Head & Neck/Thyroid Cancers

New research shows that men in their 20s and 30s have worse survival from many different types of brain tumors than women of the same age. And, researchers say, it’s not exactly clear why.

Differences in treatment may mediate some of the association, but biologic sex itself appears to be a stronger risk factor for death, according to the study published online Feb. 8 in Cancer.

The excess in male deaths is “concerning, and we need more clinical data and more biological tumor data within each histologic type of brain tumor to understand why these young adult men who would be otherwise healthy are dying of these brain tumors,” study author Lindsay Williams, PhD, MPH, with the division of epidemiology and clinical research, University of Minnesota, Minneapolis, told this news organization.

Central nervous system tumors rank among the top five cancers diagnosed in young adults aged 20-39 years.

Dr. Williams and her colleagues previously showed that men are more likely to develop brain tumors. Their latest study shows that men die more frequently from brain tumors as well.

Using the National Cancer Database, they identified 47,560 young adults aged 20-39 (47% male) diagnosed with a CNS tumor between 2004 and 2016.

After adjusting for relevant factors, males had a 47% increased risk of dying after a brain tumor diagnosis compared with females (hazard ratio, 1.47; 95% confidence interval, 1.41-1.53).

Males had significantly worse overall survival than females for all CNS tumors combined and for nine of 16 histologic types – namely, diffuse astrocytoma (HR, 1.30), anaplastic astrocytoma (HR, 1.25), glioblastoma (HR, 1.14), oligodendroglioma (HR, 1.37), oligoastrocytic tumors (HR, 1.22), ependymal tumors (HR, 1.29), other malignant gliomas (HR, 1.43), neuronal and mixed neuronal-glial tumors (HR, 1.52), and meningioma (HR, 2.01; all P < .05).

The researchers identified no histologies where females had worse survival.

Five-year survival differed between females and males by at least 5% for all histologies combined (83.2% female and 71.2% male) as well as for diffuse astrocytoma (75.1% vs. 68.5%), anaplastic astrocytoma (63.5% vs. 57.5%), oligoastrocytic tumors (80.2% vs. 74.7%), other malignant gliomas (74.1% vs. 64.9%), and germ cell tumors (92.4% vs. 86.5%).

The researchers estimated that had survival in men been equal to that of women over the study period, 20% of total deaths and 34% of male deaths could have been avoided.

They say future population-based studies are needed to confirm these findings and determine whether tumor biology or responses to therapy are driving forces of the observed male excess in death from brain tumors.

“We cannot discount the role of sex differences in diagnosis, treatment, or behavioral risk factors that may underlie the better survival for women after a brain tumor diagnosis,” they write. 

“Hopefully, our research will increase awareness of sex differences in brain tumor outcomes in young adults and encourage other researchers with similar datasets to look at this same question and see if they observe a similar trend,” Dr. Williams said in an interview.

The study was supported by the National Cancer Institute. Dr. Williams has no relevant disclosures. One author, Christopher L. Moertel, MD, is chief medical officer for OX2 Therapeutics, has stock in OX2 Therapeutics, and reports patents relevant to his relationship with OX2 Therapeutics.

A version of this article first appeared on Medscape.com.

New research shows that men in their 20s and 30s have worse survival from many different types of brain tumors than women of the same age. And, researchers say, it’s not exactly clear why.

Differences in treatment may mediate some of the association, but biologic sex itself appears to be a stronger risk factor for death, according to the study published online Feb. 8 in Cancer.

The excess in male deaths is “concerning, and we need more clinical data and more biological tumor data within each histologic type of brain tumor to understand why these young adult men who would be otherwise healthy are dying of these brain tumors,” study author Lindsay Williams, PhD, MPH, with the division of epidemiology and clinical research, University of Minnesota, Minneapolis, told this news organization.

Central nervous system tumors rank among the top five cancers diagnosed in young adults aged 20-39 years.

Dr. Williams and her colleagues previously showed that men are more likely to develop brain tumors. Their latest study shows that men die more frequently from brain tumors as well.

Using the National Cancer Database, they identified 47,560 young adults aged 20-39 (47% male) diagnosed with a CNS tumor between 2004 and 2016.

After adjusting for relevant factors, males had a 47% increased risk of dying after a brain tumor diagnosis compared with females (hazard ratio, 1.47; 95% confidence interval, 1.41-1.53).

Males had significantly worse overall survival than females for all CNS tumors combined and for nine of 16 histologic types – namely, diffuse astrocytoma (HR, 1.30), anaplastic astrocytoma (HR, 1.25), glioblastoma (HR, 1.14), oligodendroglioma (HR, 1.37), oligoastrocytic tumors (HR, 1.22), ependymal tumors (HR, 1.29), other malignant gliomas (HR, 1.43), neuronal and mixed neuronal-glial tumors (HR, 1.52), and meningioma (HR, 2.01; all P < .05).

The researchers identified no histologies where females had worse survival.

Five-year survival differed between females and males by at least 5% for all histologies combined (83.2% female and 71.2% male) as well as for diffuse astrocytoma (75.1% vs. 68.5%), anaplastic astrocytoma (63.5% vs. 57.5%), oligoastrocytic tumors (80.2% vs. 74.7%), other malignant gliomas (74.1% vs. 64.9%), and germ cell tumors (92.4% vs. 86.5%).

The researchers estimated that had survival in men been equal to that of women over the study period, 20% of total deaths and 34% of male deaths could have been avoided.

They say future population-based studies are needed to confirm these findings and determine whether tumor biology or responses to therapy are driving forces of the observed male excess in death from brain tumors.

“We cannot discount the role of sex differences in diagnosis, treatment, or behavioral risk factors that may underlie the better survival for women after a brain tumor diagnosis,” they write. 

“Hopefully, our research will increase awareness of sex differences in brain tumor outcomes in young adults and encourage other researchers with similar datasets to look at this same question and see if they observe a similar trend,” Dr. Williams said in an interview.

The study was supported by the National Cancer Institute. Dr. Williams has no relevant disclosures. One author, Christopher L. Moertel, MD, is chief medical officer for OX2 Therapeutics, has stock in OX2 Therapeutics, and reports patents relevant to his relationship with OX2 Therapeutics.

A version of this article first appeared on Medscape.com.

New research shows that men in their 20s and 30s have worse survival from many different types of brain tumors than women of the same age. And, researchers say, it’s not exactly clear why.

Differences in treatment may mediate some of the association, but biologic sex itself appears to be a stronger risk factor for death, according to the study published online Feb. 8 in Cancer.

The excess in male deaths is “concerning, and we need more clinical data and more biological tumor data within each histologic type of brain tumor to understand why these young adult men who would be otherwise healthy are dying of these brain tumors,” study author Lindsay Williams, PhD, MPH, with the division of epidemiology and clinical research, University of Minnesota, Minneapolis, told this news organization.

Central nervous system tumors rank among the top five cancers diagnosed in young adults aged 20-39 years.

Dr. Williams and her colleagues previously showed that men are more likely to develop brain tumors. Their latest study shows that men die more frequently from brain tumors as well.

Using the National Cancer Database, they identified 47,560 young adults aged 20-39 (47% male) diagnosed with a CNS tumor between 2004 and 2016.

After adjusting for relevant factors, males had a 47% increased risk of dying after a brain tumor diagnosis compared with females (hazard ratio, 1.47; 95% confidence interval, 1.41-1.53).

Males had significantly worse overall survival than females for all CNS tumors combined and for nine of 16 histologic types – namely, diffuse astrocytoma (HR, 1.30), anaplastic astrocytoma (HR, 1.25), glioblastoma (HR, 1.14), oligodendroglioma (HR, 1.37), oligoastrocytic tumors (HR, 1.22), ependymal tumors (HR, 1.29), other malignant gliomas (HR, 1.43), neuronal and mixed neuronal-glial tumors (HR, 1.52), and meningioma (HR, 2.01; all P < .05).

The researchers identified no histologies where females had worse survival.

Five-year survival differed between females and males by at least 5% for all histologies combined (83.2% female and 71.2% male) as well as for diffuse astrocytoma (75.1% vs. 68.5%), anaplastic astrocytoma (63.5% vs. 57.5%), oligoastrocytic tumors (80.2% vs. 74.7%), other malignant gliomas (74.1% vs. 64.9%), and germ cell tumors (92.4% vs. 86.5%).

The researchers estimated that had survival in men been equal to that of women over the study period, 20% of total deaths and 34% of male deaths could have been avoided.

They say future population-based studies are needed to confirm these findings and determine whether tumor biology or responses to therapy are driving forces of the observed male excess in death from brain tumors.

“We cannot discount the role of sex differences in diagnosis, treatment, or behavioral risk factors that may underlie the better survival for women after a brain tumor diagnosis,” they write. 

“Hopefully, our research will increase awareness of sex differences in brain tumor outcomes in young adults and encourage other researchers with similar datasets to look at this same question and see if they observe a similar trend,” Dr. Williams said in an interview.

The study was supported by the National Cancer Institute. Dr. Williams has no relevant disclosures. One author, Christopher L. Moertel, MD, is chief medical officer for OX2 Therapeutics, has stock in OX2 Therapeutics, and reports patents relevant to his relationship with OX2 Therapeutics.

A version of this article first appeared on Medscape.com.

The names of health care professionals and patients cited within the dialogue text have been changed to protect their privacy.

Early in my career, before I had any notion that years later I would be doing palliative care consults in a cancer center, I heard a senior physician refer to palliative care as “the most misunderstood” medical specialty. I wasn’t sure what she meant at that time, but over the years I have come to realize that she was right – most people, including many within health care, don’t have a good appreciation of what palliative care is or how it can help patients and health care teams.

A recent national survey about cancer-related health information found that of more than 1,000 surveyed Americans, less than 30% professed any knowledge of palliative care. Of those who had some knowledge of palliative care, around 30% believed palliative care was synonymous with hospice.¹ Another 15% believed that a patient would have to give up cancer-directed treatments to receive palliative care.¹

It’s not giving up

This persistent belief that palliative care is equivalent to hospice, or is tantamount to “giving up,” is one of the most commonly held myths I encounter in everyday practice.

I knock on the exam door and walk in.
A small, trim woman in her late 50s is sitting in a chair, arms folded across her chest, face drawn in.

“Hi,” I start. “I’m Sarah, the palliative care nurse practitioner who works in this clinic. I work closely with Dr. Smith.”
Dr. Smith is the patient’s oncologist.

“I really didn’t want to meet you,” she says in a quiet voice, her eyes large with concern.

I don’t take it personally. Few patients really want to be in the position of needing to meet the palliative care team.

“I looked up palliative care on Google and saw the word hospice.”

“Yeah,” I say. “I hear that a lot. Well, I can reassure you that this isn’t hospice.
In this clinic, our focus is on your cancer symptoms, your treatment side effects, and your quality of life.”

She looks visibly relieved. “Quality of life,” she echoes. “I need more of that.”
“OK,” I say. “So, tell me what you’re struggling with the most right now.”

That’s how many palliative care visits start. I actually prefer if patients haven’t heard of palliative care because it allows me to frame it for them, rather than having to start by addressing a myth or a prior negative experience. Even when patients haven’t had a negative experience with palliative care per se, typically, if they’ve interacted with palliative care in the past, it’s usually because someone they loved died in a hospital setting and it is the memory of that terrible loss that becomes synonymous with their recollection of palliative care.

Many patients I meet have never seen another outpatient palliative care practitioner – and this makes sense – we are still too few and far between. Most established palliative care teams are hospital based and many patients seen in the community do not have easy access to palliative care teams where they receive oncologic care.² As an embedded practitioner, I see patients in the same exam rooms and infusion centers where they receive their cancer therapies, so I’m effectively woven into the fabric of their oncology experience. Just being there in the cancer center allows me to be in the right place at the right time for the right patients and their care teams.
 

More than pain management

Another myth I tend to dispel a lot is that palliative care is just a euphemism for “pain management.” I have seen this less lately, but still occasionally in the chart I’ll see documented in a note, “patient is seeing palliative/pain management,” when a patient is seeing me or one of my colleagues. Unfortunately, when providers have limited or outdated views of what palliative care is or the value it brings to patient-centered cancer care, referrals to palliative care tend to be delayed.³

“I really think Ms. Lopez could benefit from seeing palliative care,” an oncology nurse practitioner says to an oncologist.
I’m standing nearby, about to see another patient in one of the exam rooms in our clinic.
“But I don’t think she’s ready. And besides, she doesn’t have any pain,” he says.
He turns to me quizzically. “What do you think?”

“Tell me about the patient,” I ask, taking a few steps in their direction.

“Well, she’s a 64-year-old woman with metastatic cancer.
She has a really poor appetite and is losing some weight.
Seems a bit down, kind of pessimistic about things.
Her scan showed some new growth, so guess I’m not surprised by that.”

“I might be able to help her with the appetite and the mood changes. 
I can at least talk with her and see where she’s at,” I offer.

“Alright,” he says. “We’ll put the palliative referral in.”
He hesitates. “But are you sure you want to see her? 
She doesn’t have any pain.” He sounds skeptical.

“Yeah, I mean, it sounds like she has symptoms that are bothering her, so I’d be happy to see her. She sounds completely appropriate for palliative care.”

I hear this assumption a lot – that palliative care is somehow equivalent to pain management and that unless a patient’s pain is severe, it’s not worth referring the patient to palliative care. Don’t get me wrong – we do a lot of pain management, but at its heart, palliative care is an interdisciplinary specialty focused on improving or maintaining quality of life for people with serious illness. Because the goal is so broad, care can take many shapes.⁴

In addition to pain, palliative care clinicians commonly treat nausea, shortness of breath, constipation or diarrhea, poor appetite, fatigue, anxiety, depression, and insomnia.
 

Palliative care is more than medical or nursing care

A related misconception about palliative care held by many lay people and health care workers alike is that palliative care is primarily medical or nursing care focused mostly on alleviating physical symptoms such as pain or nausea. This couldn’t be further from the truth.

We’ve been talking for a while.
Ms. Lopez tells me about her struggles to maintain her weight while undergoing chemotherapy. She has low-grade nausea that is impacting her ability and desire to eat more and didn’t think that her weight loss was severe enough to warrant taking medication.
We talk about how she may be able to use antinausea medication sparingly to alleviate nausea while also limiting side effects from the medications—which was a big concern for her.

I ask her what else is bothering her.

She tells me that she has always been a strong Catholic and even when life has gotten tough, her faith was never shaken – until now.
She is struggling to understand why she ended up with metastatic cancer at such a relatively young age—why would God do this to her?
She had plans for retirement that have since evaporated in the face of a foreshortened life.
Why did this happen to her of all people? She was completely healthy until her diagnosis.
Her face is wet with tears.

We talk a little about how a diagnosis like this can change so much of a person’s life and identity. I try to validate her experience. She’s clearly suffering from a sense that her life is not what she expected, and she is struggling to integrate how her future looks at this point.

I ask her what conversations with her priest have been like.

At this point you may be wondering where this conversation is going. Why are we talking about Ms. Lopez’s religion? Palliative care is best delivered through high functioning interdisciplinary teams that can include other supportive people in a patient’s life. We work in concert to try to bring comfort to a patient and their family.⁴ That support network can include nurses, physicians, social workers, and chaplains. In this case, Ms. Lopez had not yet reached out to her priest. She hasn’t had the time or energy to contact her priest given her symptoms.
 

