Poor oral health influences head and neck cancer patient survival: an International Head and Neck Cancer Epidemiology Consortium pooled analysis

Prevention of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy

BACKGROUND

Osteoradionecrosis is a long-term, serious side effect of head and neck radiation therapy and is associated with significant morbidity and quality of life issues.

METHODS

This paper sought to determine consensus on the prevention and management of osteoradionecrosis by an international panel of multidisciplinary professionals expert in the management of patients with head and neck cancer using a Delphi methodology. Unique to this work is our direct inclusion of the views of patients and carers in our findings.

RESULTS

This study reached consensus on the importance of pre and post oral health assessment and education for patients with head and neck cancer. This was also noted by the patients and carers who took part in the study.

CONCLUSIONS

This work highlights the need for a standardized oral health assessment tool and multidisciplinary care of patients to prevent and manage osteoradionecrosis.

Smac/DIABLO protein acts as an independent prognostic factor in oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) poses significant health risks with increasing incidence and mortality rates. In this context, there is an urgent need to explore novel biomarkers to enhance therapeutic strategies and improve survival. Understanding apoptotic evasion in cancer pathogenesis, this pioneering study aims to investigate the correlation between a pro-apoptotic protein Smac/DIABLO and patient prognosis within the OSCC cohort. Immunohistochemistry (IHC) was employed to analyze Smac/DIABLO protein expression and correlate with clinicopathological and prognostic factors during a long-term follow-up. Smac/DIABLO low expression was associated with worse overall survival (OS), relapse-free survival (RFS), disease-specific survival (DSS), and an increase in risk of lymph node metastasis (LNM) in univariate analyses. Furthermore, multivariate analyses confirmed Smac/DIABLO as an independent prognostic factor, predicting poorer OS [Hazard Ratio (HR) = 3.6 (95% CI 1.7-7.6), p < 0.001], RFS [HR = 2.9 (95% CI 1.4-5.6), p = 0.003], DSS [HR = 6.7 (95% CI 2.7-16.7), p < 0.001], and increased likelihood of LNM [Odds Ratio (OR) = 4.8 (95% CI 1.4-15.9), p = 0.011]. Patients with positive Smac/DIABLO expression exhibited three times higher survival probability. Low proapoptotic protein Smac/DIABLO expression significantly influences prognostic predictions and strongly correlates with poor OSCC outcomes. Future studies involving Smac-mimetic drugs in OSCC are needed to evaluate their pro-apoptotic potential in cancer cells.

Financial Burden of Dental Care Among Patients With Head and Neck Cancer

Importance

Patients undergoing treatment for head and neck cancer (HNC) experience oral complications requiring substantial dental treatment. This treatment is commonly not reimbursed by medical insurers, presenting a potential financial burden for patients.

Objective

To characterize the dental care needs and associated cost burden for patients with HNC.

Design, Setting, and Participants

This survey study included Head and Neck Cancer Alliance (HNCA) members who were surveyed from March 23 to October 27, 2023, using Qualtrics. The survey was promoted using the HNCA's social media and email list. Data analysis was performed between October 2023 and May 2024.

Main Outcomes and Measures

Main outcomes were oral and dental complications of cancer treatment among patients with HNC, the association of cancer treatment with dental care use, and costs of associated dental treatment.

