human papilloma virus

Be your own advocate

Source: www.wvnews.com
Author: Mary McKinley

The importance of dental care goes beyond cavities — it’s also about preventing cancer. The week of April 8 is National Oral, Head and Neck Cancer Awareness Week, and your dentist or dental hygienist may be your first line of defense against oral cancer.

More than 50,000 Americans are expected to be diagnosed with oral or oropharyngeal cancer (cancer of the back of the throat, including the base of the tongue and the tonsils) in 2018, and 350 will be diagnosed in West Virginia alone.

Routine dental exams can detect cancer or pre-cancers during the early stages. If you notice a persistent sore or pain, swelling or changes in your mouth, or red or white patches on the gums, tongue, tonsils or lining of the mouth, visit a doctor or dentist so they can examine your mouth more closely.

Some people diagnosed with oral cancer have no risk factors, so it’s important for everyone to keep those dental appointments.

If you use tobacco, drink alcohol in excess, or have the human papillomavirus (HPV), you have an increased risk for oral cancer. Oral cancer is more common in older adults, particularly men, but oropharyngeal cancer is on the rise in middle-aged, nonsmoking white men between the ages of 35 and 55. The majority of these types of cancer cases are caused by HPV.

Take charge of your health and reduce your risk of oral cancer. If you smoke or chew tobacco, quit now (it’s never too late). Moderate your alcohol consumption to no more than one drink a day for women or two for men.

If you have children, make sure they receive the HPV vaccine, which is recommended for all girls and boys ages 11 and 12; a “catch-up” vaccine is also available for young women up to age 26 and most young men up to age 21.

You can be your own best advocate. Check the inside of your mouth in the mirror each month, and speak up to your dentist or dental hygienist if you notice any changes that concern you.

Ask about cancer screenings when making your dental appointments. And to learn more about cancer prevention, be sure to visit www.preventcancer.org.

April, 2018|Oral Cancer News|

Accurately identifying aggressive head and neck cancers

Source: www.eurekalert.org
Author: press release

The Case Western Reserve-led research team will analyze computerized images of tissue samples for patterns which could become “biomarkers,” or predictors, for determining relative risk for recurrence in one particularly common type of head and neck cancers.

Those tumors, known as oropharyngeal cancers, occur primarily at the base of the tongue and in the tonsils.

Currently, however, oncologists tend to treat all of these tumors with the same aggressive level of therapy. This is the case even though many of the oropharyngeal tumors which are caused by the human papilloma virus (HPV) tend to have favorable outcome-regardless of treatment-while another subset of the tumors progress and metastasize, or spread.

“Right now, it’s a one-size-fits-all therapy for all of these patients with HPV head and neck cancers,” said Anant Madabhushi, MD, the F. Alex Nason Professor II of Biomedical Engineering, founding director of the CCIPD at the Case School of Engineering and primary investigator in the new research.

“There are currently very few validated biomarkers and approaches that are accurate enough to be able to identify which of these cancers are more aggressive or which ones are less aggressive,” he said. “That has limited the ability of clinicians to even hold clinical trials to find out if they can de-escalate therapy for some of these patients-or who needs more aggressive therapy.”

The National Cancer Institute (NCI) recently awarded a $3.15 million, five-year academic-industry partnership grant to Madabhushi and his team to pursue the research and build toward establishing those clinical trials.

Co-primary investigator on the grant is Vanderbilt University’s James Lewis Jr., MD, whose specialty is head and neck pathology, while Cleveland Clinic’s Shlomo Koyfman, MD, and David Adelstein, MD, are co-investigators with expertise in radiation and medical oncology.

Additionally, Pingfu Fu, an associate professor of population and quantitative health statistics at Case Western Reserve, brings expertise in biostatistics. Cheng Lu, a senior research associate in CCIPD is also involved with the project.

Madabhushi’s team is again working with Mark Lloyd, MD, of industry partner Inspirata Inc., the Florida-based company also teaming up with the lab on studies of breast and lung cancer-work supported by more than $6.3 million in NCI funding.

