Anticipation of the Impact of Human Papillomavirus on Clinical Decision Making for the Head and Neck Cancer Patient

Race and socioeconomic status interact with HPV to influence survival disparities in oropharyngeal squamous cell carcinoma

BACKGROUND

HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the emergence of HPV has impacted race and SES survival disparities in OPSCC.

METHODS

A retrospective cohort of 18,362 OPSCC cases from 2010 to 2017 was assembled using the SEER (Surveillance, Epidemiology, and End Results) database. Cox proportional regression and Fine and Gray regression models were used to calculate hazard ratios (HRs) adjusting for race, SES, age, subsite, stage, and treatment.

RESULTS

Black patients had lower overall survival than patients of other races in HPV-positive and HPV-negative OPSCC (HR 1.31, 95% CI 1.13-1.53 and HR 1.23, 95% CI 1.09-1.39, respectively). Higher SES was associated with improved survival in all patients. Race had a diminished association with survival among high SES patients. Low SES Black patients had considerably worse survival than low SES patients of other races.

CONCLUSION

Race and SES interact variably across cohorts. High SES was protective of the negative effects of race, although there remains a disparity in outcomes among Black and non-Black patients, even in high SES populations. The persistence of survival disparities suggests that the HPV epidemic has not improved outcomes equally across all demographic groups.

Human Papillomavirus-Associated Oral Cavity Squamous Cell Carcinoma: An Entity with Distinct Morphologic and Clinical Features

BACKGROUND

HPV-associated oral cavity squamous cell carcinoma (SCC) is not well-characterized in the literature, and also has a clinical significance that is poorly understood.

METHODS

We gathered a cohort of oral cavity (OC) SCC with nonkeratinizing morphology, either in the invasive or in situ carcinoma (or both), tested for p16 by immunohistochemistry and high risk HPV E6/E7 mRNA by RTPCR (reference standard for transcriptionally-active high risk HPV) and gathered detailed morphologic and clinicopathologic data.

RESULTS

Thirteen patients from two institutions were proven to be HPV-associated by combined p16 and high risk HPV mRNA positivity. All 13 patients (100%) were males, all were heavy smokers (average 57 pack/year), and most were active drinkers (9/11 or 81.8%). All 13 (100%) involved the tongue and/or floor of mouth. All had nonkeratinizing features, but maturing squamous differentiation varied widely (0-90%; mean 37.3%). Nonkeratinizing areas had high N:C ratios and larger nests, frequently with pushing borders, and minimal (or no) stromal desmoplasia. The carcinoma in situ, when present, was Bowenoid/nonkeratinizing with cells with high N:C ratios, full thickness loss of maturation, and abundant apoptosis and mitosis. HPV was type 16 in 11 patients (84.6%) and type 33 in two (15.4%). Nine patients had treatment data available. These underwent primary surgical resection with tumors ranging from 1.6 to 5.2 cm. Most had bone invasion (6/9-66.7% were T4a tumors), and most (6/9-66.7%) had extensive SCC in situ with all 6 of these patients having final margins positive for in situ carcinoma.

CONCLUSIONS

HPV-associated OCSCC is an uncommon entity that shows certain distinct clinical and pathologic features. Recognition of these features may help pathologic diagnosis and could potentially help guide clinical management.

Socioeconomic Status Drives Racial Disparities in HPV-negative Head and Neck Cancer Outcomes

OBJECTIVES/HYPOTHESIS

To determine drivers of the racial disparity in stage at diagnosis and overall survival (OS) between black and white patients with HPV-negative head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

Data were examined from of a population-based HNSCC study in North Carolina. Multivariable logistic regression and Cox proportional hazards models were used to assess racial disparities in stage at diagnosis and OS with sequential adjustment sets.

