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Tackling the complications from oral cancer and treatment

Source: www.medscape.com
Author: Tara Haelle

Complications from oral cancer and the toxic effects of treatment — including demineralization, caries, fibrosis, candidiasis, pain, sensitivity, and aesthetic concerns — can continue long after any evidence of cancer is apparent, experts reported at the World Dental Congress 2019.

One of the major toxic effects is changes in saliva, said Joel Epstein, DMD, director of cancer dentistry at the Cedars Sinai Health System in Los Angeles and director of dental oncology at the City of Hope Comprehensive Cancer Center in Duarte, California.

Another problem area — one that is often ignored — is taste, he told Medscape Medical News.

And toxic effects are common, he added, citing one study that showed that 16% of patients experienced dental toxicity in the year after undergoing radiotherapy. The rates increased to 36% after 3 years, 55% after 5 years, and 74% after 7 years.

For patients undergoing cancer therapy, dentists should look at overall oral hygiene, decay prevention, lip lubrication, dental emergencies, and oral mucosal infections, Epstein told the audience during his presentation on the management of patients with oral cancer, both during and after treatment.

Fortunately, there are a lot of things that dentists can help with, he pointed out. For example, fluoride can be used to promote mineralization and chlorhexidine rinse can be used to reduce cariogenic bacteria.

And photobiomodulation therapy, or low-level laser light therapy, can be used for the prevention of mucositis, which can be particularly painful, he added. Pain related to oral mucositis can be treated with transdermal fentanyl, 2% morphine mouth rinse, and 0.5% doxepin mouth rinse.

Dentists also need to emphasize prevention and monitor survivors for recurrence. “The highest-risk person for cancer,” said Epstein, “is the person who has already had cancer.”

Recognizing Worrisome Lesions
It can be difficult to determine which abnormalities in the mouth are cause for concern, said Mark Lingen, DDS, PhD, from the University of Chicago Pritzker School of Medicine. For example, candidiasis and squamous cell carcinoma can look similar, he pointed out.

Lingen opened the session on oral cancer prevention, early diagnosis, and patient management with an interactive exercise. He showed images of various oral lesions and it did not take long to winnow out the audience members who could correct identify all the worrisome lesions without false positives.

Some of the images were fairly textbook, said attendee Andrew Barnes, a dental hygienist from Santa Rosa, California, but others were a helpful refresher.

“Some of the more subtle stuff, you would look at it and think, ‘that’s nothing’,” Barnes told Medscape Medical News. “You need to be reminded that that might not be nothing.” In contrast, other images might appear concerning but probably aren’t cancerous.

The review of images was particularly helpful, said James Friedman, DDS, a dentist in private practice in Greenbrae, California. “I was one of the first people to sit down because I thought something wasn’t as serious as it turned out to be,” he said.

The use of cytology for the evaluation of suspicious lesions in patients who are resistant to biopsy or who live far from a provider who does biopsies, presented by Takashi Inoue, DDS, from the Tokyo Dental College, was also helpful, Friedman added.

The prevention guidelines, also presented by Lingen, were more familiar to Barnes and Friedman, and are part of conversations they have with their patients everyday about quitting smoking, reducing alcohol use, practicing good oral hygiene, and getting vaccinated against human papillomavirus (HPV), the most common cause of oral cancer.

Although the HPV vaccine has typically been regarded as the province of pediatricians, dental providers have taken an increasingly active role in preventing 70% of the 13,500 new cases of oropharyngeal cancer diagnosed each year in the United States.

“Dentists should be at least as involved as the medical community in advising vaccination for HPV,” said Epstein. “HPV cancers are preventable, but only by immunization, and it’s part of healthcare delivery that dentists should be more involved in.”

Although the prevention of oral cancer is a mainstay of daily dental practice, far fewer dentists feel confident about caring for patients who have oral cancer, said Epstein. In one study of Michigan dentists, for example, 55% of respondents said they did not feel adequately trained to care for patients with oral cancer, and 72% said they were interested in additional education.

The first part of this education is learning how to discuss bad news with patients. Epstein explained that he uses a version of the SPIKES protocol to talk to patients about a new oral cancer diagnosis.

Understanding a patient’s preferences can guide the provider’s approach, Epstein told the audience. “Some want a frank picture, the worst-case scenarios, while others want optimistic views” and a clear picture of all the treatment options from the start.

World Dental Congress (WDC) 2019.

December, 2019|Oral Cancer News|

Late stage head and neck cancer in the U.S. sees increasing incidence

Source: www.cancernetwork.com
Author: Hannah Slater

A study released in Cancer indicates that there is an increasing incidence of late stage head and neck cancer (HNC) in the U.S., mostly due to an increasing incidence of oropharyngeal cancer, most likely due to HPV-related disease in patients diagnosed at stage IVC.1

Blacks, males, those who are underinsured or uninsured, and those who are unmarried tend to fare worse than others. The presented research highlights the need for continuous public health efforts toward the early detection of HNC.

In this cohort of 57,118 patients with stage IV HNC, the age-adjusted rates for stage IV HNC significantly increased by 26.1% (6.11 per 100,000 person-years in 2004 to 7.70 per 100,000 person-years in 2015). Despite a decreasing overall incidence of stage IV HNC in black patients (adjusted OR, 1.28; 95% CI, 1.22-1.34), they along with males (adjusted OR, 3.95; 95% CI, 3.80-4.11) had significantly increased risks of being diagnosed with late-stage HNC.

“In the absence of a mortality benefit for asymptomatic mass screenings, as per the U.S. Preventive Services Task Force oral cancer screening guideline, it is critical that there is sustained public awareness and education regarding the early detection of HNC, and prevention through cancer risk mitigation practices,” the researchers wrote.

Although black males had the highest risk of being diagnosed, the most significant change in annual incidence patterns was driven by white males (annual percent changes, 3.13; P < .01). A significant increase in incidence occurred in the population >50 years, with males tending to be younger at the time of diagnosis than females.

Of all primary tumor sites, the oropharynx was the most likely site for a late-stage diagnosis. The incidence of oropharyngeal cancer has increased dramatically in the U.S. within the last 40 years and is predominantly experienced by white males. Approximately 75% of cases of oropharyngeal cancer are associated with human papillomavirus (HPV), and these tumors often present with small primary tumors and larger cystic regional lymph node metastases as the first notable symptom.

