Monthly Archives: August 2003

Photodynamic therapy with new sensitizer effective in small head-and-neck cancers

  • 8/25/2003
  • New York
  • Reuters Health / Arch Otolaryngol Head Neck Surg 2003;129:709-711.

Photodynamic therapy (PDT) utilizing meta-tetra(hydroxyphenyl)chlorin (mTHPC) is a feasible alternative to surgery or radiotherapy in patients with early-stage squamous cell carcinoma of the oral cavity and oropharynx, a study suggests.

Second-generation photosensitizers such as mTHPC (Foscan; Scotia Pharmaceuticals, Stirling, Scotland) are “more effective and less phototoxic to the skin than their forerunners,” Dr. Marcel P. Copper, and colleagues from the Netherlands Cancer Institute in Amsterdam note in the July issue of Archives of Otolaryngology – Head and Neck Surgery.

They prospectively evaluated the long-term outcome of PDT using mTHPC in 25 patients with 29 T1-T2 NO tumors of the oral cavity and/or oropharynx. Follow-up lasted a mean of 37 months.

In all patients, necrosis of the illuminated area occurred within 24 hours but subsided within 4 to 6 weeks after treatment.

Complete remission of the primary tumor was achieved in 25 (89%) of 29 tumors. The complete remission rate was 95% for T1 tumors and 57% in T2 tumors. Surgery and/or radiotherapy effectively salvaged all four patients that developed recurrent local disease.

Five patients who developed lymph node metastasis were treated by radical
(modified) neck dissection and four underwent postoperative radiotherapy.

None of the patients in the study experienced any long-term functional or cosmetic deficits.

In comments to Reuters Health, Dr. Copper said: “The most important findings of this study are that mTHPC PDT gives excellent cure rates in small cancers of the mouth and pharynx, without the morbidity that is usual after treatment with conventional therapies like surgery and/or radiotherapy.”

August, 2003|Archive|

Patients who received three-drug combination show improved results

  • 8/13/2003
  • Chicago
  • Journal of Hem / Onc

Adding paclitaxel to a cisplatin and 5-fluorouracil (5-FU) regimen led to significantly longer survival in patients with locally advanced head and neck cancer, according to a phase-3 study presented here at the 39th Annual Meeting of ASCO. “This new chemotherapy combination may soon become the standard treatment option for some patients with head and neck cancer,” said lead researcher Ricardo Hitt, MD, from the Hospital ‘12 de Octubre’ in Madrid. The expanded combination also halted tumor progression more effectively than the standard regimen, and patients who received the three-drug combination were more likely to retain the ability to speak and swallow, as well as exhibit less mucocitis.

The study involved 384 patients who had various types of head and neck cancer, particularly tumors of the oropharynx, larynx and oral cavity. All patients were treatment naive. In the standard arm, patients received 100 mg/m2 of cisplatin daily, and 1 gm/m2 of 5-FU on days 1 through 5 of a 21-day cycle. In the expanded regimen, patients received 100 mg/m2 of cisplatin daily, 500 mg/m2 of 5-FU on days 1 through 5, and 175 mg/m2 of paclitaxel on the first day of a 21-day cycle.

The trial “appeared to demonstrate a superior outcome and far better tolerability by adding paclitaxel to 5-FU and cisplatin for head and neck cancer in a dose schedule associated with less toxicity,” said Robert Mayer, MD, the director of the Center for Gastrointestinal Oncology at Dana-Farber Cancer Institute in Boston.

August, 2003|Archive|

Pathologic lymph node staging can predict tongue cancer outcomes

  • 8/11/2003
  • New York
  • Reuters Health

In patients with squamous cell carcinoma of the oral tongue (SCCOT), pathologic lymph node staging based on neck dissection is more reliable in predicting treatment outcomes than clinical lymph node staging based on physical examination and/or radiographic studies.

That’s according to Dr. Jeffrey N. Myers from M.D. Anderson Cancer Center in Houston and others who retrospectively reviewed all 266 patients who underwent surgical resection for SCCOT including a neck dissection.

In analyses comparing clinical outcomes with respect to clinical and pathologic lymph node stages, statistically significant differences in survival emerged for both clinical (cN0-N2) and pathologic (pN0-N2) stages.

However, the differences in survival and disease-free interval reached a higher level of statistical significance for pathologic lymph node staging (p < 0.0001) than for clinical lymph node staging (p < 0.002).

“This disparity can be explained by stage migration,” according to the team. That is, patients with cN0-1 disease had a more advanced lymph node stage at the time of pathologic review, they explain in the August 1 issue of the journal Cancer.

Neck dissection identified occult lymph node disease in 34 percent of the cN0 group, with extracapsular spread in 19 percent. Moreover, 43 percent of cN1 patients had greater than pN2b disease and 50 percent had extracapsular spread on pathologic review.

