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January is cervical cancer awareness month. The human papillomavirus (HPV) is the most common sexually transmitted virus in the United States, and also a risk factor for cervical cancer. In this blog post, we discuss a new type of cancer associated with HPV- head and neck cancer. 

There are over 100 types of HPV, and more than 40 strains that can infect the genital areas of men and women, as well as the mouth and throat. HPV is passed through genital contact through vaginal and anal sex, and can also be passed through oral sex.

HPV and Head and Neck Cancer

The connection you should know about

In recent years, the human papilloma virus (HPV) has been linked to cervical, anus and skin cancers.

“HPV is the most common sexually transmitted infection in the United States,” says Ann Honebrink, MD, associate professor of clinical obstetrics and gynecology at Penn. “Even without showing symptoms of HPV, people can transmit the virus and barrier methods like condoms don’t work as well to prevent HPV transmission as they do other infections like HIV.”

While HPV can cause symptoms, a person can go for years without ever knowing they have the virus. That, along with the ability of the HPV virus to remain present in a person for a long time, make this virus so prevalent — people continue to spread the virus through sexual contact without knowing they carry the virus. In most cases, the body fights off HPV naturally and eventually the virus is cleared. However, when the body cannot fight off HPV, the virus can persist and also can trigger cellular changes that may lead to cancer.

“Some types of HPV must be present in order for a women to develop squamous cell cancer of the cervix, the most common type of cervical cancer,” says Dr. Honebrink.

Oral cancer – HPV’s new connection
While HPV has most been linked to cervical, anus and skin cancers, recent studies suggest the same strain of HPV can also cause oropharyngeal (head and neck) cancer.

“We are seeing more cancer located at the base of the tongue and in the tonsils,” says Jason Newman, MD, assistant professor of otorhinolaryngology, and head and neck surgeon at Pennsylvania Hospital.

Oropharyngeal cancer develops in the part of the throat including the back of the tongue, back part of the roof of the mouth, the tonsils, and the side and back wall of the throat.

“Historically, people who get head and neck cancer are older – over 70 – and have been heavy smokers or drinkers,” says Dr. Newman. “But we are seeing an increase in young, otherwise healthy men and women who develop head and neck cancer related to the HPV virus.”

Treatment for head and neck cancer may include transoral robotic surgery (TORS). TORS is the world’s first group of minimally invasive robotic surgery techniques enabling surgeons to remove tumors of the mouth and throat. This revolutionary breakthrough results in shorter, virtually scarless head and neck surgery. TORS is performed through the patient’s mouth and provides unprecedented access to the small and often difficult-to-reach areas of the mouth and throat.

Surgeons at Penn Medicine created da Vinci TransOral Robotic Surgery (TORS) in 2005. The adoption of this highly advanced robotics technique demonstrates Penn Medicine’s commitment to providing world-class health care.

“It’s important to know the signs of head and neck cancer, and to not ignore symptoms that do not go away,” says Dr. Newman. “Treatment options and outcomes improve greatly when cancer is found early.”

Preventing HPV

The good news is that there is protection for both girls and boys who have not yet encountered the HPV virus. There are two FDA approved HPV vaccines on the market: Gardasil and Cervarix.

Gardasil protects against four major types of HPV; HPV 16 and 18, the two types that cause about 70 percent of cervical cancer and HPV 6 and 11 which cause 90 percent of genital warts.
Cervarix protects against HPV 16 and 18.

HPV vaccines are given as three shots to protect against HPV infection and HPV-related diseases, and they offer the greatest health benefits to individuals who receive all three doses before having any type of sexual activity. This is why the HPV vaccination is recommended for preteen girls and boys at age 11 or 12 years.

Facts about HPV

• Nearly 20 million people in the United States are infected with HPV.
• 6.2 million Americans become infected each year with more than 50 percent of sexually active men and women infected with HPV at some time in their lives.
• Most HPV infections do not cause any symptoms and go away on their own.
• HPV can cause genital warts and warts in the oral and upper respiratory tract in both men and women.

There is no treatment for an HPV infection, but many of the conditions it causes can be treated.

Elizabeta Evtimovska, DDS, MS, is a maxillofacial prosthodontist at Penn. In this article, she discusses complications from treatments for head and neck cancer, and how patients can prevent long-term side effects of head and neck cancer treatment.

Head and neck radiation and chemotherapy can cause a range of short and long-term oral complications.

