CEO of JPMorgan has Throat Cancer

Image from Wikipedia by Steve Jurvetson

The CEO and President of JPMorgan, Jamie Dimon, announced that he has throat cancer and is currently undergoing treatment at Memorial Sloan Kettering Cancer Center in Manhattan for the next eight weeks. According to a letter he sent to shareholders on July 1, 2014:

"I wanted to let you know that I have just been diagnosed with throat cancer. The good news is that the prognosis from my doctors is excellent, the cancer was caught quickly, and my condition is curable. Following thorough tests that included a CAT scan, PET scan and a biopsy, the cancer is confined to the original site and the adjacent lymph nodes on the right side of my neck. Importantly, there is no evidence of cancer elsewhere in my body." [link]

Based on this information, he has a Stage 3 or 4 (out of possible 4) throat cancer. Stage 1 is the early and best stage to have. It is less clear exactly where the throat cancer is whether it be tonsil, tongue, oropharynx, or some other location. Based on probabilities, he most likely has squamous cell carcinoma which is the most common type of cancer of the head and neck including the throat.

Although he states the prognosis is good, it is not as good compared to patients where no neck mass is present (Stage 1 or 2) where chemotherapy may not even be necessary.

He also mentions the word "curable" which I am leary of when he has just started treatment. Even if no cancer is detectable at the end of treatment, throat cancer, especially stage 3 or 4, has the potential to come back.

Recall the case of actor Larry Hagman of Dallas fame... He had throat cancer and was declared "cured" 8/29/12. Than on 11/24/13, he died of cancer recurrence and complications.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Because the risk of cancer recurrence is so high in the first few years after treatment completion, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Source:
JPMorgan CEO Jamie Dimon has cancer. USA Today 7/2/14

JPMorgan CEO Jamie Dimon's letter to shareholders. USA Today 7/1/14

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Sleep Apnea Increases Risk of Cancer

Obstructive sleep apnea has been getting accused of causing all sorts of medical problems including hypertension, stroke, heart disease, heart attacks, peripheral vascular disease, etc. We can also add cancer now.

According to Australian researchers, moderate to severe sleep apnea increases the risk of cancer by 2.5 times and death from cancer by 3.4 times. They also reported that sleep apnea increases risk of death (any cause) by 4.2x and stroke by 3.7x.

This conclusion was reached evaluating 397 subjects with obstructive sleep apnea with 20 years follow-up. Of course, further study is needed to confirm these findings.

If sleep apnea is suspected, the first step is to get a sleep study. Surgical options can also be considered which may encompass UPPP, base of tongue reduction, etc.

Source:
Sleep Apnea and 20-Year Follow-Up for All-Cause Mortality, Stroke, and Cancer Incidence and Mortality in the Busselton Health Study Cohort. Journal of Clinical Sleep Medicine 2014;10(4):355-362.

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Esophagoscopy without Sedation [VIDEO]

Here is a video demonstrating how esophagoscopy can be performed in the office without any sedation. The esophagus is the tube that connects the mouth to the stomach. The exam, called trans-nasal esophagoscopy (TNE), can be performed in any patient as long as the nose is large enough to accommodate the endoscope and lack a severe gag reflex. A very thin disposable sheath (like a condom) is used to protect endoscope and maintain sterility between patient use.

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Mouthwash May Increase Risk of Oral Cancer

Drinking alcoholic beverages is known to increase risk of oral cancer. It is now suspected that using mouthwash containing alcohol (i.e., original Listerine) may also increase risk for oral cancer.

When it comes to drinking alcoholic beverages like beer, individuals who consume 50 or more grams of alcohol per day (approximately 3.5 or more drinks per day) have at least a two to three times greater risk of developing oral cancer than nondrinkers. Moreover, the risk of cancer is substantially even higher among individuals who consume this amount of alcohol and also use tobacco.

What people may not realize is that some popular over-the-counter mouthwashes ALSO contain alcohol... quite a bit of it with some containing up to 27% of volume. Alcohol is added to provide flavor and "bite." For example, Listerine contains alcohol concentrations of 21.6% in the flavored product and 26.9% in the original gold Listerine Antiseptic.

Whether alcohol is introduced into the mouth via beer or mouthwash, carcinogenic risk is present.

According to one preliminary research, the risk of developing oral cancer from mouthwash containing alcohol is almost 5 times higher than those who do not. Subsequent small studies have not supported this cancer risk, but in 2014, research performed on 3,956 patients did find an independent increased risk of cancer if alcohol-containing mouthwash was used 3 or more times a day.

