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Interviewer: Your doctor told you that you have a type of head and neck cancer that was caused by the HPV virus. Now what? We're going to talk about that next on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: You've been told by your doctor that you have a type of cancer that was caused by the HPV virus and it's in your head and your neck. We're going to talk about an HPV head and neck cancer right now with Dr. Marcus Monroe. He's a head and neck cancer expert in the University of Utah Health Care. Let's just start with the basic. First of all, head neck cancer caused by HPV, tell me about it? What's happened?

Dr. Monroe: So HPV is Human Papilloma Virus and it actually causes a very specific subset of head to neck cancers. Cancers in the region of the head and neck that we call the oropharynx, which includes the tonsils and the base of the tongue so the part of the tongue that's behind what you can actually see in your mouth.

The important things for a patient that has been newly diagnosed are, one, to seek out a medical team that has experience in treating head and neck cancers. Probably more than any other cancer, the treatment of head and neck cancer's really a team sport. Typically treatments can include surgery, radiation, chemotherapy and so having physicians with expertise in radiation oncology, medical oncology as well as surgical oncology are very important. It's important to seek out a team that works well together.

In addition because the head and neck, you can think of the tonsils and the back part of your throat if you've ever had a sore throat just the pain and the difficulty of getting through that infection. Treatments in the area can be particularly rough and so it's really important not only to have the physicians but to have the entire support team. And so that includes dentists, swallowing and language therapists, nutritionists, physical therapists, and really a complete support group.

Interviewer: How bad can it get? I would imagine most people are concerned, "Is this going to kill me?"

Dr. Monroe: So the good news for HPV or oropharynx cancer is that when we look at that in comparison to other types of head and neck cancers, typically cancers that are caused by tobacco and alcohol use, the overall survival is better. In fact, if we look at for cancer specifically of the tonsil and the base of the tongue, the increase in survival is 25% absolute percentage points across all stages, so very significant increase in survival.

So I think the first take-home message is that if you're starting to search the Internet and you're at some of what has been recorded for head and neck cancer, you realize that, in many times, HPV-related cancers have an improved prognosis. And that's because of that some of . . . because it's a relatively new phenomenon, some of the data that we do have on there on survival is outdated and doesn't really apply to oropharynx cancer. Now, that being said, treatment in this area does carry some toxicity.

Interviewer: What does that mean?

Dr. Monroe: So toxicity means side effects from the treatment.

Interviewer: Okay. Typically, what is the treatment? Is it surgery? Is it chemotherapy?

Dr. Monroe: The treatment that's curative includes surgery and radiation. Chemotherapy given by itself . . . while the responses are high, meaning the tumor strings down, the long-term control is very, very low. So chemotherapy is typically not given by itself. The two treatments that have been shown to be associated with the cure of the diseases, surgery and radiation, are both used and it depends upon the individual patient and the individual tumor characteristics.

Across the US, the most common treatment is probably radiation based, the combination of radiation and chemotherapy. Chemotherapy is often given along with radiation to make the radiation work better. For patients with lower volume disease, meaning smaller tumors in the back part of their throat, we're beginning to evaluate the role of surgery to remove the tumors mainly so that we can achieve, one, the elimination of chemotherapy or, two, the reduction in the dose of radiation with the goal being of minimizing some of the long-term side effects of treatment. So the side effects of treatment can include difficulty swallowing long term. The radiation therapy also affects the salivary glands and so most patients will experience dry mouth.

Interviewer: So this is for the rest of their life or just immediately after treatment?

Dr. Monroe: Yeah, for the rest of their life.

Interviewer: Okay.

Dr. Monroe: And so most patients who undergo radiation treatment for the oropharynx will have increases salivary production. Now, the good news is that some of it returns over time, but it never returns to the level that it was prior to treatment. And that has important implications only just from a quality of life perspective, but the saliva has important function particularly in preserving our teeth. And so patients who undergo radiation therapy also are at higher risk of developing dental decay and it's one of the reasons why having a dentist onboard who is trained in treating patients who have radiation therapy to their mouth is important. There are specific dental precautions that can be done to minimize the risk of dental decay in patients.

Interviewer: What are some of the other concerns or considerations you get from patients after being diagnosed with HPV head and mouth cancer?

Dr. Monroe: Yes, I think that one of the most frequent questions that we get is not from the patient itself but from their loved ones or spouses. Many have gone online and read that HPV is a sexually transmitted disease and there are fears of, one, that they may acquire the infection or, two, that there's infidelity on the part of their loved one. I think there are a couple of important points to consider.

The first is that HPV is a ubiquitous infection, while over 80% of the population is exposed and many times, these infections occur decades before the actual onset of cancer. Many people have already been exposed if their loved one has HPV. The increased risk of cancer for loved ones has been demonstrated, but it's incredibly small. So we do know from studies that have done in the Scandinavian countries that women who have cervical cancer, there's a slight increase in the risk of developing oropharynx cancer or head and neck in their spouses.

