April 29, 2019
Devante Morrow, age 26, hadn’t been to a dentist since the 6th grade. “I never really had any pain, so didn’t feel Iike I needed to go to a dentist.”
A few years ago, Morrow’s aunt began suffering from cancer, which upon diagnosis, was believed to have spread from her mouth and throat. “By the time the doctors found out what was the problem, it was really too late, because she ended up having stage four cancer,” says Morrow. His aunt unfortunately did not survive after the diagnosis.
This experience stirred a change in Morrow’s life.
He decided to pay more attention to his health overall, from taking care of his teeth, to trying to lose some weight. “I recently started going to the gym because my doctor said I have high cholesterol and I need to lose some weight,” says Morrow.
These concerns also motivated Morrow to attend a recent oral cancer screening held at UIC.
Luckily, the cancer screening result was good – no cancer or other abnormal findings. And, he came away with some good information.
“I didn’t even know oral cancer existed,” Morrow says. “I had heard of colon, lung and other cancers, but I never knew cancer could grow inside my mouth too, or that it can spread.”
Morrow has since found a new dentist for more regular exams. “Seeing my aunt suffer, got me to start thinking more about my health.” And now that I have insurance, I plan to start going to the dentist more regularly.”
Low awareness of oral cancer
According to the American Cancer Society, about 53,000 people in the US will get oral cavity or oropharyngeal cancer this year, and an estimated 10,860 people will die of these cancers. These numbers make oral head and neck cancers the sixth most common cancer type in the world. There are more than 640,000 new cases of oral cancer diagnosed annually worldwide. Oral, head and neck cancer refers to many types of cancer, including those that arise in oral cavity (mouth), pharynx (throat), larynx (voicebox), sinuses, nasal cavity or salivary glands. Yet, most people aren't aware of how serious head and neck cancers can be.
Oral cancer is twice as common in men as in women. This difference may be related to the use of alcohol and tobacco, which is a major oral cancer risk factor seen more commonly in men than in women. For people who smoke and drink heavily, the risk of oral cancer may be as high as 100% more than the risk for people who do not smoke or drink.
According to a 2017 US survey by Vigilant Biosciences, the majority (62%) of adults in the U.S. know very little, or nothing at all, about oral cancer (including cancer of the oral cavity, tongue, larynx and pharynx).
Most people aren’t aware of how serious head and neck cancers can be.
Another study in 2014 reported that two-thirds (66%) of respondents to an online survey were “not very” or “not at all” knowledgeable about the risks and symptoms of head and neck cancers.
Yet, according to a 2018 survey in Wisconsin, awareness of these risks among people who exhibit these behaviors should be much higher.
What are the risk factors?
Alcohol and tobacco use are major risk factors for cancers of the head and neck – in fact, 85% of head and neck cancers are linked to tobacco use – smoking cigarettes, cigars or pipes; chewing tobacco; and using snuff. Secondhand smoke may also increase a person’s risk of developing head and neck cancer. The second leading cause of head and neck cancer is frequent and heavy alcohol use.
You are 3 times more likely to get oral cancer if you drink or use tobacco. And 30 times more likely if you have HPV.
You can lower your risk of getting head and neck cancer in several ways:
- If you are a smoker or tobacco user – quit smoking and use of smokeless tobacco products.
- Limit the amount of alcohol you drink.
- Get evaluated for head and neck cancer by your doctor or dentist, at least once a year.
- If you are 26 years old or younger, or are sexually active with multiple partners talk to your doctor about HPV vaccines.
HPV and oral cancer
Another aspect of these cancers that most people are not aware of, is their connection to human papillomavirus (HPV), the most common sexually transmitted virus in the US. About 8 out of 10 people will get an HPV infection at some point in their lives. The combined cost of HPV-associated cancers and other conditions is estimated to be $8 billion per year in the US.
HPV has become the leading cause of cancers of the mouth and throat. And, it has replaced cervical cancer as the most common site for HPV associated cancer. About 70% of cancers in the oropharynx (which includes the back of the tongue, the soft palate and tonsillar region) are linked to HPV, according to the Centers for Disease Control and Prevention (CDC).
“HPV oral and oropharyngeal cancers can be harder to discover than tobacco related cancers because the symptoms are not as obvious,” says Dr. Joel Schwartz, professor of Oral Maxillofacial Pathology, who has been researching the HPV oral cancer connection for 40 years. “The symptoms can be very subtle and painless, and it is harder to detect early on.”
