Human papillomavirus status in head and neck cancer: the ethics of disclosure

Strategies for communicating oral and oropharyngeal cancer diagnosis: why talk about it?

OBJECTIVE

This review aimed to explore the paradigms of disclosing a cancer diagnosis with a focus on oral and oropharyngeal cancer and patient-related considerations.

STUDY DESIGN

A search of MEDLINE, Embase, and Scopus was conducted using the following keywords: oral cancer; mouth lesions; oncology; breaking bad news; truth disclosure; and communication skills training. English and Spanish language studies published through October 2019 were included.

RESULTS

The way bad news is conveyed to patients with cancer may affect their comprehension of information, emotional distress, treatment adherence, and health outcomes. Models of communication that are focused on patients' preferences may result in better treatment outcomes. Available protocols, such as SPIKES and ABCDE, have useful recommendations for health care professionals communicating an oral cancer diagnosis. However, it is important to be attentive to the particular information needs of patients.

CONCLUSIONS

When communicating a cancer diagnosis, providers should employ validated methods of information delivery and support for oncology patients. Further studies are needed to evaluate the experiences and preferences of patients with oral cancer during these communications.

Psychosocial impact of human papillomavirus-related head and neck cancer on patients and their partners: A qualitative interview study

OBJECTIVE

Increasing numbers of patients face the psychosocial challenge of a diagnosis of oropharyngeal squamous cell carcinoma (OSCC) caused by human papillomavirus (HPV). We explored the psychosocial impact of an HPV-OSCC diagnosis for patients and their partners.

METHODS

In-depth interviews were conducted with patients (n = 20) and a subset of their partners (n = 12), identified through medical records at two UK hospitals. Interviews were recorded, transcribed verbatim and analysed using thematic Framework Analysis.

RESULTS

Only 12/20 patients interviewed (and five partners) were aware of their HPV status and the main analysis focused on this sub-sample. In discussing the cause of their cancer, patients and their partners talked about not wanting to know; whether they disclosed the cause of their cancer to others; their reactions to being diagnosed with HPV; the prognosis information they were given and the questions they had about HPV. Most concerns were cancer-related rather than HPV-related, but some patients (n = 3) described feelings of embarrassment and perceived stigma about HPV.

CONCLUSION

Some patients and partners who are told HPV is the cause of their OSCC have questions about HPV and seek further information. Concerns and uncertainties about the sexually transmitted nature of HPV need to be addressed by health professionals.

Talking about human papillomavirus and cancer: development of consultation guides through lay and professional stakeholder coproduction using qualitative, quantitative and secondary data

BACKGROUND

High-risk human papillomaviruses (HPVs) cause all cervical cancer and the majority of vulvar, vaginal, anal, penile and oropharyngeal cancers. Although HPV is the most common sexually transmitted infection, public awareness of this is poor. In addition, many clinicians lack adequate knowledge or confidence to discuss sexual transmission and related sensitive issues. Complex science needs to be communicated in a clear, digestible, honest and salient way. Therefore, the aim of this study was to coproduce with patients who have cancer appropriate resources to guide these highly sensitive and difficult consultations.

METHODS

A matrix of evidence developed from a variety of sources, including a systematic review and telephone interviews with clinicians, supported the production of a draft list of approximately 100 potential educational messages. These were refined in face-to-face patient interviews using card-sorting techniques, and tested in cognitive debrief interviews to produce a ‘fast and frugal’ knowledge tool.

RESULTS

We developed three versions of a consultation guide, each comprising a clinician guidance sheet and patient information leaflet for gynaecological (cervical, vaginal, vulvar), anal or oropharyngeal cancers. That cancer could be caused by a sexually transmitted virus acquired many years previously was surprising to many and shocking to a few patients. However, they found the information clear, helpful and reassuring. Clinicians acknowledged a lack of confidence in explaining HPV, welcomed the clinician guidance sheets and considered printed information for patients particularly useful.

CONCLUSION

Because of the ‘shock factor’, clinicians will need to approach the discussion of HPV with sensitivity and take individual needs and preferences into account, but we provide a novel, rigorously developed and tested resource which should have broad applicability in the UK National Health Service and other health systems.

The "HPV Discussion": Effective Use of Data to Deliver Recommendations to Patients Impacted by HPV

OBJECTIVE

The dramatic rise in oropharyngeal squamous cell carcinoma associated with the human papilloma virus (HPV) has brought significant change to the interaction between patients and head and neck oncologists. HPV-induced cancers are generally the result of elements from the patient's sexual history, and otolaryngologists are generally less experienced than primary care physicians in addressing patient questions relating to sexual history and practices. This article addresses questions commonly posed by patients relating to HPV-induced head and neck cancers, issues related to HPV vaccination, and surveillance of HPV-related lesions. Supporting data are provided such that physicians may be better equipped to sufficiently address patient queries on this topic.

