- Email: [email protected]
North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma
Oral Oncology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma q Anastasios Maniakas a,b, Sami P. Moubayed b, Tareck Ayad b, Louis Guertin b, Phuc Felix Nguyen-Tan b, Olga Gologan b, Denis Soulieres b, Apostolos Christopoulos a,b,⇑ a b
Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
a r t i c l e
i n f o
Article history: Received 30 December 2013 Received in revised form 23 May 2014 Accepted 15 July 2014 Available online xxxx Keywords: Human papillomavirus p16 Head and neck squamous cell carcinoma Oropharyngeal cancer Survey North America
s u m m a r y Objectives: Human papillomavirus (HPV)-positive head and neck squamous cell carcinomas (HNSCC) have been shown to have a significantly better prognosis and response to current treatment modalities. Current guidelines recommend systematic HPV-DNA and/or p16 testing on HNSCCs, although treatment approach should not be directed by test results. The objectives of this study were to (1) assess whether HPV-DNA and/or p16 status are systematically evaluated across North American otolaryngologists-head and neck surgeons and (2) whether the status is used to direct treatment approach. Materials and methods: A 15-question online survey was sent to three associations: the Association of Oto-rhino-laryngology-Head and Neck Surgery of Quebec, the Canadian Society of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society. Results: Sixty-seven percent of respondents systematically test for HPV-DNA and/or p16 on HNSCC sites, while 58.3% report using test results to direct treatment for oropharyngeal cancers. A lack of official guidelines was the primary reason (81.8%) physicians did not use test results to direct treatment. Academic centre physicians (83.3%) and physicians with P50% oncologic practice (87.6%) were more likely to test for HPV-DNA and/or p16 in HNSCC compared to non-academic centre physicians (39.7%) and physicians with <50% oncologic practices (51.4%) (p < 0.001). Cost of the tests (69.2%), lack of relevance (46.1%) and time constraints (30.8%) were the primary reasons HPV-DNA and/or p16 were not tested. Conclusion: The majority of North American respondents in this survey systematically test for HPV-DNA and/or p16 in HNSCC sites, and most indicate that test results influence their treatment approach for oropharyngeal cancers. Ó 2014 Elsevier Ltd. All rights reserved.
Introduction Cancer of the head and neck is presently the 8th most common cancer in men and 15th in women in the United States [1], while being 9th and 14th, respectively, in Canada [2]. While tobacco smoking and excessive alcohol use have long been associated as the principle risk factors for developing head and neck squamous cell carcinoma (HNSCC), the rates of tobacco use have been in decline in the United States over the past few decades [3]. However, HNSCC, and more specifically oropharyngeal squamous cell
q Presented at the 117th Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Vancouver, BC, September, 2013. ⇑ Corresponding author. Address: Division of ORL-HNS, Department of Surgery, Centre Hospitalier de l’Université de Montréal, 1560 Rue Sherbrooke Est, Montréal, Québec H2L 4M1, Canada. Tel.: +1 (514) 890 8000x27201. E-mail address: [email protected] (A. Christopoulos).
carcinoma (OPSCC), do not seem to be following the same trend. In fact, incidence rates have been increasing throughout North America [4–8], Europe [9–12] and Australia [13], and this due to the human papillomavirus (HPV) as the causative independent risk factor. In addition, younger males have been showing the steadiest increase in HPV-positive HNSCCs [7]. According to the current literature, HPV-DNA can be found anywhere between 20% and 79% of HNSCCs [9,13–16] and in as much as 93% of OPSCCs specifically [9], with HPV type 16 being detected in 80–90% of these cases [17,18]. Although the incidence of HPV-positive HNSCC has been on the rise, overall prognostics, compared to HPV-negative HNSCC, have been shown to be more favourable [19–22]. Presently, treatment de-intensification is of primary concern, as patients develop severe side-effects following the combination of tumor resection, radiation therapy, and chemotherapy, such as chronic dysphagia with gastric tube dependence, tracheostomy dependency, and aspiration, among others [20,23].
http://dx.doi.org/10.1016/j.oraloncology.2014.07.004 1368-8375/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
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A. Maniakas et al. / Oral Oncology xxx (2014) xxx–xxx
Currently, HPV-DNA testing is recommended to be part of standard pathologic evaluation, both by the College of American Pathologists [24] and the American Joint Committee on Cancer [25]. HPV-positive HNSCCs can be detected in either a direct or indirect manner. The most commonly used direct methods include polymerase chain reaction (PCR)-based amplification and DNA in situ hybridization (ISH), while immunohistochemical (IHC) detection of the p16 protein has become the primary indirect method in detecting HPV-positive HNSCCs [26]. Albeit the current recommendations, there is a lack of information available on the practice of detection methods used by otolaryngologists-head and neck surgeons (OHNS) in North America on HNSCCs. Thus, our goal was to assess the current state of North American OHNS and their systematic testing of HPV-DNA and/or p16 in HNSCCs, and to determine if their treatment approach is driven by test results. Materials and methods Following ethics committee approval, a 15-question English language survey requiring between five and ten minutes to complete, was formulated and sent by email to the administration offices of registered members of three medical associations: the Association of Oto-rhino-laryngology-Head and Neck Surgery of Quebec (AOHNSQ), the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS), and the American Head and Neck Society (AHNS). Members of the AOHNSQ and the CSOHNS also received a French version of the survey in order to accommodate French-speaking physicians. The survey was prepared using the web survey development cloud base SurveyMonkey (SurveyMonkey Inc., Palo Alto, CA). A link specific to each association was sent between the months of July and September 2012 along with a cover letter explaining our purpose and the confidentiality of participants’ answers. Our contact information was also provided in the unforeseen eventuality of any technical difficulties or any other issues with regard to the survey. A reminder email was sent out two to three weeks following the first email. Inclusion and exclusion criteria Physicians from the following specialties were included in our study: Otolaryngologists-head and neck surgeons, radiation oncologists, medical oncologists, and pathologists. Survey responses received from physicians primarily practicing outside of North America were excluded. Furthermore, incomplete surveys, or surveys completed more than once by the same physician were excluded from our study.
