The Impact of Human Papillomavirus (HPV) Associated Oropharyngeal Squamous Cell Carcinoma (OPSCC) on Nutritional Outcomes

Associations between Human Papillomavirus Status, Weight Change, and Survival of Oropharyngeal Cancer Patients

This study examined associations between HPV status and weight change in oropharyngeal cancer (OPC). OPC patients receiving concurrent chemoradiotherapy in Toronto, Canada were included. Relationships were assessed between HPV status and weight loss grade (WLG, combining weight loss and current body mass index); weight change during treatment; and HPV status and WLG/weight change on overall (OS) and cancer-specific (CSS) survival. Of 717 patients, WLG pre-radiation was less severe among HPV-positive compared to HPV-negative, though weight loss during treatment was greater. The adjusted odds ratio for greater WLG among HPV-positive versus HPV-negative was 0.47 (95%CI 0.28-0.78). Grade-4 WLG (worst category) experienced poorer OS and CSS (OS adjusted hazard ratio (aHR) 4.08; 95%CI 1.48-11.2, compared to Grade-0); and was non-significant for HPV-negative (aHR 2.34; 95%CI 0.69-7.95). Relationships between weight change before/during treatment and survival had similar direction between HPV-positive and HPV-negative, but of greater magnitude in HPV-positive patients.

Enteral Nutrition during Radiotherapy for Oropharyngeal Cancers: Prevalence and Prognostic Factors Based on HPV Status (A GETTEC Study)

Nutritional support during radiotherapy is crucial to tolerating and completing oropharyngeal squamous cell carcinoma (OPSCC) treatment. The impact of HPV status on nutritional support is debated. The objective was to evaluate the rate of Reactive Feeding Tube (RFT) use and determine its prognostic factors during definitive radiotherapy for OPSCC. All OPSCC patients treated from 2009 to 2014 were included in this multicentric retrospective study. The impact of tumor p16 status on the risk of RFT was assessed through multivariate analyses. Among the 543 patients, 103 patients required an RFT (19.0%). The use of RFT differed between centers (5% to 32.4%). In multivariate analysis, only tongue base involvement and concurrent chemotherapy were significantly associated with RFT (OR = 2.18 and 3.7, respectively). Tongue base involvement and concomitant chemotherapy were prognostic factors for RFT. HPV status was not a prognostic factor for enteral nutrition during radiotherapy for OPSCC.

[Impact of HPV status on nutritional status during radio chemotherapy for oropharyngeal cancer]

PURPOSE

Patients with oropharyngeal cancer are at high nutritional risk before and during treatment. Little is known about the influence of human papillomavirus (HPV) infection on nutritional status and its evolution during treatment.

MATERIALS AND METHODS

A single-center retrospective study was conducted between August 2017 and December 2020 including 48 patients (14 HPV-induced: HPV+ and 34 non-HPV-induced: HPV-) with oropharyngeal squamous cell carcinoma treated by radiotherapy±chemotherapy (RT/CT). Nutritional risk at the time of tumor assessment (TA) was assessed by weight loss, swallowing ability, and the presence of digestive disorders in 4 stages of increasing severity. Nutritional status was assessed by weight and nutrition risk index (NRI) at the time of TA, before the start and at 3 months from the end of RT±CT. During RT±CT, the NRI and the systemic inflammatory response index (SIRI=neutrophils * monocytes/lymphocytes) were assessed weekly.

RESULTS

HPV+patients were at lower nutritional risk at TA (50% grade ≥2 vs 85%, P=0.02), lost more weight (6% of their body weight vs 3%, P=0.05), and increased their SIRI by 7.5 points more than HPV- patients (P=0.04) during RT/CT.

CONCLUSION

HPV+ oropharyngeal cancer patients are at high nutritional risk even in the absence of undernutrition at the outset of management.