RESULTS

A total of 340 black patients and 864 white patients diagnosed with HPV-negative HNSCC were included. In the unadjusted model, black patients had increased odds of advanced T stage at diagnosis (OR 2.0; 95% CI [1.5-2.5]) and worse OS (HR 1.3, 95% CI 1.1-1.6) compared to white patients. After adjusting for age, sex, tumor site, tobacco use, and alcohol use, the racial disparity persisted for advanced T-stage at diagnosis (OR 1.7; 95% CI [1.3-2.3]) and showed a non-significant trend for worse OS (HR 1.1, 95% CI 0.9-1.3). After adding SES to the adjustment set, the association between race and stage at diagnosis was lost (OR: 1.0; 95% CI [0.8-1.5]). Further, black patients had slightly favorable OS compared to white patients (HR 0.8, 95% CI [0.6-1.0]; P = .024).

CONCLUSIONS

SES has an important contribution to the racial disparity in stage at diagnosis and OS for HPV-negative HNSCC. Low SES can serve as a target for interventions aimed at mitigating the racial disparities in head and neck cancer.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1301-1309, 2021.

The different role of PD-L1 in head and neck squamous cell carcinomas: A meta-analysis

Programmed cell death-ligands 1 (PD-L1) is a promising immune target for tumor immunotherapy. We conducted this meta-analysis to investigate association between PD-L1 expression and clinicopathological characteristics of head and neck squamous cell carcinomas (HNSCC). Electronic databases were searched for eligible studies. Hazard ratio (HR) with 95 % confidence interval (CI) were extracted to assess the relationship between PD-L1 expression and overall survival (OS) and disease-free survival (DFS) of patients. Odds ratio (OR) with 95 %CI were applied to assess the association between PD-L1 expression and clinicopathological features. A total of 1729 patients were identified for this meta-analysis. PD-L1 expression was higher in female patients in HNSCC (OR = 0.58, 95 %CI:0.44-0.76). In oral squamous cell carcinoma (OSCC), female(OR = 0.56, 95 %CI: 0.41-0.77)and lower grade(OR = 0.48, 95 %CI: 0.24-0.93)were associated with the higher PD-L1 level. There was no significant association between OS and PD-L1 in OSCC patients (HR = 0.89, 95 %CI: 0.37-2.14). In oropharyngeal squamous cell carcinoma (OPSCC), PD-L1 was overexpressed in younger patients (OR = 0.43, 95 %CI: 0.21-0.86), higher tumor grade (OR = 2.46, 95 %CI: 1.38-4.37)and positive HPV status (OR = 2.09, 95 %CI:1.42-3.07). No significant correlation was detected between PD-L1 expression and OS in OPSCC patients (HR = 0.78, 95 %CI: 0.57-1.06). However, the higher PD-L1 expression in tumor cells indicated a better DFS of OPSCC (HR = 0.34, 95 %CI: 0.18-0.67). This meta-analysis demonstrated that PD-L1 overexpression in HNSCC associated with female patients. However, no significant difference was observed in OS or DFS, except the DFS in OPSCC.

Effects of tobacco abuse on major chromosomal instability in human papilloma virus 16-positive oropharyngeal squamous cell carcinoma

A substantial number of patients with oropharyngeal squamous cell carcinoma (OPSCC) have two oncogenic risk factors: Human papilloma virus (HPV) infection and tobacco use. These factors can be competitive or synergistic at the chromosomal and genomic levels, with strong prognostic and therapeutic implications. HPV16 has been shown in vitro to be a high‑risk HPV that induces low rates of chromosomal copy number alterations. However, chromosomal instability can be increased by smoking. Evaluating chromosomal instability in HPV‑positive patients according to their smoking status is therefore critical for assessing the prognosis and therapeutic impact. The aim of this study was to assess chromosomal instability in patients with HPV‑positive OPSCC according to smoking status. Chromosomal instability was investigated with array‑based comparative genomic hybridization (aCGH) in 50 patients with OPSCC. Differences in chromosomal alterations were examined according to the HPV and smoking status of the patients. HPV‑positive tumors (24/26 were HPV16‑positive) had fewer genomic aberrations (P=0.0082) and fewer breakpoints (P=0.048) than HPV‑negative tumors. We confirmed the association between HPV‑positive OPSCC and chromosomal losses at 11q. We verified the association between HPV‑negative OPSCC and losses at 3p and 9p and gains at 7q and 11q13. In the patients with OPSCC who were HPV‑positive, the total number of chromosomal aberrations per tumor was significantly higher in the group of patients who were smokers (P=0.003). However, the cytobands did not differ significantly according to the smoking status. On the whole, the data of this study may help to improve the stratification of HPV‑positive OPSCC patients and must be supplemented by next‑generation sequencing studies in order to describe the mutational and transcriptomic profiles of such patients according to smoking status.

