radiation

Study supports immunotherapy/radiation combo in head and neck cancer

Source: www.onclive.com
Author: Laura Panjwani

There may be potential synergy between radiation therapy, given with or without chemotherapy, and immune checkpoint inhibitors in patients with squamous cell carcinoma of the head and neck (SCCHN), according to results of a prospective study.

The study, which was presented at the the 2016 Multidisciplinary Head and Neck Cancer Symposium in February 2016, examined blood samples from 16 consecutive patients with SCCHN undergoing curative-intent radiation therapies.

Samples were obtained at week 1 and week 6 to 7. Patients received a median of 70 Gy for disease in the oropharynx (n = 12, 75%), nasopharynx (n = 2, 12%), larynx (n = 1, 6%), or oral cavity (n = 1, 6%). The majority of patients had stage IV disease that was metastatic to regional lymph nodes and received concurrent platinum-based chemotherapy.

The analysis found that, during radiation treatment, circulating CD8-positive T-effector cells increased (P = .01), as did CD4-positive PD-1–positive cells (P = .02), CD8-positive LAG3-positive cells (P = .02), and regulatory T cells (P = .04). sPD-L1 levels also increased, mirroring increases in CD8-positive T cells over the course of therapy (P = .047).

While the extent to which these systemic changes reflect changes in the tumor microenvironment is unknown, the study authors noted that these findings support the “complex immunologic effects of fractionated chemoradiation therapy and mechanisms for potential synergy between chemotherapy, radiation treatment, and immunotherapy in SCCHN.”

To learn more about the impact of the research, OncLive spoke to one of the study’s authors, Jonathan D. Schoenfeld, MD, physician, assistant professor of Radiation Oncology, Harvard Medical School, Dana-Farber Cancer Institute, who presented the findings at the meeting.

OncLive: What were the goals of this study?

Schoenfeld: Immunotherapy, particularly immune checkpoint blockade, is demonstrating some exciting results in head and neck cancer. Largely, that work has been done in metastatic head and neck cancer. Our goal was to look at the immunologic effects of a treatment that is commonly given to patients with early-stage head and neck cancer: chemotherapy and radiation.

We found that the combination of chemotherapy and radiation—and in some cases, just radiation alone—led to immune effects that we could see not just in the site where we were radiating, but also if we looked at markers in the peripheral blood.

One of the interesting things that we found was that radiation, with or without chemotherapy, has the potential to increase the number of tumor antigens that were targeted by the host immune response. One of the ways that we hope to use radiation in the future is to stimulate an initial immune response.

Based on the data that is emerging with PD-1 inhibitors, we know that the majority of patients will not respond to these agents. We need to determine if we can use radiation and chemotherapy to increase the number of responders initially that can then be stimulated even further with immune checkpoint blockade.

What immune effects were investigated?
We looked at a variety of effects. We looked at chemokines, which are cytokines that could mediate effects outside of the radiation treatment field. We looked at circulating T cells, including CD8-positive T cells, CD4-positve T cells, and markers of activated T cells.

We also looked at potentially inhibitory T cells as well, including T-regulatory cells, T cells that were expressing checkpoint receptors, and myeloid-derived suppressor cells. We also looked, in more detail, at the types of T-cell receptors that were expressed on the surface of these T cells, and it looked like the combination of radiation and chemotherapy could change the clonality of the receptor on these T cells, suggesting that radiation or targeted tumor death could stimulate a more targeted immune response.

What can a community oncologist take away from these findings?

Chemotherapy and radiation have long been appreciated for their immunosuppressive effects. We all know that when you treat someone with radiation or chemotherapy, you can see a decrease in cytopenia and lymphocytes.

We are now learning that certain types of chemotherapy and radiation, given in the proper circumstance, can cause immunogenic cell death. That can possibly synergize with the newer types of immune checkpoint blockade that are being developed.

One of our study’s findings was that we saw an increase in T cells expressed in the PD-1 receptor. Those could potentially be targeted with new checkpoint inhibitors that target the PD-1 receptor. As we develop these therapies even further, there are exciting new combinations between immunotherapies and some of the traditional therapies that have long been used for head and neck cancer with potential.

In melanoma, there are case reports of patients who have progressed on immune checkpoint blockade and are then treated with high-dose palliative radiation that then began to experience a response outside of the radiation treatment field. That is a very exciting avenue of research for head and neck cancer, as well. Can we take patients who don’t respond to the current checkpoint inhibitors that we have and use radiation in a targeted way to stimulate a broader immune response?

