Risk and outcomes for second primary human papillomavirus-related and -unrelated head and neck malignancy

Clinical Value of Endoscopic Esophageal Screening in Head and Neck Squamous Cell Carcinoma Patients

OBJECTIVE

To investigate the clinical benefit of routine esophageal screening in newly diagnosed head and neck squamous cell carcinoma (HNSCC) patients.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary medical center.

METHODS

This retrospective study selected newly diagnosed HNSCC patients from the Chang Gung Research Database between January 2007 and December 2019. Patients who underwent endoscopic esophageal examinations within 2 months of the initial diagnosis of HNSCC were included in the screening group. The clinical outcomes of the screening and nonscreening groups were analyzed.

RESULTS

In total, 13,627 HNSCC patients were included, comprising 1032 females and 12,640 males (mean age 55.0 years), and the esophageal screening group included 7033 (51.4%) patients. The prevalence rate of esophageal tumors was 4.5%. Hypopharyngeal cancer patients were the most likely to have (13.4%) second primary esophageal tumors. The American Joint Committee on Cancer stage of the esophageal tumor was lower in the esophageal screening group than in the nonesophageal screening group. The oral, oropharyngeal, and hypopharyngeal cancer patients in the esophageal screening group had better survival outcomes than their counterparts in the nonesophageal screening group.

CONCLUSION

Endoscopic esophageal screening of newly diagnosed HNSCC patients can detect esophageal tumors at an early stage and improve overall survival. Esophageal screening could be a routine survey in HNSCC patients, particularly those with lifestyle risk factors and in countries with a high prevalence of esophageal cancer.

Mortality patterns of patients with tonsillar squamous cell carcinoma: a population-based study

Objective

Tonsillar squamous cell carcinoma (TSCC) and second primary malignancies (SPMs) are the most common causes of mortality in patients with primary TSCC. However, the competing data on TSCC-specific death (TSD) or SPM-related death in patients with TSCC have not been evaluated. This study aimed to analyze the mortality patterns and formulate prediction models of mortality risk caused by TSCC and SPMs.

Methods

Data on patients with a first diagnosis of TSCC were extracted as the training cohort from the 18 registries comprising the Surveillance, Epidemiology, and End Results (SEER) database. A competing risk approach of cumulation incidence function was used to estimate cumulative incidence curves. Fine and gray proportional sub-distributed hazard model analyses were performed to investigate the risk factors of TSD and SPMs. A nomogram was developed to predict the 5- and 10-year risk probabilities of death caused by TSCC and SPMs. Moreover, data from the 22 registries of the SEER database were also extracted to validate the nomograms.

Results

In the training cohort, we identified 14,530 patients with primary TSCC, with TSCC (46.84%) as the leading cause of death, followed by SPMs (26.86%) among all causes of death. In the proportion of SPMs, the lungs and bronchus (22.64%) were the most common sites for SPM-related deaths, followed by the larynx (9.99%), esophagus (8.46%), and Non-Melanoma skin (6.82%). Multivariate competing risk model showed that age, ethnicity, marital status, primary site, summary stage, radiotherapy, and surgery were independently associated with mortality caused by TSCC and SPMs. Such risk factors were selected to formulate prognostic nomograms. The nomograms showed preferable discrimination and calibration in both the training and validation cohorts.

Conclusion

Patients with primary TSCC have a high mortality risk of SPMs, and the competing risk nomogram has an ideal performance for predicting TSD and SPMs-related mortality. Routine follow-up care for TSCC survivors should be expanded to monitor SPMs.

Endoscopic screening of the upper gastrointestinal tract for second primary tumors in patients with head and neck cancer in a Western country

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) can develop second primary tumors (SPTs) in the esophagus. Endoscopic screening could lead to detection of SPTs at early stages and improve survival.

METHODS

We performed a prospective endoscopic screening study in patients with curably treated HNSCC diagnosed between January 2017-July 2021 in a Western country. Screening was performed synchronously (< 6 months) or metachronously (≥ 6 months) after HNSCC diagnosis. Routine imaging for HNSCC consisted of flexible transnasal endoscopy with positron emission tomography/computed tomography or magnetic resonance imaging, depending on primary HNSCC location. The primary outcome was prevalence of SPTs, defined as presence of esophageal high grade dysplasia or squamous cell carcinoma.