“Can I contact your priest for you?
Maybe he can visit or call and chat with you?”
She nods and wipes tears away.
“That would be really nice,” she says. “I’d love it if he could pray with me.”

A few hours after the visit, I call Ms. Lopez’s priest.
I ask him to reach out to her and about her request for prayer.
He says he’s been thinking about her and that her presence has been missed at weekly Mass. He thanks me for the call and says he’ll call her tomorrow.

I say my own small prayer for Ms. Lopez and head home, the day’s work completed.

Sarah D'Ambruoso was born and raised in Maine. She completed her undergraduate and graduate nursing education at New York University and UCLA, respectively, and currently works as a palliative care nurse practitioner in an oncology clinic in Los Angeles. 

References

1. Cheng BT et al. Patterns of palliative care beliefs among adults in the U.S.: Analysis of a National Cancer Database. J Pain Symptom Manage. 2019 Aug 10. doi: 10.1016/j.jpainsymman.2019.07.030.

2. Finlay E et al. Filling the gap: Creating an outpatient palliative care program in your institution. Am Soc Clin Oncol Educ Book. 2018 May 23. doi: 10.1200/EDBK_200775.

3. Von Roenn JH et al. Barriers and approaches to the successful integration of palliative care and oncology practice. J Natl Compr Canc Netw. 2013 Mar. doi: 10.6004/jnccn.2013.0209.

4. Ferrell BR et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2016 Oct 31. doi: 10.1200/JCO.2016.70.1474.

The names of health care professionals and patients cited within the dialogue text have been changed to protect their privacy.

Early in my career, before I had any notion that years later I would be doing palliative care consults in a cancer center, I heard a senior physician refer to palliative care as “the most misunderstood” medical specialty. I wasn’t sure what she meant at that time, but over the years I have come to realize that she was right – most people, including many within health care, don’t have a good appreciation of what palliative care is or how it can help patients and health care teams.

A recent national survey about cancer-related health information found that of more than 1,000 surveyed Americans, less than 30% professed any knowledge of palliative care. Of those who had some knowledge of palliative care, around 30% believed palliative care was synonymous with hospice.¹ Another 15% believed that a patient would have to give up cancer-directed treatments to receive palliative care.¹

It’s not giving up

This persistent belief that palliative care is equivalent to hospice, or is tantamount to “giving up,” is one of the most commonly held myths I encounter in everyday practice.

I knock on the exam door and walk in.
A small, trim woman in her late 50s is sitting in a chair, arms folded across her chest, face drawn in.

“Hi,” I start. “I’m Sarah, the palliative care nurse practitioner who works in this clinic. I work closely with Dr. Smith.”
Dr. Smith is the patient’s oncologist.

“I really didn’t want to meet you,” she says in a quiet voice, her eyes large with concern.

I don’t take it personally. Few patients really want to be in the position of needing to meet the palliative care team.

“I looked up palliative care on Google and saw the word hospice.”

“Yeah,” I say. “I hear that a lot. Well, I can reassure you that this isn’t hospice.
In this clinic, our focus is on your cancer symptoms, your treatment side effects, and your quality of life.”

She looks visibly relieved. “Quality of life,” she echoes. “I need more of that.”
“OK,” I say. “So, tell me what you’re struggling with the most right now.”

That’s how many palliative care visits start. I actually prefer if patients haven’t heard of palliative care because it allows me to frame it for them, rather than having to start by addressing a myth or a prior negative experience. Even when patients haven’t had a negative experience with palliative care per se, typically, if they’ve interacted with palliative care in the past, it’s usually because someone they loved died in a hospital setting and it is the memory of that terrible loss that becomes synonymous with their recollection of palliative care.

Many patients I meet have never seen another outpatient palliative care practitioner – and this makes sense – we are still too few and far between. Most established palliative care teams are hospital based and many patients seen in the community do not have easy access to palliative care teams where they receive oncologic care.² As an embedded practitioner, I see patients in the same exam rooms and infusion centers where they receive their cancer therapies, so I’m effectively woven into the fabric of their oncology experience. Just being there in the cancer center allows me to be in the right place at the right time for the right patients and their care teams.
 

More than pain management

Another myth I tend to dispel a lot is that palliative care is just a euphemism for “pain management.” I have seen this less lately, but still occasionally in the chart I’ll see documented in a note, “patient is seeing palliative/pain management,” when a patient is seeing me or one of my colleagues. Unfortunately, when providers have limited or outdated views of what palliative care is or the value it brings to patient-centered cancer care, referrals to palliative care tend to be delayed.³

“I really think Ms. Lopez could benefit from seeing palliative care,” an oncology nurse practitioner says to an oncologist.
I’m standing nearby, about to see another patient in one of the exam rooms in our clinic.
“But I don’t think she’s ready. And besides, she doesn’t have any pain,” he says.
He turns to me quizzically. “What do you think?”

“Tell me about the patient,” I ask, taking a few steps in their direction.

“Well, she’s a 64-year-old woman with metastatic cancer.
She has a really poor appetite and is losing some weight.
Seems a bit down, kind of pessimistic about things.
Her scan showed some new growth, so guess I’m not surprised by that.”

“I might be able to help her with the appetite and the mood changes. 
I can at least talk with her and see where she’s at,” I offer.

“Alright,” he says. “We’ll put the palliative referral in.”
He hesitates. “But are you sure you want to see her? 
She doesn’t have any pain.” He sounds skeptical.

“Yeah, I mean, it sounds like she has symptoms that are bothering her, so I’d be happy to see her. She sounds completely appropriate for palliative care.”

I hear this assumption a lot – that palliative care is somehow equivalent to pain management and that unless a patient’s pain is severe, it’s not worth referring the patient to palliative care. Don’t get me wrong – we do a lot of pain management, but at its heart, palliative care is an interdisciplinary specialty focused on improving or maintaining quality of life for people with serious illness. Because the goal is so broad, care can take many shapes.⁴

In addition to pain, palliative care clinicians commonly treat nausea, shortness of breath, constipation or diarrhea, poor appetite, fatigue, anxiety, depression, and insomnia.
 

Palliative care is more than medical or nursing care

A related misconception about palliative care held by many lay people and health care workers alike is that palliative care is primarily medical or nursing care focused mostly on alleviating physical symptoms such as pain or nausea. This couldn’t be further from the truth.

We’ve been talking for a while.
Ms. Lopez tells me about her struggles to maintain her weight while undergoing chemotherapy. She has low-grade nausea that is impacting her ability and desire to eat more and didn’t think that her weight loss was severe enough to warrant taking medication.
We talk about how she may be able to use antinausea medication sparingly to alleviate nausea while also limiting side effects from the medications—which was a big concern for her.

I ask her what else is bothering her.

She tells me that she has always been a strong Catholic and even when life has gotten tough, her faith was never shaken – until now.
She is struggling to understand why she ended up with metastatic cancer at such a relatively young age—why would God do this to her?
She had plans for retirement that have since evaporated in the face of a foreshortened life.
Why did this happen to her of all people? She was completely healthy until her diagnosis.
Her face is wet with tears.

We talk a little about how a diagnosis like this can change so much of a person’s life and identity. I try to validate her experience. She’s clearly suffering from a sense that her life is not what she expected, and she is struggling to integrate how her future looks at this point.

I ask her what conversations with her priest have been like.

At this point you may be wondering where this conversation is going. Why are we talking about Ms. Lopez’s religion? Palliative care is best delivered through high functioning interdisciplinary teams that can include other supportive people in a patient’s life. We work in concert to try to bring comfort to a patient and their family.⁴ That support network can include nurses, physicians, social workers, and chaplains. In this case, Ms. Lopez had not yet reached out to her priest. She hasn’t had the time or energy to contact her priest given her symptoms.
 

“Can I contact your priest for you?
Maybe he can visit or call and chat with you?”
She nods and wipes tears away.
“That would be really nice,” she says. “I’d love it if he could pray with me.”

A few hours after the visit, I call Ms. Lopez’s priest.
I ask him to reach out to her and about her request for prayer.
He says he’s been thinking about her and that her presence has been missed at weekly Mass. He thanks me for the call and says he’ll call her tomorrow.

I say my own small prayer for Ms. Lopez and head home, the day’s work completed.

Sarah D'Ambruoso was born and raised in Maine. She completed her undergraduate and graduate nursing education at New York University and UCLA, respectively, and currently works as a palliative care nurse practitioner in an oncology clinic in Los Angeles. 

References

1. Cheng BT et al. Patterns of palliative care beliefs among adults in the U.S.: Analysis of a National Cancer Database. J Pain Symptom Manage. 2019 Aug 10. doi: 10.1016/j.jpainsymman.2019.07.030.

2. Finlay E et al. Filling the gap: Creating an outpatient palliative care program in your institution. Am Soc Clin Oncol Educ Book. 2018 May 23. doi: 10.1200/EDBK_200775.

3. Von Roenn JH et al. Barriers and approaches to the successful integration of palliative care and oncology practice. J Natl Compr Canc Netw. 2013 Mar. doi: 10.6004/jnccn.2013.0209.

4. Ferrell BR et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2016 Oct 31. doi: 10.1200/JCO.2016.70.1474.

The names of health care professionals and patients cited within the dialogue text have been changed to protect their privacy.

Early in my career, before I had any notion that years later I would be doing palliative care consults in a cancer center, I heard a senior physician refer to palliative care as “the most misunderstood” medical specialty. I wasn’t sure what she meant at that time, but over the years I have come to realize that she was right – most people, including many within health care, don’t have a good appreciation of what palliative care is or how it can help patients and health care teams.

A recent national survey about cancer-related health information found that of more than 1,000 surveyed Americans, less than 30% professed any knowledge of palliative care. Of those who had some knowledge of palliative care, around 30% believed palliative care was synonymous with hospice.¹ Another 15% believed that a patient would have to give up cancer-directed treatments to receive palliative care.¹

It’s not giving up

This persistent belief that palliative care is equivalent to hospice, or is tantamount to “giving up,” is one of the most commonly held myths I encounter in everyday practice.

I knock on the exam door and walk in.
A small, trim woman in her late 50s is sitting in a chair, arms folded across her chest, face drawn in.

“Hi,” I start. “I’m Sarah, the palliative care nurse practitioner who works in this clinic. I work closely with Dr. Smith.”
Dr. Smith is the patient’s oncologist.

“I really didn’t want to meet you,” she says in a quiet voice, her eyes large with concern.

I don’t take it personally. Few patients really want to be in the position of needing to meet the palliative care team.

“I looked up palliative care on Google and saw the word hospice.”

“Yeah,” I say. “I hear that a lot. Well, I can reassure you that this isn’t hospice.
In this clinic, our focus is on your cancer symptoms, your treatment side effects, and your quality of life.”

She looks visibly relieved. “Quality of life,” she echoes. “I need more of that.”
“OK,” I say. “So, tell me what you’re struggling with the most right now.”

That’s how many palliative care visits start. I actually prefer if patients haven’t heard of palliative care because it allows me to frame it for them, rather than having to start by addressing a myth or a prior negative experience. Even when patients haven’t had a negative experience with palliative care per se, typically, if they’ve interacted with palliative care in the past, it’s usually because someone they loved died in a hospital setting and it is the memory of that terrible loss that becomes synonymous with their recollection of palliative care.

Many patients I meet have never seen another outpatient palliative care practitioner – and this makes sense – we are still too few and far between. Most established palliative care teams are hospital based and many patients seen in the community do not have easy access to palliative care teams where they receive oncologic care.² As an embedded practitioner, I see patients in the same exam rooms and infusion centers where they receive their cancer therapies, so I’m effectively woven into the fabric of their oncology experience. Just being there in the cancer center allows me to be in the right place at the right time for the right patients and their care teams.
 

More than pain management

Another myth I tend to dispel a lot is that palliative care is just a euphemism for “pain management.” I have seen this less lately, but still occasionally in the chart I’ll see documented in a note, “patient is seeing palliative/pain management,” when a patient is seeing me or one of my colleagues. Unfortunately, when providers have limited or outdated views of what palliative care is or the value it brings to patient-centered cancer care, referrals to palliative care tend to be delayed.³

“I really think Ms. Lopez could benefit from seeing palliative care,” an oncology nurse practitioner says to an oncologist.
I’m standing nearby, about to see another patient in one of the exam rooms in our clinic.
“But I don’t think she’s ready. And besides, she doesn’t have any pain,” he says.
He turns to me quizzically. “What do you think?”

“Tell me about the patient,” I ask, taking a few steps in their direction.

“Well, she’s a 64-year-old woman with metastatic cancer.
She has a really poor appetite and is losing some weight.
Seems a bit down, kind of pessimistic about things.
Her scan showed some new growth, so guess I’m not surprised by that.”

“I might be able to help her with the appetite and the mood changes. 
I can at least talk with her and see where she’s at,” I offer.

“Alright,” he says. “We’ll put the palliative referral in.”
He hesitates. “But are you sure you want to see her? 
She doesn’t have any pain.” He sounds skeptical.

“Yeah, I mean, it sounds like she has symptoms that are bothering her, so I’d be happy to see her. She sounds completely appropriate for palliative care.”

I hear this assumption a lot – that palliative care is somehow equivalent to pain management and that unless a patient’s pain is severe, it’s not worth referring the patient to palliative care. Don’t get me wrong – we do a lot of pain management, but at its heart, palliative care is an interdisciplinary specialty focused on improving or maintaining quality of life for people with serious illness. Because the goal is so broad, care can take many shapes.⁴

In addition to pain, palliative care clinicians commonly treat nausea, shortness of breath, constipation or diarrhea, poor appetite, fatigue, anxiety, depression, and insomnia.
 

Palliative care is more than medical or nursing care

A related misconception about palliative care held by many lay people and health care workers alike is that palliative care is primarily medical or nursing care focused mostly on alleviating physical symptoms such as pain or nausea. This couldn’t be further from the truth.

We’ve been talking for a while.
Ms. Lopez tells me about her struggles to maintain her weight while undergoing chemotherapy. She has low-grade nausea that is impacting her ability and desire to eat more and didn’t think that her weight loss was severe enough to warrant taking medication.
We talk about how she may be able to use antinausea medication sparingly to alleviate nausea while also limiting side effects from the medications—which was a big concern for her.

I ask her what else is bothering her.

She tells me that she has always been a strong Catholic and even when life has gotten tough, her faith was never shaken – until now.
She is struggling to understand why she ended up with metastatic cancer at such a relatively young age—why would God do this to her?
She had plans for retirement that have since evaporated in the face of a foreshortened life.
Why did this happen to her of all people? She was completely healthy until her diagnosis.
Her face is wet with tears.

We talk a little about how a diagnosis like this can change so much of a person’s life and identity. I try to validate her experience. She’s clearly suffering from a sense that her life is not what she expected, and she is struggling to integrate how her future looks at this point.

I ask her what conversations with her priest have been like.