giving us an overall response rate of 15.2%. Survey responses were incomplete twenty-seven times, while ten originated from physicians practicing primarily outside of North America. OHNS represented 90.7% of all respondents (196 of 216), while the remaining were medical oncologists (2.3%), radiation oncologists (1.3%), pathologists (1.3%), and other specialists (4.4%). Responses were primarily completed in English (82.4%) and came from physicians practicing mainly in academic centres (63.9%). Results indicated that AOHNSQ respondents tested for HPVDNA and/or p16 statistically significantly less often than CSOHNS and AHNS respondents (p < 0.001) (Table 1). Physicians from academic centres reported using HPV-DNA and/or p16 testing more often (83.3%) than non-academic centre physicians (39.7%) (p < 0.001) (Table 1), while physicians with P50% oncologic practices reported systematic testing of HPV-DNA and/or p16 statistically significantly more often than physicians with <50% oncologic practices (87.6% vs. 51.4%, respectively) (p < 0.001) (Table 1). When reported, the physicians that tested for HPVDNA and/or p16 began doing so as early as in 2005, with most having begun between 2007 and 2011 (Fig. 1). HPV-DNA and/or p16 testing and cancer site specificity When tested, respondents reported looking for both HPV-DNA and p16 77.4% of the time, while only HPV-DNA 11.6% and only p16 11.0% of the time. ISH was the most common method (53.8%) used for HPV-DNA testing, followed by PCR (26.9%) or both methods (19.2%). The oropharynx was the most common site for HPV-DNA and/or p16 testing, with 67.5% of respondents answering that they systematically search for the latter markers, followed by the oral cavity (31.9%) and other sites (20.3%) such as the larynx, hypopharynx, and nasopharynx, when specified (Fig. 2). Of the 70 respondents that reported not testing for HPV-DNA or p16 on their specimens, 18 (25.7%) gave no reason. For the remaining respondents, the cost of the tests was the most important reason (69.2%) to refrain from ordering the tests, while lack of relevance and time were given as reasons for 46.1% and 30.8% of respondents, respectively. When asked if HPV-DNA testing was in their practices’ future plans, 64.3% of the respondents replied that they do not plan on beginning any testing, 19.6% replied that they would begin within 6 months, 10.7% within a year, while 5.4% in more than a year. The latter values for p16 were 62.7%, 20.3%, 13.6%, and 3.4%, respectively. Test results and their influence on treatment When HPV-DNA or p16 testing was performed, 58.3% of respondents reported that the results of these tests influenced
Statistical analyses All data were tabulated using Microsoft Excel and all statistical analyses were performed using SPSS 19.0 (SPSS Inc., Chicago, Ill). A two-tailed Pearson Chi-Square test was performed to compare descriptive proportions from our respondents, as well as to analyze the difference in responses between the three associations. For all statistical analyses, a p < 0.05 was considered statistically significant. Results Demographics Of a total of 1694 sent emails, 34 were unsuccessfully transmitted and 253 completed responses were received. Of these 144 were from the AHNS, 66 from the CSOHNS, and 43 from the AOHNSQ,
Table 1 HPV-DNA and/or p16 testing according to medical society, practice setting, and oncologic practice. Yes
No
Do not know
P value
Medical society AHNS CSO QC
104 (88.1%) 36 (61.0%) 6 (15.4%)
14 (11.9%) 19 (32.2%) 22 (56.4%)
0 (0.0%) 4 (6.8%) 11 (28.2%)
<0.001
Practice setting Academic Non-academic
115 (83.%) 31 (39.7%)
20 (14.5%) 35 (44.9%)
3 (2.2%) 12 (15.4%)
<0.001
Oncologic practice <50% 57 (51.4%) P50% 85 (87.6%)
41 (36.9%) 12 (12.4%)
13 (11.7%) 0 (0.0%)
<0.001
AHNS = American Head & Neck Society; CSO = Canadian Society of Otolaryngology; QC = Quebec Association of Otolaryngology.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
A. Maniakas et al. / Oral Oncology xxx (2014) xxx–xxx
Figure 1. Number of physicians beginning to test for HPV-DNA and/or p16 per year.
Figure 2. HPV-DNA and/or p16 testing and site specificity.
their treatment approach when dealing with oropharyngeal lesions, while 12.9% reported it did so for oral cavity lesions (Fig. 3). For the respondents for whom test results did not affect their treatment approach, a lack of official guidelines was the primary reason (81.8%), followed by a lack of significant data on increased survival rates (9.1%) or by the opposition of fellow colleagues (9.1%).