DATA SOURCES

Available peer-reviewed literature and clinical practice guidelines.

REVIEW METHODS

Assessment and discussion of specific topics by authors selected from the Head and Neck Surgery Education Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

RESULTS

An educational "miniseminar" resulted in a notable increase in attendee knowledge and comfort regarding oropharyngeal squamous cell carcinoma counseling for patients in the setting of HPV-positive disease.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The dramatic increase in HPV-associated head and neck cancers has resulted in a changed paradigm of the physician-patient interaction. Care providers in today's environment must be prepared to counsel patients regarding sexually transmitted diseases and high-risk sexual behaviors. Examination of the existing data provides the foundation with which to construct a framework in which physicians can effectively communicate information and recommendations as they pertain to HPV-related carcinoma.

Discussing a diagnosis of human papillomavirus oropharyngeal cancer with patients: An exploratory qualitative study of health professionals

Background

The role of human papillomavirus (HPV) in oropharyngeal squamous cell cancer (SCC) has now been well established. Clinicians' experiences and challenges of talking to patients about HPV have yet to be explored.

Methods

Fifteen health professionals caring for patients with oropharyngeal SCC were interviewed. Interviews were analyzed thematically.

Results

Participants expressed mixed views about explaining the causal role of HPV to their patients. Normalizing HPV and emphasizing the positive prognosis associated with it were regarded as key messages to be communicated. Challenging experiences included managing couples in a consultation and patients' concerns about transmitting HPV to their partners. Some participants described limitations to their HPV knowledge and identified the need for further information and training.

Conclusion

This study identified challenges experienced by health professionals working with patients with oropharyngeal SCC and highlights some key messages to convey to patients. Clinical guidance for health professionals and further information for patients about HPV‐positive oropharyngeal SCC are needed. © 2015 The Authors Head & Neck Published by Wiley Periodicals, Inc. Head Neck 38: 394–401, 2016

DNMT3B C46359T and SHMT1 C1420T polymorphisms in the folate pathway in carcinogenesis of head and neck

Folate is an essential nutrient with important roles in the synthesis, repair, and DNA methylation. Polymorphisms in genes encoding enzymes involved in folate metabolism can change these processes and modulate cancer development. We investigated DNMT3B C46359T (rs2424913) and SHMT1 C1420T (rs1979277) polymorphisms related to folate pathway in head and neck cancer (HNC) risk and the association of the disease with gender, risk factors and clinical histopathological parameters. A case-control study was conducted in 725 individuals (237 patients with HNC and 488 control individuals). Real-time PCR technique was performed for genotyping. Chi square and multiple logistic regression tests were used for statistical analysis. Male gender (OR 1.80; 95 % CI 1.11-2.94; P < 0.02) and tobacco consumption (OR 6.14; 95 % CI 4.13-9.13; P < 0.001) were associated with increased risk for this neoplasia. There were no significant associations between the polymorphisms and risk of disease, however, the tobacco and alcohol habits together showed association with SHMT1 C1420T polymorphism (OR 1.48; 95 % CI 1.08-2.03; P = 0.014). SHMT1 C1420T polymorphism was associated with larynx tumor (OR 0.48; 95 % CI 0.27-0.86; P < 0.05). In conclusion, tobacco habit and male gender can be predictors for HNC risk. SHMT1 C1420T and DNMT3B C46359T polymorphisms are not associated with HNC development in Brazilian population, however, SHMT1 C1420T polymorphism is less frequent in patients with primary site of tumor in larynx and more frequent in individuals who consume tobacco and alcohol together. Further studies involving gene-gene interactions in folate pathway in different populations can contribute to the understanding of the polymorphisms effect on HNC risk.

Sharing a diagnosis of HPV-related head and neck cancer: the emotions, the confusion, and what patients want to know

BACKGROUND

Oropharyngeal cancers are increasingly associated with human papillomavirus (HPV). Little is known about the experience of patients receiving this diagnosis.

METHODS

Semistructured interviews were conducted with ten survivors of HPV-related oropharyngeal cancer. The interviews were transcribed, and recurring themes were identified.

RESULTS

Physicians were a trusted source of information regarding HPV. Framing the diagnosis in terms of prognosis resonated with patients. The uncertainty about transmission, latency, and communicability colored the dialogue about HPV. Despite some understanding of prevalence and transmission, patients worried about their partner's risk. Patients sought information about HPV on the Internet, but it was not easily navigable. Emotional reactions to the diagnosis remained mostly cancer-centric rather than HPV-centric. A patient-education handout was developed in response to patient questions.

CONCLUSIONS

Additional educational resources explaining the facts about HPV in HNSCC in a consistent way including content of highest priority to patients may improve understanding of HPV.

