Oral, head and neck cancer screening is critical to early detection-but otolaryngologists often find that they aren’t reaching the populations at highest risk for the disease. Consequently, many physicians are taking the initiative to develop novel and creative outreach programs to target people who are likely to regularly use tobacco and alcohol, as well as individuals who do not have ready access to health care.
Explore This IssueAugust 2009
Screenings Not Targeting High-Risk Populations
One recent study (Laryngoscope 2009;119: 679-82) illustrates how head and neck cancer screenings held in doctors’ offices may not reach high-risk populations.
In Baltimore, high-risk neighborhoods are just a stone’s throw away from Johns Hopkins, but it is still challenging to capture those residents for screenings, said lead study author Christine Gourin, MD, Associate Professor and Director of the Clinical Research Program in Head and Neck Cancer at Johns Hopkins School of Medicine.
Reasons for this may be cultural distrust of physicians, fatalism about developing cancer, or lack of education about what screening can offer, she explained.
To conduct the study, Dr. Gourin and her colleagues evaluated data collected during a one-day screening of 89 participants in the Department of Otolaryngology-Head and Neck Surgery during Oral, Head and Neck Cancer Awareness Week (OHANCAW), an event promoted by the Head and Neck Cancer Alliance and held every April.
They found that the majority of participants did not fit the typical profile of high-risk patients. Fifty-seven percent of participants were female, and only 29% used tobacco products. Seventy-two percent had attended college or graduate school. Sixty-six percent of participants reported head and neck cancer symptoms; however, only 35% were aware of the association between these symptoms and disease.
Researchers reported no correlation between symptom prevalence and the exam. Eleven percent of participants had suspicious findings for neoplasia and were referred to follow-up care. However, the screenings did not identify any people with cancer, said Dr. Gourin.
We didn’t attract typical high-risk profile patients, said Dr. Gourin, adding that many of the people screened worked at the university. This problem isn’t just unique to Johns Hopkins. You see it elsewhere.
Other otolaryngologists tend to agree. For example, the Feist-Weiller Cancer Center at Louisiana State University (LSU) in Shreveport has offered free head and neck cancer screening to the public over the past 12 years during OHANCAW.
But one of the things we realized is that of the approximately 140 patients who show up every year, most are health conscious and have access to health care already, said Cherie-Ann Nathan, MD, Professor and Vice-Chairman of Otolaryngology-Head and Neck Surgery at LSU’s Health Sciences Center and Director of Head and Neck Surgical Oncology at the Feist-Weiller Cancer Center. Participants are self-selected and tend to be highly motivated and generally on top of any health problems they might have, she said.
Most academic-based programs market the oral, head and neck cancer screening to local audiences, and whoever wants to be screened shows up at an office clinic, said Michael M. Johns III, MD, Assistant Professor of Otolaryngology at Emory University and Director of the Emory Voice Center in Atlanta. The problem is that the people coming in for the screening aren’t those who are at high risk, he said.
Reaching High-Risk Populations
The solution to the problem is actively reaching out to the high-risk community, said Dr. Gourin, adding that a history of tobacco use, alcohol use, poor nutritional status, and low educational status increase the likelihood of developing oral, head and neck carcinoma.
Human papillomavirus (HPV) is another risk factor to consider (see sidebar), although physicians can still reach more people at risk by targeting tobacco and alcohol users, noted Kristen Pytynia, MD, MPH, Assistant Professor of Otolaryngology at the University of Illinois at Chicago.
To reach high-risk populations, otolaryngologists may want to consider taking screening events to homeless shelters, churches in urban or rural settings, and community medical centers that provide care to uninsured populations, said Dr. Gourin.
Every April, OHANCAW provides otolaryngologists with the opportunity to educate and reach out to these communities, said Dr. Johns, adding that free health screenings usually attract local media attention, thereby helping to increase public awareness of the disease and its risk factors. It’s very common for people to be unaware that smoking and drinking raise disease risk, he said.
Additionally, publicizing disease symptoms through media and public education may help people seek out screening if they are experiencing any signs of oral, head and neck cancer, said Dr. Pytynia.
The majority of people with oral, head and neck cancer don’t use the health care system until they have symptoms such as a lump or sore that does not heal, a chronic sore throat, dysphagia, and/or a change or hoarseness in the voice, noted Dr. Gourin.
Fortunately, otolaryngologists are developing creative ways to reach at-risk populations before signs of the disease develop, said Dr. Johns.