Discussion Our online survey has brought forth several points on the evolution of HNSCC treatment in North America. Presently, more than two thirds of physicians in our survey systematically test for HPVDNA or p16 in HNSCC specimens, with an additional 10% stating that they will incorporate such practices in their institutions in
Figure 3. HPV-DNA and/or p16 testing results influence on treatment.
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the near future. As shown in a similar study, where United-States radiation oncologists were surveyed in early 2009 [27], our study shows a 27.5% increase in HPV-DNA and/or p16 testing in OPSCCs. More specifically, when comparing the responses we received from the AHNS, a primarily American-member association, and Shoushtari et al.’s study results, the proportion of respondents systematically testing for HPV-DNA and/or p16 has increased by over 100% in three years. Furthermore, the practice of HPV-DNA and/or p16 testing has seen a steady increase across North America since 2005, with an average of 11 centres per year adding these tests to their systematic protocol. These findings not only demonstrate the current trend across the oncologic scientific community, but also the importance of HPV-DNA and/or p16 status in patient management. However, although the most recent guidelines by the National Comprehensive Cancer Network (NCCN) on head and neck cancers recommend the systematic testing of HPV-DNA on specimens, HPV-DNA status is not to be used to guide treatment [28]. It is suggested that HPV-DNA status currently remain a prognostic reference, while being of value when considering enrollment in clinical trials. Nevertheless, over half of all respondents in our survey who systematically test for HPV-DNA and/or p16 reported using the test results to direct their treatment approach, likely towards some form of de-intensification. The latter proportion represents close to a 500% increase, compared to the group of radiation oncologists surveyed in 2009 [27]. To date, there is no gold standard in the clinical setting for screening HPV in HNSCCs, although PCR-based assays are primarily used in HPV research [18]. Institutions may use a variety of tests, and this is influenced by personal choice, time constraints, and more often than not, the cost of the tests. Our survey has shown that physicians primarily test for both HPV-DNA and p16, with ISH being the primary method of direct HPV-DNA testing. These results correlate with the current consensus that ISH may be a more practical tool for clinical diagnostic purposes [26], while testing for p16 alone can lead to the false interpretation of certain carcinomas due to the inactivation of the Rb gene in other ways than with the HPV E7 oncoprotein [29]. In our centre, PCR and p16 IHC are systematically performed on all HNSCCs. Other centres choose to test for p16 alone, followed by further direct HPV testing if p16 results are unclear or negative [30–32]. Research groups have also looked into other molecular markers that may act as further prognostic and/or treatment factors, such as Bcl2 [33]. Recently, RNA in situ hybridization has been shown to be an excellent test for HPV with a sensitivity of 97% and specificity of 93% [34]. What is clear is that some form of HPV screening should be performed to allow physicians to have a better understanding of the disease at hand. Creating a clinical standard test in the near future is of utmost importance, as it will not only standardize clinical practice, but may also further persuade physicians to incorporate such habits in their patient work-up. With the advent of de-intensification clinical trial results showing similar, if not superior, overall survival rates in HPV-positive compared to HPV-negative HNSCCs [23,35,36], while having fewer and/or milder side-effects, instating an HPV testing protocol can be beneficial. Furthermore, although the majority of respondents in our survey who did not perform any HPV testing did not do so due to the high costs of the tests, a recent study by Moore et al. demonstrated a significant reduction in treatment costs if de-intensification is to be undertaken in HPV-positive HNSCC patients [37]. However, for the time being, no change should be performed in the standard treatment based solely on HPV status, as there are no official guidelines and a holistic understanding of the disease has yet to be reached. Current and future clinical trials will shed light not only on the long-term effect of de-intensification, but also on patient and tumor variability within the HPV-positive HNSCC spectrum.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
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A. Maniakas et al. / Oral Oncology xxx (2014) xxx–xxx
Canadian practice
References
According to our survey respondents, compared to AHNS members, the CSOHNS members seem to be following the same trend for HPV-DNA and/or p16 testing. However, when comparing Quebec, to the rest of Canada and the United-States, there seems to be a significant delay in implementing such clinical practices. With further published guidelines and clear benefit-cost ratio arising in the near future, and the influence of major provincial academic centres, we are optimistic that Quebec will be at par with the rest of North America in terms of clinical practice. As one of the major head and neck oncology centres in Quebec, we systematically test for both HPV-DNA and p16 in all HNSCCs.
