Human Papillomavirus-Associated Oropharyngeal Cancer: Global Epidemiology and Public Policy Implications.

Global trends in human papillomavirus (HPV)-associated head and neck cancers (HNC), specifically in the oropharynx subsite, have been dynamically changing, leading to new staging and treatment paradigms. Epidemiologic studies have noted regional variations in HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). While HPV vaccination remains the main preventative approach, vaccination policy in relation to gender neutrality is heterogeneous and particularly sparse in low- and middle-income countries, where the burden of global cancer cases and HPV-associated HNC are not well-characterized in certain regions. This review summarizes the existing literature on regional variations of HPV-associated OPSCC and gender-neutral vaccine policies. Based on available data, the incidence of HPV-associated OPSCC is highest in North America, Europe, and Oceania. As of 2022, 122 of 195 (63%) World Health Organization (WHO) member states had incorporated HPV vaccinations nationally; of these, 41 of 122 (34%) member states have introduced gender-neutral vaccine coverage. Future research is needed to describe continued evolving trends in HPV-associated OPSCC, understand underlying risk factors leading to regional variation in disease, and implement gender-neutral policy more broadly.

Human Papillomavirus-Associated Head and Neck Malignancies in Sub-Saharan Africa: A Systematic Review.

PURPOSE: The proportion of head and neck cancers (HNCs) with human papillomavirus (HPV) positivity in sub-Saharan Africa (SSA) is poorly characterized. Characterizing this has implications in staging, prognosis, resource allocation, and vaccination policies. This study aims to determine the proportion of HPV-associated HNC in SSA. MATERIALS AND METHODS: This systematic review included searches from PubMed, EMBASE, Web of Science, African Index Medicus, Google Scholar, and African Journals Online. All English publications reporting the proportion of HNC specimens from SSA patients who tested positive for HPV and/or p16 were included. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Case Series Studies. RESULTS: In this systematic review of 31 studies and 3,850 patients, the overall p16 positivity was 13.6% (41 of 1,037 patients tested) with the highest proportion among oropharyngeal cancers (20.3%, 78 of 384 patients) and the overall HPV polymerase chain reaction positivity was 15.3% (542 of 3,548 samples tested) with the highest proportion among nasopharyngeal cancers (16.5%, 23 of 139 patients). Among the 369 HPV strains detected, the most common genotypes were HPV 16 (226 patients, 59.2%) and HPV 18 (78, 20.4%). CONCLUSION: HPV was found to be associated with a significant proportion of HNC in SSA. The genotypes reported suggest that the nine-valent vaccine and gender-neutral vaccination policies should be considered. Given that these studies may not accurately capture prevalence nor causation of HPV in HNC subsites, additional research is needed to provide a more thorough epidemiologic understanding of HPV-associated HNC in SSA, including risk factors and clinical outcomes.

AfHNS fellowship: Model to improve access to head and neck cancer care in Africa and developing countries.

BACKGROUND: Head and neck cancers occur predominantly in developing countries where access to care is poor. Sub-Saharan Africa has <20 head and neck surgeons for >1 billion people and has only two fellowship training programs. METHODS AND RESULTS: The AfHNS Head and Neck Fellowship is being introduced to accelerate training of African surgeons to improve access to resource appropriate cancer care. By avoiding fixed time-in-training and single training sites, training can be offered at multiple centers in Africa, even with lower patient volumes. It also creates opportunities for accredited international surgical outreach programs to contribute to training. CONCLUSIONS: Having prescribed reading and appropriate Entrustable Professional Activities that are assessed through Workplace Based Assessment, and having a summative virtual oral examination ensures that fellows are fit-for-purpose to practice in an African resource-constrained setting. Other developing countries are encouraged to adopt a similar approach to expanding head and neck cancer services.

Is AJCC/UICC Staging Still Appropriate for Head and Neck Cancers in Developing Countries?

