAO-HNSF Patient Month Program. 2011;40(5): 1-25.

10. Arya S, et al. Head and neck symposium: imaging in oral cancers. Indian J Radiol Imaging. 2012.22(3):195-208.

11. Akram S, et al. Emerging patterns in clinico-pathological spectrum of oral cancers. Pak J Med Sci. 2013;29(3):783-787.

12. Scully C. Cancers of the oral mucosa. Medscape. 2016. http://emedicine.medscape.com/article/1075729-overview

13. Institute of Medicine. Improving access to oral health care for vulnerable and underserved populations. https://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations/Report-Brief.aspx.

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October, 2016|Oral Cancer News|

Immunotherapy drug a ‘gamechanger’ for head and neck cancer

Source: www.theguardian.com
Author: staff

An immunotherapy drug hailed as a potential gamechanger in the treatment of cancer could soon offer new hope to patients with currently untreatable forms of the disease.

Nivolumab outperformed chemotherapy significantly in keeping relapsed head and neck cancer patients alive. Photograph: Alamy

Nivolumab outperformed chemotherapy significantly in keeping relapsed head and neck cancer patients alive. Photograph: Alamy

Nivolumab was found to extend the lives of relapsed patients diagnosed with head and neck cancers who had run out of therapy options. After a year of treatment, 36% of trial patients treated with the drug were still alive compared with 17% of those given standard chemotherapy.

Trial participants treated with nivolumab typically survived for 7.5 months, and some for longer. Middle-range survival for patients on chemotherapy was 5.1 months. The phase-three study, the last stage in the testing process before a new treatment is licensed, provided the first evidence of a drug improving survival in this group of patients.

Prof Kevin Harrington, from the Institute of Cancer Research, London, who led the British arm of the international trial, said: “Nivolumab could be a real gamechanger for patients with advanced head and neck cancer. This trial found that it can greatly extend life among a group of patients who have no existing treatment options, without worsening quality of life.

“Once it has relapsed or spread, head and neck cancer is extremely difficult to treat. So it’s great news that these results indicate we now have a new treatment that can significantly extend life, and I’m keen to see it enter the clinic as soon as possible.”

Before it can be offered on the NHS, the treatment will have to be approved by the European Medicines Agency and the National Institute for Health and Care Excellence (Nice), which vets new therapies in England and Wales for cost-effectiveness.

Of the 361 patients enrolled in the trial, 240 were given nivolumab while the remaining 121 received one of three different chemotherapies. UK patients were assigned the chemotherapy drug docetaxel, the only treatment currently approved for advanced head and neck cancer by Nice.

Patients whose tumours tested positive for the HPV virus, which is linked to cervical cancer and may be spread by oral sex, did especially well. They typically survived for 9.1 months, compared with 4.4 months when treated with chemotherapy. More than half of patients relapse within three to five years.

Nivolumab is one of a new class of antibody drugs called checkpoint inhibitors that help the immune system fight cancer. It works by blocking signals from tumour cells that stop the immune system attacking.

The drug is already licensed for the treatment of advanced melanoma skin cancer and non-small-cell lung cancer in the UK. However while Nice has backed its use on the NHS for melanoma it has so far refused to recommend making the drug freely available to lung cancer patients.

Prof Paul Workman, chief executive of the Institute of Cancer Research, said: “Nivolumab is one of a new wave of immunotherapies that are beginning to have an impact across cancer treatment. This phase-three clinical trial expands the repertoire of nivolumab even further, showing that it is the first treatment to have significant benefits in relapsed head and neck cancer.

“We hope regulators can work with the manufacturer to avoid delays in getting this drug to patients who have no effective treatment options left to them.”

October, 2016|Oral Cancer News|

Particular HPV strain linked to improved prognosis for throat cancer

Source: medicalxpress.com
Author: provided by University of North Carolina Health Care

When it comes to cancer-causing viruses like human papillomavirus, or HPV, researchers are continuing to find that infection with one strain may be better than another.

In an analysis of survival data for patients with a particular type of head and neck cancer, researchers from the University of North Carolina Lineberger Comprehensive Cancer Center confirmed findings that a particular strain of HPV, a virus linked to a number of cancers, resulted in better overall survival for patients with oropharyngeal cancer than patients with other strains of the virus in their tumors.