At this point you may be wondering where this conversation is going. Why are we talking about Ms. Lopez’s religion? Palliative care is best delivered through high functioning interdisciplinary teams that can include other supportive people in a patient’s life. We work in concert to try to bring comfort to a patient and their family.⁴ That support network can include nurses, physicians, social workers, and chaplains. In this case, Ms. Lopez had not yet reached out to her priest. She hasn’t had the time or energy to contact her priest given her symptoms.
 

“Can I contact your priest for you?
Maybe he can visit or call and chat with you?”
She nods and wipes tears away.
“That would be really nice,” she says. “I’d love it if he could pray with me.”

A few hours after the visit, I call Ms. Lopez’s priest.
I ask him to reach out to her and about her request for prayer.
He says he’s been thinking about her and that her presence has been missed at weekly Mass. He thanks me for the call and says he’ll call her tomorrow.

I say my own small prayer for Ms. Lopez and head home, the day’s work completed.

Sarah D'Ambruoso was born and raised in Maine. She completed her undergraduate and graduate nursing education at New York University and UCLA, respectively, and currently works as a palliative care nurse practitioner in an oncology clinic in Los Angeles. 

References

1. Cheng BT et al. Patterns of palliative care beliefs among adults in the U.S.: Analysis of a National Cancer Database. J Pain Symptom Manage. 2019 Aug 10. doi: 10.1016/j.jpainsymman.2019.07.030.

2. Finlay E et al. Filling the gap: Creating an outpatient palliative care program in your institution. Am Soc Clin Oncol Educ Book. 2018 May 23. doi: 10.1200/EDBK_200775.

3. Von Roenn JH et al. Barriers and approaches to the successful integration of palliative care and oncology practice. J Natl Compr Canc Netw. 2013 Mar. doi: 10.6004/jnccn.2013.0209.

4. Ferrell BR et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2016 Oct 31. doi: 10.1200/JCO.2016.70.1474.

Pembrolizumab (Keytruda) plus chemotherapy should be considered the new first-line standard of care in advanced esophageal cancer, according to the final results of a large phase 3 study.

An interim analysis of the KEYNOTE-590 study, published in 2020, found that the combination of pembrolizumab and chemotherapy in the first-line setting proved superior to chemotherapy alone in all outcome measures.

The updated analysis, which adds 12 months of follow-up data, shows “first-line pembrolizumab plus chemotherapy continued to provide clinically meaningful benefits in all patients with locally advanced and metastatic esophageal cancer, including [gastroesophageal junction] adenocarcinoma,” said lead author Jean-Philippe Metges, MD, of the CHU Brest-Institut de Cancerologie et d’Hematologie ARPEGO Network, Brest, France.

Similar quality of life and safety data were also observed with pembrolizumab plus chemotherapy versus chemotherapy alone, Dr. Metges added.

“These longer-term data further support first-line pembrolizumab plus chemotherapy as a new standard of care in patients with locally advanced and metastatic esophageal cancer,” he said.

The updated analysis was presented at the 2022 Gastrointestinal Cancers Symposium.
 

Pembro for esophageal cancer

Pembrolizumab first received regulatory approval in 2019 as monotherapy in the second-line setting to treat recurrent locally advanced or metastatic squamous cell carcinoma of the esophagus in tumors with programmed death–ligand 1 (PD-L1) expression.

In response to the interim KEYNOTE-590 data, the FDA expanded the indication in 2021, granting accelerated approval for pembrolizumab in combination with platinum and fluoropyrimidine-based chemotherapy in the first-line setting for patients who were not candidates for surgical resection or definitive chemoradiotherapy.

The updated KEYNOTE-590 data lend greater weight for the use of pembrolizumab plus chemotherapy as first-line standard of care in advanced esophageal cancer.

In the analysis, a total of 749 eligible patients with previously untreated locally advanced, unresectable, or metastatic esophageal squamous cell carcinoma (ESCC), adenocarcinoma, or Siewert type 1 esophagogastric junction adenocarcinoma, regardless of PD-L1 status, were randomly assigned (1:1) to pembrolizumab 200 mg or placebo plus 5-fluorouracil and cisplatin once every 3 weeks for up to 35 cycles.

The authors evaluated overall survival in all patients as well as subgroups including those with ESCC, ESCC PD-L1 combined positive score ≥10 tumors, and PD-L1 CPS ≥10 tumors. The research team also looked at progression-free survival in most groups and overall response rate, duration of response, safety, and health-related quality of life.

Treatment continued until progression, unacceptable toxicity, withdrawal, or until 2 years, with no crossover permitted.

At the median follow-up of 34.8 months, median overall survival was longer for all patients receiving the combination therapy (hazard ratio, 0.73) as well as patients with ESCC (HR, 0.73), ESCC CPS ≥10 (HR, 0.59), CPS ≥10 (HR, 0.64), and adenocarcinoma (HR, 0.73).

For progression-free survival, pembrolizumab plus chemotherapy was superior in all patients (HR, 0.64), the ESCC group (HR, 0.65), as well as the PD-L1 CPS ≥10 tumor group (HR, 0.51).

The 24-month overall survival in all patients was also notably higher for those receiving the combination therapy – 26.3% versus 16.1% – as was 24-month progression-free survival – 11.6% versus 3.3%.

The overall response rate was 45.0% in the combination group, with 25 complete responses (6.7%), versus 29.3% in the control group, with 9 complete responses (2.4%). The median duration of response was 8.3 months in the combination group versus 6.0 months in the chemotherapy group. About 20% of patients in the combination group had a response rate lasting 24 months or longer, compared with 6% who received chemotherapy alone.

As for safety, grade 3-5 drug-related adverse events were similar in both arms – 72% for the combination versus 68% for chemotherapy alone. However, more patients in the combination group discontinued treatment because of drug-related adverse events – 21% versus 12%.

No additional or surprise adverse events occurred with the longer follow-up, plus quality of life was comparable between groups, Dr. Metges noted.

Stefano Cascinu, MD, Università Vita-Salute, San Raffaele Hospital, Milan, who was not involved in the analysis, reiterated that this update confirms the findings from earlier analyses and shows a benefit across all subgroups.

“One of the most relevant findings was that 20% of patients were responding for more than 24 months,” he said. “It is also important that a similar quality of life was maintained.”

Although Dr. Cascinu emphasized that this is a landmark trial in advanced esophageal and gastric cancers, he indicated to several points that remain to be investigated. These include the reproducibility of the findings in common clinical situations – such as a patient with impaired performance status, malnutrition, or peritoneal involvement – as well as the role of PD-L1.

The efficacy of the combination therapy across all subgroups led to a wide FDA approval, though the European Medicines Agency limited its approval to patients with PD-L1 CPS ≥10 tumors.

“Even though all subgroups did well, patients with [PD-L1] CPS ≥10 did better,” said Dr. Cascinu. “[And] in reality, the benefit may only be driven by a specific subpopulation.”

Dr. Cascinu added: “PD-L1 may be a negative biomarker and may be informative about the magnitude of benefit. This may be useful to discuss with patients regarding the expected benefit [of this therapeutic option].”

The study was supported by Merck & Co. Dr. Metges reported receiving payment for travel, accommodations, expenses from Amgen, LEO Pharma, and MSD Oncology, and receiving honoraria from Bristol-Myers Squibb, Lilly, Novartis, Sanofi, and Syncore. Dr. Cascinu has disclosed honoraria from BMS, Lilly, MSD Oncology, and others, as well as a consulting or advisory role for many of these same manufacturers and serving on the speakers’ bureau of Lilly and SERVIER. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

A version of this article first appeared on Medscape.com.

Pembrolizumab (Keytruda) plus chemotherapy should be considered the new first-line standard of care in advanced esophageal cancer, according to the final results of a large phase 3 study.

An interim analysis of the KEYNOTE-590 study, published in 2020, found that the combination of pembrolizumab and chemotherapy in the first-line setting proved superior to chemotherapy alone in all outcome measures.

The updated analysis, which adds 12 months of follow-up data, shows “first-line pembrolizumab plus chemotherapy continued to provide clinically meaningful benefits in all patients with locally advanced and metastatic esophageal cancer, including [gastroesophageal junction] adenocarcinoma,” said lead author Jean-Philippe Metges, MD, of the CHU Brest-Institut de Cancerologie et d’Hematologie ARPEGO Network, Brest, France.

Similar quality of life and safety data were also observed with pembrolizumab plus chemotherapy versus chemotherapy alone, Dr. Metges added.

“These longer-term data further support first-line pembrolizumab plus chemotherapy as a new standard of care in patients with locally advanced and metastatic esophageal cancer,” he said.

The updated analysis was presented at the 2022 Gastrointestinal Cancers Symposium.
 

Pembro for esophageal cancer

Pembrolizumab first received regulatory approval in 2019 as monotherapy in the second-line setting to treat recurrent locally advanced or metastatic squamous cell carcinoma of the esophagus in tumors with programmed death–ligand 1 (PD-L1) expression.

In response to the interim KEYNOTE-590 data, the FDA expanded the indication in 2021, granting accelerated approval for pembrolizumab in combination with platinum and fluoropyrimidine-based chemotherapy in the first-line setting for patients who were not candidates for surgical resection or definitive chemoradiotherapy.

The updated KEYNOTE-590 data lend greater weight for the use of pembrolizumab plus chemotherapy as first-line standard of care in advanced esophageal cancer.

In the analysis, a total of 749 eligible patients with previously untreated locally advanced, unresectable, or metastatic esophageal squamous cell carcinoma (ESCC), adenocarcinoma, or Siewert type 1 esophagogastric junction adenocarcinoma, regardless of PD-L1 status, were randomly assigned (1:1) to pembrolizumab 200 mg or placebo plus 5-fluorouracil and cisplatin once every 3 weeks for up to 35 cycles.

The authors evaluated overall survival in all patients as well as subgroups including those with ESCC, ESCC PD-L1 combined positive score ≥10 tumors, and PD-L1 CPS ≥10 tumors. The research team also looked at progression-free survival in most groups and overall response rate, duration of response, safety, and health-related quality of life.

Treatment continued until progression, unacceptable toxicity, withdrawal, or until 2 years, with no crossover permitted.

At the median follow-up of 34.8 months, median overall survival was longer for all patients receiving the combination therapy (hazard ratio, 0.73) as well as patients with ESCC (HR, 0.73), ESCC CPS ≥10 (HR, 0.59), CPS ≥10 (HR, 0.64), and adenocarcinoma (HR, 0.73).

For progression-free survival, pembrolizumab plus chemotherapy was superior in all patients (HR, 0.64), the ESCC group (HR, 0.65), as well as the PD-L1 CPS ≥10 tumor group (HR, 0.51).

The 24-month overall survival in all patients was also notably higher for those receiving the combination therapy – 26.3% versus 16.1% – as was 24-month progression-free survival – 11.6% versus 3.3%.

The overall response rate was 45.0% in the combination group, with 25 complete responses (6.7%), versus 29.3% in the control group, with 9 complete responses (2.4%). The median duration of response was 8.3 months in the combination group versus 6.0 months in the chemotherapy group. About 20% of patients in the combination group had a response rate lasting 24 months or longer, compared with 6% who received chemotherapy alone.

As for safety, grade 3-5 drug-related adverse events were similar in both arms – 72% for the combination versus 68% for chemotherapy alone. However, more patients in the combination group discontinued treatment because of drug-related adverse events – 21% versus 12%.

No additional or surprise adverse events occurred with the longer follow-up, plus quality of life was comparable between groups, Dr. Metges noted.

Stefano Cascinu, MD, Università Vita-Salute, San Raffaele Hospital, Milan, who was not involved in the analysis, reiterated that this update confirms the findings from earlier analyses and shows a benefit across all subgroups.

“One of the most relevant findings was that 20% of patients were responding for more than 24 months,” he said. “It is also important that a similar quality of life was maintained.”

Although Dr. Cascinu emphasized that this is a landmark trial in advanced esophageal and gastric cancers, he indicated to several points that remain to be investigated. These include the reproducibility of the findings in common clinical situations – such as a patient with impaired performance status, malnutrition, or peritoneal involvement – as well as the role of PD-L1.

The efficacy of the combination therapy across all subgroups led to a wide FDA approval, though the European Medicines Agency limited its approval to patients with PD-L1 CPS ≥10 tumors.

“Even though all subgroups did well, patients with [PD-L1] CPS ≥10 did better,” said Dr. Cascinu. “[And] in reality, the benefit may only be driven by a specific subpopulation.”

Dr. Cascinu added: “PD-L1 may be a negative biomarker and may be informative about the magnitude of benefit. This may be useful to discuss with patients regarding the expected benefit [of this therapeutic option].”

The study was supported by Merck & Co. Dr. Metges reported receiving payment for travel, accommodations, expenses from Amgen, LEO Pharma, and MSD Oncology, and receiving honoraria from Bristol-Myers Squibb, Lilly, Novartis, Sanofi, and Syncore. Dr. Cascinu has disclosed honoraria from BMS, Lilly, MSD Oncology, and others, as well as a consulting or advisory role for many of these same manufacturers and serving on the speakers’ bureau of Lilly and SERVIER. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

A version of this article first appeared on Medscape.com.

Pembrolizumab (Keytruda) plus chemotherapy should be considered the new first-line standard of care in advanced esophageal cancer, according to the final results of a large phase 3 study.

An interim analysis of the KEYNOTE-590 study, published in 2020, found that the combination of pembrolizumab and chemotherapy in the first-line setting proved superior to chemotherapy alone in all outcome measures.

The updated analysis, which adds 12 months of follow-up data, shows “first-line pembrolizumab plus chemotherapy continued to provide clinically meaningful benefits in all patients with locally advanced and metastatic esophageal cancer, including [gastroesophageal junction] adenocarcinoma,” said lead author Jean-Philippe Metges, MD, of the CHU Brest-Institut de Cancerologie et d’Hematologie ARPEGO Network, Brest, France.

Similar quality of life and safety data were also observed with pembrolizumab plus chemotherapy versus chemotherapy alone, Dr. Metges added.

“These longer-term data further support first-line pembrolizumab plus chemotherapy as a new standard of care in patients with locally advanced and metastatic esophageal cancer,” he said.

The updated analysis was presented at the 2022 Gastrointestinal Cancers Symposium.
 

Pembro for esophageal cancer

Pembrolizumab first received regulatory approval in 2019 as monotherapy in the second-line setting to treat recurrent locally advanced or metastatic squamous cell carcinoma of the esophagus in tumors with programmed death–ligand 1 (PD-L1) expression.

In response to the interim KEYNOTE-590 data, the FDA expanded the indication in 2021, granting accelerated approval for pembrolizumab in combination with platinum and fluoropyrimidine-based chemotherapy in the first-line setting for patients who were not candidates for surgical resection or definitive chemoradiotherapy.

The updated KEYNOTE-590 data lend greater weight for the use of pembrolizumab plus chemotherapy as first-line standard of care in advanced esophageal cancer.

In the analysis, a total of 749 eligible patients with previously untreated locally advanced, unresectable, or metastatic esophageal squamous cell carcinoma (ESCC), adenocarcinoma, or Siewert type 1 esophagogastric junction adenocarcinoma, regardless of PD-L1 status, were randomly assigned (1:1) to pembrolizumab 200 mg or placebo plus 5-fluorouracil and cisplatin once every 3 weeks for up to 35 cycles.

