Sexual and non-sexual transmission of Human Papilloma Virus (HPV)

Human papillomavirus (HPV), is the most common sexually transmitted disease in the US and responsible for around 5% of cancers worldwide, most notably cervical and throat cancer. The virus can spread through sexual contact but non sexual transmission is also possible. A study by Myers et al. suggests that non sexual transfer can occur because HPV is resistant to many surface disinfectants and hand sanitizers that are alcohol based.

A report by Dahlstrom et al. has provided further evidence that HPV is not restricted to sexual intercourse and can also be spread via mouth-to-genital and mouth-to-mouth contact, with individuals who use tobacco being at the highest risk for infection.

Fakhry et al. demonstrated statistically significant relationships between current tobacco use and oral HPV-16 infection. This association may be due to the fact that smokers are more likely to have mouth ulcers and chronic inflammation that allows the virus to enter the oral mucosa and persist there. Because tobacco use may make HPV infections less likely to clear, smokers may have a higher risk of eventually developing oropharyngeal cancers. 

Understanding how HPV is transmitted is important because it can helps identify those who are most at risk for HPV infection and how they can protect themselves and their partners.

Combined effects of smoking and HPV16 in oropharyngeal cancer

A new study explored the effects of joint exposure impacts of smoking and HPV infection on oropharyngeal cancer risk. Specifically, the investigators studied if smoking confers any additional risk to HPV-positive oropharyngeal cancer.

Anantharamanet al.  examined the interaction between smoking and HPV16 in 1904 cancer patients and 3024 control from two large European multi-center studies. They observed that both smoking and HPV seropositivity were independently associated with oropharyngeal cancer. The joint association of smoking and HPV infection was additive suggesting they act as independent risk factors for oropharyngeal cancer.

An additional observation was that the prevalence of oropharyngeal cancer increases with smoking for both HPV16-positive and HPV16-negative persons. 

The authors concluded that the impact of smoking on HPV16-positive oropharyngeal cancer highlights the continued need for smoking cessation programs for primary prevention of head and neck cancer.

Good dental hygiene may reduce the risk of head and neck cancers

Daily tooth brushing and annual dentist visits may reduce the risk of head and neck cancers by a small margin, according to a recent study by Hashin et al. of the department of preventive medicine at Icahn School of Medicine at Mount Sinai in New York.

The researchers combined data from 13 past studies including a total of almost 9,000 oropharyngeal, hypopharyngeal, and pharyngeal cancer patients and more than 12,000 comparison subjects without cancer. The studies were done in the Americas, Europe and Japan. In all of them, oral hygiene was assessed based on gum disease or bleeding, missing teeth, daily tooth brushing, visiting a dentist at least once per year and whether a person wore dentures.

Individuals with fewer than five missing teeth, annual dentist visits, daily tooth brushing and no gum disease had lower risk than others of having head and neck cancer. Wearing dentures was not related to cancer risk. 

The indicators of oral hygiene/health used in the study are all connected with chronic irritation to the head and neck and are indicative of tooth wear, mechanical trauma, and general health maintenance.

The authors conclude that good oral hygiene, as characterized by few missing teeth, annual dentist visits, and daily tooth brushing, may modestly reduce the risk of head and neck cancer.

Acupuncture can help head and neck cancer patients' pain, dry mouth, lymphedema, neuropathy, tirednes, and nausea

Acupuncture can help head and neck cancer with managing some physical and emotional problems such as pain, feeling sick, and anxiety. It can also help individuals relax and improve their overall feeling of wellbeing.

Acupuncture is helpful in relieving some symptoms of cancer and the side effects of cancer treatment. It has sown to work in relieving chemotherapy related sickness, tiredness and cancer related pain.

Needling a variety of trigger and painful points, percutaneous electrical nerve stimulation, and osteo-puncture, along with whole body energetic acupuncture support, are approaches available to the acupuncturists.

Acupuncture is used to treat a wide range of pain conditions and some other symptoms. Some of the condition that acupuncture can be helpful that relate to head and neck cancer include:

• Acute and chronic pain control
• Dry mouth after radiation
• Muscle spasms, tremors, tics, contractures
• Peripheral neuropathy (after chemotherapy)
• Lymphedema after radiation (preliminary studies only)
• Anxiety, fright, panic
• Cancer and chemotherapy related tiredness
• Certain functional gastro-intestinal disorders (nausea and vomiting, esophageal spasm, hyperacidity, etc.)
• Headache, migraine, vertigo, tinnitus
• Cervical and lumbar spine syndromes and frozen shoulder
• Insomnia
• Anorexia
• Constipation  

Acupuncture performed by professionally qualified practitioners is generally very safe and has few side effects. Read more at Medical  issues in head and neck cancer section.

