Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

The impact of colonialism on head and neck cancer in Brazil: a historical essay focussing on tobacco, alcohol and slavery

Colonialism's enduring impact on Brazil has had significant implications for health and oncology outcomes. This historical essay delves into the profound changes brought about by the transatlantic slave trade from Africa to the Americas, particularly in terms of its influence on the economy, sociocultural habits, and health outcomes. This essay explores the enduring connections between the colonial period's operational dynamics in Brazil and the current epidemiological panorama of head and neck cancer (HNC). The examination provides original insights on the role of tobacco and alcohol production and consumption, alongside the investigation of structural racism, which contributes to disparities in access to diagnosis, treatment, and prognosis for patients with HNC. This article presents novel visions and an analysis of evidence-based strategies to disrupt the adverse impact of colonialism's legacy on the epidemiology of HNC in Brazil.

Differentiated thyroid carcinoma: what the nonspecialists needs to know

Differentiated thyroid carcinoma (DTC) accounts for most cases of thyroid cancer, and the heterogeneity of DTC requires that management decisions be taken by a multidisciplinary team involving endocrinologists, head and neck surgeons, nuclear medicine physicians, pathologists, radiologists, radiation oncologists, and medical oncologists. It is important for nonspecialists to recognize and refer patients with DTC who will benefit from a specialized approach. Recent advances in knowledge and changes in management of DTC call for the need to raise awareness on the part of these nonspecialist physicians, including general endocrinologists and medical oncologists at large. We provide an overview of diagnostic and therapeutic principles in DTC, especially those that bear direct implication on day-to-day management of these patients by generalists. Patients with DTC may be broadly categorized as having localized, locally persistent/recurrent, or metastatic disease. Current recommendations for DTC include a three-tiered system that classifies patients with localized disease into low, intermediate, or high risk of persistent or recurrent disease. Risk stratification should be performed at baseline and repeated on an ongoing basis, depending on clinical evolution. One of the overarching goals in the management of DTC is the need to personalize treatment by tailoring its modality and intensity according to ongoing prognostic stratification, evolving knowledge about the disease, and patient characteristics and preference. In metastatic disease that is refractory to radioactive iodine, thyroid tumors are being reclassified into molecular subtypes that better reflect their biological properties and for which molecular alterations can be targeted with specific agents.

Direct costs associated with the management of mucositis: A systematic review

Mucositis is one of the more frequent and costly adverse events following cancer treatment. To evaluate and report the direct economic outcomes associated with the management of mucositis across several cancer treatments we conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE/PubMed, and Embase were searched electronically and a total of 37 relevant studies were included. The costs attributable to mucositis in the hematopoietic stem cell transplantation setting ranged from 1124,47 US dollars (USD) to 299 214,14 USD per patient. The radiotherapy/chemoradiotherapy/radiotherapy plus molecular targeted therapy accounted for mucositis costs that ranged from 51,23 USD to 33 560,58 USD per patient. Costs for mucositis in the chemotherapy setting ranged from 4,18 USD to 31 963,64 USD per patient. When the cancer treatment was not specified, costs of mucositis ranged from 565,85 USD to as high as 20 279, 12 USD per patient. Mucositis costs from multimodal therapy ranged from 12,42 USD to 5670,46 USD per patient. The molecular targeted therapy setting included only one study and depending on the healthcare providers' perspective of each country evaluated, mucositis' costs ranged from 45,78 USD to 3484,91 USD per patient. Mucositis is associated with increased resource use, consultations, hospitalizations and extended hospitalizations, leading to a substantial incremental cost that exacerbates the economic burden on the patient, health plan and health system across several cancer treatments and diagnosis. More studies with a prospective evaluation of the economic costs associated with mucositis management are needed.

Global prevalence of human papillomavirus-driven oropharyngeal squamous cell carcinoma following the ASCO guidelines: A systematic review and meta-analysis

OBJECTIVES

to provide accurate information about the global prevalence of human papillomavirus (HPV) in oropharyngeal squamous cell carcinomas (OPSCC).

MATERIAL AND METHODS

a systematic review was performed using three main electronic databases. Studies were independently assessed by two reviewers based on established eligibility criteria, to identify the prevalence of HPV-driven OPSCC following criteria defined by the American Society of Clinical Oncology. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Statistical software MedCalc was used to perform meta-analyses.

