human papillomavirus

HPV symptoms and health consequences

Source: www.kristv.com
Author: Roland Rodriguez

No one dreams of walking into his or her doctor’s office and hearing the words “you have been diagnosed with human papillomavirus, or HPV.” Unfortunately, this scenario is all too real.

HPV is the most common sexually-transmitted infection (STI) in the United States. In fact, it’s so common that nearly all sexually active men and women get it at some point in their lives.

There are over 100 different kinds of HPV but only some of them can cause serious health problems like genital warts or cancer of the cervix, vagina, vulva or anus.

Testing positive for HPV does not automatically mean you will get cancer. Some studies estimate that 50 percent of those infected with HPV will clear the virus within eight months— and 90 percent will be cured within two years. It’s only when your immune system isn’t able to fight off the infection that some strains of HPV can persist and possibly lead to cancer.

The number of human papilloma virus (HPV)-associated cancers in the United States has increased by 17 percent, to nearly 39,000 cases a year, according to a report released from the Centers for Disease Control and Prevention.

While men cannot get HPV-linked cervical cancers, they are particularly vulnerable to HPV-related cancers of the mouth, tongue and throat, called oropharyngeal cancers. According to the new CDC report, the rates of mouth and throat cancers are more than four times higher among males than females.

In the past, people always felt that the boys needed to be vaccinated to protect the girls but, truthfully, the most effective way to prevent HPV: early vaccination.

Boys and girls are supposed to get three doses of the HPV vaccine — starting at age 11 or 12 because the vaccine works best before sexual activity begins.

The other benefit of giving it early is that our immune response is better, and that it may last longer.

Yet the latest statistic from the CDC shows that in 2014, only 40 percent of teenage girls received all three doses of the vaccine needed. In boys, that number is even lower: Only 22 percent of boys between 13 and 17 are properly vaccinated against HPV, increasing their chances for HPV-caused cancers later in life.

According to the CDC, the HPV vaccine — which is usually covered by insurance — is safe and not associated with serious side-effects of the HPV.

What are the signs, symptoms and health consequences of HPV?

In most cases, HPV goes away on its own and does not cause any health problems. But when HPV does not go away, it can cause health problems like genital warts and cancer.

Genital warts usually appear as a small bump or groups of bumps in the genital area. They can be small or large, raised or flat, or shaped like a cauliflower. A healthcare provider can usually diagnose warts by looking at the genital area.

Cervical cancer usually does not have symptoms until it is quite advanced, very serious and hard to treat. For this reason, it is important for women to get regular screening for cervical cancer. Screening tests can find early signs of disease so that problems can be treated early, before they ever turn into cancer.

Other HPV-related cancers might not have signs or symptoms until they are advanced and hard to treat. These include cancers of the vulva, vagina, penis, anus, and oropharynx (cancers of the back of the throat, including the base of the tongue and tonsils.

September, 2016|Oral Cancer News|

Why men need to start caring about HPV

Source: www.refinery29.com
Author: Sarah Jacoby

The human papillomavirus (HPV) is one of very few STIs that we have a vaccine for. And — bonus! — that vaccine prevents cancer. But a report from the U.S. Centers for Disease Control and Prevention (CDC) released last month indicated that although we’ve made some improvements in the vaccination rates, they still aren’t where we want them — especially for boys. This is despite the fact that pretty much everyone who’s sexually active will get the virus at some point and men are at risk for their own unique set of HPV-related health consequences.

Let’s start with the basics: “HPV is a virus that’s sexually transmitted, but it’s incredibly common,” explains Kathleen Schmeler, MD, of the University of Texas MD Anderson Cancer Center. Up to 80% of people get it at some point in their lives, she says, which is why some doctors refer to it as the “common cold” of STIs. For most people, the virus goes away on its own, without causing symptoms or needing treatment. Some people develop genital warts that can be treated with medication. But in some rare instances, the virus can go on to cause more serious health issues — including some types of cancer.

“The problem is we don’t know who’s going to clear it and who won’t,” Dr. Schmeler says. Most notably, HPV is known to cause cervical cancer. In fact, nearly all cases of cervical cancer are attributed to HPV. In 2013, the most recent year with available data, almost 12,000 women were diagnosed with cervical cancer in the U.S. and about 4,200 women died from the disease.

In addition to the risks of passing on the virus to their partners, men may face other consequences of HPV. Some types of HPV-related cancer, including throat cancer, are actually more common among men than women. “The rates for that are increasing significantly,” says Dr. Schmeler. “That’s been a huge deal recently.”

However, there is currently no accepted test for HPV-related cancers in men. Women are recommended to get a routine Pap screening, which can detect abnormal cervical cells that may be a result of an HPV infection. But similar screening for anal, penile, and throat cancers in men isn’t recommended.

“The common story that we hear is that [men are] shaving and they find a big lump in their neck,” says Dr. Schmeler. “But by then, it’s advanced disease because it’s spread to the lymph nodes.”