p16 Immunohistochemistry in Oropharyngeal Squamous Cell Carcinoma Using the E6H4 Antibody Clone: A Technical Method Study for Optimal Dilution

Routine testing for p16 immunohistochemistry (with selective HPV-specific test use) has been recommended for clinical practice in oropharyngeal squamous cell carcinoma (OPSCC). Data suggests that the E6H4 clone performs best for this purpose, yet no studies have evaluated the optimal antibody concentration for OPSCC testing. We evaluated three concentrations (undiluted, 1:5, and 1:10) of the primary antibody solution for E6H4 using tissue microarrays from a cohort of 199 OPSCC patients with a > 70% staining cutoff for positivity. Concordance was evaluated using percent agreement and Cohen's kappa. The concentrations were evaluated for sensitivity and specificity using high risk HPV RNA in situ hybridization (RNA-ISH) and also correlated with Kaplan-Meier overall survival analysis. Inter-rater agreement was very high between p16 results at each concentration and also with RNA in situ hybridization (p < 0.0001 for all). Agreement between p16 undiluted and 1:5 dilution (agreement 98.2%; Kappa 0.943; p < 0.0001) was very high and between p16 undiluted and 1:10 dilution (agreement 79.2%; Kappa 0.512; p < 0.0001) much lower. Intensity of the staining did decrease with the 1:5 and 1:10 dilutions compared to undiluted, but not in a manner that obviously would change test interpretation or performance. Results suggest that the E6H4 antibody performs well at dilutions of up to 1:5 fold with a minor decrease in staining intensity, minimum loss of sensitivity, and no loss of specificity in OPSCC patients. This could result in reagent and cost savings.

Long-term survival and swallowing outcomes in advanced stage oropharyngeal squamous cell carcinomas

BACKGROUND

There is a paucity of studies reporting long-term survival outcomes for HPV/p16 positive oropharyngeal squamous cell carcinoma (OPSCC). This study aims to compare long-term outcomes of advanced stage p16 positive and negative OPSCCs, treated by surgical and non-surgical modalities.

METHODS

OPSCC patients from 1998 to 2012 were identified through a prospectively collected cancer registry. P16 immunohistochemistry was used as a surrogate marker for HPV-OPSCC. Overall survival (OS) and aspiration free survival (AFS) comparisons were made between patients treated with chemoradiation (CRT) versus primary surgery and radiation/chemoradiation (S+RT/CRT) at 5, 10 and 15 years post-treatment.

RESULTS

A total of 319 patients were included. P16 positive patients and non-smokers had significantly higher long-term (5, 10 and 15-year) OS. Smokers and p16 negative patients treated with S+RT/CRT had improved long-term OS compared to patients who received CRT. Smokers and p16 negative patients had lower long-term AFS. Multivariate analysis showed improved OS was associated with p16 positivity (HR 0.42, 0.28-0.61) and surgery (HR 0.47, 0.32-0.69), whereas lower OS was associated with ECOG ≥ 2 (HR 2.46, 1.61-3.77), smoking (HR 2.37, 1.41-3.99) and higher stage (HR 1.68, 1.05-2.68).

CONCLUSIONS

In smokers and p16-negative OPSCC patients, primary surgery may be associated with improved long-term survival and dysphagia-related outcomes.

Retrospective study of survival in human papillomavirus-negative oropharyngeal squamous cell carcinoma treated with primary surgery and associated prognostic factors

Background

Oropharyngeal squamous cell carcinoma (OPSCC) is an aggressive malignancy which has been investigated for decades and reported highly associated with the human papillomavirus (HPV) infection, yet there is no consensus reached on the optimal treatment paradigm. The relatively lower prevalence of HPV in China makes it important to evaluate the outcomes of HPV-negative OPSCC.