RESULTS

202 patients (mean age 65 years, 80.7 % male) underwent 250 screening endoscopies. HNSCC was located in the oropharynx (31.9 %), hypopharynx (26.9 %), larynx (22.2 %), and oral cavity (18.5 %). Endoscopic screening was performed within 6 months (34.0 %), 6 months to 1 year (8.0 %), 1-2 years (33.6 %), and 2-5 years (24.4 %) after HNSCC diagnosis. We detected 11 SPTs in 10 patients (5.0 %, 95 %CI 2.4 %-8.9 %) during synchronous (6/85) and metachronous (5/165) screening. Most patients had early stage SPTs (90 %) and were treated with curative intent with endoscopic resection (80 %). No SPTs in screened patients were detected with routine imaging for HNSCC before endoscopic screening.

CONCLUSION

In 5 % of patients with HNSCC, an SPT was detected with endoscopic screening. Endoscopic screening should be considered in selected HNSCC patients to detect early stage SPTs, based on highest SPT risk and life expectancy according to HNSCC and comorbidities.

Association between radiotherapy for surgically treated oral cavity cancer and secondary lung cancer

Background

There is limited research on the incidence of secondary lung cancer (SLC) after radiotherapy (RT) for oral cavity cancer (OCC). Therefore, we investigated the association between RT for OCC and the risk of SLC and the overall survival of these patients.

Methods

Patients diagnosed with OCC between 1975 and 2015 were selected from the Surveillance, Epidemiology, and End Results database. The cumulative incidence of SLC, relative risk (RR) of RT vs. no RT (NRT), standardized incidence ratios (SIR), and survival outcomes were assessed.

Results

A total of 10,936 patients with OCC were included. Of these, 429 (3.92%) patients developed SLC, where 136 (5.02%) received RT and 293 (3.56%) did not. The cumulative incidence of SLC during follow-up was 6.89% and 4.84% in the RT and NRT patients, respectively. RT was associated with a higher risk of SLC. In the subset analysis, the results showed that a higher risk of developing SLC among patients with index OCC in most subgroups. Dynamic RR and SIR revealed a decreased risk of SLC with increasing latency time. No difference was observed in the 10-year survival rates for patients with SLC who received RT or not or compared with primary lung cancer.

Conclusion

RT was associated with a higher risk of SLC, and patients diagnosed with OCC could be followed for 5-10 years after diagnosis.

Factors associated with the development of second primary tumours in head and neck cancer patients

INTRODUCTION

The development of second primary tumours (SPTs) is one of the main causes of low survival in patients with head and neck cancer (HNC). The aim of this study was to review the evidence about factors associated with developing SPTs in patients with HNC.

METHODS

An updated systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and the search was performed in Pubmed and Scopus. Only original articles with a cohort or case-control design were included. Article quality was assessed with the Newcastle-Ottawa scale.

RESULTS

Thirty-six and two case-control studies were included, with quality medium (n = 5) to high (n = 33). Tobacco showed a significant association with SPT development, with risks ranging from 1.41 (95%CI: 1.04-1.91) to 5.52 (95%CI: 2.91-10.49). Regarding alcohol, risks ranged from 1.46 (95%CI: 1.12-1.91) to 21.3 (95%CI: 2.9-156). Location of the index tumour in the hypopharynx/oropharynx, absence of human papillomavirus and presence of a premalignant lesion also increased the risk of SPTs. More controversy was found for sex, age and other clinical factors of the tumour.

CONCLUSION

Toxic lifestyle habits and clinical factors were associated with the risk of SPTs in HNC patients. These findings may improve individualised prevention strategies in its follow-up.

Prevalence of Transcriptionally Active HPV Infection in Tumor-Free Oropharyngeal Tissue of OPSCC-Patients

Objectives

The natural history of HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is still largely unknown. Since reports of second primary tumors (SPTs) in patients with HPV-related OPSCCs are increasing, a multifocal HPV infection, hinting a «virus-induced field effect», has been hypothesized. This study aimed to investigate the HPV-prevalence in normal appearing oropharyngeal tissue in patients with OPSCCs.

Materials and Methods

49 OPSCC patients undergoing panendoscopy were prospectively enrolled. Tumor specimens and biopsies of normal appearing oropharyngeal tissue adjacent to and distant from the index OPSCC underwent histopathological examination, p16INK4A immunohistochemical staining, HPV DNA and mRNA-detection. Patient characteristics and follow-up data on SPTs were obtained.