American Cancer Society key recommendations for head and neck cancer (HNC) survivorship care

The American Cancer Society published key recommendations for head and neck cancer (HNC) survivorship care. These are important recommendations that can improve patients’ care that includes surveillance for HNC recurrence, Assessment and management of physical and psychosocial long-term and late effects of HNC and its treatment (i.e. GERD, aspiration, fatigue, lymphedema, hypothyroidism, oral and dental care, taste problems, muscle dysfunction, speech and hearing ), psychological issues (Distress/depression/anxiety) , and nutrition.

To read the recommendations go to 

http://dribrook.blogspot.com/p/americancancer-society-key.html

Risk factors for pharyngocutaneous fistula after laryngectomy

Pharyngocutaneous fistula (PCF) is the most common surgical complication after total laryngectomy. Controversy still remains regarding the multiple risk factors implicated.

Dedivitiset al. surveyed the literature up to December 2013. The risk factors analyzed were age, sex, smoking habit, alcohol use, comorbidity, preoperative hemoglobin level, blood transfusion, preoperative tracheotomy, previous radiotherapy and chemoradiotherapy, primary tumor site, T classification, cartilage invasion, tumor grade, surgical margins, suture material, second layer of suture, reconstruction, tracheoesophageal prosthesis, and neck dissection. Of the 311 studies that were evaluated 63 met the inclusion criteria.

The author found that the risk factors for PCF were: chronic obstructive pulmonary disease (COPD), previous hemoglobin < 12.5 g/dL, blood transfusion, previous radio or chemotherapy, advanced primary tumor, suprglotic subsite, hypopharyngeal tumor site, positive surgical margins, and the performance of neck dissection.

Liang et al. who performed meta-analysis on on 16 studies found that tumor ssubsite, T stage, previous radiotherapy, postoperative hemoglobin < 12.5 g/dL, and surgical margins were the risk factors associated with the development of PCF.

Recognition of these factors can assist clinicians in expecting and treating PCF.

MRI of a pharyngocutaneous fistula after laryngopharyngectomy, and radial forearm free flap

Can proton pump inhibitors (PPI) cause dementia?

Proton pump inhibitors (PPIs) are widely used by head and neck cancer patients (including laryngectomees). PPIs have been shown to be potentially involved in cognitive decline including dementia. The use of PPIs has also been associated with chronic renal disease, and myocardial infarction.

A prospective cohort study from Germany evaluated 73 679 individuals 75 years of age or older that were treated with PPIs (omeprazole, pantoprazole, lansoprazole, esomeprazole, or rabeprazole) from 2004 to 2011. Those receiving regular PPI medication had a significantly increased risk of incident dementia compared with the patients not receiving PPI medication. This finding is supported by recent analyses on primary data and is in line with mouse models in which the use of PPIs increased the levels of β-amyloid in the brains of mice. 

A significant association of previous and current PPI use with vitamin B12 deficiency was found in a previous study in a population-based sample. Vitamin B12 deficiency has been shown to be associated with cognitive decline. In another study, PPIs were observed to enhance β-amyloid (Aβ) levels in the brains of mice by affecting the enzymes β- and γ-secretase. However, the underlying mechanism by which PPIs might influence the development of dementia is yet to be determined.

The authors concluded that avoidance of PPI medication may prevent the development of dementia. Randomized, prospective clinical trials are needed to examine this connection in more detail. 

Vocal cords grown from human cells

Laboratory grown vocal cord tissue that produces realistic sounds is a step toward creating new vocal cords for patients suffering from diseases such as cancer or injuries that damage their voice. Vocal cords that produce voice sounds have been grown in the laboratory from human cells. Details of the research are reported in the journal Science Translational Medicine.

Investigators from the University of Wisconsin in Madison harvested connective tissue and lining cells from the vocal cords of four patients whose voice boxes had been removed for medical reasons, and one human cadaver. They grew those cells onto scaffolds that produced strong elastic tissue similar to the one in the natural voice box.  After two weeks of allowing the cells to grow in the laboratory, the cells assemble into layers that resembled the structure of healthy vocal cords.

To test the freshly-grown tissue folds, scientists implanted them into one side of voice boxes taken from dogs, and attached them to an artificial windpipe and blew humidified air through them. When air was blown over the tissue it vibrated, producing sounds that had the same characteristics as those made by natural dog vocal cords. High speed digital imaging showed that the cords vibrated like natural tissue too. In follow-up studies using mice the transplants tissue were not rejected during a three months follow-up.  It is unlikely that replacement voice boxes will be created from vocal cord tissue from patients with cancer.  However, vocal cords could be created from stem cells that are turned into muscle and lining cells to form the cords.