The authors evaluated overall survival in all patients as well as subgroups including those with ESCC, ESCC PD-L1 combined positive score ≥10 tumors, and PD-L1 CPS ≥10 tumors. The research team also looked at progression-free survival in most groups and overall response rate, duration of response, safety, and health-related quality of life.

Treatment continued until progression, unacceptable toxicity, withdrawal, or until 2 years, with no crossover permitted.

At the median follow-up of 34.8 months, median overall survival was longer for all patients receiving the combination therapy (hazard ratio, 0.73) as well as patients with ESCC (HR, 0.73), ESCC CPS ≥10 (HR, 0.59), CPS ≥10 (HR, 0.64), and adenocarcinoma (HR, 0.73).

For progression-free survival, pembrolizumab plus chemotherapy was superior in all patients (HR, 0.64), the ESCC group (HR, 0.65), as well as the PD-L1 CPS ≥10 tumor group (HR, 0.51).

The 24-month overall survival in all patients was also notably higher for those receiving the combination therapy – 26.3% versus 16.1% – as was 24-month progression-free survival – 11.6% versus 3.3%.

The overall response rate was 45.0% in the combination group, with 25 complete responses (6.7%), versus 29.3% in the control group, with 9 complete responses (2.4%). The median duration of response was 8.3 months in the combination group versus 6.0 months in the chemotherapy group. About 20% of patients in the combination group had a response rate lasting 24 months or longer, compared with 6% who received chemotherapy alone.

As for safety, grade 3-5 drug-related adverse events were similar in both arms – 72% for the combination versus 68% for chemotherapy alone. However, more patients in the combination group discontinued treatment because of drug-related adverse events – 21% versus 12%.

No additional or surprise adverse events occurred with the longer follow-up, plus quality of life was comparable between groups, Dr. Metges noted.

Stefano Cascinu, MD, Università Vita-Salute, San Raffaele Hospital, Milan, who was not involved in the analysis, reiterated that this update confirms the findings from earlier analyses and shows a benefit across all subgroups.

“One of the most relevant findings was that 20% of patients were responding for more than 24 months,” he said. “It is also important that a similar quality of life was maintained.”

Although Dr. Cascinu emphasized that this is a landmark trial in advanced esophageal and gastric cancers, he indicated to several points that remain to be investigated. These include the reproducibility of the findings in common clinical situations – such as a patient with impaired performance status, malnutrition, or peritoneal involvement – as well as the role of PD-L1.

The efficacy of the combination therapy across all subgroups led to a wide FDA approval, though the European Medicines Agency limited its approval to patients with PD-L1 CPS ≥10 tumors.

“Even though all subgroups did well, patients with [PD-L1] CPS ≥10 did better,” said Dr. Cascinu. “[And] in reality, the benefit may only be driven by a specific subpopulation.”

Dr. Cascinu added: “PD-L1 may be a negative biomarker and may be informative about the magnitude of benefit. This may be useful to discuss with patients regarding the expected benefit [of this therapeutic option].”

The study was supported by Merck & Co. Dr. Metges reported receiving payment for travel, accommodations, expenses from Amgen, LEO Pharma, and MSD Oncology, and receiving honoraria from Bristol-Myers Squibb, Lilly, Novartis, Sanofi, and Syncore. Dr. Cascinu has disclosed honoraria from BMS, Lilly, MSD Oncology, and others, as well as a consulting or advisory role for many of these same manufacturers and serving on the speakers’ bureau of Lilly and SERVIER. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

A version of this article first appeared on Medscape.com.

In a large-scale study among Danish children, no statistically significant association was found between maternal hormonal contraception use and increased risk for central nervous system (CNS) tumors in their offspring.

The study was based on population-based registry data and included 1.1 million children age 19 or younger born in Denmark between 1996 and 2014.

The study, by Marie Hargreave, PhD, Danish Cancer Society Research Center, and colleagues, was published online Jan. 4 in the Journal of the American Medical Association.

Exposure to sex hormones in utero is a recognized cause of cancer in affected offspring, note the authors. Also, the incidence of CNS tumors, among the most common and lethal childhood cancer types, appears to be increasing. Hence, they sought to investigate if there may be a relationship between the two.

During a mean follow-up of 12.9 years, the team found that 725 children were diagnosed with a CNS tumor (47.2% female). Mean age at diagnosis was 7 years. The team noted that 11.5%, 65.7%, and 22.8% of diagnosed children were born to mothers with recent, previous, or no use of hormonal contraception, respectively.

The adjusted incidence rate of CNS tumors was 5.0 per 100,000 person-years for children born to mothers with recent hormonal contraception use (hazard ratio, 0.95), 4.5 per 100,000 person-years for children born to mothers with previous use (HR, 0.86), and 5.3 per 100,000 person-years for children born to mothers with no use.

While recent use of implants (HR, 0.9) and intrauterine devices (HR, 1.5) showed no statistically significant associations for the subgroups of nonoral progestin-only hormonal contraception assessed, the team found that progestin-only injections were significantly associated with an increased risk compared with no use (HR, 6.7). Also, in all post hoc sensitivity analyses, recent use of the main group of nonoral progestin-only products was significantly associated with CNS tumors.

The authors observe that an association between maternal use of injectable contraceptives and increased risk of chromosomal anomalies and major malformations in children has previously been reported. Those results for injections, however, were based on a small number of cases, the result of the likelihood test was null, and adjustments for multiple comparisons were not made. Even if the results for this subgroup are confirmed, the authors point out, because CNS tumors in children are uncommon, the high relative risk estimates would translate to low absolute risk increases.

Although the large number of person-years and cancers increases the statistical precision, and the population-based nationwide design increases the generalizability of the results, the authors caution that uncommonness of CNS tumors in children and the small number of cases in the studied cohort limit subgroup analyses and the statistical precision of certain estimates.

In an accompanying editorial, Logan G. Spector, PhD, and Christopher L. Moertel, MD, from the University of Minnesota Medical School, and H. Irene Su, MD, from the University of California, San Diego, echo the authors’ conclusions, and state: “Thus, women should be reassured about the use of hormonal contraception, including progestin-only injections, and the lack of any increased risk of CNS tumors in their offspring.”

The study was supported by the Danish Cancer Research Foundation, the Arvid Nilssons Foundation, the Gangsted Foundation, the Harboe Foundation, and the Johannes Clemmesens Foundation. Co-author Lina S. Mørch, PhD, reported receiving personal fees from Novo Nordisk as an employee from 2017 to 2019 and grants from Novo Nordisk for a collaborative research project outside the submitted work. Editorialist Christopher Moertel, MD, reported receiving personal fees from OX2 Therapeutics, a spin-off of the University of Minnesota that is involved in the development of brain tumor therapeutics.

A version of this article first appeared on Medscape.com.

In a large-scale study among Danish children, no statistically significant association was found between maternal hormonal contraception use and increased risk for central nervous system (CNS) tumors in their offspring.

The study was based on population-based registry data and included 1.1 million children age 19 or younger born in Denmark between 1996 and 2014.

The study, by Marie Hargreave, PhD, Danish Cancer Society Research Center, and colleagues, was published online Jan. 4 in the Journal of the American Medical Association.

Exposure to sex hormones in utero is a recognized cause of cancer in affected offspring, note the authors. Also, the incidence of CNS tumors, among the most common and lethal childhood cancer types, appears to be increasing. Hence, they sought to investigate if there may be a relationship between the two.

During a mean follow-up of 12.9 years, the team found that 725 children were diagnosed with a CNS tumor (47.2% female). Mean age at diagnosis was 7 years. The team noted that 11.5%, 65.7%, and 22.8% of diagnosed children were born to mothers with recent, previous, or no use of hormonal contraception, respectively.

The adjusted incidence rate of CNS tumors was 5.0 per 100,000 person-years for children born to mothers with recent hormonal contraception use (hazard ratio, 0.95), 4.5 per 100,000 person-years for children born to mothers with previous use (HR, 0.86), and 5.3 per 100,000 person-years for children born to mothers with no use.

While recent use of implants (HR, 0.9) and intrauterine devices (HR, 1.5) showed no statistically significant associations for the subgroups of nonoral progestin-only hormonal contraception assessed, the team found that progestin-only injections were significantly associated with an increased risk compared with no use (HR, 6.7). Also, in all post hoc sensitivity analyses, recent use of the main group of nonoral progestin-only products was significantly associated with CNS tumors.

The authors observe that an association between maternal use of injectable contraceptives and increased risk of chromosomal anomalies and major malformations in children has previously been reported. Those results for injections, however, were based on a small number of cases, the result of the likelihood test was null, and adjustments for multiple comparisons were not made. Even if the results for this subgroup are confirmed, the authors point out, because CNS tumors in children are uncommon, the high relative risk estimates would translate to low absolute risk increases.

Although the large number of person-years and cancers increases the statistical precision, and the population-based nationwide design increases the generalizability of the results, the authors caution that uncommonness of CNS tumors in children and the small number of cases in the studied cohort limit subgroup analyses and the statistical precision of certain estimates.

In an accompanying editorial, Logan G. Spector, PhD, and Christopher L. Moertel, MD, from the University of Minnesota Medical School, and H. Irene Su, MD, from the University of California, San Diego, echo the authors’ conclusions, and state: “Thus, women should be reassured about the use of hormonal contraception, including progestin-only injections, and the lack of any increased risk of CNS tumors in their offspring.”

The study was supported by the Danish Cancer Research Foundation, the Arvid Nilssons Foundation, the Gangsted Foundation, the Harboe Foundation, and the Johannes Clemmesens Foundation. Co-author Lina S. Mørch, PhD, reported receiving personal fees from Novo Nordisk as an employee from 2017 to 2019 and grants from Novo Nordisk for a collaborative research project outside the submitted work. Editorialist Christopher Moertel, MD, reported receiving personal fees from OX2 Therapeutics, a spin-off of the University of Minnesota that is involved in the development of brain tumor therapeutics.

A version of this article first appeared on Medscape.com.

In a large-scale study among Danish children, no statistically significant association was found between maternal hormonal contraception use and increased risk for central nervous system (CNS) tumors in their offspring.

The study was based on population-based registry data and included 1.1 million children age 19 or younger born in Denmark between 1996 and 2014.

The study, by Marie Hargreave, PhD, Danish Cancer Society Research Center, and colleagues, was published online Jan. 4 in the Journal of the American Medical Association.

Exposure to sex hormones in utero is a recognized cause of cancer in affected offspring, note the authors. Also, the incidence of CNS tumors, among the most common and lethal childhood cancer types, appears to be increasing. Hence, they sought to investigate if there may be a relationship between the two.

During a mean follow-up of 12.9 years, the team found that 725 children were diagnosed with a CNS tumor (47.2% female). Mean age at diagnosis was 7 years. The team noted that 11.5%, 65.7%, and 22.8% of diagnosed children were born to mothers with recent, previous, or no use of hormonal contraception, respectively.

The adjusted incidence rate of CNS tumors was 5.0 per 100,000 person-years for children born to mothers with recent hormonal contraception use (hazard ratio, 0.95), 4.5 per 100,000 person-years for children born to mothers with previous use (HR, 0.86), and 5.3 per 100,000 person-years for children born to mothers with no use.

While recent use of implants (HR, 0.9) and intrauterine devices (HR, 1.5) showed no statistically significant associations for the subgroups of nonoral progestin-only hormonal contraception assessed, the team found that progestin-only injections were significantly associated with an increased risk compared with no use (HR, 6.7). Also, in all post hoc sensitivity analyses, recent use of the main group of nonoral progestin-only products was significantly associated with CNS tumors.

The authors observe that an association between maternal use of injectable contraceptives and increased risk of chromosomal anomalies and major malformations in children has previously been reported. Those results for injections, however, were based on a small number of cases, the result of the likelihood test was null, and adjustments for multiple comparisons were not made. Even if the results for this subgroup are confirmed, the authors point out, because CNS tumors in children are uncommon, the high relative risk estimates would translate to low absolute risk increases.

Although the large number of person-years and cancers increases the statistical precision, and the population-based nationwide design increases the generalizability of the results, the authors caution that uncommonness of CNS tumors in children and the small number of cases in the studied cohort limit subgroup analyses and the statistical precision of certain estimates.

In an accompanying editorial, Logan G. Spector, PhD, and Christopher L. Moertel, MD, from the University of Minnesota Medical School, and H. Irene Su, MD, from the University of California, San Diego, echo the authors’ conclusions, and state: “Thus, women should be reassured about the use of hormonal contraception, including progestin-only injections, and the lack of any increased risk of CNS tumors in their offspring.”

The study was supported by the Danish Cancer Research Foundation, the Arvid Nilssons Foundation, the Gangsted Foundation, the Harboe Foundation, and the Johannes Clemmesens Foundation. Co-author Lina S. Mørch, PhD, reported receiving personal fees from Novo Nordisk as an employee from 2017 to 2019 and grants from Novo Nordisk for a collaborative research project outside the submitted work. Editorialist Christopher Moertel, MD, reported receiving personal fees from OX2 Therapeutics, a spin-off of the University of Minnesota that is involved in the development of brain tumor therapeutics.

A version of this article first appeared on Medscape.com.

Less can sometimes be more. New findings show that low-dose postoperative radiation therapy following transoral surgery led to “outstanding oncologic outcome and favorable functional outcomes” in patients with intermediate-risk human papillomavirus (HPV) and oropharynx cancer.

In the phase 2 trial, 95% of patients with locally advanced oropharynx cancer and HPV remained progression free at 2 years following reduced-dose radiation therapy (50 Gy), compared with 96% of patients receiving standard-dose radiation therapy (60 Gy). Both groups avoided chemotherapy as well.

The results, published in the Journal of Clinical Oncology, suggest that postoperative radiation therapy at 50 Gy without chemotherapy was safe and effective in this intermediate-risk subset of patients, the authors concluded.

Although it’s hard for one trial to define standard of care, this study “may be an example of a practice-changing phase 2 [trial],” said lead author Robert L. Ferris, MD, PhD, director of the University of Pittsburgh Medical Center Hillman Cancer Center. “We and others have adopted 50 Gy without chemo as our adjuvant treatment for up to 4 positive nodes and 1 mm of extranodal extension.”

Treatment deintensification for patients with HPV and oropharynx cancer is an active area of investigation, but whether undergoing transoral surgery can allow intermediate-risk patients to receive a lower dose of adjuvant therapy remains uncertain.

Recent results from a phase 3 trial, presented during the plenary session at the 2021 annual meeting of the American Society for Radiation Oncology, showed that de-escalated adjuvant radiation therapy resulted in robust responses and lower toxicity as compared with standard care radiotherapy in patients with HPV and oropharyngeal squamous cell carcinoma.

The goal of the current ECON-ACRIN (E3311) trial was to prospectively assess the 2-year progression-free survival of transoral surgery and reduced adjuvant therapy in intermediate-risk patients with HPV and oropharynx cancer.

The phase 2 trial included 359 patients with HPV and oropharynx cancer who underwent surgery and were then assigned to one of four treatment groups based on individual risk factors for recurrence: low-risk patients under observation (arm A); intermediate-risk patients receiving low-dose radiation therapy (50 Gy, arm B) and those receiving standard-dose radiation (60 Gy, arm C) both without chemotherapy; and finally high-risk patients receiving chemotherapy in combination with high-dose radiation (arm D).

