Advanced Reconstructive Surgery for Head and Neck Cancer

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:04Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:09with the director of the
00:09 --> 00:10Yale Cancer Center, doctor Eric
00:10 --> 00:11Winer.
00:11 --> 00:13Yale Cancer Answers features
00:13 --> 00:16conversations with oncologists and specialists
00:16 --> 00:16who are on the forefront
00:16 --> 00:18of the battle to fight
00:18 --> 00:18cancer.
00:19 --> 00:20This week, it's a conversation
00:20 --> 00:21about head and neck cancers
00:21 --> 00:23with doctor Saral Mehra. Doctor
00:23 --> 00:25Mehra is an associate professor
00:25 --> 00:26of surgery and otolaryngology
00:27 --> 00:28at the Yale School of
00:28 --> 00:28Medicine.
00:29 --> 00:30Here's doctor Winer.
00:32 --> 00:34How is it that
00:34 --> 00:36someone becomes interested
00:37 --> 00:39in the field of ear,
00:39 --> 00:40nose, and throat?
00:41 --> 00:43And then more specifically,
00:44 --> 00:45how is it that you
00:45 --> 00:46got interested
00:47 --> 00:49in cancers that arise in
00:49 --> 00:51this region that is the
00:51 --> 00:52head and neck?
00:53 --> 00:54So when I was
00:54 --> 00:55in medical school in New
00:55 --> 00:56York City,
00:57 --> 00:58I didn't know what
00:58 --> 00:59ENT was barely. I thought
00:59 --> 01:01maybe they'd take some tonsils
01:01 --> 01:02out, put some ear tubes
01:02 --> 01:03in, but it had a
01:03 --> 01:04mandatory rotation.
01:05 --> 01:06And what I loved about
01:06 --> 01:06ENT,
01:08 --> 01:09right off the bat, was
01:10 --> 01:11I realized that they did
01:11 --> 01:12surgeries that
01:13 --> 01:14I did not imagine an
01:14 --> 01:17ENT surgeon, in my idea
01:17 --> 01:18of one, would do, but
01:18 --> 01:20more importantly, the culture
01:20 --> 01:22of ENT surgeons and otolaryngologist
01:22 --> 01:24just fit with me.
01:24 --> 01:25They worked hard,
01:26 --> 01:28did some really delicate fine
01:28 --> 01:29work, and had a
01:29 --> 01:30good time doing it. And
01:30 --> 01:32I thought this is the
01:32 --> 01:33type of culture and specialty
01:33 --> 01:34I wanna be in.
01:36 --> 01:37That's great.
01:37 --> 01:38And it's
01:38 --> 01:39an area where
01:40 --> 01:42the anatomy is really complicated.
01:42 --> 01:43I mean, there are all
01:43 --> 01:43these structures in
01:45 --> 01:47our nose, mouth, throat,
01:48 --> 01:50that just are all
01:51 --> 01:52very close to one another
01:52 --> 01:54and yet serve very different
01:54 --> 01:54functions.
01:55 --> 01:57Totally agree. And that's really
01:57 --> 01:58what I enjoyed about it too.
01:58 --> 01:59Working in the nose,
01:59 --> 02:00you're right next to the
02:00 --> 02:02eye and the brain.
02:02 --> 02:03You're working in the neck,
02:03 --> 02:05you're near important cranial nerves
02:05 --> 02:06that move the tongue
02:06 --> 02:07that
02:07 --> 02:09help with speech and breathing.
02:10 --> 02:12It's just really intricate fine
02:12 --> 02:14anatomy and requires a lot
02:14 --> 02:15of attention to detail, which,
02:15 --> 02:17again, I thought really fit
02:17 --> 02:18well with my personality.
02:19 --> 02:21And when you made the
02:21 --> 02:21decision to
02:23 --> 02:25apply to residency programs in ENT
02:27 --> 02:28ear, nose, and throat,
02:28 --> 02:29did you know at that
02:29 --> 02:30time that you were interested
02:30 --> 02:31in cancer?
02:32 --> 02:33Definitely not.
02:34 --> 02:36In fact, it was almost
02:36 --> 02:37on my short list of
02:37 --> 02:40subspecialties within ENT I would
02:40 --> 02:41probably not do.
02:41 --> 02:43There were long, complicated
02:43 --> 02:44surgeries,
02:44 --> 02:46difficult patients, challenging,
02:48 --> 02:49social issues,
02:50 --> 02:52in addition to a disease
02:52 --> 02:53that
02:54 --> 02:56can be devastating to many
02:56 --> 02:56patients.
