smokers

Electronic nicotine delivery systems: is there a need for regulation?

Source: http://tobaccocontrol.bmj.com/
Author: Anna Trtchounian, Prue Talbot

Purpose:
Electronic nicotine delivery systems (ENDS) purport to deliver nicotine to the lungs of smokers. Five brands of ENDS were evaluated for design features, accuracy and clarity of labeling and quality of instruction manuals and associated print material supplied with products or on manufacturers’ websites.

Methods:
ENDS were purchased from online vendors and analyzed for various parameters.

Results:
While the basic design of ENDS was similar across brands, specific design features varied significantly. Fluid contained in cartridge reservoirs readily leaked out of most brands, and it was difficult to assemble or disassemble ENDS without touching nicotine-containing fluid. Two brands had designs that helped lessen this problem. Labeling of cartridges was very poor; labelling of some cartridge wrappers was better than labelling of cartridges. In general, packs of replacement cartridges were better labelled than the wrappers or cartridges, but most packs lacked cartridge content and warning information, and sometimes packs had confusing information. Used cartridges contained fluid, and disposal of nicotine-containing cartridges was not adequately addressed on websites or in manuals. Orders were sometimes filled incorrectly, and safety features did not always function properly. Print and internet material often contained information or made claims for which there is currently no scientific support.

Conclusions:
Design flaws, lack of adequate labeling and concerns about quality control and health issues indicate that regulators should consider removing ENDS from the market until their safety can be adequately evaluated.

Authors affiliation:
Department of Cell Biology and Neuroscience, University of California, Riverside, California, USA

December, 2010|Oral Cancer News|

U.S. cigarette brands tops in cancer causing chemicals

Source: CNN
Author: Miriam Falco

Smokers of U.S. brand cigarettes may get more bang for their buck in the worst way according to a small study conducted by the Centers for Disease Control and Prevention.

Researchers found U.S. made cigarettes contain more cancer-causing chemicals than some cigarettes brands made elsewhere around the world.

“Not all cigarettes are made alike” says Dr. Jim Pirkle, deputy director for science at the CDC’s National Center for Environmental Health. He says this is the first study to show that “U.S. cigarettes have more of the major carcinogen [TSNAs] than foreign made cigarettes.” TSNAs are “tobacco-specific nitrosamines,” the major cancer-causing substance in tobacco.

126 smokers in five cities – Waterloo, Ontario; Melbourne, Victoria (Australia); London, England, Buffalo, New York, and Minneapolis, Minnesota – were recruited for this study.

They were between the ages of 18 and 55 and smoked at least 10 cigarettes a day for the past year and had been brand loyal for at least three months. The cigarettes smoked by the study recruits represented some of the more popular brands for each country including: Players light and DuMaurier in Canada; Marlboro, Newport Light, Camel Light in the U.S.; Peter Jackson and Peter Stuyvesant in Australia; and Benson & Hedges and Silk Cut Purple in the United Kingdom.

Scientists analyzed more than 2,000 cigarette butts to get the data they are reporting today, says Pirkle.

When researchers compared cigarette brands in the U.S. to those in Canada and Australia, they found three times higher levels of the cancer causing substance in the U.S. smokers’ mouths. The mouth levels are important because they give an indication of what levels if carcinogens are going into the lungs. (Smoking tobacco is a major cause of lung cancer).

“If you want to stop exposure to these things, you have to stop smoking.”

They also found twice as much TSNA in the urine samples of U.S. smokers compared to those in Canada and Australia, an indication that cancer-causing substance has traveled throughout the body.

There is no one group that speaks for the tobacco institute anymore, according to Darryl Jason, a spokesman for the Tobacco Merchants Association (TMA), which is why he couldn’t comment on the study. The TMA was founded in 1915 to “manage information of vital interest to the worldwide tobacco industry according to their website. Jason did point out that cigarettes manufactured in the U.S. contain a different blend of tobacco from cigarettes made elsewhere.

The study acknowledges that there are different types of tobacco depending where the cigarettes are made. But that’s only one factor says Pirkle: “The TSNA levels largely come from the way tobacco is cured.” The heating process, humidity and the type of the ferlizer used to grow the tobacco also contribute to the levels of cancer causing substances, says Pirkle.

Editor’s Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation.

June, 2010|Oral Cancer News|

Oral Cancer Foundation donates screening devices to West Virginia Free Clinics

Source: www.prnewswire.com
Author: press release

In 2009 the Oral Cancer Foundation initiated a program of donating VELscope® Oral Cancer Screening Systems to free clinics. The most recent recipients of this program are two West Virginia clinics: WV Health Right in Charleston, and the Susan Dew Hoff Memorial Clinic in West Milford.

“Our intent is to identify free clinics in areas that have a high concentration of people who are both at risk for oral cancer and without the financial means to pay for comprehensive oral exams,” said Oral Cancer Foundation founder and executive director Brian Hill. “It is difficult to think of an area that better fits those criteria than West Virginia.” The state ranks highest in the country in tobacco usage, and next-to-last in per capita income. In identifying free clinics to be potential recipients of the device which identifies loss of tissue auto-fluorescence, an indicator of abnormal tissues, the Oral Cancer Foundation is careful to ensure that each candidate clinic has at least one dentist on staff who can be trained to use the device and can train other staff members.