Prevalence and Impact of Computed Tomography-Defined Sarcopenia on Survival in Patients with Human Papillomavirus-Positive Oropharyngeal Cancer: A Systematic Review

Sarcopenia is a known independent prognostic factor for decreased survival in patients with head and neck cancer; yet, its importance for the growing number of younger patients diagnosed with human papillomavirus (HPV)-positive oropharyngeal carcinoma (OPC+) has not been established. This systematic literature review aimed to determine the prevalence and impact of computed tomography (CT)-defined sarcopenia on survival outcomes for adult OPC+ patients (>18 y) undergoing any treatment modality. Prospective studies were searched using PubMed, Embase, CENTRAL, CINAHL, and Web of Science up until and including February 2022. Bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In total, 9 studies (total pooled OPC+ patients, n  = 744) were identified and included in this review; 2 at low, 6 at moderate, and 1 at high risk of bias. All studies varied in sarcopenia assessment methods and skeletal muscle index threshold cutoff values. These studies demonstrated the cumulative prevalence of sarcopenia for OPC+ patients to be 42.9% (95% CI: 37.8%, 47.9%). While overall survival (3 studies, n = 253) and progression-free survival (1 study, n = 117) was lower in sarcopenic OPC+ patients, this was not statistically significant. GRADE certainty of evidence for impact of pretreatment sarcopenia on overall survival was low and progression-free survival was very low. Although these studies showed there to be a high prevalence of pretreatment sarcopenia in patients with OPC+, which may decrease survival, the impact on progression-free survival is very uncertain. Further, high-quality research utilizing consistent sarcopenia definitions and assessment methods that are conducted specifically in OPC+ is required to strengthen evidence certainty and determine if sarcopenia is an independent prognostic factor for this population.

Does Human Papillomavirus Infection Influence the Frequency and Severity of Nutritional Disorders in Head and Neck Cancer?

BACKGROUND

About 87% of head and neck cancer (HNC) patients (mostly oropharyngeal cancer-OPC) are infected with human papillomavirus (HPV). Recent studies have demonstrated a significant correlation between HPV infection and nutritional disorders in HNC patients. Therefore, we formed a hypothesis that nutritional disorders or their severity in HNC patients may be associated with the occurrence of HPV infection due to known molecular differences in involved tissue. This literature review aimed to evaluate the influence of HPV infection on the occurrence and severity of nutritional disorders in HNC patients.

MATERIALS AND METHODS

The PubMed database was used to search papers with the keywords "HPV", "HNC", and "nutritional disorders" in different variants and combinations.

CONCLUSIONS

The data available in the discussed papers indicate, among other things, that HPV-positive patients may be at higher risk of malnutrition, critical weight loss, and necessity for gastrostomy after radiotherapy or chemoradiotherapy (C-RT). It should be highlighted that despite some studies demonstrating positive results, currently available data regarding the influence of HPV infection on the occurrence and severity of nutritional disorders in HNC remain limited and inconclusive, and thus further research on this issue is warranted.

The changing face of head and neck cancer: are patients with human papillomavirus-positive disease at greater nutritional risk? A systematic review

PURPOSE

Human papillomavirus (HPV) is now the primary cause of oropharyngeal head and neck cancer (OPC) worldwide; yet limited research has examined the effect of HPV-positive status (OPC+) on nutrition outcomes. This study aims to determine the impact of HPV status on nutritional outcomes for adult patients with OPC undergoing any treatment modality.

METHODS

A systematic literature review was conducted up to and including July 2021 of PubMed, Embase, CENTRAL, CINAHL, and Web of Science to identify studies conducted in adults (>18 years) with known OPC reporting on any outcome(s) related to nutrition, according to HPV status (OPC+ versus OPC-). Bias was assessed using QUIPS tool, with certainty of evidence assessed using GRADE system.