Radiation and chemotherapy are a backbone of some of the definitive treatments currently used for head and neck cancer. There is a lot of interest with the success of PD-1/PD-L1 inhibitors to integrate these into the definitive management, and combine them the proper way with chemotherapy and radiation to better maximize our results.

Chemotherapy and radiation are still very important for patients with curative head and neck cancer, but perhaps we should be giving these treatments in a different way—different types of radiation and chemotherapy and different targets for radiation. All of these things need to be explored, as new therapies, such as immune checkpoint inhibitors, are developed in this disease.

What impact will immunotherapy will have in head and neck cancer?
It will have a huge impact. Exciting data are emerging in metastatic head and neck cancer that show that PD-1 inhibitors offer real benefit to patients. Many of these patients had very few other treatment options and could obtain a survival benefit after treatment with PD-1 inhibitors. That opens up a whole new realm of opportunities to study immunotherapy in different settings, in different groups of patients, and in combination with other agents.

Source:
Sridharan V, Margalit D, Curreri S, et al. Systemic immunologic effects of definitive radiation in head and neck cancer. Presented at: 2016 Multidisciplinary Head and Neck Cancer Symposium; February 18-20, 2016; Scottsdale, AZ. Abstract 2.

April, 2016|Oral Cancer News|

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|

Patient survives stage IV, inoperable throat cancer in clinical trial

Source: medicalxpress.com
Author: staff

It took a white lie to get David Polisini, 79, to a doctor in 2004, after months of being unable to swallow.

“Two of my daughters, Toni and Susie, showed up on my back porch and told me to put my jacket on,” he says. “They told me we were just going for a ride, but the next thing I knew, we were pulling into the Clermont Mercy Hospital.”

Polisini says tests ordered in the emergency room uncovered a tumor in his throat.

“It was the size of a golf ball,” he says, adding that he then scheduled an appointment with his primary care physician, Francis Dumont, MD. “I was then referred to an ear, nose and throat physician within his group who said I needed to see someone at the University of Cincinnati (UC) Cancer Institute.”

A biopsy was performed, and a diagnosis was confirmed—it was Stage IV cancer.

“I began seeing Dr. (Bill) Barrett who explained that I would need to go through very aggressive radiation along with chemotherapy five days a week for three months,” he says. “I’d drive myself every day to every visit in my little Miata. The therapy really zapped my strength, but I’m here because of it.

“I really don’t think I realized how much trouble I was in with Stage IV inoperable cancer, but I knew I had to do what I had to do to get through it.”

The radiation and chemo regimen was a Phase III clinical trial at UC, studying the effects of the use of both radiation and chemotherapy for advanced head and neck cancers.

Besides his family, Polisini credits Barrett, chair and professor of the UC Department of Radiation Oncology and director of the UC Cancer Institute, as well as the staff and care providers at the Barrett Center, where he received treatment, with being a tremendous support.

“Dr. Barrett was there with me every step of the way,” he says. “He was so dedicated to helping me, as were the other nurses and staff at UC. I’m just so impressed with everyone who works there. They stood by me the whole time, and more than 10 years later, I’m doing fine, and the cancer hasn’t come back. To me, Dr. Barrett is an angel come to Earth.”
The clinical trial seems to have worked, and Polisini, who lives in Clermont County, says that while he has a primarily liquid diet, he doesn’t regret a thing.

“By golly, I’ll trade the ability to eat with the ability to get up every morning,” he says. “I have the energy to do the things I want and have to do. I go to the ‘Y’ every other day to exercise. I do my own house and lawn work. I just put a new floor on my front porch. I can only do these things because of the outstanding treatment I received at the UC Cancer Institute and the Barrett Center.”

And he warns others to not ignore symptoms, like he did.

“If you have something wrong, see a doctor right away, unlike I did,” he says. “I’m just thankful for my daughters and Dr. Barrett for helping me.”

March, 2016|Oral Cancer News|

Immunotherapies gaining traction in head and neck cancers

Source: www.targetedonc.com
Author: Greg Kennelty

An explosion of immunotherapies is on the horizon for patients with metastatic head and neck cancer, specifically as phase III trials begin to report findings for PD-1 inhibitors. This upcoming wave of new therapies places importance on understanding optimal treatment settings and adverse events associated with these therapies.