They believe their findings, reported in the journal Oral Oncology, are particularly important as physicians move to lessen treatment intensity for patients with HPV-linked oropharyngeal cancer in clinical trials to try to spare them negative side effects of radiation or drugs. They also found that a test used widely to determine patients’ HPV status may not be sensitive enough to select patients for de-intensification.

“What we demonstrate in this study is that the type of HPV can help us to better determine a patient’s prognosis,” said the study’s senior author Jose P. Zevallos, MD, MPH, an associate member of UNC Lineberger and an associate professor in the UNC School of Medicine. “We think this is important because HPV positive patients do so well generally, and there’s been a huge move nationally to take treatment down a couple notches to limit morbidity and side effects. The risk is that if you de-intensify too much, and you happen to have a high-risk tumor because you have a different type of HPV, then this could be harmful to patients who don’t warrant it.”

The UNC study was based on an analysis of survival data for 238 patients in North Carolina diagnosed between January 2002 and February 2006 with oropharyngeal cancer, a type of head and neck cancer in the throat at the back of the mouth, as part of the Carolina Head and Neck Cancer Study, or CHANCE. The Centers for Disease Control and Prevention estimates that more than 15,600 cases of HPV-associated oropharyngeal cancer are diagnosed in the United States each year.

Previous studies have shown that patients with HPV-linked oropharyngeal cancer have higher survival and lower recurrence rates compared to those with HPV-negative oropharyngeal cancer. As those patients tend to respond better to treatment, researchers are studying whether patients with HPV-linked oropharyngeal cancer can receive less intensive treatment with good outcomes. The researchers point out, however, that there has been limited research that tracks outcomes for oropharyngeal cancer based on the particular strain of HPV that patients have.

Zevallos and his colleagues confirmed earlier findings that patients with oropharyngeal cancer tumors infected with HPV16 had improved overall survival. They also determined that patients whose cancer was infected with other HPV strains had similar survival rates as patients whose cancer did not have HPV at all.

They found that 71.4 percent of patients with HPV16-linked oropharyngeal cancer lived at least five years. Meanwhile, the five-year survival-rates for patients with other strains of the virus in their tumors, and for patients who were HPV-negative, were lower: 57 percent for patients with other types of HPV and 50 percent for HPV-negative patients.

Zevallos said the finding of a lower survival rate for patients positive for HPV strains other than HPV16 is important in that it indicates that those patients may not be good candidates for treatment de-intensification.

“The finding that non-HPV16 types are closer to the HPV-negative group in terms of survival differences suggests that those patients should definitely not be considered for anything other than standard aggressive therapy,” he said.

The researchers noted that additional research needs to be done in a larger sample size to rule out the possibility that characteristics other than HPV status are driving survival differences, and to clarify whether the patients found to have other HPV strains were not false-positives.

The also cautioned that based on their findings, a commonly used clinical test that measures for the presence of the p16 protein may not be specific enough to identify HPV-linked oropharyngeal cancer patients who are good candidates for treatment de-intensification. To determine whether patients had HPV-positive tumors, they compared the results of the p16 test with results of a more specific genetic test.

They found that 4.3 percent of the patients were positive for p16, but negative for HPV according to the genetic test. Another approximately 11 percent of p16-positive cases had HPV strains other than HPV16, according to the genetic tests. Zevallos said this is an important finding because patients whose cancer was not infected with HPV16 had a lower 5-year survival rate, meaning they would not be good candidates for treatment de-escalation.

Yet the researchers report that many of the clinical trials that de-intensify treatment use p16 expression alone to determine if a patient’s cancer is HPV-positive, and whether they should be considered for treatment de-intensification.

“Even though we rely almost exclusively around the country on p16 positivity as a surrogate for HPV16 presence, this sheds some light on the fact that maybe we should be considering HPV genotyping because of the survival differences we saw here,” Zevallos said.

September, 2016|Oral Cancer News|

Men with throat cancer will soon outnumber women with cervical cancer In The US

Source: www.houstonpublicmedia.org
Author: Carrie Feibel

The national increase in cases of oropharyngeal cancer related to the human papilloma virus is troubling, because there is no screening test to catch it early, like the Pap test for cervical cancer.

