Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Oral HPV-Related Cancers and the Dentist’s Role Alessandro Villa, DDS, PhD, MPH Division of Oral Medicine and Dentistry Brigham and Women’s Hospital, Boston Dana-Farber Cancer Institute, Boston Department of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine, Boston Disclosure I, Alessandro Villa, have been asked to disclose any significant relationships with commercial entities that are either providing financial support for this program or whose products or services are mentioned during my presentations. I have no relationships to disclose (or disclose relationships). I may/will discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration, but in accordance with ACIP recommendations Objectives • Identify the relationship between HPV and head and neck cancers • Familiarize with the risk factors, signs and symptoms of HPV-related head and neck cancers • Describe the role of oral health care providers in the prevention and diagnosis of HPV-related head and neck cancers Head and neck cancer Head and neck cancer: risk factors • • • • • • • • • Cigarette smoking (less with other tobacco) Alcohol (synergistic) Areca nut (India) Immunosuppression (pts with cancer, HIV) Family history of cancer HPV (OP– which ones?) Age Sunlight Plummer Vinson syndrome (iron deficiency anemia, esophageal webs, oral ca) Scully C et al., 2009 D’Souza et al., 2007 Oral HPV and cancers 1983 2000 Oropharyngeal cancer • 48,330 new cases are expected in the United States in 2016 • > 70%: HPV infection American Cancer Society, 2016 HPV and the oral cavity Disease HPV Type OP cancer 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 69, 66, 68, 73 Squamous papilloma 6, 11 Verruca vulgaris 2, 4, 6, 40, 57 Condyloma acuminatum 6, 11, 42, 43, 44, 53, 54, 55, and others Focal epithelial hyperplasia 13, 32, 55 OPMD (?) Oral HPV infection Persistent infection Oral Oncol. 2015 Mar;51(3):229-36 HIM study Int J Cancer. 2015 Jun 15;136(12):2752-60. Does HPV-16 detection precede the incidence of OPC? • 96,650 participants, cancer free at baseline, with available mouthwash samples; 2 prospective cohort studies • Incident cases of HNSCC (n = 132) (f/u: 3.9 years) • Oral HPV-16 detection was associated with incident HNSCC (OR, 7.1; 95% CI, 2.2-22.6) + positive association for oropharyngeal SCC (OR, 22.4; 95% CI, 1.8-276.7) HPV-16 detection precedes the incidence of OPC JAMA Oncol. 2016 Jan 21 Role of HPV after cancer treatment All participants with persistent oral HPV16 DNA detected after treatment experienced disease recurrence JAMA Oncol. 2015;1(7):907-915 Incidence trends over the past 2 decades (1992-2012) 4 3.5 Lip, -4.7* 2.5 Oral tongue, 0.8* 2 Other mouth, -2.4* Salivary gland, 0.6 1.5 OP, 1.6* Other pharynx, -3.3* 1 *p<0.05 0.5 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Rate per 100,000 3 Incidence trends stratified by sex (1992-2012) Men Women Oral tongue, 0.4 4 Other mouth, -2.7* 3 Salivary gland, 0.8 2 OPC, 2.1* 1 0 Other pharynx, -3.3* *p<0.05 Rate per 100,000 Lip, -5.5* 5 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Rate per 100,000 6 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Lip, -2.6* Oral tongue, 1.4* Other mouth, -2.2* Salivary gland, -0.2 OPC, -0.7* 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 7 Other pharynx, -3.9* *p<0.05 HPV and OPC • The incidence of HPV-related OSCC continues to increase in North America and Western Europe • Up to 70% of new OPC cases in the US are attributed to HPV • Data from the developing world remain lacking Laryngoscope, 126:894–900, 2016 Risk factors for oral HPV infection Increased risk of HNC for: – number of sexual partners [OR=1.29, 95% CI: 1.02-1.63] (19 studies) – number of oral sex partners [OR=1.69, 95% CI: 1.00-2.84] (5 studies) JCO 2015;33:3235-3242 Cancer Epidemiol. 2015;39(6):1036-46 HPV and SCC • • • • Fasting-growing type of SCCa in men under age 40 Mostly HPV-16 Mostly tonsillar Highly-associated with number of sex partners regardless of sexual preference • Better prognosis than conventional SCCa J Dent Res. 2009 Apr; 88(4): 300–306 Prev Med. 2011 Oct 1; 53(Suppl 1): S5–S11 HPV + and HPV - SCC HPV + HPV - Younger age (<45) Older age (>50) Increasing incidence Stable incidence Frequently basaloid, nonkeratinizing, poorly differentiated SCC Frequently keratinizing SCC Predominantly oropharynx (tonsil and tongue base) All head and neck sites Better survival Worse survival More radiosensitive Higher rates of patients presenting with nodal metastases and SCC of unknown primary Adv Genet. 