It is hypothesized that alcohol content in mouthwashes allows for carcinogens to penetrate into the mouth lining increasing cancer risk.

Given the possible increased risk of oral cancer, it may be worthwhile to avoid mouthwashes containing alcohol, especially given there are plenty of alcohol-free mouthwashes commercially sold.




References:
The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Aust Dent J. 2008 Dec;53(4):302-5. doi: 10.1111/j.1834-7819.2008.00070.x.

Carcinogenicity of alcoholic beverages Exit Disclaimer. Lancet Oncology 2007;8(4):292-293.

Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers & Prevention 2009;18(2):541-550.

Oral health, dental care and mouthwash associated with upper aerodigestive tract cancer risk in Europe: The ARCAGE study. Oral Oncol. 2014 Mar 26. pii: S1368-8375(14)00065-7. doi: 10.1016/j.oraloncology.2014.03.001

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Lisa Marie Presley Throat Cancer Scare

Image from Wikipedia

The National Enquirer reported 1/20/14 that Lisa Marie Presley suffered a throat cancer scare when she was told by a medical expert that "the 45-year-old singer’s throat is so severely ravaged that ... the damage could lead to deadly esophageal cancer!" [link]

The National Enquirer, which is not know for stellar journalism, goes on to report that she has been pushing her voice hard in order to succeed as a singer like her more famous father Elvis.

In spite of what the story implies, although singing can lead to vocal cord damage (i.e., nodules)... singing in and of itself does not cause or lead to increased risk of cancer.

However, uncontrolled reflux which can cause throat and vocal cord damage CAN lead to throat cancer. In one report, reflux can increase the risk of throat cancer by 78% (this risk is separate from esophageal cancer).

Source:
WORLD EXCLUSIVE: LISA MARIE THROAT CANCER NIGHTMARE. National Enquirer 1/20/14.

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Do Reflux Medications Increase Risk of Esophageal and Throat Cancer?

Image by Steven Fruitsmakk from Wikipedia

Over the last 30 years, the incidence of esophageal cancer has been steadily rising in spite of increased use of reflux medications. In fact, one can almost say that there is an inverse relationship between risk of esophageal cancer and reflux medication usage.

BUT, it is also a foregone conclusion that reflux increases the risk of esophageal and throat cancer too. So, why would there be an increased incidence of esophageal cancer when reflux is being better "controlled" now more than ever with medical acid suppression?

The answer might be bile... the substance made in the liver and secreted into the small intestine via the gallbladder. Bile is what helps the body digest dietary fat.

But when bile not uncommonly refluxes into the esophagus... bad things may happen, especially when acid production has been suppressed by reflux medications.

Disclaimer... The following is hypothetical and unproven.

Bile, if it happens to be in the esophagus or throat, is more destructive to the mucosal lining when acid is suppressed.

Bile salts/acids have fairly complicated acid-base properties, but an over-simplified explanation for the purpose of this blog is as follows.

Bile in a chemically unconjugated state has a pKa of 7. When such bile is in an acid environment (pH less than 6), it is insoluble and relatively harmless. However, when unconjugated bile enters a relatively alkaline environment (pH greater than 6), it becomes water soluble and "active" in its ability to damage mucosal linings.

As such, when acid suppression is induced by medications like zantac and prilosec, yes... the acid is suppressed but by the very fact that it raises the stomach and distal esophageal pH to a relative alkaline state, any bile that may be present now becomes activated and causes potentially just as much damage as acid.

And that's why over a prolonged period of time repeated bile exposure in a relative alkaline environment may explain why esophageal cancer incidence seems to be increasing as the use of acid reflux medications has increased.

Proof?

Regardless of the "how," does taking reflux medications actually increase risk of cancer???

In one study (2011), patients taking proton pump inhibitors were 61.3% to 81.5% more likely to develop esophageal pre-cancerous lesions or frank cancer (adenocarcinoma).

In another study published in the summer of 2013, it was found that patients with reflux were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but NOT proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

To reiterate, antacids reduced risk of throat cancer... but NOT proton pump inhibitors like prilosec and H2 blockers like zantac.

Why? Because antacids work transiently to neutralize acid, but not suppress acid production whereas proton pump inhibitors and H2 blockers actually suppress acid production for a prolonged period of time.

