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Cancer…It’s On the Move - Let’s Find It!

Cancer…It’s On the Move - Let’s Find It!. Association of State and Territorial Dental Directors Webinar Wednesday, September 25, 2013. Cancer…It’s On the Move – Let’s Find It !.

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Cancer…It’s On the Move - Let’s Find It!

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  1. Cancer…It’s On the Move - Let’s Find It! Association of State and Territorial Dental Directors Webinar Wednesday, September 25, 2013

  2. Cancer…It’s On the Move – Let’s Find It! • This presentation was supported by Cooperative Agreement IU58DP004919-01 from CDC, Division of Oral Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

  3. General Reminders • This webinar will be recorded and archived on the ASTDD website; • Questions will be addressed after the speakers are finished. Please type your question into the “chatbox” that will appear at the end of the webinar and then click on the bubble to the right of where you type your question to send it to the moderator; • Please respond to the polling questions at the conclusion of the webinar.

  4. Objectives • To describe the relationship between HPV and oropharyngeal cancers, prevalence, and associated risk factors • To describe the oral cancer programs and replicability potential of the UNLV School of Dental Medicine and Illinois SOHP • To describe the policy implications of HPV oropharyngeal increases nationwide

  5. Speakers • Jennifer L. Cleveland, DDS, MPH • Christina A. Demopoulos, DDS, MPH • Julie A. Janssen, RDH, MA • Janet A. Yellowitz, DMD, MPH

  6. Human Papillomavirus and Oropharyngeal Cancer • Jennifer L. Cleveland, DDS, MPH • Dental Officer/Epidemiologist • JLCleveland@cdc.gov National Center for Chronic Disease Prevention and Health Promotion Division of Oral Health

  7. Background • Located in the oropharynx, specifically, the base of the tongue and tonsils • Almost 65% of all oropharyngeal cancers (OPCs) are HPV-positive; 85-95% of these are high risk HPV-16. • HPV-associated OPCs are the only head and neck cancers that are increasing.

  8. HPV Classification Over 100 different types of HPV Cutaneous HPVs (common body warts, ~60 types) Mucosal HPVs (oral, genital, ~40 types) Low Risk ex: 6, 11 High Risk ex: 16, 18 Common warts (hands, feet…) Low and high grade cervical changes; and anogenital and oropharyngeal cancers Genital and oral warts, Low grade cervical changes, Respiratory papillomas Adapted from:http://therotundaramblings.wordpress.com/2009/03/07/facts-about-cervical-cancer-hpv-infection/

  9. Natural History of HPV Infection • ~80-85% of people acquire any HPV infection at some point in their lives • ~90% infections clear in 1-2 years in healthy individuals • Almost all cervical cancers are caused by HPV infections that persist more than 2 years.

  10. Oral Cavity and Oropharynx

  11. HPV-Positive Squamous Cell Carcinoma of the Palatine Tonsil Soft palate Photo Title – Myriad Pro, Bold, Shadow, 20pt Back of tongue Caption for photo, references, citations, or credits – Myriad Pro, 14pt

  12. Screening for Oropharyngeal Cancers • Difficult to detect OPCs at early stage • No standardized screening tests • No oral “PAP” smear to detect cellular changes • No FDA approved test for oral HPV infection • No evidence that detection of oral HPV could be used to predict development of OPCs.

  13. Established Risk Factors for Head and Neck Cancers

  14. Risk Factors for HPV-associated OPCs • Associated with lifetime number of vaginal or oral sex partners • Compared with HPV-negative cancers, occur more often: • Among white men • In a population younger by about 4 years (median age 52-56 years) • In people who may or may not use tobacco or alcohol

  15. Yearly Incidence Counts HPV-associated Cancers, US 2004-2007 Yearly Incidence Counts of HPV-Associated Cancers in the United States, 2003–2007 Total 11,242 Defined by histology and anatomic site; Watson M et al. Cancer 2008. Data source: National Program of Cancer Registries (CDC) and SEER (NCI), covering 99% of US population.