The team presented its data at the 2018 United States and Canadian Association of Pathology (USCAP) meeting in Vancouver this month and has generated data to suggest that the approach could soon become a clinically actionable tool.

Initial results on almost 400 oropharyngeal cancer patients suggests that the technology is independently prognostic of disease progression-meaning that it could stand alone in helping clinicians figure out how aggressive the disease is and then make a more informed decision on how aggressively to treat the cancer.

“In those cancers, they’ve established whether you can modulate your therapy based on the risk profile for those tumors,” Madabhushi said. “But in head and neck, clinicians might have a sense that there are different risk profiles for different patients, but nobody knows for certain. We want to change that by giving them the risk stratification tools to better help the patient.”

March, 2018|Oral Cancer News|

Experts reveal why men are four times more likely to get cancer from oral sex than women

Source: www.thesun.co.uk
Author: Sofia Petkar

Men are four times more likely than women to be diagnosed with oral cancer, as studies suggest a lower immune system could be behind this. Research has found men who perform oral sex on their female partners have a higher than average chance of developing an oral cancer triggered by the human papilloma virus (HPV).

While sexual norms and fewer inhibitions have played a role in this alarming trend, scientists now say the male immune system is the real problem. Research has found that compared with women, men are more likely to be infected with HPV and its “high-risk” cancerous strains. Men are also less able to get rid of the infection through the body’s natural defences, harbouring the virus for longer periods of time.

Ashish A. Deshmukh, a University of Florida HPV researcher, said: “There is good evidence that men acquire oral infections more readily than women, even if they have similar sex practices.

“And more than the acquisition, it’s the persistence of the virus.

“The clearance rate is not that fast in men.”

Traditionally, smoking and heavy alcohol usage were seen as the big risk factors for oral cancer. However, studies have shown that non-HPV tumours linked to these bad habits has declined significantly in recent years. In stark contrast, HPV-related tumours have increased more than 300 per cent over the last 20 years, with the virus now found in 70 per cent of all new oral cancers.

In 2013, Michael Douglas hit the headlines when he blamed his throat cancer on oral sex. The 72-year-old actor said he believed his cancer was triggered by the HPV virus, which he says he contracted after performing oral sex.

While many ridiculed his theory, experts say there is growing evidence to support his claims. The human papillomavirus (HPV) is a very common sexually transmitted disease which affects at least half of people who are sexually active. The STD is the most widespread worldwide and four out of five of the population will contract some form of the virus at least once in their life.

The types of HPV found in the mouth are almost entirely sexually transmitted, so oral sex is seen as the primary route of contracting them. In most cases, the body’s immune system will fight off the virus and there won’t be any need for further tests, in fact, some people may not even know they contracted it at all.

The HPV infection affects the skin and mucosa (any moist membrane, such as the lining of the mouth and throat, the cervix and the anus).

Dentists have warned that dating apps such as Tinder are putting more people at risk of catching HPV passed on by oral sex. The British Dental Association said: “Data used to model sexual behaviour are out of date, and factors such as the recent introduction of dating apps may have led to significant changes in behaviour over the last few years, which have not been taken into account.”

March, 2018|Oral Cancer News|

Biofilms in tonsil crypts may explain HPV-related head and neck cancers

Source: www.genengnews.com
Author: staff

Human papilloma virus (HPV) encased in biofilms inside tonsil crypts (pictured) may explain why the roughly 5% of HPV-infected people who develop cancer of the mouth or throat are not protected by their immune systems. Tonsil crypts with HPV are shown in green; epithelial and biofilm layers are shown in red. [Katherine Rieth. M.D.]

How can human papilloma virus (HPV) be prevalent in otherwise healthy people not known to carry it? A just-published study concludes that the virus may be lurking in small pockets on the surface of their tonsils.

Researchers from University of Rochester Medical Center (URMC) found HPV encased in biofilms inside tonsil crypts, where HPV-related head and neck cancers often originate. HPV is shed from the tonsil during an active infection and gets trapped in the biofilm, where it may be protected from immune attack.

In the crypts, the virus likely lays in wait for an opportunity to reinstate infection or invade the tonsil tissue to develop cancer.