The majority of HPV oral cancers affect the base of tongue, tonsils and back of the throat, with only a very small number in the front of the mouth. HPV 16 is the strain most commonly responsible but there are other lower risk HPV subtypes that are associated with oral cancers.
UIC researchers map at-risk Chicago neighborhoods
Dr. Schwartz and other researchers at UIC are working to improve awareness of the connections between HPV and oral cancer, specifically in Chicago. Through analysis of clinical, geographic, and demographic data, they aim to better understand the bacterial associations that lead to HPV oral cancer conditions.
In addition to the geographic population study, they are also investigating the HPV oral cancer connection at the biological level. In a recent study, published in Microbiologyopen, Dr. Tao and Dr. Schwartz reported that common oral bacteria, Streptococcus species can contribute to HPV infection, in the invitro setting.
“The larger public health message that we want to share is that there are certain segments in the Chicago area population that are at higher risk of getting cancer in their mouth or throat, being caused by HPV,” said Schwartz. “Additionally, want to inform communities that lifestyle and living conditions are also important factors, just as they are with lung and colon cancers,” added Schwartz.
Schwartz and his team are mapping the geographic distribution of risk in Chicago by analyzing the incidence of these cancers within certain neighborhoods. They are using data from the Chicago Health Atlas, developed through a partnership between the City Tech Collaborative and the Chicago Department of Public Health.
This type of analysis has never been done before at the neighborhood level in Chicago.
“What this shows us is that underserved and low socioeconomic affected neighborhoods are at a higher risk compared to US rates of oral cavity, throat, lung and colon cancers,” added Schwartz.
The team is combining local neighborhood data with other data sources and tools provided by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), along with UIC College of Dentistry patient data to assemble a more comprehensive picture of what is happening in these neighborhoods in relation to oral health as a contributing factor for appearance of these cancers. From this, they plan to produce a mapping of the number of dental emergencies, tooth extractions, combined with other oral and systemic health factors that can help public health professionals better pinpoint population cohorts that are at highest risk of HPV related cancers.
“This analysis gives us a much better picture of how oral health is connected to the epidemiology in local communities, and we hope it can inform broad public health policies,” say Schwartz.
Analyzing the risk from an epidemiological and biological standpoint
In addition to the geographic population study, they are also investigating the HPV oral cancer connection at the biological level. In a recent study, published in Microbiologyopen, Dr. Tao and Dr. Schwartz reported that common oral bacteria, Streptococcus species can contribute to HPV infection, in the invitro setting. “Recognition of this relationship between various oral microbes and HPV infection opens the opportunity to aid vaccination in controlling HPV infection,” said Schwartz.
These new insights could one day inform and enhance gene studies that influence the development of “personalized medicine” innovations. The next step is to validate these findings through cellular level analysis using human specimens from the study populations. From there, scientists could then better understand the biological process of how HPV causes oral cancer, specifically, how the microbiome regulates the entry of infections and cancers that originate in the mouth and throat.
"By combining the geographic data with the epidemiology and genomic profiles in those neighborhoods, it gives us much better insight into the connection between lifestyle, socioeconomic and other variables, from one neighborhood to the next," Schwartz explained. "We could began to evaluate why one neighborhood has a higher risk of cancer than another, even if they are socioeconomically similar."
The team plans to continue their work, which holds a lot of promise for enhancing understanding of the prevalence of cancerous risks and conditions. "We can aid the development of new treatments and increase effectiveness of HPV vaccination," says Dr. Lin Tao, Professor, Oral Biology, who is studying the role of interaction between bacteria and viruses. "We can also improve the effectiveness of cancer fighting medications once the cancers form."
The importance of regular exams and early diagnosis
The death rate associated with the head and neck cancers is particularly high because these cancers can go un-diagnosed for so long, but they are readily recognizable without a professional examination. Often oral cancer is only discovered when it has metastasized to another location, such as the lymph nodes of the neck. Prognosis at this later stage of discovery is significantly worse than when it is caught in the mouth at the site where growth first occurs.
Dr. Beth Miloro, Clinical Assistant Professor in the Department of Oral Medicine and Diagnostic Sciences and Dr. Joel Schwartz, professor, Director of Oral Maxillofacial Pathology and oral cancer researcher for forty years -- share why early detection is so important.