By 2030, 70% of cancers will occur in developing countries. Head and neck cancers are primarily a developing world disease. While anatomical location and the extent of cancers are central to defining prognosis and staging, the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) have incorporated nonanatomic factors that correlate with prognosis into staging (eg, p16 status of oropharyngeal cancers). However, 16 of 17 head and neck surgeons from 13 African countries cannot routinely test for p16 status and hence can no longer apply AJCC/UICC staging to oropharyngeal cancer. While the AJCC/UICC should continue to refine staging that best reflects treatment outcomes and prognosis by incorporating new nonanatomical factors, they should also retain and refine anatomically based staging to serve the needs of clinicians and their patients in resource-constrained settings. Not to do so would diminish their global relevance and in so doing also disadvantage most of the world's cancer patients.

African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings.

BACKGROUND: International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources. METHODS: Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined. RESULTS: Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines. CONCLUSIONS: Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

Oral cavity cancer management guidelines for low-resource regions.

BACKGROUND: The diagnosis and management of oral cavity cancer has been well described in developed countries, however, in regions with fewer medical resources, alternative methods may need to be used. We outline an approach to evaluation and treatment of oral cavity cancer in low-resource areas. METHODS: Reviews of the Cochrane and Pubmed databases were performed and literature compiled. Expert opinions from the American and African Head and Neck Societies were also provided. RESULTS: Treatment guidelines for managing oral cavity cancer in low-resource regions are outlined and the level of supporting evidence is defined. DISCUSSION: Successful treatment typically involves the use of upfront surgical resection of the primary lesion and any involved or at-risk cervical lymph node basins, with adjuvant therapy based on the final pathology findings. In situations where services such as adjuvant therapy and/or appropriate reconstruction are not available, alternative approaches to treatment may be needed.

African head and neck fellowships: A model for a sustainable impact on head and neck cancer care in developing countries.

BACKGROUND: There is an extreme shortage of head and neck surgeons in Africa. Fourteen head and neck surgeons have completed fellowships in Cape Town and Cameroon. This study determines whether such Africa-based fellowships are a good model for developing countries by making a sustainable impact on head and neck cancer care. METHODS: An observational study was conducted by emailing questionnaires to past fellows. RESULTS: All fellows had returned to teaching hospitals in their counties. Seven established new multidisciplinary cancer teams. Head and neck operations had increased by >335%, as had complexity of the surgery. There was effective transfer of surgical skills to trainees. All considered head and neck fellowships to be the best model to grow head and neck care. CONCLUSION: Head and neck fellowships in developing countries are effective models for establishing training programs and for increasing provision of specialized surgical services in a sustainable fashion.

Head and neck surgical subspecialty training in Africa: Sustainable models to improve cancer care in developing countries.

BACKGROUND: Cancer poses a health crisis in the developing world where surgery is the mainstay of treatment for head and neck cancers. However, a shortage of surgeons with appropriate skills exists. How do we train head and neck surgeons in developing countries and avoid a brain drain? The ideal model provides appropriate affordable training leading to establishment of head and neck cancer centers that teach and train others. METHODS: Different head and neck surgery training models are presented based on the personal experiences of the authors. Surgical exposure of head and neck fellows in Cape Town and (potentially) in Nairobi is benchmarked against programs in the United States. RESULTS: Surgical exposure in Cape Town is equivalent to that in the United States, but more appropriate to a developing world setting. CONCLUSION: Training can be achieved in a number of ways, which may be complimentary. Fellowship training is possible in developing countries. © 2016 Wiley Periodicals, Inc. Head Neck 39: 605-611, 2017.

Free Flaps in a Resource Constrained Environment: A Five-Year Experience-Outcomes and Lessons Learned.