Although patients with oropharyngeal cancer typically have a better prognosis, they also remain at risk of having positive lymph nodes and developing distant metastasis. Research indicated that the oropharynx, an HPV-related site, was the only site to experience a significant increase in the incidence of metastatic stage IV disease.

“If rates of true late-stage HNC continue to rise, it remains paramount to identify those patients who are at risk of potentially worse prognoses when HPV status is unknown,” the researchers wrote.

Stage IV was defined using the American Joint Committee on Cancer (AJCC) sixth edition stage classification as stages IVA, IVB, IVC, and IV not otherwise specified. With recent changes in AJCC staging, future studies are warranted to describe incidence trends based on new staging guidelines.

According to the CDC, HPV is so common that nearly all sexually active men and women get the virus at some point in their lives. Oropharyngeal cancers have traditionally been caused by tobacco and alcohol; however recent studies have suggested that about 70% of cancers of the oropharynx may be linked to HPV.2

References:
1. Thompson-Harvey A, Yetukuri M, Hansen AR, et al. Rising Incidence of Late-Stage Head and Neck Cancer in the United States. Cancer. doi:10.1002/cncr.32583.
2. CDC. Human Papillomavirus (HPV) Statistics. CDC website. cdc.gov/std/hpv/stats.htm. Published January 4, 2017. Accessed November 21, 2019.

November, 2019|Oral Cancer News|

How to encourage vaccination against HPV cancers? Drexel study suggests taking a cue from anti-vaxxers

Source: www.inquirer.com
Author: Marie McCullough

To persuade more people to get the cancer-preventing HPV vaccination, public health groups should emulate a tactic of the anti-vaccine movement, concludes a Drexel University study of Instagram posts.

The researchers aren’t suggesting that vaccine proponents spread misinformation on social media, as vaccine foes do. But the study found that emotional, personal accounts with photos of youngsters — a staple of anti-vaccine content — get way more “likes” than the dispassionate, factual messages typical of pro-vaccine posts.

“By studying what makes these messages so effective, we can improve fact-based, pro-vaccination messaging,” said senior author Philip M. Massey, a community health researcher at Drexel.

The study, which analyzed 360 Instagram posts from April to August of last year, was conducted before Facebook — the owner of Instagram — announced this spring that it would curb anti-vaccine messages. But such content still abounds, because Facebook’s crackdown is limited to recommendations and ads.

Before the crackdown, a majority of Facebook ads spreading vaccine misinformation were funded by just two groups, one led by Robert F. Kennedy Jr.’s World Mercury Project, according to a study published this month in the journal Vaccine.

Another study, in JAMA Pediatrics in September, found that 13 years after Merck’s Gardasil vaccine was hailed as a revolution in cancer prevention, most Americans still don’t know that HPV (human papillomavirus) is a family of sexually transmitted germs that can cause oral and genital cancers, and most doctors still aren’t promoting the shots.

The immunization is recommended for boys and girls at age 11 or 12, before they become sexually active, and as “catch-up” shots to age 26. But only about half of U.S. teens have been fully vaccinated, federal data show. (Adults ages 27 to 45 can opt for the immunization, although they are less likely to benefit.)

Despite low uptake, many studies show vaccination has reduced genital warts and precancerous lesions that can progress to cancer. (It will take more time to see the impact on cancer rates.)

But studies also show that while cervical cancer rates have declined over the last 20 years because of routine Pap screening, rates of mouth and throat cancers in men have risen more than 200%, and anal cancers in women have risen 150%.

Scientific groups and global health authorities who continue to monitor the vaccine assert that it is safe and does not cause chronic pain, heart arrhythmias, autoimmune diseases, life-threatening allergic reactions, stroke, neurological disorders, premature ovarian failure, miscarriages, or other health problems.

But that does not prevent vaccine foes from saying it does.

“So many sad stories on here,” a woman posted recently on the Facebook page Gardasil Class Action Australia. “Here’s mine. I had Gardasil in 2007, had a miscarriage in early 2008, and now have chronic fatigue and fibromyalgia. It’s so hard to be a good mum and give the kids what they need and the house clean when you’re sooo tired and your body aches.”

The Drexel study found that 46% of anti-vaccine posts on Instagram featured personal narratives, compared with 28% of pro-vaccine posts. Each anti-vaccine message got an average of 86 likes, compared with 24 likes per pro-vaccine post.

The paper, published in the journal Health Education and Behavior, has only a few examples of actual pro and con posts, including these:

“Your child can get protection for HPV cancers during the same visit they are protected against other serious diseases,” says the U.S Centers for Disease Control and Prevention.

“Jamie is not doing well after her first Gardasil vaccine for HPV prevention. She keeps turning yellow, wants to throw up and pass out,” says a post that shows a teenage girl folded over her knees in a chair.

Although the study does not propose potential pro-vaccine narratives, Massey said in an interview that developing and testing such messages on parents of preadolescents is the next step in his research.

He pointed to a recent Merck TV commercial as an example of a pro-vaccine message that “pulls at the heartstrings.” It portrays a young woman or young man with HPV-related cancer, voicing over a retrospective of photos and videos going back to age 11 or 12. The man speculates that his parents didn’t know about HPV or the vaccine, then his tween self asks, “Right, Mom? Dad?”

“The bottom line,” Massey said, “is that there’s a great opportunity to incorporate storytelling into our pro-vaccine messages.”

November, 2019|Oral Cancer News|

Reducing RT toxicity in head and neck cancer: recent research context

Source: www.medpagetoday.com
Author: Kristin Jenkins, contributing writer, MedPage Today

In patients with head and neck malignancies, studies show that the significant acute and long-term toxicities and poor quality of life (QOL) associated with postoperative radiation therapy (PORT) can be improved by selectively reducing larger radiotherapy volumes. This includes treating just one side of the neck.

In patients with locally advanced head and neck squamous cell carcinoma (HNSCC), however, locoregional failure rates with the omission of PORT to the pathologically uninvolved neck (PN0) have been less clear. As a result, PORT has historically been delivered to the PN0 neck, with several studies showing high rates of regional control ranging from 95% to 100%. Notably, consensus clinical practice guidelines continue to recommend the use of bilateral irradiation of node-negative necks.