Laboratory grown replacements for damaged vocal cords are still years away and more research is needed in animals to show that they work well and do not provoke an immune response, and the process must be performed with clinical grade cells before the implants can be tried in humans.

Normal vocal cords

High Suicide Rate for Patients with Head and Neck Cancer

Patients with head and neck cancer have more than 3 times the incidence of suicide compared with the general population, with rates highest among patients with cancers of the larynx and hypopharynx, according to a study published by JAMA Otolaryngology-Head & Neck Surgery.

Dr. Chan Woo Park R, M.D., of Rutgers New Jersey Medical School, Newark, and colleagues examined the incidence rate, trends, and risk factors of suicide in patients with cancer of the head and neck between 1973 and 2011. Compared with the suicide rate of the general population, the researchers found that patients with head and neck cancer have more than 3 times the incidence of suicide. Suicide rates were higher in those treated with radiation alone compared with those treated with surgery alone.

There was a nearly 12-fold higher incidence of suicide in patients with hypopharyngeal cancer and a 5-fold higher incidence in those with laryngeal cancer. The authors suggested that this may be linked to these anatomic sites’ intimate relationship with the ability to speak and/or swallow and that loss of these functions can dramatically lower patients’ quality of life. It is possible that the increased rates of tracheostomy dependence and dysphagia [difficulty swallowing] and/or gastrostomy tube dependence in these patients are exacerbating factors in the increased rate of suicide observed.

The authors recommended that additional research and effort should also be devoted to the psychological toll that the cancer, treatments, and resulting morbidity have on patients.

Persistence of HPV in saliva of patients with oropharyngeal carcinoma predicts recurrence

Human papillomavirus–related oropharyngeal carcinoma (HPV-OPC) is increasing in incidence in the United States. Although HPV-OPC has favorable prognosis, 10% to 25% of HPV-OPCs recur. Detection of human papillomavirus (HPV) DNA in oral rinses is associated with HPV-OPC, but its potential as was unclear.

Rettig et al. determined whether HPV DNA detection in oral rinses after treatment for HPV-OPC is a  prognostic biomarker that  associated with recurrence and survival.

The investigators studied 124 patients with HPV-OPC.  Oral rinse samples were collected at diagnosis and after treatment (9, 12, 18, and 24 months after diagnosis), and evaluated for HPV DNA.

Oral HPV type 16 (HPV16) DNA was common at diagnosis (67 of 124 participants [54%]). Oral HPV16 DNA persisted in only 6 participants after treatment (5%).  Two-year disease-free survival (DFS) and overall survival (OS)  were 92%  and 98%. Persistent oral HPV16 DNA was associated with worse DFS and OS . All 5 participants with persistent oral HPV16 DNA developed recurrent disease, 3 with local disease involvement. In contrast, just 9 of 119 participants (8%) without persistent oral HPV16 DNA developed recurrent disease, only 1 (11%) with local disease involvement. Median (range) time from earliest posttreatment oral HPV16 DNA detection to recurrence was 7.0 (3.7-10.9) months.

This study illustrates that although HPV type 16 DNA in oral rinses is common at diagnosis, it is rare after treatment for HPV-OPC. Detection of HPV16 DNA in oral rinses after treatment for HPV-OPC may be a useful adjunct to current post-treatment tumor surveillance strategies, potentially facilitating earlier diagnosis of progressive or recurrent HPV-OPC. This may enable earlier intervention and the administration of proper surgical and medical treatment.

The psychosocial impact of a total laryngectomy on the patient and their partners

A recent study by Offerman et al. from the Netherlands evaluated the psychosocial impact of a total laryngectomy (TL) on the patient and their partners.  The  study (http://www.ncbi.nlm.nih.gov/pubmed/25631352 ) surveyed 151 laryngectomees and their partners inquiring about their quality of life. A variety of psychosocial problems are reported by partners of laryngectomees, such as mood disorder, feelings of hopelessness, fear for losing their life companion and caregiver burden.

The investigators found that a considerable number of partners of laryngectomees experience a psychosocial impact of the consequences of the TL, specifically on their social life (35%) and on their sexual relationship (31%). Also, the tendency of other people to neglect their laryngectomized life companion, affects more than half of the partners negatively. Clinical levels of anxiety and depression were found in around 20% of the partners. TL has a negative effect on the sexual functioning for more than 30% of both laryngectomees and their partners, the communication for about one fifth of both laryngectomees and partners, and the feelings of dependency of the partner for one third of the laryngectomees.

The authors recommended that health care professionals should screen not only the patients but also their partners for need of support to deal with sexuality and intimacy. 

