Kelly Johnson

Despite national evidence and consensus-based guidelines on post-treatment care, less than half of adolescents and young adults (AYAs) who have survived Hodgkin lymphoma receive all of the recommended services within the first year after treatment, according to results of a pilot study presented at the 2016 Cancer Survivorship Symposium.

In addition, only 30 percent of survivors at high risk for cardiac damage adhered to long-term recommendations including an echocardiogram, electrocardiogram or multigated acquisition (MUGA) scan.

“When we examine adherence to guidelines like these, it’s actually an important part of high-quality care to see if we can identify gaps and hopefully close them,” lead author Erin E. Hahn, a research scientist at Kaiser Permanente Southern California's Department of Research and Evaluation, said during a press cast held in advance of the symposium.

Hodgkin lymphoma accounts for 12 percent of all new cancer diagnoses among AYAs, and while the overall survival rate is very high, those in this population remain at high risk for shortand long-term effects related to their treatment throughout survivorship.

The study evaluated electronic medical records of 354 AYA patients aged 15 to 39 who were diagnosed with Hodgkin lymphoma between 2000 and 2010. The patients were diagnosed, treated and followed for at least two years at the Kaiser Permanente Southern California integrated health care system.

Using National Comprehensive Cancer Network (NCCN) guidelines, the investigators measured adherence to shortterm recommendations, including oncology visits, labs, imaging and the flu vaccine, which was categorized as preventive care.

Nearly all of the patients (96 percent) had annual visits with their oncologists within the first five years after treatment, and 70 percent received the recommended labs. Two-thirds received a recommended CT scan within the first year after treatment.

However, only 20 percent of patients received the recommended flu vaccine, bringing overall adherence to 48 percent within the first 12 months.

“I was happy to see that most patients were seeing their oncologists and having some appropriate testing in the first five years after treatment,” Hahn said in a statement. “I think there is work to be done to increase awareness of other guideline recommendations, and potentially access to services.”

The study also examined a subgroup of patients who were at least 10 years out of treatment and had received high-dose anthracycline-based chemotherapy plus radiation. NCCN guidelines recommend that this population of high-risk patients receive cardiac screening.

The majority of AYA patients in this population received annual blood pressure testing, but less than half received one of the other recommended modalities — an echocardiogram, electrocardiogram or MUGA scan. Researchers noted that AYA patients who were diagnosed with Hodgkin lymphoma between 2006 and 2010 were more likely to adhere to post-treatment recommendations than those diagnosed between 2000 and 2005.

“One of our hypotheses was that, as these guidelines became more familiar to clinicians and hopefully also to our patients, it might actually change the patterns of care that we see,” Hahn said, “and that did turn out to be true.”

The study authors plan to expand their research to include a larger cohort of patients and investigate long-term recommended services. Hahn noted that next steps involve designing and implementing systematic programs to address gaps in recommended care for the AYA patient population.

Presscast moderator and ASCO expert Merry-Jennifer Markham added that Hahn’s study highlights a need for further interventions.

“The survivorship care is really crucial in the adolescent and young adult population of Hodgkin lymphoma survivors because many of them — most of them, in fact &mdash; have long lives ahead of them,” she said.

“Clearly, we have some opportunities ahead of us to improve adherence to post-treatment guidelines and hopefully, as a result, survivorship outcomes for all.”

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Only 30 percent of survivors at high risk for cardiac damage adhered to long-term recommendations including an echocardiogram, electrocardiogram or multigated acquisition scan.

Survivors of Young-Adult Hodgkin Lymphoma Not Getting All Recommended Checkups

A cancer diagnosis and subsequent treatment can impact many areas of life —physically, emotionally, psychologically and cognitively. But one of the most commonly affected areas of life impacted by disease and treatment &mdash; sexual health and intimacy &mdash; is often underestimated, according to world-renowned sexual medicine gynecologist and survivorship medicine expert Michael Krychman. To gain further insight on sexual intimacy in cancer survivorship, CURE magazine spoke with Krychman, executive director, The Southern California Center for Sexual Health and Survivorship, about the impact of cancer on sexual health, discussing the issues during clinical visits and simple solutions for optimal quality of life.

Should issues with intimacy and sexual health be anticipated with a cancer diagnosis?

Krychman: The vast majority of people diagnosed with cancer have issues with sexual intimacy at some point. The extent to which they’re impacted really depends on a lot of variables — type of cancer, the patient’s age, the grade and the treatment.

Clearly, if someone has early-stage cancer and is able to be treated in a less aggressive way, it may still have an impact on a variety of things, but not to the extent as it would for someone who is aggressively treated with chemotherapy, radiation or surgery. Cancer does change how you think about yourself, look at yourself and feel about yourself as a sexual person. 

What sexual health effects can be associated with cancer diagnosis and treatment?

There are certainly a lot of things that are quite similar between both men and women, and I would say that they’re broken down into different classes. There are direct and indirect effects. 