However, results from a prospective phase II study in 72 patients with primary HNSCC and high-risk pathology features now suggest that PORT to the PNo neck can be eliminated without sacrificing excellent disease control or QOL. At a median follow-up of 53 months, absolute regional control in the unirradiated neck was 97%, even though 67 patients (93%) had stage III/IV disease and 71% of tumors involved or crossed midline.

No patient received contralateral neck PORT, and 17 patients (24%) were treated for the primary neck tumor only, said Wade Thorstad, MD, of Washington University in St. Louis, and colleagues. The 5-year rates of local control, regional control, progression-free survival, and overall survival (OS) were 84%, 93%, 60%, and 64%, respectively, they reported in their study in the Journal of Clinical Oncology.

The study also showed that QOL measures were not significantly different from baseline at 1 year and 2 years post-completion of PORT (P>0.05).

“Our study demonstrated that this approach is safe and results in excellent control in a high-volume center where physicians are sub-site specialists,” Thorstad told the Reading Room. “All patients had complete preoperative staging and were discussed in a multidisciplinary setting. In this context, we feel this approach is reasonable, although confirmatory studies are needed.”

Has Been Ongoing Challenge
Achieving optimal disease control using the smallest volumes of QOL-destroying radiotherapy remains an ongoing clinical challenge for clinicians managing various subgroups of patients with HNSCC. What’s more, uncertainty about how to find the right balance between survival and QOL may have been seeded almost 50 years ago.

In October 1971, results from a seminal review of metastasis in previously untreated patients with HNSCC were presented at the annual meeting of ASTRO, then called the American Society of Therapeutic Radiologists and now the American Society for Radiation Oncology. In that presentation, Robert Lindberg, MD, of the University of Texas MD Anderson Cancer Center in Houston, included detailed maps of the seven common regions of metastasis seen on admission in 2,044 previously untreated patients.

Meanwhile, evidence for the impact of larger radiotherapy volumes on patients’ QOL has continued to accumulate. In 2009, a review of dysphagia related to treatment for HNSCC confirmed that the severity of radiation-associated effects on the tongue, larynx, and pharyngeal muscles is directly related to dosimetry.

The review authors noted that in addition to dysphagia and aspiration — recognized as potentially devastating complications of irradiation of the head and neck — the acute side effects of radiotherapy in HNSCC include xerostomia, hoarseness, erythema, and desquamation of the skin. Potential late sequelae include osteonecrosis, dental decay, trismus, hypogeusia, subcutaneous fibrosis, thyroid dysfunction, esophageal stenosis, hoarseness, and damage to the middle or inner ear.

Although radiation-induced xerostomia is also the most commonly reported late side effect, swallowing problems and the risk of aspiration remain the dose-limiting toxicity.

In the last 2 decades, advances in treatment technology have made significant strides towards improved survival that does not forfeit QOL. The widespread adoption of three-dimensional intensity-modulated radiation therapy (IMRT) in locally advanced HNSCC has made it possible to selectively restrict treatment volumes, sparing normal tissue.

A 2014 analysis of 50 consecutive survivors of locally advanced HNSCC at the University of California-Davis Comprehensive Cancer Center provided evidence for improved long-term QOL with IMRT. Five years after bilateral neck IMRT, the vast majority of patients reported being satisfied with their QOL. Using the University of Washington Quality of Life (UW-QOL) questionnaire, 41 of 50 patients (82%) rated their overall QOL as “outstanding” or “very good.”

At 5 years, the lowest domain score on the UW-QOL questionnaire was salivary function. Nevertheless, 42 patients (84%) reported saliva “of normal consistency” or “less saliva than normal but enough.” Although eight patients (16%) said they had “too little saliva,” none reported having “no saliva.”

In a 2017 study, Thorstad and colleagues reported that unilateral IMRT delivered oncologic outcomes similar to those of bilateral IMRT in 154 patients with surgically treated squamous cell carcinoma of the palatine tonsil. There were no contralateral neck recurrences in the unilateral IMRT group. In addition, patient self-reports indicated that those treated unilaterally had less acute toxicity, less need for use of gastrostomy tubes, and better QOL than patients treated bilaterally.

“Significant controversy remains regarding the use of unilateral RT in some subgroups of patients with palatine tonsillar cancer, particularly in those with N2b neck disease,” the study authors noted. “[Although] the 2011 American College of Radiology (ACR) appropriateness criteria recommended bilateral RT for this subgroup of patients, some authors challenged this recommendation.”

As far back as 1999 — the year that IMRT was introduced — the Brazilian Head and Neck Cancer Study Group reported that radiotherapy volumes could be safely reduced using unilateral rather than bilateral neck treatment in patients with PN0 necks. The findings showed that the rates of 5-year OS, neck recurrence, and complications were similar in both groups. When PORT was omitted in 83 patients with PN0 necks, there were only three treatment failures.

In Australia, experience at the Peter MacCallum Cancer Center at the University of Melbourne also appears to support the potential use of unilateral radiation therapy for lateralized tonsil primaries, even with advanced ipsilateral nodal disease. Results from a 2013 retrospective review of all 167 tonsillar cancer patients treated with curative intent (1990-2002) showed that the 5-year rates for local, nodal, locoregional, and distant failures were 14%, 4%, 18%, and 8%, respectively. The majority (58%) of patients had stage IV disease, and 86% were current or ex‐smokers. There were no contralateral nodal failures in 58 patients treated unilaterally, even though 33% had N2a, N2b, or N3 nodal disease.

Evidence for improved morbidity with IMRT restricted to the ipsilateral neck is also growing. In 2011, the phase III randomized controlled PARSPORT study demonstrated significant functional and overall QOL benefits in pharyngeal squamous cell carcinoma (T1-4, N0-3, M0) with the use of parotid-sparing IMRT compared with conventional radiotherapy.

In 94 patients treated at six radiotherapy centers in the U.K., significant recovery of saliva secretion was seen at 12 and 24 months with IMRT compared with conventional radiotherapy. Clinically significant improvements in dry mouth-related and global QOL scores were also reported. At 2 years, there were no significant differences in non-xerostomia late toxicities, locoregional control, or OS between the groups.