Oral cancer belongs to the head and neck cancer group, and is often referred to by other names such as; tongue cancer, mouth cancer, tonsil cancer, lip cancer, and throat cancer. While some people think this is a rare cancer, it is not. Approximately 100 people in the U.S. will be newly diagnosed with oral cancer each day, and it takes a life in the U.S. every hour of every day.

WV Health Right was founded in 1982 by a small group of physicians and nurses who recognized the need for a source of ongoing health care for Charleston’s low-income uninsured. The clinic has grown so much since its’ founding that it is now in its third location. In 2001, it added a three-unit dental operatory, making it West Virginia’s first free dental clinic. It now serves almost 20,000 patients per year thanks to over 180 medical and dental professional volunteers.

According to WV Health Right executive director Patricia White, “West Virginia has some of the worst oral health statistics in the country, in large part because of the relatively high percentage of residents who are spit tobacco users and smokers.” Because of the well-established connection between tobacco usage and oral cancer, WV Health Right’s dental clinic has always insisted on giving all patients a conventional oral cancer examination regardless of their reason for visiting the clinic. The conventional exam is a manual palpation and visual inspection of the oral cavity and the neck. “Now,” says Ms. White, “our clinicians can also view the oral cavity using fluorescence visualization technology, which will enhance our ability to detect cancerous and pre-cancerous lesions that might be hard to see with the naked eye.”

The Susan Dew Hoff Memorial Clinic serves over 1,800 active patients in West Virginia’s Harrison County. Volunteers include five dentists, five dental assistants, and one hygienist. Roughly half of the patients are employed but without health insurance, while the other half are elderly and rely largely on Medicare.

“A high percentage of our patients use chewing tobacco, smoking tobacco or both,” said clinic director Sister Mary Rebecca Fidler, Ph. D., RSM. “If patients have cancer or any other serious condition, they will want to know about it at the earliest possible time, when survival rates are the highest, and treatment related morbidity the lowest,” she said. She added, “Up until now, we’ve discovered oral lesions on several patients merely by having our clinicians examine them using a visual and tactile conventional screening. Now, with this technology, we look forward to doing not only a better job of detecting early stage oral cancer, but even pre-cancerous tissues changes.”

In the words of the Oral Cancer Foundation’s Hill, “The key to reducing the death rate of oral cancer is earlier detection, and the key to that is for all adults to receive opportunistic oral cancer examinations at least once a year.” Mr. Hill pointed out that tobacco users, heavy alcohol users, and those with a prior history of cancer should be examined more frequently Even people who do not share those traits should be examined annually in light of the mounting evidence of a link between oral cancer and the sexually-transmitted human papilloma virus.

Peter Whitehead, founder and chief executive officer of VELscope manufacturer LED Dental, said, “When we started our company, our goal was to help achieve a significant reduction in the incidence of oral cancer, by elucidating pre-malignant tissue abnormalities. Unfortunately, many times the people who are most at risk for the disease are also the people who cannot afford the regular dental exams that can allow us to discover these early or pre-malignant changes.” According to Mr. Whitehead, “Now, thanks to the efforts of the Oral Cancer Foundation, our potentially life-saving technology is able to reach people we otherwise would likely have missed. Our relationship with OCF in this effort speaks to the core reasons that most of us at LED worked in the arena of adapting high technologies to enable better outcomes in the area of oral cancer. We could not be more pleased to see our technology end up in these underserved areas.”

About the Oral Cancer Foundation: The Oral Cancer Foundation, founded by oral cancer survivor Brian R. Hill, is a non-profit 501(c)(3) public service charity that provides information, patient support, sponsorship of research, and advocacy related to this disease. It maintains a Web site at http://www.oralcancer.org, which receives millions of hits per month. At the forefront of this year’s agenda is the drive to promote solid awareness in the minds of the American public about the need to undergo an annual oral cancer screening, and an outreach to the dental community to provide this service as a matter of routine practice. Supporting the foundation’s goals is a scientific advisory board composed of leading cancer authorities from varied medical and dental specialties, and from prominent educational, treatment, and research institutions in the United States.

Source: Oral Cancer Foundation

HPV-linked head and throat cancers easier to treat unless patient is a smoker, University of Michigan study finds

Source: annarbor.com
Author: Tina Reed

A growing incidence of head and throat cancers have been traced back to the human papillomavirus, or HPV, rather than smoking. With that in mind, University of Michigan researchers recently decided to examine the difference in outcomes between smokers with HPV-linked head and throat cancer and those who had never smoked.

Turns out, the HPV-linked tumors were easier to treat than non-HPV associated cancers. That is, unless the patient was a smoker. Those with HPV-linked cancers who smoked were six times as likely to recur than those who had never smoked.

According to a Los Angeles Time health blog, treatments for head and neck cancers include harsh treatments such as radiation, chemotherapy and surgery. The researchers from U-M’s Comprehensive Cancer Center said they planned to begin a clinical trial to milder treatments later this year.

February, 2010|Oral Cancer News|

Quitting cigarettes completely or switching to smokeless tobacco: do US data replicate the Swedish results?

Source: Tob Control 2009;18:82-87 doi:10.1136/tc.2008.028209
Authors: S-H Zhu et al.

Background:
Swedish male smokers are more likely than female smokers to switch to smokeless tobacco (snus) and males’ smoking cessation rate is higher than that of females. These results have fuelled international debate over promoting smokeless tobacco for harm reduction. This study examines whether similar results emerge in the United States, one of few other western countries where smokeless tobacco has long been widely available.