Direct effects from chemotherapy, radiation or surgery can include pain, fatigue, and issues with desire, arousal and achieving orgasms. Women can experience vaginal dryness and loss of sensation, which can easily lead to feeling a loss of femininity. Procedures resulting in scarring can also alter the patient’s view of themselves as a sexual person  

Indirect effects are results of treatment that negatively impact sexual health, including stress, financial concerns, difficulty finding comfort and losing strength. If you have radiation and can’t even put your arm around your partner, it may become a big issue. It affects a variety of different things, and it impacts the whole relationship.

For patients, is the psychological or physical aspect more impactful on sexual health?

I think that it’s a dual issue. It’s a dual process, and it really depends on the person — every person is different. In terms of perception, the disease changes the way that people view themselves as sexual beings, in particular, and this causes sexual self-esteem issues.

It’s estimated that for breast cancer, anywhere between 50 percent and 100 percent of people have issues and that’s really related to the fact that people can be diagnosed at a variety of different stages and grades.

For clinicians, it’s a balance. You can’t treat a problem if you don’t know that one exists, and I think that it’s important that you talk about the issue. Clinicians need to create a comfortable environment. They don’t need to be experts, but they need to make themselves available for partial assessments and be able to refer patients to specialized clinics. Silence is the biggest deterrence. 

Are patients typically apprehensive to talk with their providers about sexual health and intimacy?

I think that patients want to talk about it, but they don’t know how and they have their own hang-ups. Why do they have their own hang-ups? I think it’s because they feel like they have a laundry list of things to discuss and there’s only a certain amount of time to talk to their doctor. They also don’t want to embarrass their clinician.

Then there is this “conspiracy of silence.” Patients feel that if sexual health were important, their health care provider would raise the topic during the visit. At the same time, the health care provider feels that if it were important to the patient, the patient would bring it up. So, either side is waiting for the other to talk about it first and, ultimately, nobody brings it up.

Patients often think that they’re being selfish and should just be thankful they are alive, but it’s not about being selfish — it’s about quality of life.

Are there gender discrepancies in discussing sexual health in cancer survivorship?

Both men and women are very uncomfortable talking about this issue. And believe it or not, men speak up more often because it’s much more acceptable for men to be sexualized in our society. Every day on television, we see ads for Viagra, Cialis and Levitra; presidential candidates talking about erections, famous athletes talking about testosterone — for men, it is very common to have that discussion. Women, however, are not allowed to be sexual in our society, so this is an issue.

How can nurses and health care providers ease patients into conversations about sexual health issues?

I think that breaking the silence is the most important thing. Again, you can’t treat a problem if you don’t know that one exists. Talking with patients about sexual health and intimacy in survivorship decreases isolation, normalizes the problem, and lets them know that they’re not crazy. 

Sometimes, it’s a challenge for providers. Clinicians can feel inadequate about their knowledge of treatment, but it’s important to know that there are a lot of simple solutions. There are hormone therapies, non-hormonal moisturizers and lubricants, herbal supplements and vaginal dilators. It’s also important for providers to be aware of the many facilities and experts that focus on sexual health and reclaiming sexual intimacy in order to refer patients in need.

What is your overarching message to survivors who feel that they may never regain a normal sex life?

My message is one of hope. There are simple solutions, and the best predictor of how you will do after is how you did before. Not everyone is going to be forthcoming and able to help you, but it’s important to recognize that there are solutions: sexual health is important for survivorship, and you have to advocate for your own health.

My philosophy is that sexual health is general health. There is emerging data showing that regular sex, ejaculations and orgasms, may lead to lower grades of chronic disease and decrease chronic illness. It’s also known that sex can decrease the risk of cardiovascular disease and increase immunity, and other studies have linked regular sex to lower rates of prostate and breast cancer.

I think that the power of sexual intimacy — the ability to change your hormones, improve emotional closeness, boost your immunity &mdash; is existential. We need to make sure that we don’t underestimate what we’re doing in terms of sexual health in cancer survivorship.

A cancer diagnosis often takes a hit on patients' sexual health. Michael Krychman, executive director of The Southern California Center for Sexual Health and Survivorship, talks about the impact cancer has on one's sex life, as well as tips to help.

Sexual Health in Cancer Survivorship

According to results from a new study, individuals with detectable human papillomavirus (HPV)-16 in their mouthwash samples were more likely to develop oropharyngeal cancer than those without the virus. The likelihood of developing oropharyngeal cancer was 22 times higher.

Researchers from Albert Einstein College of Medicine also reported that the presence of other HPVs, usually on the skin, is linked to an increased risk of developing head and neck squamous cell carcinoma (HNSCC).

 and led by Led by Ilir Agalliu, is based on a nested case-control study with 96,650 participants who did not have cancer at baseline. The patients participated in the American Cancer Society Cancer Prevention Study II Nutrition Cohort and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and were monitored for nearly four years.

A total of 132 participants (103 men and 29 women) developed HNSCC during the follow-up period, and detection of oral HPV-16 resulted in a positive association for oropharyngeal squamous cell carcinoma.

HPV-16 is a well-known cause of head and neck cancers, and in a companion editorial to the study, authors Dana L. Rollison, Moffitt Cancer Center, and Maura E. Gillison, Ohio State University, noted that this study is the first to demonstrate conclusively that the presence of oral HPV-16 precedes the development of oropharyngeal cancers.