In 2007, results from a Danish study in patients with cancer of the oropharynx showed that ipsilateral radiotherapy of curative intent did not negatively influence locoregional control or survival compared with bilateral radiotherapy. In fact, the researchers found that the only factors that differed between the two treatment groups were primary tumor extension outside the tonsillar fossa and T stage.

However, the significant difference in adverse effects seen in patients who received ipsilateral treatment were compelling. These patients experienced a 50% reduction in moderate to severe treatment side effects compared with those treated with bilateral radiotherapy. This included all radiotherapy-induced morbidity — xerostomia, dysphagia, hoarseness, atrophy, and edema — with the exception of fibrosis.

Note:
Thorstad reported a financial relationship with Elekta; several co-authors also disclosed financial relationships with industry.

November, 2019|Oral Cancer News|

Studies confirm HPV shot is safe

Source: www.webmd.com
Author: Serena Gordon, HealthDay Reporter

The HPV vaccine gives parents a chance to prevent their children from developing some types of cancer, and two new studies reaffirm what past research has found — the vaccine is safe. The two studies included millions of doses of Gardasil 9 vaccine, the only vaccine currently used in the United States for the prevention of HPV-related cancers.

“The data from our study were very reassuring. We saw nothing unexpected or surprising. With Gardasil 9, we can now prevent a large portion of cervical, oropharyngeal [mouth, tongue and throat] and other cancers,” said one of the studies’ lead author, Dr. James Donahue. He’s an epidemiologist with the Marshfield Clinic Research Institute in Wisconsin.

The studies and an accompanying editorial were published Nov. 18 in the journal Pediatrics.

Human papillomavirus (HPV) is a sexually transmitted virus. It’s estimated that 79 million people in the United States are already infected with HPV. Around 14 million new infections with HPV occur every year. About half of those are teens and young adults, according to the editorial. Sometimes these infections get better on their own, but many do not.

HPV is responsible for more than 33,000 cancers each year — 20,000 in women and 13,000 in men. Routine use of the Gardasil 9 vaccine could prevent about 90% of these cancers, the editorial said. Yet editorial author Dr. H. Cody Meissner, from Tufts University Medical Center in Boston, noted that the rates of immunization with the HPV vaccine remain low. He said there are a number of reasons why people are vaccine-hesitant overall, and those issues are compounded because this vaccine prevents a sexually transmitted infection.

“Sexuality is a difficult topic for pediatricians and many parents, and this vaccine got designated as a way to prevent sex-transmitted infection. But what’s far more important is that it prevents a common deadly cancer,” Meissner said.

Some people worry that giving a child a vaccine for a sexually transmitted infection might encourage their child to be more promiscuous, but Meissner said studies have shown that isn’t true.

Additionally, he said, “People may be misinformed or misunderstand safety issues surrounding the vaccine. No vaccine is absolutely safe, but aspirin isn’t safe and people take it. The likelihood of complications is very low, and there’s an enormous upside to this vaccine.”

Dr. David Fagan, vice chair of pediatrics at Cohen Children’s Medical Center in New Hyde Park, N.Y., wasn’t involved in the studies, but reviewed the findings.

“What the public may not and clearly needs to know is that there are systems in place to monitor for vaccine safety. Both of these studies confirm what we as physicians already know, that vaccines are safe and specifically that the HPV vaccine is safe,” Fagan said.

Donahue’s study involved near real-time surveillance of vaccine safety data from 2015 to 2017. During the study period, nearly 839,000 vaccine doses were given. Researchers didn’t find any new safety concerns.

The second study, led by Dr. Tom Shimabukuro from the U.S. Centers for Disease Control and Prevention, looked at a three-year period and included about 28 million vaccine doses given. In that large group, approximately 7,200 people had an adverse reaction.

More than 97% of the adverse events weren’t serious, that study found. These events included headache, dizziness, fainting and injection site irritation.

Fagan said he frequently points out to parents that the HPV vaccine prevents cancer.

“If you had the choice to prevent your child getting cancer by immunizing them with a vaccine that is safe, wouldn’t you do that for your child?” he said.

The CDC recommends the HPV vaccine for males and females between the ages of 9 and 26. Two doses are recommended between the ages of 11 and 12, though they can be given as early as age 9. If someone hasn’t been given the HPV vaccine by their 15th birthday, they’ll need three doses of the vaccine.

November, 2019|Oral Cancer News|

Survivorship clinic helps patients with what comes after head and neck cancer

Source: www.pittwire.pitt.edu/
Author: Gavin Jenkins, excerpted from the fall 2019 issue of Pitt Med magazine

Jonas Johnson presses his hand on Edward Christopher’s neck. The examination room at the UPMC Head and Neck Cancer Survivorship Clinic is chilly on this June morning as Johnson, chair of the University of Pittsburgh Department of Otolaryngology, glides his fingers along the left side of Christopher’s throat.

“Your skin is stiff,” Johnson says. “Scar tissue doesn’t go away.”

Five years ago, Christopher was diagnosed with human papillomavirus (HPV) positive cancer on the base of his tongue, left tonsil and the lymph nodes on the left side of his neck. After undergoing surgery to remove the tumors, he received radiation treatment and chemotherapy, followed by another procedure to remove his lymph nodes.

When he completed the treatment, he posted a picture on Facebook holding a sign that read “cancer free!” That night, he and his family celebrated with dinner at an Italian restaurant. Christopher felt lucky to be alive and grateful to Pitt doctors. He had no idea how difficult the years to come would be. He credits Marci Lee Nilsen, a nurse who is an assistant professor in Pitt’s School of Nursing, with opening his eyes.

In 2016, Johnson and Nilsen created the Survivorship Clinic to help patients like Christopher improve their quality of life after beating head and neck cancer. Most patients grapple with dysphagia—difficulty swallowing—and trismus, commonly known as lockjaw. They might experience a loss of taste, tooth decay, dry mouth and mouth sores. The side effects from radiation and chemotherapy can often cause patients to struggle to talk, hear and sleep, as well. The combination of these treatments with surgery can also lead to mobility issues; many patients end up on disability. Insomnia and sleep apnea can exacerbate anxiety and depression, which also are common issues.