So although Dr. Schmeler’s team is working to find one, there’s no early or precancerous-stage test to detect HPV-related cancer in men.

Because they can’t be tested, it’s that much more important for boys to get the vaccine. Currently, the vaccine is recommended for boys and girls ages 11 to 12 to make sure they get it before they come in contact with the virus. But according to that August report, only about 50% of boys and 63% of girls actually got the vaccine in 2015. While the rates are improving quickly, they’re still nowhere near where they should be.

So why is it that the already-low vaccination rate is even lower for boys than girls? Part of that appears to be due to the way the vaccine was originally marketed: “When it first came out [in 2006], it was recommended only for girls because the primary focus was cervical cancer,” explains Dr. Schmeler. Since then, the CDC has expanded its recommendations to include boys, too. Parents may simply be unaware of the update.

According to research from the CDC, another big problem is that parents don’t believe their kids are (or are about to be) sexually active at that age. Doctors may be reluctant to push the issue or, in some cases, even bring it up.

“Everyone’s so obsessed with the fact that it’s a sexually transmitted disease,” says Dr. Schmeler. “[And in the process, we’re] forgetting that, with this vaccine, we can prevent cancer.”

It may be too late for adult men to get the most out of vaccination — it’s recommended that everyone get the vaccine by age 26. But for it to be it’s most effective, you should ideally get the vaccine before you’re exposed to the virus. And if you’ve already had multiple sexual partners, it’s likely that you’ve already been exposed.

But that doesn’t mean men don’t have to worry about this. In addition to the risk of spreading the virus to their partners, men are at risk for various cancers, as well. The bottom line is that HPV affects everyone, so we should all be equally sharing the burden of stopping the virus — and its associated cancers.

September, 2016|Oral Cancer News|

Despite medical backing, HPV vaccine rates remain low amid sexual and moral controversy

Source: www.omaha.com
Author: Rick Ruggles, World-Herald staff writer

pharynx_cancer

The HPV vaccine can reduce the rates of certain cancers, including many cervical and oral cancers, physicians and medical organizations say. But opposition by some individuals is strong, and HPV vaccination rates remain low when compared with other kinds of vaccinations recommended for adolescents.

Because the human papillomavirus is sexually transmitted and seventh grade is considered the ideal time to receive the three-dose vaccine regimen, the issue is rife with sexual and moral implications. Perhaps more potent today, though, are Internet horror stories and concerns about side effects.

A World-Herald Facebook request for views on the HPV vaccine generated far more negatives than positives. “NO NO & NO!! There is NO reason for this vaccine,” one wrote. Another called it a “deadly shot.”

Two Omaha mothers who were interviewed expressed their belief that it’s wise to have children vaccinated, and said their kids suffered no side effects. But an Iowa man described health problems suffered by his daughter, and he and an Ohio physician believe the girl was injured by the HPV vaccinations.

So mediocre are HPV vaccination rates that GSK, the maker of Cervarix, plans to cease distribution of its HPV vaccine in the United States in September. It will continue to supply it in many other nations, such as Great Britain, Germany, France and Mexico. The departure of Cervarix leaves the market to Gardasil, a vaccine produced by Merck.

“GSK has made the decision to stop supplying Cervarix … in the U.S. due to very low market demand,” the company told The World-Herald last week by email.

Many doctors in the Omaha area express disappointment with the low HPV vaccination rates but are optimistic that the situation will improve.

“As pediatricians, we’re trying to change that,” said Dr. Katrena Lacey, a Methodist Physicians Clinic pediatrician in Gretna. “I think we’re on the right track.”

A survey of adolescents reported last year by the federal Centers for Disease Control and Prevention found that 39.7 percent of girls ages 13 to 17 had received the three-dose regimen of the HPV vaccine in 2014, and 21.6 percent of boys.

This compares with 87.6 percent of boys and girls who had received the tetanus-diphtheria-pertussis vaccination and 79.3 percent who had received the meningococcal vaccine.

Dr. Megann Sauer, a pediatrician with Boys Town Pediatrics, said parents accept use of the vaccine if it’s explained well and described as a cancer-prevention strategy. “It’s a huge responsibility for us as providers to offer this to our patients,” Sauer said. “My job is to keep my patients healthy.”

Gardasil was approved in the United States 10 years ago. It was met with concern that having a child vaccinated for HPV, which is the most common sexually transmitted infection, would promote promiscuity.

Today, the global Christian ministry Focus on the Family says it “supports universal availability of HPV vaccines,” but it opposes government-mandated HPV vaccinations for public-school enrollment. The mandates are in place in Virginia, Rhode Island and Washington, D.C.

Tom Venzor of the Nebraska Catholic Conference said the vaccine itself isn’t morally problematic. But “the promotion of chastity and parental consent should never be undermined in the promotion of the HPV vaccine,” Venzor said in an email.