Purpose

Our study was carried out in an attempt to evaluate the outcomes of squamous cell carcinoma of the oropharynx treated with primary surgery and identify the associated prognostic factors.

Patients and methods

We retrospectively analyzed the outcomes of the primary surgically treated HPV-negative OPSCC cases at our institution between 2008 and 2013. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were determined by Kaplan-Meier analysis. Prognostic factors of outcomes were investigated by uni- and multivariate analyses.

Results

In this study, neck metastasis rate was 61.3%. Level II nodes were the most vulnerable. The 3-year disease-specific survival, overall survival, and disease-free survival rates were 76.7%, 75.6%, and 62.8%, respectively. Forearm free flaps were the most commonly utilized in the reconstructions. A multivariate analysis indicated that N stage and adjuvant radiotherapy were predictive factors for 3-year disease-specific survival.

Conclusion

The outcomes of the surgical treatment of oropharyngeal squamous cell carcinoma were acceptable, and N-stage, adjuvant radiotherapy were identified as prognostic factors.

Mouse Models for Studying Oral Cancer: Impact in the Era of Cancer Immunotherapy

Model systems for oral cancer research have progressed from tumor epithelial cell cultures to in vivo systems that mimic oral cancer genetics, pathological characteristics, and tumor-stroma interactions of oral cancer patients. In the era of cancer immunotherapy, it is imperative to use model systems to test oral cancer prevention and therapeutic interventions in the presence of an immune system and to discover mechanisms of stromal contributions to oral cancer carcinogenesis. Here, we review in vivo mouse model systems commonly used for studying oral cancer and discuss the impact these models are having in advancing basic mechanisms, chemoprevention, and therapeutic intervention of oral cancer while highlighting recent discoveries concerning the role of immune cells in oral cancer. Improvements to in vivo model systems that highly recapitulate human oral cancer hold the key to identifying features of oral cancer initiation, progression, and invasion as well as molecular and cellular targets for prevention, therapeutic response, and immunotherapy development.

Differences in incidence and survival of oral cavity and pharyngeal cancers between Germany and the United States depend on the HPV-association of the cancer site

INTRODUCTION

The epidemiology of squamous cell oral cavity and pharyngeal cancers (OCPC) has changed rapidly during the last years, possibly due to an increase of human papilloma virus (HPV) positive tumors and successes in tobacco prevention. Here, we compare incidence and survival of OCPC by HPV-relation of the site in Germany and the United States (US).

MATERIALS AND METHODS

Age-standardized and age-specific incidence and 5-year relative survival was estimated using data from population-based cancer registries in Germany and the US Surveillance Epidemiology and End Results (SEER) 13 database. Incidence was estimated for each year between 1999 and 2013. Relative survival for 2002-2005, 2006-2009, and 2010-2013 was estimated using period analysis.

RESULTS

The datasets included 52,787 and 48,861 cases with OCPC diagnosis between 1997 and 2013 in Germany and the US. Incidence was much higher in Germany compared to the US for HPV-unrelated OCPC and more recently also for HPV-related OCPC in women. Five-year relative survival differences between Germany and the US were small for HPV-unrelated OCPC. For HPV-related OCPC, men had higher survival in the US (62.1%) than in Germany (45.4%) in 2010-2013. These differences increased over time and were largest in younger patients and stage IV disease without metastasis. In contrast, women had comparable survival for HPV-related OCPC in both countries.