2016;93:1-56 HPV + OPC signs/symptoms • • • • • • • • • A sore throat that does not go away Trouble swallowing Trouble opening the mouth fully Trouble moving the tongue Ear pain A lump in the back of the mouth, throat, or neck A change in voice Coughing up blood Enlarged lymph nodes or weight loss ADA, statement and NCI Role of HPV in non-OPC? Oral Oncol. 2014 May;50(5):370-9 HPV-associated epithelial dysplasia • • • • 20 cases (7 men, 3 women); median age 56 years All had the exact same unusual dysplasia All were high risk HPV positive, p16 positive 20% developed HPV-positive SCC What does it mean? • Unsure how many cases exist • All but two cases were HPV-16 (unpublished) • Will prognosis be better? HPV Vaccines Bivalent 2vHPV (Cervarix) Quadrivalent 4vHPV (Gardasil) 9-Valent 9vHPV (Gardasil 9) Manufacturer GlaxoSmithKline Merck Merck HPV Types Included 16, 18 6, 11, 16, 18 6, 11, 16, 18, 31, 33, 45, 52, 58 Contraindications Hypersensitivity to latex* Hypersensitivity to yeast Hypersensitivity to yeast 3 dose series: 0, 2, 6 months 2 dose series 11-12 yo: 0, 6 months 3 dose series 15-26 yo: 0, 2, 6 months Dose Schedule 3 dose series: 0, 1, 6 months FEMALES 9-26 and MALES 9-26 (off label) * May be present in tip of pre-filled syringes Oral protection in women? J Natl Cancer Inst (2016) 108(1): djv302 Oral protection in men? • 3 doses of Gardasil. • Saliva and serum tested for anti–HPV-16 and anti–HPV-18 antibodies + total IgG levels. • 100% developed detectable serum anti-HPV16 and anti-HPV-18 antibodies, and most had detectable antibodies in both oral specimen types at month 7 (93% and 72%). J Infect Dis. 2016 Oct 15;214(8):1276-83. Why the dental professionals? • Oral cancer screening examinations • Frequent visit compared to other health care providers • Evidence of dentists playing a preventative role has been demonstrated in the area of tobacco cessation Asian Pacific Journal of Cancer Prevention.2015 16(10) 4429-4434 Public Health. 2014 March; 128(3): 231–238 Why the dental professionals? Dentists make a significant difference • Educating on HPV • Explaining that HPV causes oro-pharyngeal cancers • Showing how to perform oral cancer screenings • Referring patients to get vaccinated Public Health. 2014 March; 128(3): 231–238 Initial reluctance from dentists • Immunizations not normally discussed in health history • Limited knowledge on the topic • Discomfort with discussing STIs • Insufficient time during appointments • Scope of practice concerns Public Health. 2014 Mar;128(3):231-8 Medical History • Include a question on immunizations in general: – “Are you (or your child) current on all immunizations, including HPV?” – “Would you like a link to or printout of the current CDC immunization schedule?” – www.cdc.gov/vaccines Explaining HPV • “HPV is a virus that can cause cancers in several parts of the body, including the mouth and throat.” • “There is a vaccine for HPV that can help prevent these cancers. It works really well and fewer people are getting HPV-related cancers because of it.” • “We’ll be doing an oral cancer screening today and will teach you how to do self-screenings at home.” Explaining HPV Vaccine • “The vaccine is most effective for people ages 10-14 (all genders; better immune response), and most insurances cover it for ages 9-26.” • “Adults over 26 can still pay out of pocket.” • “The vaccine is very safe. It is as safe as all other vaccinations. Controversy comes from claims not founded in science, and I recommend vaccination to all of my patients.” Explaining HPV Vaccine • Remind patients that it is given in 3 doses (or 2 depending on age). • Referrals to go to their PCP, health clinic, pharmacist, or other immunization provider. • Encourage parents and patients to keep you updated with their injection dates. To summarize • HPV primarily causes oropharyngeal cancer • Different from squamous cell carcinoma (SCC) of the oral cavity • Some support that HPV can also cause oral SCC • Screening for oropharyngeal cancer is mainly done by asking patients questions about their symptoms • HPV vaccination may offer oral protection