  16. Number of HPV-Attributable Cancers per Year, US 2004-2007

  17. Rates of OPC by Site and Age Group, 2004-2007 *Significantly different compared to other sites within age group, p<0.05

  18. Rates of HPV-Associated Cancer and Median Age at Diagnosis Among Females in the U.S., 2004-2008 Rates of HPV-Associated Cancer and Median Age at Diagnosis Among Females in the United States, 2004–2008 (CDC). Human papillomavirus–associated cancers—United States, 2004–2008.MMWR 2012;61(15):258–261.

  19. Rates of HPV-Associated Cancer and Median Age at Diagnosis Among Males in the U.S., 2004-2008 Rates of HPV-Associated Cancer and Median Age at Diagnosis Among Males in the United States, 2004–2008 (CDC). Human papillomavirus–associated cancers—United States, 2004–2008.MMWR 2012;61(15):258–261.

  20. Annual Percentage Change in OPC by Sex and Race/Ethnicity, 1999-2007 Overall, incidence of HPV-associated OPCs increased 2.5% per year. Defined by histology and anatomic site; Watson M et al. Cancer 2008. Data source: National Program of Cancer Registries (CDC) and SEER (NCI), covering 89% of US population.

  21. HPV and Rising OPC Incidence in the U.S. • 271 OPCs collected by 3 cancer registries in 1988-2004. • Incidence of HPV-positive OPCs increased by 225% during 1988-2004 -- incidence of HPV-negative cancers declined by 50%. • Should recent trends continue, the annual number of HPV-positive OPCs among men will surpass that of cervical cancers among women by the year 2020. Source: Chaturvedi A et al., J Clin Oncology, 2011.

  22. Prognosis • HPV-positive OPCs have improved prognosis/outcomes relative to HPV-negative OPCs. • HPV-positive tumors have higher survival rates, respond better to radiation and chemotherapy treatment, and are less likely to recur than HPV-negative ones. • HPV +/─ tumor status may drive treatment decisions.

  23. Differences in HPV-Positive Oropharyngeal Cancers by Race/Ethnicity • HPV-positive oropharyngeal cancers occur more often in whites and are associated with improved outcomes • Settle, 2009 • Median overall survival: 70.6 months for whites vs. 20.9 months for blacks • Survival was similar for black and white HPV-negativepatients • HPV positivity in OPC patients nearly 9-fold higher in whites than blacks

  24. ACIP Recommendations for HPV Vaccine in the United States Quadrivalent or Bivalent vaccine Routine, females 11 or 12 yrs* Catch-up, 13-26 yrs Quadrivalent vaccine Routine, females 11 or 12 yrs* Catch-up, 13-26 yrs Quadrivalent vaccine May be given, males 9-26 yrs June October Quadrivalent (HPV 6,11,16,18) vaccine; Bivalent (HPV 16,18) vaccine; ACIP: Advisory Committee on Immunization Practices * Can be given starting at 9 years of age

  25. Potential for HPV Vaccines to Prevent Oral HPV Infection • Effectiveness to prevent HPV-positive oropharyngeal cancers is unknown. • High prevalence of HPV16 in OPCs suggests HPV vaccination may have a major impact on incidence of OPCs. • Periodic surveillance in HPV-associated OPCs will be important to monitor the impact of HPV vaccines.

  26. Conclusions • Rates of HPV-positive OPCs are increasing in young, white males. • HPV-positive OPCs are diagnosed later but have better prognosis than HPV-negative cancers. • HPV vaccines may greatly affect the US public health by preventing non-cervical cancers, such as OPCs.

  27. Oral Cancer Prevention and Early Detection in Illinois Julie Ann Janssen, RDH, MA Program Administrator Illinois Department of Public Health Division of Oral Health julie.janssen@illinois.gov Charles W. LeHew, PhD Research Scientist University of Illinois-Chicago College of Dentistry lehew@uic.edu Association of State and Territorial Dental Directors Webinar Wednesday, September 25, 2013