02:58 --> 03:00But during my journey in residency I
03:01 --> 03:03saw head and neck cancer
03:04 --> 03:06done as a team and
03:06 --> 03:06done right.
03:07 --> 03:09And once I saw
03:09 --> 03:10the team approach to head
03:10 --> 03:11and neck cancer care,
03:12 --> 03:13that's when I realized this
03:13 --> 03:15was definitely the specialty
03:15 --> 03:17for me.
03:19 --> 03:20I played a
03:20 --> 03:22lot of sports growing up,
03:22 --> 03:23and I was
03:23 --> 03:24a key member of
03:24 --> 03:25a lot of different teams.
03:25 --> 03:26I was a range guy,
03:26 --> 03:27and that's what head neck
03:27 --> 03:28cancer is. It's a
03:28 --> 03:29team sport.
03:32 --> 03:34People are very familiar with
03:34 --> 03:36breast cancer and colon cancer
03:36 --> 03:39and even pancreatic cancer and,
03:39 --> 03:41you know, tumors like glioblastomas
03:42 --> 03:43because some very famous people
03:43 --> 03:44have had them and
03:45 --> 03:46are in the news.
03:47 --> 03:48People know a little bit
03:48 --> 03:49less
03:49 --> 03:51about head and neck cancers.
03:51 --> 03:52I think that's
03:53 --> 03:53partially
03:54 --> 03:55in the past,
03:56 --> 03:58because maybe there were fewer
03:58 --> 03:59famous people who had them.
04:00 --> 04:02And, also, because
04:02 --> 04:03it's an area
04:03 --> 04:04where
04:04 --> 04:06there are many different types
04:06 --> 04:07of cancers.
04:08 --> 04:09Can you just talk a
04:09 --> 04:11little bit about about, you
04:11 --> 04:13know, all the different cancers
04:13 --> 04:13that exist?
04:14 --> 04:15Yeah. It's strange,
04:16 --> 04:17in a number of ways,
04:19 --> 04:20as related to other cancers.
04:20 --> 04:22It's definitely not one of
04:22 --> 04:23the big four,
04:23 --> 04:24however you
04:24 --> 04:26wanna classify them. Head and
04:26 --> 04:27neck cancers make up about
04:27 --> 04:29four percent of all cancers,
04:30 --> 04:31in the United States.
04:32 --> 04:34There's about sixty six thousand
04:34 --> 04:36new cases diagnosed each year.
04:36 --> 04:36And you think about it,
04:36 --> 04:38that's actually a pretty small
04:38 --> 04:39number when you compare it
04:40 --> 04:41to breast and prostate,
04:41 --> 04:42the colon, the big ones
04:42 --> 04:43that you mentioned. So it's
04:43 --> 04:45relatively rare, and those are
04:45 --> 04:46the numbers. And not only
04:46 --> 04:47that, it's sort of,
04:48 --> 04:49as you pointed out, it's
04:49 --> 04:50a weird term, head and
04:50 --> 04:51neck cancers.
04:52 --> 04:54Really it comprises cancers
04:54 --> 04:55in the mouth,
04:56 --> 04:57the throat,
04:59 --> 05:00the nose,
05:00 --> 05:02the salivary glands,
05:02 --> 05:04and then in the neck,
05:04 --> 05:05like thyroid
05:05 --> 05:07or skin cancer. So it's
05:07 --> 05:08this whole
05:08 --> 05:10milieu of different types of
05:10 --> 05:12cancers. We'll have carcinomas. We'll
05:12 --> 05:14have sarcomas. We have even
05:14 --> 05:16diagnosed lymphomas in the head
05:16 --> 05:17and neck. So it is
05:17 --> 05:18a huge variety of cancers
05:18 --> 05:20that show up in this
05:20 --> 05:21part of the body.
05:25 --> 05:26And of the
05:27 --> 05:29sixty plus thousand people who
05:29 --> 05:31develop head and neck cancers,
05:32 --> 05:34we've made progress, but how
05:34 --> 05:35many people are still dying
05:35 --> 05:36from these cancers?
05:36 --> 05:37Yeah. Unfortunately,
05:38 --> 05:38it depends,
05:40 --> 05:40or fortunately,
05:41 --> 05:42when you catch the cancer.
05:42 --> 05:44For advanced stage head and
05:44 --> 05:45neck cancers, meaning cancers that
05:45 --> 05:47have spread beyond just the
05:47 --> 05:48primary site,
05:49 --> 05:50survival rates are still, unfortunately,
05:51 --> 05:52around fifty percent at five
05:52 --> 05:53years.