[1] Cancer facts and figures 2013. ; 2013 [accessed 20.09.13]. [2] Canadian Cancer Statistics 2013. ; 2013 [accessed 20.09.13]. [3] Giovino GA. The tobacco epidemic in the United States. Am J Prev Med 2007;33:S318–326. [4] Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol 2011;29: 4294–301. [5] Frisch M, Hjalgrim H, Jaeger AB, Biggar RJ. Changing patterns of tonsillar squamous cell carcinoma in the United States. Cancer Causes Control 2000;11:489–95. [6] Wang XI, Thomas J, Zhang S. Changing trends in human papillomavirus-associated head and neck squamous cell carcinoma. Ann Diagn Pathol 2012;16:7–12. [7] Marur S, D’Souza G, Westra WH, Forastiere AA. HPV-associated head and neck cancer: a virus-related cancer epidemic. Lancet Oncol 2010;11:781–9. [8] Sturgis EM, Cinciripini PM. Trends in head and neck cancer incidence in relation to smoking prevalence: an emerging epidemic of human papillomavirus-associated cancers? Cancer 2007;110:1429–35. [9] Nasman A, Attner P, Hammarstedt L, et al. Incidence of human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm, Sweden: an epidemic of viralinduced carcinoma? Int J Cancer 2009;125:362–6. [10] Ramqvist T, Dalianis T. An epidemic of oropharyngeal squamous cell carcinoma (OSCC) due to human papillomavirus (HPV) infection and aspects of treatment and prevention. Anticancer Res 2011;31:1515–9. [11] Nygard M, Aagnes B, Bray F, Moller B, Mork J. Population-based evidence of increased survival in human papillomavirus-related head and neck cancer. Eur J Cancer 2012;48:1341–6. [12] Rietbergen MM, Leemans CR, Bloemena E, et al. Increasing prevalence rates of HPV attributable oropharyngeal squamous cell carcinomas in the Netherlands as assessed by a validated test algorithm. Int J Cancer 2013;132:1565–71. [13] Hong AM, Grulich AE, Jones D, et al. Squamous cell carcinoma of the oropharynx in Australian males induced by human papillomavirus vaccine targets. Vaccine 2010;28:3269–72. [14] Hammarstedt L, Lindquist D, Dahlstrand H, et al. Human papillomavirus as a risk factor for the increase in incidence of tonsillar cancer. Int J Cancer 2006;119:2620–3. [15] Gillison ML, D’Souza G, Westra W, et al. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst 2008;100:407–20. [16] Ang KK, Harris J, Wheeler R, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med 2010;363:24–35. [17] Kreimer AR, Clifford GM, Boyle P, Franceschi S. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomark Prev 2005;14:467–75. [18] Schlecht NF, Brandwein-Gensler M, Nuovo GJ, et al. A comparison of clinically utilized human papillomavirus detection methods in head and neck cancer. Mod Pathol 2011;24:1295–305. [19] Lindel K, Beer KT, Laissue J, Greiner RH, Aebersold DM. Human papillomavirus positive squamous cell carcinoma of the oropharynx: a radiosensitive subgroup of head and neck carcinoma. Cancer 2001;92:805–13. [20] Chen AM, Li J, Beckett LA, et al. Differential response rates to irradiation among patients with human papillomavirus positive and negative oropharyngeal cancer. Laryngoscope 2013;123:152–7. [21] Fakhry C, Westra WH, Li S, et al. Improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst 2008;100:261–9. [22] Ragin CC, Taioli E. Survival of squamous cell carcinoma of the head and neck in relation to human papillomavirus infection: review and meta-analysis. Int J Cancer 2007;121:1813–20. [23] Quon H, Richmon JD. Treatment deintensification strategies for HPVassociated head and neck carcinomas. Otolaryngol Clin North Am 2012;45: 845–61. [24] Seethala RR, Weinreb I, Carlson DL et al. Protocol for the examination of specimens from patients with carcinomas of the pharynx. ; 2013 [accessed 20.09.13]. [25] AJCC cancer staging manual. 7th ed. New York, NY: Springer, 2011. [26] Westra WH. Detection of human papillomavirus in clinical samples. Otolaryngol Clin North Am 2012;45:765–77. [27] Shoushtari AN, Rahimi NP, Schlesinger DJ, Read PW. Survey on human papillomavirus/p16 screening use in oropharyngeal carcinoma patients in the United States. Cancer 2010;116:514–9. [28] Pfister DG, Burtness BA, Colevas AD et al. NCCN Guidelines 2.2013 head and neck cancers. ; 2013 [accessed 20.09.13]. [29] Shapiro GI, Park JE, Edwards CD, et al. Multiple mechanisms of p16INK4A inactivation in non-small cell lung cancer cell lines. Cancer Res 1995;55:6200–9. [30] Lewis Jr JS, Thorstad WL, Chernock RD, et al. P16 positive oropharyngeal squamous cell carcinoma:an entity with a favorable prognosis regardless of tumor HPV status. Am J Surg Pathol 2010;34:1088–96.
