3 Oral/Jaw Cancer 1991-2008University of Maryland 2554 patients Cancer Oral Cavity/Jaws Epidermoid carcinoma (scca) 1044 CIS 83 Salivary (intra-oral) 147 Sarcomas 48 Lymphoma 35 Metastatic 29 Others 17 1363 76 4 DemographicsOral and Pharynx cancer
USA (oral pharyngeal scca)
2-6 of all cancers
30 of head and neck cancers
3000 cases diagnosed per year
2007 estimated (SEER)
34360
7555 deaths
5 DemographicsOral and Pharynx cancer
World
Western Europe Australia ( 5)
France India Brazil Eastern Europe
6 DemographicsOral and Pharynx cancer World wide incidence of cancers by site 7 DemographicsOral and Pharynx cancer Maryland -8th incidence -national death rate 8 Oral Cancer-Maryland Baltimore City Anne Arundel County Charles County 9 Oral Cancer-Maryland Survival has not changed Dramatically in past 30 years Blacks Whites 10 DemographicsOral and Pharynx cancer
Age at diagnosis (SEER 2004)
Median age 62
lt20 0.5
20-34 2.4
35-44 7.1
45-54 20.6
55-64 24.7
65-74 22.3
75-84 16.7
gt85 5.7
65 11 Stage at Presentation
Presentation stage Survival (5 yr OS)
Local 35 81.1
Regional 50 52.1
Distant 10 26.5
Unknown 5
12 DemographicsOral and Pharynx cancer
Survival (5-year)
How long will I live
60 alive at 5 years
White men 60.2
White women 62.8
Black men 35.5
Black women 51.3
13 Projected Estimates
1 in 98 men and women will be diagnosed with cancer of the oral cavity and pharynx during their lifetime
0.74 of men will develop cancer of the oral cavity and pharynx between their 50th and 70th birthdays compared to 0.25 for women
14 Cancer Survival African Americans 15 Non-traditional patients
Women
African Americans
lt40 year
Non-smokers
16 Gender Trends
Male Female
1930 10 1
1950 6 1
2000 3 2
Women have an increased risk of developing cancer with the same level of exposure to environmental mutagens
17 Why do African American do so much worse
Treatment (non-operative)
radiation
More aggressive disease
Nodal disease at presentation
Extracapsular spread
Risk factors
Utilization of care/Access to care
Insurance status had a significant effect on survival in black patients after controlling for other variables
Laryngoscope. 116(7)1093-1106 July 2006
18 Tongue Cancer lt40
60 increase in tongue cancer in patients lt40
-1973-1984 versus 1985-1997
SEER data
19 Tongue Cancer lt40
Finland 4 1960s 7 1980s
Atula et al Arch OtoHNS 1221996
USA 4 1971 18 1993
Myers et al OtoHNS 1222000
20 Tongue Cancer lt40
Implicated causality
Genetic predisposition
Greater sensitivity to mutagens
HPV
21 Tongue Cancer lt40Genetics
Are these different cancers than in older patients
LOH at 39and 17 p chromosomes in young adults no different to those found in older patients.
Jin Y-T Oral Oncology 351999
No significant differences in the expression of p53 p21 Rb and MDM2 proteins from tongue SCC in patients lt35 years compared to patients gt75 years.
Regezi JA Oral Oncology 351999
22 Tongue Cancer lt40Survival
Historical trends
Recent trends
A Matched Control Study of Treatment Outcome in Young Patients with SCC of the Head and Neck
69 The NeckLikelihood of occult metastasis related to depth of invasion -Risk increases at 3mm 70 The Neck Tumor Thickness Occult Cervical Metastasis lt2 mm 7.5 2-8 mm 25.7 gt8 mm 41.2 Spiro et al.1986 71 The Old
Radical Neck Dissection
Formerly the standard ND for all patients
N necks with bulky nodal disease
72 The New
Modified Radical Neck Dissection
N necks
Preservation of selected structures
IJV
SCM
Spinal accessory nerve
Selective Neck Dissection
N0 necks
Selected N1 necks
73 Rationale for the Elective Neck Dissection Level I 20 II 17 III 9 IV 3 V 0.5
192 patients resection Elective RND
34 had positive nodes
Shah et al. Cancer 1990 74 The Neck
Rationale
Staging
30-35 patients clinical N0 actually have occult metastasis in levels I-III (IV)
adjuvant therapy
75 The dilemma
Only 30-35 of patients have occult metastasis
So 65-70 of patients have an unnecessary procedure
BUT
It allows us to stage the patient
Can be therapeutic in early stage neck disease
76 Alternatives to END
No treatment (watch and wait)
If they have occult metastases and develop a lymph node later
Patient survival is NOT different
But they require a MRND or RND
Decrease in QOL!
