Strategies For a New Generation of Oral Cancer Patients Once mostly confined to an older population, head and neck cancer is showing up in younger patients because of HPV exposure. On the Pulse
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On the Pulse  |   October 01, 2018
Strategies For a New Generation of Oral Cancer Patients
Author Notes
  • Julie Blair, MA, CCC-SLP, is a clinician and instructor at the Medical University of South Carolina. She is an affiliate of ASHA Special Interest Groups 3, Voice and Voice Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). blairju@musc.edu
    Julie Blair, MA, CCC-SLP, is a clinician and instructor at the Medical University of South Carolina. She is an affiliate of ASHA Special Interest Groups 3, Voice and Voice Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). blairju@musc.edu×
Article Information
Special Populations / On the Pulse
On the Pulse   |   October 01, 2018
Strategies For a New Generation of Oral Cancer Patients
The ASHA Leader, October 2018, Vol. 23, 42-44. doi:10.1044/leader.OTP.23102018.42
The ASHA Leader, October 2018, Vol. 23, 42-44. doi:10.1044/leader.OTP.23102018.42
The face of head and neck cancer has changed since I began working as a speech-language pathologist at a university cancer center 24 years ago.
At that time, my patients tended to be older men with a long history of tobacco and alcohol use. Today, my patients are much younger, healthier and tobacco-free—but they have HPV, the human papilloma virus. HPV comprises more than 200 related viruses, many of which are known to cause certain types of cancer.
HPV is sexually transmitted and also known to cause cervical cancers. While other cancers are showing a decline in numbers, HPV-related cancers are on the rise. According to the U.S. Centers for Disease Control and Prevention, studies show that about 70 percent of oropharyngeal cancers in the U.S. may be linked to HPV.
Late diagnoses
The initial symptoms of head and neck cancer are often similar to a cold or allergies: sore throat, painful swallowing, earache or voice changes. Many young, healthy people dismiss those symptoms. If they do seek help, they are often treated for allergies, infections or reflux because of their perceived low risk for cancer. Only when those symptoms persist or get worse, despite treatment with antibiotics and other medications, is the correct diagnosis made.
Other patients may not experience any symptoms at all until they notice a lump in their neck. This lump signifies the spread of cancer into the lymph nodes.
The misattributions and the lack of symptoms until a lump appears increase the stage of the cancer to be treated. Because of this delay in diagnosis, patients with HPV-related head and neck cancer often have advanced-stage disease by the time they come to the cancer clinic for the first time.
Better outcomes
The news isn’t all bad—treatment has made remarkable progress in the past two decades. The patients with advanced oropharyngeal cancer that I saw early in my career often had poor outcomes. Their treatment required disfiguring surgeries followed by chemotherapy and radiation. The disease-free survival rate for patients in advanced stages was less than 25 percent.
However, HPV-related cancer is more responsive to radiation, chemotherapy and immunotherapy (see sources below), giving patients a prognosis for disease-free survival of 85 to 90 percent. This increased responsiveness allows physicians to de-escalate their treatment protocols, reducing the intensity and severity of the associated side effects.

Patients with HPV-related head and neck cancer often have advanced-stage disease by the time they come to come to the cancer clinic for the first time.

In addition, transoral robots have eased surgical approaches to these hard-to-access areas of the throat.
HPV is also the only cancer for which there is a vaccine. There are three vaccines available. They are given in two doses and are most effective if administered at puberty, prior to onset of sexual activity and exposure to the virus.
In addition to prevention, early detection is vital. The Head and Neck Cancer Alliance encourages talks during the annual oral, head and neck cancer awareness week in April to educate middle school students about the risks, symptoms and prevention of head and neck cancer. Medical and dentistry programs are standardizing head and neck exams as a routine part of the patient visit. And media campaigns have raised awareness for the general public.
New population, new practices
So how has HPV-related cancer changed my practice? Younger patients present a very different profile from older patients, and have very different needs. They are working, have spouses and young children—and have higher standards for their outcomes. They need to communicate, not just for socialization, but to perform in their jobs to meet their financial responsibilities. They want to return to an active social life that includes eating and drinking. And they want and expect to be able to do those things for a long time after their cancer treatment.
My treatment starts at the patient’s diagnosis. I counsel patients about their disease and treatment and their potential effects on communication and swallowing. We start them on swallowing exercises at diagnosis, to maximize their recovery potential.
Patients undergoing transoral robotic surgery (TORS) typically have significant swallowing discomfort for about a week after surgery—not unlike the swallowing pain after a tonsillectomy—but are often sent home the day after surgery. During this time, patients are often on a liquid diet. I encourage them not to forcefully cough to allow the throat to heal.
I emphasize strategies to maximize intake while minimizing risks and discomfort. Once a patient has healed from surgery, exercises can resume. This is very different from my early-career patients, who often had a split mandible and tracheotomy, were in the hospital for one to two weeks, and on alternate nutrition for several weeks.

Younger patients present a very different profile from older patients, and have very different needs. They are working, have spouses and young children—and have higher standards for their outcomes.

