Sexual health in oral oncology: Breaking the news to patients with human papillomavirus-positive oropharyngeal cancer

Are UK healthcare professionals equipped to provide information and support on Human Papillomavirus to patients diagnosed with cancer of the head and neck?

Aim:

Incidence rates of Human Papillomavirus (HPV) positive head and neck cancer (HNC) are increasing. The aim of this study was to explore the availability of information and the knowledge and confidence of healthcare professionals (HCPs) involved in the cancer pathway to provide information on HPV to patients.

Materials and method:

An online questionnaire was designed using closed and open questions to investigate the availability of patient information for patients diagnosed with HPV-associated HNC; health professional’s knowledge of the information available; and their confidence in discussing the topic. The questionnaire was advertised to health professionals through the British Association of Head and Neck Oncologists website. Twenty-five health professionals from six professions across five UK Cancer Alliances completed the questionnaire between November and December 2018.

Results:

Nearly half of the participants did not know whether patients were routinely provided with information on HPV following an HPV-positive (HPV+) cancer diagnosis; 52% indicated that specific information was available within their hospital trust, however, there were inconsistencies with participants’ knowledge of the content of the information leaflets currently available. On a scale of 1–100, the mean confidence in providing HPV-related information was 58.

Findings:

Inconsistencies appear to exist with respect to information about HPV available to patients presenting with HNC. A need has been identified for the education of health professionals involved in the patient care to support information provision.

Human papilloma virus-associated squamous cell carcinoma of the larynx in an 18-year-old woman

BACKGROUND

Human papilloma virus (HPV)-associated malignancies are considered to be sexually transmitted diseases.

METHODS

We report a HPV-positive larynx cancer in an 18-year-old female clarinet player, despite vaccination with the quadrivalent HPV-6-11-16-18-vaccine Gardasil (Merck Sharp & Dohme Corp., West Point, Pennsylvania). The patient showed no evidence of genito-oral infection but showed some evidence for oral-oral HPV transmission through the sharing of saliva-infested clarinet mouthpieces. A right vocal cord lesion of benign appearance was removed via free margin resection.

RESULTS

Histopathology revealed a microinvasive squamous cell carcinoma inside a zone of high-grade dysplasia that was positive for HPV-45. No tumor recurrence was observed during a 4-year follow-up evaluation.

CONCLUSION

Benign lesion appearance and quadrivalent HPV vaccine status do not exclude HPV-associated malignancies. In our patient, the Gardasil vaccine did not provide crossover protection against HPV 45 infection. HPV-associated disease may not necessarily be transmitted via sexual practice patterns alone.

Aetiological heterogeneity of head and neck squamous cell carcinomas: the role of human papillomavirus infections, smoking and alcohol

Tobacco and alcohol consumption are the main risk factors for head and neck squamous cell carcinoma (HNSCC). In addition, human papillomavirus (HPV) infection plays a causal role in oropharyngeal cancer (OPC), a subset of HNSCC. We assessed the independent effects of tobacco, alcohol and HPV infection on OPC risk in the head and neck cancer (HeNCe) Life study, a hospital-based case-control study of HNSCC with frequency-matched controls by age and sex from four Montreal hospitals. Interviewers collected information on socio-demographic and behavioural factors. We tested exfoliated oral cells for HPV DNA by polymerase chain reaction (PCR). We included only OPC cases (n = 188) and controls (n = 427) without missing values for HPV, smoking or alcohol. We examined associations by estimating odds ratios (ORs) and corresponding 95% confidence intervals (CI) using unconditional logistic regression. Smoking (OR = 1.90, 95% CI: 1.04-3.45) and alcohol (OR = 2.74, 95% CI: 1.45-5.15) were associated with an increased risk of OPC independent of HPV status. Positivity for HPV 16 among heavy smokers and heavy alcohol users was associated with a 30.4-fold (95% CI: 8.94-103.26) and 18.6-fold (95% CI: 5.75-60.13) elevation in risk of OPC relative to participants who were HPV negative, respectively. Moreover, the combined effect of heavy smoking and alcohol comsumption with HPV 16 infection substantially increased OPC risk (OR = 48.76, 95% CI: 15.83-150.17) and (OR = 50.60, 95% CI: 15.96-160.40), respectively. Our results support the independent roles of smoking, alcohol and HPV infection in OPC risk and a possible combined effect. Efforts should be made to tackle these major risk factors simultaneously.

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.