Methods:
US data source: national sample in Tobacco Use Supplement to Current Population Survey, 2002, with 1-year follow-up in 2003. Analyses included adult self-respondents in this longitudinal sample (n = 15 056). Population-weighted rates of quitting smoking and switching to smokeless tobacco were computed for the 1-year period.

Results:
Among US men, few current smokers switched to smokeless tobacco (0.3% in 12 months). Few former smokers turned to smokeless tobacco (1.7%). Switching between cigarettes and smokeless tobacco, infrequent among current tobacco users (<4%), was more often from smokeless to smoking. Men quit smokeless tobacco at three times the rate of quitting cigarettes (38.8% vs 11.6%, p<0.001). Overall, US men have no advantage over women in quitting smoking (11.7% vs 12.4%, p = 0.65), even though men are far likelier to use smokeless tobacco.

Conclusion:
The Swedish results are not replicated in the United States. Both male and female US smokers appear to have higher quit rates for smoking than have their Swedish counterparts, despite greater use of smokeless tobacco in Sweden. Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programmes may not result in any positive population effect on smoking cessation.

Authors:
S-H Zhu1, J B Wang1, A Hartman2, Y Zhuang1, A Gamst1, J T Gibson3, H Gilljam4, M R Galanti4

Author Affiliations
1University of California, San Diego, California, USA
2National Cancer Institute
3Information Management Services, Rockville, Maryland, USA
4Karolinska Institutet, Stockholm, Sweden

December, 2009|Oral Cancer News|

U.S. smoking rates remain steady, but vary widely by state

Source: Medical News
Author: John Gever

National rates of cigarette smoking showed little change in 2008 from a year earlier, the CDC reported, though states vary widely both in rates of current smoking and exposures of nonsmokers to secondhand smoke.

Some 20.6% of Americans were current smokers in 2008 (95% CI 19.9% to 21.4%), not significantly different from the 19.8% found in 2007 (95% CI 19.0% to 20.6%) according to the the government’s ongoing National Health Interview Survey, detailed by Shanta R. Dube, PhD, and other CDC researchers in the Nov. 13 issue ofMorbidity and Mortality Weekly Report.

But analysis of a another data set in MMWR — the 2008 results from the Behavioral Risk Factor Surveillance System (BRFSS) — revealed a twofold variation in rates among states.

Utah had by far the lowest rate of current cigarette smoking, at 9.2%, followed by California (14.0%), New Jersey (14.8%) and Maryland (14.9%), according to Ann M. Malarcher, PhD, and CDC colleagues.

West Virginia led the other end of the list at 26.6%. Other states with current smoking rates of 25% or more included Indiana, Kentucky, and Missouri.

West Virginia had several other smoking distinctions.

It was the only state in which the current smoking rate was higher among women than men — 27.1% versus 26.1% — although the difference was not statistically significant.

The BRFSS data showed the Mountain State had the highest rate of home exposure to secondhand smoke among 12 states and territories for which data were available.

Some 10.6% of West Virginia adults said there was secondhand smoke in their homes (95% CI 9.2% to 12.0%), while the lowest rate was in Arizona (3.2%, 95% CI 2.3% to 4.1%). The national median was 7.8%

West Virginia respondents were also least likely to report that smoking was banned inside their homes, at 68.8% (95% CI 67.0% to 70.6%).

The U.S. Virgin Islands sported the highest home smoking ban figure, 85.7% (95% CI 83.8% to 87.6%), a statistical tie with Arizona’s 85.6%. The national median was 78.1%.

Similar variation in workplace exposure to secondhand smoke was apparent in the result, though with a different pattern of highs and lows.

Tennessee had the lowest rate, with 6.0% of survey respondents saying there was secondhand smoke at work (95% CI 4.0% to 8.0%). Mississippi had the highest, at 15.8% (95% CI 13.7% to 17.9%). The national median was 8.6%.

As in previous surveys, the 2008 National Health Interview data showed that smoking rates were markedly higher among individuals with a high school education or less (27.5%, 95% CI 25.5% to 29.6%) compared with those with more education.

People with “some college” had a 2008 smoking rate of 22.7% (95% CI 21.3% to 24.2%) while just 5.7% of those holding graduate degrees were current smokers (95% CI 4.6% to 7.1%).

Dube and colleagues also found substantial racial-ethnic differences in 2008 smoking rates, similar to those seen in previous years:

  • Non-Hispanic whites: 22.0%
  • Non-Hispanic blacks: 21.3%
  • Hispanics: 15.8%
  • American Indian/Alaska native: 32.4%
  • Asian: 9.9%

In an unsigned commentary, MMWR editors noted that the national prevalence of smoking has declined significantly since 1998, when 24.1% of adults smoked. That was the year when the “master settlement agreement” with tobacco companies began limiting their marketing activities, the editors said.

But year-to-year decreases have been sporadic, they added.

“Although comprehensive tobacco control programs have been effective in decreasing tobacco use in the U.S., they remain underfunded,” the editors wrote.

The editors added that state-level tobacco control programs “need to continue to encourage the public to make their homes smoke-free.”

More states also need to legislate smoking bans in restaurants, bars, and other workplaces, they said, as the patchwork nature of such bans appears to be a major factor in the state-to-state variation in exposure to secondhand smoke on the job.

No external funding for the CDC studies was reported.

No potential conflicts of interest were reported.