The Laryngectomee Guide is available

The 170 pages guide provides practical information assisting laryngectomees and their caregivers in dealing with medical, dental and psychological issues. The guide contains information about the side effects of radiation and chemotherapy; the methods of speaking after laryngectomy; and how to care for the airway, stoma, heat and moisture exchanger filter, and voice prosthesis. In addition it addresses eating and swallowing issues, medical, dental and psychological concerns, respiration and anesthesia, and travelling as a laryngectomee.

A Guide is available as paperback, Kindle Edition, and eBook.
To obtain a free paperback copy file this form and fax it to 414 227 9033. Alternatively it can be mailed to J. Harrison 11390 W. Theo Trecker West Allis WI 53214. It can also be requested by e mailing customersupport.us@atosmedical.com or calling 1-800-217-0025.

To obtain a free e book copy of the Guide in English click this link.
To obtain a free e book of the Guide in Turkish click this link.
To obtain a free copy of the Guide in Russian click this link. 
To obtain a free copy of the Guide in Italian click on this link.

The guide is endorsed by the American Academy of Otolaryngology-Head and Neck Surgery and the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. 

Reviews of the Guide (see all reviews):

March 8, 2014

This book is a great resource for patients, families, health care providers, and medical and speech pathology students. It is a comprehensive guide to understanding and managing the issues associated with laryngectomy surgery and radiation treatment. It provides the unique perspective of Dr. Brook, a laryngectomee, physician, and patient advocate. Thank you Dr. Brook for all of your wonderful contributions to the laryngectomee community. As a speech pathologist in the field, I highly recommend this book.

Meryl Kaufman M.Ed., CCC-SLP, BRS-S

The Emory Voice Center, Emory University

Department of Otolaryngology Head and Neck Surgery

Atlanta, GA

March 10, 2015

Dr. Brook,

Your book has become an excellent resource that we now use in our facility for all our laryngectomy patients.  It now has replaced the previous educational materials we used to provide the patients.  Thank you so much for your rich contribution!

Ginny Chapa, CCC-SLP

Mayo Clinic Florida

Jacksonville Florida

See comments from laryngectomees who got the laryngectomee Guide:

• Yes, it's worth the time to order a copy.
• Yes. When in Beth Israel in NYC having my operation, my team of interns all carried copies of Dr Brook's books with them on rounds.
• Helped us many times !! Three years July 8th and I still use it to refresh .
• I wish I would have had that book right after my surgery instead of 2 years later. I still learned more from the book than I was offered from the surgeon and hospital.
• Yes indeed
• great reference! get it!!
• Yes. Lots of good information. And I got Jim Lauder's Dad's book when I was in the hospital from the speech therapist.
• Yes and yes Many many times!!
• Has helped me very much. In fact, I got the book about two weeks before my surgery.

Input from Tony Branch, laryngectomee since June 2016:

The very best resource I've seen is THE LARYNGECTOMEE GUIDE by Dr. Itzhak Brook M.D. Dr. Brook is not an ENT or an otolaryngologist, but an accomplished pediatrician on the staff at Georgetown Medical Center. However, he himself went through the very same experience that most of us have coped with, His book is written from a patient's perspective. From

first initial diagnosis to methods of speaking after the operation, Dr. Brook covers it all in easily language understandable to the layman. At the same time, he also has that invaluable medical background.

This has been an extremely important resource for me these past few months.

Initial surgical therapy for advanced-stage laryngeal cancer may increase survival.

A single academic center performing a high rate of surgical therapy, including total laryngectomy, to treat advanced-stage laryngeal cancer had a higher 5-year survival rate than national levels in a small study. Dr Blake Joseph LeBlanc, of Louisiana State University (LSU) Health-Shreveport and co-authors evaluated survival rates at their institution for primary surgical treatment of advanced-stage tumor with outcomes in the National Cancer Database (NCDB).

 In an analysis of 165 patients with laryngeal cancer in the LSU Health tumor registry from 1998 to 2007, 48 (29%) had clinically early-stage (I/II) disease and 117 (71%) had advanced-stage (III/IV) disease.

Of the 117 patients with advanced-stage disease, 64 (55%) underwent primary surgical therapy to include total laryngectomy or pharyngolaryngectomy .Data from the NCDB shows the national rate of laryngectomy declined from 60% in the 1980s to 32% in 2007.

Five-year survival for stage IV was at LSU was 56% compared with 32% nationally.

The authors noted "This study suggests that initial surgical therapy for advanced-stage disease may result in increased survival compared with organ preservation".

Better survival even after disease progression in HPV-positive head and neck cancer

Human papillomavirus (HPV)-positive tumor status is associated with a significantly better rate of overall survival in patients with oropharyngeal squamous cell carcinoma (OPSCC) that has progressed, according to Carole Fakhry, MD, and colleagues of Johns Hopkins Medical Center, Baltimore, Maryland.