The Kaiser Family Foundation estimates that there are more than 14 million new human papillomavirus infections annually in the U.S. Most resolve on their own, but some chronic HPV infections can embed in tissues and lead to cervical cancers and tongue, tonsil, anal, vulvar, vaginal and penile cancers.

The American Cancer Society estimated there will be close to 13,000 new cases of cervical cancer this year and 4,120 deaths. HPV was detected in more than 90 percent of cervical cancers, a 2015 study reported in the Journal of the National Cancer Institute said.

“If you’ve ever seen anyone die of cervical cancer, it will tear you apart, because it’s a nasty, nasty disease,” said Dr. Steve Remmenga, a specialist in gynecologic oncology at the University of Nebraska Medical Center. Remmenga advocates getting the vaccination.

The CDC recommends routine HPV vaccinations beginning at 11 or 12 years of age for girls and boys, but the series can start as early as 9 years of age. The second dose should be given a month or two later and the third at least six months after the first. The vaccinations may be completed by 26 years of age. The recommendations have been adopted by the American Cancer Society and other medical organizations.

The recommendations suggest children receive the vaccinations “so they are protected before ever being exposed to the virus,” the CDC said. The agency said clinical trials indicate the vaccination provides “limited or no protection” against HPV-related diseases for women older than 26.

The CDC says the vaccine has repeatedly been shown to be safe.

Kari Nelson, a biology instructor at the University of Nebraska at Omaha, said two of her daughters, Claire and Emma, have had the full regimen and her third daughter, Gretchen, is about to get her second shot.

“I definitely believe in protecting my kids as much as possible,” Nelson said. “I do always try to weigh the pros and cons of anything. I just feel that the pros far outweigh the cons in this case.”

The Nelsons’ pediatrician, Dr. Tina Scott-Mordhorst, supports children and adolescents receiving the HPV vaccine. Why, she asked, would anyone not get a shot that might prevent cancer? “It works,” said Scott-Mordhorst, a clinical professor in UNMC’s department of pediatrics.

A study reported this year in the journal Pediatrics found that among sexually active females ages 14 to 24, the prevalence of four key HPV types was 16.9 percent among the unvaccinated and 2.1 percent among the vaccinated.

Scientists say it can take many years for chronic HPV to turn cancerous.

Dr. Bill Lydiatt, a head and neck cancer surgeon at Methodist Hospital, said oral sex and the sexual revolution of the late 1960s have contributed to an increase in cancers of the pharynx, or tonsil and back of tongue. The cancer society reported there will be 16,420 cases of cancer of the pharynx this year, most of them in men, compared with 8,950 in 2006. More than 3,000 will die this year from that kind of cancer, the society says.

Lydiatt said scientists only about 10 years ago made the clear link between HPV and cancers of the pharynx and tonsils.

There are more than 150 strains of HPV and more than 40 that can cause cancer, the Kaiser Family Foundation reported. The first form of Gardasil protected against four strains, including the two believed to be most prevalent in cancers. Two years ago the FDA approved a Gardasil vaccine that protected against nine strains. The study in the Journal of the National Cancer Institute says that “current vaccines will reduce most HPV-associated cancers.”

The vaccines are expensive. The Gardasil nine-strain vaccine is close to $250 per dose at Kohll’s Pharmacy if a family pays out of pocket. But many insurers, such as Blue Cross Blue Shield of Nebraska, Aetna/Coventry and UnitedHealthcare, participate in the payment.

A Merck spokeswoman said GSK’s decision to cease supplying Cervarix to the U.S. market hasn’t affected Gardasil prices as of now. An Omaha pharmacist said it wouldn’t be unusual to see prices go up with the departure of a competitor. “The reality is that they can,” Mohamed Jalloh said. “I’m not saying they’re going to.”

Merck has applied to the Food and Drug Administration to market a two-dose regimen of Gardasil, which would reduce the overall price of the series.

Facebook posts and the Internet contain scathing reviews of Gardasil, including stories of children being hurt and families being scared of the vaccination.

Laura Hansen, a cancer researcher at Creighton University, said she wishes she could find the words to persuade people to get their kids vaccinated.

“About all of us have family members impacted by cancer,” said Hansen, a professor of biomedical sciences. By having their kids vaccinated, she said, “Every parent could make an impact on cancer deaths.”

She said it’s hard to fight Internet scare stories and “anecdotal science” as opposed to real science and legitimate studies. The discussion should be “more about facts and less about hysteria,” said Hansen, who saw to it that her two teen-age sons, Charlie and Jack, were vaccinated.

Jeff Weggen of Muscatine, Iowa, has an entirely different view. Weggen said his daughter, Sydney, had the vaccines about four years ago. Soon after, she began to lose weight, suffered back pain and became pale. Over a period of months she was hospitalized and saw specialists in state and out-of-state. She was eventually found to have a fungal infection and a large tissue mass in her chest.