The transient nature of acid neutralizers like TUMS allow for acid to still be produced thereby theoretically preventing bile from becoming soluble and damaging.

Prediction

So which is worse for you? Acid reflux or bile reflux? I'm not sure... but personally, I predict that once additional studies are performed that may ultimately strengthen the relationship between bile reflux and mucosal injury that may lead to cancer formation, reflux medications may go out-of-favor along with a class-action lawsuit. That's a big if... I might end up being completely wrong.

Of course, that may be the reason why drug companies specify that such reflux medications should not be used longer than 2 months and prescribing information stress "short-term" treatment rather than long-term.

More Confusion

We can also throw more mud into this messy predicament... Pepsin, which is a stomach enzyme that breaks down proteins, can also damage esophageal and laryngeal mucosa. However, it is most active in an acidic environment. Once pH levels rise above 6.5, pepsin becomes inactivated. At pH 8.0, it becomes irreversibly inactivated.

As such, acid and pepsin cause damage in an acidic environment. Taking reflux medications to eliminate the acid creates an alkaline environment.

However, an alkaline environment than activates bile which can also cause damage.

Treatment

So what to do?

Ideally, given this no-win situation, the best way to treat reflux would be to keep bile where it is supposed to be (in the small intestine) and acid/pepsin in the stomach where it is supposed to be.

As such, I suspect that even more emphasis will be placed on lifestyle/dietary changes for reflux control. Medication-wise, use of antacids and barrier-type medications like alginate will become the main way of treating reflux long-term while medications that suppress acid will be prescribed only for short-term treatment spans.

Surgical management of reflux will become much more accepted and popular for patients who suffer from bad reflux to try and restore proper anatomical compartmentalization of bile, acid, and pepsin. Surgical management will include LINX, TIF, Nissen, etc. (more info)

At the very least, certainly caution should be present when placing a patient on long-term acid suppression with medications like prilosec and zantac, especially when such medications are already known to cause a whole host of other problems including bone fractures, clostridium difficile infections,  and malabsorption of vitamins and minerals. (more info)

Special thanks to Dr. Kevin Gillian who assisted in writing this blog.


References:
Bile Acid. Wikipedia

Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011 Jul;146(7):851-8. doi: 10.1001/archsurg.2011.174.

Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

Bile reflux gastritis and Barrett's oesophagus: further evidence of a role for duodenogastro-oesophageal reflux? Gut 2001 Sep;49(3):359-63.

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus. Hepatogastroenterology. 55 (82-83), 442-7.

The role of bile acids in the neoplastic progression of Barrett's esophagus - a short representative overview. Z Gastroenterol. 50 (9), 1028-34.

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What are the Risks for Throat Cancer? (Humor)

Check out this info-advertisement photographed by Twitter user @durf showing the risks of throat cancer.

I truly think the American public is a bit smarter than this... though not perhaps in Ann Arbor, MI where this ad most likely got published (I suspect AATA is the Ann Arbor Transportation Authority). jk...

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Vaccine to Prevent Throat Cancer

Spread through oral sex, it is well established that human papilloma virus (HPV) types 16 and 18 cause the vast majority of throat cancer especially in men... even more than smoking and drinking alcohol. What was not known, but suspected, was whether in BOTH men and women the HPV vaccine Cervarix (made by GSK) or Gardasil (made by Merck) would help prevent throat cancer as effectively as cervical cancer for which it is FDA approved for.

At least for the vaccine Cervarix, a randomized, control, double-blinded, prospective study has shown that it highly protects individuals from HPV 16 and 18 infection in the mouth/throat. The vaccine efficacy was calculated to be 93.3%. The big assumption being that reduced oral HPV 16/18 would lead to a decreased risk of throat cancer.

It is for these reasons that BOTH boys and girls are encouraged to get the HPV vaccine. We are talking about protecting our sons and daughters from getting throat and cervical CANCER later in life.

To be clear, more study is needed to really PROVE that such vaccines prevent throat cancer. For full disclosure, the weaknesses of this current study are as follows:

• It was performed only in women (the study would need to be replicated in males)
• The study lasted only 4 years... the question is whether life-long protection is present or will booster shots be needed?
• Does Gardasil also work for oral HPV 16/18?
• Does reduced HPV 16/18 presence in spit actually translate to decreased risk of throat cancer
• It is suspected that vaginal secretions carry a higher HPV viral load than the penis leading to a higher risk of throat cancer in men performing oral sex on infected women. As such, the other questions that need to be answered is whether such vaccines will:
     • Prevent a vaccinated woman from giving HPV to the man as well as
     • Prevent an infected woman to actually infect a vaccinated man?
     • Or, does BOTH partners need to be vaccinated to prevent HPV throat cancer?