Radiation therapy (RT) techniques have also changed significantly over the past decades as a result of improvements in engineering and computing: the use of photon beams, intensity-modulated RT, and adaptive RT that individually tailors the treatment and reduces the intensity of side effects.
Nonetheless, radiation toxicities can produce side effects including reduced saliva production (xerostomia), reduced or altered taste (dysguesia), and pain with swallowing (odynophagia). These acute side effects typically show up about 10 days into radiation treatment.
I advise patients to address symptoms as they appear, modify their diet if necessary to maintain oral intake, and perform prophylactic exercises to maintain swallow function and preserve salivation, taste and mouth opening (see sources). Side effects typically resolve six to eight weeks after radiation ends, but most patients continue to experience some degree of chronic dry mouth and taste changes or sensitivities.
If patients don’t address these acute effects, they may lead to chronic issues with scarring (fibrosis), reduced jaw opening (trismus), dental decay and reduced bone integrity (osteoradionecrosis), all of which can affect speech and swallowing function. To motivate patients to stick with aggressive oral care, swallow exercises and normal diet texture, I emphasize the importance of working to maintain function versus trying to regain a lost function.
Because these younger patients are surviving longer than ever before, we have no data on the long-term effects of their treatment. Reports of late radiation-acquired dysphagia (late RAD) indicate that patients are developing fibrosis years after their cancer treatment, resulting in profound swallowing deficits. I am hopeful that advances in treatment options and de-escalation of treatment will reduce the percentage of patients with late RAD, and that preventative measures through vaccination will reduce or even eliminate HPV-related cancer.
However, until then, we have to educate the public and our colleagues on head and neck cancer and advocate for the rehabilitation services our patients need in the years following treatment.
Sources
Carnaby-Mann, G., Crary, M. A., Schmalfus, I., & Amdur, R. (2012). “Pharyngocise”: Randomized controlled trial of preventive exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology Biology Physics, 83(1), 210–219. [Article]
Carnaby-Mann, G., Crary, M. A., Schmalfus, I., & Amdur, R. (2012). “Pharyngocise”: Randomized controlled trial of preventive exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology Biology Physics, 83(1), 210–219. [Article] ×
Dodd, R. H., Waller, J., & Marlow, L. A. V. (2016). Human papillomavirus and head and neck cancer: Psychosocial impact in patients and knowledge of the link—A systematic review. Clinical Oncology, 28(7), 421–439. [Article] [PubMed]
Dodd, R. H., Waller, J., & Marlow, L. A. V. (2016). Human papillomavirus and head and neck cancer: Psychosocial impact in patients and knowledge of the link—A systematic review. Clinical Oncology, 28(7), 421–439. [Article] [PubMed]×
Fakhry, C., Westra, W. H., Li, S., Cmelak, A., Ridge, J. A., Pinto, H., … Gillison, M. L. (2008). Improved survival of patients with human papillomavirus–positive head and neck squamous cell carcinoma in a prospective clinical trial. Journal of the National Cancer Institute, 100(4), 261–269. [Article] [PubMed]
Fakhry, C., Westra, W. H., Li, S., Cmelak, A., Ridge, J. A., Pinto, H., … Gillison, M. L. (2008). Improved survival of patients with human papillomavirus–positive head and neck squamous cell carcinoma in a prospective clinical trial. Journal of the National Cancer Institute, 100(4), 261–269. [Article] [PubMed]×
Hutcheson, K. A., Bhayani, M. K., Beadle, B. M., Gold, K. A., Shinn, E. H., Lai, S. Y., & Lewin, J. (2013). Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: Use it or lose it. JAMA Otolaryngology–Head & Neck Surgery, 139(11), 1127–1134. [Article] [PubMed]
Hutcheson, K. A., Bhayani, M. K., Beadle, B. M., Gold, K. A., Shinn, E. H., Lai, S. Y., & Lewin, J. (2013). Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: Use it or lose it. JAMA Otolaryngology–Head & Neck Surgery, 139(11), 1127–1134. [Article] [PubMed]×
Hutcheson, K. A., Lewin, J. S., Barringer, D. A., Lisec, A., Gunn, G. B., Moore, M. W., & Holsinger, F.C. (2012). Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer, 118(23), 5793–5799. [Article] [PubMed]
Hutcheson, K. A., Lewin, J. S., Barringer, D. A., Lisec, A., Gunn, G. B., Moore, M. W., & Holsinger, F.C. (2012). Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer, 118(23), 5793–5799. [Article] [PubMed]×
Resources
Centers for Disease Control and Prevention: HPV and Oropharyngeal Cancer, https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm.
Centers for Disease Control and Prevention: HPV and Oropharyngeal Cancer, https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm.×
Head and Neck Cancer Alliance www.headandneck.org
Head and Neck Cancer Alliance www.headandneck.org×
National Cancer Institute www.cancer.gov
National Cancer Institute www.cancer.gov×
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October 2018
Volume 23, Issue 10