Driving the HPV-associated cancer prevention message home

Wade Smith knew something was wrong when he spotted the lump on his neck while shaving one morning in September 2015. He wasn’t too surprised when Steven Frank, M.D., a radiation oncologist and director of MD Anderson’s Proton Therapy Center, told him it was tonsil cancer. And he wasn’t even surprised when Head and Neck Surgery professor Neil Gross, M.D., told him that the biopsy revealed that the cancer was caused by the human papillomavirus, more commonly called HPV.

As a dentist specializing in making replacements for teeth and parts of the jaw, Smith was very familiar with the rising numbers of men middle age and older being diagnosed with HPV-related head and neck cancers.

“Head and neck cancers were already something I was talking to my patients about. And now I’m even quicker to tell them about HPV-associated cancers, what signs they should look for and how it can be prevented through vaccines,” Smith says. “I also tell them that I had an HPV-associated cancer to show just how common it really is. It doesn’t bother me to tell people that I’ve had it.”

Smith isn’t alone. According to the Centers for Disease Control and Prevention, 14,800 men and 3,400 women are diagnosed with new cases of HPV-associated oropharyngeal cancer, also known as throat cancer, each year. The average age at diagnosis is 61 and 62 for men and women respectively.

In the past, many cases of head and neck cancers were typically thought of as associated with tobacco. It was spotted in older patients who had used tobacco for years. Often, the prognosis wasn’t good. But now, that’s changing. Recent studies show that more than 70 percent of throat cancers are linked to HPV.

“We’re seeing an epidemic of HPV-related throat cancers,” says Faye Johnson, M.D., Ph.D., associate professor of Thoracic, Head and Neck Medical Oncology at MD Anderson.

But there is some good news. These cancers respond well to treatment, giving patients a prognosis for disease-free survival of 80 percent.  

“These cancers are treatable, but historically the treatment was very difficult for the patient. The treatment-related side effects can affect our patients for the rest of their lives,” Johnson says. “So our mission has evolved to help patients not only beat cancer, but allow them to do so while experiencing less side effects and a better quality of life.”
MD Anderson is tackling every stage of fighting this increase in HPV-related head and neck cancers, including efforts in research, treatment – including advances in chemotherapy, immunotherapy, radiation and surgery – survivorship and prevention.

Treatment

When patients with HPV-related head and neck cancers first come to MD Anderson, they enter the “fast track program,” a streamlined program that helps patients get in and out quickly. Since the effort started about four years ago, about 1,000 patients have gone through the program. They meet with different members of the multidisciplinary team, including specialists from Radiation Oncology, Medical Oncology, Dental Oncology, Surgery and Speech Pathology, because many patients undergo multiple types of treatment. Here’s how MD Anderson’s physicians and researchers are working to make improvements in each of these areas:

Immunotherapy: Working with surgeon-scientist Gross, medical oncologist Renata Ferrarotto, M.D., is focusing on identifying predictive biomarkers that can be used to select patients who will benefit most from immunotherapy. The goal of the project is to determine if the immunotherapy drug durvalumab, alone or in combination with tremelimumab, another immunotherapy drug, can control or shrink cases of oropharyngeal squamous cell carcinoma before standard-of-care surgery is conducted.

Surgery: Historically, surgery was a common type of treatment. But over time, doctors moved away from it because recovery from these surgeries was so difficult. But as surgical advances and treatments improved with the advent of robotics, surgery for tonsil cancer, like Smith’s, is becoming more common again.

And now MD Anderson surgeons have a new robotic tool to help them perform less invasive surgeries that help patients heal more quickly. Unlike other robots used in surgery, the Da Vinci SP is designed specifically for operating on the mouth and throat, which without the robot’s camera and arms can be difficult to reach. The robot recently was approved by the Food and Drug Administration for treating head and neck cancers.

“The robotic arms are small and nimble and the camera makes me feel like I’m almost inside the patient’s mouth,” Gross says.

Radiation: Radiation therapy techniques have changed significantly over the past two decades as a result of improvements in engineering and delivery: the use of photon energy, intensity-modulated radiation therapy and adaptive radiation therapy that individually tailors the treatment and reduces the intensity of side effects. Customized radiation stents – now being fabricated by 3D technology – allow for the oral cavity to be placed in a repeatable position throughout the course of treatment, reducing soft and hard tissue damage.