Getting care for these conditions can place a financial strain on patients who have already spent tens of thousands of dollars to overcome cancer.

Survivorship clinics for head and neck cancer are sprouting up across the country. Some of those clinics have more than a few specialists. UPMC’s clinic patients see an otolaryngologist, audiologist, dentist, speech pathologist and physical therapist in one day. And unlike any other survivorship clinic in the United States, they are charged just one co-pay.

The Survivorship Clinic also sets itself apart by how it monitors patients from the start. Nilsen and Johnson meet with patients before they receive radiation and chemotherapy, and then again a month after treatment is completed. After that, patients visit the clinic at least once a year, and depending on their needs, Johnson and Nilsen will coordinate with the appropriate primary care physician, dentist or physical therapist.

Historically, the struggles of head and neck cancer survivors have been approached as an afterthought by many hospitals and primary care physicians. That’s changing as providers recognize the fallout from treatments, which can be lifesaving but also life hobbling. Johnson and Nilsen have seen more than a thousand patients in their three years at UPMC’s Survivorship Clinic. Their work has highlighted the importance of long-term care.

For Johnson, a renowned head and neck cancer surgeon who has been with Pitt since 1977, the Survivorship Clinic represents a new chapter in his career.

“I’ve reinvented myself,” he says. “I say to my residents: Don’t think I’ve repudiated the last 40 years of my career. I still believe in surgery. But I’ve embraced the notion that we must recognize the trouble we cause (treating cancer), and we have to help people with it.”

There’s more to this story. Continue reading about Johnson and Nilsen’s partnership and more patients benefiting from their work.

November, 2019|Oral Cancer News|

Pembrolizumab: New standard of care in head and neck cancer

Source: www.medscape.com
Author: Roxanne Nelson, RN, BSN

Immunotherapy with pembrolizumab (Keytruda, Merck & Co), either as monotherapy or in combination with chemotherapy, offers a new standard of care for patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC), say experts discussing the results from the company-sponsored KEYNOTE-48 trial.

Pembrolizumab plus chemotherapy yielded a significant survival benefit in comparison with standard therapy for both the total patient population and for patients whose tumors were positive for programmed cell death–ligand-1 (PD-L1).

Monotherapy with pembrolizumab yielded a significant overall survival benefit for patients with tumors that were PD-L1 positive; and in the total study population, overall survival was noninferior.

“Thus, pembrolizumab monotherapy is a new standard of care, first-line therapy option for patients with PD-L1-positive recurrent or metastatic HNSCC. Pembrolizumab with chemotherapy is also a new option for all patients, regardless of PD-L1 status,” comment Robert L. Ferris, MD, PhD, from the University of Pittsburgh, Pennsylvania, and Lisa Licitra MD, from the University of Milan, Italy, in a commentary that accompanies article in the Lancet.

“The positive results of KEYNOTE-048 represent substantial progress for patients with recurrent or metastatic HNSCC,” Ferris and Licitria add.

These comments echo the reactions from experts when the study was presented earlier this year at the annual meeting of the American Society for Clinical Oncology (ASCO), as reported by Medscape Medical News at that time.

Presenter Danny Rischin, MD, from the Peter MacCallum Cancer Center, Melbourne, Australia, said: “These data support pembrolizumab plus platinum-based CT [chemotherapy] and pembrolizumab monotherapy as new first-line standard-of-care therapies for relapsed/metastatic head and neck squamous cell carcinoma.”

At the ASCO meeting, the study was highlighted as “most important” by Francis P. Worden, MD, of the University of Michigan Rogel Cancer Center, Ann Arbor. He predicted that pembrolizumab in combination with chemotherapy will replace the EXTREME regimen (cetuximab with platinum-based therapy and fluorouracil) as first-line therapy in HNSCC.

However, while agreeing that the data are practice changing, Vinita Noronha, MD, of the Tata Memorial Cancer Center in Mumbai, India, emphasized that several questions remained unanswered.

In a discussion of the paper, Noronha pointed out that the findings do not provide guidance on which patients should receive pembrolizumab alone or in combination with chemotherapy, and there are also questions as to why both the response rate and progression-free survival rate failed to improve. It was also unclear whether there was a role for sequential therapy or whether all patients should receive the combination up front. Some of these questions have been addressed in the commentary to the Lancet article.

Study Details
KEYNOTE-048 was a randomized, phase 3 study that included 882 participants with untreated locally incurable recurrent or metastatic HNSCC. It was conducted at 200 sites in 37 countries.

November, 2019|Oral Cancer News|

Year in review: Head and neck cancer

Source: www.medpagetoday.com
Author: Ian Ingram, Deputy Managing Editor, MedPage

In 2019, headlines in head and neck cancer were dominated by a new first-line approval in squamous cell carcinoma (SCC), further attempts at treatment deintensification in the lower-risk human papillomavirus (HPV) population, and a provocative trial looking at patients’ quality of life following either robotic surgery or radiation.

Immunotherapy OK’d in First-line
Based on data from the three-arm KEYNOTE-048 trial, the FDA approved pembrolizumab (Keytruda) for the first-line treatment of metastatic or unresectable recurrent head and neck SCC. The PD-1 immune checkpoint inhibitor was approved in combination with chemotherapy for all patients, or as monotherapy for those with PD-L1 expression.

Final results of the study demonstrated a 23% reduction in the hazard for death for the group treated with pembrolizumab plus platinum chemotherapy (cisplatin or carboplatin) and 5-fluorouracil. This group had a median overall survival of 13.0 months, as compared with 10.7 months for those treated with the EXTREME regimen of platinum chemotherapy plus 5-fluorouracil and cetuximab (Erbitux).

A pembrolizumab monotherapy arm of KEYNOTE-048 showed non-inferiority to EXTREME in all comers and superiority in patients with a PD-L1 combined positive score (CPS) ≥1, as represented by a 22% reduction in the hazard for death over the study period. In this CPS ≥1 population, which made up about 85% of the study population, median overall survival was 12.3 with pembrolizumab alone versus 10.3 months with EXTREME.