Limitations The overall response rate of 15.2% is lower compared to other published survey studies with physicians (30–40%) [27,38]. This may be due to the timing of our survey, as associations were contacted during summer months. Moreover, although we did expect a better response rate from the AHNS, low response rates from the CSOHNS and AOHNSQ are likely due to the fact that a large proportion of their members do not practice head and neck oncology, leading to a ‘‘voluntary response bias’’. Since there is no distinct Canadian or Quebec head and neck society per se, we were limited to contacting entire otolaryngology associations. Conversely, this allowed us to receive the input of general otolaryngologists, and have an idea of the current HPV-DNA and p16 testing state in this population. Although this selection bias might lead to a slight overestimation of the rate of HPV and/or p16 testing, it is evident that the rates are continuously increasing, and will continue to do so in the years to come. Our findings are in line with the available data on this issue where increasing trends in HPV screening in the clinical setting are shown [27]. Lastly, although not part of the primary scope of this study, further questioning on the precise method used to test for HPV and/or p16 would be interesting and for which future research is warranted. Overall, although the number of surveyed physicians may not represent the entire OHNS population, we believe that by ensuring the clarity and anonymity of our survey we were able to obtain accurate and truthful responses. Conclusion Overall, over two thirds of North American physicians who participated in our survey reported testing for HPV-DNA and/or p16 on HNSCCs, and more specifically of the oropharynx. Although current recommendations suggest that physicians should avoid using HPV-DNA and/or p16 testing results to direct their treatment, more than half of the respondents reported using HPV-DNA and/or p16 status to direct their treatment approach for OPSCCs. A close follow-up of the current clinical trials on de-intensification therapy is warranted, as these studies may significantly alter our current approach to HNSCC. Conflict of interest None declared. We have no conflict of interest and no financial disclosures. Acknowledgement Jocelyne Fortin (AOHNSQ), Kim Iverson (CSOHNS), and Aaron Goodman (AHNS) for having assisted in the distribution of our survey to their association members.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
A. Maniakas et al. / Oral Oncology xxx (2014) xxx–xxx [31] El-Naggar AK, Westra WH. P16 expression as a surrogate marker for HPVrelated oropharyngeal carcinoma: a guide for interpretative relevance and consistency. Head Neck 2012;34:459–61. [32] Smeets SJ, Hesselink AT, Speel EJ, et al. A novel algorithm for reliable detection of human papillomavirus in paraffin embedded head and neck cancer specimen. Int J Cancer 2007;121:2465–72. [33] Nichols AC, Finkelstein DM, Faquin WC, et al. Bcl2 and human papilloma virus 16 as predictors of outcome following concurrent chemoradiation for advanced oropharyngeal cancer. Clin Cancer Res 2010;16: 2138–46. [34] Schache AG, Liloglou T, Risk JM, et al. Validation of a novel diagnostic standard in HPV-positive oropharyngeal squamous cell carcinoma. Br J Cancer 2013;108:1332–9.
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[35] Moore EJ, Olsen SM, Laborde RR, et al. Long-term functional and oncologic results of transoral robotic surgery for oropharyngeal squamous cell carcinoma. Mayo Clin Proc 2012;87:219–25. [36] Dobrosotskaya IY, Bellile E, Spector ME, et al. Weekly chemotherapy with radiation versus high-dose cisplatin with radiation as organ preservation for patients with HPV-positive and HPV-negative locally advanced squamous cell carcinoma of the oropharynx. Head Neck 2013. [37] Moore EJ, Hinni ML, Olsen KD, Price DL, Laborde RR, Inman JC. Cost considerations in the treatment of oropharyngeal squamous cell carcinoma. Otolaryngol Head Neck Surg 2012;146:946–51. [38] Nieder AM, Lotan Y, Nuss GR, et al. Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urologic Oncol 2010;28:500–3.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma q Anastasios Maniakas a,b, Sami P. Moubayed b, Tareck Ayad b, Louis Guertin b, Phuc Felix Nguyen-Tan b, Olga Gologan b, Denis Soulieres b, Apostolos Christopoulos a,b,⇑ a b
Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
a r t i c l e
i n f o
Article history: Received 30 December 2013 Received in revised form 23 May 2014 Accepted 15 July 2014 Available online xxxx Keywords: Human papillomavirus p16 Head and neck squamous cell carcinoma Oropharyngeal cancer Survey North America
s u m m a r y Objectives: Human papillomavirus (HPV)-positive head and neck squamous cell carcinomas (HNSCC) have been shown to have a significantly better prognosis and response to current treatment modalities. Current guidelines recommend systematic HPV-DNA and/or p16 testing on HNSCCs, although treatment approach should not be directed by test results. The objectives of this study were to (1) assess whether HPV-DNA and/or p16 status are systematically evaluated across North American otolaryngologists-head and neck surgeons and (2) whether the status is used to direct treatment approach. Materials and methods: A 15-question online survey was sent to three associations: the Association of Oto-rhino-laryngology-Head and Neck Surgery of Quebec, the Canadian Society of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society. Results: Sixty-seven percent of respondents systematically test for HPV-DNA and/or p16 on HNSCC sites, while 58.3% report using test results to direct treatment for oropharyngeal cancers. A lack of official guidelines was the primary reason (81.8%) physicians did not use test results to direct treatment. Academic centre physicians (83.3%) and physicians with P50% oncologic practice (87.6%) were more likely to test for HPV-DNA and/or p16 in HNSCC compared to non-academic centre physicians (39.7%) and physicians with <50% oncologic practices (51.4%) (p < 0.001). Cost of the tests (69.2%), lack of relevance (46.1%) and time constraints (30.8%) were the primary reasons HPV-DNA and/or p16 were not tested. Conclusion: The majority of North American respondents in this survey systematically test for HPV-DNA and/or p16 in HNSCC sites, and most indicate that test results influence their treatment approach for oropharyngeal cancers. Ó 2014 Elsevier Ltd. All rights reserved.