  28. Oral Cancer Prevention and Control Over Time 2002 2007 IL Oral Health Plans 1997 Tobacco Free Steering Comm. 2001 School- based Tobacco Prevention 1987 Smoke- less Survey 1991 NIH Tobacco Cessation 1999 Half for Tobacco Campaign 2005 IL Cancer Plan 2012 IL Cancer Plan 1994 IPHA Conf. 1988 Project SOS 1993 - Youth Tobacco Surveys 1995 NSTEP 1998 CDC MMWR Oral Cancer 2000 Tobacco Free Communities 2001 Research NIDCR Steering Comm. Build local capacity 2004 Local Plans 2005 - 2011 Local Oral Cancer Prev. & Control Program

  29. Funding Community Programs Data Partnerships Tobacco & Alcohol Use Healthcare Workforce Contributing Factors Risk/Prevention Factors Health Problem Education Awareness Addiction Prevention & Treatment Oral Cancer HPV HPV Vaccination Access to Care Early Screening PublicPolicy Outcome Objectives Impact Objectives Intervention Strategies

  30. State Oral Health Program Role • Coordinate partnerships • Policy development • Fiscal agent • Expertise • Data • Evaluation

  31. State Oral Health Program Partnerships • University of Illinois – Chicago • Health Research and Policy Center • College of Dentistry • IDPH Division of Chronic Disease • Tobacco Program • Cancer Control Program • Illinois Tobacco Quitline • Local Health Departments/ Community partners • Southern Illinois University-Carbondale • Dental Hygiene • IFLOSS Coalition • Illinois Public Health Association • Illinois Cancer Registry • Behavioral Risk Factor Surveillance System

  32. Funding & Support Sources • US Dept. of Health & Human Services • Maternal and Child Health Block Grant • Preventive Health Block Grant • National Institute of Health • National Cancer Institute • Oral Health America • American Dental Association – State Society • IFLOSS Coalition • American Dental Hygienists’ Association – State Association • Illinois Public Health Association • Illinois Cancer Registry • IDPH Division of Chronic Disease – Cancer Control Program • Master Tobacco Settlement Agreement • Illinois Tobacco Free Communities Grant • Illinois Quitline

  33. External Funders UIC UIC Illinois Department of Public Health Division of Oral Health Leading Local Health Department Leading Local Health Department Leading Local Health Department Other LHDs & Community Partners Community Partners At Risk Populations and their Clinical Providers Other LHDs & Community Partners

  34. Community-based Oral Cancer Assessment and Program Planning 2001 Oral Cancer Late Stage Diagnosis

  35. Oral Cancer Prevention and Control Program

  36. Program Expectations • Derive goals and objectives • Local needs assessment and plans • Healthy People 2010 Objectives • Illinois Oral Health Plan • Illinois Comprehensive Cancer Control Plan • Maintain / expand the community advisory group.

  37. Program Expectations • Increase public awareness of oral cancer and late-stage diagnosis, of associated risk factors, and of ways to reduce risk of oral cancer. • Promote awareness of the need for cancer screening in populations that do not see a dentist or other health care provider regularly • Improve the capacity of local health care providers to detect and manage oral cancers and to help their patients reduce the risks for oral cancer.

  38. Program Expectations • Consult with academic partners at UIC and SIUC to implement and evaluate training programs. • Work collaboratively with other local tobacco prevention and cancer control programs. • Utilize and evaluate health promotion brochures and training materials developed for this program.

  39. Advantages of Basing Community Programs in Local Health Departments • Institutions • Consistent funding/strong resource base • Knowledge of community • Existing partnerships and linkages • Resources • Dedicated coordinator (essential) • Other staff and support • Health educators • Institutional knowledge • Complementary Programs (natural allies) • Chronic disease/cancer control • Tobacco control • STD Programs

  40. Program Accomplishments • 18 Health Departments participated • Hundreds of organizations involved • 707 Providers and staff trained • ~50,000 materials distributed • >500,000 people reached • 1,770 Screened • 83 Referred (1/21)

  41. Program Accomplishments • Tested BRFSS county level questions • An oral cancer screening is… Have you ever had this type of oral exam? • In the past 12 months, has a dentist or dental hygienist advised you to stop smoking? • Have you ever read a booklet or pamphlet that describes oral cancer of the mouth? • Oral cancer embedded in local cancer and tobacco control programs • Oral health represented in State Cancer Partnership

  42. Next Steps • Need a “Ribbon” • Need national policies to support states • Who to screen • When to screen • How to screen • Funding & Reimbursement • Workforce capacity • Referral for biopsies • Referral for treatment • Oral health components in cancer & tobacco prevention grants/programs

  43. Thank youFor more information Acknowledgments Go to: www.ihrp.uic.edu www.idph.state.il.us Thanks to Illinois Department of Public Health, divisions of Oral Health and Chronic Disease, University of Illinois – Chicago, 18 local health departments, three regional program coordinators, and hundreds of community partners.