Results

26 of 49 (53%) OPSCC were positive for HPV DNA and p16INK4A. HPV mRNA was detected in 23 of 26 (88%) of these tumor samples. HPV DNA was detected in 36% adjacent mucosa and in 17% distant mucosa samples and only in patients with an HPV-related index OPSCC. HPV mRNA could not be detected in tumor-free distant and adjacent mucosa samples. No evidence of association between HPV detection in normal appearing mucosa and development of second primary tumors was found.

Conclusions

HPV was detectable but not transcriptionally active in adjacent/distant tumor-free oropharyngeal tissue. This suggests that a multifocal HPV infection, hinting a «virus-induced fielcd cancerization», may not be pertaining to HPV-related OPSCC.

Incidence and Survival of Multiple Primary Cancers in US Women With a Gynecologic Cancer

Objectives

To evaluate risk of a second cancer and associated survival times in United States women with diagnosis of cancer.

Methods

The Surveillance Epidemiology and End Results (SEER) database was queried for 2 cohorts of women aged 18 - 89 with either an index gynecologic or non-gynecologic cancer diagnosed between 1992 - 2017. Index cases were followed to determine if a second primary cancer was subsequently diagnosed; defined according to SEER multiple primary and histology coding rules. Standard Incident Ratios (SIR) and latency intervals between index diagnosis and second primary diagnosis were evaluated. Among those who developed a second primary cancer, median survival times from diagnosis of second primary cancer were also calculated.

Results

Between 1992 - 2017, 227,313 US women were diagnosed with an index gynecological cancer and 1,483,016 were diagnosed with an index non-gynecologic cancer. Among patients with index gynecologic cancer, 7.78% developed a non-gynecologic subsequent primary cancer. The risk of developing any non-gynecologic cancer following an index gynecologic cancer was higher than the risk in the general population (SIR 1.05, 95% CI 1.04 - 1.07). Organs especially at risk were Thyroid (SIR 1.45), Colon and Rectum (SIR 1.23), and Urinary System (SIR 1.33). Among women diagnosed with an index non-gynecologic cancer, 0.99% were diagnosed with a subsequent gynecologic cancer. The risk of developing a gynecologic cancer following a non-gynecologic cancer was also elevated compared to the average risk of the general population (SIR 1.05, 1.03 - 1.07), with uterine cancer having the highest SIR of 1.13.

Conclusion

The risk of a developing a second primary cancer and the corresponding survival time is based on the order and site of the index and subsequent cancer. Surveillance guidelines should be examined further to optimize survivorship programs.

Frequency and Localization of Second Primary Tumors in Patients with Oropharyngeal Carcinoma-The Influence of the Human Papilloma Virus

Simple Summary

Human papillomavirus (HPV) infection, smoking, and excessive alcohol consumption have been established as risk factors for the development of oropharyngeal squamous cell carcinoma (OPSCC). While the HPV epidemic has led to an increasing incidence of OPSCC, HPV-negative OPSCC cases associated with smoking and alcohol remain stable. As HPV-positive and -negative OPSCC present two distinct etiological, clinical, and prognostic entities, different treatment and follow-up strategies are being discussed. Still, specific surveillance strategies for HPV-positive OPSCC are lacking, as the risk of second primary tumors (SPT) in the era of HPV-associated OPSCC has not been comprehensively assessed. Our study investigated the frequency and localization of SPT of HPV-positive OPSCC, as well as their prognostic impact. We find that the SPT of HPV-positive OPSCC are less frequent than those of HPV-negative OPSCC, and they are also associated with higher survival rates. The localization of SPT of HPV-positive OPSCC did not differ from the localization of SPT of HPV-negative OPSCC.