HPV detection methods and genotyping techniques in screening for cervical cancer

Human papillomaviruses (HPV), double-stranded DNA viruses, are causing many mucocutaneous diseases, benign or malignant, ranging from common warts to malignancies involving the upper aerodigestive tract and the anogenital sphere. The diagnosis of HPV infection is based primarily on the viral genome detection by molecular biological methods, given the difficulty in routine cultivation of these viruses. The current trend in screening against cervical cancer is to improve the sensitivity of screening with new methods and to propose new algorithms for diagnostic and therapeutic decisions. The development of liquid-based cytology facilitates the cytologic diagnosis and molecular assays from the same sample. There are two main types of HPV detection methods used on uterine cervical samples: signal amplification methods (hybridization techniques in liquid phase) and target amplification methods (the techniques of gene amplification or Polymerase Chain Reaction [PCR]). Genotyping techniques are also developed: they are based on an amplification technique followed by hybridization with probe specific types. In addition to the detection, genotyping techniques allow quantitative detection of viral DNA of HPV genotype and so monitor changes in viral load over time. Another approach relies on the detection of messenger RNA (mRNA) of HPV proteins E6 and E7 oncogenes, which would appear to be a relevant marker to identify and monitor women at risk of progression to a precancerous lesion or cervical cancer.

Improving end-of-life care for head and neck cancer patients

Despite improvements in the treatment of head and neck cancer, many patients still succumb to their disease. A litany of medical, psychosocial and ethical challenges arise in managing the end-of-life experiences within this patient population. In this article, we attempt to review existing data about the end-of-life experiences of this cohort, extrapolate relevant data from other cancer patients, and suggest the most promising avenues for additional research and practice improvement for terminal head and neck cancer patients. Clinical decision-making for patients dying of head and neck cancer requires proactive consideration of quality of life, functionality, symptom control and other patient-centered objectives, and frequently benefits from palliative care team involvement. Additional research aimed toward optimizing the end of life experience of head and neck cancer patients and their families is greatly needed.

HPV specific testing: a requirement for oropharyngeal squamous cell carcinoma patients

Human papillomavirus (HPV) testing is now recommended as part of the work up for patients with oropharyngeal squamous cell carcinoma (OPSCC) and those patients with cervical lymph node metastasis of unknown origin. The laboratory testing strategy should accurately assess the presence or absence of oncogenic HPV infection in routinely collected tumour samples that are subject to standard fixation protocols, alcohol-fixed cytological preparations and formalin-fixed tissue samples. The HPV status should correlate with biologically relevant outcome measures such as overall, disease-specific and disease-free survival. Whilst increased expression of p16 by immunohistochemistry is considered to be a surrogate marker of oncogenic HPV infection and is a validated independent prognostic biomarker, only HPV specific tests provide definitive evidence of the aetiological agent. We provide an overview of HPV testing in OPSCC, justifying the use of HPV specific tests. We examine the analytical accuracy of HPV specific tests against the 'reference' test--high risk HPV mRNA in fresh tissue--and contrast this with the performance of p16 immunohistochemistry as a stand alone test. We highlight the added value of HPV specific tests in prognostication, clinical trial design, and population-based disease surveillance. We consider that HPV specific testing is the starting point for developing increasingly informative biomarker panels in the context of 'stratified medicine'. We briefly frame test information in the context of disclosure of HPV status to patients. We conclude that only a testing strategy that includes HPV specific tests can deliver more effective care for patients with OPSCC. The international head and neck oncology community should work together to clearly define the minimum requirements for assigning a diagnosis of HPV-related OPSCC in order to ensure consistent reporting of this emerging and increasingly prevalent disease.

Role of molecular markers in the management of head and neck cancers

PURPOSE OF REVIEW

Head and neck squamous cell carcinoma (HNSCC) is the fifth most common cancer worldwide. Despite advances in treatment, the prognosis remains poor. HNSCC comprise a wide spectrum of neoplasms with different tumor biologies, prognosis and response to therapies. Current tumor classification is based on morphology and anatomic distribution, which leads to a homogeneous treatment for different diseases. Moreover, traditional diagnostic methods such as clinical assessment, histopathological examination, and imaging techniques are limited in their capacity to provide information on prognosis and decision making.

RECENT FINDINGS

Molecular markers have increased the understanding of the pathogenesis of head and neck cancer because they give increasing insight into tumor biology, prognosis, and response to therapy. The practical application of these discoveries is beginning to assist greatly in the evaluation and treatment of HNSCC to achieve a more personalized and effective approach.

SUMMARY

This article focuses on the molecular markers that have already been extensively studied such as epidermal growth factor receptor and human papillomavirus as well as those that offer potential for personalized therapy such as HIF-1 and ERCC-1. The ideal biomarker should be assayed accurately and easily, highly specific, and cost effective. Thus, a validation is required before their implementation into clinical guidelines.