“The virus gains access to the basal layer of stratified squamous epithelium through structural breaks in the stratified epithelial superstructure,” the investigators reported in the study. “Tonsillar crypt reticulated epithelium itself has been shown to contain numerous small blood vessels and has a discontinuous basement membrane, which may facilitate this infection and reinfection process.”

The URMC researchers said their finding could help prevent oropharyngeal cancers that form on the tonsils and tongue—and may explain why the roughly 5% of HPV-infected people who develop cancer of the mouth or throat are not protected by their immune systems.

HPV 16 and 18, high-risk strains that are known to cause cervical cancer, also cause head and neck cancers. While verified tests can detect HPV in people before they develop cervical cancer, that’s not the case with head and neck cancers, which according to a 2016 study are expected to outnumber cervical cancer cases by 2020.

“Far-Reaching Implications”
“Given the lack of universal HPV immunization and the potential for the virus to evade the immune system, even in individuals with detectable HPV in their blood, our findings could have far-reaching implications for identifying people at risk of developing HPV-related head and neck cancers and ultimately preventing them,” Matthew Miller, M.D., associate professor of otolaryngology and neurosurgery at URMC, said in a statement.

Dr. Miller and six colleagues detailed their findings in “Prevalence of High-Risk Human Papillomavirus in Tonsil Tissue in Healthy Adults and Colocalization in Biofilm of Tonsillar Crypts,” published online January 25 in JAMA Otolaryngology-Head & Neck Surgery, and announced by URMC today. The study’s corresponding author is Katherine Reith, M.D., an otolaryngology resident at URMC.

The researchers carried out a retrospective, cross-sectional study using samples obtained from tonsils archived at a university hospital following elective nononcologic tonsillectomy from 2012 to 2015. The samples consisted of formalin-fixed, paraffin-embedded samples of tumor-free tonsil tissue from 102 adults who had elective tonsillectomies and were between ages 20 and 39. More than half the patients (55, or 53.9%) were female.

Five of the samples contained HPV and four contained HPV 16 and 18. In every case, HPV was found in tonsil crypts biofilms.

HPV status was assessed by polymerase chain reaction (PCR), and high-risk subtypes 16 and 18 were assessed with quantitative PCR assay. Samples that demonstrated presence of HPV were then analyzed by in situ hybridization to localize the viral capsid protein.

These samples were then stained with concanavalin A to establish biofilm presence and morphology and with 4′,6-diamidino-2-phenylindole (DAPI) to visualize location of the virus in relation to cell nuclei. Data was assembled for aggregate analysis to colocalize HPV in the biofilm of the tonsillar crypts, the URMC researchers reported.

The research team plans to develop topical antimicrobials designed to disrupt the biofilm and allow the immune system to clear the virus—part of their investigation of potential screening tools, such as an oral rinse, to detect HPV in the mouth and throat.

February, 2018|Oral Cancer News|

7 million American men carry cancer-causing HPV virus

Source: www.nytimes.com
Author: Nicholas Bakalar

The incidence of mouth and throat cancers caused by the human papilloma virus in men has now surpassed the incidence of HPV-related cervical cancers in women, researchers report.

The study, in the Annals of Internal Medicine, found that 11 million men and 3.2 million women in the United States had oral HPV infections. Among them, 7 million men and 1.4 million women had strains that can cause cancers of the throat, tongue and other areas of the head and neck.

The risk of infection was higher for smokers, for people who have had multiple sex partners, and for men who have sex with men. Frequent oral sex also increased the risk. The rate was higher among men who also had genital HPV. (Almost half of men aged 18 to 60 have a genital HPV infection, according to the Centers for Disease Control and Prevention.)

Neither age nor income made a difference in high-risk oral infection rates, but rates among non-Hispanic blacks were higher than other races and ethnicities.

HPV vaccination is recommended starting at age 11 or 12 and is effective, said the senior author, Ashish A. Deshmukh, an assistant professor at the University of Florida, and “it’s crucial that parents vaccinate boys as well as girls.”