Targeting Tobacco Users
For example, in 2006, Edie Hapner, PhD, Assistant Professor of Otolaryngology at Emory University and Director of Speech-Language Pathology at the Emory Voice Center, developed a screening program held at a NASCAR race at Atlanta Motor Speedway.
Screening organizers targeted NASCAR because the event traditionally attracts a white, rural population that tends to be more prone to tobacco and alcohol use, said Dr. Johns, adding that sponsor tents often used to include tobacco products.
The event was established through the efforts of the Atlanta Chapter of the Head and Neck Cancer Alliance, which at the time was still the Yul Brynner Head and Neck Cancer Foundation. However, the screening program is made possible each race weekend through the generosity of hundreds of volunteers, Emory University’s Department of Otolaryngology, and Atlanta Motor Speedway, which provides free vendor space, electricity, and tenting in the parking lot to hold the screening, said Dr. Hapner.
We would do screening in our office or at the mall for free to reach out to the community, but we weren’t getting to the masses, said Dr. Hapner. So we took the concept of free screening to the racetrack.
Organizing a private comprehensive head and neck screening in middle of a parking lot is a huge undertaking, Dr. Hapner added. However, she has the help of 60 to 65 volunteers each race day, including physicians, nurses, speech pathologists, and graduate and medical students.
Survivors of head and neck cancer also help by encouraging people milling outside the screening station to come in for an exam, said Dr. Hapner. I hear so many people say, ‘I know I must have cancer, but I don’t want to find out and ruin the race,’ she said.
Physicians provide comprehensive oral, head and neck cancer screenings to about 200 people a day over the two-day NASCAR event. Supplies includes disposable laryngeal mirrors and tongue depressors. You don’t want anything that needs to be disinfected, explained Dr. Hapner. Grant funding has also allowed Dr. Hapner to buy physician headlamps and otoscopes.
Results are checked as normal or abnormal, and participants know by the end of the exam whether they have a suspicious lesion and if they need to pursue follow-up care, she said.
Dr. Hapner currently has grant funding through Emory University to examine epidemiological information gathered from the screenings.
Over the last seven NASCAR race days held, Dr. Hapner and her colleagues have screened 1455 people. This population smokes cigarettes and uses smokeless tobacco at twice to three times the national average, respectively, she said. Screening participants also started smoking at a younger age than the general population, and the relapse rate on smoking cessation is higher.
We also found concerning findings in about 12% of the people we screened, which is significantly higher than what would be expected, said Dr. Hapner.
Dr. Hapner and her research partner, Justin Wise, PhD, are following up with all participants to see if they sought further care based on their screening results. They will also see if tobacco cessation counseling offered on screening days had any impact on risky behavior. The results are expected to be published by the end of the year and will be presented at several national conferences this year.
Overall, screening at NASCAR has taken off from a public relations standpoint, and public relations is important to the success of cancer screening, said Dr. Johns. For example, colon cancer was not on the media map until Katie Couric’s husband died from the disease and she became an advocate of screening, he added.
Because of the success of the NASCAR screenings, Dr. Hapner and her colleagues in Atlanta were commissioned to train a group of volunteers in Indianapolis to replicate the event in at the Allstate 400 at the Brickyard racetrack in July, with funding from Bristol-Myers Squibb. Screenings were offered in the vendor area inside the track on the day before and the day of the race.
Targeting the Homeless Population
Otolaryngologists are also offering screening for oral, head and neck cancer to the homeless, an at-risk population due to its lack of access to health care.
Dr. Nathan and her colleagues took a mobile screening unit to a homeless shelter in Shreveport this year. Overall, Louisiana has a much higher rate of oral tobacco and alcohol use when compared with the rest of the country, said Dr. Nathan, adding that these habits seem to be increasing in adult minority populations and teenagers in the state.
The mobile unit was originally established as part of the cancer center’s Partners in Wellness health program, which offers free screening for prostate, colorectal, breast, and cervical cancers to financially qualified uninsured or underinsured individuals. In addition to Dr. Nathan, clinical coordinator Teresa Harris, a nurse practitioner, and two residents helped to organize use of the mobile unit for oral, head and neck cancer screening.
With the unit, Dr. Nathan and her colleagues screened 54 people at the homeless shelter, and 22.2% had suspicious lesions. In contrast, at the LSU cancer center this year, 116 people were screened and 14.6% were found to have suspicious lesions. Data are not yet available on how many participants at either location pursued follow-up care.