Previous studies has shown reduced risk of cancer progression in patients with newly diagnosed local-regionally HPV-positive OPSCC. However, no information was available regarding the role of the HPV status in overall survival after cancer had progressed.

The retrospective study evaluated 181 patients with stage III-IV OPSCC, and included 105 who were HPV-positive and 76 who were HPV-negative.

Even though no difference was found in the median time to progression in relation to the HPV tumor status (8.2 vs 7.3 months; P = .67), HPV-positive OPSCC had significantly improved rates of overall survival at 2 years compared with HPV-negative patients (54.6% vs 27.6%; P< .001).

Factors significantly associated with increased risk of death included high tumor stage (T4 vs T2-3) at diagnosis, fewer cisplatin treatment cycles (≤1 vs 2-3), and distant versus local/regional recurrence. Smoking was also an important risk factor, with the risk of death after progression increased by 1% per cigarette pack-year at diagnosis (P = .002).

Significant reductions in the risk of death were associated with HPV-positive tumor status and undergoing salvage surgery. The overall rate of mortality was reduced by 50% in individual with HPV-positive tumors.

Sites of HPV oral cancer

HPV-positive squamous cell carcinoma of the oropharynx linked to later onset distant metastasis

Squamous cell carcinomas of the oropharynx (SCCOP) associated with human papillomavirus (HPV) usually have better outcomes that those not associated with HPV.  Patients with these cancers experience a later onset of distant metastasis and more metastatic sites in atypical locations, according to a new study by Samuel Trosman, MD and colleagues, of the Cleveland Clinic, Cleveland, Ohio. 

The study illustrated that even though the rates of distant metastasis is similar between patients with HPV-positive and HPV-negative SCCOP, distant metastases occur significantly later and involves more body sites. The researchers evaluated 285 patients with Stage III to IV SCCOP who were treated with chemo-radiation therapy between 2002 and 2013. Among the patients, 27 of 245 (11%) HPV-positive and 8 of 40 (20 %) HPV-negative patients developed distant metastases.

The radiation therapy regimen for the patients was either 3-dimensional radiotherapy or intensity modulated radiation therapy with doses from 66 to 79 Gy. Concurrent chemotherapy consisted of cisplatin, cisplatin/5-fluorouracil, or cetuximab.

Even though the distant metastasis rate between the HPV-positive and HPV-negative groups was similar, the mean time to develop the distant metastasis was significantly longer after the completion of treatment for HPV-positive patients (21.6 months) than for HPV-negative patients (7.0 months; P = .03).

The most common site of metastasis in both HPV-positive and negative individuals were the lung followed by bone. Patients who were HPV-positive had significantly higher average numbers of involvement in metastatic subsites compared with HPV-negative patients (2.0 vs 1.1; P = .026).

Among HPV-positive patients, 21 of 27 (78%) had  >1 metastatic site, and 12 (44%) had distant metastases involving >1 organ system, compared with only 1 of 8 (12.5%) HPV-negative patients. Spread to less typical metastatic sites occurred more often  in HPV-positive patients, and included liver (6), intra-abdominal lymph nodes (3), brain (2), pleura (2), and peritoneum (1). Local treatment failure occurred more often in HPV-negative patients (3 of 8  or 38%) compared to HPV-positive patients (4 of 27 or 15%).

 Sites of  oropharyngeal cancer caused by HPV

The Laryngectomee Guide is published

The 170 pages guide is aimed at providing practical information that can assist laryngectomees and their caregivers in dealing with medical, dental and psychological issues. The guide contains information about the side effects of radiation and chemotherapy; the methods of speaking after laryngectomy; and how to care for the airway, stoma, heat and moisture exchanger filter, and voice prosthesis. In addition it addresses eating and swallowing issues, medical, dental and psychological concerns, respiration and anesthesia, and travelling as a laryngectomee.

A Guide is available as paperback, Kindle Edition, and e book.
To obtain a free e book copy of the guide click this link.

The guide is endorsed by the American Academy of Otolaryngology-Head and Neck Surgery and the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. 

Dustin Hoffman treated for throat cancer

Oscar-winning actor Dustin Hoffman, has been successfully treated for throat cancer and is "feeling great," his spokeswoman confirmed to People magazine. His publicist said the actor had been "surgically cured" after his cancer was detected at an early stage. No further details were provided though Hoffman is thought to be recovering well and is in good health.

The two-time Oscar winner and director, 75, will undergo doctor-recommended preventative treatments to minimize the chance of a recurrence of cancer in the years ahead.