Weggen eventually linked Sydney’s ongoing medical problems to Gardasil, he said. Online groups, other parents and the timeline of her vaccines and her illness helped lead him to this opinion, he said. An anti-Gardasil Facebook post introduced him to a doctor in Ohio who early this year generally confirmed Weggen’s suspicions.

Dr. Phillip DeMio of the Cleveland area said he has several patients he believes were sickened by Gardasil. DeMio, a general practitioner who said his practice focuses on chronically ill people, said some of his patients have been injured by other vaccines, too.

“These are challenging situations, no two ways about it,” he said. Most people have received a variety of vaccinations, he said, and he believes the aluminum in Gardasil and other vaccines can be a problem for some people.

He saw Sydney early this year. Based on the extensive testing that ruled out other diseases, the severity of her illness, the timing of vaccination and other factors, he said he believes “there’s a component of vaccine damage for her and for many of my patients.”

He said there are good reasons to have an adolescent receive Gardasil and mentioned the likelihood that some individuals will be sexually active. But it makes no sense to have a 9-year-old get it, he said. He said parents should be well-informed of the risks and benefits of Gardasil and other vaccines.

“I think people should have a choice,” he said. “I’m not saying I’m against the vaccine.”

The CDC sent a written statement saying that millions of doses of Gardasil have been administered.

Scientific studies have detected no link to “unusual or unexpected adverse reactions,” the CDC said.

Side effects can include pain from the shot and occasionally a patient might faint after any injectable vaccine, the CDC said. But “the benefits of vaccination far outweigh any risks.”

HPV vaccine important preventive tool for survivors of childhood cancer

Source: www.curetoday.com
Author: Ellie Leick

As childhood cancer survivors are at an increased risk of developing second cancers later in life, James Klosky recommends that this population receive the human papillomavirus (HPV) series of vaccines.

A survey of 679 survivors one to five years out of treatment was conducted to evaluate how many received the vaccine compared with their healthy peers. A great disparity was discovered, as survivors — all of whom were between age 13 and 26 — were less likely to receive the vaccine. Researchers also investigated the reasons why many survivors did not receive it.

Klosky, an associate member and director of psychological services in cancer survivorship at St. Jude Children’s Research Hospital, presented the findings from this research at the 2016 Annual Meeting of the American Society of Clinical Oncology (ASCO), a gathering of 30,000 oncology professionals in Chicago. CURE spoke with Klosky at the meeting to discuss the key takeaways and the importance of the HPV vaccine to survivors of childhood cancer.

Can you give an overview of the study and its purpose?
The HPV vaccine is the first vaccine that’s designed to prevent cancers. We are particularly interested in the application of this vaccine amongst survivors of childhood cancers, who are at increased risk for HPV-related cancers in young adulthood relative to their healthy peers.

On average, the onset of these cancers occur seven years earlier in survivors of childhood cancers compared to their healthy peers. Additionally, survivors of childhood cancer have an increased risk of acquiring a second cancer. Therefore, the application of this vaccine is very important. We at St. Jude Children’s Research Hospital do everything we can to protect our survivors from second cancers, and the HPV vaccine is one mechanism we are able to utilize.

Why are second cancers more likely in survivors of childhood cancer?
As a general population, 80 percent of people who are sexually active will be exposed to HPV in their lifetime. For those of us who have a strong immune system, the virus will typically clear out of our systems in approximately two years. Often, there will not be any symptoms. However, for survivors of childhood cancers and other groups that have immune deficiencies, it appears they might be more likely for complications associated with HPV upon infection.

What did this study specifically find? What are the key takeaways?
This study compared survivors of childhood cancer with their peers in the U.S. We analyzed the rates of initiation of the HPV vaccine amongst survivors and then of the U.S. population, focusing on two different groups: those who are 13 to 17 years of age and those who are 18 to 26 years of age.

Within the 18 to 26 age group, the rates of the HPV vaccine initiation were essentially equivalent; 26 percent of survivors had initiated the vaccine whereas 24 percent in the general population had initiated it.

However, there were differences in the 13 to 17 age groups. Among survivors of childhood cancers, only 22 percent had initiated the vaccine compared with 42 percent of the general population.

It is important to note that the HPV vaccine is designed to be administered prior to sexual activity. It is important to get vaccinated as a young teenager because the HPV vaccine is protective, not therapeutic. Therefore, once a patient is exposed to the virus, there is not much we can do about it.

Among survivors of childhood cancers, were there predictors of not initiating the vaccine?
We found the most robust predictor was among survivors who stated their doctors had not recommended the vaccine. And essentially, one of the main messages here is that we really need our physicians to be recommending the vaccine because that should translate into a higher initiation rate.

Another strong influence against receiving the vaccine was hearing about it from a friend. Adolescents often talk about the negative aspects of the vaccine, such as the pain involved when receiving the vaccine and the fact that three vaccines are necessary to complete the protection. Hearing this does not encourage other adolescents to initiate the vaccine.