Abstract

Purpose: To investigate the frequency, localization, and survival of second primary tumors (SPT) of oropharyngeal squamous cell carcinoma (OPSCC) depending on human papillomavirus (HPV) status. Methods: We performed a retrospective chart analysis of 107 OPSCC patients treated at the Zurich University Hospital from 2001 to 2010. Rate and localization of SPT after an index OPSCC were stratified according to smoking and HPV infection status. Results: In total, 57/91 (63%) included patients showed an HPV-associated OPSCC. Of these, 37/57 (64.9%) patients with an HPV-positive and 32/34 (94.1%) patients with an HPV-negative OPSCC were smokers. The median age at diagnosis of the SPT was 59.54 years (interquartile range 52.7–65.6). In addition, 8/57 (14%) HPV-positive and 13/34 (38.2%) HPV-negative patients developed SPT. The rate of SPT in patients with HPV-positive index tumors was significantly lower than in patients with HPV-negative OPSCC (p-value 0.01). Smokers showed significantly more SPT in the head and neck area than outside. The development of an SPT led to a significantly lower survival time in HPV-negative patients, while it did not significantly affect the survival time of HPV-positive patients. Conclusions: Patients with HPV-positive index tumors had a significantly lower risk of developing SPT than patients with HPV-negative tumors. If SPT developed, survival was significantly shorter in patients with HPV-negative tumors than with HPV-positive tumors.

Second primary tumors in head and neck cancer patients: The importance of a "tailored" surveillance

OBJECTIVE

Head and neck cancer survivors have increased risk of developing second primary tumors compared to overall population. Because second primary represents a major cause of morbidity and mortality in this population, early detection is fundamental.

MATERIALS AND METHODS

In this 10-year single-institution study, we investigated the following: incidence, clinical-pathological risk factors, and survival of patients with second primary tumor. We included all patients with diagnosis of squamous cell carcinoma of the head and neck seen at the Modena University Hospital from 2008 to 2018.

RESULTS

Among 1,177 patients included, 222 (18.9%) developed second primary tumor; its survival probability at 5 years was 40.6%. Alcohol consumption (p = .0055) and index cancer in oropharynx (p = .0029), supraglottic larynx (p = .0000), glottic larynx (p = .0222) were associated with higher risk of second primary. The most common second primary sites were head and neck district and lung (70, 31.5%, and 67, 30.2%, respectively). Head and neck district were more common in oral cavity (18, 43%) and oropharynx index cancer (20, 31%); lung second primary in hypopharynx (4, 40%), supraglottic larynx (17, 43%), and glottic larynx index cancer (23, 35%).

CONCLUSION

Head and neck cancer survivors developing a second primary tumor have dismal prognosis. Tailored surveillance is recommended.

Risk of second primary cancers among survivors of gynecological cancers

OBJECTIVE

Survivors of gynecologic cancers have an increased risk of developing second primary cancers (SPC); however it is unclear which sites have higher risks. We aimed to ascertain risk of SPC among survivors of gynecological cancer, and identify anatomic sites at risk of SPC.

METHODS

We queried the Surveillance, Epidemiology and End Results database (2000-2016) for confirmed cases of index gynecological (cervix uteri [cervical], corpus and uterus [endometrial], ovarian, vaginal, and vulvar) cancers. Risk of SPC was estimated using standardized incidence ratios (SIRs: observed/expected cases) and excess absolute risks (EARs: observed - expected cases) per 10,000 person-years at risk (PYR). SIRs and EARs were stratified by index anatomic site and latency interval.

RESULTS

Among the cohort of 301,210 gynecological cancer survivors, 19,005 (6.31%) developed an SPC (SIR = 1.16; 95% CI, 1.15-1.18 and EAR = 17.2 cases per 10,000 PYR) compared with the general population. All gynecological cancer survivors (except survivors of ovarian) had a significant risk of developing SPC (SIR range 1.06-2.16), with survivors of vulvar cancer having the highest risk (SIR = 2.16; 95% CI, 2.06-2.27; EAR = 139.5 per 10,000 PYR). Risk of SPC was highest within the first 5 years post-diagnosis for survivors of cervical, vulvar and vaginal cancers.

CONCLUSIONS

While most index gynecological cancer sites are associated with increased risk of SPC, risk is highest among survivors of vulvar cancer. These findings have the potential to inform lifelong surveillance recommendations for gynecological cancer survivors.

Risk of subsequent malignant neoplasms after an index potentially-human papillomavirus (HPV)-associated cancers

BACKGROUND

Since the number of cancer survivors is increasing, it is imperative that we better understand the long-term consequences of these survivors. We assessed the risk of developing a second primary malignant neoplasm (SPMN) after an index potentially-HPV-associated cancers (P-HPV-AC).