RESULTS

Six studies (total n = 635) all at moderate-high risk of bias were included. Three studies reported on weight change (n = 255), three feeding tube dependency (n = 380), three feeding tube timing of placement (prophylactic or reactive) and/or utilisation (n = 255), two nutritional (energy and/or protein) intake (n = 230), and one nutritional status (n = 83). Patients with OPC+ may experience greater weight loss, may have higher utilisation of reactive feeding tubes (both GRADE low certainty, downgraded due to serious bias and imprecision), and may have lower feeding tube dependency rates (GRADE low certainty, downgraded due to serious bias and inconsistency) versus OPC- . It is uncertain whether nutritional intake and nutritional status differed between populations (GRADE very low certainty, downgraded due to serious bias and very serious imprecision).

CONCLUSION

Further, high-quality research is needed to understand optimal nutritional care practices for patients with OPC + to achieve positive health outcomes into survivorship.

Vaginal microbiota and personal risk factors associated with HPV status conversion—A new approach to reduce the risk of cervical cancer?

Vaginal microbiota (VMB) is associated with changes in Human papilloma virus (HPV) status, which consequently influences the risk of cervical cancer. This association was often confounded by personal risk factors. This pilot research aimed to explore the relationship between vaginal microbiota, personal risk factors and their interactions with HPV status conversion to identify the vaginal microbiota that was associated with HPV clearance under heterogeneous personal risk factors. A total of 38 women participated by self-collecting a cervicovaginal mucus (CVM) sample that was sent for metagenomics sequencing. Most of the participants also filled in personal risk factors questionnaire through an eHealth platform and authorized the use of their previous HPV genotyping results stored in this eHealth platform. Based on the two HPV results, the participants were grouped into three cohorts, namely HPV negative, HPV persistent infection, and HPV status conversion. The relative abundance of VMB and personal factors were compared among these three cohorts. A correlation investigation was performed between VMB and the significant personal factors to characterize a robustness of the panel for HPV status change using R programming. At baseline, 12 participants were HPV-negative, and 22 were HPV-positive. Within one year, 18 women remained HPV-positive, 12 were HPV-negative and 4 participants showed HPV clearance. The factors in the eHealth questionnaire were systematically evaluated which identified several factors significantly associated with persistent HPV infection, including age, salary, history of reproductive tract infection, and the total number of sexual partners. Concurrent vaginal microbiome samples suggest that a candidate biomarker panel consisting of Lactobacillus gasseri, Streptococcus agalactiae, and Timona prevotella bacteria, which may be associated with HPV clearance. This pilot study indicates a stable HPV status-related vaginal microbe environment. To establish a robust biomarker panel for clinical use, larger cohorts will be recruited into follow-up studies.

Analysis of Selected Nutritional Parameters in Patients with HPV-Related and Non-HPV-Related Oropharyngeal Cancer before and after Radiotherapy Alone or Combined with Chemotherapy