“For patients with tongue cancer, we can more accurately determine their prognosis by performing a neck dissection and analyzing the pathology specimen than we can by assessing the lymph node status purely on physical examination and/or radiographic studies,” Dr. Myers told Reuters Health.

“When we use physical examination or radiographic studies, we often underestimate the disease burden (though we sometimes overestimate it) and undertreat our patients,” he said.

“Obviously, more extensive surgery means more potential risk and possible morbidity for the patient,” Dr. Myers acknowledged. “However, we feel that in well trained, experienced hands this risk and morbidity are acceptably low and that neck dissection is justified as it allows us to more accurately treat and assess a patient’s prognosis and therefore more rationally select adjuvant therapies such as radiation and chemotherapy.”

August, 2003|Archive|

Dental Abstracts magazine features editorial by OCF founder Brian Hill

  • 8/10/2003
  • Brian Hill
  • Dental Abstracts Magazine,. Mosbey Publishing

This month’s issue of Dental Abstracts, from Mosbey Publishing, features an editorial regarding the need for additional efforts on the part of the US dental community in the early detection of oral cancers written by OCF founder Brian Hill. The Spanish language version of the magazine also carries the editorial outside the US. “ I was surprised but pleased that a US dental magazine would invite me to write a piece on the foundation’s perspectives related to the late diagnosis of oral cancer here in the US,” says Hill. “I believe this is largely a result of Dr. Larry Meskin becoming the editor of this journal. Dr. Meskin has a long history as an advocate for oral cancer screening within the dentist community. Hill has long believed that more could be done by American dentists to discover these lesions in their earliest, highly curable stages. The content of the editorial follows.

Dental Lifesavers?

An oxymoron? Perhaps not. We know that dentists and hygienists are not thought of by the public, and do not think of themselves, as people who engage in the saving of lives. After all, they are not ER doctors. But when either of these dental professionals finds an oral cancer in the course of their examinations, especially if at an early stage one or two, they have undoubtedly saved a life. The Oral Cancer Foundation has begun a Dental Lifesavers Program, designed to raise the visibility, awareness, and recognition of these individuals who, through two simple acts, educating themselves about oral cancers, and taking the time to screen their patient population for oral cancer, actually save lives. Those who are publicly recognized in this program in news stories, invariably say they were just doing their job. But to the patients who nominated them to be recognized, and to the foundation, they are heroes. By incorporating a program of cancer screening into their practice of dentistry and dental hygiene, they significantly contribute to reducing the death rate and the morbidity of this disease. They help engrain in the public’s mind, that a visit to the dentist is not just about cosmetics, hygiene, a crown or filling. When oral cancer screenings are part of a complete dental examination, it is also about saving a life. Their effort reflects the highest standards of dental practice and a commitment to providing the optimum in quality care to patients. It’s a great news story, and certainly helps elevate the dental community in the public’s eye.

But what is the real story here? With over 30,000 individuals being diagnosed with oral cancer each year, you would think that the early discovery of this disease by members of the dental community wouldn’t be that extraordinary, and certainly not newsworthy. After all, oral cancers, and even the precursor tissue changes that lead up to a malignancy, are visible to the naked eye, making them an easy target for early detection. Its discovery does not require any special tests, or high-tech equipment. Oral cancer is not hidden in a region of the body which requires an invasive procedure that might complicate the patient’s willingness to be screened, or make the disease difficult to find. When all this is considered, it would seem that a dental teams discovery and diagnosis story would be a commonplace event. While all that would seem logical, sadly, it is not the case. Most oral cancers are not found in their early stages by the dental profession.

We know that in all cancers, the greatest progress we have made in reducing death rates, has come through early detection. The PAP smear for cervical cancer, the digital exam and PSA test for prostate cancer, the mammogram and self-exam for breast cancers, have all contributed to reductions in the death rate from these diseases. The American public is very aware that these tests are annual necessities, and that concept is well engrained in the public’s mind. Compare these examples with oral cancer, where public awareness is low, and screening for it seems below most people’s radar, including that of the dental profession. Because its early detection happens too infrequently, oral cancer maintains its high ranking as a killer. It is most commonly diagnosed when it is a stage three or four disease. At these stages, it is not hard to detect, and I would argue that my gardener could diagnose it once it is the size of quarter. If oral cancer is detected early, survival rates are in the 80-90% range. Late stage detection yields less than a 20% survival rate. Overall, only 50% of those diagnosed this year will survive five years. Given these current statistics, it is clear that early detection is not routinely taking place.