We also found those who are male and those who had never been sexually active are also more likely not to initiate the vaccine. That’s a bit concerning because although HPV is typically implicated in terms of cervical cancers and a lot of the gynecological-associated cancers, men can also have oropharyngeal cancers, anal cancers, penile cancers and other types of cancers within HPV ideology. Additionally, males are often the carriers.

Finally, those who do not feel receiving the vaccine makes you a responsible or good person are less likely to receive it.

What are the next steps for this project?
Overall, the lack of physician recommendation was most strongly associated with not initiating. Our next step in the research is to create intervention programs to get physicians to make clear recommendations with conviction and confidence to survivors of childhood cancer. This will hopefully translate into more survivors getting protected.

Is there ever a reason to refrain from receiving the HPV vaccine?
The indication of the vaccine is very broad. For survivors of childhood cancer who have had a particularly complex treatment history and are continuing to have severe late effects of childhood cancer, a conversation needs to happen between their oncologist, the family and the patient.

In terms of vaccine programs, they are designed as more of a public health tool; the vaccines should be safe for everyone. If there are any concerns about the vaccine, we want you to talk to your doctor.

Regardless of the direction of the effect, increasing these types of communications will hopefully translate to the best health care for our patients.

What are your hopes for this project?
If we are able to demonstrate the immunogenicity, safety and tolerability of the HPV vaccine among survivors of childhood cancer, we’ll have a platform for a vaccine program within this high-risk group. Protecting survivors from second cancers in any way we can is the ultimate goal. There’s not much I can do about patients’ genetics or other fixed factors, but getting the vaccine is something, behaviorally, I can influence. If I, my group or the consumers of this research have influenced conversations that translate into initiating and completing the three-vaccine series, then this research has been successful.

Nivolumab Demonstrated Survival Benefit, Good Tolerance in Refractory HNSCC

Source: www.asco.org
Author: Tim Donald, ELS
 

In the phase III comparative CheckMate 141 trial, nivolumab demonstrated a “significant improval in survival” in patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC), compared with therapy of the investigator’s choice, according to Robert L. Ferris, MD, PhD, FACS, of the University of Pittsburgh Cancer Institute (Abstract 6009). There were fewer treatment-related adverse events with the PD-1 inhibitor than with investigator’s choice therapy, Dr. Ferris said, and nivolumab stabilized patient-reported quality-of-life outcome measures, whereas the investigator’s choice therapy led to meaningful declines in function and worsening of symptoms.

AM16.6009-Ferris2Dr. Robert L. Ferris

“Nivolumab is a new standard-of-care option for patients with refractory or metastatic HNSCC after platinum-based therapy,” Dr. Ferris said.

Dr. Ferris presented the trial results at the “Harnessing the Immune System in Head and Neck Cancer: Evolving Standards in Metastatic Disease” Clinical Science Symposium on June 6. He noted that in this trial of patients whose disease had progressed after platinum-based therapy, nivolumab doubled the 1-year overall survival (OS) rate, with 36.0% OS for the immunotherapeutic drug compared with 16.6% for the investigator’s choice therapy. These top-line results were presented at the 2016 American Association of Cancer Research meeting1; Dr. Ferris presented data the additional endpoints of quality of life, correlative biomarkers, and safety.

There is an extremely poor prognosis for patients with platinum-refractory recurrent or metastatic HNSCC, with median OS of 6 months or fewer. Previous research, by Dr. Ferris and others, has shown that HNSCC can express T-cell suppressive ligands, such as PD-L1, thereby evading host immune response. PD-L1 is frequently expressed on HNSCC cells, both HPV-positive and -negative.

The phase III CheckMate 141 study enrolled patients with HNSCC aged 18 and older with ECOG status 0 or 1, and with disease progression within 6 months after the most recent dose of platinum-based therapy. Patients were enrolled regardless of PD-L1 status and irrespective of number of previous lines of therapy. Immunohistochemistry testing for p16 was performed to determine HPV status. Patients were randomly assigned 2:1 to nivolumab (3 mg/kg intravenous [IV] every 2 weeks) or investigator’s choice of single-agent therapy with methotrexate (40 mg/m² IV weekly), docetaxel (30 mg/m² IV weekly), or cetuximab (400 mg/m² IV once, then 250 mg/m² weekly).

OS was compared between arms and by PD-L1 expression and HPV (p16) status. Nivolumab demonstrated a survival benefit in the overall study population, regardless of PD-L1 expression or p16 status, Dr. Ferris said. The magnitude of the OS benefit of nivolumab was greater in patients expressing PD-L1 at 1% or more (HR 0.55, 95% CI [0.36, 0.83]) compared with those expressing PD-L1 at less than 1% (HR 0.89, 95% CI [0.54, 1.45]). However, increasing levels of PD-L1 expression ( ≥ 5%, ≥ 10%) did not result in further OS benefit.

The OS benefit was greater with nivolumab than investigator’s choice therapy in both patients who were p16 positive (HR 0.56, 95% CI [0.32, 0.99]) and p16 negative (HR 0.73, 95% CI [0.42, 1.25]). When OS was analyzed for both PD-L1 expression and p16 status, the hazard ratios favored nivolumab for all subgroups.