Background: Radiotherapy plays an essential role in the treatment of oropharyngeal carcinoma (OPC). The aim of this study was to assess and compare the nutritional status (NS) of patients with HPV-related (HPV+) and non-HPV-related (HPV-) OPC before and after radiotherapy (RT) or chemoradiotherapy (CRT). Methods: The analysis included 127 patients with OPC who underwent radiotherapy (RT) alone, or in combination with chemotherapy (CRT), in the I Radiation and Clinical Oncology Department of Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland. Patients were divided according to HPV status. Confirmation of HPV etiology was obtained from FFPE (formalin-fixed, paraffin-embedded) tissue material and/or extracellular circulating HPV DNA. Basic anthropometric and biochemical parameters before and after RT/CRT were compared between the HPV- and HPV+ groups. The effect of NS on survival was also analyzed. Results: In both groups, a significant decrease in all analyzed nutritional parameters was noted after RT/CRT (p < 0.01). CRT caused significant weight loss and decreases in BMI, albumin, total lymphocyte count (TLC), and hemoglobin concentration, as well as an increase in the Nutritional Risk Score (NRS) 2002, in HPV- and HPV+ patients. A significant decrease in prealbumin levels after CRT was noted only in HPV+ patients. RT caused a significant decrease in hemoglobin concentration and TLC in HPV- patients. There were no significant differences regarding other nutritional parameters after RT in either group. RT did not have negative impact on body mass index (BMI), weight, NRS, CRP, Alb, Prealb, or PNI. Overall survival (OS) and disease-free survival (DFS) were significantly better in patients with a higher BMI in the HPV- group (OS, p = 0.011; DFS, p = 0.028); DFS was significantly better in patients with C-reactive protein (CRP) < 3.5 g/dL in the HPV- (p = 0.021) and HPV+ (p = 0.018) groups, and with total lymphocyte count (TLC) >1.28/mm3 in the HPV+ group (p = 0.014). Higher NRS 2002 was an independent adverse prognostic factor for OS and DFS in HPV-, but not in the HPV+ group. Kaplan−Meier analysis showed that both OS and DFS were significantly better in HPV- patients with lower NRS 2002 scores. However, this relationship was not observed in the HPV+ group. Conclusions: Regardless of HPV status, patients with OPC can develop malnutrition during RT/CRT. Therefore, nutritional support during RT/CRT is required in patients with HPV- and HPV+ OPC.

Comparison of Selected Immune and Hematological Parameters and Their Impact on Survival in Patients with HPV-Related and HPV-Unrelated Oropharyngeal Cancer

Simple Summary

This is a research article on oropharyngeal cancer (OPC). The aim of the study was to assess and compare basic immune parameters and ratios in patients with Human Papilloma Virus (HPV)+ and HPV− OPC, before and after radiotherapy (RT) or chemoradiotherapy (CRT), and to investigate their impact on overall survival (OS) and disease-free survival (DFS). The higher neutrophil-lymphocyte ratio (NLR) and systemic immune inflammation (SII) are significant adverse prognostic factors for HPV+ OPC patients, because they are significantly associated with both inferior OS and DFS in this group, whereas the higher platelet cells (PLT) count is significant adverse prognostic factor for HPV− OPC patients, because it is significantly associated with inferior OS and DFS in this group. This study confirmed that determination of HPV etiology as well as analysis of various hematological and immune parameters should be a standard management in OPC patients in order to properly treat them for improved prognosis.

Abstract

Several immune and hematological parameters are associated with survival in patients with oropharyngeal cancer (OPC). The aim of the study was to analyze selected immune and hematological parameters of patients with HPV-related (HPV+) and HPV-unrelated (HPV−) OPC, before and after radiotherapy/chemoradiotherapy (RT/CRT) and to assess the impact of these parameters on survival. One hundred twenty seven patients with HPV+ and HPV− OPC, treated with RT alone or concurrent chemoradiotherapy (CRT), were included. Patients were divided according to HPV status. Confirmation of HPV etiology was obtained from FFPE (Formalin-Fixed, Paraffin-Embedded) tissue samples and/or extracellular circulating HPV DNA was determined. The pre-treatment and post-treatment laboratory blood parameters were compared in both groups. The neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), and systemic immune inflammation (SII) index were calculated. The impact of these parameters on overall (OS) and disease-free (DFS) survival was analyzed. In HPV+ patients, a high pre-treatment white blood cells (WBC) count (>8.33 /mm³), NLR (>2.13), SII (>448.60) significantly correlated with reduced OS, whereas high NLR (>2.29), SII (>462.58) significantly correlated with reduced DFS. A higher pre-treatment NLR and SII were significant poor prognostic factors for both OS and DFS in the HPV+ group. These associations were not apparent in HPV− patients. There are different pre-treatment and post-treatment immune and hematological prognostic factors for OS and DFS in HPV+ and HPV− patients. The immune ratios could be considered valuable biomarkers for risk stratification and differentiation for HPV− and HPV+ OPC patients.