publication date: Jan. 5, 2018

Clinical Roundup

CAP publishes guideline to ensure accurate HPV testing in head and neck cancers

Certain head and neck cancers that are positive for high-risk types of human papillomavirus have a better prognosis and may need less aggressive treatment.

To help ensure that patients with these cancers are accurately diagnosed and effectively treated, the College of American Pathologists released its newest evidence-based practice guideline, “Human Papillomavirus Testing in Head and Neck Carcinomas,” now available in Archives of Pathology and Laboratory Medicine.

An interdisciplinary, expert panel of pathologists, surgeons, radiation oncologists, medical oncologists, patients, and patient advocates developed the guideline, which recommends accurate assessments of a patient’s high-risk HPV status, directly or by surrogate markers.

Based on a screening of 2,200 peer-reviewed articles and a review of evidence from 492 studies, the panel issued 14 final recommendations in the guideline. Notably:

  • High-risk HPV testing should be performed on all patients with newly diagnosed oropharyngeal squamous cell carcinoma, including all histologic subtypes.

  • HR-HPV testing should NOT be routinely performed on nonsquamous carcinomas of the oropharynx, nor on nonoropharyngeal primary carcinomas of the head and neck.

  • Because marked overexpression of the tumor suppressor protein p16 is strongly associated with transcriptionally-active high-risk HPV, pathologists should perform HR-HPV testing by surrogate marker p16 immunohistochemistry on oropharyngeal tissue specimens. Additional HPV-specific testing may be done at the discretion of the pathologist, treating clinician, or in the context of a clinical trial.

For HPV-positive/p16 cases, tumor grade (or differentiation status) is not recommended. Resources to implement the new guideline are available on


CAR-T therapy cancer study published in the New England Journal of Medicine

The study, “Axicagagene Ciloleucel (CD19 CAR T) in Refractory Large B-Cell Lymphoma,” was led by Sattva Neelapu of the MD Anderson Cancer Center and Frederick Locke of the H. Lee Moffitt Cancer Center and Research Institute.

The CAR-T cell treatment used in the study, is offered by Kite Pharma. Two other companies, Novartis and Juno Therapeutics, are also developing CAR-T Cell therapies.

Based on results of the study, the FDA approved a CAR-T treatment called xicabtagene ciloleucel or Yescarta. The study included 111 patients from 22 centers, including John Theurer Cancer Center. The patients had refractory large B-cell lymphoma -who failed chemotherapy- or patients who relapsed early after stem cell transplantation.

The basis of this new cell therapy is to harness the patient’s own T-cells, or white blood cells that are part of the immune system. T-cells are collected from the patient and sent to the manufacturing lab. There, the cells are genetically modified through introduction of a gene that instructs the cells to target and kill lymphoma cells. These genetically modified T-cells are then expanded in the lab before being infused back into the patient.

In the study, T-cells were successfully produced and expanded in 99 percent of patients. Eighty-four percent of patients responded, with 42 percent of all patients achieving a complete remission. More than half of all patients were alive as of 15.4 months.

Regarding toxicity, 95 percent of patients experienced at least one side effect that was severe. The most common adverse events of grade III or higher during treatment were neutropenia (in 78 percent of patients), anemia (in 43 percent), and thrombocytopenia (in 38 percent).

Grade III or higher cytokine release syndrome (released because of overstimulation of the immune system with CAR T-cells expanding) and neurologic events occurred in 13 percent and 28 percent of the patients, respectively. The use of low dose steroids and/or monoclonal antibody anti-IL6 receptor (to block one of the commonly found elevated cytokines IL6), tocilizumab, has dramatically helped manage toxicities.

Ongoing studies are looking at improving both toxicities and efficacy of CAR T-cell therapy using combinations particularly with checkpoint inhibitors.  

Hackensack Meridian Health – John Theurer Cancer Center at Hackensack University Medical Center is the only New Jersey center that participated in a pivotal clinical trial of a groundbreaking cancer treatment, CAR-T cell therapy, which genetically modifies a patient’s immune system to attack cancer cells.

André Goy, chairman and director, chief of lymphoma, and director of clinical and translational cancer research at John Theurer Cancer Center, is a co-author of the study, presented at the 59th Annual Meeting of the American Society of Hematology in the New England Journal of Medicine.


Cancer mortality in the U.S. continues decades-long drop

The cancer death rate dropped 1.7% from 2014 to 2015, continuing a decline that began in 1991 and has reached 26%, resulting in nearly 2.4 million fewer cancer deaths during that time.

The data is reported in Cancer Statistics 2018, the American Cancer Society’s comprehensive annual report on cancer incidence, mortality, and survival. It is published in CA: A Cancer Journal for Clinicians and is accompanied by its consumer version: Cancer Facts and Figures 2018.

The report estimates that there will be 1,735,350 new cancer cases and 609,640 cancer deaths in the United States in 2018. The cancer death rate dropped 26% from its peak of 215.1 per 100,000 population in 1991 to 158.6 per 100,000 in 2015. A significant proportion of the drop is due to steady reductions in smoking and advances in early detection and treatment.

The overall decline is driven by decreasing death rates for the four major cancer sites: Lung (declined 45% from 1990 to 2015 among men and 19% from 2002 to 2015 among women); female breast (down 39% from 1989 to 2015), prostate (down 52% from 1993 to 2015), and colorectal (down 52% from 1970 to 2015).

Over the past decade, the overall cancer incidence rate was stable in women and declined by about 2% per year in men.

The report also finds that while the racial gap in cancer mortality continues to narrow, this mainly reflects progress in older age groups, and masks stark persistent inequalities for young and middle-aged black Americans.

Among all ages combined, the cancer death rate in 2015 was 14% higher in non-Hispanic blacks than in non-Hispanic whites, down from a peak of 33% in 1993. However, while the gap narrowed to 7% in those 65 or older, likely in part due to universal health care access for seniors through Medicare, mortality rates were 31% higher in blacks than in whites under 65, with much larger disparities in many states.

While the new report also finds that death rates were not statistically significantly different between whites and blacks in 13 states, a lack of racial disparity is not always indicative of progress. For example, cancer death rates in Kentucky and West Virginia were not statistically different by race, but are the highest of all states for whites.

Other highlights:

  • The overall estimate of 1,735,350 cases for 2018 equals more than 4,700 new cancer diagnoses each day.

  • Prostate, lung, and colorectal cancers account for 42% of all cases in men, with prostate cancer alone accounting for almost one in five new diagnoses.

  • For women, the three most common cancers are breast, lung, and colorectal, which collectively represent one-half of all cases; breast cancer alone accounts for 30% all new cancer diagnoses in women.

  • The most common causes of cancer death are lung, prostate, and colorectal cancers in men and lung, breast, and colorectal cancers in women. These four cancers account for 45% of all cancer deaths, with one in four cancer deaths from lung cancer.

  • The lifetime probability of being diagnosed with cancer is slightly higher for men (39.7%) than for women (37.6%).  Adult height has been estimated to account for one-third of the difference.

  • Liver cancer incidence continues to increase rapidly in women, but appears to be plateauing in men. The long-term, rapid rise in melanoma incidence appears to be slowing, particularly among younger age groups. Incidence rates for thyroid cancer also may have begun to stabilize in recent years, particularly among whites, in the wake of changes in clinical practice guidelines.

  • The decline in cancer mortality, which is larger in men (32% since 1990) than in women (23% since 1991), translates to approximately 2,378,600 fewer cancer deaths (1,639,100 in men and 739,500 in women) than what would have occurred if peak rates had persisted.

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