Dustin Hoffman lighting a cigarette

No increased risk of infection for sex partners of individuals with HPV-related oral cancers

Human papilloma virus (HPV)-related oral cancers are rising in prevalence among white men in the US, and fear of transmitting the virus can lead to anxiety, divorce, and curtailing of sex and intimacy among couples. Persistent oral HPV infections are a risk for developing oropharyngeal cancers, located at the base of the tongue, tonsils, pharynx and soft palate.

A multicenter, pilot study performed by Johns Hopkins investigators found that spouses and long-term partners of patients with mouth and throat cancers related to infection with the HPV appear to have no increased prevalence of oral HPV infections. The study’s results suggest that long-term couples need not change their sexual practices.

The researchers conducted surveys and took oral rinse samples from 166 male and female patients with HPV-related oropharyngeal cancers and 94 spouses and partners. More than half of patients had at least one type of HPV DNA detectable in their oral rinses, including HPV16, the viral type most commonly associated with oral and other cancers. After a year, only seven patients (6%) still had oral HPV16 DNA detectable.

Of the 94 spouses/partners, six had oral HPV infections (6.5 %). These infections were not detectable one year later. No oral cancers were detected among 60 spouses/partners who underwent a visual oral examination.

The investigators concluded that oral HPV prevalence among partners was comparable to rates observed among the general population, and even though long-term spouses and partners have been exposed to HPV they cleared the virus. They also concluded that more research is needed to determine the timeline of progression for HPV-related oral cancers and how HPV is transmitted and suppressed by the immune system.

Importance of patient reporting new symptoms in the early detection of head and neck cancer recurrence

A recent study by Nisa and colleagues from Sion, Switzerland, evaluated the value of patients' reported symptoms as an indicator of tumor recurrence after definitive treatment for head and neck squamous cell carcinoma. Cancer recurrence occurred in 30 of the 101 patients included in the study had local and/or regional recurrences.

One-third of all patients had early stage, and two-thirds had advanced-stage tumors; two-thirds received only single treatment modality (i.e., surgery, radiation) and one-third had multiple treatment modalities. Most patients were male, with a mean age of 61.5 years (range, 29-85 years), and had at least one risk factor (tobacco and alcohol).

New-onset symptoms had the best correlation with cancer recurrences. Localized pain, pain on swallowing (odynophagia), and impaired ability to produce voice (dysphonia) were independently correlated with recurrences. Correlation was better between 6 to 12 and 18 to 21 months after therapy and in patients initially treated with only one type of therapy (i.e., surgery or radiation alone).  Primary stage and tumor site had no effect on the correlation.

The study underlines the importance of close and continuous follow-up after treatment of head and neck cancer especially during the first 2 years. It also illustrates that patient input and vigilance in reporting new symptoms are instrumental in diagnosing cancer recurrence. Close follow-up has other important goals, especially the identification and management of treatment-related complications and psycho-social support.

Can smoking marijuana offer protection from head and neck cancer?

Cannabinoids, constituents of marijuana smoke, have been recognized to have potential antitumor properties. A study by Liang and colleagues from  Brown University, Providence, RI, found that long-term marijuana smokers were roughly 62 % less likely to develop head and neck cancers than people who did not smoke pot.

The study featured 434 patients with head and neck cancers, which include tumors in the mouth, tongue, nose, sinuses, throat and lymph nodes in the neck, and 547 individuals without these cancers seen in the Greater Boston area from 1999 to 2003. After adjusting for potential confounders (including smoking and alcohol drinking), 10 to 20 years of marijuana use was associated with a significantly reduced risk of HNSCC even in those who smoked or consumed alcohol. Among marijuana users moderate weekly use was associated with reduced risk. The magnitude of reduced risk was more pronounced for those who started use at an older age. 

In contrast a pooled analysis from nine case-control studies from the US and Latin America by Marks and colleges, found that as compared with never marijuana smokers, ever marijuana smokers had an elevated risk of oropharyngeal and a reduced risk of oral tongue cancer. Evaluated were 1,921 oropharyngeal cases, 356 oral tongue cases, and 7,639 controls. The risk of oropharyngeal cancer remained elevated among never tobacco and alcohol users. The risk of oral tongue cancer was reduced among never users of tobacco and alcohol. These results suggest that the association of marijuana use with head and neck carcinoma may differ by tumor site.

Marijuana leaves

Human papillomavirus (HPV) and oropharyngeal cancer. An update on prevention from the CDC.

Human papillomavirus (HPV) can cause serious health problems, including genital warts and certain cancers. However, in most cases HPV goes away on its own before causing any health problems. The same types of HPV that infect the genital areas can also infect the mouth and throat. Some types of oral HPV can cause cancers of the head and neck. Other types of oral HPV can cause warts in the mouth or throat.