The lead author, Kalyani Sonawane, also at the University of Florida, said that behavioral change is important, too, particularly smoking cessation. “The difference in oral HPV infection between smokers and nonsmokers is staggering,” she said.

October, 2017|Oral Cancer News|

Trans oral robotic surgery saves public Australian hospital patients from disfiguring procedure

Source: www.smh.com.au
Author: Kate Aubusson

The cancerous tumour growing at the back of Brian Hodge’s tongue was about as hard-to-reach as cancers get. The 73-year-old was told he’d need radical, invasive surgery to remove the 50¢-sized tumour. His surgeon would make an incision almost from ear-to-ear and split his jaw in two for the 10-12 hour surgery.

After five days in intensive care, another three weeks in hospital and four to six months recovery, re-learning how to eat and talk Mr Hodge would have been left with disfiguring scars, and a voice that he may not recognise as his own.

“My kids didn’t want me to have it,” Mr Hodge said. “But I’m not one to throw in the towel … Then the unbelievable happened,” he said.

Mr Hodge became one of the first public patients to undergo robotic surgery for head, neck and throat cancer at Nepean Hospital, the state’s only hospital offering the service to patients who can’t afford private healthcare.

Mr Hodge’s surgeon, Associate Professor Ronald Chin, performed the trans oral robotic surgery (TORS) by guiding the robot’s arm into his patient’s open mouth to remove the cancerous tumour.

“I went in on Monday morning for the surgery and I was discharged Tuesday night,” Mr Hodge said of his surgery performed on June 19.

“It’s just amazing. Two days compared to six months recovering.

“What’s got me is that before it was only available to people who could pay the big money. I’ve worked all my life, I’ve paid tax and I think, why can’t we people get this surgery as well,” he said.

TORS is available for private health patients in other NSW hospitals, but its use at a major tertiary hospital in Sydney’s west – surrounded by suburbs with some of the highest smoking rates and lowest private health insurance rates in Sydney – was significant.

“It’s an enormous step forward to be able to offer this state-of-the-art treatment with such obvious benefits both cost-wise and [avoiding] disfigurement-wise … to patients who may not have previously had the resources to access it,” Dr Chin said.

The da Vinci robot Dr Chin used was the same one Nepean Hospital’s urological surgeons use to perform prostatectomies on prostate cancers. The TORS procedure takes about 45 minutes.

“Traditionally surgery is incredibly invasive. We had to make very large incisions across the neck, then lift the skin well above the lower lip and cut the jaw open,” said the otolaryngology, head and neck surgeon.

“We’re talking about a massive operation. Then reconstruction is very difficult.

“Not only did people face a horrendously long operation, they had to deal with long post-operative recovery and rehabilitation to regain speech, language, voice and the ability to eat and drink.

“With TORS, patients can go home the next day [with minimal discomfort],” he said.

More than 400,000 cases of oropharyngeal squamous cell carcinomas are diagnosed each year worldwide. The five-year survival rate for head and neck cancer in Australia is 69 per cent, according to government estimates.

Nepean Hospital would see between 10 and 15 patients with head and neck cancers per year who would be suitable for TORS, Dr Chin said. The cancerous tumours, usually linked to smoking and excessive drinking as well as the human papilloma virus, were “extraordinarily difficult to access, almost impossible”, said Dr Chin.

Robotic surgery costs significantly more than traditional surgeries. But Dr Chin said TORS could save the public health system up to $100,000 per procedure, where patients no longer needed to spend days in ICU, costing more than $3000 per night, or weeks in hospital. The robotic surgery is primarily indicated for patients with oropharyngeal carcinomas of up to four centimetres in size. Roughly one-third of TORS patients will not need chemo and radiotherapy.

“The early evidence available on trans oral robotic surgery for oropharyngeal cancer is promising,” said Dr Tina Chen, medical and scientific adviser at the Cancer Institute NSW.

“However, higher-quality research is needed to definitively say whether it means better clinical outcomes for patients, compared to other treatments already available,” she said.

There was currently no high-quality evidence from randomised controlled trials comparing TORS to chemotherapy and radiotherapy for these types of cancers, a 2016 Cochrane review concluded. It noted “data are mounting”.