Interviewer: And then you said a slight.

Dr. Monroe: A slight. It's a very small percentage of patients.

Interviewer: Okay. So not likely.

Dr. Monroe: Not likely, generally speaking.

Dr. Monroe: In Utah, studies that we have done here have demonstrated that patients with oropharyngeal cancer, there is a higher risk of cervical cancer in their spouses above the population so the converse of the studies that have been done in Europe.

So I think what this points to is that what you might expect from a disease that's sexually transmitted is that if one partner has HPV exposure then the other partner is likely to be exposed to HPV. And if they're exposed, there's a very small risk of developing cancer. As of right now, there are no recommended guidelines other than many people will have recommended spouses, female spouses of patients with head and neck . . . to undergo their already recommended cervical cancer screening.

Interviewer: I think kind of the final point then would be also that this is a completely preventable if you have vaccination when you're young before you're exposed to it. And that's kind of a tough thing, especially here in Utah. We're not getting these vaccinations taken care of.

Dr. Monroe: I think that's an incredibly important point. So vaccination rates in Utah are lower than the national average. This is a really important preventable, not just from the head and neck cancer perspective, but there are many other cancers and non-cancer conditions caused by HPV. So, prevention is really key.

Interviewer: And there's a prevention out there. It's just that we're not using it to scale.

Dr. Monroe: We're not using it, yes.

Interviewer: So if you have been diagnosed with the head and neck cancer because of the HPV virus and you have young children, then really be sure you get that vaccination taken care of.

Dr. Monroe: That's true. So I encourage all of your loved ones and children of the appropriate age to become HPV vaccinated. It's something that's relatively easy to do and has been shown to be effective for many other cancers and is thought to be effective for oropharyngeal cancer as well.

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Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: If you're listening to this podcast, it's because you want to learn more about the HPV virus and the cancer that causes it and probably more specifically because you've heard that it's causing more cases of head and neck cancer. We're with Dr. Marcus Monroe. He is a head and neck cancer expert and let's talk about HPV. There is one type of HPV that maybe more people are familiar with, not so much the head/neck aspect. So first of all, what is HPV? Just give us the basics.

Dr. Monroe: Yeah, sure. So HPV stands for Human Papilloma Virus. It's actually a group of well over a hundred different viruses of which, about 40 are known to be transmitted in humans and of these, a few of these subtypes are known to cause cancer in humans. The most well-known association, which has been known for decades, is the link between HPV and cervical cancer. That's the reason why women are recommended to get yearly screening pap smears.

Interviewer: Thyroid Cancer, what is it, what causes it, what are the signs, and what can you do about it? That's next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Marcus Monroe is a head and neck cancer expert at University of Utah Health Care. Today, it's thyroid cancer. First of all, let's just start out with, what is your thyroid and then we'll get to what is thyroid cancer.

Dr. Monroe: So your thyroid is an endocrine gland. It's a gland that's located in the neck, just above the collar bones. It's a butterfly shaped gland and it crosses over your windpipe. Its main functions are actually quite broad. It is involved in regulating a variety of bodily functions, including blood pressure, heart rate, body temperature, energy use, metabolism. In a very basic way, your thyroid gland can be thought of as your body's thermostat.

Interviewer: And then what causes... what is thyroid cancer? Other than cancer of the thyroid.

Dr. Monroe: Yes, so thyroid cancer is actually a group of cancers. The most common types are termed well-differentiated thyroid cancer, include papillary thyroid cancer, follicular cancer, and these account for over 95% of all thyroid cancers. There are rare, inherited types of thyroid cancer called medullary thyroid cancer and then some rare aggressive variants called anaplastic thyroid cancer.

But in general, when most people speak of thyroid cancer, they're most commonly referring to those most common types of follicular and papillary thyroid cancer. Something we've demonstrated in research that is that is done here at University of Utah, demonstrating in small but increased risk of even these well differentiated thyroid cancers in family members of patients with thyroid cancer. And that's been known before, that there is probably a family link. For the medullary thyroid cancer, there is a very clear genetic component associated with mutations in the RET gene, so that's a little bit different entity but also has a very strong genetic link.

Interviewer: And, as a result of that stronger genetic link, if you know that that's in your family then you should be a little bit more aware of that, I suppose?

Dr. Monroe: Yeah, it's something to be aware of.

Interviewer: So what else causes it? There can be a genetic component, what else?

Dr. Monroe: The majority of patients we know of no specific genetic component. The number of environmental exposures that have been associated with thyroid cancer are actually pretty few. The one that has really been conclusively demonstrated is the previous exposure to radiation, and we know that from some of the follow-up studies that have been done in areas that have had nuclear fallout, like the Chernobyl region, have seen vastly increased rates of thyroid cancer.