In late January, the phase III CheckMate-141 trial investigating the anti–PD-1 agent nivolumab was stopped early, due to a substantial improvement in the primary endpoint of overall survival (OS). The drug was put up against the investigator’s choice of cetuximab (Erbitux), methotrexate, or docetaxel following progression on a platinum-based therapy.

At this time, data from the study have not yet been released but are being prepared for future presentation. Findings from the study are being discussed with the FDA and other health authorities.

In addition to nivolumab, the PD-1 inhibitor pembrolizumab (Keytruda) demonstrated encouraging activity in patients with with advanced PD-L1–positive esophageal carcinoma during the phase Ib KEYNOTE-028 study. Additionally, the agent was effective for patients with squamous cell carcinoma of the head and neck in the phase I KEYNOTE-012 study.

In the head and neck cancer population, the objective response rate with pembrolizumab was 24.8% in 117 evaluable patients. Tumor shrinkage was experienced by 56% of patients and another 25% had stable disease. The response rate seen with pembrolizumab was similar, regardless of HPV infection status. In those with HPV-positive disease, the ORR was 20.6% compared with 27.2% in the negative group.

To gain further insight, Targeted Oncology spoke with head and neck cancer expert Barbara Burtness, MD, professor of Medicine (Medical Oncology), Clinical Research Program Leader, Head and Neck Cancers Program, co-director, Developmental Therapeutics Research Program, Yale Cancer Center.

TARGETED ONCOLOGY: Can you give us an overview of where immunotherapy is currently in head and neck cancer?

BURTNESS: The first trials for immunotherapy in head and neck cancer began two or three years ago and we now have sufficient reason to believe that these therapies are going to be active in the cancer. For example, there is the KEYNOTE-012 trial, which was a trial of pembrolizumab given to an expansion cohort of either HPV-positive or HPV-negative head and neck cancer. The response rate there was about 25%.

There is some reason to believe that if either PD-L1 or PD-L2 are expressed, that that would predict for a higher response rate. There are now phase III trials going forward for both platinum-refractory disease and for first-line patients looking at pembrolizumab compared with chemotherapy.

There are also data with MEDI4736, which if a patient is expressing PD-L1, appears to have a pretty high response rate of about 50% in a small group of patients. There are currently ongoing trials looking at the combination of MEDI4736 with tremelimumab, though we don’t have any data on that just yet.

Then there are novel strategies people have for trying integrate immunotherapy with standard treatment. We have some reason to believe that when head and neck cancer is treated with radiation there is upregulation in tumor-infiltrating lymphocytes and PD-L1. There are trials now moving forward that are integrating immune checkpoint inhibitors together with chemoradiation, or taking patients who have completed their chemoradiation but have persistent disease and exposing them to pembrolizumab in that setting.

The last thing is there is some evidence that siltuximab can upregulate a co-stimulatory molecule, CD137. There are some trials looking at co-targeting EGFR and CD137.

TARGETED ONCOLOGY: What are the side effects in immunotherapy?

BURTNESS: The one thing community oncologists should be aware of is toxicities. As these drugs roll out, these toxicities that will be present are a lot different to manage than the usual cytotoxic agent toxicities. There are a lot of unusual or unexpected side effects that are autoimmune in nature.

The most common toxicity is fatigue. Across all the patients with head and neck cancer who received pembrolizumab, about 17% of them had grade 3 or 4 toxicities. This is a lot easier to tolerate than chemotherapy or chemoradiation. The other things that you might look for are pneumonitis, nephritis, pancreatitis with diabetic symptoms, thyroiditis, and a variety of unusual autoimmune side effects.

TARGETED ONCOLOGY: What do you see as the overall potential for immunotherapy in head and neck cancer?

BURTNESS: Everybody with biomarker expression of either the ligands or the targets in this pathway is likely to be exposed to these drugs in the future. The challenge for us is going to be to figure out, for those patients who are not PD-L1 expressing or who don’t have tumor-infiltrating lymphocytes, other ways that we can prime patients for immunotherapy with our standard treatments. It’s speculative – it’s not something that people are doing in clinics now, but the first trials of those approaches are starting.

There is also ADXS11-001 that is fused to the E7 oncogene from HPV. The idea is that that would increase antigenic presentation and then the immune checkpoint inhibitor could potentially be more effective. That treatment is still in phase I.