Results

Of 100 individuals administered the survey, 85 (85%) completed all required questions and were included in the analysis. Of 84 participants with age and sex data, 51 (61%) were aged 65 years or older and 45 (54%) were female. Of 85 respondents, 59 (70%) indicated that their current oral health was worse than before cancer treatment. Most respondents (73 of 85 [86%]) endorsed oral complications from cancer treatment, including xerostomia (66 of 73 [90%]), caries (35 of 73 [48%]), and oral mucositis (29 of 73 [40%]); 64 of 73 respondents (88%) required follow-up dental treatment. Overall, 4 of 28 (14%) before HNC treatment and 17 of 53 (32%) after treatment reported finances as the reason that not all recommended dental care was received. A total of 33 of the 85 respondents (39%) said that their postcancer dental care had caused them financial hardship. Individuals who were less likely to endorse financial hardship were more likely to have greater educational attainment (odds ratio [OR], 0.20; 95% CI, 0.06-0.58), higher income (OR, 0.33; 95% CI, 0.11-0.94), increased pre-HNC dental visit frequency (OR, 0.30; 95% CI, 0.10-0.86), same or better oral health after HNC (OR, 0.13; 95% CI, 0.02-0.50), and lower out-of-pocket dental expenses after HNC (OR, 0.09; 95% CI, 0.03-0.29).

Conclusions and Relevance

In this survey study, most patients undergoing treatment for HNC required extensive dental treatment throughout cancer treatment; this treatment presented a financial burden for 39% of patients that was a limiting barrier to care. Since most private medical insurers do not reimburse for dental treatment, more comprehensive coverage deserves policy attention.

Gaps in Access to Medically Necessary Dental Care for Patients Living With and Beyond Cancer: We Must Do Better

Delivery of high-quality, evidence-based oral care for those living with and beyond cancer needed!

Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer.

METHODS

The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008.

RESULTS

A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation.

RECOMMENDATIONS

Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Implications of oral dysbiosis and HPV infection in head and neck cancer: from molecular and cellular mechanisms to early diagnosis and therapy

Head and neck cancer (HNC) is the sixth most common type of cancer, with more than half a million new cases annually. This review focuses on the role of oral dysbiosis and HPV infection in HNCs, presenting the involved taxons, molecular effectors and pathways, as well as the HPV-associated particularities of genetic and epigenetic changes and of the tumor microenvironment occurred in different stages of tumor development. Oral dysbiosis is associated with the evolution of HNCs, through multiple mechanisms such as inflammation, genotoxins release, modulation of the innate and acquired immune response, carcinogens and anticarcinogens production, generation of oxidative stress, induction of mutations. Thus, novel microbiome-derived biomarkers and interventions could significantly contribute to achieving the desideratum of personalized management of oncologic patients, regarding both early diagnosis and treatment. The results reported by different studies are not always congruent regarding the variations in the abundance of different taxons in HNCs. However, there is a consistent reporting of a higher abundance of Gram-negative species such as Fusobacterium, Leptotrichia, Treponema, Porphyromonas gingivalis, Prevotella, Bacteroidetes, Haemophilus, Veillonella, Pseudomonas, Enterobacterales, which are probably responsible of chronic inflammation and modulation of tumor microenvironment. Candida albicans is the dominant fungi found in oral carcinoma being also associated with shorter survival rate. Specific microbial signatures (e.g., F. nucleatum, Bacteroidetes and Peptostreptococcus) have been associated with later stages and larger tumor, suggesting their potential to be used as biomarkers for tumor stratification and prognosis. On the other hand, increased abundance of Corynebacterium, Kingella, Abiotrophia is associated with a reduced risk of HNC. Microbiome could also provide biomarkers for differentiating between oropharyngeal and hypopharyngeal cancers as well as between HPV-positive and HPV-negative tumors. Ongoing clinical trials aim to validate non-invasive tests for microbiome-derived biomarkers detection in oral and throat cancers, especially within high-risk populations. Oro-pharyngeal dysbiosis could also impact the HNCs therapy and associated side-effects of radiotherapy, chemotherapy, and immunotherapy. HPV-positive tumors harbor fewer mutations, as well as different DNA methylation pattern and tumor microenvironment. Therefore, elucidation of the molecular mechanisms by which oral microbiota and HPV infection influence the HNC initiation and progression, screening for HPV infection and vaccination against HPV, adopting a good oral hygiene, and preventing oral dysbiosis are important tools for advancing in the battle with this public health global challenge.