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Human Papillomavirus– Related Oropharyngeal Cancer: a Review of Nursing Considerations

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Human Papillomavirus– Related Oropharyngeal Cancer: a Review of Nursing Considerations 2.5 HOURS CE Continuing Education Cancer survivorship care from the Memorial Sloan Kettering Cancer Center Human Papillomavirus– Related Oropharyngeal Cancer: A Review of Nursing Considerations A rise in head and neck tumors presents new challenges for patients and nurses. ABSTRACT: The overall incidence of head and neck cancer—which includes laryngeal, hypopharyngeal, na- sal cavity, paranasal sinus, nasopharyngeal, oral, oropharyngeal, and salivary gland cancers—has declined in the United States over the past 30 years with the concomitant reduction in tobacco use. Over that same pe- riod, however, the worldwide incidence of oropharyngeal cancer has escalated significantly, most notably among men and women under age 60 who live in developed countries. This epidemic rise in oropharyngeal cancer is largely attributed to certain genotypes of the human papillomavirus (HPV). In the United States, HPV prevalence in oropharyngeal tumors increased dramatically, from roughly 16% between 1984 and 1989 to nearly 73% between 2000 and 2004, and the annual incidence of HPV-positive oropharyngeal cancer is expected to surpass that of HPV-related cervical cancer by 2020. This article provides an overview of head and neck cancer—its incidence, risk factors, treatment, and post- treatment sequelae—with a focus on HPV-related oropharyngeal cancer. Unlike other forms of head and neck cancer, HPV-related oropharyngeal cancer tends to affect younger patients with few or none of the traditional risk factors and has a distinctive presentation, histology, and natural course. In order to provide appropriate patient education and to help these patients monitor and manage late and long-term treatment effects, it is important for nurses to be aware of this disease and its treatment, and of the unique survivorship issues that arise for affected patients. Keywords: head and neck cancer, human papillomavirus, human papillomavirus–related oropharyngeal cancer, oropharyngeal cancer arcus Atkins, a 46-year-old finance executive sent Mr. Atkins for a computed tomography scan and father of two young children, was re- of the neck to evaluate the lymph nodes and neck Mferred by his primary care provider to an region. Testing revealed that Mr. Atkins had meta- ear, nose, and throat specialist (ENT) for evalua- static squamous cell carcinoma, originating in the tion of a painless, firm lump on the left side of his left tonsil. neck. (This case is a composite based on our clini- Mr. Atkins was divorced three years ago and is cal experience.) The ENT performed a biopsy and currently in a sexually exclusive relationship with 34 AJN ▼ August 2016 ▼ Vol. 116, No. 8 ajnonline.com By Janet McKiernan, RN, NP-C, OCN, and Bridgette Thom, MS Sandra Weir, a 30-year-old woman with whom he shares a home. When biopsy results came in, the ENT met with Mr. Atkins and Ms. Weir to discuss test re- sults and to refer Mr. Atkins to a team of radiation and medical oncologists for evaluation and treatment. In the meeting, Ms. Weir asked what might have caused this disease, since Mr. Atkins had always been very healthy and had never smoked. The ENT explained that the cancer may be associated with human papillo- mavirus (HPV) infection and that the tumor was cur- rently undergoing HPV testing. (The tumor’s HPV positivity was later confirmed.) Surprised, Mr. Atkins responded, “Isn’t that a sex infection?” The ENT in- formed the couple that HPV is the most prevalent sex- ually transmitted infection worldwide and, in fact, almost every sexually active person in the United States has been exposed to HPV—with exposure of- ten occurring many years, or even decades, before an HPV-related cancer is diagnosed. Ms. Weir then shared that her last Pap and HPV DNA tests were negative for HPV. The ENT informed the couple that they need not alter their sexual behavior since has certain Govt. rights. U.S. LLC, Winslow Terese Illustration © 2012 the risk of developing HPV-related oropharyngeal Figure 1. Anatomy of the Pharynx cancer from an established sexual partner with the disease is relatively low. The ENT also informed the couple that HPV-related head and neck cancers re- spond better to treatment than head and neck can- 62,000 people in the United States develop some form cers associated with tobacco and alcohol exposure. of head and neck cancer, which includes laryngeal, Mr. Atkins was treated with radiation therapy hypopharyngeal, nasal cavity, paranasal sinus, naso- and concurrent chemotherapy, as recommended by pharyngeal, oral, oropharyngeal, and salivary gland the oncology team. Although his cancer treatment cancers.1 Together, head and neck cancers account for was successful (as indicated by posttreatment posi- nearly 13,200 deaths per year.1 Depending on the site, tron emission tomography–computed