February, 2016|Oral Cancer News|

Depressed Head and Neck Cancer Patients Have Lower Survival and Higher Recurrence Risk

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

Depression is a significant predictor of 5-year survival and recurrence in patients with head and neck cancer, according to a new study published in Pyschosomatic Medicine (doi: 10.1097/PSY.0000000000000256). These findings represent one of the largest studies to report on the impact of depression on cancer survival.

Although depression can have obvious detrimental effects on a person’s quality of life, its impact on cancer patients is more apparent, explained lead author Eileen Shinn, PhD, assistant professor of Behavioral Science at The University of Texas MD Anderson Cancer Center, in Houston. Increasing evidence shows modest associations between elevated symptoms of depression and greater risk for mortality among patients with lung, breast, ovarian, and kidney cancers.

The research team sought to clarify the influence of depression on survival, focusing their analysis on a single cancer type. By limiting the sample set and adjusting for factors known to affect outcome, such as age, tumor size, and previous chemotherapy, they were able to uncover a more profound impact of depression.

The researchers followed 130 patients at MD Anderson with newly diagnosed oropharyngeal squamous cell carcinoma (OSCC), a type of cancer in which the tumor originates at the back of the throat and base of the tongue.

At the beginning of their radiation therapy, Patients completed a validated questionnaire at the beginning of their radiation therapy to identify symptoms of clinical depression. Researchers monitored the participants, all of whom completed treatment, until their last clinic visit or death, a median period of 5 years.

“The results of this study were quite intriguing, showing depression was a significant factor predicting survival at 5 years, even after controlling for commonly accepted prognostic factors,” said senior author Adam Garden, MD, professor, Radiation Oncology. Furthermore, depression was the only factor shown to have a significant impact on survival.

Patients who scored as depressed on the questionnaire were 3.5 times less likely to have survived to the 5-year interval compared with those who did not score as depressed. The degree of depression was also found to be significant, as every unit increase on this scale indicated a 10% higher risk for reduced survival.

The results were replicated with a different psychological health survey and were not influenced by how soon following diagnosis the depression assessment was done.

OSCC is diagnosed in 10 000 to 15 000 Americans each year. Major risk factors known to be associated with OSCC include smoking and tobacco use, alcohol consumption, and human papillomavirus (HPV) infection. Incidence of OSCC has doubled in the last 20 years due to increasing HPV infection rates, noted Shinn.

Neither alcohol nor tobacco use, also surveyed in this group, had a significant impact on survival. HPV infection status, when available, also did not appear correlated.

Despite a high cure rate, normally 60% to 80%, recurrence rate of disease is unusually high in these patients (approximately 30%). The researchers also investigated a potential link between depression and disease recurrence.

“When we controlled for all variables, depression was linked with a nearly 4 times higher risk of recurrence,” said Shinn. In addition, never smokers had a 73% lower chance of recurrence, compared with current smokers. Those were the only two factors associated with cancer recurrence.

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

December, 2015|Oral Cancer News|

Poison’s Rikki Rockett Reveals He Is Battling Oral Cancer

Source: www.loudwire.com
Author: Chad Childers
 

Poison drummer Rikki Rockett revealed during an appearance on the Eddie Trunk Live radio show that he’s completed nine rounds of chemotherapy and seven weeks of radiation treatments after being diagnosed with oral cancer this past summer and that he’ll find out in February if the treatments were successful.

Rockett told Trunk (as transcribed by Blabbermouth), “[In] June, I kind of got sick. I had this horrible cold, sore-throat thing, and they were scoping me and they were doing biopsies, and nothing was coming up. And finally a doctor at USC did a biopsy and took a look and he said, ‘I believe you have oral cancer.’ And what it was is a tumor at the base of my tongue … This is very similar to Bruce Dickinson, very similar to Michael Douglas, similar to Tom Hamilton, as far as I know; I don’t know the details of his. And two adjacent lymph nodes that it kind of … Normally, it does spread to the lymph nodes; that’s typical. That’s how you find out you have it ninety percent of the time.”

According to the Rockett, his doctor told him that it was a very treatable cancer, but was “a son of a bitch to treat.” He was then told that he would either have to undergo radiation and chemotherapy at the same time or undergo surgery, but even if he chose the latter, he might still have to do radiation and chemotherapy.