It is truly an exciting time when vaccines can be given to prevent not only infections like mumps or shingles, but also cancer!

As a reminder, the HPV vaccines ONLY work when given to children before they become sexually active. It is too late to give the HPV vaccine for sexually active adults (ie, it won't work).

Source:
HPV Vaccine Found to Help With Cancers of Throat. NYT 7/18/13

Reference:
Reduced Prevalence of Oral Human Papillomavirus (HPV) 4 Years after Bivalent HPV Vaccination in a Randomized Clinical Trial in Costa Rica. PLOS One

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Pro Golfer with History of Leukemia and ENT Emergencies

The New York Times published a story about pro golfer Laura Kueny who was diagnosed with acute lymphocytic leukemia at 3 years of age and the harrowing experiences she had to go through to beat the cancer.

It certainly brought back memories when I was a resident at Duke University and was filled with dread whenever I got consulted to evaluate a sick child with leukemia undergoing treatment.

It is breathtaking just how sick such children are... what in a normal child is not considered an ENT emergency like strep throat, tonsillitis, sinusitis, and ear infections, are now considered an emergency. Such common childhood infections can literally kill a child undergoing chemotherapy and/or bone marrow transplant. With cancer treatment, these kids have no immune system and significantly reduced ability to clot due to platelet loss.

Being poked and prodded is a given... but there's also the ENT endoscopies and surgeries that often need to be performed to either save a life or to just figure out what germ is causing an infection so the appropriate powerful antibiotic can be given.

Making a hole in the eardrum as well as nasal endoscopies are routinely performed in order to culture the pus present.

Tonsillectomy surgery can be a particularly harrowing experience for an ENT surgeon as it can be literally life-saving and life-ending all at the same time. A bad tonsillitis can overwhelm what little immune system these children have in spite of antibiotics and emergency tonsillectomy may need to be performed to help the child recover from a potentially lethal infection... BUT... performing this type of surgery when platelet counts may be non-existent can also result in life-threatening blood loss. In the end, the child remains intubated after surgery while getting IV platelet infusions, and the entire oral cavity packed with gauze to provide direct pressure to manually stop bleeding for a few days. Once the gauze packing is removed and no bleeding is seen, extubation can proceed.

Sinus surgery for persistent sinusitis can also result in a nosebleed that just will not stop bleeding thereby requiring prolonged nasal packing.

And is it worth it in the end?

Yes... for what used to be a death sentence has now become one of the more curable cancers.

Source:
Golfer Leaves Hospital as a Survivor, Returns as a Winner. New York Times 6/22/13

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Possible Blood Test for Oral Cancer Caused by HPV?

There might be a blood test which can possibly predict individuals who may develop oral cancer caused by HPV years before it happens. HPV, an abbreviation for human papilloma virus, encompasses over 100 different strains among which only a few can cause problems in humans. Specifically, HPV 16 can lead to cervical cancer in woman and oral cancer in both genders.

HPV triggered oral cancer is also the most common cause of oral cancer now exceeding even smoking and drinking alcohol.

Unlike HPV that causes cervical cancer which can be screened for by pap smears in women, there's currently no good screening test to look for HPV that might cause oral cancer.

However, that's not to say that researchers aren't busy looking for just such a test...

In June 2013, researchers published a possible blood test that might predict those individuals at risk for developing HPV oral cancer.

By analyzing blood samples taken from 638 patients with head and neck cancers, they discovered that antibodies against HPV16 E6 was present in pre-diagnostic samples for 34.8% of patients with oropharyngeal cancer and 0.6% of controls (healthy patients without cancer). Furthermore, HPV16 E6 was NOT associated with other cancer sites. The increased risk of oropharyngeal cancer among HPV16 E6 seropositive participants was independent of time between blood collection and diagnosis and was observed more than 10 years before diagnosis.

Now I should state that HPV16 E6, which is actually a gene found in the virus, only accounted for 34.8% of patients. It bears repeating... it was positive only 34.8% of the time. In other words, this test predicted oral cancer only one out of every 3 patients who actually developed cancer.

As such, it is not a very specific test... ideally, you want a number as close to 100% as possible, otherwise patients who test negative to this blood test may falsely think they are not at risk.