Dr. Nathan also brought literature about tobacco cessation to the homeless shelter. The main goal was to educate them about tobacco and alcohol use and their causative role with head and neck cancer, she said.
-Christine Gourin, MD
Future plans for the program include buying physician headlights, otoscopes, and nasal speculums with grant money from the American Head and Neck Society, said Dr. Nathan.
Ideally, we’d like to choose a different homeless shelter every year and educate a different patient population, said Dr. Nathan.
Charles Moore, MD, Assistant Professor of Otolaryngology at Emory University, is also taking oral, head and neck cancer screening to underserved urban populations, which include the homeless.
While working at Emory University’s Grady Memorial Hospital, which provides care primarily to an indigent population in Atlanta, Dr. Moore saw a number of patients come into the hospital with head and neck cancer that had progressed to the point of limited options.
The rates of oral, head and neck cancer were about the same as in the general population, but patients were not finding early access to screening and care, explained Dr. Moore, who is also Chief of Service in Otolaryngology at the Grady Health System and Co-Director of the Center for Cranial Base Surgery.
Consequently, in 2004, Dr. Moore began to provide oral, head and neck cancer screenings in areas of the community where these patients lived to help detect the disease early.
Initially, I would load up the car with just a few tools for screening, said Dr. Moore, adding that, with the help of otolaryngology and medicine residents, he provides a general oral cavity, anterior rhinoscopy, and neck exam. He eventually received a grant to fund a mobile unit, which has extended his reach to underserved areas.
-Charles Moore, MD
The majority of screenings occur in homeless shelters in Atlanta. Alcohol use in homeless shelters is not allowed, noted Dr. Moore. So you can’t say whether they were using alcohol or whether it may have been underreported, he said. Tobacco use tends to be variable, as with other populations.
Dr. Moore also reaches the urban community with screenings at local health fairs, churches, and civic events.
Since the program’s inception, approximately 600 people have been screened. About 10% of these individuals had suspicious lesions, and about 75% were followed up with additional testing, said Dr. Moore.
We were initially surprised that follow-up was that high, but most of the patients who had come in said that no one had shown that much interest in them before, and that was the main reason they sought further care, he explained.
Dr. Moore is now working with several organizations to create a free medical facility where physicians will offer screening, diagnosis, and treatment for head and neck cancer.
For more information about OHANCAW, see the Head and Neck Cancer Alliance’s Web site at www.headandneck.org .
Although most cases of oral, head and neck cancer are linked to tobacco and alcohol use, about 25% may be attributable to a strain of human papillomavirus (HPV), according to the American Academy of Otolaryngology-Head and Neck Surgery.
If physicians consider the prevalence of HPV, to which most people have been exposed, then ideally, everyone would be screened for oral, head and neck cancer, noted Dr. Kristen Pytynia.
While these cancers occur most often in people older than 45 years, HPV is contributing to disease development in younger populations, said Dr. Pytynia. According to the American Cancer Society, more than 6 million men and women get an HPV infection every year, and nearly half are between ages 15 and 25.
Dr. Pytynia noted that the cervical cancer vaccine, which targets the same HPV that causes oral, head and neck cancer, could be used in both girls and boys to prevent the disease.
News & Notes
Chemotherapy and Radiation Can Save Larynx
Some patients with large laryngeal tumors can preserve their speech by choosing chemotherapy and radiation over laryngectomy, according to a June 5 online article in Laryngoscope.
Researchers from the University of Michigan, led by Francis P. Worden, MD, reviewed data from two U-M studies of advanced laryngeal cancer patients, looking specifically at 36 patients with T4 tumors. Study participants were given one round of induction chemotherapy. If the tumor shrank by more than 50% after the first round, patients were given three more rounds of chemotherapy, along with daily radiation therapy. Participants whose tumors did not respond to induction chemotherapy were referred for surgery.
They found that 81% of the patients responded to the induction chemotherapy, and many saw their tumors shrink completely. The three-year survival rate was 78%, and 58% had an intact larynx. Those who preserved their larynx reported better quality of life and less depression that those who had surgery. Few patients required a feeding tube or tracheostomy.
There was no survival difference between patients with the smallest and the largest tumors, Dr. Worden said, which suggests that organ preservation is a viable alternative to surgery for even large laryngeal cancers.
©2009 The Triological Society