HPV can cause cancers in the back of the throat (oropharynx), most commonly in the base of the tongue and tonsils. These cancers are called “oropharyngeal cancers.” Cancer caused by HPV often takes years to develop after initially getting an HPV infection.  It is unclear if having HPV alone is sufficient to cause oropharyngeal cancers, or if other factors interact with HPV to cause these cancers. 

Signs and symptoms oropharyngeal cancers may include persistent sore throat, earaches, hoarseness, enlarged lymph nodes, pain when swallowing, and unexplained weight loss. Some individuals have no signs or symptoms or may only have a lump in the neck as the initial presentation.

Knowing whether ones cancer was caused by HPV may help physicians determine the prognosis for survival.  Head and neck cancers caused by HPV infection respond better to current treatments as compared to head and neck cancers caused by tobacco or alcohol use.  There are also new treatment options such as vaccine clinical trials and de-intensification radiation protocols available to patients whose cancers are caused by HPV.

About 7% of people in the USA have oral HPV. But only 1% of them have the type of oral HPV that is found in oropharyngeal cancers (HPV type 16). Oral HPV and cancers of the oropharynx are about 3 times more common in men than in women. About 8,400 people are diagnosed in the USA with cancers of the oropharynx caused by HPV. This means that the annual risk of acquing head and neck cancer in those who are HPV positive is about 1 in 20 000.

Oncogenic oral HPV infection is detectable in most patients with HPV associated oropharyngeal cancer, but the incidence of such HPV infection in long-term sexual partners is not increased beyond the one seen in the general population.

It is uncertain how people get oral HPV. Some studies suggest that oral HPV may be passed on during oral sex (from mouth-to-genital or mouth-to-anus contact) or open-mouthed (“French”) kissing, others have not. The likelihood of getting HPV from kissing or having oral sex with someone who has HPV is not known. One can reduce the risk of getting HPV by using condoms and dental dams during oral sex, since they serve as barriers, and can stop its transmission from person to person.

There is no FDA-approved test to diagnose HPV in the mouth or throat, and medical and dental organizations do not recommend screening for oral HPV.

HPV vaccines that are now on the market were developed to prevent cervical and other genital cancers. It is possible that HPV vaccines might also prevent oropharyngeal cancers, since the vaccines prevent an initial infection with HPV types that can cause oropharyngeal cancers, but studies have not yet determined if HPV vaccines will prevent oropharyngeal cancers.

Psychological disorders ( including depression and PTSD) and social withdrawal in laryngectomees

The loss of voice and a decrease in physical functioning due to breathing through a stoma are known to result in long-term changes in daily and professional life. There is growing evidence that head and neck cancer patients including laryngectomees are more often anxious and distressed than other cancer patients. Prevalence rates of psychiatric problems in laryngeal cancer patients vary from 20% to 60 %, if nicotine dependence is taken included. Studies reported depression in 4-20% of head and neck cancer patients, anxiety disorder and phobia in 2 - 6%,  adjustment disorder in 4 - 13%, post traumatic stress disorder (PTSD) in 1 -2% and alcohol dependence in 5-33%.

Several recent studies from the University of Leipzig in Germany explored the role of psychological problems in laryngectomees.

Psychological disorders were diagnosed in about a quarter of patients during the first year after laryngectomee according to a new study by Keszte et al. These were evenly distributed among males and females. However, women suffered more often from PTSD and generalized anxiety disorder. Alcohol dependency developed in 80% of the patients who had acquired no voice 80% following laryngectomy. Only 7% of individuals with any mental disorder received psychotherapy one year after laryngectomy. None of the patients diagnosed with alcohol dependency received psychotherapy or psychiatric treatment.

Another study by Danker et al. found that more than 40% of larngectomees withdrew from conversation. Only one-third of all laryngectomees regularly took part in social activities. About 87% perceived stigmatization because of their changed voice and more than 50% felt embarrassed because of their tracheostoma. Almost one-third of the patients had increased anxiety and depression.

These studies illustrates that only one in twelve patients who suffered from psychological disorders following laryngectomy receive adequate psychotherapeutic support. Because mental health seems to be related to successful voice restoration, more effort is needed to promote speech rehabilitation after laryngectomy.  Also more programs are needed to combat alcohol dependency. The studies also highlights the urgent need for psychological and social support programs for laryngeal cancer patients. 