Elective radiation
Equivalent regional control and survival
Never know what stage the patient
77 SOMND (I-III)
Risks
Nerve injury
Facial
Lingual
Hypoglossal
Great auricular
Vagus
Spinal accessory nerve
78 The importance of NStatus of cervical node single most important prognostic factor 79 The importance of N
N
Rate of distant metastasis doubles
6.9 to 13.6
Patients gt3 positive nodes
Incidence of distant metastasis 46.8
Patients with extra-nodal spread
3 times incidence of distant metastasis
6.7 to 19.1
Leemans et. al. 1993 80 Prognosticators
Type Squamous vs. Verrucous vs. Spindle cell
Differentiation
Mode of Invasion
Perineural/Perivascular Spread
Host Response
81 Who benefits from adjuvant therapy
Advanced stages
T3/T4
Any bone invasion
Adverse histologic features
gt1 cervical lymph node
1 cervical lymph node with
Extracapsular spread
Perineural/Perivascular invasion
Poor margin status (lt4mm)
82 Recent Advances
Chemoradiotherapy
Monoclonal antibody therapy
HPV vaccine trial
83 Post-operative Chemo/Radiotherapy
Post-operative Radiotherapy and Chemotherapy for High Risk Squamous Cell Carcinoma of the Head and Neck
Cooper J.S. et al RTOG 9501/
Bernier J. et al EORTC 22931
Local/Regional control
Disease free survival
Toxicity
84 Monoclonal antibody
Cetuximab (Erbitux)
EGFR antibody
Radiation versus Radiation Erbitux
LR control 14.9 vs 29.3 months
Overall survival 29.3 vs 49 months
Improved progression free survival
Limited toxicities (skin rash)
Bonner NEJM 2006 85 HPV vaccine trial
Portions of the HPV genome block p53 tumor suppressor
Peptide vaccine aims to inactivate HPV proteins responsible for p53 inactivation
PowerShow.com is a leading presentation/slideshow sharing website. Whether your application is business, how-to, education, medicine, school, church, sales, marketing, online training or just for fun, PowerShow.com is a great resource. And, best of all, most of its cool features are free and easy to use.
You can use PowerShow.com to find and download example online PowerPoint ppt presentations on just about any topic you can imagine so you can learn how to improve your own slides and presentations for free. Or use it to find and download high-quality how-to PowerPoint ppt presentations with illustrated or animated slides that will teach you how to do something new, also for free. Or use it to upload your own PowerPoint slides so you can share them with your teachers, class, students, bosses, employees, customers, potential investors or the world. Or use it to create really cool photo slideshows - with 2D and 3D transitions, animation, and your choice of music - that you can share with your Facebook friends or Google+ circles. That's all free as well!
For a small fee you can get the industry's best online privacy or publicly promote your presentations and slide shows with top rankings. But aside from that it's free. We'll even convert your presentations and slide shows into the universal Flash format with all their original multimedia glory, including animation, 2D and 3D transition effects, embedded music or other audio, or even video embedded in slides. All for free. Most of the presentations and slideshows on PowerShow.com are free to view, many are even free to download. (You can choose whether to allow people to download your original PowerPoint presentations and photo slideshows for a fee or free or not at all.) Check out PowerShow.com today - for FREE. There is truly something for everyone!