Introduction Cancer of the head and neck is presently the 8th most common cancer in men and 15th in women in the United States [1], while being 9th and 14th, respectively, in Canada [2]. While tobacco smoking and excessive alcohol use have long been associated as the principle risk factors for developing head and neck squamous cell carcinoma (HNSCC), the rates of tobacco use have been in decline in the United States over the past few decades [3]. However, HNSCC, and more specifically oropharyngeal squamous cell
q Presented at the 117th Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Vancouver, BC, September, 2013. ⇑ Corresponding author. Address: Division of ORL-HNS, Department of Surgery, Centre Hospitalier de l’Université de Montréal, 1560 Rue Sherbrooke Est, Montréal, Québec H2L 4M1, Canada. Tel.: +1 (514) 890 8000x27201. E-mail address: [email protected] (A. Christopoulos).
carcinoma (OPSCC), do not seem to be following the same trend. In fact, incidence rates have been increasing throughout North America [4–8], Europe [9–12] and Australia [13], and this due to the human papillomavirus (HPV) as the causative independent risk factor. In addition, younger males have been showing the steadiest increase in HPV-positive HNSCCs [7]. According to the current literature, HPV-DNA can be found anywhere between 20% and 79% of HNSCCs [9,13–16] and in as much as 93% of OPSCCs specifically [9], with HPV type 16 being detected in 80–90% of these cases [17,18]. Although the incidence of HPV-positive HNSCC has been on the rise, overall prognostics, compared to HPV-negative HNSCC, have been shown to be more favourable [19–22]. Presently, treatment de-intensification is of primary concern, as patients develop severe side-effects following the combination of tumor resection, radiation therapy, and chemotherapy, such as chronic dysphagia with gastric tube dependence, tracheostomy dependency, and aspiration, among others [20,23].
http://dx.doi.org/10.1016/j.oraloncology.2014.07.004 1368-8375/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
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Currently, HPV-DNA testing is recommended to be part of standard pathologic evaluation, both by the College of American Pathologists [24] and the American Joint Committee on Cancer [25]. HPV-positive HNSCCs can be detected in either a direct or indirect manner. The most commonly used direct methods include polymerase chain reaction (PCR)-based amplification and DNA in situ hybridization (ISH), while immunohistochemical (IHC) detection of the p16 protein has become the primary indirect method in detecting HPV-positive HNSCCs [26]. Albeit the current recommendations, there is a lack of information available on the practice of detection methods used by otolaryngologists-head and neck surgeons (OHNS) in North America on HNSCCs. Thus, our goal was to assess the current state of North American OHNS and their systematic testing of HPV-DNA and/or p16 in HNSCCs, and to determine if their treatment approach is driven by test results. Materials and methods Following ethics committee approval, a 15-question English language survey requiring between five and ten minutes to complete, was formulated and sent by email to the administration offices of registered members of three medical associations: the Association of Oto-rhino-laryngology-Head and Neck Surgery of Quebec (AOHNSQ), the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS), and the American Head and Neck Society (AHNS). Members of the AOHNSQ and the CSOHNS also received a French version of the survey in order to accommodate French-speaking physicians. The survey was prepared using the web survey development cloud base SurveyMonkey (SurveyMonkey Inc., Palo Alto, CA). A link specific to each association was sent between the months of July and September 2012 along with a cover letter explaining our purpose and the confidentiality of participants’ answers. Our contact information was also provided in the unforeseen eventuality of any technical difficulties or any other issues with regard to the survey. A reminder email was sent out two to three weeks following the first email. Inclusion and exclusion criteria Physicians from the following specialties were included in our study: Otolaryngologists-head and neck surgeons, radiation oncologists, medical oncologists, and pathologists. Survey responses received from physicians primarily practicing outside of North America were excluded. Furthermore, incomplete surveys, or surveys completed more than once by the same physician were excluded from our study.
giving us an overall response rate of 15.2%. Survey responses were incomplete twenty-seven times, while ten originated from physicians practicing primarily outside of North America. OHNS represented 90.7% of all respondents (196 of 216), while the remaining were medical oncologists (2.3%), radiation oncologists (1.3%), pathologists (1.3%), and other specialists (4.4%). Responses were primarily completed in English (82.4%) and came from physicians practicing mainly in academic centres (63.9%). Results indicated that AOHNSQ respondents tested for HPVDNA and/or p16 statistically significantly less often than CSOHNS and AHNS respondents (p < 0.001) (Table 1). Physicians from academic centres reported using HPV-DNA and/or p16 testing more often (83.3%) than non-academic centre physicians (39.7%) (p < 0.001) (Table 1), while physicians with P50% oncologic practices reported systematic testing of HPV-DNA and/or p16 statistically significantly more often than physicians with <50% oncologic practices (87.6% vs. 51.4%, respectively) (p < 0.001) (Table 1). When reported, the physicians that tested for HPVDNA and/or p16 began doing so as early as in 2005, with most having begun between 2007 and 2011 (Fig. 1). HPV-DNA and/or p16 testing and cancer site specificity When tested, respondents reported looking for both HPV-DNA and p16 77.4% of the time, while only HPV-DNA 11.6% and only p16 11.0% of the time. ISH was the most common method (53.8%) used for HPV-DNA testing, followed by PCR (26.9%) or both methods (19.2%). The oropharynx was the most common site for HPV-DNA and/or p16 testing, with 67.5% of respondents answering that they systematically search for the latter markers, followed by the oral cavity (31.9%) and other sites (20.3%) such as the larynx, hypopharynx, and nasopharynx, when specified (Fig. 2). Of the 70 respondents that reported not testing for HPV-DNA or p16 on their specimens, 18 (25.7%) gave no reason. For the remaining respondents, the cost of the tests was the most important reason (69.2%) to refrain from ordering the tests, while lack of relevance and time were given as reasons for 46.1% and 30.8% of respondents, respectively. When asked if HPV-DNA testing was in their practices’ future plans, 64.3% of the respondents replied that they do not plan on beginning any testing, 19.6% replied that they would begin within 6 months, 10.7% within a year, while 5.4% in more than a year. The latter values for p16 were 62.7%, 20.3%, 13.6%, and 3.4%, respectively. Test results and their influence on treatment When HPV-DNA or p16 testing was performed, 58.3% of respondents reported that the results of these tests influenced