November, 2009|Oral Cancer News|

Understanding the link between HPV and oropharyngeal cancers

Source: www.jaapa.com (Journal of the American Academy of Physician Assistants, October, 2009)
Authors: Denise Rizzolo, PA-C, PhD, Mona Sedrak, PA-C, PhD

Head and neck cancer is diagnosed in approximately 650,000 patients each year worldwide.1 The term head and neck cancer refers to a group of biologically similar cancers originating from the upper aerodigestive tract, including the lip, oral cavity (mouth), nasal cavity, paranasal sinuses, pharynx, and larynx. Oropharyngeal refers to all the structures of the mouth and pharynx, including the tonsils and tongue. Oral squamous cell carcinoma (OSCC) is the most common form of head and neck cancer.2 Seventy-five percent of all OSCCs are attributable to tobacco and alcohol use.3 People who smoke cigarettes are 4 times more likely to develop oral cancer than nonsmokers. Furthermore, individuals who consume alcohol are 3 times more likely than nondrinkers to develop oral cancer.3 According to the Substance Abuse and Mental Health Services Administration, the prevalence of cigarette smoking has decreased among Americans, and alcohol use has also declined since the 1970s.4,5 However despite this, the incidence of oropharyngeal cancers, including cancer of the base of the tongue and tonsils, has increased, especially in younger patients. These trends have led researchers to investigate other potential risk factors.6-8

New studies suggest that there may be an alternative pathway for the development of oropharyngeal cancers. The high-risk types of human papillomavirus (HPV), especially type 16 (HPV-16), are now thought to be potential etiologic agents.2,3 The concept that HPV plays a role in head and neck cancers is not new. This link has been under investigation for at least 20 years.6 This is a worrisome public-health concern because patients with HPV-positive OSCC are 3 to 5 years younger at diagnosis than those with HPV-negative OSCC, and they have a history of high-risk sexual behavior.9-12 Interestingly, patients with HPV-positive OSCC are also less likely to have a history of alcohol and tobacco abuse.3 Therefore, educating patients regarding the disturbing trend of HPV-positive oropharyngeal cancer is important.

Incidence and Prevalence
In the United States alone, an estimated 34,360 people received a diagnosis of oropharyngeal cancer in 2007; of these, 7,550 (5,180 men and 2,370 women) died.13 On average, more than 25% of people who develop oropharyngeal cancer will die of the disease, with only 60% surviving for more than 5 years.14 In fact, oropharyngeal cancer is as common as leukemia and claims more lives than either melanoma or cervical cancer.13

Since the mid 1970s, oropharyngeal cancer rates have increased approximately 15%, with significant disparities in some population groups. For instance, oropharyngeal cancer prevalence is significantly higher in males than in females.14 Prevalence is also higher in Hispanic and black males than it is in white males.14 The risk of oropharyngeal cancer increases with age, and occurrence is highest in persons older than 50 years and peaks between ages 60 and 70 years.14 However, there has been a startling 5-fold increase in the incidence of oral cancer in patients younger than 40 years, many of whom have no known risk factors.4

HPV is associated with 15% to 35% of head and neck cancers worldwide.11 Fifty percent to 90% of OSCCs in the pharynx, tonsil, and tongue are HPV-positive.11 Chaturvedi and colleagues investigated the impact of HPV on the epidemiology of OSCCs in the United States.9 These researchers reported that HPV-positive OSCCs were diagnosed at younger ages than HPV-negative OSCCs (mean age at diagnosis was 61.0 and 63.8 years, respectively) and the incidence increased significantly for HPV-positive OSCC from 1973 to 2004, particularly among younger white men.

Kreimer and colleagues conducted a systematic review of 60 studies and determined that 25.9% of the 5,046 patients with head and neck squamous cell carcinoma (HNSCC) were HPV-positive.2 Furthermore, these researchers noted that HPV-16 was the most prevalent genotype in these cancers, accounting for 86.7% of cases.

Although there is research that supports the association between HPV and oropharyngeal cancers, some studies dispute that relationship. Specifically, controversy exists over the prevalence and significance of HPV in oral tongue cancers (cancer of the anterior two-thirds of the tongue). In a 2008 Mayo Clinic study, researchers examined fresh-frozen tissues from 51 patients with oral tongue cancers.15 Their findings suggest that the incidence of oral HPV in oral tongue cancer was low and was unlikely to play a significant role in the etiology, pathogenesis, and clinical outcomes of oral tongue cancers.15 The authors admit the study was limited by a small sample size and that more research is needed.

Pathogenesis
The oropharyngeal sites that are most often associated with the HPV infection are the tonsils and the tongue.16,17 Reasons why the oropharynx is more susceptible to the HPV infection remain unclear; however, the similarity in accessibility to infection between the tonsillar tissue and the uterine cervical mucosa is believed to make the oropharyngeal area more vulnerable. Another explanation is that tonsillar tissue contains deep invaginations that may capture the virus and facilitate it into the basal cells.

The mechanism of HPV carcinogenesis was first characterized in cervical cancer. Ninety percent of cervical cancer cases are related to HPV infection, predominantly HPV-16 and HPV-18.18 The viral oncoproteins E6 and E7 of the high-risk HPV types are associated with the malignant process in both anogenital and head and neck cancers.17 These oncoproteins inactivate the p53 and pRb tumor suppressor pathways, which is important to the genetic progression of head and neck cancers. HPV infection may therefore represent an alternate but functional pathway for HNSCC pathogenesis. Yet, despite recent literature confirming that HPV is a risk factor associated with oropharyngeal cancers, the HPV infection is not necessary nor is it sufficient for oropharyngeal carcinoma to develop. Therefore, more research is needed to closely define the link between the acquisition of the virus and the progression to cancer.