Interestingly here in Utah, there have been studies done that have demonstrated higher rates of thyroid cancer, particularly in areas that have nuclear fallout from the nuclear testing that was done in Nevada in the 1950s and '60s.

Other risk factors for thyroid cancer that aren't quite as well established include female gender, so we know that thyroid cancer is more common in females and is thought to potentially be related to some hormones, but that hasn't really been worked out. And we also have a link with obesity. We see an increase in thyroid cancer with an increase in obesity, although these links are not as strongly linked as the one with radiation.

Interviewer: What are some of the signs? What am I looking for? How do I know that I might need to Google something or go to my doctor?

Dr. Monroe: Yeah, so thyroid cancer is a little unique in that the vast majority of patients are asymptomatic and have thyroid nodules discovered either on a routine exam for some other condition or an imaging studies performed for a completely unrelated diagnosis. Specific signs of thyroid cancer can include a lump in the neck, changes in voice or swallowing, or rarely, coughing up blood. But the vast majority of patients are actually asymptomatic at the time of diagnosis.

Interviewer: So what should somebody do if their physician had done some other tests and discovered that they actually do have a thyroid nodule?

Dr. Monroe: The first thing that's important to realize is that thyroid nodules are incredibly common. They increase with age and, in fact, if you look with sensitive measures like ultrasound, over 50% of people will have thyroid nodules by the age of 50 or 60. So an incredibly common condition.

Interviewer: So it doesn't mean cancer?

Dr. Monroe: It does not mean cancer. In fact, the risk of cancer in any individual with thyroid nodules is actually quite low, somewhere in the range of 5 to 10%.

Interviewer: So that's kind of nice to hear.

Dr. Monroe: Yes. So I think it's nice. Now, as of right now we don't have great ways of differentiating them other than characteristics on the ultrasound and by biopsy. So for patients who are diagnosed with a thyroid nodule most will be referred to an endocrinologist or a surgeon who specializes in thyroid cancer for evaluation of the characteristics of the nodule as well as their thyroid gland function.

The testing typically begins with measurement, a blood test to measure your thyroid function, and then, in most cases then an ultrasound. There are very specific criteria that have been laid out that demonstrate which nodules harbor an increased risk of thyroid cancer and which nodules should be biopsied, so not all nodules need to be biopsied. Those that are larger in size or have worrisome characteristics by ultrasound, the next step is to then attain a fine needle aspiration, which is a small biopsy with a needle that can be done in clinic.

Interviewer: So a nodule doesn't necessarily mean cancer. If it is diagnosed and it is determined that there is cancer going on, what would be the steps after that? What's the treatment look like?

Dr. Monroe: The treatment for thyroid cancer typically involves surgery. Depending on the size and location of the cancer within the thyroid, that may involve removing either half or the entire thyroid gland. Occasionally, removal of regional lymph nodes is required if the cancer has spread to the lymph nodes or if there's a particularly high risk of cancer spreading to the lymph nodes.

Once surgery is over, a select group of patients that are at higher risk may need additional therapies. The most common of those is radioactive iodine, which is a pill that can be taken afterwards that has radiation tagged to an iodine molecule. Now the thyroid is a little bit unique in that it takes up this iodine and can concentrate the radiation to kill any remaining thyroid cancer. That's really only used in patients that are deemed higher risk for the cancer coming back afterwards.

Interviewer: And what's life look like after thyroid cancer treatment?

Dr. Monroe: The good news is that if we look at all the different shades of thyroid cancers, the most common thyroid cancer rates of survival are excellent. Survival rates at 5 and 10 years are well above 95%. Survival is great. The unfortunate thing is that we don't really have a lot of data on what sort of health problems people have after treatment, so that remains an unanswered question. But in the vast majority of cases, patients are able to go back to their normal life and function normally.

Interviewer: So for the most part, quality of life after the treatment

Dr. Monroe: Yeah, as far as I know--

Interviewer: Is normal, unaffected?

Dr. Monroe: Yeah.

Interviewer: Any final thoughts? Anything you wish I would have asked or anything you feel compelled to say?

Dr. Monroe: I think the important thing to realize is that, because survival is so good, nodules are so common, thyroid cancer is not something we recommend screening for. In fact, if we look at countries that have started screening for thyroid cancer, we see some really interesting findings. So if we look at South Korea, for instance, they started a screening program for cancers in the '90s and, as part of that, many hospitals offer ultrasound based thyroid screening. And what they have found is that thyroid cancer has now become the most common malignancy in that country, far surpassing any other cancers.

The interesting thing about it is the number of people who die of thyroid cancer has remained unchanged. So I think it's really important when we talk about screening for these cancers is that to realize that one, these cancers are actually very common, and two, they are unlikely to affect a person significantly during their lifetime. There's general though that, in many cases, the risks of screening and all the testing and biopsies that need to go into finding these nodules probably outweighs any benefit.

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