Among patients who underwent transoral surgery, 11% were assigned to arm A, 28% and 30% were randomly allocated to arms B and C, respectively, and 31% were assigned to arm D. For those who underwent transoral laser microsurgery, 11% were assigned to arm A, 32% and 24% were randomly allocated to arms B and C, respectively, and 34% were assigned to arm D.

Almost all patients (95%) in arm B remained progression free at 2 years after receiving reduced-dose radiation therapy. This rate of progression-free survival aligned with those observed in the other cohorts: 91% in high-risk patients receiving chemotherapy in combination with standard 66 Gy high-dose radiation, 96% in intermediate-risk patients in the 60 Gy standard-dose radiation arm, and 97% in the low-risk observation arm.

Although progression-free survival did not differ statistically between the arms (P = .90 for B vs. C; P = .30 for B vs. D; P = .30 for C vs. D), the authors urged caution when interpreting the results because the study was not powered to compare arms B and C directly.

Overall, these results show that “we could reduce radiation therapy and eliminate chemotherapy for 70% of patients,” Dr. Ferris said in an interview. Plus, “a small group of the lowest-risk [patients] did well with surgery alone.”

Regarding outcomes for quality of life (functional assessment of cancer therapy–head and neck) and swallowing (MD Anderson Dysphagia Index), patients reported a consistent decline in both during treatment. Patient scores, however, recovered to baseline levels in arms A-C and remained slightly lower after adjuvant therapy in arm D; however, it is unknown whether differences will emerge over a longer-term period.

Bhishamjit S. Chera, MD, an associate professor and radiation oncologist at the University of North Carolina at Chapel Hill, noted that reduced doses are not the current standard of care but it’s the “direction we’re headed.”

“I have started to use lower doses in selected patients” and other experts are offering it as well, said Dr. Chera, who was not involved in the research.

He also said that patients appear very interested in participating in lower-intensity therapy, judging by how rapidly accrual is for clinical trials of this nature.

However, caution is warranted.

“You have to be careful when you reduce intensity and there are different ways of doing it,” Dr. Chera said. “It’s not ready for community practice, and if it is offered to patients, it needs to be explained carefully with informed consent.”

The study was supported by the National Cancer Institute of the National Institutes of Health. Dr. Ferris has disclosed relationships Novasenta, Merck, Pfizer, EMD Serono, Numab, Macrogenics, Aduro Biotech, Sanofi, Zymeworks, Bristol-Myers Squibb, AstraZeneca/MedImmune, and Tesaro. Dr. Chera disclosed stock and other ownership interests in Naveris, and a consulting or advisory role with Naveris. He is a coinventor on a patent application regarding a method for measuring tumor-derived viral nucleic acids in blood samples, which is owned by the University of North Carolina at Chapel Hill and licensed to Naveris.

A version of this article first appeared on Medscape.com.

Less can sometimes be more. New findings show that low-dose postoperative radiation therapy following transoral surgery led to “outstanding oncologic outcome and favorable functional outcomes” in patients with intermediate-risk human papillomavirus (HPV) and oropharynx cancer.

In the phase 2 trial, 95% of patients with locally advanced oropharynx cancer and HPV remained progression free at 2 years following reduced-dose radiation therapy (50 Gy), compared with 96% of patients receiving standard-dose radiation therapy (60 Gy). Both groups avoided chemotherapy as well.

The results, published in the Journal of Clinical Oncology, suggest that postoperative radiation therapy at 50 Gy without chemotherapy was safe and effective in this intermediate-risk subset of patients, the authors concluded.

Although it’s hard for one trial to define standard of care, this study “may be an example of a practice-changing phase 2 [trial],” said lead author Robert L. Ferris, MD, PhD, director of the University of Pittsburgh Medical Center Hillman Cancer Center. “We and others have adopted 50 Gy without chemo as our adjuvant treatment for up to 4 positive nodes and 1 mm of extranodal extension.”

Treatment deintensification for patients with HPV and oropharynx cancer is an active area of investigation, but whether undergoing transoral surgery can allow intermediate-risk patients to receive a lower dose of adjuvant therapy remains uncertain.

Recent results from a phase 3 trial, presented during the plenary session at the 2021 annual meeting of the American Society for Radiation Oncology, showed that de-escalated adjuvant radiation therapy resulted in robust responses and lower toxicity as compared with standard care radiotherapy in patients with HPV and oropharyngeal squamous cell carcinoma.

The goal of the current ECON-ACRIN (E3311) trial was to prospectively assess the 2-year progression-free survival of transoral surgery and reduced adjuvant therapy in intermediate-risk patients with HPV and oropharynx cancer.

The phase 2 trial included 359 patients with HPV and oropharynx cancer who underwent surgery and were then assigned to one of four treatment groups based on individual risk factors for recurrence: low-risk patients under observation (arm A); intermediate-risk patients receiving low-dose radiation therapy (50 Gy, arm B) and those receiving standard-dose radiation (60 Gy, arm C) both without chemotherapy; and finally high-risk patients receiving chemotherapy in combination with high-dose radiation (arm D).

Among patients who underwent transoral surgery, 11% were assigned to arm A, 28% and 30% were randomly allocated to arms B and C, respectively, and 31% were assigned to arm D. For those who underwent transoral laser microsurgery, 11% were assigned to arm A, 32% and 24% were randomly allocated to arms B and C, respectively, and 34% were assigned to arm D.

Almost all patients (95%) in arm B remained progression free at 2 years after receiving reduced-dose radiation therapy. This rate of progression-free survival aligned with those observed in the other cohorts: 91% in high-risk patients receiving chemotherapy in combination with standard 66 Gy high-dose radiation, 96% in intermediate-risk patients in the 60 Gy standard-dose radiation arm, and 97% in the low-risk observation arm.

Although progression-free survival did not differ statistically between the arms (P = .90 for B vs. C; P = .30 for B vs. D; P = .30 for C vs. D), the authors urged caution when interpreting the results because the study was not powered to compare arms B and C directly.

Overall, these results show that “we could reduce radiation therapy and eliminate chemotherapy for 70% of patients,” Dr. Ferris said in an interview. Plus, “a small group of the lowest-risk [patients] did well with surgery alone.”

Regarding outcomes for quality of life (functional assessment of cancer therapy–head and neck) and swallowing (MD Anderson Dysphagia Index), patients reported a consistent decline in both during treatment. Patient scores, however, recovered to baseline levels in arms A-C and remained slightly lower after adjuvant therapy in arm D; however, it is unknown whether differences will emerge over a longer-term period.

Bhishamjit S. Chera, MD, an associate professor and radiation oncologist at the University of North Carolina at Chapel Hill, noted that reduced doses are not the current standard of care but it’s the “direction we’re headed.”

“I have started to use lower doses in selected patients” and other experts are offering it as well, said Dr. Chera, who was not involved in the research.

He also said that patients appear very interested in participating in lower-intensity therapy, judging by how rapidly accrual is for clinical trials of this nature.

However, caution is warranted.

“You have to be careful when you reduce intensity and there are different ways of doing it,” Dr. Chera said. “It’s not ready for community practice, and if it is offered to patients, it needs to be explained carefully with informed consent.”

The study was supported by the National Cancer Institute of the National Institutes of Health. Dr. Ferris has disclosed relationships Novasenta, Merck, Pfizer, EMD Serono, Numab, Macrogenics, Aduro Biotech, Sanofi, Zymeworks, Bristol-Myers Squibb, AstraZeneca/MedImmune, and Tesaro. Dr. Chera disclosed stock and other ownership interests in Naveris, and a consulting or advisory role with Naveris. He is a coinventor on a patent application regarding a method for measuring tumor-derived viral nucleic acids in blood samples, which is owned by the University of North Carolina at Chapel Hill and licensed to Naveris.

A version of this article first appeared on Medscape.com.

Less can sometimes be more. New findings show that low-dose postoperative radiation therapy following transoral surgery led to “outstanding oncologic outcome and favorable functional outcomes” in patients with intermediate-risk human papillomavirus (HPV) and oropharynx cancer.

In the phase 2 trial, 95% of patients with locally advanced oropharynx cancer and HPV remained progression free at 2 years following reduced-dose radiation therapy (50 Gy), compared with 96% of patients receiving standard-dose radiation therapy (60 Gy). Both groups avoided chemotherapy as well.

The results, published in the Journal of Clinical Oncology, suggest that postoperative radiation therapy at 50 Gy without chemotherapy was safe and effective in this intermediate-risk subset of patients, the authors concluded.

Although it’s hard for one trial to define standard of care, this study “may be an example of a practice-changing phase 2 [trial],” said lead author Robert L. Ferris, MD, PhD, director of the University of Pittsburgh Medical Center Hillman Cancer Center. “We and others have adopted 50 Gy without chemo as our adjuvant treatment for up to 4 positive nodes and 1 mm of extranodal extension.”

Treatment deintensification for patients with HPV and oropharynx cancer is an active area of investigation, but whether undergoing transoral surgery can allow intermediate-risk patients to receive a lower dose of adjuvant therapy remains uncertain.

Recent results from a phase 3 trial, presented during the plenary session at the 2021 annual meeting of the American Society for Radiation Oncology, showed that de-escalated adjuvant radiation therapy resulted in robust responses and lower toxicity as compared with standard care radiotherapy in patients with HPV and oropharyngeal squamous cell carcinoma.

The goal of the current ECON-ACRIN (E3311) trial was to prospectively assess the 2-year progression-free survival of transoral surgery and reduced adjuvant therapy in intermediate-risk patients with HPV and oropharynx cancer.

The phase 2 trial included 359 patients with HPV and oropharynx cancer who underwent surgery and were then assigned to one of four treatment groups based on individual risk factors for recurrence: low-risk patients under observation (arm A); intermediate-risk patients receiving low-dose radiation therapy (50 Gy, arm B) and those receiving standard-dose radiation (60 Gy, arm C) both without chemotherapy; and finally high-risk patients receiving chemotherapy in combination with high-dose radiation (arm D).

Among patients who underwent transoral surgery, 11% were assigned to arm A, 28% and 30% were randomly allocated to arms B and C, respectively, and 31% were assigned to arm D. For those who underwent transoral laser microsurgery, 11% were assigned to arm A, 32% and 24% were randomly allocated to arms B and C, respectively, and 34% were assigned to arm D.

Almost all patients (95%) in arm B remained progression free at 2 years after receiving reduced-dose radiation therapy. This rate of progression-free survival aligned with those observed in the other cohorts: 91% in high-risk patients receiving chemotherapy in combination with standard 66 Gy high-dose radiation, 96% in intermediate-risk patients in the 60 Gy standard-dose radiation arm, and 97% in the low-risk observation arm.

Although progression-free survival did not differ statistically between the arms (P = .90 for B vs. C; P = .30 for B vs. D; P = .30 for C vs. D), the authors urged caution when interpreting the results because the study was not powered to compare arms B and C directly.

Overall, these results show that “we could reduce radiation therapy and eliminate chemotherapy for 70% of patients,” Dr. Ferris said in an interview. Plus, “a small group of the lowest-risk [patients] did well with surgery alone.”

Regarding outcomes for quality of life (functional assessment of cancer therapy–head and neck) and swallowing (MD Anderson Dysphagia Index), patients reported a consistent decline in both during treatment. Patient scores, however, recovered to baseline levels in arms A-C and remained slightly lower after adjuvant therapy in arm D; however, it is unknown whether differences will emerge over a longer-term period.

Bhishamjit S. Chera, MD, an associate professor and radiation oncologist at the University of North Carolina at Chapel Hill, noted that reduced doses are not the current standard of care but it’s the “direction we’re headed.”

“I have started to use lower doses in selected patients” and other experts are offering it as well, said Dr. Chera, who was not involved in the research.

He also said that patients appear very interested in participating in lower-intensity therapy, judging by how rapidly accrual is for clinical trials of this nature.

However, caution is warranted.

“You have to be careful when you reduce intensity and there are different ways of doing it,” Dr. Chera said. “It’s not ready for community practice, and if it is offered to patients, it needs to be explained carefully with informed consent.”

The study was supported by the National Cancer Institute of the National Institutes of Health. Dr. Ferris has disclosed relationships Novasenta, Merck, Pfizer, EMD Serono, Numab, Macrogenics, Aduro Biotech, Sanofi, Zymeworks, Bristol-Myers Squibb, AstraZeneca/MedImmune, and Tesaro. Dr. Chera disclosed stock and other ownership interests in Naveris, and a consulting or advisory role with Naveris. He is a coinventor on a patent application regarding a method for measuring tumor-derived viral nucleic acids in blood samples, which is owned by the University of North Carolina at Chapel Hill and licensed to Naveris.

A version of this article first appeared on Medscape.com.

For the first time, researchers have analyzed oropharyngeal cancer trends in all 50 states and Washington, D.C., and the cross-sectional study shows the condition is increasingly common among older men. The researchers also found an increase in the proportion of regional stage oropharyngeal cancer (3.1% per year in men, 1.0% in women) and mortality among men (2.1% per year).

There were also significantly higher rates of oropharyngeal cancer in Midwestern and Southeastern states, suggesting a need for improved prevention efforts. In addition to older men, an increasing number of people with oropharyngeal cancer are immunosuppressed patients who, like older men, present with advanced tumors.

The new data present a picture of an evolving landscape. “Fifteen or 20 years ago, the increase was largely occurring among young individuals, but now, it has shifted. In our study, we found the most rapid rise now is among men aged 65 years and older, and a rise in mortality as a result of these increases,” said lead author Ashish A. Deshmukh, PhD, MPH, an assistant professor of health services, research, management, and policy at the University of Florida, Gainesville.

The Southeast and Midwest aren’t just hotspots for men. Although the incidence was lower among women overall, the Southeast and Midwest saw greater increases.

The study, published Dec. 16, 2021, in JAMA Otolaryngology – Head & Neck Surgery, also hints that the human papillomavirus (HPV) vaccine, first introduced in 2006, may be having an impact on oropharyngeal cancer incidence. When the researchers stratified incidence by age group, they found a decline among individuals younger than 45 from 2008 to 2017 of 2.1% per year. “It might be still quite early to say that the decrease is driven by HPV vaccination, but we are starting to see a decrease in oropharyngeal cancer incidence among the youngest age group, which is likely to benefit from HPV vaccination earliest,” Dr. Deshmukh said in an interview.

The researchers examined data on 260,182 oropharyngeal cancer cases from the U.S. Cancer Statistics data set from 2001 to 2017. About 80% of cases were in men, and 54% occurred in Southeastern (32%) or Midwestern states (22%). Overall, there was a 2.7% annual increase in oropharyngeal cancer nationally among men, and 0.5% among women. Increases were highest among men in states in the Southeast and Midwest regions, and a similar trend was seen among women with a greater than 2% increase per year. Mortality increased 2.1% per year among men between 2006 and 2017, but declined by 1.2% in women.

According to Nosayaba Osazuwa-Peters, PhD, of Duke University, Durham, N.C., and Louise Davies, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., the study leads to cautious optimism that the HPV vaccine may be having an effect on oropharyngeal cancer incidence in young men. Still, unvaccinated older individuals will remain vulnerable. “This makes the recent extension of the age of eligibility for HPV vaccination to age 45 years a critical advance. The more adults up to the age of 45 years who get vaccinated now, the more benefit we will see from their vaccination in the next 2 or more decades. We need to ring out this message loud and clear as head and neck cancer clinicians,” they wrote in an accompanying editorial.