Treatment-related adverse events of any grade were lower in the nivolumab arm (58.9%) than the investigator’s choice therapy arm (77.5%). Serious (grade 3 or 4) treatment-related adverse events were also lower in the nivolumab arm (13.1%) than in the investigator’s choice therapy arm (35.1%). Patient-reported outcome measures for quality of life were assessed based on two EORTC scales. Treatment with nivolumab stabilized the outcome measures of physical function, social function, absence of sensory problems, and absence of trouble with social contact, whereas the investigator’s choice therapy led to meaningful declines in function and worsening of symptoms.

AM16.6009-Uppaluri_0Dr. Ravindra Uppaluri

Discussant Ravindra Uppaluri, MD, PhD, of Washington University School of Medicine, said that the CheckMate 141 trial “continues to highlight the use of PD-L1 status as a stratifier.” The trial results “offer hope for patients with refractory or metastatic HNSCC,” he said. “Obviously better biomarkers are needed, and, ultimately, a composite immune profile may be required.”

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

June, 2016|Oral Cancer News|

Heading back to the office following head and neck cancer

Source: blogs.biomedcentral.com
Author: Daniel Caley

In Cancers of the Head & Neck launching today publishes the first study looking at disability and employment outcomes in patients with head and neck cancer related to the human papillomavirus (HPV). Dr Shrujal Baxi, Section Editor for survivorship and patient related outcomes and author of this study, explains more about their work in this Q&A:

The rates of patients diagnosed with HPV-related head and neck cancer is rising annually. By 2020, there will be more cases of HPV-related head and neck cancer than HPV-related cervical cancer in the United States. Numerous studies have shown that most patients with this diagnosis are likely to be cured of their disease, placing an increased emphasis on quality of life and non-cancer outcomes in this population of survivors. The majority of patients diagnosed with HPV-related head and neck cancer are working-age adults and employment is a serious issue both financially and psychologically.

How can treatment for head and neck cancer impact employment?
Treatment for head and neck cancer often involves a combination of chemotherapy and radiation given over a six to seven week period, often known as concurrent chemoradiation or combined modality chemoradiation. This process is considered toxic and can impact a patient’s ability to function normally including speaking, chewing, breathing and swallowing. Many patients require numerous supportive medications to get through treatment including narcotics for pain and anti-nausea medications. Patients can lose on average 10-15% of their weight within a few months and can suffer from severe fatigue and post-treatment depression.

Who was in your study?
We included 102 participants with HPV-related head and neck cancer treated with chemoradiation at our institution who were employed full-time for pay at the time of diagnosis.

How did the treatment impact employment?
97% of patients had to change their employment responsibilities in some way from reducing work, taking a break and then returning at a later date, or stopping altogether and not returning. There were 73 patients that stopped but eventually returned to work after treatment, and they required a median of 14.5 weeks to return. This is longer than the 12 weeks currently allowed according to the Family Medical Leave Act (FMLA).

Eight patients stopped working altogether and never went back. Eight patients stopped working during treatment and never returned to work. Aside from younger age predicting extra time off before returning to work, we did not find a patient, treatment or disease factor that accounted for needing extra time off.

What happened to these patients?
The majority of patients who returned to work continued. At nearly two years from completion of treatment, 85% of the original 102 patients were working for pay. Overall, survivors were doing very well in terms of quality of life with the majority not having any major limitations secondary to their treatment.

There were a group of survivors who were dissatisfied with their ability to work. Some were working but not satisfied with their abilities, while others were looking for work. Compared to those who were satisfied with their abilities, those that were unsatisfied were more likely to have more functional problems and more head and neck specific late toxicities from their treatment.

What does this mean for patients and providers?
I think that this study provides some guidance for patients and providers as they prepare for chemoradiation to treat HPV-related head and neck cancer. It is hopeful that most patients will return to work, but realistic expectations of ability to work will help in treatment planning. Employment is another reason why managing late toxicities remains an important aspect of optimal care for head and neck cancer survivors.

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

Source: www.fredhutch.org
Author: Diane Mapes and Sabrina Richards

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

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

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

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

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

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

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

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

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

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

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

Some patients, literally, have no voice.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Not surprisingly, communication is strongly emphasized in the guidelines.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sabrina Richards is a staff writer at Fred Hutchinson Cancer Research Center. She has written about scientific research and the environment for The Scientist and OnEarth Magazine. She has a Ph.D. in immunology from the University of Washington, an M.A. in journalism and an advanced certificate from the Science, Health and Environmental Reporting Program at New York University. Reach her at srichar2@fredhutch.org.