Now, the other problem is what if a patient DOES test positive to HPV16 E6?

Does that mean such patients need to undergo routine fiberoptic endoscopy screening examinations every few months or years? Are biopsies required or not if visual examination appears normal? If biopsies are required, how often and from where? After all, oral cancer encompasses the tongue, tonsil, pharynx, larynx, supraglottis, palate, buccal mucosa, etc, etc, etc. That's a lot of biopsies...

Coincident with the development of a good blood test is the need for research to develop a protocol of what to do with the results of such test information.

Reference:
Evaluation of Human Papillomavirus Antibodies and Risk of Subsequent Head and Neck Cancer. Journal of Clinical Oncology. Published online before print June 17, 2013, doi: 10.1200/JCO.2012.47.2738

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Def Leppard's Guitarist Vivian Campbell's Chronic Cough Due to Lung Cancer

Image from Wikipedia

A chronic cough that's been going on for months to years is an extremely tough problem to figure out due to the many possible triggers including reflux, reactive airway disease, post-nasal drip, allergies, etc.

For Def Leppard's guitarist Vivian Campbell, his chronic cough was ultimately found to be due to Hodgkin's Lymphoma in his chest around his windpipe. In his own word's that he posted on the band's Facebook page (June 10, 2013 post):

“I feel fortunate that my cancer sent me an alarm call in the form of ‘the cough that wouldn’t quit’. Otherwise, how would I have known? After several months of trying every inhaler known to man, my doctor finally had me X-rayed. A further CAT scan revealed that enlarged lymph nodes were doing wrestling manoeuvres on my windpipe – hence the cough. What was causing the enlarged lymph nodes, however, was yet to be determined, so I underwent a surgical biopsy on March 11th, the first day of Leppard rehearsals for our Viva Las Vegas shows. Obviously, I didn’t make it to rehearsal that day, but it’s okay; I know the songs by now…"

Fortunately, compared to other types of lung cancer, Hodgkin's Lymphoma is more indolent leading to vague symptoms like a chronic cough that goes on for months if not years. It is also highly curable.

Just goes to show you that for patients suffering from chronic cough, more needs to be done than just a chest x-ray, breathing tests, and trying out different inhalers.

Sometimes, a CT scan of the chest and even bronchoscopy may need to be performed to fully evaluate pulmonary etiologies for a chronic cough.

And if nothing is found wrong with the lungs... further testing to check out other disease processes that may lead to a chronic cough is required and may include barium swallow, allergy testing, methacholine testing, 24 hour impedance testing, etc, etc, etc.


Media Report:
Def Leppard's Vivian Campbell battling Hodgkin's. USAToday 6/10/13

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Taking Too Much Vitamins May Even Cause Cancer

Image by David Richfield from Wikipedia

Too much of anything can be harmful... even vitamins which people seem to consider benign regardless of how much is taken. In fact, taking regular large doses of vitamins  (greater than 150% of what is recommended per day) actually INCREASES the risk of cancer.

To be clear, vitamins and supplements are great, but only when taking the recommended daily amount in a normal, healthy individual. Supplements may be necessary only if there's a deficiency, but not when you are a healthy individual.

The New York Times wrote a nice expose regarding this issue along with why the FDA doesn't say anything about it (vitamin lobbyists passed a law in 1976 prohibiting the FDA from saying anything).

So, let's take a look at the studies mentioned in the NYT documenting the adverse affects of too much vitamins:

The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1994 Apr 14;330(15):1029-35.

"Unexpectedly, we observed a higher incidence of lung cancer among the men who received beta carotene than among those who did not (change in incidence, 18 percent; 95 percent confidence interval, 3 to 36 percent)... more deaths from hemorrhagic stroke were observed among the men who received this supplement than among those who did not. Total mortality was 8 percent higher (95 percent confidence interval, 1 to 16 percent) among the participants who received beta carotene than among those who did not, primarily because there were more deaths from lung cancer and ischemic heart disease."

Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med. 1996 May 2;334(18):1150-5.

"After an average of four years of supplementation, the combination of beta carotene and vitamin A had no benefit and may have had an adverse effect on the incidence of lung cancer and on the risk of death from lung cancer, cardiovascular disease."

Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005 Jan 4;142(1):37-46. Epub 2004 Nov 10.

A dose-response analysis showed a statistically significant relationship between vitamin E dosage and all-cause mortality, with increased risk of dosages greater than 150 IU/d.