Mr Hodge will soon be able to swap the pureed food he has eaten since the day after his surgery for his favourite meal, barbecue chicken, and the avid karaoke singer is already planning his first post-surgery crooning set-list. First, Engelbert Humperdinck’s Please Release Me, and the song he has been singing to his wife for decades, Anne Murray’s Could I Have This Dance.

Genetic variants are associated with susceptibility to mouth and throat cancer

Source: www.eurekalert.org
Author: news release

A number of genetic variants associated with susceptibility to oral cavity and pharyngeal cancer have been described in an international study published in the journal Nature Genetics.

The most noteworthy finding was an association between cancer of the oropharynx and certain polymorphisms (alternative versions of a given DNA sequence) found in the human leukocyte antigen (HLA) genomic region. HLAs, proteins found on the surface of most cells in the body, play an important role in recognizing potential threats and triggering the immune response to foreign substances.

According to Eloiza Helena Tajara, a professor at the São José do Rio Preto Medical School (FAMERP) in São Paulo State, Brazil, and co-author of the article, a specific group of variants in this region, located on chromosome 6, is associated with enhanced protection against oropharyngeal cancer caused by human papilloma virus (HPV).

“Previous research showed that these same variants confer protection against cancer of the uterine cervix, which is known to be associated with HPV,” Tajara said. “Our findings suggest that the genes that control the immune system play a key role in predisposition to HPV-related tumors. This discovery points to the possibility of clarifying the mechanisms whereby such tumors develop and of designing methods for monitoring risk groups.”

The study was coordinated by the International Agency for Research on Cancer (IARC) and involved 40 research groups in Europe, the United States, and South America. The Brazilian participants are members of the Head & Neck Genome Project (GENCAPO), a consortium of scientists affiliated with several institutions.

In a recent study, GENCAPO evaluated more than 7 million genetic variants in samples from 6,034 patients with head and neck cancer. The cases comprised 2,990 oral cavity tumors, 2,641 oropharyngeal tumors, 305 tumors in the hypopharynx (the bottom part of the pharynx near the esophagus), and 168 tumors in other regions or more than one region concurrently. The study population also included samples from 6,585 people without cancer as controls.

The researchers detected eight loci (genomic sites) associated with susceptibility to these types of tumor. Seven had not previously been linked to mouth or throat cancer.

According to Tajara, the IARC set out to focus on analyzing oral cavity and oropharynx tumors because there are no genome-wide association studies of these two tumor types. Although these cancers are predominantly caused by tobacco and alcohol use, the importance of HPV, particularly HPV16, as a cause of oropharyngeal cancer has become more evident in recent years.

“The throat is the most affected area among head and neck cancer subsites, likely because its tissue is more receptive to the virus,” Tajara said.

In the article, the researchers note that the proportion of HPV-related oropharyngeal cancer cases is estimated to be approximately 60% in the US and 30% in Europe but lower in South America.

“One finding that was expected to some extent was the absence of HLA associations with oropharyngeal cancer, which may be due to the fact that the frequency of HPV-positive oropharyngeal cancer is less than 10% in South America,” Tajara said. “The same factor appears to account for the weak association between the variants identified and HPV-positive oral cavity cancer, which is also far less frequent than HPV-negative oral cavity cancer.”

In her view, the strong rise in cases linked to HPV in the US could be partly due to a change in sexual habits, especially regarding the practice of oral sex. “It’s possible that Brazil is still in a transition stage and that the habits that favor infection are only starting to become more common. If so, the effects will appear in a few years’ time,” she said.

Previous studies have already shown that HPV-associated head and neck cancers affect younger people and develop rapidly. By contrast, cases associated with tobacco and alcohol use as well as poor oral hygiene are more prevalent in those over fifty years old and progress more slowly but are harder to treat.

In addition to DNA in tissue samples taken from participants of the study, data were also collected on environmental and clinical factors possibly associated with the development of this type of cancer, such as smoking, alcohol consumption, and age.