Note:
1. Original article available at: http://www.fredhutch.org/en/news/center-news/2016/04/new-survivorship-guidelines-spotlight-head-and-neck-cancers.html

April, 2016|Oral Cancer News|

Imaging, physical examination find most recurrences of HPV-positive oropharyngeal cancer

Source: www.oncologynurseadvisor.com
Author: Kathy Boltz, PhD

Posttreatment imaging at 3 months and physical examinations during the 6 months following treatment can detect most recurrences in patients treated with definitive radiation therapy for oropharyngeal cancer caused by human papillomavirus (HPV).1 This research was presented at the 2016 Multidisciplinary Head and Neck Cancer Symposium.

A dramatic increase in oropharyngeal squamous cell carcinoma (OPSCC) cases associated with HPV has been reported by the American Cancer Society. Survival rates after definitive radiation therapy have also increased. This has led to the need to determine general time to recurrence and the most effective modes of recurrence detection, to guide standards for optimal follow-up care by oncology teams.

This study examined 246 cases of HPV-positive or p16-positive non-metastatic OPSCC treated with definitive radiation therapy at a single, large-volume cancer center between 2006 and 2014.

Follow-up care included a PET/CT scan 3 months after completing treatment and physical examinations every 3 months in the first year following treatment, every 4 months in the second year and every 6 months in years 3 through 5. Median follow-up care length for all patients was 36 months. Patient outcomes, including recurrence and survival rates, were calculated using the Kaplan-Meier method from the end of radiation therapy.

Most recurrences were detected either by persistent disease appearing on 3-month post-treatment imaging or by patients presenting with symptoms at follow-up examinations.

Disease characteristics that increase the likelihood of recurrence include presenting with 5 or more nodes or having level 4 lymph nodes (P < .05). Distant metastases were a greater risk in patients with a lymph node larger than 6 cm or with bilateral lymphadenopathy (P < .05). “For most patients with HPV-associated oropharynx cancer, after a negative 3-month PET scan, physical exams with history and direct visualization are sufficient to find recurrences,” said Jessica M. Frakes, MD, an assistant member of the department of radiation oncology at the H. Lee Moffitt Cancer Center in Tampa, Florida, and lead author in the study. “Minimizing the number of unnecessary tests may alleviate the financial and emotional burden on these patients, including overall health care costs, time spent away from work and family, and the anxiety of waiting for scan results.” This study also supports the effectiveness of specialist teams in treating HPV-positive OPSCC with definitive radiotherapy (RT). Within 3 years, local control was achieved in 97.8% of all patients in the study; regional control in 95.3%; locoregional control in 94%; and freedom from distant metastases in 91.4%. The 3-year overall survival rate was 91%. “We were pleasantly surprised by the high cure rates and the low permanent side effect rates for these patients,” said Frakes. “These findings demonstrate that individuals with HPV-associated oropharyngeal cancer who are treated with definitive RT and cared for by multidisciplinary specialists have excellent outcomes.” Reference: 1. Frakes JM, Naghavi AO, Strom T, et al. Detection of recurrence in HPV associated oropharynx squamous cell carcinoma. Presented at 2016 Multidisciplinary Head and Neck Cancer Symposium; Scottsdale, AZ; February 18, 2016. Abstract 6.

March, 2016|Oral Cancer News|

NCCN Is ‘Vague,’ So Study Clarifies H&N Cancer Follow-up

Source: www.medscape.com
Author: Nick Mulcahy
 

Clinical guidelines can sometimes be slow to respond to epidemiology.

Take the case of oropharyngeal cancers that are associated with human papillomavirus (HPV) infection. They are increasingly common in the United States and, as several studies have demonstrated, have better survival than cancers of this type that are not HPV-positive.

Nonetheless, one of the beacons in oncology care, the National Comprehensive Cancer Network (NCCN), recommends the same follow-up care guidance for oropharynx squamous cell carcinoma whether it is associated with HPV or not, according to two experts.

For post-treatment follow-up, including recurrence detection, “the NCCN guidelines are one-size-fits-all,” said Jessica Frakes, MD, a radiation oncologist at the Moffitt Cancer Center and Research Institute in Tampa, Florida.

She spoke during a press briefing at the Multidisciplinary Head and Neck Cancer Symposium 2016 in Scottsdale, Arizona.

“You are exactly right: the NCCN is fairly vague about when to perform imaging,” said Christine Gourin, MD, an otolaryngologist at Johns Hopkins University in Baltimore, who moderated the press briefing.

Dr Frakes and her colleagues have stepped into this informational breach with a new study that might help clinicians gain clarity on the use of surveillance imaging in HPV-positive oropharyngeal cancer and reduce its frequency.

“The purpose of our study is to determine when these patients fail and when they have side effects so we know how to guide optimal follow-up,” Dr Frakes explained.

The study authors examined 246 cases of nonmetastatic HPV-positive oropharynx squamous cell carcinoma treated with radiation therapy at Moffitt from 2006 to 2014. Most patients (84.6%) received radiation therapy and a concurrent systemic therapy; a minority (15.4%) received radiation alone. Most patients had locally advanced disease.