ORATOR Trial Upends Assumption of Surgical Superiority
In the first randomized trial to pit transoral robotic surgery (TORS) against radiotherapy for patients with oropharyngeal SCC, the ability to swallow and other outcomes appeared to be better with radiation — contradicting previous retrospective data that favored surgery.

With roughly 2 years of follow-up, the phase II trial of 68 patients met its primary endpoint, showing a statistically significant improvement in swallowing 1 year after treatment in the radiotherapy group.

This group had a nearly 7-point advantage on the 100-point MD Anderson Dysphagia Inventory (MDADI) scale compared with the surgery cohort (86.9 vs 80.1, respectively, P=0.042), suggesting that these patients may have improved swallowing function — the trial had prespecified that a 10-point difference would be considered “clinically meaningful.”

Investigators said the findings indicate that patients should be offered both treatment options.

Less Therapy in HPV-Positive Disease
At the American Society for Radiation Oncology (ASTRO) annual meeting, results from the HN002 trial showed impressive results with two de-escalation strategies in low-risk HPV-positive head and neck cancer. Among the 306 mostly non-smoking patients in the phase II multi-institutional study, those assigned to lower-dose (60 Gy) intensity-modulated radiotherapy (IMRT) plus weekly cisplatin had a 2-year progression-free survival (PFS) of 90.5%, as compared with 87.6% in a group treated with IMRT at 60 Gy alone.

Only the combination arm met the investigators’ prespecified PFS target, while both met their swallowing-related quality-of-life criteria. On the MDADI scale, patients reported scores of 85.3 (5.6-point decline from baseline) in the combined modality arm and 81.8 (6.2-point decline) in the radiation-alone arm. Overall survival (OS) rates at 2 years were greater than 95% for the two arms.

Meanwhile, a prospective study from the University of North Carolina reported 2-year rates of locoregional control and OS of 95% with a dual strategy of deintensified treatment for HPV-positive oropharyngeal cancer.

PFS at 2 years was 86%, and 91% of the 114 patients remained free of distant metastases. No grade ≥3 late adverse events occurred, and global quality of life improved from pretreatment to 2 years.

Experts emphasized, however, that deintensification should only be attempted in clinical trials

“What is the best treatment for patients with low-risk oropharynx cancer?” said ASTRO discussant Beth Beadle, MD, of Stanford University Medical Center in California, in discussing the HN002 trial. “Standard of care is standard of care, we do not have phase III data supporting de-escalation off protocol.”

Standard of care remains 70 Gy with concurrent cisplatin for patients with low-risk disease.

Retrospective Studies Provoke
A single-arm trial in New York reported that a treatment delay greater than 2 months from diagnosis was significantly associated with worse OS in patients with head and neck SCC.

In a group of 956 patients treated at an urban academic center, those with a time to treatment initiation (TTI) longer than 60 days were significantly more likely to die from their disease (odds ratio [OR] 1.69, 95% CI 1.32-2.18) and have disease recurrence (OR 1.77, 95% CI 1.07-2.93) compared to those treated within this timeframe. The 5-year overall survival for patients dropped from 64.5% to 47.0% when the TTI stretched beyond 60 days.

“If I invented a drug that could give a 20% improved survival in head and neck cancer patients, a disease where survival has not changed for many years, I would probably be getting handed a large amount of funding,” study author Vikas Mehta, MD, MPH, of Montefiore Medical Center in New York City, told MedPage Today.

“This study is just as important,” he continued. “Getting patients to treatment in a timely manner can independently improve survival.”

Another retrospective study pointed to the possible benefit of regular use of aspirin or other common nonsteroidal anti-inflammatory drugs (NSAIDs) for head and neck cancers with a particular gene mutation.

In 75 patients with PIK3CA mutations or amplification, users of NSAIDs for at least 6 months after curative treatment had significantly prolonged disease-specific survival (HR 0.23, 95% CI 0.09-0.62) and OS (HR 0.31, 95% CI 0.14-0.69) compared with non-regular NSAID users. The effect was seen regardless of patients’ HPV status. Predicted 5-year OS rates were 78% for the regular NSAID users and 45% for non-regular users.

Is Magic Mouthwash Just an Illusion?
Two medicated mouthwashes led to reductions in oral mucositis pain for head and neck cancer patients treated with radiotherapy, but not at a level deemed clinically important, a randomized phase III study found.

Within 4 hours of radiotherapy, pain from oral mucositis dropped by 11.7 points (as defined by the area under the curve) with a diphenhydramine-lidocaine-antacid rinse — or “magic mouthwash” — and 11.6 points with a doxepin mouthwash, compared with 8.7 points with placebo, researchers reported.

Compared with placebo, diphenhydramine-lidocaine-antacid led to a 3.0-point improvement (95% CI 0.1-5.9) while the doxepin mouthwash led to a 2.9-point improvement, both of which were less than what the investigators said would be clinically important differences going into the trial.

“These data tell us that magic mouthwash (or doxepin) is not the sole answer to managing mucositis — physicians should not prescribe magic mouthwash and expect magic!” Arjun Gupta, MD, of the Sidney Kimmel Comprehensive Cancer Center in Baltimore, who was not involved in the study, told MedPage Today.

“Most providers do not know the contents or concentrations of the ingredients in these mixed-medication formulations,” he said. “They could also contain unnecessary and harmful ingredients such as steroids and antibacterials/antifungals. How many other drugs do physicians prescribe without knowing the contents or concentration?”

November, 2019|Oral Cancer News|

Supporting patients at every stage of living with head and neck cancers

Source: www.nursingtimes.net
Author: Wendy Robson

Wendy Robson, lead head and neck clinical nurse specialist at University Hospitals of North Midlands NHS Trust, shares her perspective on how her role supports the multidisciplinary team to care for patients living with head and neck cancers

Before, during and after treatment for head and neck cancers, the care pathway is complex and often overwhelming for patients. Without support, patients often have anxieties around cancer care and concerns related to employment and finances.