tomography patients with head and neck cancer may present with scans showing that both the left tonsillar tumor and a wide range of symptoms (see Table 12, 3). the left cervical lymphadenopathy had completely More than 90% of head and neck cancers are resolved), he experienced several adverse effects of squamous cell carcinomas that arise in the epithelial treatment, both physical and psychological. cells lining the oral cavity, pharynx, larynx, para- To provide patients like Mr. Atkins appropriate pa- nasal sinuses, nasal cavity, and salivary glands (see tient teaching while helping them monitor and man- Figures 1 to 3).4 If the tumor is confined to the su- age late and long-term effects of treatment, nurses perficial squamous layer, it is called carcinoma in situ; must be aware of the rising incidence of HPV-related if it invades neighboring tissues, it is called invasive oropharyngeal cancer, which affects a younger group squamous cell carcinoma. Because both the major of patients than other forms of head and neck cancer. salivary glands (the parotid, submandibular, and sub- These patients may have few or none of the traditional lingual glands) and the minor glands (those found risk factors associated with head and neck cancer and throughout the upper aerodigestive tract) are made their disease has a distinctive presentation, histology, up of a variety of cell types, salivary tumors may be and natural course. This article provides a general mucoepidermoid carcinoma, adenoid cystic carci- overview of head and neck cancer—its incidence, risk noma, and acinic cell carcinoma. The majority of sal- factors, treatment, and posttreatment sequelae—with ivary gland tumors, however, are benign.5 Salivary a focus on HPV-related oropharyngeal cancer and the gland cancers affect only one per 100,000 people in unique survivorship issues it creates. the United States annually.5 Risk factors for developing head and neck cancer CANCERS OF THE HEAD AND NECK include the following1, 6, 7: About 3% of all cancers are cancers of the head • male sex (men are two to three times as likely as 1 and neck. It’s estimated that, each year, nearly women to develop head and neck cancer) [email protected] AJN ▼ August 2016 ▼ Vol. 116, No. 8 35 Table 1. Common Presentations of Head and Neck Cancer by Site2, 3 Sign or Symptom Associated Site of Cancer • Sore in the mouth or throat that doesn’t heal in 2–3 weeks Oropharyngeal • Persistent sore throat • Ill-fitting dentures or loosening teeth • Dysphagia or odynophagia • Prolonged ear or jaw pain • Decreased mobility of the tongue with change in speech • New mass or lump in the neck (usually painless) • Continued hoarseness Laryngeal • Stridor or change in voice • Frequent epistaxis Nasopharyngeal • Nasal obstruction • Numbness of the tongue or other area of the head or neck Salivary (specifically, parotid) gland (due to cranial nerve involvement) • any form of tobacco use HPV-RELATED OROPHARYNGEAL CANCER • exposure to secondhand smoke The United States has seen a decline in the overall inci- • excessive alcohol use dence of head and neck cancer over the past 30 years, • combined use of tobacco and alcohol, which in- concurrent with the reduction in tobacco use.1, 8, 9 Over creases risk by 35 times over that of abstainers that same period, however, the worldwide incidence of • inhalation of wood or metal dust, asbestos, paint, oropharyngeal cancer has escalated significantly, most or other chemical irritants notably among men and women under age 60 who • a diet high in salt-cured fish live in developed countries.8 Because the epidemic rise • exposure to Epstein–Barr virus (also known as hu- in oropharyngeal cancer is specific to younger adults in man herpesvirus 4) economically developed countries—among whom to- • poor nutrition (for example, a diet low in vita- bacco use is believed to be less common and sexual be- mins A and B) haviors such as oral sex and multiple sex partners are • HPV infection believed to be more common—it has been largely at- tributed to certain HPV genotypes.8, 10 HPV is a group of over 150 associated viruses.11 The HPV viruses are responsible for a wide variety of infections, including common skin warts; genital warts; laryngeal polyps; and carcinomas of the anus, cervix and vagina, many of which can be spread by skin-to-skin contact.12, 13 Initially identified in head and neck carcinogenesis in the 1980s, HPV has recently been acknowledged as a risk factor for oropharyn- geal cancer, specifically, squamous cell carcinoma of the tonsillar pillar and the base of the tongue.13 In the United States, HPV prevalence in oropharyngeal tu- mors increased dramatically, from roughly 16% be- tween 1984 and 1989 to nearly 73% between 2000 and 2004. The annual incidence of HPV-positive oro- pharyngeal cancer, which increased by 225% between 1988 and 2004, is expected to surpass that of HPV- related cervical cancer by 2020,10 though it’s hoped that HPV vaccines, introduced in 2006, may slow this disturbing trend.
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