The study was limited in part by the fact that U.S. cancer registry data has no information on risk factors.

The study was funded by the National Cancer Institute and the National Institutes of Health.

For the first time, researchers have analyzed oropharyngeal cancer trends in all 50 states and Washington, D.C., and the cross-sectional study shows the condition is increasingly common among older men. The researchers also found an increase in the proportion of regional stage oropharyngeal cancer (3.1% per year in men, 1.0% in women) and mortality among men (2.1% per year).

There were also significantly higher rates of oropharyngeal cancer in Midwestern and Southeastern states, suggesting a need for improved prevention efforts. In addition to older men, an increasing number of people with oropharyngeal cancer are immunosuppressed patients who, like older men, present with advanced tumors.

The new data present a picture of an evolving landscape. “Fifteen or 20 years ago, the increase was largely occurring among young individuals, but now, it has shifted. In our study, we found the most rapid rise now is among men aged 65 years and older, and a rise in mortality as a result of these increases,” said lead author Ashish A. Deshmukh, PhD, MPH, an assistant professor of health services, research, management, and policy at the University of Florida, Gainesville.

The Southeast and Midwest aren’t just hotspots for men. Although the incidence was lower among women overall, the Southeast and Midwest saw greater increases.

The study, published Dec. 16, 2021, in JAMA Otolaryngology – Head & Neck Surgery, also hints that the human papillomavirus (HPV) vaccine, first introduced in 2006, may be having an impact on oropharyngeal cancer incidence. When the researchers stratified incidence by age group, they found a decline among individuals younger than 45 from 2008 to 2017 of 2.1% per year. “It might be still quite early to say that the decrease is driven by HPV vaccination, but we are starting to see a decrease in oropharyngeal cancer incidence among the youngest age group, which is likely to benefit from HPV vaccination earliest,” Dr. Deshmukh said in an interview.

The researchers examined data on 260,182 oropharyngeal cancer cases from the U.S. Cancer Statistics data set from 2001 to 2017. About 80% of cases were in men, and 54% occurred in Southeastern (32%) or Midwestern states (22%). Overall, there was a 2.7% annual increase in oropharyngeal cancer nationally among men, and 0.5% among women. Increases were highest among men in states in the Southeast and Midwest regions, and a similar trend was seen among women with a greater than 2% increase per year. Mortality increased 2.1% per year among men between 2006 and 2017, but declined by 1.2% in women.

According to Nosayaba Osazuwa-Peters, PhD, of Duke University, Durham, N.C., and Louise Davies, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., the study leads to cautious optimism that the HPV vaccine may be having an effect on oropharyngeal cancer incidence in young men. Still, unvaccinated older individuals will remain vulnerable. “This makes the recent extension of the age of eligibility for HPV vaccination to age 45 years a critical advance. The more adults up to the age of 45 years who get vaccinated now, the more benefit we will see from their vaccination in the next 2 or more decades. We need to ring out this message loud and clear as head and neck cancer clinicians,” they wrote in an accompanying editorial.

The study was limited in part by the fact that U.S. cancer registry data has no information on risk factors.

The study was funded by the National Cancer Institute and the National Institutes of Health.

For the first time, researchers have analyzed oropharyngeal cancer trends in all 50 states and Washington, D.C., and the cross-sectional study shows the condition is increasingly common among older men. The researchers also found an increase in the proportion of regional stage oropharyngeal cancer (3.1% per year in men, 1.0% in women) and mortality among men (2.1% per year).

There were also significantly higher rates of oropharyngeal cancer in Midwestern and Southeastern states, suggesting a need for improved prevention efforts. In addition to older men, an increasing number of people with oropharyngeal cancer are immunosuppressed patients who, like older men, present with advanced tumors.

The new data present a picture of an evolving landscape. “Fifteen or 20 years ago, the increase was largely occurring among young individuals, but now, it has shifted. In our study, we found the most rapid rise now is among men aged 65 years and older, and a rise in mortality as a result of these increases,” said lead author Ashish A. Deshmukh, PhD, MPH, an assistant professor of health services, research, management, and policy at the University of Florida, Gainesville.

The Southeast and Midwest aren’t just hotspots for men. Although the incidence was lower among women overall, the Southeast and Midwest saw greater increases.

The study, published Dec. 16, 2021, in JAMA Otolaryngology – Head & Neck Surgery, also hints that the human papillomavirus (HPV) vaccine, first introduced in 2006, may be having an impact on oropharyngeal cancer incidence. When the researchers stratified incidence by age group, they found a decline among individuals younger than 45 from 2008 to 2017 of 2.1% per year. “It might be still quite early to say that the decrease is driven by HPV vaccination, but we are starting to see a decrease in oropharyngeal cancer incidence among the youngest age group, which is likely to benefit from HPV vaccination earliest,” Dr. Deshmukh said in an interview.

The researchers examined data on 260,182 oropharyngeal cancer cases from the U.S. Cancer Statistics data set from 2001 to 2017. About 80% of cases were in men, and 54% occurred in Southeastern (32%) or Midwestern states (22%). Overall, there was a 2.7% annual increase in oropharyngeal cancer nationally among men, and 0.5% among women. Increases were highest among men in states in the Southeast and Midwest regions, and a similar trend was seen among women with a greater than 2% increase per year. Mortality increased 2.1% per year among men between 2006 and 2017, but declined by 1.2% in women.

According to Nosayaba Osazuwa-Peters, PhD, of Duke University, Durham, N.C., and Louise Davies, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., the study leads to cautious optimism that the HPV vaccine may be having an effect on oropharyngeal cancer incidence in young men. Still, unvaccinated older individuals will remain vulnerable. “This makes the recent extension of the age of eligibility for HPV vaccination to age 45 years a critical advance. The more adults up to the age of 45 years who get vaccinated now, the more benefit we will see from their vaccination in the next 2 or more decades. We need to ring out this message loud and clear as head and neck cancer clinicians,” they wrote in an accompanying editorial.

The study was limited in part by the fact that U.S. cancer registry data has no information on risk factors.

The study was funded by the National Cancer Institute and the National Institutes of Health.

Field cancerization and subsequent second cancer in squamous cell carcinoma (SCC) patients was significantly associated with cigarette and alcohol use, based on data from more than 300 individuals.

Cigarette and alcohol use are established risk factors for SCCs of the esophagus, head, and neck, Manabu Moto, MD, of Kyoto University, and colleagues wrote. “In addition, squamous cell carcinoma and squamous dysplastic epithelium develop multifocally in these organs,” in a phenomenon known as field cancerization, but the interaction of multiple dysplastic epithelium with other factors, notably whether cessation of cigarette and alcohol use would reduce risk of SCC, has not been well studied.

In a study published in Gastro Hep Advances, the researchers identified 331 adults with newly diagnosed superficial esophageal SCC who underwent endoscopic resection, and 1,022 healthy controls. Field cancerization was based on the number of Lugol-voiding lesions (LVLs) per endoscopic view according to three groups: grade A, 0 LVLs; grade B, 1-9; or grade C, at least 10. The primary study outcome was a measure of risk factors for the development of LVLs.

“Multiple LVLs are closely associated with inactive aldehyde dehydrogenase 2 (ALDH2) and field cancerization,” the researchers wrote. Before assessing their human subjects, they used a mouse model to investigate whether alcohol intake and abstinence would affect acetaldehyde-induced DNA damage to the esophageal epithelium among individuals with ALDH2 dysfunction.

The researchers found that DNA damage, measured by acetaldehyde-derived DNA adduct levels (via N²-ethylidene-dG), accumulated with alcohol consumption over time, but decreased with alcohol cessation in the mouse model.

For the human part of the study, participants completed a lifestyle survey at entry, with questions about alcohol consumption history, alcohol flushing response, smoking, consumption of high-temperature foods, and consumption of green and yellow vegetables and fruit. Drinking status was divided into five groups: never/rarely (of less than 1 unit/week), light (1-8.9 units/week), moderate (9-17.9 units/week), heavy (18 or more units/week), and ex-drinker, with 1 unit defined as 22 g of ethanol. Smoking was divided into three groups: never (0 pack-years), light (less than 30 pack-years), and heavy (30 or more pack-years). Patients were given educational materials at study entry about the importance of alcohol and smoking cessation, as well as verbal advice to cease these behaviors.

Participants underwent endoscopic surveillance at 3-month intervals for up to 6 months following endoscopic resection.

Overall, increased alcohol consumption was associated with increased risk in development of LVL across all LVL grades; higher grades of LVLs were positively associated with high-intensity alcohol consumption, smoking, flushing, and high-temperature foods, and negatively associated with eating vegetables and fruit.

The risk of LVL grade progression was most strongly associated with increased alcohol consumption and with reported flushing. “The greatest risk was observed in the patients with flushing reactions who consumed an average of 30 units per week in grade C LVL,” with an odds ratio of 534, compared with healthy controls. “Since flushing reaction is caused by accumulation of acetaldehyde due to ALDH2 deficient, our result also means that acetaldehyde is a strong carcinogen in field cancerization.”

Secondary outcomes included the incidence of second primary esophageal SCC and head/neck SCC; these were significantly more prevalent in patients with grade C LVL (cumulative 5-year incidence of 47.1% for ESCC and 13.3% for head and neck SCC). However, alcohol and smoking cessation significantly reduced the development of second primary esophageal SCC (adjusted hazard ratios, 0.47 for alcohol and 0.49 for smoking).

The study findings were limited by several factors including the lack of randomization to noncessation and cessation groups and the inclusion of cancer patients, but not long-term cancer survivors, the researchers noted.

“We believe that our data will be useful to establish a prevention and surveillance strategy for cancer survivors, because the overall prognosis of esophageal cancer and head and neck cancer is still poor,” with a 5-year survival rate of less than 20%, and the results highlight the need to educate cancer survivors on the value of smoking and alcohol cessation, they added.

The study was supported by the National Cancer Center Research and Development Fund 36 by the Ministry of Health, Labour, and Welfare of Japan. The researchers had no financial conflicts to disclose.

Field cancerization and subsequent second cancer in squamous cell carcinoma (SCC) patients was significantly associated with cigarette and alcohol use, based on data from more than 300 individuals.

Cigarette and alcohol use are established risk factors for SCCs of the esophagus, head, and neck, Manabu Moto, MD, of Kyoto University, and colleagues wrote. “In addition, squamous cell carcinoma and squamous dysplastic epithelium develop multifocally in these organs,” in a phenomenon known as field cancerization, but the interaction of multiple dysplastic epithelium with other factors, notably whether cessation of cigarette and alcohol use would reduce risk of SCC, has not been well studied.

In a study published in Gastro Hep Advances, the researchers identified 331 adults with newly diagnosed superficial esophageal SCC who underwent endoscopic resection, and 1,022 healthy controls. Field cancerization was based on the number of Lugol-voiding lesions (LVLs) per endoscopic view according to three groups: grade A, 0 LVLs; grade B, 1-9; or grade C, at least 10. The primary study outcome was a measure of risk factors for the development of LVLs.

“Multiple LVLs are closely associated with inactive aldehyde dehydrogenase 2 (ALDH2) and field cancerization,” the researchers wrote. Before assessing their human subjects, they used a mouse model to investigate whether alcohol intake and abstinence would affect acetaldehyde-induced DNA damage to the esophageal epithelium among individuals with ALDH2 dysfunction.

The researchers found that DNA damage, measured by acetaldehyde-derived DNA adduct levels (via N²-ethylidene-dG), accumulated with alcohol consumption over time, but decreased with alcohol cessation in the mouse model.

For the human part of the study, participants completed a lifestyle survey at entry, with questions about alcohol consumption history, alcohol flushing response, smoking, consumption of high-temperature foods, and consumption of green and yellow vegetables and fruit. Drinking status was divided into five groups: never/rarely (of less than 1 unit/week), light (1-8.9 units/week), moderate (9-17.9 units/week), heavy (18 or more units/week), and ex-drinker, with 1 unit defined as 22 g of ethanol. Smoking was divided into three groups: never (0 pack-years), light (less than 30 pack-years), and heavy (30 or more pack-years). Patients were given educational materials at study entry about the importance of alcohol and smoking cessation, as well as verbal advice to cease these behaviors.

Participants underwent endoscopic surveillance at 3-month intervals for up to 6 months following endoscopic resection.

Overall, increased alcohol consumption was associated with increased risk in development of LVL across all LVL grades; higher grades of LVLs were positively associated with high-intensity alcohol consumption, smoking, flushing, and high-temperature foods, and negatively associated with eating vegetables and fruit.

The risk of LVL grade progression was most strongly associated with increased alcohol consumption and with reported flushing. “The greatest risk was observed in the patients with flushing reactions who consumed an average of 30 units per week in grade C LVL,” with an odds ratio of 534, compared with healthy controls. “Since flushing reaction is caused by accumulation of acetaldehyde due to ALDH2 deficient, our result also means that acetaldehyde is a strong carcinogen in field cancerization.”

Secondary outcomes included the incidence of second primary esophageal SCC and head/neck SCC; these were significantly more prevalent in patients with grade C LVL (cumulative 5-year incidence of 47.1% for ESCC and 13.3% for head and neck SCC). However, alcohol and smoking cessation significantly reduced the development of second primary esophageal SCC (adjusted hazard ratios, 0.47 for alcohol and 0.49 for smoking).

The study findings were limited by several factors including the lack of randomization to noncessation and cessation groups and the inclusion of cancer patients, but not long-term cancer survivors, the researchers noted.

“We believe that our data will be useful to establish a prevention and surveillance strategy for cancer survivors, because the overall prognosis of esophageal cancer and head and neck cancer is still poor,” with a 5-year survival rate of less than 20%, and the results highlight the need to educate cancer survivors on the value of smoking and alcohol cessation, they added.

The study was supported by the National Cancer Center Research and Development Fund 36 by the Ministry of Health, Labour, and Welfare of Japan. The researchers had no financial conflicts to disclose.

Field cancerization and subsequent second cancer in squamous cell carcinoma (SCC) patients was significantly associated with cigarette and alcohol use, based on data from more than 300 individuals.

Cigarette and alcohol use are established risk factors for SCCs of the esophagus, head, and neck, Manabu Moto, MD, of Kyoto University, and colleagues wrote. “In addition, squamous cell carcinoma and squamous dysplastic epithelium develop multifocally in these organs,” in a phenomenon known as field cancerization, but the interaction of multiple dysplastic epithelium with other factors, notably whether cessation of cigarette and alcohol use would reduce risk of SCC, has not been well studied.

In a study published in Gastro Hep Advances, the researchers identified 331 adults with newly diagnosed superficial esophageal SCC who underwent endoscopic resection, and 1,022 healthy controls. Field cancerization was based on the number of Lugol-voiding lesions (LVLs) per endoscopic view according to three groups: grade A, 0 LVLs; grade B, 1-9; or grade C, at least 10. The primary study outcome was a measure of risk factors for the development of LVLs.