Rockett revealed that it was tough, explaining, “I did thirty-five rounds of radiation; it was five days a week for seven weeks, and that kicks your dick into the dirt. But I went, ‘Okay, this is what I’m gonna do. I wanna beat it, so I’m just gonna go head first into this. I’m gonna set myself up where every single day, I do something positive for my health. I’m gonna work out one day, I’m gonna go to therapy one day.’”

He continued, “At the end of the day, it was really the worst thing that you can go through, for me. I’ve had a decent life, you know what I mean? I mean, we all go through our stuff. I’m not saying my life is a bed of roses, but I’m not a war veteran who got this too. I didn’t get my leg blown off and get cancer. Those guys are the guys that are really the heroes and paying for it. So for me, it was just a battle that I had to get through, and I got to the point where I couldn’t really talk. I had, I think, sixteen canker sores in my mouth at one time. And it’s, like, if you could take your throat and turn it inside out and sunburn it… I had to use this stuff called Magic Mouthwash just to drink the water. It hurt so bad, I couldn’t… And I’m still on a liquid diet.”

As for his decision to keep his cancer treatment quiet, the rocker revealed, “I wanted to see how I would do with [the treatment]. And I didn’t want people to maybe come down to USC and [take] spy photos, like TMZ guys or something like that. And I didn’t want anybody talking to my family about it or anything like that. It’s, like, you wanna forget about it when you can. So when I first start to talk about it, [I didn’t want it to be a situation where] I’d be at the mall, and I’m playing with my little girl or something, and somebody would go, like, ‘Hey, man, how’s the throat doing?’ It’s, like, ‘I just forgot about it for the last forty-five minutes and now you had to remind me.’ And everybody has a horror story. ‘Oh, you have cancer? My mom had cancer. She died from it.’ I don’t wanna hear anybody’s horror stories.”

Rockett revealed that all signs are that he’s responded well to the treatment and that he’s hoping to get good news when he goes for his PET scan in February. “I’m just gonna try to put that out of my mind for now and just continue to get better and feel better,” says Rockett. “There’s nothing that looks like it’s there anymore. They’ve gone down, they’ve looked at my throat… But it’s swelled up and it’s hard to tell, but it looks like it’s in remission.”

During the chat, Rockett revealed that his tongue cancer was caused by HPV, which is currently the number one cause of oral cancer.

While Poison were out of action during 2015, Rockett kept busy with the self-titled debut album from his band Devil City Angels.

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

December, 2015|Oral Cancer News|

Cetuximab plus RT linked with high toxicity in head and neck cancer

Source: www.cancernetwork.com
Author: Anna Azvolinsky, PhD

The combination of radiation therapy plus the EGFR inhibitor cetuximab had higher rates of acute toxicity among patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) compared with radiation therapy plus the chemotherapy cisplatin, according to results of a phase II trial based in Italy. Efficacy was similar with both combination therapies.

According to Stefano Maria Magrini, MD, professor of radiotherapy at the Università degli Studi di Brescia in Italy, and colleagues, this is the first clinical trial to directly compare radiation therapy plus cetuximab to a chemoradiation regimen for SCCHN.

The results of the randomized trial are published in the Journal of Clinical Oncology.

Cetuximab was approved in combination with radiation therapy by the US Food and Drug Administration in 2006 for the treatment of unresectable SCCHN.

Despite a goal of recruiting 130 patients, only 70 patients were recruited between 2011 and 2014.

The 1- and 2-year overall survival rates were 75% and 68% in the cetuximab arm compared with 78% in the cisplatin arm. The 1- and 2-year local control rates were 64% and 53% in the cetuximab arm and 84% and 80% in the cisplatin arm, yet the differences between arms were not statistically significant (P = .073), reflecting the inadequate statistical power of the relatively small trial.

Compliance in both treatment arms was relatively low. Only 28% of patients in the cetuximab arm and 20% of patients in the cisplatin arm received at least 7 cycles of therapy.

Patients in the radiation therapy plus cetuximab arm experienced more serious adverse events including severe cutaneous toxicity of grade 3 or higher. Four patients in the cetuximab arm developed infectious complications that led to septic shock and three of the patients died after the end of treatment. An additional patient died from respiratory failure caused by aspiration pneumonia.

Patients in the cisplatin arm had more frequent hematologic toxicities compared to patients in the cetuximab arm and one patient died from adverse events possibly related to treatment.

“The incidence of both the infusion reactions and of the other severe adverse events does not allow to consider cetuximab a safer and easy-to-use alternative to standard chemotherapy regimens,” wrote the study authors.

