Safeguarding Against the Rise in Throat Cancer

You're listening to the Phil Klein Dental Podcast Every single day, thousands of people in the United States succumb to preventable diseases. For this reason, more people are integrating preventative, functional medicine into their wellness routines and medical care. And more recently, wellness dentistry has also been gaining momentum, as more dentists are taking a whole-body approach to overall dental care. And being that the dentist is the healthcare professional seen most often, it can't be overstated how important it is for the dentist to perform regular oral cancer exams. We've all heard it many times. Early detection of cancer is critical for a favorable prognosis. In today's episode, we'll be specifically talking about the rise in throat cancer and the dentist's role in safeguarding patients against this insidious and potentially deadly disease. To tell us more about it and how it relates to our dental practices is our guest, Dr. Mohammad Kamal, founder and CEO of Omni Pathology Laboratory. Dr. Kamal completed his pathology training at Harbor UCLA Medical Center in California. Serving as a chief resident, he completed subspecialty fellowship training in gastrointestinal and liver pathology at UCLA. and he is board certified in anatomic pathology. Dr. Kamal has extensive experience in managing large national pathology laboratories, having served as medical director of LabCorp's Dianon Laboratory and as chief medical officer for PLUS Diagnostics. Dr. Kamal is going to be joining us in a second, but first, if you're looking to make teeth whitening a successful part of your practice, then you need a system that not only dramatically whitens teeth fast, but also ensures little to no sensitivity. Philips Zoom Whitespeed does both. Whitespeed's light-accelerated technology speeds up the whitening process, clinically proven to whiten up to eight shades in one visit. And what's really impressive is that 99% of patients surveyed experienced little to no sensitivity with Philips Zoom. Philips offers two professional whitening solutions, in-office whitening using Philips Zoom Whitespeed and take-home whitening. with a range of whitening gels for either daytime or nighttime use with custom trays. For a comprehensive, tried-and-true, state-of-the-art whitening solution for your practice, check out Philips Zoom Whitespeed. To learn more, visit philipsoralhealthcare.com. Dr. Kamal, thanks for joining us. Phil, thank you so much for having me on your program. I look forward to speaking with you and your audience. Yeah, so to begin, Dr. Kamal, let me ask you this as a medical doctor. Why do you think the dental professional should take an active role in throat cancer screening? In other words, how would you respond to a dentist who feels that the dental office is really not the right place to screen for throat cancer? Phil, when I thought about oropharyngeal or throat cancer, we noticed that this is a cancer caused by HPV. The vast majority of cases are HPV related. And as a pathologist dealing with different organ systems, I know there are a lot of similarities between throat cancer and cervical cancer, the cervical cancer in the GYN uterine cervix. Both cancers are squamous cell carcinomas. Both cancers are caused by HPV. And HPV is a sexually transmitted disease. In fact, HPV is the most common sexually transmitted disease in America. So because of the similarities you would expect that because today cervical cancer is declining, then throat cancer must also be declining. The surprise is it's not. Throat cancer cases are rising while cervical cancer is declining. The reason behind this is we have a well-defined surveillance program, guidelines to... Women doing periodical pap smears, getting tested for HPV and getting examined cytologically with those pap smear samples. When a patient is positive, there are well-defined guidelines on what to do with her. She gets a follow-up and she gets a colposcopy and she can get a biopsy on any suspicious lesion. And that is how the incidence of cervical cancer declined. in the United States and in the Western countries. So for us to look at this and to see how much similarities between the two, but one is going up and one is going down, made me think, okay, so what is it? Who's supposed to be testing those? So I thought that dentists and dental hygienists have unparalleled access to patients' throats. We are aware of... tests that are done on the oral cavity and they're done with rinse. When you do an oral rinse, of course, you're not getting near the oropharynx, the back of the mouth. So you have to do rinse and gargle. That is something that is done by the patient versus what we thought would be a more effective, maybe a better yield for the sample acquisition would be to swab the oropharynx, swab the back of the throat and get the sample from there. So before we get into the details of that, which I want to hear about, the dentist is saying, I'm not fully trained on this. And I may have had some pathology in dental school. And we do have pathology in dental school. For sure, we have pathology. Right. Some of the dentists feel uncomfortable being responsible for this in some ways. I'm not in that mindset. I agree with you 100%. The frequency of patients seeing the dentist far outreaches the general physician, especially when it comes to how many times they see a healthcare professional. And it is in the purview of a dentist, right? I mean, it's the... pharyngeal area is just a little bit posterior to where their teeth are. So how does a dentist recognize that there's a problem? What should they be looking for? What's the mindset they should have about throat cancer? Because it is on the rise. Yes. So number one, this is called oropharyngeal cancer. So oral is the mouth. So it is part of the mouth. Number two, Because we, today, in a regular dental exam, they