The Beyond Clinical Outcomes: UK patient experience in head and neck cancers survey report of patients living with head and neck cancers focused on how these cancers affect people and what they valued from cancer care. The report was funded by Bristol-Myers Squibb (BMS) and co-developed via a three-way partnership between BMS, The Swallows Head and Neck Cancer Patient Support Group and the Mouth Cancer Foundation – two charities that provide support and advice to patients living with head and neck cancers.1

It identified a need for an engaged multidisciplinary team to be involved throughout the patient pathway. Wendy Robson, head and neck clinical nurse specialist at University Hospitals of North Midlands (UHNM) agrees, stating that “we provide holistic support from day one regarding treatment and every other aspect of a patient’s life that is affected by a cancer diagnosis”.

Ms Robson and the team at UHNM are driving best practice care for head and neck cancer patients that aligns to national guidelines, offers support throughout the care pathway and helps patients return to their day-to-day lives at their own pace. Ms Robson’s responsibilities are usually split between meetings with the multidisciplinary team, oncology clinics and wards.

The team is formed of a range of specialists who work collaboratively and are engaged at each stage of head and neck cancer care.

  • Consultant oncologists;
  • Ear, nose and throat surgeons;
  • Clinical nurse specialists (CNSs);
  • Lymphoedema nurse specialists;
  • Oral and maxillofacial surgeons;
  • Restorative dentists;
  • Clinical psychologists;
  • Radiologists;
  • Speech and language therapists;
  • Dieticians;
  • Histopathologists;
  • Physiotherapists.

Continuity of care
With the CNS team helping to coordinate the multidisciplinary team and ensuring all members continually communicate with each other, they help enable the whole team to provide joined up care for patients from diagnosis to post-treatment care.

The CNSs lead an allied health professional clinic, managing patients who are new to the clinic and those on the ward. Key members of the multidisciplinary team are present at the clinics, which ensures patients receive specialist support in a prompt and timely manner. The team prepares patients for care before and after diagnosis and treatment – this can include surgery, radiotherapy, or chemotherapy.

The report found that 32% of patients surveyed self-reported difficulties eating a balanced diet and 37% experienced communication challenges, highlighting the need for support when dealing with functional changes and physical disfigurement caused by treatment and surgery.1

Therefore, the CNS provides patients with a resource pack and coordinates pre-treatment care in collaboration with dieticians and speech and language therapists to ensure appointments are in place to support:

  • The patient’s current standard of nutrition and whether tube feeding may be required;
  • Challenges with verbal communication and functional changes patients may experience following treatment, such as issues with swallowing;
  • The social concerns a patient may have, by referring them to the appropriate services for financial support and advice on how to return to work after receiving treatment.

After a patient has received treatment for their cancer, they return to the clinic to discuss potential concerns when returning home. These can be clinical or non-clinical, demonstrating how central the CNS is to providing continuity of care for patients.

The CNS coordinates post-treatment care by referring patients to the in-hospital Macmillan Cancer Support Centre and community-based care services to help patients return to their everyday life. The ongoing post-treatment care provided by UHNM is vital, as the potential side-effects, primarily resulting from radiotherapy and chemotherapy, can be challenging and may take years to manifest and affect a patient’s quality of life.

Going one step further, Ms Robson explained that currently at UHNM, patients usually attend the follow up clinic for up to five years. “We support them from their first day in the clinic and we constantly communicate as a multidisciplinary team to ensure we can provide continued care through each stage of cancer.”

The CNS orchestrates additional support services for patients living with head and neck cancers that go beyond standard care, demonstrating commitment to patients.

The buddy system
At UHNM, patients are buddied with volunteer patients who have been through the clinic and experienced similar care. This support system is split between head and neck cancer, laryngectomy and thyroid specialties, with buddies participating in a Macmillan training course to be able to provide an additional level of support for patients whenever it’s needed.

Caring for carers
Carers are often a group that can feel less supported in the care of loved ones. The recent report showed only 7% of patients surveyed received any type of domestic carer support.1 Carers form a key part of the support network for patients with head and neck cancers and Ms Robson invests in building relationships with them to make them feel supported. The CNS team support carers in between consultations with the multidisciplinary team by hosting social events at UHNM, that focus on the health and well-being of patients.

Psychological support at UHNM
Another finding from the report showed less than half of patients (46%) reported that they were offered services for emotional and psychological support.1 UHNM provides additional psychological support for patients dealing with head and neck cancers. CNSs undergo advanced communication skills and level 2 psychological support training to be equipped with the vital skills to have difficult conversations, such as communicating a diagnosis or a change of treatment plan, as well as helping patients to overcome the physical disfigurement that can result from treatment or surgery. If a patient requires further support, clinical psychologists are available to help patients living with head and neck cancers throughout the care pathway. It’s a great example of how important an engaged multidisciplinary team is in the care of patients.

Putting the patient at the centre of decision making
Of the patients surveyed, 16% did not feel very involved in decisions made by the lead health professional, and this is something UHNM meets head on.1

Putting patients at the centre of a treatment decision is made more complex by the multitude of factors affecting a patient who has undergone, or is undergoing, treatment for head and neck cancer. As the survey demonstrates, there are a number of unique psychological and physical factors to consider alongside new therapeutic advances that have been introduced to the treatment landscape. From surgery through to post-treatment care, CNSs help to build a care pathway that is right for each patient given their everyday challenges. By providing rationale and advice for each treatment option, the patient is included in the decision-making process and feels engaged in their care.

The CNS not only plays a key role in coordinating the multidisciplinary team, they also ensure that services support patients so they can carry on living their lives, “from managing referrals to speech therapists, dieticians and dentists, to providing support for carers and buddying patients up with other patients, we play a part in patient survivorship, as well as improving the patient experience of living with head and neck cancer, and beyond,” said Ms Robson.

References
1Bristol-Myers Squibb (2019) Beyond Clinical Outcomes: UK Patient Experience in Head and Neck Cancers. www.theswallows.org.uk/wp-content/uploads/2019/08/APPROVED-HN-Report-final-1.pdf

Declaration of interest: This article has been developed and funded by Bristol-Myers Squibb Pharmaceuticals Limited (BMS). BMS has had full editorial control over the content.