RESULTS

from 2215 records found, 15 were included, reporting data from 6009 patients (time period range: 1980-2016), distributed in 11 countries. Eleven studies were considered as presenting low risk, and four as moderate risk of bias. Using proportion meta-analysis, pooled prevalence of HPV-driven OPSCC was 44.8 % (95 %CI: 36.4-53.5 %; i² = 97.6 %), with the highest rates in New Zealand (74.5 %; 95 %CI: 60.9-85.3 %), and the lowest in Brazil (11.1 %; 95 %CI: 4.5-21.5 %). HPV prevalence was similar between males (45.7 %; 95 %CI: 36.5-55.0 %; i² = 96.4 %) and females (42.2 %; 95 %CI: 34.3-50.5 %; i² = 85.4 %). Mean/median age ranged from 59.1-67.1 years in the HPV-negative group, and from 55.7-63.5 years in the HPV-positive group. There was an overall discordance between testing by p16 (49.4 %; 95 %CI, 38.2-60.5 %; i² = 96.2 %) and p16+ISH/PCR (44.7 %; 95 %CI, 33.5-56.2 %; i² = 96.4 %).

CONCLUSION

Overall pooled prevalence of HPV-driven OPSCC was approximately 45 %, with similar distribution among males and females. Double p16/HPV-DNA/RNA testing may be considered to increase specificity and prognostic accuracy.

Evaluation of the Erythrocyte Membrane in Head and Neck Cancer Patients

Head and neck squamous cell carcinoma (HNSCC) is a heterogeneous and complex disease, both from a clinical and molecular point of view. The prolonged use of alcohol and tobacco, along with the release of tumor secretions can modulate blood cells, such as erythrocytes. Here, this study was conducted with 24 patients diagnosed with HNSCC and an equal number of healthy individuals are matched by age and gender. The levels of lipid peroxidation were measured using the individual plasma, while for lipid concentrations, identification and quantification Na, K-ATPase activity and osmotic fragility, the red blood cell concentrate were used. The release of TBARS was significantly higher in patients with HNSCC. The lipid profile assays demonstrated a rearrangement of the erythrocyte membrane due to a decrease in total phospholipids and phosphatidylethanolamine followed by an increase in total cholesterol and phosphatidylcholine. Na, K-ATPase activity also increased. Erythrocytes were more fragile in patients with HNSCC than in health individuals. Therefore, the membrane of erythrocytes were rearranged and Na, K-ATPase function altered in the HNSCC patients. Our findings suggests that the alcohol, tobacco and tumor secretion modulate in a specific manner that the erythrocytes membranes of these patients making this system a potential tool for HNSCC biomarker of tumor progression.

Effect of the COVID-19 Pandemic on the Activity of Physicians Working in the Areas of Head and Neck Surgery and Otorhinolaryngology

Introduction  Coronavirus disease 2019 (COVID-19) is an acute infection caused by the new coronavirus (SARS-CoV-2) and it is highly transmissible, especially through respiratory droplets. To prepare the health system for the care of these patients also led to a restriction in the activity of several medical specialties. Physicians who work with patients affected by diseases of the head and neck region constitute one of the populations most vulnerable to COVID-19 and also most affected by the interruption of their professional activities.

Objective  The aim of the present study was to assess the impact of the COVID-19 pandemic on the practice of head and neck surgeons and otorhinolaryngologists in Brazil.

Methods  An anonymous online survey of voluntary participation was applied, containing 30 questions regarding demographic aspects, availability of personal protective equipment (PPE), and impact on the routine of head and neck surgeons and otorhinolaryngologists, as well as clinical oncologists and radiation oncologists who work with head and neck diseases.

Results  Seven hundred and twenty-nine answers were received in a period of 4 days, ∼ 40 days after the 1 ^st confirmed case in Brazil. With professionals working in public and private services, there was a high level of concerns with the disease and its consequences, limited availability of PPE and a significant decrease in the volume of specialized medical care.

Conclusion  The study demonstrated a direct impact of the COVID-19 pandemic on the clinical practice of specialties related to the treatment of patients with diseases of the head and neck region already in the beginning of the illness management in Brazil.

Impact of systemic treatment associated to radiotherapy on quality of life in locally advanced head and neck cancer patients in Brazil: Prospective real-world data study