Statistical analyses All data were tabulated using Microsoft Excel and all statistical analyses were performed using SPSS 19.0 (SPSS Inc., Chicago, Ill). A two-tailed Pearson Chi-Square test was performed to compare descriptive proportions from our respondents, as well as to analyze the difference in responses between the three associations. For all statistical analyses, a p < 0.05 was considered statistically significant. Results Demographics Of a total of 1694 sent emails, 34 were unsuccessfully transmitted and 253 completed responses were received. Of these 144 were from the AHNS, 66 from the CSOHNS, and 43 from the AOHNSQ,
Table 1 HPV-DNA and/or p16 testing according to medical society, practice setting, and oncologic practice. Yes
No
Do not know
P value
Medical society AHNS CSO QC
104 (88.1%) 36 (61.0%) 6 (15.4%)
14 (11.9%) 19 (32.2%) 22 (56.4%)
0 (0.0%) 4 (6.8%) 11 (28.2%)
<0.001
Practice setting Academic Non-academic
115 (83.%) 31 (39.7%)
20 (14.5%) 35 (44.9%)
3 (2.2%) 12 (15.4%)
<0.001
Oncologic practice <50% 57 (51.4%) P50% 85 (87.6%)
41 (36.9%) 12 (12.4%)
13 (11.7%) 0 (0.0%)
<0.001
AHNS = American Head & Neck Society; CSO = Canadian Society of Otolaryngology; QC = Quebec Association of Otolaryngology.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
A. Maniakas et al. / Oral Oncology xxx (2014) xxx–xxx
Figure 1. Number of physicians beginning to test for HPV-DNA and/or p16 per year.
Figure 2. HPV-DNA and/or p16 testing and site specificity.
their treatment approach when dealing with oropharyngeal lesions, while 12.9% reported it did so for oral cavity lesions (Fig. 3). For the respondents for whom test results did not affect their treatment approach, a lack of official guidelines was the primary reason (81.8%), followed by a lack of significant data on increased survival rates (9.1%) or by the opposition of fellow colleagues (9.1%).
Discussion Our online survey has brought forth several points on the evolution of HNSCC treatment in North America. Presently, more than two thirds of physicians in our survey systematically test for HPVDNA or p16 in HNSCC specimens, with an additional 10% stating that they will incorporate such practices in their institutions in
Figure 3. HPV-DNA and/or p16 testing results influence on treatment.
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the near future. As shown in a similar study, where United-States radiation oncologists were surveyed in early 2009 [27], our study shows a 27.5% increase in HPV-DNA and/or p16 testing in OPSCCs. More specifically, when comparing the responses we received from the AHNS, a primarily American-member association, and Shoushtari et al.’s study results, the proportion of respondents systematically testing for HPV-DNA and/or p16 has increased by over 100% in three years. Furthermore, the practice of HPV-DNA and/or p16 testing has seen a steady increase across North America since 2005, with an average of 11 centres per year adding these tests to their systematic protocol. These findings not only demonstrate the current trend across the oncologic scientific community, but also the importance of HPV-DNA and/or p16 status in patient management. However, although the most recent guidelines by the National Comprehensive Cancer Network (NCCN) on head and neck cancers recommend the systematic testing of HPV-DNA on specimens, HPV-DNA status is not to be used to guide treatment [28]. It is suggested that HPV-DNA status currently remain a prognostic reference, while being of value when considering enrollment in clinical trials. Nevertheless, over half of all respondents in our survey who systematically test for HPV-DNA and/or p16 reported using the test results to direct their treatment approach, likely towards some form of de-intensification. The latter proportion represents close to a 500% increase, compared to the group of radiation oncologists surveyed in 2009 [27]. To date, there is no gold standard in the clinical setting for screening HPV in HNSCCs, although PCR-based assays are primarily used in HPV research [18]. Institutions may use a variety of tests, and this is influenced by personal choice, time constraints, and more often than not, the cost of the tests. Our survey has shown that physicians primarily test for both HPV-DNA and p16, with ISH being the primary method of direct HPV-DNA testing. These results correlate with the current consensus that ISH may be a more practical tool for clinical diagnostic purposes [26], while testing for p16 alone can lead to the false interpretation of certain carcinomas due to the inactivation of the Rb gene in other ways than with the HPV E7 oncoprotein [29]. In our centre, PCR and p16 IHC are systematically performed on all HNSCCs. Other centres choose to test for p16 alone, followed by further direct HPV testing if p16 results are unclear or negative [30–32]. Research groups have also looked into other molecular markers that may act as further prognostic and/or treatment factors, such as Bcl2 [33]. Recently, RNA in situ hybridization has been shown to be an excellent test for HPV with a sensitivity of 97% and specificity of 93% [34]. What is clear is that some form of HPV screening should be performed to allow physicians to have a better understanding of the disease at hand. Creating a clinical standard test in the near future is of utmost importance, as it will not only standardize clinical practice, but may also further persuade physicians to incorporate such habits in their patient work-up. With the advent of de-intensification clinical trial results showing similar, if not superior, overall survival rates in HPV-positive compared to HPV-negative HNSCCs [23,35,36], while having fewer and/or milder side-effects, instating an HPV testing protocol can be beneficial. Furthermore, although the majority of respondents in our survey who did not perform any HPV testing did not do so due to the high costs of the tests, a recent study by Moore et al. demonstrated a significant reduction in treatment costs if de-intensification is to be undertaken in HPV-positive HNSCC patients [37]. However, for the time being, no change should be performed in the standard treatment based solely on HPV status, as there are no official guidelines and a holistic understanding of the disease has yet to be reached. Current and future clinical trials will shed light not only on the long-term effect of de-intensification, but also on patient and tumor variability within the HPV-positive HNSCC spectrum.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
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Canadian practice
References
According to our survey respondents, compared to AHNS members, the CSOHNS members seem to be following the same trend for HPV-DNA and/or p16 testing. However, when comparing Quebec, to the rest of Canada and the United-States, there seems to be a significant delay in implementing such clinical practices. With further published guidelines and clear benefit-cost ratio arising in the near future, and the influence of major provincial academic centres, we are optimistic that Quebec will be at par with the rest of North America in terms of clinical practice. As one of the major head and neck oncology centres in Quebec, we systematically test for both HPV-DNA and p16 in all HNSCCs.