November, 2019|Oral Cancer News|

Despite only a 50% HPV vaccination rate in adolescents, cervical precancer incidence rates drop

Source: www.targetedonc.com
Author: Tony Berberabe, MPH

Although a vaccine for the human papillomavirus (HPV) is widely available, an average of 34,800 HPV-associated cancers attributable to the virus, including cervical, vaginal, vulva, penile, anal, and oropharynx were reported in the United States from 2012 through 2016, according to data published in Morbidity and Mortality Weekly Report.1 The estimated number of cancers attributable to HPV types targeted by the 9-valent HPV vaccine (9vHPV) is also rising. These recent increases are due in part to an aging and growing population and increases in oropharyngeal, anal, and vulvar cancers, lead author Virginia Senkomago, PhD, MPH, an epidemiologist and senior service fellow at the Centers for Disease Control and Prevention in Atlanta, Georgia, said in an email.

Although HPV vaccination is an important component of cancer prevention, only about 50% of adolescents have received the vaccine. Of cancer cases attributable to the HPV types targeted by the vaccine, 19,000 (59%) occurred in female patients and 13,100 (41%) occurred in male patients.

But there is some good news.

Senkomago said HPV infections and cervical precancers have dropped significantly since the vaccine was introduced. Infections with HPV types have dropped 86% among teenage girls. Among vaccinated women aged 20 to 24 years, the percentage of cervical precancers caused by the HPV types most often linked to cervical cancer dropped by 40%. The vaccination is recommended through age 26 for all individuals, especially for those who were not vaccinated when they were younger. The vaccine is not recommended for individuals older than 26 years, but some adults between 27 and 45 years may decide to get the HPV vaccine based on a discussion with their clinician. HPV vaccination provides less benefit to adults in this age range, as more have already been exposed to HPV, said Senkomago.

Further, it is anticipated that compliance should increase because the original 3 doses every 2 months now seems to be getting replaced by 2 doses with similar efficacy rates.

Previous annual estimates of cancers attributable to the types targeted by 9vHPV were 28,500 (2008-2012),2 30,000 (2010-2014),3 and 31,200 (2011-2015).4

“HPV is a distinct subset of head and neck cancers. It now exceeds cervical cancer as a major health burden in the [United States] because, in part, there’s no effective screening strategy,” said Robert L. Ferris, MD, PhD, director of the University of Pittsburgh Medical Center’s Hillman Cancer Center in Pittsburgh, Pennsylvania, and co–physician editor in chief of Targeted Therapies in Oncology. A number of challenges exist in the treatment of patients with HPV-positive head and neck cancer, Ferris said. These include lack of a screening tool and relatively low adherence to vaccination. The disease also has a long latency period,5 adding to the difficulty in treatment.

“These patients don’t have traditional risk factors,” Ferris continued. “They may just present to their doctor with a lump in the neck area with very few symptoms. They usually have no history of tobacco use or exposure history, so they can be overlooked for weeks and months before a needle biopsy is ordered. Needle biopsy can be diagnostic.”

Of the 32,100 HPV cancer types, those with the highest incidence were oropharyngeal and the lowest was vaginal (FIGURE 1), the report said.1

“We are striving to vaccinate as many people as possible. Right now our goals are identifying groups with the lower rates, such as people who live in rural areas, and working to remove unique barriers to vaccination they may face,” Senkomago said.

Senkomago added that the most surprising finding was that oropharyngeal cancer was the most common cancer attributable to HPV types targeted by 9vHPV in most states, except in Texas, where cervical cancer was most common, and in Alaska, New Mexico, New York, and Washington DC, where estimates of oropharyngeal and cervical cancers attributable to the 9vHPV-targeted types were the same (FIGURE 2).1

In particular, Senkomago said, these findings can inform community oncologists of the burden of HPV-associated cancers, especially in light of the increase of cases of oropharyngeal, anal, and vulvar cancers. Increasing awareness of the burden of the 7 HPV-associated cancers, individually and as a group, is a powerful prevention tool. Oncologists can advocate for strategies such as screening and HPV vaccination. In addition, community oncologists can work together with cancer survivors to engage communities to vaccinate and get screened as appropriate, she said.

Ferris cautioned against changing treatment algorithms too soon, especially before prospective clinical trials result are fully analyzed. “We need specific clinical trials before we can reduce the intensity of therapy because we don’t want to impair the very good survival, which can be 80% to 90%, in these patients and put that at risk,” he said. “We don’t want to jeopardize that strong survival rate. Those prospective clinical trials are ongoing, and those results should be reported out intensively in 2020, 2021, and beyond.”

Although the report focused on only the 9vHPV vaccine, a quadrivalent vaccine is also available. Investigators are evaluating whether any shift in the subtypes of HPV that cause cervical or head and neck cancer has been detected with the implementation of the quadrivalent vaccine. Senkomago said scientists continue to evaluate HPV types before and after vaccine introduction in population-based studies. To date, they have not found any evidence that type replacement is occurring.6

References:
1. Senkomago V, Henley J, Thomas CC, Mix JM, Markowitz LE, Saraiya M. Human papillomavirus—attributable cancers—United States, 2012-2016. MMWR Morb Mortal Wkly Rep. 2019;68(33):724-728. doi: 10.15585/mmwr.mm6833a3.
2. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus–associated cancers — United States, 2008–2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666. doi: 10.15585/mmwr.mm6526a1
3. Cancers associated with human papillomavirus, United States—2010–2014. Centers for Disease Control and Prevention website. cdc.gov/cancer/uscs/about/data-briefs/no1-hpv-assoc-cancers-UnitedStates-2010-2014.htm. Accessed September 12, 2019.
4. Cancers associated with human papillomavirus, United States—2011–2015. Centers for Disease Control and Prevention website. cdc.gov/cancer/uscs/about/data-briefs/no4-hpv-assoc-cancers-UnitedStates-2011-2015.htm. Accessed September 12, 2019.
5. Human papillomavirus (HPV). Centers for Disease Control and Prevention website. cdc.gov/hpv/parents/cancer.html. Accessed September 10, 2019.
6. Mesher D, Soldan K, Lehtinen M, et al. Population-level effects of human papillomavirus vaccination programs on infections with nonvaccine genotypes. Emerg Infect Dis. 2016;22(10):1732-1740. doi: 10.3201/eid2210.160675.

November, 2019|Oral Cancer News|