Based on the study results, larger prospective trials are needed to understand which SCCNH patients would best benefit from radiation therapy plus cetuximab regimen.

In an accompanying editorial, Roy H. Decker, MD, PhD, associate professor of therapeutic radiology at the Yale School of Medicine in New Haven, Connecticut, and colleagues highlighted the limitations of the current trial but look forward to results from ongoing studies to clarify the role of cetuximab in the treatment of SCCHN.

“We continue to selectively consider the use of cetuximab-based radiation therapy in patients with otherwise-favorable, low-risk disease—p16-positive, T1–T3 N0–N2b with a smoking history of less than 10 pack-years,” wrote the editorial authors.

December, 2015|Oral Cancer News|

Head, Neck Cancer Patients May Be at Higher Risk for Suicide: Study

Source: www.health.usnews.com
Author: Robert Preidt
 

THURSDAY, Nov. 12, 2015 (HealthDay News) — Head and neck cancer patients may be at raised risk for suicide, new research suggests.

However, the overall risk is still small, the findings showed.

The study included over 350,000 patients in the United States diagnosed with head and neck cancer between 1973 and 2011. Of those patients, 857 died by suicide.

The investigators found that the suicide rate among head and neck cancer patients was three times higher than in the general population. And suicide rates were higher among patients treated with radiation alone compared to surgery alone.

Suicide rates were highest among those with cancers of the lower part of the throat, including the larynx (“voice box”) and hypopharynx, at five times and 12 times higher, respectively, than in the general population.

“This may be linked to these anatomic sites’ intimate relationship with the ability to speak and/or swallow. Loss of these functions can dramatically lower patients’ quality of life,” Dr. Richard Chan Woo Park, of Rutgers New Jersey Medical School, and colleagues wrote.

“It is possible that the increased rates of tracheostomy [breathing tube] dependence and dysphagia [difficulty swallowing] and/or gastrostomy [feeding] tube dependence in these patients are . . . factors in the increased rate of suicide observed,” the authors added.

The study was published online Nov. 12 in the journal JAMA Otolaryngology–Head & Neck Surgery.

“While there is a considerable body of research that examines survival outcomes for patients with head and neck cancer, additional research and effort should also be devoted to the psychological toll that the cancer, treatments and resulting morbidity have on patients,” the researchers concluded.

Suicide is the 10th leading cause of death in the United States and cancer patients are at increased risk for suicide, the study authors pointed out in a journal news release.

More information

The American Cancer Society offers resources on coping with cancer.

Copyright © 2015 HealthDay. All rights reserved.

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

November, 2015|Oral Cancer News|

Marathoner Harriette Thompson, 92, runs to her own inspiring rhythm

Source: http://espn.go.com/
Author: Lynn Olszowy

Harriette Thompson has found a clever way to pass the time when she runs marathons. The classically trained concert pianist imagines her favorite pieces of music.

“When I’m in a place that might be pretty boring, I run to some music in my mind,” she explained. “I hardly know I’m running when I’m thinking about that.”

92_marathoner

Over the weekend, musical thoughts helped Thompson run into the history books for the second year in a row. Last year, she broke the marathon record by a woman over 90 by more than two hours. On Sunday, she became the oldest woman to ever complete a marathon at the age of 92 years, 65 days.

Two days later, she had a spring in her step.

“I feel like a million dollars right now,” Thompson said Tuesday from her home in a Charlotte, North Carolina, retirement community. “I think it must do something to your life system or something that makes you feel up on top of the world after you’ve done a marathon.”

Throughout her 7 hours, 24 minutes and 36 seconds of running, she had Russian composer Sergei Rachmaninoff and his Prelude in D Major keeping her company.

“It’s fun to just think about it because I think it’s one of his most beautiful preludes,” she said over the phone Tuesday.

But there was something else that occupied Thompson’s mind while she ran the 26.2 miles of Sunday’s San Diego Rock ‘n’ Roll Marathon.

“I also think about all the ways I’m working to help other people,” she said.

Thompson has run 16 marathons to raise money for the Leukemia & Lymphoma Society as part of Team in Training. In all, she’s garnered more than $100,000 in donations.

“It makes me very grateful to all the people who have been so generous,” she said. “Every year, when I write my little letter asking my friends [to donate], they keep saying, ‘I thought last year was your last one.'”

