Background: Comprehensive screening mechanisms are critical and must be utilized in an appropriate fashion in populations with a presumed high prevalence of disease, requires low cost of screening, and available and effective treatment modalities. Alarmingly, racial and socioeconomic disparities in medical screening programs remain vast and ultimately contribute to poorer outcomes. Improving screening in areas of lower socioeconomic status extends a service to individuals who may have otherwise gone undiagnosed, in areas where disease is often diagnosed as late-stage disease, accompanied by comorbid conditions.
Methods: The authors coordinated and implemented three unique mobile health initiatives throughout underserved populations in metropolitan Atlanta. For each health initiative, a corresponding review of the English literature was performed using PubMed/MEDLINE. Special attention was paid to minority populations. Reference searches of the retrieved articles were performed manually to ensure that all available studies and data were reviewed.
Results: Mobile health screening was performed in three ways. The first focused on hypertension and asthma by screening individuals at a location commonly visited, ie, the grocery store. The second targeted obesity in underserved populations through a simple identification program that educated individuals on foods that are healthy and those that are not. This was performed in grocery stores, which we consider the “frontline” of nutrition-based decisions. Lastly, we developed an educational program targeting tobacco products, particularly e-cigarettes, which we implemented for adolescent populations through our metropolitan area.
Conclusion: Mobile screening is the first step in a facet of prevention that goes beyond traditional “in-office” screening. Targeting specific populations is of utmost importance, and engaging individuals at the community level can greatly improve the likelihood of success, particularly if the health care practitioners involved understand the cultural characteristics and customs of that population. Engaging health care practitioners in mobile screening represents a significant previously untapped resource that can increase screening throughput and greatly improve outcomes for patients who would otherwise go with an undiagnosed disease process.
Human immunodeficiency virus (HIV)-infected individuals are at increased risk for developing several non-AIDS related malignancies and are often excluded from cancer immunotherapy regimens. To evaluate the immune competence of this cancer patient population, we evaluated HLA class I antigen presenting machinery (APM) component expression and PD-1:PD-L1 pathway upregulation in HIV(+) and HIV(−) head and neck cancers (HNCs). Sixty-two HIV(+) and 44 matched HIV(−) controls diagnosed with HNC between 1991 and 2011 from five tertiary care referral centers in the United States were identified. HLA class I APM component, PD-1, and PD-L1 expression were analyzed by immunohistochemical staining with monoclonal antibodies (mAbs). Clinical data was abstracted from the medical records. There was no significant difference between the cases and controls in LMP2, TAP1, HLA-A and HLA-B/C, as well as PD-1 and PD-L1 expression. Overall, 62% of all subjects had high PD-1 expression and 82% of the subjects expressed PD-L1 within the tumor microenvironment. LMP2, HLA-A and HLA-B/C expression were significantly associated with moderate to high PD-1 expression in the HIV(+) HNC cases (p =.004, p =.026, and p =.006, respectively) but not in the HIV(−) controls. In addition, HLA-A expression was significantly associated with PD-L1 expression in the HIV(+) HNC cases only (p =.029). HIV-infected individuals diagnosed with HNC do not have any detectable defects in HLA class I APM component expression and in PD-1:PD-L1 pathway activation. Given the current successes of HAART therapy in maintaining immune cell counts, HIV(+) patients diagnosed with cancer may benefit from the recently FDA-approved immune checkpoint blockade therapy.
by
Evan Graboyes;
John Cramer;
Karthik Balakrishnan;
David M. Cognetti;
Daniel Lopez-Cevallos;
John R. de Almeida;
Uchechukwu C. Megwalu;
Charles Moore;
Cherie-Ann Nathan;
Matthew E. Spector;
Carol M. Lewis;
Michael J. Brenner
The COVID-19 pandemic has profoundly disrupted head and neck cancer (HNC) care delivery in ways that will likely persist long term. As we scan the horizon, this crisis has the potential to amplify preexisting racial/ethnic disparities for patients with HNC. Potential drivers of disparate HNC survival resulting from the pandemic include (a) differential access to telemedicine, timely diagnosis, and treatment; (b) implicit bias in initiatives to triage, prioritize, and schedule HNC-directed therapy; and (c) the marked changes in employment, health insurance, and dependent care. We present four strategies to mitigate these disparities: (a) collect detailed data on access to care by race/ethnicity, income, education, and community; (b) raise awareness of HNC disparities; (c) engage stakeholders in developing culturally appropriate solutions; and (d) ensure that surgical prioritization protocols minimize risk of racial/ethnic bias. Collectively, these measures address social determinants of health and the moral imperative to provide equitable, high-quality HNC care.