The major prognostic factors for head and neck cancer are the presence of local and regional metastasis, vascular or lymphatic invasion, positive surgical margins, and extracapsular spread of tumor cells from the lymph nodes into the soft tissue of the head and neck.19 Thus, understanding the mechanism of tumor progression may help to identify new prognostic and predictive markers that will aid in the development of new therapeutic agents for the treatment of HPV-positive cancer.20

Incidence of HPV Transmission
The association between high-risk sexual behavior and transmission of HPV is well-established.10,21 Certain sexual behaviors are associated with a significantly increased risk of HPV transmission, including engaging in casual sex, young age at first intercourse, and infrequent use of condoms. Specifically, a high number of lifetime sex partners (26 or more vaginal-sex partners, 6 or more oral-sex partners) is associated with an increased risk of oropharyngeal cancer. A study conducted from 2000 to 2006 positively correlated HPV-16-positive cancer of the head and neck with number of oral-sex partners, as well as with marijuana use.22

Diffuse white area on the buccal mucosa

Diffuse white area on the buccal mucosa

The onset of the HIV epidemic has resulted in an increase in oral sex practices among teenagers and young adults, which may be contributing to the increase in the incidence of HPV-positive cancers.23 A common belief among people in these age-groups is that oral sex represents a form of “safe sex,” leading to a worry-free behavior that precludes them from contracting sexually transmitted diseases. These findings emphasize a significant implication to public health. The increase in the incidence of tonsillar and base-of-tongue cancers in the United States may be a result of a higher incidence of oral-sex practices.7,8

Clinical Signs and Symptoms
HPV-positive oropharyngeal cancer manifests in the same manner as HPV-negative oropharyngeal cancer. Therefore, clinicians should be aware of the signs and symptoms that suggest OSCC. Patients present with a variety of signs and symptoms depending on the site of origin, including a sore throat, dysphagia, odynophagia, and hoarseness14 (Table 1). The two precursor lesions clinicians should look for are leukoplakia, white lesions (Figure 1), and erythroplakia, red lesions. Although leukoplakia lesions are more common, erythroplakia and lesions with erythroplakic components have a much greater potential for becoming cancerous. Any white or red lesion that does not resolve within 2 weeks should be reevaluated and considered for biopsy to obtain a definitive diagnosis.14 The following are the four basic steps to early detection and prevention of disease:

• Take a thorough history
• Perform a detailed examination of the head and neck
• Educate patients on the risk factors associated with oral cancers
• Provide adequate follow-up to ensure a definitive diagnosis of any suspicious lesions.14

table-1

A thorough history and physical examination of the head and neck should be a routine part of each patient’s general medical examination. Clinicians should be particularly vigilant when examining patients who have a history of tobacco use or drink excessive amounts of alcohol. The examination is conducted with the patient seated. The patient should remove any intraoral prostheses before beginning the examination. The extraoral assessment includes inspection of the face, head, and neck; note any asymmetry or skin pathology, such as crusts, fissuring, growths, and/or color changes. The regional lymph node areas are bilaterally palpated to detect any enlarged nodes.14 The perioral and intraoral examination follows a detailed, seven-step systematic assessment14 (Table 2).

table-2

Therapeutics
Recent data suggests a better prognosis for those patients with HPV-positive HNSCC than for those with HPV-negative HNSCC; however, there is still intense debate over this theory.20 Treatment is the same for patients, regardless of whether they have HPV-positive or HPV-negative HNSCC. Traditional therapy for patients with stage I or II head and neck cancer consists of radiation and/or surgery, and prognosis is excellent. Unfortunately, most patients present with stage III or IV disease, and treatment consists of a combination of chemotherapy, radiation, and surgery.20 Survival rates are greatly diminished when the disease is diagnosed at a later stage.

An interesting note is that research suggests that HPV-positive tumors behave in a different fashion, have a different response to therapy, and are more sensitive to radiation-based therapies; therefore, HPV-positive HNSCCs may require a different therapeutic approach compared with HPV-negative HNSCCs.24 Fakhry and colleagues found that patients with HPV-positive HNSCC had better overall and progression-free survival rates than did patients with HPV-negative HNSCC.24 These findings raise the question of whether traditional therapy is the best option for HPV-positive disease. Even when HNSCC is diagnosed early, treatment still consists of removal of the diseased tissue and/or weeks of radiation therapy that may leave some patients disfigured or with permanent negative sequela (dry mouth, loss of taste, alteration of speech patterns, etc). If HPV-positive cancers are more sensitive to traditional therapy, can less aggressive and extensive treatment be used thereby minimizing the side effects of current therapeutic regimens on this subset of patients? The study authors interpret their results cautiously, suggesting that more research is needed on treatment response and subsequent survival patterns of patients with HPV-positive cancers. Until further research is conducted, therapeutic treatment strategies are the same for HPV-positive and HPV-negative HNSCC.24

Patient Education: Prevention and Detection
The best way to prevent oropharyngeal cancer is to avoid tobacco and alcohol use. In addition, regular dental checkups, including an examination of the entire mouth, are essential for early detection of cancerous and precancerous conditions. Red or white lesions often precede the development of oropharyngeal cancer; therefore, if patients notice any new lesions in their mouths, they should have them evaluated by their clinicians. Lesions that do not resolve after 2 weeks should be biopsied. Detection of oropharyngeal carcinoma while the disease is still localized can dramatically increase survival rates. The 5-year survival rate for patients with localized disease at diagnosis is 82%, compared with only 28% for those whose cancer has spread to other parts of the body.14