CONCLUSIONS

Strong survival differences between Germany and the US were observed for HPV-related OCPC in men, which might be explained by differences in HPV-attributable proportions. Close monitoring of the epidemiology of OCPC in each country is needed.

p16 immunohistochemistry in oropharyngeal squamous cell carcinoma: a comparison of antibody clones using patient outcomes and high-risk human papillomavirus RNA status

High-risk human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas have a more favorable prognosis than HPV-negative ones. p16 immunohistochemistry has been recommended as a prognostic test in clinical practice. Several p16 antibodies are available, and their performance has not been directly compared. We evaluated three commercially available p16 antibody clones (E6H4, JC8 and G175-405) utilizing 199 cases of oropharyngeal squamous cell carcinoma from a tissue microarray, read by three pathologists with three different cutoffs for positivity: any staining, >50% and >75%. Positive predictive values for high-risk HPV status by RNA in situ hybridization for the E6H4, JC8 and G175-405 clones were 98%, 100% and 99% at the 75% cutoff, but negative predictive values were much more variable at 86%, 69% and 56%, respectively. These improved using the 50% cutoff, becoming similar for all three antibodies. Intensity varied substantially, with 85% of E6H4, 72% of JC8 and 67% of G175-405 showing strong (3+) intensity. With Kaplan-Meier survival plots at the 75% cutoff, the E6H4 clone showed the largest differential in disease specific and overall survival between p16-positive and -negative results. Decreasing the cutoff to 50% increased correlation with HPV in situ hybridization and improved the survival differential for the JC8 and G175-405 clones without worsening of performance for the E6H4 clone. Interobserver agreement was also assessed by kappa scores and was highest for the E6H4 clone. Overall, these study results show modest but important performance differences between the three different p16 antibody clones, suggesting that the E6H4 clone performs best because of strongest staining intensity, greatest differential in outcomes between positive and negative results, lowest interobserver variability, and lowest background, nonspecific staining. The results also suggest that a 75% cutoff is very functional but that, in this patient population with high HPV incidence, 50% and any staining cutoffs may be more effective, particularly for the non-E6H4 clones.

Targeting the Tumor Environment in Squamous Cell Carcinoma of the Head and Neck

OPINION STATEMENT

The survival rate for patients with advanced stages of squamous cell carcinoma of the head and neck (SCCHN) remains poor despite multimodal treatment options. Cetuximab, an anti-EGFR inhibitor, is the only FDA-approved targeted agent for this disease. Recent findings have implicated modifications of the microenvironment and, consequently, phenotypical modifications of the cancer cell, in treatment resistance mechanisms. For many years, cancer research has focused mainly on targetable sites on or inside the cancer cell. Nowadays, in preclinical and clinical studies, a greater emphasis is being placed on drugs that target the tumor microenvironment. Potential targets relate to tumor vascularization, immunology, extracellular matrix components, or cancer-associated fibroblasts. The combination of these new agents with standard treatment options is of particular interest to overcome resistance mechanisms and/or to increase treatment efficacy. Whereas antiangiogenic agents show poor clinical activity, immunotherapy seems to be a more promising tool with an objective response rate (ORR) of 20 % in patients with recurrent and/or metastatic squamous cell carcinoma (R/M SCC). Other targets, located inside the extracellular matrix or on cancer associated fibroblasts, are under preclinical investigation. These new agents all need to be tested in clinical trials alone, or in combination with standard treatment modalities, based on preclinical data. To increase our knowledge of the complex network between the cancer cell and its environment, preclinical studies should consider co-culture models, and clinical studies should incorporate a translational research objective.

Oropharyngeal cancer prognosis by tumour HPV status in France: The multicentric Papillophar study

AIMS

To evaluate the impact of human papillomavirus (HPV) status, tobacco smoking and initial treatment approach on progression-free survival (PFS) and overall survival (OS) for oropharyngeal cancer (OPC) in France, a country where smoking declines started late (1990s).

METHODS

340 OPC patients (median age: 60years) from 14 French hospitals were followed up (median 26.7months). PCR-based positivity for both HPV DNA and E6/E7 mRNA was used to distinguish HPV-positive OPC (27.1%). Hospital-stratified hazard ratios (HR) and corresponding 95% confidence intervals (CI) were used to compare PFS and OS according to HPV and other prognostic factors in hospital-stratified unadjusted and multivariate models. The combined effect of HPV status with either smoking, stage, or initial treatment on PFS was also evaluated.