Antioxidant supplements for preventing gastrointestinal cancers. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004183.

We could not find evidence that antioxidant supplements prevent gastrointestinal cancers. On the contrary, they seem to increase overall mortality.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2012 Mar 14;3:CD007176. doi: 10.1002/14651858.CD007176.pub2.

We found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. Antioxidant supplements need to be considered as medicinal products and should undergo sufficient evaluation before marketing.

There are many more studies that show the adverse affects of taking mega-vitamins as well as additional studies that show that taking mega-vitamins makes absolutely no difference. Of course, with any medical issue, there are also studies that support the consumption of mega-vitamins, but the studies are not as rigorous nor as conclusive.

What to do?

I would suggest taking a regular multi-vitamin daily which contains enough vitamins to supplement any deficiencies that may occur from insufficient dietary intake... Otherwise, additional vitamin supplementation is not necessary unless a known deficiency is present.

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Former Bills QB Jim Kelly Diagnosed with Jaw Cancer

Image from Wikipedia

Former QB for the Buffalo Bills, Jim Kelly, announced that he has a squamous cell carcinoma of his upper jawbone.

He had been experiencing jaw pain since Dec 2012. When the pain failed to resolve with antibiotics, follow-up testing which probably included a CT scan revealed a cystic mass of the maxillary bone. Removal of this nickel-sized cyst in March 2013 revealed cancer.

Additional testing reported by Jim Kelly showed that the cancer has not spread elsewhere. Such testing may have included bloodwork and a PET/CT scan.

This Friday, a complete cancer resection operation will be performed. Given what information was provided, he will likely have his maxillary bone removed along with a rim of soft tissue until no pathological evidence for cancer is present. A limited neck dissection which entails removal of all the lymph nodes in the neck may also be performed.

Of course, after removal of his upper jawbone, there will be a big hole present. As such, he will likely also undergo simultaneous reconstruction to replace what was removed. Bone, muscle, and soft tissue will likely be obtained from either the leg or arm to reconstruct Mr. Kelly's jawbone.

It is also not unusual to have a feeding tube placed for some time to allow healing before oral intake is allowed.

This operation takes a LONG time... typically anywhere from 4-12+ hours depending on what is found during the operation.

Depending on final pathology which may take up to one week for results, Mr. Kelly may need to undergo further cancer treatment with radiation therapy with or without chemotherapy.

I wish him the best of luck!

Source:
Former Bills QB Kelly battling cancer of the jaw. Boston.com 6/3/13

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Can HPV be Caught by Kissing Someone with HPV Throat Cancer?

HPV transmitted by oral sex is the leading cause of oral and throat cancer now. And for spouses/partners of patients diagnosed with HPV throat cancer, the main concern is whether it is "contagious".

After all, if HPV is transmittable by oral sex, than it would seem that kissing can also transfer HPV to the partner as well.

Well, a small Johns Hopkins study suggests that intimately kissing someone who has HPV oropharyngeal cancer does NOT lead to a new HPV infection in the mouth or throat in the partner. Among 93 partners of 164 patients, prevalence of HPV infection in the throat was no higher than would have been expected. Specifically, about 1.2% had HPV which is equivalent to what one would find in couples without history of HPV throat cancer (1.3%). There were only six male partners, none of whom had oral infection with HPV.

Please keep in mind that this study is far from definitive and further study is required before one can say with absolute certainty that kissing and other intimate activities are totally safe. After all, oral sex leading to HPV infection of the mouth is a relatively recent discovery. Who is to say that with enough time and study, even kissing may eventually be found to do the same???

The study was originally presented at the 2013 annual meeting of the American Society for Clinical Oncology and published in April 2014.

Reference:
Oral Human Papillomavirus (HPV) Infection in HPV-Positive Patients With Oropharyngeal Cancer and Their Partners. Journal of Clinical Oncology. April 28, 2014, doi: 10.1200/JCO.2014.55.1341

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Reflux Increases Risk of Throat Cancer by 78%

Brown University researchers found that frequent heartburn was an independent risk factor for not only esophageal cancer but also cancer of the throat and vocal cords. This conclusion was based on a large population study involving 631 patients with throat cancer and 1,234 without throat cancer as a control group.

The study group also did not heavily smoke, drink, or have HPV (other independent risk factors for throat cancer).