The acute complications such as mucositis (sores) and infections, as well as others are managed by the oncology team during the treatment. Some of the long-term complication, such as xerostomia (dry mouth) and osteoradionecrosis (ORN), is a serious complication of radiation therapy for head and neck cancer that occurs in a small percentage of patients as result of head and neck radiation treatment.

Osteoradionecrosis is bone that has died. Because radiation works to destroy cancerous cells through the deprivation of oxygen and vital nutrients, it inevitably destroys normal cells as well, damaging small arteries and reducing circulation to the area of the mandible (jaw bone).

As there is no treatment for ORN, the focus is on prevention. This means, avoiding extractions of teeth from the radiated parts of the jaws and making sure that dentures fit properly and don’t cause any sores. It most often occurs in the setting of tooth extraction from the radiated parts of the jaws, but can also occur spontaneously. In both cases, there is exposed bone in the mouth which can be asymptomatic or it can be further complicated by infections, pain, and/or malodor.

Preparing for head and neck cancer therapy

Patients who are planning to undergo chemotherapy or radiation should be evaluated by a dentist prior to the start of treatment.

During this appointment, the patient’s oral condition is evaluated and it is determined if any teeth need to be extracted prior to the start of radiation treatment. This visit is also a perfect time to go over good oral health care.

In our practice, I advise patients to do the following during and after radiation:

• Maintain excellent oral hygiene by flossing and brushing every morning and evening and after every meal. If dry mouth develops, it is especially crucial to brush teeth after every meal and only drink water between meals, as opposed to sugary drinks or snacks.
• Use fluoride to prevent caries (when xerostomia, dry mouth, is present, the patient has increased risk of caries). Fluoride is especially important to prevent extracting teeth from the radiated parts of the jaws and therefore prevent osteoradionecrosis.
• Visit a local dentist regularly for regularly scheduled maintenance visits (cleanings), as well as any other routine dental treatment.

The severity of oral complications from chemoradiation differs depending on the diagnosis, the type of treatment administered, the amount and location of the delivered radiation, etc. Therefore, it is best to consult with a dentist prior to and after radiation in terms of the above discussed needs and recommended treatment.

Learn about managing cancer treatment side effects.

Learn about the Abramson Cancer Center Center’s Center for Head and Neck Cancer.

After a head or neck cancer diagnosis, pain caused by the tumor or from surgical procedures or treatment can make chewing and swallowing difficult. 

Altering the consistency of your food and carefully selecting food items can make a big difference in your ability to eat and aid in making sure your body receives adequate calories, protein and other nutrients. 

It is important to maintain good nutrition during this period to aid recovery and healing as well as prevent complications that may impact treatment. 

Excessive weight loss during treatment and recovery may result in frequent hospitalizations and poor outcomes. For this reason, it’s important to choose foods that require little to no chewing and that don’t cause choking.  The food may not look as appealing as you are used to, but with the right seasonings, it still can be very flavorful.  In addition, sprinkling dried herbs such as parsley can enhance the eye appeal and taste.

Dietitians work closely with speech and swallowing therapists to determine patients’ nutritional needs and appropriate food and liquid consistencies. Those with head and neck cancer should seek support from a registered dietitian to make they are receiving the proper nutritional needs during treatment.

Learn more about nutrition programs at the Joan Karnell Cancer Center, or how to meet with a registered dietitian at the Joan Karnell Cancer Center at Pennsylvania Hospital.  Learn about nutrition services offered at the Abramson Cancer Center.

Watch videos to learn more about head and neck cancer treatment options offered at the Abramson Cancer Center.

Watch for upcoming recipes on this blog that are modified for smooth creamy textures.

Debra DeMille, MS, RD, CSO is a nutritional counselor at the Joan Karnell Cancer Center. Debra has worked at Pennsylvania Hospital since 1988 with the last 12 years specializing in oncology. Debra guides individuals receiving chemotherapy and radiation as well as addressing survivorship issues including the use of integrative therapies.


She conducts cooking programs and group counseling sessions for cancer survivors.

Transoral robotic surgery (TORS) was invented and developed by the pioneering team of Bert W. O'Malley, Jr., MD and Gregory S. Weinstein, MD at Penn Medicine

TORS uses the state-of-the-art da Vinci® Surgical System, which allows surgeons better access to the areas of the throat for the removal of cancers and benign lesions via a minimally invasive robotic approach.

Surgeons benefit by having improved access to the tight confines of the throat and patients benefit in the short term with a faster and easier recovery and, in the long term, by outstanding cancer results and improved swallowing results compared to alternative treatments.