Lectures by Dr. Brook

Itzhak Brook MD gave a Grand Rounds lecture on May 16, 2012 for the Department of Surgery at Scott & White Medical Center, Texas A&M College of Medicine in Temple Texas. The lecture entitled " The patient Experience as a Laryngectomee" was about his experiences as a patient with head and neck cancer. The topics discussed include dealing with the medical and psychological issues, voice rehabilitation and life challenges as a laryngectomee. The presentation can be watched on YouTube. 

Dr. Brook delivered the  J. Conley Medical Ethics Lecture, the Scholar Award keynote lecture at the opening ceremony of the Annual Meeting of the American Academy of Otolaryngology - Head and Neck surgery Foundation & OTO EXPO in Washington DC on September 9, 2012. His lecture is entitled " A Physician’s Perspective as a Throat Cancer Patient ". A description of the presentation was published in the Meeting Daily Newsletter. The presentation can be watched on YouTube.

                                   

A Physician’s Perspective as a Throat Cancer Patient 

A presentation entitled “ Patient Voices in Diagnostic Error in Medicine “ in Diagnostic Error in Medicine, 5^th international Conference of the Society to Improve Diagnosis in Medicine, John Hopkins School of  Medicine, Baltimore Maryland, November 13, 2012.

A Grand Rounds lecture entitled  "Preventing Medical Errors: a Physician's Personal Experience as a laryngeal Cancer" was delivered to the Department of Medicine Louisiana State University on April 16, 2013. The lecture can be read on line and It can be viewed on YouTube.

Preventing medical errors

Keynote speaker University Hospitals Quality and Patient Safety Fair, Case Medical Center, School of Medicine Case Western University:  “Preventing medical errors: a physician personal experience as a laryngeal cancer patient.” Cleveland, Ohio, March 5, 2014. The presentation can be watched on YouTube.

Personal experiences as a patient with laryngeal cancer: Medical errors. University Hospitals , Cleveland,  March 5, 2014.

 Signing copies of "My Voice"

With the Laryngectomee Patients Group after delivering the 17th Raymer Family Annual Lecture “Improving patient care: a physician’s perspectives as a head and neck cancer patient”, and “Life Challenges of Laryngectomees” at Jewish General Hospital, Montreal McGill University, Montreal. Quebec, Canada. May 1, 2015.

A Grand Rounds lecture entitled “A Physician’s Personal Experience as a Head and Neck Cancer Patient” was delivered to the Department of Medicine Veterans Administration Medical Center Washington DC, June 26, 2013. It can be viewed on YouTube.

Dr Brook presenting a lecture on October 10, 2014, about "Voice rehabilitation after laryngectomee" in the Humanism in Medicine seminar at Iona College New York.

Dr. Brook's  interview on Feb. 2, 2014 about the power of a hug and human touch in patient care based  on his personal experiences as a physician and a patient.

The power of a hug

Dr. Brook's was interviewed on iRadio on February 21, 2014, about life challenges as a laryngectomy,prevention of medical errors, patient's advocacy, and choosing the best treatment. To listen click here.

A presentation entitled "Life challenges as a laryngectomee" was delivered to the Lost Cord Club in Cleveland Ohio on September 28, 2012, and the Louisiana State University Feist-Weiller Cancer Center in Shreveport, New Voice Club on April 17, 2013. The last lecture can be viewed on YouTube. Comments on the lecture are available.

Life challenges as a laryngectomee

Dr. Brook gave a talk at the 5th Annual David Nasto Memorial Oral Cancer Awareness Walk in New Jersey on September 22, 2012 . He also signed copies of his book "My Voice". All proceeding were donated to the Oral Cancer Foundation.

He also presented a talk in a symposium about medical errors in oncology at the American Society of Clinical Oncology (ASCO) Annual Meeting on June 3, 2012 in Chicago, Illinois. see picture below. 
The contents of the lecture was published in the ASCO Educational Book. A summay of the lecture was published at the ASCO Post. A news release about the symposium was published at the ASCO Daily News. 

Dr. Brook presented a lecture at the 8^th International Conference on Head and Neck Cancer in Toronto, Ontario, Canada on July 23, 2012. The talk's title was “ Putting the Personal Back in Personalized Cancer Therapy; A Physician’s Experience as a Head and Neck Cancer Patient”.

The Head and Neck Cancer Alliance (HNCA) booth in the International Society of Laryngectomee  Annual Meeting in Durham NC June 6-8, 2012. Copies of the book " My Voice" by I. Brook MD were given out to the attendees. In the picture: from left to right: John Groves Director of HNCA, Itzhak Brook MD, member of the HNCA Board of Directors, and Doug Ulery Marketing Director of HNCA.

Dr. Brook presented Grand Rounds in Rambam Medical Center , Technion School of Medicine, Haifa, Israel, on April 14, 2016; entitled " A Physician’s Perspective as a Throat Cancer Patient ".