Individuals with frequent heartburn were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but not proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

The explanation for how reflux can cause throat cancer is similar to how it can also cause esophageal cancer. With repetitive mucosal injury by gastric juices to the delicate lining of the throat, there is a cycle of healing and injury that may eventually trigger cancer development. Patients with reflux that reaches the throat level have a condition called LPR or laryngopharyngeal reflux. Although symptoms may be similar to the more common GERD, it is not unusual for patients to experience only throat symptoms without the heartburn. Such atypical symptoms include:

• Chronic cough
• Phlegmy throat
• Chronic throat clearing
• Vocal cord dysfunction
• Globus pharyngeus

It is also notable that it takes far less reflux episodes in the throat region compared to the esophagus in order to trigger mucosal damage... it takes fewer than THREE episodes per WEEK! [link]

In any case, more research is needed to determine at what point cancer risk increases in individuals with LPR, what type of reflux (acid?, non-acid?, pepsin?, bile?) triggers cancer concern, to what degree of reflux prevention is required to protect against cancer development.

Also more needs to be done to figure out why antacids help reduce cancer risk, but not other types of reflux medications.

References:
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

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Gwyneth Paltrow's Dad Had Throat Cancer

Image by Andrea Raffin from Wikipedia

Gwyneth Paltrow recently divulged that her father was diagnosed with throat cancer in 1998 and eventually passed away in 2002 due to pneumonia complications.

It is unclear exactly what type of throat cancer Mr. Paltrow had, but it could have been anything from tonsil cancer to vocal cord cancer.

Depending on the location, symptoms and physical signs (ie, neck mass) may have been present which ultimately would have required a biopsy. Once the type of cancer has been determined after biopsy, treatment would have included surgery, radiation therapy, and/or chemotherapy.

In any case, the actress credits her dad's cancer diagnosis as a wake-up call to a healthier lifestyle.

Source:
Gwyneth Paltrow; Father's Throat Cancer Diagnosis Encouraged Healthier Diet. Medical Daily 5/20/13

Gwyneth Paltrow Reveals Dad's Cancer Diagnosis Got Her on Healthy-Eating Track. Eonline 5/17/13

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Actress Sofia Vergara Underwent Total Thyroidectomy for Thyroid Cancer

Actress Sofia Vergara, best known for her role in the TV hit comedy Modern Family, had her entire thyroid removed for thyroid cancer when she was 28 in 2000. This was followed by radioactive iodine therapy and now takes a daily thyroid hormone replacement for her hypothyroidism.

Image by Jenn Davis from Wikipedia

Thyroid cancer is typically first suspected on a routine examination if a neck mass consistent with a thyroid nodule is palpated. An ultrasound of the neck is typically performed to characterize the thyroid mass further which is than followed by a biopsy. Should the biopsy come back malignant, thyroid removal surgery is performed. Even if the biopsy comes back indeterminate, surgery may still be pursued to be on the safe side.

Other studies may be pursued including CT scan and a thyroid nuclear scan.

Although the type of thyroid cancer Sofia Vergara had was never revealed, she most likely had papillary thyroid carcinoma which is the most common form of thyroid cancer and is highly curable (which is where the comment of being a "good" cancer comes from).

Other less common thyroid cancers include follicular thyroid carcinoma and medullary thyroid carcinoma.

It should be mentioned that until the thyroid is removed, one can NOT be absolutely sure that thyroid cancer actually truly is present. Indeed, the president of Argentina announced that she had thyroid cancer only to find out after her thyroid was removed that no cancer was actually present. Read blog post about this "mistake".

Read more about the surgery here or watch the video below of what Sofia's thyroid surgery might have looked like.

Source:
The Workout: Sofia Vergara Hates to Exercise. NYT 5/3/13

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Diagnose Cancer with Flash of a Light!

Traditionally, cancer is diagnosed by a surgical biopsy with pathology results taking days later. Supportive evidence for a cancer is also determined based on visualizing the lesion as well as radiological studies (CT, MRI, Ultrasound, etc).

However, there is a very exciting breakthrough technology that may be able to make a cancer determination under 1 second with only a flash of a light... meaning no biopsy with associated pain and scar to go along with it.

Called Verisante Aura, a probe emits a light that non-invasively analyzes a lesion by scanning 21 different cancer biomarkers at the cellular level using Raman spectroscopy.