Oral cancer holds an undeserved high ranking as a killer. More than cervical cancer, melanoma, Hodgkin’s disease, and others you hear much more about, it takes the life of someone every hour, of every day, of every month, of every year. It has maintained this high ranking for decades, with no significant improvement in the death rate. Given its ease of detection, the real story here is… How can this be?

In one study, only 7% of those who regularly visit a dentist report having had an examination for oral cancer. If you argue that they received one and did not know it, triple the number in the study to compensate for a possible statistical error, and still less that one quarter of that study population would have received the exam. Another published study indicates that the dental community is poorly prepared to identify early cancers. In it, only 54% of dentists knew the two most common sites where oral cancer occurs. Only 36% knew that erythroplakia and leukoplakias were the two most common lesions to be associated with oral cancer. The statistic which I find the most disturbing, comes in a report from the State of Maryland Cancer Registry, which found 83% of oral cancers are diagnosed by non-dental personnel. It is probable that this number is not unique to Maryland. By the time an individual approaches an M.D. with their complaint, it is likely an enlarged neck node, this location and symptom taking their thought process away from dentistry and towards general medicine. Of course malignant nodes are infrequently the primary tumor, and being the most common metastatic location for oral cancer, it is reasonable to conclude that someone did not catch it early in the oral environment. Something is very wrong with all this.

There is a wave building in the US. It is a wave of awareness. The ADA, with the generous financial support of OralScan Laboratories, has embarked on an ambitious public awareness campaign. A free public screening effort initiated by NYU has blossomed into a multi-center consortium of universities and hospitals in the Northeast, which with the help of ABC-TV, is pushing the public awareness of oral cancer. The federal government’s national health goals for 2010 have for the first time, included objectives which are aimed exclusively at oral cancer. An Oral Cancer Foundation has been created to fill a void and a need for information, advocacy, and support. Their six-month-old web site is receiving over 775,000 hits a month. Simultaneous events like these do not occur in a vacuum. There is always a precipitating factor. In this case, that factor is the realization that five decades with no improvement in the early detection of this disease, and the subsequent high death rate, is no longer acceptable. What does this mean to dentistry and to general medicine? The status quo is about to change… with their cooperation, or without it. The only question remaining is, what role will the dental community play in this change?

At a recent meeting of the oral cancer planning committee at the Centers for Disease Control, which I attended and spoke at, this very issue was a topic of discussion. Of all the comments made by presenters there, one stuck in my mind more than the others. “If dentists do not take the initiative, it is likely they will be litigated into being more concerned about the early detection of oral cancer.” Indeed, I am aware of several cases currently in the court systems where dentists are defendants in cases of missed diagnosis involving oral cancer, or worse, treating the patient with what I can only characterize as watchful neglect. Monitoring over a protracted period as the patient’s small “non typical aphthae, or atypical herpetic lesion” blossomed over the course of a year of observation into a late stage squamous cell carcinoma. Given simple alternatives, such as the brush biopsy to determine early in the process, if a benign condition or a dangerous lesion has been encountered, and a well-established referral system, this should not occur. Certainly the majority of lesions or soft tissue abnormalities (in one study 3-5 a day) that are seen by dentists are benign, and many of these innocuous conditions mimic oral cancer. But this should not induce apathy. Any condition which has not resolved with in a 14-day period, with or without treatment, should be considered suspect and worthy of further diagnostic procedures or referral. While I normally save this observation for those in general medicine, it bears repeating here. When a patient over 40 presents with an enlarged neck node, cancer should be the first differential diagnosis. Please do not spend weeks using up your prescription pads on antibiotics.

Dentistry has a unique opportunity to catch this wave of momentum, and turn it into a positive force, reversing decades of passive neglect. Decades
I might add, that are not currently in the public’s awareness. Each opportunity that we are presented with exists for a finite moment in time. The time to capitalize on this one is right now. A dental community involved with saving lives through early detection will add prestige to its profession, build practices using the annual cancer screening as a vehicle, and serve the public good. I ask you to become an involved active partner in changing the status quo. Take a CE course and apply that refreshed knowledge in your practice, or join the Oral Cancer Foundation, and take advantage of the resources and information they provide. Get involved, and take a stand against this killer.

August, 2003|OCF In The News|

ADA, coalition ask FTC to prohibit smokeless tobacco health claims

  • 8/7/2003
  • Washington
  • Stacie Crozier
  • ADA

The ADA joined some 40 national health and other organizations in signing a Feb. 25 letter urging the Federal Trade Commission to reject a smokeless tobacco manufacturer’s request to make positive health claims in its product advertising.

The coalition letter, coordinated by the Campaign for Tobacco-Free Kids, says that the smokeless tobacco company’s request is, in essence, asking that the Federal Trade Commission “review, revise and overturn the scientific conclusions of the U.S. Surgeon General, the National Cancer Institute and every other major scientific and public health agency that has examined the health effects of smokeless tobacco.”