METHODS

We constructed a population-based cohort of patients with P-HPV-AC using Surveillance, Epidemiology, and End Results registry data (2000-2015). We limited patients to those with invasive P-HPV-AC [cervical, vagina, vulva, penile, anal, and oropharynx] based on the International Classification of Diseases for Oncology, 3rd edition. Excess SPMN risks were calculated based on standardized incidence ratios (SIRs) and excess absolute risks (EARs) per 10,000 person-years at risk (PYR).

RESULTS

A total of 105,644 patients with an index P-HPV-AC were identified, and 7.8 % developed a SPMN. In all P-HPV-AC patients, the overall SIR was 1.73 (95 % CI: 1.69-1.77) and EAR of 70.72 per 10,000 PYR. All index P-HPV-AC sites showed statistically significant increases in the risk of SPMN, except for anal cancer among men, compared with the general population. The greatest increase in risk of SPMN was observed among patients diagnosed with an index P-HPV-oropharyngeal cancer (SIR = 1.83; 95 % CI, 1.70-1.82 and SIR = 2.29; 95 % CI, 2.12-2.47 for men and women, respectively). Men developed SPMN mostly in aero-digestive tract whiles women developed SPMN both in aero-digestive tract and other HPV-associated cancer sites.

CONCLUSIONS

P-HPV-AC survivors experienced excess risk of SPMN. These findings have the potential to affect future surveillance practices and improve preventive healthcare for survivors of P-HPV-ACs.

The risk of second primary tumors in head and neck cancer: A systematic review

BACKGROUND

Second primary tumors (SPTs) are a common cause of reduced life expectancy in patients treated for head and neck cancer (HNC). This phenomenon forms an area to be addressed during posttreatment follow-up.

METHODS

We conducted a systematic review of literature following PRISMA guidelines, from 1979 to 2019, to investigate incidence of SPTs, synchronous, and metachronous, in HNC population.

RESULTS

Our review includes data of 456 130 patients from 61 articles. With a minimum follow-up of 22 months, mean incidence of SPTs was 13.2% (95% CI: 11.56-14.84): 5.3% (95% CI: 4.24-6.36) for synchronous SPTs and 9.4% (95% CI: 7.9-10.9) for metachronous SPTs. The most frequent site for SPTs was head and neck area, followed by the lungs and esophagus.

CONCLUSION

Although with wide variations between studies, the rate of SPTs in HNC patients is high. Given the impact in the prognosis, we must develop strategies for the early diagnosis of SPTs.

Differences in human papillomavirus (HPV) vaccine uptake by nativity status among men aged 18-34 years

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Only 1 in 11 men had initiated and 1 in 30 men had completed the HPV vaccine series.

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Immigrants from Indian subcontinent had the lowest HPV vaccination rates.

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Foreign-born men who reported US citizenship had higher rates of HPV vaccination rates.

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Foreign-born men had lower odds of having initiated the HPV vaccination compared with US-born men.

Annually, about 16,500 HPV-associated cancers occur in the US among men. Data regarding HPV vaccine uptake among men based on nativity status (i.e., US-versus foreign-born) is limited, yet potentially important for informing interventions. We assessed differences in HPV vaccine uptake by nativity status among men aged 18–34 years in the US. The 2014–2017 National Health Interview Survey was examined for men, aged 18–34 years (n = 14,056). HPV vaccine initiation was defined as receipt of at least one dose of the vaccine and completion as receipt of three doses. Weighted, multivariable binary logistic regression models were used to assess the association between nativity status and HPV vaccine uptake, adjusting for demographic, socioeconomic, and healthcare factors. Analyses were performed in July 2018. Overall, 17% of men self-identified as foreign-born, 9.9% of men had initiated the HPV vaccine, and 3.3% had completed the HPV vaccine. Among foreign-born men, Asians had the highest HPV vaccination rates whereas those from Indian subcontinental region had the lowest rates. After accounting for demographic, socioeconomic, and healthcare factors, compared to US-born men, foreign-born men were 46% (adjusted odds ratio = 0.54; 95% CI = 0.39–0.72) less likely to initiate the HPV vaccine but there was no difference between the two groups in terms of vaccine completion. We found that HPV vaccine uptake among men was very low overall, and foreign-born men had lower initiation compared to US-born men. Public health interventions which improve HPV vaccination need to be developed for all men, irrespective of nativity status.