05:55 --> 05:56You can look at it
05:56 --> 05:57two ways. We can cure
05:57 --> 05:58for long term half of
05:58 --> 06:00the patients with stage three
06:00 --> 06:02and stage four cancer, which
06:02 --> 06:04is great, but it's also
06:05 --> 06:06we can't cure about
06:06 --> 06:08half of them. Now early
06:08 --> 06:09stage cancer is one that
06:09 --> 06:10when caught caught early, we
06:10 --> 06:10can cure
06:12 --> 06:14eighty, ninety percent plus of
06:14 --> 06:15those patients. So it really
06:15 --> 06:17counts. Cancers that haven't spread
06:17 --> 06:19to lymph nodes, they're localized
06:20 --> 06:21in a given organ,
06:21 --> 06:22like
06:22 --> 06:24in the tonsil or on
06:24 --> 06:26the tongue.
06:27 --> 06:28Yeah.
06:28 --> 06:29And,
06:30 --> 06:31talk a little bit about
06:31 --> 06:32the risk factors for head
06:32 --> 06:34and neck cancers because
06:34 --> 06:35there is
06:36 --> 06:38quite a spectrum there,
06:38 --> 06:40and not everyone is at
06:40 --> 06:41equal risk. There are some
06:41 --> 06:43people who are dramatically higher
06:43 --> 06:43risk.
06:44 --> 06:45Absolutely. The
06:46 --> 06:47big three risk factors that
06:47 --> 06:48we talk about in head
06:48 --> 06:50and neck cancer are the
06:50 --> 06:51ones that your listeners might
06:51 --> 06:53be well aware of, tobacco
06:53 --> 06:54and alcohol. That's all
06:54 --> 06:55the cancers, you know, not
06:55 --> 06:57all, but many cancers.
06:58 --> 07:00And they synergize, correct?
07:00 --> 07:03Yeah. Totally. Tobacco is a
07:03 --> 07:04biggest risk factor. Alcohol is
07:04 --> 07:05a risk factor. But as
07:05 --> 07:06you point out, they synergize.
07:06 --> 07:08When you combine the two,
07:08 --> 07:09the risk factor doesn't just
07:09 --> 07:11double. It goes up
07:11 --> 07:13significantly more than just double,
07:13 --> 07:14probably ten times.
07:15 --> 07:15So those are the two
07:15 --> 07:16big ones that we talk
07:16 --> 07:18about. But the third big
07:18 --> 07:19one that we don't talk
07:19 --> 07:20about as much is the
07:20 --> 07:21HPV virus.
07:23 --> 07:24And how long have we
07:24 --> 07:26appreciated that?
07:26 --> 07:27When I was a
07:27 --> 07:28medical student
07:28 --> 07:30quite a number of years
07:30 --> 07:30ago,
07:30 --> 07:32we didn't really know about
07:32 --> 07:32HPV
07:33 --> 07:34and head and neck
07:34 --> 07:35cancers.
07:37 --> 07:38I mean,
07:38 --> 07:39in our field,
07:39 --> 07:42the HPV associated neck cancers
07:42 --> 07:43is almost a new disease.
07:43 --> 07:44We're talking
07:44 --> 07:46really identifying it and thinking
07:46 --> 07:47about it maybe only in
07:47 --> 07:48the last
07:48 --> 07:50twenty to thirty years.
07:50 --> 07:52And for a new disease,
07:52 --> 07:53that is a very short
07:53 --> 07:54amount of time in the
07:54 --> 07:55grand scheme of things.
07:56 --> 07:57And this is the one
07:57 --> 07:58head neck cancer that is
07:58 --> 08:00on the rise. All of
08:00 --> 08:02our smoking, drinking related cancers,
08:02 --> 08:03the mouth cancers are
08:04 --> 08:04decreasing
08:05 --> 08:07but HPV associated head
08:07 --> 08:08and neck cancers are really
08:08 --> 08:09on the rise. We're talking
08:09 --> 08:10probably more than a two
08:10 --> 08:12hundred percent increase in the
08:12 --> 08:13last twenty years.
08:13 --> 08:15And is that because
08:15 --> 08:16there's more
08:17 --> 08:17HPV?
08:19 --> 08:20That's a great question.
08:20 --> 08:21I wish I had a great
08:21 --> 08:22answer for you of exactly
08:22 --> 08:24why it's on the rise.