Clinicians should take the time to educate young patients regarding HPV infection, its correlation to oropharyngeal cancer, and safe-sex practices. Some discussions in the literature suggest that the HPV vaccine could be considered for the prevention of HPV-positive HNSCC.6,10,20 The HPV vaccine has become an important strategy in the prevention of cervical cancer because HPV has been shown to cause nearly all cases of female cervical cancer. Ninety-five percent of patients with HPV-positive HNSCC are positive for HPV-16; therefore, researchers are exploring whether the vaccine could provide the same prophylactic effect against HPV-positive HNSCC as it does for HPV-associated anogenital cancers.25 D’Souza and colleagues argue that a rationale for HPV vaccination in both boys and girls is that oropharyngeal cancers occur in both men and women.10 They also suggest that if the vaccine prevents oral disease as effectively as it prevents cervical disease, a substantial reduction in the incidence of oropharyngeal cancer in vaccinated populations would provide the ultimate evidence of causality. However, no definitive recommendations to use the HPV vaccine to prevent HPV-positive HNSCC have been made.

table-4

Conclusion
Cancers of the head and neck are a worldwide concern. The incidence of HPV-related head and neck cancer is increasing. Clinicians should be aware of the risk factors as well as the clinical signs and symptoms of oropharyngeal cancers. The best way to prevent oropharyngeal cancer is to avoid tobacco and alcohol use. However, consistent safe-sex practices are also effective preventive measures because of the strong correlation between HPV infection and oropharyngeal cancers. This association has researchers considering the potential effectiveness of the HPV vaccine in the prevention of HPVpositive head and neck cancers. JAAPA

Authors’ affiliations
Mona Sedrak is an associate professor in the PA program at Seton Hall University, South Orange, New Jersey. Denise Rizzolo works at the Care Station, Springfield, New Jersey, and is faculty assistant professor in the PA program at Seton Hall University. They have indicated no relationships to disclose relating to the content of this article.

References
1. Boyle P, Ferlay J. Cancer incidence and mortality in Europe, 2004. Ann Oncol. 2005;16(3):481-488.
2. Kreimer AR, Clifford GM, Boyle P, Franceschi S. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomarkers Prev. 2005;14(2):467-475.
3. Mork J, Lie K, Glattre E, et al. Human papillomavirus infection as a risk factor for squamous-cell carcinoma of the head and neck. N Engl J Med. 2001;344(15):1125-1131.
4. Schantz SP, Yu GP. Head and neck cancer incidence trends in young Americans, 1973-1997, with a special analysis for tongue cancer. Arch Otolaryngol Head Neck Surg. 2002;128(3):268-274.
5. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, US Dept of Health and Human Services; 2006. DHHS publication SMA 07-4293.
6. Syrjanen S. Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007;356(19):1993-1995.
7. Frisch M, Hjalgrim H, Jaeger AB, Biggar RJ. Changing patterns of tonsillar squamous cell carcinoma in the United States. Cancer Causes Control. 2000;11(6):489-495.
8. Shiboski CH, Schmidt BL, Jordan RC. Tongue and tonsil carcinoma: increasing trends in the U.S. population ages 20-44 years. Cancer. 2005;103(9):1843-1849.
9. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26(4):612-619.
10. D’Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007;356(19):1944-1956.
11. Saraiya M, Kawaoka K. Incidence of human papillomavirus (HPV)-related head and neck cancers in the US from 1998-2003: Pre-HPV vaccine licensure. [ASCO abstract 6003] J Clin Oncol. 2007;25(suppl):299s.
12. Schwartz SM, Daling JR, Doody DR, et al. Oral cancer risk in relation to sexual history and evidence of human papillomavirus infection. J Natl Cancer Inst. 1998;90(21):1626-1636.
13. American Cancer Society. Cancer Facts & Figures 2007. Atlanta, GA: American Cancer Society; 2007.
14. National Institute of Dental and Craniofacial Research. Detecting oral cancer: A guide for health care professionals. NIDCR Web site. http://www.nidcr.nih.gov/.
15. Liang XH, Lewis J, Foote R, et al. Prevalence and significance of human papillomavirus in oral tongue cancer: the Mayo Clinic experience. J Oral Maxillofac Surg. 2008;66(9):1875-1880.
16. Gillison ML, Koch WM, Capone RB, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst. 2000;92(9):709-720.
17. Haddad RI. Human papillomavirus infection and oropharyngeal cancer. Medscape CME Web site. http://cme.medscape.com/viewarticle/559789. Accessed September 4, 2009.
18. Muñoz N, Bosch FX, de Sanjosé S, et al; International Agency for Research on Cancer Multicenter Cervical Cancer Study Group. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med. 2003;348(6):518-527.
19. Forastiere A, Koch W, Trotti A, Sidransky D. Head and neck cancer. N Engl J Med. 2001;345(26):1890-1900.
20. Haddad RI, Shin DM. Recent advances in head and neck cancer. N Engl J Med. 2008;359(11):1143-1154.
21. Gillison ML, Shah KV. Chapter 9: Role of mucosal human papillomavirus in nongenital cancers. J Natl Cancer Inst Monogr. 2003;(31):57-65.
22. Gillison ML, D’Souza G, Westra W, et al. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst. 2008;100(6):407-420.
23. Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 15-44 years of age, United States, 2002. Adv Data. 2005;(362):1-55.
24. Fakhry C, Westra WH, Li S, Cmelak A, et al. Improved survival of patients with human papillomavirus—positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst. 2008;100(4):261-269.
25. Devaraj K, Gillison ML, Wu TC. Development of HPV vaccines for HPV-associated head and neck squamous cell carcinoma. Crit Rev Oral Biol Med. 2003;14(5):345-362.