palpate the neck. They look at the tongue. They look at the side and the back and underneath of the tongue. The palpation of the neck is because we want to see if there are any masses, including the positive lymph nodes that usually are the most common presentation of throat cancer. So we are already doing something to... look for throat cancer, because that's one of the things you do with the palpation of the neck during the dental exam. So we are already doing this. We're not trying to introduce something new. But again, because we feel that it is an opportunity for the patient to benefit from that encounter. So what is the most common presentation of throat cancer? And talk about this anatomically. Where would it most commonly be found? Excellent question. So the vast majority of oropharyngeal cancer arises on the tonsils and the base of the tongue, but mainly the tonsils. Anatomically, the tonsils have a unique topography because the tonsils have what they call tonsillar crypts, which are invaginations from the surface deep. Into that. And the purpose of having that, of course, is because there is a need to increase the surface area. So those invaginations give access to the HPV virus. And mainly we're talking about high risk and we're going to talk more about which type of HPV. is throat cancer. But those invaginases give access to the virus to reach the basal layer of the squamous epithelial lining, which where the cancer, these are the proliferating cells, and this is where cancer arises. The other thing about the tonsils that's unique is that also they have a transitional epithelium, which is epithelium changing from one type to another, very similar to what we see in the cervical canal. So let me ask you this. Has it been established that those that have had their tonsils removed? have a much less chance of developing oropharyngeal cancer from HPV? That is a fantastic question, Phil. As I was researching our work with oropharyngeal HPV, I came across articles around maybe 2015, 2016, where it is established that there is lower incidence of oropharyngeal cancer in patients that have their tonsils prophylactically removed as children. But then there are papers that came later in about 2019 and 2020. They basically said that they don't think that this is an ideal way to do that mass tonsillectomy for everybody to try to fight oropharyngeal cancer. So it's not a prophylactic regimen that is established as a protocol in the medical community. But here's the thing. None of these studies have looked at patients or tonsillectomy in patients that had positive HPV infection. So what I think the value, and I believe the future will lead us to this, is that, yes, it doesn't make any sense to do mass tonsillectomy, but I think it makes perfect sense to look at one piece of information here, which is HPV infection resolves on its own. And that happens in the throat and it happens in the cervical canal. But persistent HPV infection is linked to the development of cancer. Again, both in the cervix and in the throat. Therefore, I feel that if we start testing, first of all, you're never going to know who has persistent HPV infection without testing. So you need to start testing. And then those patients that are known to have persistent HPV infection, which will be a small. section of the community, those are the ones that probably a prophylactic tonsillactomy would make perfect sense. We're going to be getting right back to Dr. Kumal in a second. 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Now we're getting into the importance of testing, and that's very good that you brought up that point, Dr. Kamal, that almost the entire population has been exposed to some extent to HPV, and some immune systems handle it very well. Now, the ones that are persistent HPV, can you define that? Can you tell us what that means? It's a million dollar question because in my opinion, so first of all, they say that most HPV results within one to two years. Most of cases result. And a lot of patients, they can clear it and they get it back. And a lot of times also that getting it back is because of an event that results in reduced immunity. Could even be stress, a stressful event that results in reduced immunity and the patient get the HPV infection back. But by the way, nothing here is special to the throat. Whatever we talk about in the throat, exactly the same in the cervical canal. So we had this also an approach that we're talking about guidelines, right? So we don't have an existing guideline for follow-up. But a patient who's positive can be retested. And if they are positive, then they can maybe retest it in six, I'm talking six months to a year. Give them a chance to clear it. But if somebody is testing positive. three times over a year and a half or over two years, it is fair to consider that person to have a persistent HIV infection. Right. So now you're a CEO of a very successful laboratory and you have been in the laboratory business for a long time. So you have tremendous understanding and experience with this. What are you suggesting dentists to do in the office as part of their initial exam? One of the things that we have seen in our conversations with dentists over the past few months is that the conversation about personal behavior and sexual practices and things like that are really not something that is comfortably discussed in a dental office. What I suggest is because... that happens to me when I go to my dentist and my dental hygienist examines my neck and all that. So we basically explain to the patients that we are doing this and we are going to be screening for throat cancer, which is HPV related. And HPV is a sexually transmitted disease. And that should start the conversation. We think that, for example, we know that HPV is, there is a high risk of HPV when a patient has multiple sexual partners, oral and genitals, multiple partners