Background: We examined the prognostic value of a panel of biomarkers in patients with squamous cell carcinoma of the head and neck (SCCHN) who were human immunodeficiency virus (HIV) positive (HIV-positive head and neck cancer) and HIV negative (HIV-negative head and neck cancer). Methods: Tissue microarrays (TMAs) were constructed using tumors from 41 disease site-matched and age-matched HIV-positive head and neck cancer cases and 44 HIV-negative head and neck cancer controls. Expression of tumor biomarkers was assessed by immunohistochemistry (IHC) and correlations examined with clinical variables. Results: Expression levels of the studied oncogenic and inflammatory tumor biomarkers were not differentially regulated by HIV status. Among patients with HIV-positive head and neck cancer, laryngeal disease site (P =.003) and Clavien-Dindo classification IV (CD4) counts <200 cells/μL (P =.01) were associated with poor prognosis. Multivariate analysis showed that p16 positivity was associated with improved overall survival (OS; P <.001) whereas increased expression of transforming growth factor-beta (TGF-β) was associated with poor clinical outcome (P =.001). Conclusion: Disease site has significant effect on the expression of biomarkers. Expression of tumor TGF-β could be a valuable addition to the conventional risk stratification equation for improving head and neck cancer disease management strategies.
Epidermal growth factor receptor (EGFR) and COX-2 inhibitors synergistically inhibit head and neck squamous cell carcinoma tumorigenesis in preclinical studies. We conducted a phase I and pharmacokinetic study with the erlotinib and celecoxib combination in patients with advanced premalignant lesions. Thirty-six subjects with oral leukoplakia, mild, moderate, or severe dysplasia, or carcinoma in situ were screened for study participation; 12 consented and received therapy for a median of 5.38 months. Erlotinib was escalated following a standard 3+3 design at 50, 75, and 100 mg orally daily and celecoxib was fixed at 400 mg twice daily for 6 months. Biopsy of lesions and cytobrush of normal mucosa were performed at baseline, 3, 6, and 12 months. Erlotinib pharmacokinetics were analyzed in 10 subjects. The maximum tolerated dose of erlotinib with celecoxib 400 mg BID was 50 mg per day with skin rash being the main observed toxicity. Overall histologic response rate was 63% (complete response, 43%; partial response, 14%; stable disease, 29%; and disease progression, 14%). With median follow-up of 36 months, mean time to progression to higher-grade dysplasia or carcinoma was 25.4 months. Downregulation of EGFR and p-ERK in follow-up biopsies correlated with response to treatment. Larger average erlotinib V/F (approximately 308 L) and CL/F (8.3 L/h) compared with previous studies may be related to relatively large average bodyweights. Average erlotinib t1/2 was 25.6 hours. Encouraging responses to the celecoxib and erlotinib combination correlated with EGFR pathway inhibition. Although erlotinib-related rash was the main limitation to dose escalation, the intervention was well tolerated.
The coronavirus disease 2019 (COVID-19) pandemic is shining a spotlight on health disparities that have long been overlooked in our society. The intersection between Adverse Childhood Experiences (ACEs), longstanding health disparities, and COVID-19 cannot be ignored. The accumulation of traumatic events throughout the childhood and adolescent years can cause toxic stress in the absence of supportive adults. This repetitive activation of the stress response system can be a catalyst to long-term, negative effects on both the body and brain. A major factor to appreciate is that ACEs do not affect all populations equally. ACEs disproportionately affect groups that have been historically oppressed. The current COVID-19 pandemic highlights this point when observing both case rates and fatality rates of the virus and has the potential to create a new series of long-term health conditions that will disproportionately affect marginalized communities. A foundational first and critical step of adopting a trauma-informed approach will help lead to system change, advance equity, and create a setting of mutuality and empowerment for our patients.
Our understanding of the novel coronavirus, COVID-19, is growing; yet, there remains much we do not understand, and unique presentations are abundant. One potential presentation is retropharyngeal edema, defined as fluid in the retropharyngeal space. Multiplanar imaging with computed tomography or magnetic resonance imaging is ideal for characterizing and diagnosing these fluid collections rapidly as possible life-threatening complications may develop (eg, airway obstruction and mediastinitis). Here, we discuss the presentation, imaging identification, treatment, and recovery of retropharyngeal fluid collection in 2 COVID-19 cases. The significance of this article is to suggest conservative management as a viable treatment option for retropharyngeal fluid collection, as opposed to incision and drainage, in the setting of COVID-19.