Raman spectroscopy (RS) is a technology that involves shining a laser onto a material and interpreting the reflected light to learn more about its biochemical composition.  Healthy cells have a different reflected light "fingerprint" compared with diseased cells. Although this technology won the Nobel Prize in 1930, such RS units used to be huge and complicated machinery to operate. Fortunately, only recently has RS units been miniaturized and made robust enough to be idiot-proof to operate by Canadian researchers.

How accurate is it?

It has up to 99% accuracy leading to potential reduction in unnecessary biopsies by 50 to 100 per cent [link]. Given each scan is under 1 second, a complete body scan can also be accomplished in a single office visit. However, in order to obtain sensitivities between 95% and 99%, the specificities did range between 15% and 54% which is comparable to clinical examination and other optical-based methods.

The one caveat is that the probe needs to be able to shine a light directly on the suspicious lesion... meaning it is applicable only for lesions found on the skin and body cavities (mouth, colon, esophagus, etc)... not lesions under the skin (like a thyroid nodule). The lesion also needs to be larger than 3.5mm in size.

With such instant diagnostic accuracy, it would not only revolutionize in the diagnosis of cancer, but also in treatment! The big question mark for any surgeon is "did you get all the cancer out"? Well, with this probe, one could just scan the wound bed after excising the cancer and see if there's any residual cancer left behind that needs to be removed further. In essence, every surgeon can now perform a Mohs-like resection instantly and without need for pathology assistance with frozen sections.

Verisante Aura is currently approved for use in Canada, Europe, and Australia... but not yet available in the USA pending FDA approval.

Source:
Simply Amazing! Instantly Diagnose Melanoma with the Flash of a Light. Forbes 3/14/13

Reference:
Real-time Raman spectroscopy for in vivo skin cancer diagnosis. Cancer Res. 2012 May 15;72(10):2491-500. doi: 10.1158/0008-5472.CAN-11-4061. Epub 2012 Mar 20.

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Infographic: HPV from Oral Sex Causes Throat Cancer

I have blogged in the past regarding how HPV transmitted through oral sex (and potentially even French kissing) has now become the number 1 cause of throat cancer in individuals under the age of 50, even more than smoking and drinking alcohol [link]. Of course, smoking and alcohol further exacerbates this risk.

Indeed, A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. Having six or more oral sex partners over a lifetime was associated with a 3.4 times higher risk for oropharyngeal cancer; cancers of the base of the tongue, back of the throat, or tonsils. Having 26 or more vaginal-sex partners tripled the risk. The association continued to increase as the number of partners in either category increased. Of greater concern is that "French" kissing may also potentially be a mode of transmission.

In any case, Mt. Sinai Hospital published a great infographic to further educate the risks of oral sex. Needless to say, if you find/see an abnormal bump in the mouth, talk to your doctor about it!

References:
Human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 Sep 13;357(11):1157; author reply 1157-8

Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007 May 10;356(19):1993-5.

Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.

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Sinus Mass Chance Finding (Incidentaloma)

The New York Times published a great story on the dreaded incidentaloma on Jan 17, 2013. An incidentaloma is essentially a chance finding of a mass most likely benign, that was incidentally discovered on a CT or MRI scan ordered for a completely different reason.

With such incidentalomas, it leads to patient anxiety causing physicians and surgeons to order even more tests and procedures (which themselves may lead to other incidentalomas). The vast majority of such incidentalomas are "nothings" without any significance, but hard to persuade patients otherwise at times.

In the ENT world, incidentalomas are very common when CT and MRI scans are performed of the head for a headache, stroke, eye pain, dizziness, or some other non-sinus related complaint.

In the report, there is the statement of:

"There is an opacified mass inside the right maxillary sinus cavity [or some other sinus cavity] two centimeters [or larger] in size."

Compare the above CT scan (red arrow pointing to the mass) with a normal CT scan of the sinuses below:

IF symptoms are localized to the corresponding mass on the CT/MRI scan, than further management which may include surgery can be pursued.

However, the vast majority of patients have absolutely NO symptoms localized to the corresponding abnormality. Radiologists and ENTs report that such a mass is most likely a benign mucosal inclusion cyst for which there is no significance and nothing more needs to be done.

However, some patients due to cancer concerns, even insist on having surgery to get it removed, even in spite of the risks associated with surgery including brain fluid leakage, eye damage, etc.

I personally usually insist a patient get a 2nd opinion prior to any surgical intervention for an incidentaloma if I'm pressured to "do something" when my gut feeling is to "do nothing."

Source:
The Fallout of a Chance Medical Finding. New York Times 1/17/13

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