  44. UNLV School of Dental Medicine Crackdown on Cancer

  45. UNLV School of Dental Medicine Crackdown on Cancer The Problem: • The Oral Cancer Foundation estimates that approximately 42,000 Americans will be diagnosed with oral or pharyngeal cancer this year (oral cavity, oropharynx, exterior lip of mouth); approximately 57% will be around in five years. * • Oral cancer will cause over 8,000 deaths each year, killing roughly one person per hour, 24 hours a day. * • Recent data reports that the fastest growing segment of the oral cancer population are non-smokers under the age of 50.* • *Oral Cancer Foundation. www.oralcancerfoundation.org

  46. UNLV School of Dental Medicine Crackdown on Cancer The Problem: • Tobacco use is the leading preventable cause of death.** • Worldwide, tobacco use causes more than 5 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030.** • According to the U.S. Centers for Disease Control and Prevention, over 90 percent of all adults who currently smoke started before the age of eighteen. ** • **Centers for Disease Control and Prevention. www.cdc.gov

  47. UNLV School of Dental Medicine Crackdown on Cancer Nevada’s Youth 17.0% of high school students smoke (18.1% US) 12.8% of male high school students use chewing tobacco (12.8% US) 2,400 kids (under 18) who become new daily smokers each year 47,000 kids (under 18) alive today who will ultimately die prematurely from smoking ***Campaign for Tobacco Free Kids, 2013

  48. UNLV School of Dental Medicine Crackdown on Cancer What is Crackdown on Cancer? • Crackdown on Cancer is a tobacco education program that is offered to middle/high schools in Nevada. The approach taken in the schools is quite innovative and has had a great impact. • The program uses two mobile dental clinics with qualified dental professionals to offer free comprehensive oral cancer screenings to students enrolled in middle/high schools in Nevada • Program staff offer: • tobacco education • brief intervention counseling • secondhand smoke information (environmental tobacco smoke) • referrals for tobacco cessation as well as follow-up services for evidence of a tobacco-related disease • By bringing the mobile dental clinic to participating schools, we are able to overcome many access issues which allows for maximum participation.

  49. UNLV School of Dental Medicine Crackdown on Cancer Crackdown on Cancer Beginnings? • In 2000, a portion of the Master Settlement Agreement (MSA) [Tobacco Settlement] funds were allocated for tobacco prevention/control programs in Nevada • At the time, Nevada was #1 for teen tobacco use and #1 for adult tobacco use • As a result, UNLV School of Dental Medicine proposed the Crackdown on Cancer Program to help reduce the prevalence of tobacco use in Nevada’s citizens • Initial funding was received to purchase the two mobile dental clinics and to hire administrative staff to help coordinate activities • Crackdown on Cancer was fully implemented in Nevada on July 1, 2001 • Crackdown on Cancer was 100% grant funded for the duration of the program (2001-2010); MSA funds were no longer allocated for tobacco programs as of June 30, 2010

  50. UNLV School of Dental Medicine Crackdown on Cancer Crackdown on Cancer Partnerships? • School district support from all 16 counties that had a high school (Esmeralda County does not have a high school) • Administrative and staff support from high schools and middle schools • Parent engagement through PTA meetings and back to school health fairs/workshops • College of Southern Nevada (CSN) Dental Hygiene Program • UNLV Institutional Review Board and individual review boards for Clark County and Washoe County school districts • American Lung Association, Nevada Tobacco User’s Helpline, Southern Nevada Health District • Collaborative efforts by all MSA funded tobacco prevention/control programs

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