Benefits of TORS can include:

• Quicker return to normal activity
• Shorter hospitalization
• Reduced risk of long-term swallowing problems (most commonly seen with chemoradiation or traditional open surgery)
• Fewer complications compared to traditional open surgery
• Less scarring than traditional open surgery
• Less risk of infection
• Less risk of blood transfusion when compared to open surgery
• No routine use of tracheostomy during surgery

In this video, Drs. O'Malley and Weinstein explain the TORS procedure, and how Penn Medicine is revolutionizing care for patients with head and neck cancer.

TORS patient, Cynthia Miller along with other Penn patients discuss how the TORS procedure changed their lives.

The Joan Karnell Cancer Center at Pennsylvania Hospital is offering a free screening for oral, head and neck cancer from 11 am to 3 pm on Friday, April 27, 2012.

Oral, head and neck cancer refers to a variety of cancers that develop in the head and neck region, such as the oral cavity (mouth), the pharynx (throat), paranasal sinuses and nasal cavity, the larynx (voice box), thyroid and salivary glands, the skin of the face and neck, and the lymph nodes in the neck.

Common symptoms of oral, head and neck cancer

• Red or white patch in the mouth that lasts more than two weeks
• Change in voice or hoarseness that lasts more than two weeks
• Sore throat that does not subside
• Pain or swelling in the mouth or neck that does not subside
• Lump in the neck

Later symptoms of oral, head and neck cancer

• Ear pain
• Difficulty speaking or swallowing
• Difficulty breathing

The most effective prevention strategy continues to be the cessation of behaviors such as smoking, use of chewing tobacco and excessive alcohol consumption.  Eighty-five percent of head and neck cancers are related to tobacco use.  

Research has linked the increase of oral cancer incidence in young adults, a population traditionally at low risk, to the rise of human papillomavirus (HPV), a cancer-causing virus that can be transmitted through oral sex.

Date: Friday, April 27 2012
Time: 11 am to 3pm
Location: Pennsylvania Hospital, Otorhinolaryngology – Head and Neck Surgery (adjacent to the Spruce Building) 811 Spruce Street, Philadelphia, PA 19107

To register for this free event, call 800-789-PENN (7366).

For more information, call 215-829-6466

April is Head and Neck Cancer Awareness month.

Oral, head and neck cancer refers to a variety of cancers that develop in the head and neck region, such as the oral cavity (mouth), the pharynx (throat), paranasal sinuses and nasal cavity, the larynx (voice box), thyroid and salivary glands, the skin of the face and neck, and the lymph nodes in the neck.

Common warning signs are:

• Red or white patch in the mouth that lasts more than two weeks
• Change in voice or hoarseness that lasts more than two weeks
• Sore throat that does not subside
• Pain or swelling in the mouth or neck that does not subside
• Lump in the neck

Other warning signs that occur during later stages of the disease include:

• Ear pain
• Difficulty speaking or swallowing
• Difficulty breathing

As a part of the Focus On Cancer video series, Focus On Head and Neck Cancers addresses head and neck cancer diagnosis, treatment, research and survivorship.

In this video, New Jersey State Senator Diane Allen, together with other patients from the Abramson Cancer Center discuss their diagnoses, and their decisions to come to Penn Medicine for their cancer care.

Alexander Lin, MD,  is a radiation oncologist at Penn Medicine who specializes in treating patients with head and neck cancer.

After enjoying all of the tasty treats of the holidays, now is a good time to get back to eating healthy.

• One 15oz. can of 100% juice-packed peaches, drained
• One 15oz. can of 100% juice-packed apricots, drained
• 1/3 cup frozen raspberries
• 1 cup plain non-fat yogurt
• 1 tbsp. ground flaxseed
• 3 oz. tofu*
• 3 ice cubes

Makes 4 servings

Per serving: 166 calories; 29g carbohydrates, 8g protein; 2g fat; 3.5g fiber

*For tofu, try a brand such as Mori-Nu® This type of tofu does not need to be refrigerated until it is opened.

Source: Suzanne Dixon, MPH, MS, RD, Cancer Nutrition Information, LLC, http://www.cancernutritioninfo.com/


Tips for Smoothie Success

• Some smoothie recipes may need ice cubes; but you can try frozen fruit instead.
• Try your smoothie before adding any sweeteners or flavors… it may already be perfect!
• Take a second to rinse out the blender right after you use it, even if you're planning to wash it later; dried-on fruit makes for slow clean-up.