The oropharynx is the area of the throat behind the mouth, and includes the tonsils and the base of the tongue. Oropharyngeal cancer is increasing in both men and women, but for reasons that aren’t well understood, male patients are outnumbering female patients by five to one, according to Dr. Erich Sturgis, a head and neck surgeon at MD Anderson Cancer Center.

“It’s usually a man, and he notices it when he’s shaving. He notices a lump there,” Sturgis said. “That lump is actually the spread of the cancer from the tonsil or the base of the tongue to a lymph node. That means it’s already stage three at least.”

In the U.S., the number of oropharyngeal cancers caused by HPV are predicted to exceed the number of cervical cancers by 2020, Stugis said.

“With cervical cancer, we’ve seen declining numbers well before we had vaccination, and that’s due to the Pap smear being introduced back in the late 50s,” he said. “But we don’t have a screening mechanism for pharynx cancer.”

Research on an effective screening test for early-stage pharynx cancer is still underway. The reasons for the disproportionate effect on men are unknown. One theory is that people are engaging in more oral sex, but that doesn’t explain why men are more affected than women. Some suspect hormonal differences between men and women may be involved, and others hypothesize that it takes longer for women to “clear” the viral infection from their genitals, compared to men, according to Sturgis.

One of Sturgis’s patients, Bert Noojin, is an attorney in Alabama. He felt a little knot in his neck in early 2011. It took three trips to his primary care doctor, then a visit with an otolaryngologist before he was referred for a biopsy. Noojin was diagnosed with oropharyngeal cancer, but he still felt fine.

“It was still hard for me to believe I was sick in any way,” he recalled. “I didn’t even have a serious sore throat.”

After being diagnosed, Noojin came to MD Anderson Cancer Center in Houston for a second opinion and to pursue treatment. It was less than three months from when he first felt the knot, but an oncologist warned him the cancer was spreading fast.
“He said ‘Well, you need to start treatment right away’ and I said, ‘Well, do I have a week or 10 days to go home and get some things in order?’ and he said ‘No.’”

“He said ‘If you leave here, and you’re not part of our treatment plan when you leave here, I don’t think we’ll be able to help you.’ That is how far this disease had progressed, in such a very short time.”

The prognosis for HPV-related oropharyngeal cancer is good, especially compared to patients whose throat cancer is caused by heavy use of tobacco or alcohol, according to Sturgis. Between 75 and 80 percent of patients with the HPV-related type survive more than five years.

But the treatment is difficult, and can include “long-term swallowing problems, long-term problems with carotid artery narrowing, and long-term troubles with the teeth and jaw bone, and things that can cause a need for major surgeries later.”

In the summer of 2011, Noojin began chemotherapy and radiation at MD Anderson. He struggled with pain, nausea, and swallowing, and had to get a temporary feeding tube.

“Your throat just shuts down,” he said. “You’re burned on the inside. Just swallowing your own saliva, as an instinct, hurts.”

Noojin lost 45 pounds during treatment but feels lucky to have survived. He went back to his law practice in Alabama.

Noojin learned that cancers related to HPV, which is sexually transmitted, are cloaked in shame and guilt.

He experienced this first-hand when his marriage fell apart during his recovery. His wife was traumatized by the difficult months of treatment, he said. In addition, she irrationally blamed herself for giving him the virus, even though he was probably exposed many years earlier. He tried to comfort her and dispel her guilt, but they eventually divorced.

“I was married over two decades, but I was married previously, and she was married previously,” he said. “It just makes no sense for any of this to have a stigma.”

An estimated 80 percent of America women and 90 percent of men contract HPV at some point in their lives, usually when they’re young and first become sexually active. But the cancers caused by HPV can take years to develop.

“It’s a virus. It’s not anybody’s fault,” Noojin said.

He echoed the public health experts in calling for an end to the silence and shame, and a shift to a focus on prevention.

“All of what I went through, and all of what hundreds of thousands of men, and women, because of cervical cancer – what they have gone through is avoidable for the next many generations … if we just got serious about making sure our kids get vaccinated.”

The series of three shots can be given as early as age nine, but must be completed before the age of 26 to be effective. Currently, the completion rate for young women in the U.S. is less than 50 percent. Among young men, it’s less than 30 percent. That’s why experts warn these particular cancers will still be a problem decades from now.

September, 2016|Oral Cancer News|