can result in that. So we don't have to get into details, but we can basically explain to the patients if this high risk. behaviors can result in HPV infection. The other thing that can make a patient more susceptible to HPV is lower immunity. Somebody who had chemotherapy, somebody who's diabetic, somebody, even smokers. Smoking actually increases the risk for HPV infection in the throat. So the doctors need to get comfortable. The dentists need to get comfortable in having these kinds of conversations. And these do not happen overnight. It requires practice and requires multiple attempts and discussions within the office and then with the patients. Then you offer the patient the test and you explain to them that this is a swab, just like the COVID swab. It's a swab. We're going to go in and swab and we're going to send it to the doctor. Now, the reason we're doing that is because if you have HPV, there's nothing that we can see. If you open your throat and you have HPV, your throat would look exactly like another person who doesn't. Having HPV does not mean that you have cancer. Having HPV is done so that we can follow up and make sure that you don't develop cancer. Why do we have to have the discussion? Why can't we just seat the patient down? It's a new patient. We're onboarding that patient into the practice. We're doing the head neck exam. We're doing the cancer screening. And part of our cancer screening is an HPV test, which is very important because it's highly linked. towards oral pharyngeal squamous cell carcinoma. If I was a patient, I would say, go ahead, do it. Why can't we just completely avoid the discussion with the patient about high-risk sexual activity? It's reasonable. And I can tell you that probably conversations, like I had one of my colleagues, a dentist, who told me that one time, you know, HPV came up with an older lady and she was like upset and offended and things like that. So people, when they are positive, they will know. You have to tell them that you're positive, therefore we do this, this, this. So they need to basically consent to the test. And what you're saying is reasonable because this is really something that as a healthcare provider, you're determining that this is part of my screening. I'm offering this to my patients because I want to screen for X, Y, and Z. So it is reasonable to do that, but a little bit of communication so that the patient is informed about it and not surprised when they hear the positive result. Out of our patient population, is there a specific group that needs to be screened for throat cancer? In my opinion, anybody who's sexually active needs to be tested. That is my opinion. And again, we're saying this because there are no existing guidelines. That doesn't mean we should sit and wait for those guidelines to descend upon us, right? We want to be proactive as healthcare provider. We're dealing with a cancer that is rising. We're not just, you know, coming up with something that is not a problem. This is a problem. It's rising and it continues to rise. Yeah. And as you said in the front end of this podcast, the reason why it's rising is because it's really not being attended to as the other forms of cancer. in this category. Exactly. And in one of my conversations with the dentist, she was mentioning, I gave a lecture at the California Dental Association last May about the test. And part of that presentation was, and that presentation actually is on my YouTube channel, is resistance to testing. Different things that we hear from dentists resisting the testing. And I said to her, again, what we're doing. is at least we're doing something. There are no other alternatives. Nobody's coming out and saying, oh, let's do this instead. What would be an effective tool to screen for throat cancer? The HPV test, oropharyngeal HP test with the swab of the oropharynx, and it is being tested for PCR. And what I think would happen with that positive result is a follow -up. And if the patient is determined to be... positive, then that patient can be referred to an ENT doctor. The ENT doctor can go in and do a scope. And with that scoping, you may be able to identify precursor lesions. So this would be a great way to get ahead of it, early detection, if that's the right term. Yes. Yeah. Where could our listeners get more information, Dr. Kamal, about this technique of screening for HPV? Yes. So if someone is interested, they can go on omnipathology.com and right there they will find a page for patients, educating patients about. oropharyngeal HPV, throat HPV, and a page for healthcare providers. And in that page, you see videos, educational videos, you see the swabbing. We have a video on how to swab. So also patients can see that, you know, what will happen when we swab them. And then we have a way to order kits. Click a button and you reach out to us. We send you kits, the kits with instructions of everything. that let you do the test, and then you send it to us, and within 24 hours, you have a result. So in your opinion, Dr. Kamal, you think there could be a dramatic shift in the rise in throat cancer with more testing from dental professionals? I believe that there will be a day where people will say that throat cancer was rising until people started testing for oropharyngeal HPV. Right. Specifically, in this case, dentists. That's who our audience is on this podcast. And dentists, yeah, dentists is the right place for it. Thank you very much, Dr. Kamal. We look forward to having you on a future podcast on this topic. Thank you so much. Thank you, Phil. If you've been enjoying our podcast, we'd love to hear your thoughts and feedback by leaving a review on your favorite podcast platform, whether it's Spotify, Apple, Google, or any other platform you listen on. Leaving a review is a fantastic way to support us and help others discover our show. Thanks for listening. See you next time.