October, 2009|Oral Cancer News|

Packing a heavier warning

Source: www.washingtonpost.com
Author: Ranit Mishori

Coming soon to the lives of American smokers: cigarette labels that go far beyond a simple warning.

Imagine gruesome color photographs showing a mouth riddled with cancer, lungs blackened, a foot rotten with gangrene. If the images sound sickening, well, that’s the point.

Under a law signed by President Obama on June 22 — the Family Smoking Prevention and Tobacco Control Act — tobacco companies will be required to cover 50 percent of the front and rear panels of cigarette packages with color graphics showing what happens when you smoke and bold, specific labels saying such things as:

“WARNING: Cigarettes cause fatal lung disease.”

“WARNING: Tobacco smoke can harm your children.”

“WARNING: Smoking can kill you.”

The first U.S.-mandated label in 1965 tentatively suggested “Cigarette Smoking May Be Hazardous to Your Health.” Although the language changed over time, critics have long dismissed U.S. labeling as anemic and ineffective.

Indeed, the inspiration for the new labeling standards comes from abroad. Canada started the trend in 2000 with a label that showed a picture of mouth cancer. “It’s the one that smokers remember more than anything else. Even after nine years,” says David Hammond, a researcher from the Department of Health Studies at the University of Waterloo in Ontario. Since then, he says, more than two dozen countries have picked up on the idea.

A sampling of how explicit the labels can be: Malaysia’s cigarette packs bear a photo of a diseased lung; some in Brazil show a dead fetus lying near cigarette butts; Thailand’s show a person with a hole in his throat, to warn about throat cancer; in New Zealand, it’s a gangrenous foot.

Compare these with the American warning label, which has not changed since 1985: no images, and only a small-type surgeon general’s warning that states: “smoking by pregnant women may result in fetal injury, premature birth and low birth weight.”

“Every piece of research that I’ve seen with smokers tells us that smokers think that [pictorial warnings] are more effective,” Hammond says. “U.S. smokers and consumers are getting worse health information than almost any other smoker in the world.”

While it is true that smoking rates in the United States are lower than in other countries — about 20 to 22 percent of the adult American population smokes — experts have long argued that a more powerful message would have a far greater impact on smoking habits.

One out of five American adults is still too many smokers, says Mitch Zeller, a former director of the Food and Drug Administration’s Office of Tobacco Programs. “That’s an unacceptable figure. Just because our smoking rate may be lower than other countries around the world is not an argument against graphic warnings when we still have so many people smoking in this country.”

According to the Centers for Disease Control and Prevention, more than 440,000 U.S. deaths are attributed to cigarette smoking every year. That includes deaths from heart disease, lung cancer, obstructive lung disease, other cancers, stroke and other conditions. An estimated 49,000 of these deaths are the result of secondhand-smoke exposure.

“The health effects of smoking are inherently hard and frightening,” Hammond says. “Lung cancer is not a pretty disease. Mouth cancer is not pretty. And any warning that falls short of communicating that probably isn’t doing its job.”

The bigger the warnings are and the more vivid they are, he says, the more they will make people pay attention, “particularly warnings that elicit negative emotions, like fear or disgust.”

The World Health Organization agrees. In May, the organization called for all countries to adopt picture-based warnings on all tobacco packages, calling them “among the strongest defences against the global epidemic of tobacco.” But not everybody agrees that fear and disgust are appropriate buttons to be pushing.

“We are not enthusiastic about any type of graphic image openly displayed in our stores,” says Lyle Beckwith of the Association of Convenience and Petroleum Retailing, a trade group that represents more than 2,000 retailers and their suppliers.

Philip Morris, the country’s largest manufacturer of tobacco products, supported the legislation, which, in addition to requiring stronger warnings, allows regulators to control the amount of addictive nicotine in a cigarette and bans most cigarette flavorings. The rest of the industry opposed the legislation.

Hammond does not think cigarette makers will mount legal battles, because lawsuits in other countries have failed. He said there were such challenges with the earliest graphic labels in Canada, “but the industry lost. . . . They challenged the E.U., they lost. They lost everywhere, and I would doubt that they would challenge it” in American courts.

Longtime smoker Karyn Kimberling, president of the smokers’ rights group Virginia Smokers Alliance, sees the coming labels as an attempt to “de-normalize and demonize” smokers and doubts habits would change. “Grotesque labels have not changed people’s habits in other countries,” she says, “so I don’t know why it would here.”

There is, however, research to support claims that graphic warnings educate smokers on the dangers of their habit, and even motivate some to quit. American smokers shown a set of graphic Canadian warning labels, for example, rated them “substantially more of a deterrent than text-only labels” in a CDC-sponsored study published in the American Journal of Preventive Medicine.

