Eric Adjei Boakye, PhD, MA Saint Louis University Center for Health Outcomes Research (SLUCOR) St. Louis, Missouri

Head and Neck Cancer Survivors at Risk of Secondary Cancers, esp if They Smoke Interview with:

Eric Adjei Boakye, PhD, MA Saint Louis University Center for Health Outcomes Research (SLUCOR) St. Louis, Missouri

Dr. Boakye

Eric Adjei PhD, MA
Saint Louis University Center for Health Outcomes Research (SLUCOR)
St. Louis, Missouri What is the background for this study? What are the main findings?

Response: Survivors of head and neck cancer (HNC) develop second primary cancers (SPCs) at a higher rate than most common cancers. This is concerning because the number of HNC survivors are increasing due to advancements in treatment and technology. Patients whose head and neck cancer was caused by smoking and alcohol are different than those whose HNC were caused by human papillomavirus (HPV). We therefore used data from 2000-2014 National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) 18 database to examine if the incidence and the type of SPC that patients with smoking-related HNC develop were different from those from HPV-related head and neck cancer.

First, independent of group of HNC (HPV-related or not), we found that SPCs among survivors of head and neck cancer were high, with about 1-in-8 patients developing an SPC. Additionally, irrespective of whether the index . head and neck cancer was from smoking-related or HPV-related, the majority of SPCs were second malignancies in head and neck region (e.g. tongue, gum, mouth floor etc), lung and esophagus. However, we observed different incidence rates between the two groups. Patients with smoking-related head and neck cancer developed SPCs at a higher rate (14%) than those with HPV-related HNC (10%). What should readers take away from your report?

Response: SPCs incidence are high among all HNC patients but the incidence is more pronounced among those with smoking-related HNCs. Even though HNCs from HPV has been increasing at higher rate (about 225% over the last three decades) and HNCs from smoking have been decreasing due to decrease in smoking prevalence in the US; patients with smoking-related HNCs still develop SPCs at higher rate. This indicates that smoking may be the driver of the second cancers among . head and neck cancer patients.

This position is stronger when you consider the fact that many patients who have HPV-related HNC also have a history of tobacco use. So, while HPV-related cancer has increased the overall incidence of HNC significantly in the United States, the role of tobacco in head and neck cancer remains as important as ever, not only in the development of primary HNC, but in the development of SPCs.

These findings could be helpful when deciding whether or not to offer smoking cessation. Healthcare providers, especially oncologists should actively discuss smoking-cessation programs if with their patients if they have had a history of smoking. Some patients have the mindset that since they have already developed cancer, it is okay to keep smoking! So, it is not uncommon (and this has been shown even in one of our previous studies) that many patients continue to smoke even after being diagnosed with the index head and neck cancer. Head and neck cancer survivors should be educated that smoking not only causes the first or primary cancer, but not quitting could predispose to second and perhaps (not accessed in study) more cancers. In addition, providers should continue to screen HNC patients for SPCs since the incidence is very high especially if a patient has had a history of tobacco use. I think smoking cessation in general (not only for patients already with cancer) could be cost-effective in reducing both primary and subsequent cancers in the country. What recommendations do you have for future research as a result of this work?

Response: Future studies should use data with actual HPV status and smoking status to do replicate this study. This is because we used the SEER cancer database which does not provide information about smoking/tobacco history, or HPV-tumor status. As a result, we used anatomic subsites that are well established for HPV-associated tumors to designate HPV status. This means that our incidence among HPV-related HNC may be overestimated since many of those patients categorized as HPV-related might have had a history of smoking also. Another study could be to look at the changes in SPC incidence among patients who quit smoking after the first cancer diagnosis compared with those who continue to smoke. Is there anything else you would like to add?

Response: More studies should also use a longitudinal/cohort approach to quantifying SPCs based on confirmed history of smoking, since this study was retrospective.

Dislosures: All the authors had no relevant financial disclosures and the study was unfunded. Dr Piccirillo is Editor of JAMA Otolaryngology Head–Neck Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance. 


Adjei Boakye E, Buchanan P, Hinyard L, Osazuwa-Peters N, Schootman M, Piccirillo JF. Incidence and Risk of Second Primary Malignant Neoplasm After a First Head and Neck Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg. Published online July 19, 2018. doi:10.1001/jamaoto.2018.0993

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Last Updated on July 25, 2018 by Marie Benz MD FAAD