This year, Thompson says she had extra motivation to run. After she lost her husband of 67 years to cancer in January, her eldest son, Sydnor Thompson III, was diagnosed with colon cancer.

“I have so much incentive because now I’m really trying to help get that research done so that maybe it will help my son get over his cancer,” she said.

“It’s humbling,” said Sydnor, 61, a pastor in suburban Charlotte. “I don’t know of any child who has ever been loved more than I’ve been loved by my mother.”

“I’m just praying that he’ll get better real fast,” adds Thompson. “The fact [I set] a record, that’s great, but that’s not my main reason.”

In fact, when Thompson first took up running at age 76, she never dreamed of setting any records. She didn’t even think she’d run a marathon. She signed up for her first marathon in 1999 figuring she’d walk the length of the course.

“But when I got out to San Diego, everybody was running, so I started to run,” she said.

Today she credits running with keeping her going all these years, though she has overcome obstacles of her own.

In 2010, while battling an aggressive form of oral cancer — which ate away the roof of her mouth — she was told she had only three months to live, two years at best. Thompson didn’t let that prognosis stop her from running the San Diego marathon that year or the two years that followed. She did take a break in 2013 when the cancer treatment proved too taxing.

And for the past year, she has received radiation treatment for squamous cell carcinoma on her legs. She wore white tights during this year’s race to cover the open wounds she still has from the treatment.

“I was really pleased my legs didn’t hurt me during the run,” she said.

“I don’t think people realize how serious the burns are on her legs,” Sydnor said. “She just endures and pushes through.”

The San Diego marathon is the only marathon she’s ever run because of its commitment to the Leukemia & Lymphoma Society, and the people who run the marathon are just as loyal to Thompson.

“As people would go by, they would say, ‘C’mon Harriette,'” she said. “At least 10 people told me they signed up to run the marathon because they read about me.”

Thompson’s biggest supporter at the race was one of her five children, Brenny, who ran alongside his mother.

“I have to have a lot of energy [to run], so he kept feeding me,” she said. “One time someone brought me a muffin.”

And when someone wanted a picture, Brenny, 56, was there as a safeguard.

“My son was protecting me from having me stop,” Thompson said. “He’d say, ‘You need to take some selfies.'”

“Even though she’s not moving that fast, she definitely has a rhythm,” said Brenny, who runs a real estate company in Charlotte.

Keeping rhythm is something Thompson has done all her life. She actually credits her background as a pianist for her being able to endure the tedium of marathon after marathon, year after year.

“The discipline you have to have when you’re a pianist certainly does play into doing another chore like running,” she said.

Thompson has every intention of running for as long as she can, and knowing she’s making a difference is what’s really music to her ears.

“I think at my age if I can do anything to help somebody, I’m amazed,” she said.

A Disorder That’s Hard to Swallow

www.usnews.com
Source: www.usnews.com
Author: Anna Medaris Miller

 

Ed Steger’s​ last meal was a bowl of soup in Las Vegas. “I remember it all too clearly, as if it were yesterday,” he says. But it wasn’t yesterday – it was 2006. “Life is very different” now, says Steger, a 63-year-old former program manager in Houston.

Steger was diagnosed with head and neck cancer​ in 2005. In addition to 36 rounds of radiation and eight regimens of chemotherapy, he underwent six surgeries, including one that replaced a portion of his pharynx and removed parts of his left jawbone, tongue, epiglottis and soft palate.

“The part that makes it odd is that I’m alive after having four recurrences,” Steger says. The part that makes it distressing is that he can’t eat solid foods.

“There are many case studies I’ve seen where patients have said [their] swallowing disorder is the worst part of their disease – and I believe this to be true,” says Steger, who’s president of the National Foundation of Swallowing Disorders. His daily diet consists of four 8-ounce cans of the nutritional drink Boost Plus, along with two to four bottled​ Starbucks Frappuccinos, which he buys at his local supermarket. “It’s a very boring diet that allows me to maintain my weight,” says Steger, who’s 5 feet 10 inches tall and 155 pounds.

It’s unknown how many people have dysphagia, or difficulty swallowing, but the condition can be caused by any one of 30 diverse health events, Steger says. While his dysphagia is a result of surgery, other people have difficulty swallowing due to neurological conditions such as Parkinson’s disease or stroke, digestive disorders including acid reflux or head injuries. Children with developmental disabilities like autism also often have dysphagia.