“These data are remarkably consistent with risk estimates from numerous case-controls studies. However, the study by Agalliu et al contributes to the existing body of evidence by supporting a temporal association between HPV exposure and HNSCC,” the authors explained. “By linking oral HPV detection directly to HNSCC risk, the Agalliu data have important implications for the use of oral HPV detection for [oropharyngeal cancer] screening.”

The study also found that oral beta- and gamma-HPVs — usually detected in the skin &mdash; were associated with the development of head and neck cancers.

Detection of β1-HPV-5 type was associated with oropharyngeal cancer, oral cavity, and laryngeal squamous cell carcinomas. The γ11- and γ12-HPV species were associated with both oral cavity and laryngeal squamous cell carcinomas.

The study authors noted that these added associations indicate a broader role for strains of HPV in causing head and neck cancers.

Rollison and Gillison also pointed out in their editorial that previous studies have shown types of β-HPV infection to be a risk factor for cutaneous squamous cell carcinoma (cSCC).

 Although the epidemiological data are limited, the findings suggest an interaction between β-HPV infection and UV exposure that may modify the risk of developing cSCC. Furthermore, they noted that other factors such as tobacco smoking and genetics may increase incidence of HNSCC among people with oral HPV types.

The study was limited by the small size, which the authors said reflects the rarity of HNSCC, but further research may help determine if simple oral tests can indicate risk of potentially developing head and neck cancers:

“The use of easily collected oral mouthwash samples can provide a prospective marker for risk of HNSCC and oropharyngeal SCC.”

Agalliu I, Gapstur S, Chen Z, et al. Associations of oral α-, β-, and γ-human papillomavirus types with risk of incident head and neck cancer [published online before print January 21, 2016].

Rollison DE, Gillison ML. The alpha, beta, gammas of orabl human papillomavirus infection and head and neck cancer risk [published online January 21, 2016]. 

The likelihood of developing oropharyngeal cancer was 22 times higher among individuals with detectable human papillomavirus (HPV)-16 in their mouthwash samples.

Presence of HPV in Mouthwash Sample May Predict Oral Cancer Risk

In an early study of mice, researchers at NYU Langone’s Laura and Isaac Perlmutter Cancer Center showed that a topical paste may prevent scarring and fibrosis caused by radiation therapy.

In order to mimic the development of radiation dermatitis — an adverse event experienced by as many as 95 percent of patients &mdash; the researchers exposed the skin of mice to a single dose of radiation similar to what patients with cancer would receive over five weeks. Some of the mice were normal, and the others were genetically engineered to lack the adenosine A2A protein receptor.

Their skin was then treated daily with either an adenosine A2A receptor—blocking paste or a placebo. Previous studies have shown that the A2A receptor stimulates collagen production and thus, scarring. Radiation to the skin causes skin thickening and the buildup of fibrotic tissue, which in some cases can be severe enough for patients to stop treatment.

One month after exposure, the genetically-engineered mice developed no skin reaction. Mice treated with the A2A receptor—blocking paste accumulated 10 percent more skin-thickening collagen, whereas mice that received the placebo doubled their amount of collagen, skin-thickening and fibrosis.

“Our latest study is the first to demonstrate that blocking or deleting the A2A receptor can be useful in reducing radiation-induced scarring in skin,” study author and rheumatologist, Bruce Cronstein, director, NYU Langone’s Clinical and Translational Science Institute, said in a statement.

The research team developed the A2A receptor-blocking paste using 2.5 mg of active ingredient per milliliter of 3 percent carboxymethyl cellulose, a gum “binder” used to make drugs.

If successful, further testing could potentially lead to this anti-scarring paste becoming a viable treatment to prevent fibrosis in patients with early-stage cancer.

“The study also suggests that adenosine A2A receptor—antagonists may have broad application as drug therapies for preventing fibrosis and scarring, not just in the liver but also in the skin,” Cronstein said.

He added that the new paste could be especially useful for patients in preventing or improving radiation-induced skin changes because there are very few effective drugs on the market to treat fibrosis. Additionally, the paste used in the study can be applied directly to the skin and was not associated with adverse events.

The findings also indicate that A2A antagonist drugs may be effective in treating other diseases involving the skin and connective tissues, such as scleroderma and interstitial pulmonary fibrosis.

The research team plans to study the A2A receptor further to determine the mechanism underlying its role in scarring and fibrosis.

Perez-Aso M, Mediero A, Low YC, et al. Adenosine A2A receptor plays an important role in radiation-induced dermal injury. 

"Our latest study is the first to demonstrate that blocking or deleting the A2A receptor can be useful in reducing radiation-induced scarring in skin," Bruce Cronstein said.

Kelly Johnson

Survivors of Young-Adult Hodgkin Lymphoma Not Getting All Recommended Checkups

Sexual Health in Cancer Survivorship

Presence of HPV in Mouthwash Sample May Predict Oral Cancer Risk

Early Study Shows Topical Paste May Prevent Dermal Injury From Radiation

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