“Multiple LVLs are closely associated with inactive aldehyde dehydrogenase 2 (ALDH2) and field cancerization,” the researchers wrote. Before assessing their human subjects, they used a mouse model to investigate whether alcohol intake and abstinence would affect acetaldehyde-induced DNA damage to the esophageal epithelium among individuals with ALDH2 dysfunction.

The researchers found that DNA damage, measured by acetaldehyde-derived DNA adduct levels (via N²-ethylidene-dG), accumulated with alcohol consumption over time, but decreased with alcohol cessation in the mouse model.

For the human part of the study, participants completed a lifestyle survey at entry, with questions about alcohol consumption history, alcohol flushing response, smoking, consumption of high-temperature foods, and consumption of green and yellow vegetables and fruit. Drinking status was divided into five groups: never/rarely (of less than 1 unit/week), light (1-8.9 units/week), moderate (9-17.9 units/week), heavy (18 or more units/week), and ex-drinker, with 1 unit defined as 22 g of ethanol. Smoking was divided into three groups: never (0 pack-years), light (less than 30 pack-years), and heavy (30 or more pack-years). Patients were given educational materials at study entry about the importance of alcohol and smoking cessation, as well as verbal advice to cease these behaviors.

Participants underwent endoscopic surveillance at 3-month intervals for up to 6 months following endoscopic resection.

Overall, increased alcohol consumption was associated with increased risk in development of LVL across all LVL grades; higher grades of LVLs were positively associated with high-intensity alcohol consumption, smoking, flushing, and high-temperature foods, and negatively associated with eating vegetables and fruit.

The risk of LVL grade progression was most strongly associated with increased alcohol consumption and with reported flushing. “The greatest risk was observed in the patients with flushing reactions who consumed an average of 30 units per week in grade C LVL,” with an odds ratio of 534, compared with healthy controls. “Since flushing reaction is caused by accumulation of acetaldehyde due to ALDH2 deficient, our result also means that acetaldehyde is a strong carcinogen in field cancerization.”

Secondary outcomes included the incidence of second primary esophageal SCC and head/neck SCC; these were significantly more prevalent in patients with grade C LVL (cumulative 5-year incidence of 47.1% for ESCC and 13.3% for head and neck SCC). However, alcohol and smoking cessation significantly reduced the development of second primary esophageal SCC (adjusted hazard ratios, 0.47 for alcohol and 0.49 for smoking).

The study findings were limited by several factors including the lack of randomization to noncessation and cessation groups and the inclusion of cancer patients, but not long-term cancer survivors, the researchers noted.

“We believe that our data will be useful to establish a prevention and surveillance strategy for cancer survivors, because the overall prognosis of esophageal cancer and head and neck cancer is still poor,” with a 5-year survival rate of less than 20%, and the results highlight the need to educate cancer survivors on the value of smoking and alcohol cessation, they added.

The study was supported by the National Cancer Center Research and Development Fund 36 by the Ministry of Health, Labour, and Welfare of Japan. The researchers had no financial conflicts to disclose.

Tongue squamous cell carcinomas are one of the most common oral cancers yet one of the most difficult to successfully treat. Getting an accurate measure of the depth of the tumor is critical to determining a patient’s prognosis and currently CT, MRI, and ultrasound are used to determine the depth and location of the tumor. Now, a new study in Scientific Reports suggests that MRI before biopsy may be the better option to determine the depth of tumor invasion.

“Several studies have reported a significant relationship between radiological depth of invasion measured on MRI and pathological depth of invasion in the tongue squamous cell carcinoma. To the best of our knowledge, this is the first study on MRI divided into ‘before biopsy’ and ‘after incision biopsy,’ ” Hiroyuki Harada, DDS, PhD, of Tokyo Medical and Dental University, and colleagues wrote.

The issue of depth of invasion is so critical to determining metastasis to neck lymph nodes that in 2017 it was added to the AJCC Cancer Staging Manual.

This retrospective Japanese study included 128 patients with tongue carcinoma who underwent glossectomy between 2006 and 2019. The researchers evaluated which radiologic depth of invasion measurement – MRI before or after biopsy and ultrasound – was the most agreeable to clinical depth of invasion.

All the participants had undergone ultrasound, while 18 had undergone MRI before biopsy and 110 had undergone MRI after biopsy. The coefficients of determination were 0.664, 0.891, and 0.422 respectively, suggesting that calculating radiologic depth of invasion using MRI before biopsy was the most reliable radiologic method. MRI before biopsy slightly overestimated clinical depth of tumor invasion, MRI after biopsy severely overestimated the clinical measurement, and ultrasound slightly underestimated the clinical depth of tumor invasion.

Ultrasound is often preferred because of its easy use, yet measuring ulcerous lesions is difficult with ultrasound. But with MRI, there is no upper limit of measured value, but tongue movement during the procedure can make getting accurate images during the procedure difficult.

“The advantage of the MRI is that the image is acquired in the tongue’s resting position and that there is no upper limit of the measured value. The disadvantages include difficult detection of superficial tumors, influence of metal artifacts, and movement of the tongue,” the authors wrote. “Biopsy may lead to edema or hemorrhage and subsequent overestimation of tumor size and invasion depth in MRI.”

A small Canadian study published in 2016 in the Journal of Otolaryngology–Head & Neck Surgery, found a strong correlation between clinical, pathological, and MRI measurements of depth of invasion in oral tongue SCC. Meanwhile, a 2017 U.K. study published in the British Journal of Oral and Maxillofacial Surgery found that the accuracy of clinical staging in oral SCC did not differ whether the biopsy was taken before or after MRI. While a good radiologic-pathological tumor thickness correlation has been reported in 2018 in the American Journal of Neuroradiology, tongue carcinoma often shows exophytic or ulcerous lesions, which are difficult to measure with MRI, CT, or ultrasound.

The authors suggested that further studies are needed to determine the effects on MRI of postbiopsy tongue inflammation. Limitations of the study included the small number of cases with MRI before biopsy.

The authors declared no conflicts of interest.

Tongue squamous cell carcinomas are one of the most common oral cancers yet one of the most difficult to successfully treat. Getting an accurate measure of the depth of the tumor is critical to determining a patient’s prognosis and currently CT, MRI, and ultrasound are used to determine the depth and location of the tumor. Now, a new study in Scientific Reports suggests that MRI before biopsy may be the better option to determine the depth of tumor invasion.

“Several studies have reported a significant relationship between radiological depth of invasion measured on MRI and pathological depth of invasion in the tongue squamous cell carcinoma. To the best of our knowledge, this is the first study on MRI divided into ‘before biopsy’ and ‘after incision biopsy,’ ” Hiroyuki Harada, DDS, PhD, of Tokyo Medical and Dental University, and colleagues wrote.

The issue of depth of invasion is so critical to determining metastasis to neck lymph nodes that in 2017 it was added to the AJCC Cancer Staging Manual.

This retrospective Japanese study included 128 patients with tongue carcinoma who underwent glossectomy between 2006 and 2019. The researchers evaluated which radiologic depth of invasion measurement – MRI before or after biopsy and ultrasound – was the most agreeable to clinical depth of invasion.

All the participants had undergone ultrasound, while 18 had undergone MRI before biopsy and 110 had undergone MRI after biopsy. The coefficients of determination were 0.664, 0.891, and 0.422 respectively, suggesting that calculating radiologic depth of invasion using MRI before biopsy was the most reliable radiologic method. MRI before biopsy slightly overestimated clinical depth of tumor invasion, MRI after biopsy severely overestimated the clinical measurement, and ultrasound slightly underestimated the clinical depth of tumor invasion.

Ultrasound is often preferred because of its easy use, yet measuring ulcerous lesions is difficult with ultrasound. But with MRI, there is no upper limit of measured value, but tongue movement during the procedure can make getting accurate images during the procedure difficult.

“The advantage of the MRI is that the image is acquired in the tongue’s resting position and that there is no upper limit of the measured value. The disadvantages include difficult detection of superficial tumors, influence of metal artifacts, and movement of the tongue,” the authors wrote. “Biopsy may lead to edema or hemorrhage and subsequent overestimation of tumor size and invasion depth in MRI.”

A small Canadian study published in 2016 in the Journal of Otolaryngology–Head & Neck Surgery, found a strong correlation between clinical, pathological, and MRI measurements of depth of invasion in oral tongue SCC. Meanwhile, a 2017 U.K. study published in the British Journal of Oral and Maxillofacial Surgery found that the accuracy of clinical staging in oral SCC did not differ whether the biopsy was taken before or after MRI. While a good radiologic-pathological tumor thickness correlation has been reported in 2018 in the American Journal of Neuroradiology, tongue carcinoma often shows exophytic or ulcerous lesions, which are difficult to measure with MRI, CT, or ultrasound.

The authors suggested that further studies are needed to determine the effects on MRI of postbiopsy tongue inflammation. Limitations of the study included the small number of cases with MRI before biopsy.

The authors declared no conflicts of interest.

Tongue squamous cell carcinomas are one of the most common oral cancers yet one of the most difficult to successfully treat. Getting an accurate measure of the depth of the tumor is critical to determining a patient’s prognosis and currently CT, MRI, and ultrasound are used to determine the depth and location of the tumor. Now, a new study in Scientific Reports suggests that MRI before biopsy may be the better option to determine the depth of tumor invasion.

“Several studies have reported a significant relationship between radiological depth of invasion measured on MRI and pathological depth of invasion in the tongue squamous cell carcinoma. To the best of our knowledge, this is the first study on MRI divided into ‘before biopsy’ and ‘after incision biopsy,’ ” Hiroyuki Harada, DDS, PhD, of Tokyo Medical and Dental University, and colleagues wrote.

The issue of depth of invasion is so critical to determining metastasis to neck lymph nodes that in 2017 it was added to the AJCC Cancer Staging Manual.

This retrospective Japanese study included 128 patients with tongue carcinoma who underwent glossectomy between 2006 and 2019. The researchers evaluated which radiologic depth of invasion measurement – MRI before or after biopsy and ultrasound – was the most agreeable to clinical depth of invasion.

All the participants had undergone ultrasound, while 18 had undergone MRI before biopsy and 110 had undergone MRI after biopsy. The coefficients of determination were 0.664, 0.891, and 0.422 respectively, suggesting that calculating radiologic depth of invasion using MRI before biopsy was the most reliable radiologic method. MRI before biopsy slightly overestimated clinical depth of tumor invasion, MRI after biopsy severely overestimated the clinical measurement, and ultrasound slightly underestimated the clinical depth of tumor invasion.

Ultrasound is often preferred because of its easy use, yet measuring ulcerous lesions is difficult with ultrasound. But with MRI, there is no upper limit of measured value, but tongue movement during the procedure can make getting accurate images during the procedure difficult.

“The advantage of the MRI is that the image is acquired in the tongue’s resting position and that there is no upper limit of the measured value. The disadvantages include difficult detection of superficial tumors, influence of metal artifacts, and movement of the tongue,” the authors wrote. “Biopsy may lead to edema or hemorrhage and subsequent overestimation of tumor size and invasion depth in MRI.”

A small Canadian study published in 2016 in the Journal of Otolaryngology–Head & Neck Surgery, found a strong correlation between clinical, pathological, and MRI measurements of depth of invasion in oral tongue SCC. Meanwhile, a 2017 U.K. study published in the British Journal of Oral and Maxillofacial Surgery found that the accuracy of clinical staging in oral SCC did not differ whether the biopsy was taken before or after MRI. While a good radiologic-pathological tumor thickness correlation has been reported in 2018 in the American Journal of Neuroradiology, tongue carcinoma often shows exophytic or ulcerous lesions, which are difficult to measure with MRI, CT, or ultrasound.

The authors suggested that further studies are needed to determine the effects on MRI of postbiopsy tongue inflammation. Limitations of the study included the small number of cases with MRI before biopsy.

The authors declared no conflicts of interest.

A new systematic review and meta-analysis finds that unvaccinated cancer patients who contracted COVID-19 last year, were more than two times more likely – than people without cancer – to develop a case of COVID-19 so severe it required hospitalization in an intensive care unit.

“Our study provides the most precise measure to date of the effect of COVID-19 in cancer patients,” wrote researchers who were led by Paolo Boffetta, MD, MPH, a specialist in population science with the Stony Brook Cancer Center in New York.

Dr. Boffetta and colleagues also found that patients with hematologic neoplasms had a higher mortality rate from COVID-19 comparable to that of all cancers combined.

Cancer patients have long been considered to be among those patients who are at high risk of developing COVID-19, and if they contract the disease, they are at high risk of having poor outcomes. Other high-risk patients include those with hypertension, diabetes, chronic kidney disease, or COPD, or the elderly. But how high the risk of developing severe COVID-19 disease is for cancer patients hasn’t yet been documented on a wide scale.

The study, which was made available as a preprint on medRxiv on Oct. 23, is based on an analysis of COVID-19 cases that were documented in 35 reviews, meta-analyses, case reports, and studies indexed in PubMed from authors in North America, Europe, and Asia.

In this study, the pooled odds ratio for mortality for all patients with any cancer was 2.32 (95% confidence interval, 1.82-2.94; 24 studies). For ICU admission, the odds ratio was 2.39 (95% CI, 1.90-3.02; I2 0.0%; 5 studies). And, for disease severity or hospitalization, it was 2.08 (95% CI, 1.60-2.72; I2 92.1%; 15 studies). The pooled mortality odds ratio for hematologic neoplasms was 2.14 (95% CI, 1.87-2.44; I2 20.8%; 8 studies).

Their findings, which have not yet been peer reviewed, confirmed the results of a similar analysis from China published as a preprint in May 2020. The analysis included 181,323 patients (23,736 cancer patients) from 26 studies reported an odds ratio of 2.54 (95% CI, 1.47-4.42). “Cancer patients with COVID-19 have an increased likelihood of death compared to non-cancer COVID-19 patients,” Venkatesulu et al. wrote. And a systematic review and meta-analysis of five studies of 2,619 patients published in October 2020 in Medicine also found a significantly higher risk of death from COVID-19 among cancer patients (odds ratio, 2.63; 95% confidence interval, 1.14-6.06; P = .023; I2 = 26.4%).

Fakih et al., writing in the journal Hematology/Oncology and Stem Cell Therapy conducted a meta-analysis early last year finding a threefold increase for admission to the intensive care unit, an almost fourfold increase for a severe SARS-CoV-2 infection, and a fivefold increase for being intubated.

The three studies show that mortality rates were higher early in the pandemic “when diagnosis and treatment for SARS-CoV-2 might have been delayed, resulting in higher death rate,” Boffetta et al. wrote, adding that their analysis showed only a twofold increase most likely because it was a year-long analysis.

“Future studies will be able to better analyze this association for the different subtypes of cancer. Furthermore, they will eventually be able to evaluate whether the difference among vaccinated population is reduced,” Boffetta et al. wrote.

The authors noted several limitations for the study, including the fact that many of the studies included in the analysis did not include sex, age, comorbidities, and therapy. Nor were the authors able to analyze specific cancers other than hematologic neoplasms.

The authors declared no conflicts of interest.

A new systematic review and meta-analysis finds that unvaccinated cancer patients who contracted COVID-19 last year, were more than two times more likely – than people without cancer – to develop a case of COVID-19 so severe it required hospitalization in an intensive care unit.