Informational and Support Needs of Patients with Head and Neck Cancer: Current Status and Emerging Issues

The objective of this article is to review and summarize the extant literature on head and neck cancer (HNC) patients’ informational needs and to characterize emerging issues in this patient population in order to define priorities for future research. HNC patients may undergo challenging treatment regimens and experience treatment-related alterations in primary daily functions such as speech and eating. These changes often persist following treatment and may lead to significant deficits in quality of life and interpersonal relations. Despite empirical evidence demonstrating that receipt of adequate information and support is predictive of improved outcomes post-treatment, relatively limited attention has been paid to the informational and support needs of HNC patients. This review focuses primarily on three topic domains: (1) managing treatment-related side effects; (2) addressing alcohol and tobacco dependence; and (3) informational needs in the areas of human papillomavirus (HPV) and clinical trials. While there is increasing awareness of the rehabilitation and survivorship needs in this patient population, patients note that the impact of treatment on social activities and interactions is under-discussed and of key concern. In addition, there is a significant gap in addressing communication and informational needs of caregivers and family members who are integral for promoting healthy behaviors and self-care post-treatment. Greater integration of programs that address tobacco or alcohol dependency within a comprehensive treatment and support plan may increase patient motivation to seek help and enhance patient success in maintaining long-term abstinence. Finally, emerging patient-provider communication needs, particularly in the context of decision making about clinical trials or surrounding an HPV-related diagnosis, have been noted among both patients and healthcare providers. Future research on the development of novel programs that offer feasible and acceptable methods for addressing unmet informational and support needs is warranted and may yield benefit for improving patient-reported outcomes.

Talking about human papillomavirus and cancer: protocol for a patient-centred study to develop scripted consultations

INTRODUCTION

Persistent infection with sexually transmitted, high-risk human papillomavirus (HPV) types is the cause of all cervical cancers and some anogenital and oropharyngeal cancers. HPV is an extremely common asymptomatic infection but little known and poorly understood by the public. Patients with HPV-related cancers have new and challenging information needs due to the complex natural history of HPV and the stigma of sexual transmission. They may ask questions that are outside the remit of the traditional cancer consultation, and there is a lack of guidance on how to counsel them. This study aims to fulfil that need by developing and testing cancer site-specific scripted consultations.

METHODS AND ANALYSIS

A synthesis of findings generated from previous work, a systematic review of information-based interventions for patients with HPV-related cancers, and interviews with cancer clinicians will provide the evidence base underpinning provisional messages. These will be explored in three phases of face-to-face interviews with 75-90 purposively selected patients recruited in cancer clinics to: (1) select and prioritise the most salient messages, (2) phrase the messages appropriately in plain English and, (3) test their acceptability and usefulness. Phases 1 and 2 will draw on card-sorting methods used in website design. In phase three, we will create cancer site-specific versions of the script and test them using cognitive interviewing techniques.

ETHICS AND DISSEMINATION

The study has received ethical approval. Findings will be published in a peer-reviewed journal. The final product will be cancer-specific scripted consultations, most likely in the form of a two-sided information sheet with the most important messages to be conveyed in a consultation on one side, and frequently asked questions for later reading on the reverse. However, they will also be appropriate and readily adaptable to web-based uses.

Human papilloma virus-related oropharyngeal cancer: opportunities and challenges in dysphagia management

PURPOSE OF REVIEW

Human papilloma virus (HPV) has emerged as the most common cause of oropharyngeal cancer (OPC) compared with traditional causes of excess alcohol and tobacco use. In this article, we will discuss HPV-related OPC and the challenges and opportunities presented in dysphagia management relative to efforts to de-escalate treatment and improve outcomes.

RECENT FINDINGS

It is becoming increasingly apparent that patients with HPV-positive disease appear to respond favourably to chemoradiation. Targeted chemoradiation is associated with severe early and late toxicities related to swallow function. Research is in progress to ascertain the benefit of treatment de-escalation with a particular focus on swallowing outcomes. Patients are younger and, with the improved outcomes reported in the literature, surviving longer with the consequences of their treatment. Given the changing demographic of this patient group, there are a number of opportunities to optimize swallowing outcomes, and this should be underpinned by detailed swallowing evaluation and counselling prior to treatment. A number of strategies have been suggested to improve swallowing outcomes; however, persisting and late-onset swallowing effects continue to be a risk. Transoral surgery is evolving as an option for the treatment of HPV-positive disease; however, more studies are required to understand functional outcomes.

SUMMARY

Clinical trials are now underway to ascertain the effectiveness of tailored treatments for HPV-positive OPC with a focus on swallowing outcomes. It is encouraging that studies are now including detailed, multidimensional swallowing evaluation. Until such time as longitudinal data are available, patients should be treated by speech-language pathologists based on existing radiation treatment protocols and in the knowledge that patients may experience significant late swallowing difficulties.