[1] Cancer facts and figures 2013.
Limitations The overall response rate of 15.2% is lower compared to other published survey studies with physicians (30–40%) [27,38]. This may be due to the timing of our survey, as associations were contacted during summer months. Moreover, although we did expect a better response rate from the AHNS, low response rates from the CSOHNS and AOHNSQ are likely due to the fact that a large proportion of their members do not practice head and neck oncology, leading to a ‘‘voluntary response bias’’. Since there is no distinct Canadian or Quebec head and neck society per se, we were limited to contacting entire otolaryngology associations. Conversely, this allowed us to receive the input of general otolaryngologists, and have an idea of the current HPV-DNA and p16 testing state in this population. Although this selection bias might lead to a slight overestimation of the rate of HPV and/or p16 testing, it is evident that the rates are continuously increasing, and will continue to do so in the years to come. Our findings are in line with the available data on this issue where increasing trends in HPV screening in the clinical setting are shown [27]. Lastly, although not part of the primary scope of this study, further questioning on the precise method used to test for HPV and/or p16 would be interesting and for which future research is warranted. Overall, although the number of surveyed physicians may not represent the entire OHNS population, we believe that by ensuring the clarity and anonymity of our survey we were able to obtain accurate and truthful responses. Conclusion Overall, over two thirds of North American physicians who participated in our survey reported testing for HPV-DNA and/or p16 on HNSCCs, and more specifically of the oropharynx. Although current recommendations suggest that physicians should avoid using HPV-DNA and/or p16 testing results to direct their treatment, more than half of the respondents reported using HPV-DNA and/or p16 status to direct their treatment approach for OPSCCs. A close follow-up of the current clinical trials on de-intensification therapy is warranted, as these studies may significantly alter our current approach to HNSCC. Conflict of interest None declared. We have no conflict of interest and no financial disclosures. Acknowledgement Jocelyne Fortin (AOHNSQ), Kim Iverson (CSOHNS), and Aaron Goodman (AHNS) for having assisted in the distribution of our survey to their association members.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004
A. Maniakas et al. / Oral Oncology xxx (2014) xxx–xxx [31] El-Naggar AK, Westra WH. P16 expression as a surrogate marker for HPVrelated oropharyngeal carcinoma: a guide for interpretative relevance and consistency. Head Neck 2012;34:459–61. [32] Smeets SJ, Hesselink AT, Speel EJ, et al. A novel algorithm for reliable detection of human papillomavirus in paraffin embedded head and neck cancer specimen. Int J Cancer 2007;121:2465–72. [33] Nichols AC, Finkelstein DM, Faquin WC, et al. Bcl2 and human papilloma virus 16 as predictors of outcome following concurrent chemoradiation for advanced oropharyngeal cancer. Clin Cancer Res 2010;16: 2138–46. [34] Schache AG, Liloglou T, Risk JM, et al. Validation of a novel diagnostic standard in HPV-positive oropharyngeal squamous cell carcinoma. Br J Cancer 2013;108:1332–9.
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[35] Moore EJ, Olsen SM, Laborde RR, et al. Long-term functional and oncologic results of transoral robotic surgery for oropharyngeal squamous cell carcinoma. Mayo Clin Proc 2012;87:219–25. [36] Dobrosotskaya IY, Bellile E, Spector ME, et al. Weekly chemotherapy with radiation versus high-dose cisplatin with radiation as organ preservation for patients with HPV-positive and HPV-negative locally advanced squamous cell carcinoma of the oropharynx. Head Neck 2013. [37] Moore EJ, Hinni ML, Olsen KD, Price DL, Laborde RR, Inman JC. Cost considerations in the treatment of oropharyngeal squamous cell carcinoma. Otolaryngol Head Neck Surg 2012;146:946–51. [38] Nieder AM, Lotan Y, Nuss GR, et al. Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urologic Oncol 2010;28:500–3.
Please cite this article in press as: Maniakas A et al. North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.07.004