“[Dysphagia] isn’t a disease, it’s a sign or an outcome of a disease,” says James Coyle​, an associate professor in the University of Pittsburgh’s School of Health and Rehabilitation Sciences who specializes in treating adults with swallowing disorders.

Difficulty swallowing can also be a part of normal aging, suggests research led by Teresa Lever​, an assistant professor of otolaryngology at the University of Missouri School of Medicine. But that doesn’t mean it’s without consequence. For example, people with dysphagia are at risk for choking, dehydration, malnutrition and pneumonia, which can be triggered when food or drink enter the lungs.

“If you can’t walk, you don’t die. If your skin looks horrible, you don’t die. But if you can’t eat and drink, you die,” Lever says. “[Swallowing] is a vital biological function that is a hugely overlooked contribution to morbidity and mortality.”

Aiming to Eat and Drink Again

How clinicians treat dysphagia depends on its cause. If, for example, the condition is brought on by a stroke that paralyzes one side of the throat, a swallowing specialist like a speech-language pathologist first ​might use an imaging test to identify what exactly is going wrong, and then coach the patient on ways to tilt his or her head while eating in order to better prevent food from getting into the airway.​ Such “compensatory strategies,” Coyle says, are “more or less exploiting either gravity or using the change in position to redirect the swallowed material more efficiently and with better airway protection.”

Steger, for one, was trained to swallow by holding his breath, reclining and “letting the liquid flow” down the back of his esophagus and avoiding the airway. “When I swallow, I need to concentrate very hard,” he says.

Mouth and throat exercises can also help patients boost their swallowing abilities. One mouthpiece-like device called SwallowSTRONG, for instance, senses how hard the patient pushes the tongue against the roof of the mouth and progressively guides him or her in resistance exercises.​ “It’s like weightlifting,” Coyle says. “You start off doing low levels of exercise, and we increase the targets every two weeks until the tongue is stronger.”

Other exercises use a similar technique but to improve respiratory function rather than tongue strength. When patients blow against progressively increasing resistance, for example, they’ll develop a better cough reflex. That, in turn, will make it more likely that any food particles or liquids inhaled into the airways will be expelled and not enter the lungs to cause harm, Coyle says. “Dysphagia doesn’t always go away,” he says. “Sometimes we have to teach the person to swallow differently, sometimes we have to beef up other parts of the body to compensate for the fact that the swallowing isn’t going to get better.”

If dysphagia is caused by dementia or another condition that compromises someone’s ability to learn, clinicians must defer to environmental or dietary modifications like prescribing a diet of thickened liquids. The route is a last resort, Coyle says, since “gobs of studies” show that people don’t like thickened liquids, don’t drink them and therefore, are at risk for dehydration.

“All of our cases aren’t successful,” he says, “but when we do have a successful case, it’s so rewarding – the ability to restore a person’s ability to eat and drink.”

Food is Secondary

If Steger woke up tomorrow without dysphagia, he’d eat a T-bone steak grilled with Lawry’s spice, a baked potato with all the fixings and crème brulee for dessert.​ But what he’d look forward to most is going to a restaurant with friends, ordering anything he wants and keeping pace with his companions. “The food is secondary at this point,” he says.

Living with dysphagia isn’t just a medical risk, but can also hamper one’s quality of life and mental health. People with the condition can feel isolated not only because they avoid social eating situations, but also because many of them have medical conditions that affect their voices and compromise their communication. In the support groups for people with Parkinson’s that Steger sometimes attends, the participants, many of whom have dysphagia, “are embarrassed to go out, they’re ashamed, it’s sad,” he says.

One of his goals is to boost funding for dysphagia research, which is slow-going since major funding organizations like the National Institutes of Health are more focused on the diseases that underlie the condition, Steger says. “[Swallowing] is never top of mind when you have head and neck cancer or Parkinson’s until it happens to you,” he says .​But a focus on swallowing itself is not trivial since, for example, hospital patients with dysphagia stay in the hospital 40 percent longer than patients without it, Coyle says. “It’s very important to identify early.”

It’s also important to dedicate resources to the disorder since it will affect more and more people as the population ages, Lever says. She’s now working to identify traits that protect mice – and hopefully, people – from developing dysphagia as they grow old. “Now that we can diagnose dysphagia, we can identify which mouse models have it, and then we can use those mouse models to try to understand what is going wrong to cause dysphagia,” she says. That, in turn, “can then give [us] some targets for treatment.”

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