The team’s major finding was that the great majority of recurrences and toxicities can be detected with imaging 3 months after treatment with definitive radiation therapy and physical exams during the 6 months after treatment.

Specifically, all six local failures were detected by sight or with flexible laryngoscopy conducted during physical exams in that 6-month period.

Eight of the nine regional recurrences (89%), 12 of the 13 locoregional failures (92%), and 15 of the 21 distant recurrences (71%) were detected from symptoms or with a PET/CT scan 3 months after treatment

“For most patients with HPV-associated oropharynx cancer, after a negative 3-month PET scan, physical exams with history and direct visualization are sufficient to find recurrences,” said Dr Frakes in a press statement.

The findings — and the suggestion that PET scans can be suspended after 3 months — are akin to what happens in clinical practice at Johns Hopkins, Dr Gourin reported.

“We have stopped routinely imaging patients after 3 months if a PET is negative, and it’s true that we do pick up more recurrences clinically than radiologically,” she said.

Cutting down on PET scans in this patient population is a good thing, suggested Dr Gourin. “I think we probably do too much post-treatment surveillance imaging,” she said.

There are multiple benefits to suspending imaging, including potentially lowering patient stress because they know their recurrence risk is low and don’t have anxiety related to test results.

Plus, there is a cost reduction.

“A PET scan costs $1500 [for the patient],” said Dr Frakes. Dr Gourin noted that the test is even more expensive in her geographic region.

Factors That Increase Recurrence Risk

The study authors also identified disease characteristics that increase the likelihood of recurrence.

Both regional and distant failures were more common in patients who presented with five or more positive lymph nodes or who had level IV lymph nodes (P < .05).

And the risk of developing distant metastases was greater in patients with a lymph node larger than 6 cm or with bilateral lymphadenopathy (P < .05).

But overall, the results are “excellent,” said Dr Frakes. Within 3 years, the rate of local control was 97.8%, of regional control was 95.3%, of locoregional control was 94.0%, and of freedom from distant metastases was 91.4%. The rate of 3-year overall survival was 91.0%.

Toxicities were also low, which is an endorsement of the multidisciplinary care, said Dr Frakes.

Only 9% of patients experienced severe late toxicities, including 19 grade 3 toxicities and two grade 4 toxicities. These were resolved in 16 of 21 toxicities (76%) at the time of last follow-up.

Most of the toxicities and/or recurrences (64%) occurred in the first 6 months after treatment; only four events occurred more than 2 years after treatment.

Dr Gourin questioned the low rate of serious late toxicities seen with this nonsurgical management of patients. Such a low rate “has not been our experience” at Johns Hopkins, she said.

Dr Frakes and Dr Gourin have disclosed no relevant financial relationships.

Multidisciplinary Head and Neck Cancer Symposium (MHNCS) 2016: Abstract 6. Presented February 19, 2016.

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

February, 2016|Oral Cancer News|

Oral cancer less likely in women who have more sex; but not the same for men

Source: www.parentherald.com
Author: Diane Ting

Having more sex partners reduces the chance of oral cancer for women. Unfortunately, men are more likely to become infected as the number of oral sex partners increases.

A study suggests that women who have more vaginal sex partners appear to have a lower risk of oral human papillomavirus (HPV) infections. The information was released during the annual conference of the American Association for the Advancement of Science. Throat and mouth cancer are linked to HPV, which is one of the most prevalent sexually transmitted diseases. HPV is rather common, as most people are treated of the virus within two years.

According to the study published by the Journal of the American Medical Association (JAMA), oral sex may increase the risk of head and neck cancer by 22 percent. In the last 20 years, the number of oral cancer patients has risen to 225 percent.

Oral cancer is typically linked to lifestyle causes such as heavy drinking and smoking, according to Mirror. Two in three sufferers of oral cancer were men, which made experts question the imbalance.

HPV is the same cancer that causes cervical cancer in women. Research states that because women are first exposed to HPV vaginally, they may develop an immune response that prevents them from getting the infection.

Unfortunately, research suggests that this may not be the same for men as they are found twice more likely to develop oral cancer. As the number of oral sex partners increase, the risk of oral HPV infections also increases. It is believed that oral sex may be the main cause at which the HPV ends up in the mouth. “Our research shows that once you become infected, men are less likely to clear this infection than women, further contributing for the cancer risk,” according to Gypsyamber D’Souza, a professor at Johns Hopkins University in Baltimore.

Oral sex can dramatically increase a person’s risk of the common human papillomavirus (HPV) by 22 times, which can eventually lead to cancer, according to a study. While HPV is very common and easily treatable, HPV may not go away in some cases particularly with men. In some rare instances, the virus can lead to cellular changes in the mouth and throat, which can lead to cancer.

Middle-aged white men are particularly at high risk compared to other races, according to Daily Mail. The US Centers for Diseases Control and Prevention (CDC) has highly recommended all pre-teenagers to take the HPV vaccination before they become sexually active.

February, 2016|Oral Cancer News|