RESULTS

PFS in multivariate analysis was better in HPV-positive patients (HR=0.42; 95% CI: 0.24-0.73) and worse in older patients (HR for 5-year age increase=1.12) and those having had firstly radiotherapy (HR=1.86; 95% CI: 1.19-2.92) or induction chemotherapy (HR=1.73; 95% CI: 1.08-2.79) instead of upfront surgery. Findings for OS were similar. Loco-regional recurrences were less frequent in HPV-positive (10.5%) than HPV-negative patients (26.0%) but distant recurrences were similarly frequent. HPV status did not modify the influence of smoking or stage on PFS but the impossibility to perform upfront surgery may be more relevant for HPV-negative patients.

CONCLUSIONS

HPV-positive OPC patients fare better than HPV-negative OPC and may benefit from toxicity-sparing. Whether HPV-negative patients responded less well to radiation and chemotherapy because of more severe genomic damage or bulkier tumours is unclear.

Human Papillomavirus-Associated Neoplasms of the Head and Neck

Human papillomavirus (HPV) is an essential causal factor in a subset of head and neck neoplasms, most notably oropharyngeal squamous cell carcinoma, for which HPV infection has important diagnostic, prognostic, and therapeutic implications. This article summarizes the current understanding of HPV-associated neoplasms of the head and neck, including the recently described carcinoma with adenoid cystic-like features. Salient clinical, gross, and microscopic features are discussed, and the utility of specific ancillary studies is highlighted.

Epigenetics of oropharyngeal squamous cell carcinoma: opportunities for novel chemotherapeutic targets

Epigenetic modifications are heritable changes in gene expression that do not directly alter DNA sequence. These modifications include DNA methylation, histone post-translational modifications, small and non-coding RNAs. Alterations in epigenetic profiles cause deregulation of fundamental gene expression pathways associated with carcinogenesis. The role of epigenetics in oropharyngeal squamous cell carcinoma (OPSCC) has recently been recognized, with implications for novel biomarkers, molecular diagnostics and chemotherapeutics. In this review, important epigenetic pathways in human papillomavirus (HPV) positive and negative OPSCC are summarized, as well as the potential clinical utility of this knowledge.This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Characteristics of carcinogenic human papillomavirus infection in Suzhou: Epidemiology, vaccine evaluation, and associated diseases

Human papillomavirus infection is a major health problem and caused substantial benign and malignancy diseases among female and male worldwide. We aim to investigate the epidemiology of high-risk human papillomavirus (HR-HPV) and related diseases in Suzhou population. As well as evaluating the potential benefit of a nine-valent HPV vaccine (regardless of HPV-6 and -11) in Suzhou. A total of 40,108 people aged 13-89 years were retrospectively examined by database retrieval from 2010 to 2015. Thirteen genotypes (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 66) of HR-HPV were detected using Tellgenplex™ xMAP™ HPV DNA Test assay. The overall prevalence of HR-HPV was 21.1%, the female and male account for 96.4% and 3.6%, respectively. The infection rate among male (25.6%, 367/1,432) was significantly higher than that among female (20.9%, 8,100/38,676), X²  = 17.341 (P < 0.001), with OR = 1.293, 95% CI (1.146-1.460). The five most frequent HR-HPV genotypes were HPV-16 (5.12%), -52 (5.07%), -58 (3.02%), -39 (2.00%), and -18 (1.74%). HR-HPV infection rate was peak in person aged <20 years, and second higher in person aged 51-60 years. Infection modes as HPV-16, -18, -31, -33, -45, -52, -58 alone or mixed accounted for 63.2%. The top three prevalent diseases in HR-HPV infected women were cervicitis, vaginitis, and cervical lesions, and in men were verruca, urethritis, and balanitis, respectively. This is the first study to demonstrate HPV infection status in Suzhou population. Both women and men had a large burden of HPV infection. The nine-valent HPV prophylactic vaccines may potentially prevent 63.2% HR-HPV infection in Suzhou. J. Med. Virol. 89:895-901, 2017. © 2016 Wiley Periodicals, Inc.