“Our study provides the most precise measure to date of the effect of COVID-19 in cancer patients,” wrote researchers who were led by Paolo Boffetta, MD, MPH, a specialist in population science with the Stony Brook Cancer Center in New York.

Dr. Boffetta and colleagues also found that patients with hematologic neoplasms had a higher mortality rate from COVID-19 comparable to that of all cancers combined.

Cancer patients have long been considered to be among those patients who are at high risk of developing COVID-19, and if they contract the disease, they are at high risk of having poor outcomes. Other high-risk patients include those with hypertension, diabetes, chronic kidney disease, or COPD, or the elderly. But how high the risk of developing severe COVID-19 disease is for cancer patients hasn’t yet been documented on a wide scale.

The study, which was made available as a preprint on medRxiv on Oct. 23, is based on an analysis of COVID-19 cases that were documented in 35 reviews, meta-analyses, case reports, and studies indexed in PubMed from authors in North America, Europe, and Asia.

In this study, the pooled odds ratio for mortality for all patients with any cancer was 2.32 (95% confidence interval, 1.82-2.94; 24 studies). For ICU admission, the odds ratio was 2.39 (95% CI, 1.90-3.02; I2 0.0%; 5 studies). And, for disease severity or hospitalization, it was 2.08 (95% CI, 1.60-2.72; I2 92.1%; 15 studies). The pooled mortality odds ratio for hematologic neoplasms was 2.14 (95% CI, 1.87-2.44; I2 20.8%; 8 studies).

Their findings, which have not yet been peer reviewed, confirmed the results of a similar analysis from China published as a preprint in May 2020. The analysis included 181,323 patients (23,736 cancer patients) from 26 studies reported an odds ratio of 2.54 (95% CI, 1.47-4.42). “Cancer patients with COVID-19 have an increased likelihood of death compared to non-cancer COVID-19 patients,” Venkatesulu et al. wrote. And a systematic review and meta-analysis of five studies of 2,619 patients published in October 2020 in Medicine also found a significantly higher risk of death from COVID-19 among cancer patients (odds ratio, 2.63; 95% confidence interval, 1.14-6.06; P = .023; I2 = 26.4%).

Fakih et al., writing in the journal Hematology/Oncology and Stem Cell Therapy conducted a meta-analysis early last year finding a threefold increase for admission to the intensive care unit, an almost fourfold increase for a severe SARS-CoV-2 infection, and a fivefold increase for being intubated.

The three studies show that mortality rates were higher early in the pandemic “when diagnosis and treatment for SARS-CoV-2 might have been delayed, resulting in higher death rate,” Boffetta et al. wrote, adding that their analysis showed only a twofold increase most likely because it was a year-long analysis.

“Future studies will be able to better analyze this association for the different subtypes of cancer. Furthermore, they will eventually be able to evaluate whether the difference among vaccinated population is reduced,” Boffetta et al. wrote.

The authors noted several limitations for the study, including the fact that many of the studies included in the analysis did not include sex, age, comorbidities, and therapy. Nor were the authors able to analyze specific cancers other than hematologic neoplasms.

The authors declared no conflicts of interest.

A new systematic review and meta-analysis finds that unvaccinated cancer patients who contracted COVID-19 last year, were more than two times more likely – than people without cancer – to develop a case of COVID-19 so severe it required hospitalization in an intensive care unit.

“Our study provides the most precise measure to date of the effect of COVID-19 in cancer patients,” wrote researchers who were led by Paolo Boffetta, MD, MPH, a specialist in population science with the Stony Brook Cancer Center in New York.

Dr. Boffetta and colleagues also found that patients with hematologic neoplasms had a higher mortality rate from COVID-19 comparable to that of all cancers combined.

Cancer patients have long been considered to be among those patients who are at high risk of developing COVID-19, and if they contract the disease, they are at high risk of having poor outcomes. Other high-risk patients include those with hypertension, diabetes, chronic kidney disease, or COPD, or the elderly. But how high the risk of developing severe COVID-19 disease is for cancer patients hasn’t yet been documented on a wide scale.

The study, which was made available as a preprint on medRxiv on Oct. 23, is based on an analysis of COVID-19 cases that were documented in 35 reviews, meta-analyses, case reports, and studies indexed in PubMed from authors in North America, Europe, and Asia.

In this study, the pooled odds ratio for mortality for all patients with any cancer was 2.32 (95% confidence interval, 1.82-2.94; 24 studies). For ICU admission, the odds ratio was 2.39 (95% CI, 1.90-3.02; I2 0.0%; 5 studies). And, for disease severity or hospitalization, it was 2.08 (95% CI, 1.60-2.72; I2 92.1%; 15 studies). The pooled mortality odds ratio for hematologic neoplasms was 2.14 (95% CI, 1.87-2.44; I2 20.8%; 8 studies).

Their findings, which have not yet been peer reviewed, confirmed the results of a similar analysis from China published as a preprint in May 2020. The analysis included 181,323 patients (23,736 cancer patients) from 26 studies reported an odds ratio of 2.54 (95% CI, 1.47-4.42). “Cancer patients with COVID-19 have an increased likelihood of death compared to non-cancer COVID-19 patients,” Venkatesulu et al. wrote. And a systematic review and meta-analysis of five studies of 2,619 patients published in October 2020 in Medicine also found a significantly higher risk of death from COVID-19 among cancer patients (odds ratio, 2.63; 95% confidence interval, 1.14-6.06; P = .023; I2 = 26.4%).

Fakih et al., writing in the journal Hematology/Oncology and Stem Cell Therapy conducted a meta-analysis early last year finding a threefold increase for admission to the intensive care unit, an almost fourfold increase for a severe SARS-CoV-2 infection, and a fivefold increase for being intubated.

The three studies show that mortality rates were higher early in the pandemic “when diagnosis and treatment for SARS-CoV-2 might have been delayed, resulting in higher death rate,” Boffetta et al. wrote, adding that their analysis showed only a twofold increase most likely because it was a year-long analysis.

“Future studies will be able to better analyze this association for the different subtypes of cancer. Furthermore, they will eventually be able to evaluate whether the difference among vaccinated population is reduced,” Boffetta et al. wrote.

The authors noted several limitations for the study, including the fact that many of the studies included in the analysis did not include sex, age, comorbidities, and therapy. Nor were the authors able to analyze specific cancers other than hematologic neoplasms.

The authors declared no conflicts of interest.

Breast cancer screening using urine samples based on the volatile organic compounds (VOCs) sensed by a trained dog is feasible, according to a preliminary study published in the journal Biology June 10.

“The extrapolation of our results to widespread implementation is still uncertain,” wrote Shoko Kure, MD, PhD, of Nippon Medical School in Tokyo, and colleagues. “However, even if few dogs could be trained to detect breast cancer, the result may open the door to a robust and inexpensive way to detect breast cancer.” They added that “dog cancer detection is entirely noninvasive, safe and easy for both patients and everyone.” 

Early detection of breast cancer, which is the leading cause of death globally, is essential for more efficient treatment. While mammography can detect asymptomatic breast cancer and reduce mortality, it has a poor compliance, is less sensitive in dense breast tissue, detects nonmalignant lesions, and has not been shown to reduce mortality in women younger than 40. VOCs are emitted in the breath, blood, and urine, with different volatile patterns correlated with a variety of diseases including cancers, which dogs can be trained to detect. Breast cancer screening by dog sniffing of the VOCs in urine samples has not been attempted.

Dogs have been used as medical detectives for several cancers and conditions. A study published in 2018 showed that trained dogs who were able to differentiate the specific odor from the metabolic waste of breast cancer in vitro could identify that of colorectal cancer, and vice versa. More recently, research showed that trained dogs could detect advanced prostate cancer in urine samples with high specificity and sensitivity. In this double-blinded pilot study, two dogs were trained to detect Gleason 9 prostate cancer in urine collected from biopsy-confirmed patients. The canine olfaction system was 71% sensitive and as much as 76% specific at detecting Gleason 9 cancer. Along with cancer, trained dogs have been shown to identify people with COVID-19, even those who were asymptomatic. In this study, dogs who sniffed swab samples of armpit sweat could identify which samples came from patients infected with COVID-19 with up to 100% accuracy, while ruling out infection with up to 99% accuracy.

The double-blind study by Dr. Kure aimed to assess the potential of VOCs in urine samples for breast cancer screening by using a single trained sniffer dog – in this case a 9-year-old female Labrador retriever. Urine samples from 40 patients with primary breast cancer and 142 patients with non-breast malignant diseases were included along with samples from 18 healthy volunteers. In 40 times out of 40 runs of the double-blind test, the dog correctly identified urine samples of patients with breast cancer, with 100% sensitivity and 100% specificity.

“The dog in this test successfully differentiated breast cancer from non-breast malignancies and healthy controls,” the authors wrote. “This is the first, preliminary study indicating the feasibility of developing a new breast cancer screening method using urine samples based on VOCs.”

While the authors noted that the study was limited as it relied on one trained dog, they suggested that this method has potential in low-income countries where access to mammography is inadequate.

“Some well-trained sniffing dogs traveling around medically underserved [countries] all over the world could save many lives. Even when a healthy control was indicated by a trained dog, there would be a suspicion of undiagnosed/early-stage cancer, and the person would be advised to undergo medical screening,” the authors wrote.

The authors declared no conflicts of interest.

Breast cancer screening using urine samples based on the volatile organic compounds (VOCs) sensed by a trained dog is feasible, according to a preliminary study published in the journal Biology June 10.

“The extrapolation of our results to widespread implementation is still uncertain,” wrote Shoko Kure, MD, PhD, of Nippon Medical School in Tokyo, and colleagues. “However, even if few dogs could be trained to detect breast cancer, the result may open the door to a robust and inexpensive way to detect breast cancer.” They added that “dog cancer detection is entirely noninvasive, safe and easy for both patients and everyone.” 

Early detection of breast cancer, which is the leading cause of death globally, is essential for more efficient treatment. While mammography can detect asymptomatic breast cancer and reduce mortality, it has a poor compliance, is less sensitive in dense breast tissue, detects nonmalignant lesions, and has not been shown to reduce mortality in women younger than 40. VOCs are emitted in the breath, blood, and urine, with different volatile patterns correlated with a variety of diseases including cancers, which dogs can be trained to detect. Breast cancer screening by dog sniffing of the VOCs in urine samples has not been attempted.

Dogs have been used as medical detectives for several cancers and conditions. A study published in 2018 showed that trained dogs who were able to differentiate the specific odor from the metabolic waste of breast cancer in vitro could identify that of colorectal cancer, and vice versa. More recently, research showed that trained dogs could detect advanced prostate cancer in urine samples with high specificity and sensitivity. In this double-blinded pilot study, two dogs were trained to detect Gleason 9 prostate cancer in urine collected from biopsy-confirmed patients. The canine olfaction system was 71% sensitive and as much as 76% specific at detecting Gleason 9 cancer. Along with cancer, trained dogs have been shown to identify people with COVID-19, even those who were asymptomatic. In this study, dogs who sniffed swab samples of armpit sweat could identify which samples came from patients infected with COVID-19 with up to 100% accuracy, while ruling out infection with up to 99% accuracy.

The double-blind study by Dr. Kure aimed to assess the potential of VOCs in urine samples for breast cancer screening by using a single trained sniffer dog – in this case a 9-year-old female Labrador retriever. Urine samples from 40 patients with primary breast cancer and 142 patients with non-breast malignant diseases were included along with samples from 18 healthy volunteers. In 40 times out of 40 runs of the double-blind test, the dog correctly identified urine samples of patients with breast cancer, with 100% sensitivity and 100% specificity.

“The dog in this test successfully differentiated breast cancer from non-breast malignancies and healthy controls,” the authors wrote. “This is the first, preliminary study indicating the feasibility of developing a new breast cancer screening method using urine samples based on VOCs.”

While the authors noted that the study was limited as it relied on one trained dog, they suggested that this method has potential in low-income countries where access to mammography is inadequate.

“Some well-trained sniffing dogs traveling around medically underserved [countries] all over the world could save many lives. Even when a healthy control was indicated by a trained dog, there would be a suspicion of undiagnosed/early-stage cancer, and the person would be advised to undergo medical screening,” the authors wrote.

The authors declared no conflicts of interest.

Breast cancer screening using urine samples based on the volatile organic compounds (VOCs) sensed by a trained dog is feasible, according to a preliminary study published in the journal Biology June 10.

“The extrapolation of our results to widespread implementation is still uncertain,” wrote Shoko Kure, MD, PhD, of Nippon Medical School in Tokyo, and colleagues. “However, even if few dogs could be trained to detect breast cancer, the result may open the door to a robust and inexpensive way to detect breast cancer.” They added that “dog cancer detection is entirely noninvasive, safe and easy for both patients and everyone.” 

Early detection of breast cancer, which is the leading cause of death globally, is essential for more efficient treatment. While mammography can detect asymptomatic breast cancer and reduce mortality, it has a poor compliance, is less sensitive in dense breast tissue, detects nonmalignant lesions, and has not been shown to reduce mortality in women younger than 40. VOCs are emitted in the breath, blood, and urine, with different volatile patterns correlated with a variety of diseases including cancers, which dogs can be trained to detect. Breast cancer screening by dog sniffing of the VOCs in urine samples has not been attempted.

Dogs have been used as medical detectives for several cancers and conditions. A study published in 2018 showed that trained dogs who were able to differentiate the specific odor from the metabolic waste of breast cancer in vitro could identify that of colorectal cancer, and vice versa. More recently, research showed that trained dogs could detect advanced prostate cancer in urine samples with high specificity and sensitivity. In this double-blinded pilot study, two dogs were trained to detect Gleason 9 prostate cancer in urine collected from biopsy-confirmed patients. The canine olfaction system was 71% sensitive and as much as 76% specific at detecting Gleason 9 cancer. Along with cancer, trained dogs have been shown to identify people with COVID-19, even those who were asymptomatic. In this study, dogs who sniffed swab samples of armpit sweat could identify which samples came from patients infected with COVID-19 with up to 100% accuracy, while ruling out infection with up to 99% accuracy.

The double-blind study by Dr. Kure aimed to assess the potential of VOCs in urine samples for breast cancer screening by using a single trained sniffer dog – in this case a 9-year-old female Labrador retriever. Urine samples from 40 patients with primary breast cancer and 142 patients with non-breast malignant diseases were included along with samples from 18 healthy volunteers. In 40 times out of 40 runs of the double-blind test, the dog correctly identified urine samples of patients with breast cancer, with 100% sensitivity and 100% specificity.

“The dog in this test successfully differentiated breast cancer from non-breast malignancies and healthy controls,” the authors wrote. “This is the first, preliminary study indicating the feasibility of developing a new breast cancer screening method using urine samples based on VOCs.”

While the authors noted that the study was limited as it relied on one trained dog, they suggested that this method has potential in low-income countries where access to mammography is inadequate.

“Some well-trained sniffing dogs traveling around medically underserved [countries] all over the world could save many lives. Even when a healthy control was indicated by a trained dog, there would be a suspicion of undiagnosed/early-stage cancer, and the person would be advised to undergo medical screening,” the authors wrote.

The authors declared no conflicts of interest.