UIC conducts free oral cancer screenings to expand awareness
A great way for people to learn about their risk is to get an oral cancer examination by their doctor or dentist. At UIC College of Dentistry, every new patient receives a free oral cancer examination. The college also holds annual free screening days which attracts many people who either aren’t yet patients, or just want to learn more.
This year’s screenings attracted over 40 people at the college, as well as an additional 187 people at additional UI Health locations across Chicago, as part of April’s Oral, Head and Neck Cancer Awareness Month. Of those individuals screened, 24 had positive results, meaning those patients require follow-up screening and care, said Nasima Mannan, MPH, senior research specialist and navigation manager at the UI Cancer Center.
“Our goal is to really spread the word about the importance of screenings and early detection,” said Dr. M. Beth Miloro Assistant Clinical Professor at UIC College of Dentistry’s Oral Medicine and Facial Pain clinic, the only specialty clinic of its kind in Chicago.
Schwartz and Miloro both agree that in addition to overall awareness of head and neck cancers, educating the public about HPV connected cancers is especially important because these cases are on the rise. According to a CDC report, the number of HPV-associated cancer cases jumped from 30,115 in 1999 to 43,371 in 2015 in the US. Oropharyngeal cancer, which forms in the narrow part of the throat, also known as the oropharynx, is now the most common HPV-associated cancer.
More of our patients now have questions about the HPV and oral health connection,” said Miloro. “So, we inform people about the different HPV strains, and the benefits of getting the HPV vaccination, even up to age 45.”
The message seems to be working, as it brought Morrow in for his first ever oral cancer screening. “I heard about the oral cancer screenings on the radio, and decided to come in, since I haven’t been to a dentist in a long time,” said Morrow. “I didn’t really suspect I had any issues, but still wanted to be on the safe side.”
During the examination, the dentist will search for precancerous and cancerous findings of the head and neck. This includes, but is not limited to, a lesion that may exhibit signs of being high risk for cancer, or possibly a lump in the neck. The lesions may be white or red, and sometimes can be painful – but not always.
Other symptoms of oral cancer may be numbness and the inability to feel certain areas of the mouth, lip, chin or face, he said. A patient may also find swallowing difficult, and the site of a tooth extraction may not heal properly, which can be suspicious for cancer.
“A new lump in the neck should always be evaluated,” said Dr. Nicholas Callahan, assistant professor of oral and maxillofacial surgery at UIC. “It is so important to be vigilant so that if a patient does develop cancer, we can catch it early. Early diagnosis is a significant factor in survival in head and neck cancer.”
American Cancer Society, Key Statistics for Oral Cavity and Oropharyngeal Cancers
Vigilant Biosciences, Oral Cancer Awareness Survey, April 4, 2017
Alexander L. Luryi, BS1; Wendell G. Yarbrough, MD, MMHC1,2; Linda M. Niccolai, PhD3; et al Steven Roser, DMD, MD4; Susan G. Reed, DDS, MPH, DrPH5; Cherie-Ann O. Nathan, MD6; Michael G. Moore, MD7; Terry Day, MD8; Benjamin L. Judson, MD1,2
Public Awareness of Head and Neck Cancers: A Cross-Sectional Survey JAMA Otolaryngol Head Neck Surg. 2014;140(7):639-646. doi:10.1001/jamaoto.2014.867
Shimpi N1, Jethwani M1,2, Bharatkumar A1,2, Chyou PH3, Glurich I1, Acharya A4,5,6. Patient awareness/knowledge towards oral cancer: a cross-sectional survey. BMC Oral Health. 2018 May 15;18(1):86. doi: 10.1186/s12903-018-0539-x.
Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer, National Cancer Institute
Pavlova SI, Wilkening RV, Federle MJ, Lu Y, Schwartz J, Tao L. Streptococcus endopeptidases promote HPV infection in vitro. Microbiologyopen. 2018;8(1):e00628. doi:10.1002/mbo3.628
Van Dyne EA, Henley SJ, Saraiya M, Thomas CC, Markowitz LE, Benard VB. Trends in Human Papillomavirus–Associated Cancers — United States, 1999–2015. MMWR Morb Mortal Wkly Rep 2018;67:918–924.