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Background: the purpose of this study was to compare quality of life (QoL) and overall survival (OS) in patients with locally advanced head and neck cancer treated with radiotherapy only (RT), chemoradiotherapy with cisplatin (CT-RT) or RT with cetuximab (CET-RT). Methods: in this real-world, multi-institutional and prospective study, QoL outcomes were assessed using EORTC QLQ-C30 and QLQ-H&N43 questionnaires. Patients were treated according to each participating institution’s protocol. The Item Response Theory was used to generate a global QoL score, based on the 71 questions of both forms. Questionnaires were completed before treatment and every three months, thereafter. Survival was calculated using the Kaplan-Meyer method, and groups were compared by the log-rank test. The impact of the treatment modalities on QoL was analyzed using multivariate regression analyses. Results: Six hundred and twenty-six patients, with tumors located at the oral cavity (36%), oropharynx (30%), larynx (21%), hypopharynx (9%) and nasopharynx (4%) were included. Median follow up was 10.2 months. RT was delivered to 39% of the patients while 58% received CT-RT and 3% received CET-RT. Patients submitted to surgery were not included. OS was higher when systemic treatment was added to RT (median OS CET-RT: 21.9 months and CT-RT: 24.3 months, versus 14.2 months with RT, p < 0.05). A decrease in QoL during treatment was observed in all patients’ groups, but CT-RT had a statistically significant negative impact on QoL when compared to CET-RT (p = 0.02). An important limitation of the study is the low number of patients that received this last treatment modality, what is, probably, a result of local policies on reimbursement. Other factors that influenced QoL were alcohol consumption (better QoL for patients with no history of chronic alcohol consumption, p = 0.007) and radiotherapy technique (better QoL for patients treated with intensity-modulated RT, when compared to conformal RT, p < 0.001). Conclusions: We observed, as expected, better OS with systemic therapy, when associated to RT. A decrease in QoL was detected, as well, during treatment, but a less pronounced decrease was seen in patients receiving CET-RT, when compared to CT-RT. More studies are needed to confirm the QoL improvement in patients submitted to this last treatment approach.

CD4, CD8 and PD1 immunoexpression in oral premalignant lesions (PML) and oral squamous cell carcinoma (OSCC) and its association with malignant transformation

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Background: OSCC is a public health problem worldwide, mainly due to its advanced stage diagnosis. The late diagnosis is a nonsense problem in view of this neoplasia often begins as PML. Clinical, molecular and immunological factors have been associated with the cancerization process. Objective: evaluate clinical differences and immunohistochemistry expression of PD1, CD4 and CD8 in PML that transformed in OSCC (PML-OSCC) and PML that didn´t transformed in OSCC (PML-NOSSC). Methods: CD4, CD8 and PD1 immunohistochemistry studies were carried out on PML and OSCC samples of 11 patients with PML – OSCC and PML samples of 14 patients with PML-NOSCC. Statistical differences were analyzed between the two groups: PML-OSCC and PML-NOSCC. Results: Non-homogenous leukoplakia, tongue and lack of exposure to tobacco were associated with cancerization. PD1 strong immunoexpression were observed in 63.6% of PML and 90.9% of OSCC. There was no statistical difference CD4+ cells level in PML-OSCC and PML-NOSCC. A significant increase in CD8+ cells was noted in OSCC comparing with PML–OSCC (p = 0.05). CD8+ cells levels is higher in PML-NOSCC compared with PML-OSCC (p = 0.027). Conclusions: CD8+ cells infiltrate more PML-NOSCC than PML-OSCC. Carcinoma is more infiltrated by CD8+ cells than its associated premalignant lesion. The evolution of immune response from an immunosurveillance phase to editing, equilibrium, suppression and immuno-escape can be present in oral carcinogenesis process. Research Funding: FAPEMIG (Minas Gerais State Research Foundation).

Câncer de boca: avaliação do conhecimento e conduta dos dentistas na atenção primária à saúde

O câncer de boca representa um problema de saúde pública devido aos diagnósticos tardios e das taxas de morbimortalidade. Esse estudo avaliou o nível de conhecimento dos odontólogos (23) da atenção primária da rede pública de Divinópolis (MG) sobre o câncer bucal. Empregou-se questionário estruturado e os dados obtidos demonstraram que 39,1% dos entrevistados não sabiam qual o tipo mais comum de câncer de boca; 35% avaliaram seu nível de conhecimento como bom ou ótimo. Fatores de risco apontados: uso do tabaco, antecedentes familiares, uso do álcool e exposição solar. Apenas 13% receberam treinamento para o exame de câncer bucal na graduação. Esses achados reforçam a necessidade de abordagem do tema no período de formação acadêmica e de educação continuada.

Effects of digoxin and Na, K-ATPase immunoexpression on human oral squamous carcinomas

AIM

The present study evaluated the expression of α1 and β1 Na,K-ATPase, as well as the effects of digoxin (DGX) on oral squamous cell carcinomas (OSCCs).

PATIENTS AND METHODS

Immunohistochemical expression of α1 and β1 Na,K-ATPase were evaluated in 60 patients who underwent treatment at the São João de Deus Hospital. SCC-25 viability was assessed by the colorimetric assay. Chi-square or Fisher's exact tests were used to analyze the association of α1 and β1 Na,K-ATPase expression with the variables.

RESULTS

Immunoexpression of α1 and β1 Na,K-ATPase were observed in 28% and 55% of the tumors, however these proteins were not significant prognostic factors. Tobacco was significantly associated with α1 expression. SCC-25 viability decreased significantly after treatment with 1 μM DGX at 24 h.

CONCLUSION

The smoking status of OSCC patients was significantly associated with α1 expression and DGX affected the SCC-25 viability in a dose- and duration-dependent manner.