Introduction. Free flap surgery is a routine procedure in many developed countries with good surgical outcomes. In many developing countries, however, these services are not available. In this paper, we audit free flaps done in a resource constrained hospital in Kenya. Objective. This is a five-year audit of free flaps done in a tertiary hospital in Kenya, between 2009 and 2014. Materials and Methods. This was a prospective study of patients operated on with free flaps between 2009 and 2014. Results. A total of one hundred and thirty-two free flaps in one hundred and twenty patients were performed during the five-year duration. The age range was eight to seventy-two years with a mean of 47.2. All the flaps were done under loupe magnification. The overall flap success rate was eighty-nine percent. Conclusion. Despite the many limitations, free flaps in our setup were successful in the majority of patients operated on. Flap salvage was noted to be low due to infrequent flap monitoring as well as unavailability of theatre space. One therefore has to be meticulous during surgery to reduce any possibilities of reexploration.

The value of a collaborative course for advanced head and neck surgery in East Africa.

OBJECTIVES/HYPOTHESIS: To determine the value of a collaborative course for advanced head and neck surgery in East Africa. STUDY DESIGN: Survey of participants. METHODS: A 3-day course in head and neck surgery was designed for otolaryngologists and trainees from Kenya and surrounding countries through a collaborative effort between Kenyatta National Hospital, the University of Nairobi, and the Head and Neck Divisions from the Vanderbilt Bill Wilkerson Center and the Massachusetts Eye and Ear Infirmary. Topics included neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, and pectoralis myocutaneous flaps. A pre- and postcourse self-evaluation survey was administered to measure course impact. RESULTS: Eighteen otolaryngologists and trainees participated in the course, with 17 completing course surveys. The majority of participants (72%) were from Kenya. Prior to the start of the course, 41%, 71%, 23%, 12%, and 0% of participants indicated they could complete a neck dissection, parotidectomy, parapharyngeal space mass excision, total laryngectomy, and pectoralis myocutaneous flap, respectively. Following the course, 50%, 94%, 69%, 25%, and 38% of participants indicated they could complete a neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, respectively, with a statistically significant increase identified for pectoralis myocutaneous flaps (P < .001) and total laryngectomy (P = .009). There was also a trend toward an increase in the number of participants indicating an ability to complete parotidectomy following the course (P = .085). CONCLUSIONS: This survey demonstrates the potential value of a collaborative course in advanced head and neck surgery as one useful model for increasing the number of well-trained head and neck surgeons in East Africa.

Prevalence and associated factors of pulmonary hypertension in Kenyan children with adenoid or adenotonsillar hypertrophy.

OBJECTIVES: Adenotonsillar hypertrophy is a common condition in childhood, whose serious complications of pulmonary hypertension and cor pulmonale are devastating but local prevalence is unknown. This study determined the prevalence and associated factors of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy at Kenyatta National Hospital, Kenya. METHODS: This was a cross sectional hospital based survey conducted among children below 12 years of age with clinical and radiological adenoid hypertrophy attending the ear, nose and throat (ENT) outpatient clinic and general pediatric wards. Doppler echocardiography was used to determine pulmonary hypertension defined as a mean pulmonary arterial pressure (mPAP) of ≥ 25 mm Hg using the Chemla equation. Children with mPAP of ≥ 25 mm Hg were compared to those with lower pressures and clinical and radiological factors associated with pulmonary hypertension determined using multivariate logistic regression analysis. RESULTS: Of the 123 eligible children in the study, 27 had pulmonary hypertension giving a prevalence of 21.9% (95% CI 14.64%-29.27%). Independent factors associated with pulmonary hypertension included nasal obstruction (OR=3.0 [95% CI 1.08-8.44] p=0.035) and hyperactivity on history (OR=0.2 [95% CI 0.07-0.59] p=0.003) and adenoid-nasopharyngeal ratio (ANR) >0.825 on lateral neck radiography (OR=5.0 [95% CI 1.01-24.37] p=0.048). CONCLUSION: One in five children with adenoid or adenotonsillar hypertrophy had pulmonary hypertension with a 3-fold and 5-fold increased odds in those with nasal obstruction on history and ANR >0.825 on lateral neck radiography respectively and an 80% reduced odds in reportedly hyperactive children.