On Feb. 5, The U.S. Smokeless Tobacco Co. petitioned the FTC for an advisory opinion that would allow it to claim through advertising that its products offer less of a health risk than smoking cigarettes.

A company statement says “there is considerable agreement among researchers that use of smokeless tobacco involves significantly less risk of adverse health effects than cigarette smoking, and there is growing support in the public health community that cigarette smokers who have not quit should be encouraged to switch to smokeless tobacco. Such a harm reduction strategy is being debated in the public health community as representing a pragmatic component of a comprehensive public health policy on cigarette smoking.”

“I suppose you could argue that shooting yourself in the leg poses less of a health risk than shooting yourself in the head,” says ADA President D. Gregory Chadwick in a statement available online. “But do we really need to have this discussion? Tobacco use kills people, period. The ADA and its 141,000 member dentists oppose USSTC’s proposal to make health claims about their spit tobacco products. It’s simply a bad idea.”

According to Associated Press reports, the U.S. Smokeless Tobacco Co. is the world’s largest manufacturer of moist snuff, a shredded tobacco product that is used by placing it between the lip and gum.

USSTC says that allowing it to use “comparative reduced risk statements in advertising…will help to educate current adult cigarette smokers and assist them in making informed choices about tobacco use.”

The Tobacco-Free Kids coalition letter notes that health claims in advertising are not limited to adult smokers, but may also be targeted at nonsmokers and young people who may be uninformed about the risks of tobacco use. The letter urges the FTC to defer scientific and medical decisions regarding the public health — such as issues related to tobacco — to the Department of Health and Human Services.

“The scientific judgments that USSTC is asking the FTC to make are more appropriately made by the federal agencies charged with protecting the public health that also possess the expertise for and experience with evaluating all of the evidence of the health effects of smokeless tobacco products,” the letter states.

In 1986, the Surgeon General’s Advisory Committee concluded, “oral use of smokeless tobacco represents a significant health risk. It is not a safe substitute for smoking cigarettes. It can cause cancer and lead to a number of non-cancerous oral conditions and can lead to nicotine addiction and dependence.”

The coalition letter also notes that ruling in favor of the smokeless tobacco company’s request would countermand the express intent of Congress in the Comprehensive Smokeless Tobacco Health Education Act of 1986, which compels the secretary of Health and Human services to establish and carry out a program to inform the public of any dangers to human health resulting from the use of smokeless tobacco products.

The coalition letter also warns that a decision to allow the company to make health claims could have significant health consequences, especially among children.

“In the early 1980s USSTC introduced new products and an aggressive marketing campaign, a part of which included statements that directly or indirectly stated and/or implied that these products were not only cool, they were safer than cigarettes,” says the letter. “Public health experts and the Surgeon General concluded that the rise in smokeless tobacco use among young people that followed was at least in part attributable to the ‘new and innovative marketing strategies’ by the tobacco industry.”

Adds the ADA’s Dr. Chadwick; “We’ve seen the consequences when people — especially children — use these products. We know that spit tobacco is a carcinogen and a risk factor for oral cancer. We know that oral cancer is the fourth most common form of cancer; that it strikes some 30,000 Americans — killing 8,000 people in this country alone — every year. Spit tobacco is also a risk factor for oral and dental disease.”

The ADA plans to draft a letter to the FTC directly on this issue and to work with Congress to help address its opposition.

August, 2003|Archive|

Roger Ebert to Have Radiation for Cancer

  • 8/6/2003
  • Chicago
  • Associated Press

Pulitzer Prize winning film critic Roger Ebert will undergo radiation treatment for cancer next month.

The treatment will be for a cancerous tumor in Ebert’s salivary gland, the Chicago Sun-Times reported in its Wednesday editions.

The 61-year-old critic underwent surgery twice in February 2002 for cancer in his thyroid and salivary gland.

He said treatment for the malignant tumor will begin later this month after he returns from a family trip to France.

“I will, however, continue to see movies, write reviews and do the ‘Ebert & Roeper’ television show,” Ebert wrote in an e-mail message to friends on Tuesday. The treatments are a follow up to earlier surgery, and I look forward to a complete recovery; this is not considered to be a life-threatening form of cancer.

“P.S. By the way, my thyroid cancer has been completely vanquished.”

Ebert said he has had a tumor in his salivary gland “in one form or another” for 16 years. He said the treatments will take 20 minutes a day, five days a week for eight weeks.

Ebert has been a film critic at the Chicago Sun-Times since 1967. He won the Pulitzer Prize for criticism in 1975, the same year he teamed up with the late Gene Siskel of the rival Chicago Tribune to launch their movie-review show.

August, 2003|Archive|