Similarly, an international telephone poll tested several thousand people on their awareness that smoking is linked to heart disease, stroke and lung cancer, among other illnesses. The calls were made in four countries: the United States, Canada, Australia and the United Kingdom. Researchers found higher level of awareness in Canada and Australia, and credit that to the more explicit labels in those countries. Impotence, for example, is specifically mentioned on Canadians labels, and Canadians polled were twice as likely to agree that smoking can cause impotence as were people from the other three countries.

Hammond keeps pressing the argument that “pictures are more likely to catch people’s attention and to hold people’s attention over time,” especially if the message reaches kids.

“Even the most hardened, recalcitrant smoker will often tell us, ‘Well, they don’t have an effect on me, but my 6-year-old keeps coming up to me and saying, “Daddy, this is going to happen to you?” ‘ ” Hammond says. “That does not happen with the text warning.”

Additionally, says Hammond, text warnings don’t work well with those who can’t read — mostly minority populations who don’t have a high level of literacy in English. “For those millions of people, you might as well be writing a health warning in Mandarin if it only has text,” he says. “You put a picture on it and it broadens the scope of those things to millions more people who cannot read English, many of whom are from a lower socioeconomic status and are more likely to smoke anyway.”

The legislation says that the Department of Health and Human Services “shall issue” regulations governing the upgraded labels within two years.

Note:
1. Ranit Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine.

August, 2009|Oral Cancer News|

Study: Do more to help patients quit smoking

Source: www.timeswv.com
Author: Mary Wade Burnside

A survey of cancer patients being treated at the Mary Babb Randolph Cancer Center indicates that many of the smokers did not quit the habit in light of their diagnosis and some of them were not even advised to do so by their doctors.

“It absolutely benefits patients to quit,” said Dr. Jame Abraham, chief of oncology at WVU Hospitals and the medical director of the Mary Babb Randolph Cancer Center in Morgantown. “No. 1, we know that smoking can potentially alter the effectiveness of chemotherapy.

“No. 2, smoking can cause many other conditions, including lung cancer and COPD (chronic obstructive pulmonary disease), and smoking can increase the chance of getting pneumonia and lung disease, which can complicate the ability to take the treatment.”

The study was the idea of Lola Burke, now a second-year medical student who performed much of the survey work, Abraham said.

Burke sent surveys to 1,000 cancer patients, and 200 of them responded. Of the 200 who responded, 52 percent had a history of smoking, but only 20 percent had been actively smoking at the time of the diagnosis, Abraham said.

Of the active smokers, 44 percent quit while 56 percent did not, Abraham said.

“Another thing we found was that 40 percent were not told by the doctors to quit,” he added. “They didn’t even hear this from their doctors or their health-care provider.”

Bruce Adkins, director of the Division of Tobacco Prevention for the West Virginia Bureau for Public Health, has teamed up with Marshall University’s Joan C. Edwards School of Medicine in an effort to offer training to physicians who would teach them how to counsel patients to quit smoking.

“We started doing some provider training about two and a half year ago,” he said. “It’s a tough addiction to break. You have to keep reinforcing it. People don’t usually quit smoking the first time they attempt to quit. The average number of times it takes someone to quit using tobacco is eight to 10 times.”

Staff members from Marshall’s School of Medicine travel throughout the state offering a three-hour course to physicians, covering topics such as cessation counseling, spit tobacco, smoking and pregnancy, and the pharmacotherapy of tobacco cessation, Adkins said.

In 2007, the Centers for Disease Control and Prevention (CDC) reported that West Virginia had the second-highest rate of adult smokers in the United States at 25.7 percent, second to Kentucky at a rate of 28.6 percent.

The findings of the study at the Mary Babb Randolph Cancer Center, which have been released in this month’s edition of Journal of Oncology, published by the American Society of Clinic Oncology, illustrate that more must be done in order to help cancer patients quit, Abraham said.

“Many times, that person has been smoking for a long time,” he said. “That addictiveness is so high, so you can’t just walk away from this in one day.”

The news came during the same week that the CDC released a report in its Morbidity and Mortality Weekly Report stating that Kentucky and West Virginia have the highest death rates from smoking.

It also comes during the same month that actor Patrick Swayze, undergoing treatment for pancreatic cancer, admitted that he still smokes.

“We do see similar behavior all the time,” Abraham said of Swayze’s admission. “But I’m not going to blame the patient. Last week, I was talking to a patient who, because of her cancer treatment has lost her hair, and she said, ‘I know it looks ridiculous to smoke.’ She knows that, but she’s still smoking. It’s more complicated than that.”

The study was filled out by people being treated for a variety of different cancers, not just those that generally have been associated with cigarette smoking, which include cancer of the lungs, head and neck, bladder, stomach and pancreas.

“Many times, some early-stage cancer patients get cured from the primary cancer and then come back with a second cancer,” Abraham said. “We had a stage-one breast cancer patient. I gave her the treatment and I told her, ‘You’re going to be fine. There is a 90 percent chance that it’s not going to come back.’

“But she was an active smoker and two years later, she had a large mass in her lung and died of lung cancer.”

The situation frustrates anti-smoking activist Adkins, who smoked in college and was treated for cancer of the tongue three years ago, about 30 years after he quit his smoking habit.

When he had cancer, Adkins said, radiation treatments were very uncomfortable, and he could not imagine smoking during that time period.

“I could barely swallow. I could barely eat. Nothing tasted good. Everything was yucky,” he said. “Smoking could not have made that better. It could only have made things worse if I was a smoker.”

January, 2009|Oral Cancer News|