According to Tajara, thanks to the joint efforts of 40 research groups it was possible to obtain data on a significant number of patients, thus enhancing the impact and reliability of the results. The GENCAPO team contributed some 1,000 samples from tumors for analysis.

“Based on these results, we can try to understand from the molecular standpoint how the observed polymorphisms interfere with the response to HPV infection,” Tajara said. “This may give us clues as to how to protect people and how to reduce the incidence of this type of tumor.”

December, 2016|Oral Cancer News|

Predicting throat cancer recurrence with a blood test

Source: knowridge.com
Author: from University of Michigan Health System

A new study suggests the possibility of predicting at its earliest stages when a type of head and neck cancer will come back.

Oropharyngeal cancer — which occurs in the throat, tonsils and back of the tongue — is frequently linked to the human papilloma virus. That’s good news, in a way, as HPV-related cancers are generally more responsive to treatment.

But for about 15 to 20 percent of these patients, the treatment won’t work and their cancer will return. There are no known biomarkers to predict when treatments are likely to fail.

In a new study in Clinical Cancer Research, researchers found that patients whose oropharyngeal cancer recurred had higher levels of antibodies for two proteins, E6 and E7, which are found in HPV-fueled cancers. The finding suggests a potential blood-based marker that could predict when cancer is likely to return.

For this study, researchers looked back at 52 patients with advanced oropharyngeal cancer who had enrolled in a prior study: 22 who had developed recurrence and 30 who had not. The two groups were similar in age, cancer classification and smoking status. All tumors were linked to the human papilloma virus.

On average, cancer recurred 13 months after a patient’s treatment ended. Serum was measured via a blood test at diagnosis or start of treatment, then repeated after treatment ended and about every three months after.

Initially, there was no difference in E6 and E7 antibody levels between those patients who recurred and those who didn’t. All patients showed a decline in their antibody levels three months after treatment.

That makes sense, says study author Matthew E. Spector, M.D., assistant professor of otolaryngology at the University of Michigan Health System. After three months, all or most of the cancer had been wiped out. Since oropharyngeal cancer almost never recurs three months after treatment, antibody levels declined in all the patients studied.

“Most patients recur within the first two years, so the window to catch it is two years after treatment. Everyone’s level goes down over time, but some start to go up a little — and those are the ones we have to focus on,” Spector says.

Finding answers in antibodies

When the researchers looked at E6 and E7 antibody levels over time, they found that in patients whose cancer recurred, the levels of E7 were not decreasing as quickly as patients who did not recur. And they could begin to detect that prior to the point when the recurrence was discovered.

“If we can monitor someone through blood markers, then instead of a patient coming for a clinic visit every two to three months, they could get blood drawn near home. If there’s evidence of high E7, we can tell the patient to come in for more evaluation,” Spector says.

The key is to look at the ratio of E7 antibodies. Every patient had a different baseline level, and the absolute level was not an indication.

“It’s very patient-specific,” Spector says. “Each patient will have different levels, but the question is what happens when you track it over time. If it rises, that suggests recurrence.”

Oropharyngeal cancer most commonly recurs in the throat, neck or lungs. If recurrence is caught early, surgery to remove the cancer in the throat or neck can eliminate the disease and is likely to be a cure. If the cancer spreads to the lungs, offering targeted therapies earlier might improve outcomes.

The test for E6 and E7 antibodies is a standard laboratory test that any cancer treatment facility could perform, so it would likely be inexpensive to implement.

More testing among a larger number of patients is needed. The U-M team has opened a phase II trial to assess the potential for E7 antibodies as a biomarker for recurrence. For information, call the U-M Cancer AnswerLine at 800-865-1125.

December, 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|

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.

14. Haber JH, et al. Putting the mouth back in the head: HEENT to HEENOT. Am J Public Health. 2015;105(3):437-441.

15. American Family Physician. Screening for the early detection and prevention of oral cancer. http://www.aafp.org/afp/2011/0501/p1047.html

16. Cohon LA. Expanding the physician’s role in addressing the oral health of adults. Am J Public Health. 2013;103(3);408-412.

October, 2016|Oral Cancer News|