Curtis Pickering, Ph.D., assistant professor of Head and Neck Surgery, conducted a study that may change the course of future treatment plans. His study identifies a genetic biomarker that separates HPV-positive patients into two groups. This grouping can potentially provide the radiation oncologist with the genetic information needed to assess whether a patient will need to intensify treatment or be safe for de-intensified treatment, based on the HPV-positive grouping. The primary focus is to ensure patients have the highest possible quality of life after treatment ends.

“What I’m hoping is we’ve found some new fundamental aspects of HPV biology related to the carcinogenic process, the progression of the tumor and response to therapy,” Pickering says. “If we’re able to validate this in future studies, it could be incredibly clinically useful across several HPV-related tumor types.” Gross and Pickering are now working together to put this test into practice.

Side effects

Even with the steps MD Anderson doctors are taking to minimize side effects, head and neck cancer patients do often experience them – especially since these patients are so young and have so many years of life ahead, giving them more time to develop side effects. And given the sensitive areas that have been treated, the symptoms – like dry mouth, trouble speaking or swallowing – can be painful and life-altering. MD Anderson is working to not just treat the cancer, but also to ease the side effects of treatment.

About 10 days into radiation, patients may start experiencing some side effects. MD Anderson has a team of oral oncologists and maxillofacial prosthodontists to assist those patients, whether by adjusting their diet to ease symptoms or creating dentures or prostheses especially for them.

“Each patient with head and neck cancer will have a personalized approach to oral care to include oral cleaning, soft tissue protectants, oral opening exercise and tooth decay prevention based on outcomes and research,” says Mark Chambers, D.M.D., a professor of Head and Neck Surgery.

In addition, about 5 to 10 percent of patients with mouth and throat cancers will develop difficulty swallowing. This often occurs about eight years after cancer treatment has been completed. To help this specific patient population, MD Anderson created the Radiation Swallowing Pathway and Swallowing Boot Camp Program.

“We organize swallowing therapies into a stepwise, intensive program to fit the needs of patients with head and neck cancer along their journey of survivorship,” explains speech-language pathologist Kate Hutcheson, Ph.D., who is conducting research designed to improve patients’ ability to comfortably swallow.

The goal is for all patients to receive basic therapies to help them maintain swallowing function during and after cancer treatment.

Since its inception nearly seven years ago, more than 130 patients with more severe swallowing problems have completed the boot camp. This highly interdisciplinary program takes patients through a stepwise program often culminating in three weeks of daily therapy. During this time, patients work on therapeutic exercises and swallowing practice under the guidance of a speech pathologist. While the techniques do not completely reverse the side effects, most patients experience functional gains and report an improved quality of life after completing the boot camp, and many are able to avoid feeding tubes.

“The program is personalized and its impact is different for each patient, but the goal is to help each patient live better with the swallowing problem,” Hutcheson says.

Hutcheson is currently conducting research to help determine which patients are most likely to experience difficulty swallowing in hopes that such therapy techniques could be used earlier as a form of prevention.

Prevention

But it’s not enough to improve treatments used for HPV-associated head and neck cancers. MD Anderson experts often say the best way to treat cancer is to prevent patients from ever developing cancer in the first place.

The only way to prevent HPV-related head and neck cancer is through a two-dose preventive vaccine, recommended by the CDC for boys and girls ages 11-13, and a three-dose vaccine for those up to age 26 who were not vaccinated before their 15th birthday. Because HPV vaccination rates of adolescents in the U.S. are modest and many people are too old to be reliably protected by vaccination, the HPV-associated throat cancer epidemic is expected to continue for some time.

Unlike cervical cancer, HPV-related oropharyngeal cancer does not have a standardized screening process.

“We don’t have a Pap smear for the throat, but we desperately need something equivalent to allow for earlier detection,” Gross says.

Erich Sturgis, M.D., professor of Head and Neck Surgery, is the primary investigator for the HPV-related Oropharyngeal and Uncommon Cancers Screening Trial of meN (HOUSTON) study. Its goal is to determine the relationship between HPV and the cancer risk in those men who test positive for the cancer-causing “E” proteins in HPV type 16.

“Without screening, most HPV-related cancers are diagnosed later, requiring complicated care that often includes a combination of radiotherapy, chemotherapy and/or radical surgery,” Sturgis says.

The study aims to discover whether HPV screening can help determine which patients have a higher risk of developing HPV-related oropharyngeal cancer, placing the focus on early detection.

“The introduction of the Pap smear brought about dramatic declines in cervical cancer incidence and death rates,” Sturgis says. “We hope to one day to eliminate the problem of HPV-related head and neck cancers through vaccination and regularly scheduled screenings.”