08:24 --> 08:24You know, it may be
08:24 --> 08:25related
08:25 --> 08:28to certain behaviors, or it
08:28 --> 08:28may be,
08:29 --> 08:30just related to
08:32 --> 08:33something in the environment that's
08:33 --> 08:35impacting the ability to
08:35 --> 08:36clear the HPV. The HPV
08:36 --> 08:37virus has been here
08:38 --> 08:40forever. Most people are exposed
08:40 --> 08:41to it at some point
08:41 --> 08:41in their life.
08:42 --> 08:43The vast majority of people
08:44 --> 08:45may be exposed to it,
08:45 --> 08:46but clear it. It's this
08:46 --> 08:48small percentage of maybe two
08:48 --> 08:49to five percent of people
08:50 --> 08:51who don't clear the HPV
08:51 --> 08:53virus. And within that, there's
08:53 --> 08:54a very small percentage of
08:54 --> 08:55people who go on and
08:55 --> 08:56develop a cancer in the
08:56 --> 08:58throat from the HPV virus.
08:58 --> 09:00And this is, in
09:00 --> 09:01theory,
09:02 --> 09:03a set of cancers that
09:03 --> 09:05could be prevented with vaccination.
09:06 --> 09:08Absolutely. We have the HPV
09:08 --> 09:09vaccine, it's been around
09:11 --> 09:13and been used for girls
09:13 --> 09:15and women for years, but
09:15 --> 09:16now we think of
09:16 --> 09:17it as prevention for cervical
09:17 --> 09:19cancer predominantly, but it
09:19 --> 09:21also prevents these head and
09:21 --> 09:21neck cancers.
09:22 --> 09:23Absolutely. And in fact, head
09:23 --> 09:24and neck cancers have now,
09:24 --> 09:25as of about two years
09:25 --> 09:27ago, surpassed cervical cancer as
09:27 --> 09:29the most common HPV associated
09:29 --> 09:31cancer in this country. And
09:31 --> 09:32we think that's probably due
09:32 --> 09:34to screening for cervical cancer
09:34 --> 09:36and probably related in some
09:36 --> 09:37ways to the vaccine as
09:37 --> 09:37well.
09:38 --> 09:38Wow.
09:39 --> 09:41And these HPV cancers,
09:42 --> 09:44or HPV associated cancers,
09:45 --> 09:46do they typically arise in
09:46 --> 09:48any particular
09:48 --> 09:50part of the head and
09:50 --> 09:50neck anatomy?
09:51 --> 09:53Definitely. Almost all of them
09:53 --> 09:54I say almost all, not
09:54 --> 09:55all, but almost all of
09:55 --> 09:57them are what we call
09:57 --> 09:58back of throat cancer to the layman
10:00 --> 10:02and laywoman. But it's basically
10:02 --> 10:02the tonsils
10:03 --> 10:04and the base of the
10:04 --> 10:04tongue,
10:05 --> 10:06sometimes a soft palate and
10:06 --> 10:07the back of the throat.
10:07 --> 10:08But back of throat cancer, it's
10:10 --> 10:11not mouth cancer per se.
10:11 --> 10:12It's back of throat cancer.
10:13 --> 10:15And so if you see
10:15 --> 10:16someone who,
10:16 --> 10:17for example,
10:18 --> 10:20doesn't have a significant smoking
10:20 --> 10:22and drinking history, they're fifty
10:22 --> 10:24years old and they have
10:25 --> 10:25a cancer
10:26 --> 10:27that is in the back
10:27 --> 10:28of the throat,
10:28 --> 10:30how likely is it that
10:30 --> 10:32that's an HPV associated cancer?
10:32 --> 10:34The short answer is very
10:34 --> 10:34likely.
10:35 --> 10:36Back of throat cancers now
10:36 --> 10:38make up about seventy percent
10:38 --> 10:41of all tonsil and base
10:41 --> 10:42of tongue cancers, and that's
10:42 --> 10:43on the rise.
10:47 --> 10:48And my understanding is the
10:48 --> 10:50treatment differs a little bit
10:50 --> 10:50too for these cancers.
10:51 --> 10:53We're still fleshing that out
10:53 --> 10:55exactly, but, yes, the short
10:55 --> 10:56answer is they do
10:56 --> 10:57differ. And the reason is
10:57 --> 10:59because the prognosis of these
10:59 --> 11:01cancers is so much better
11:02 --> 11:03than the non-HPV associated
11:03 --> 11:05cancers in the exact same
11:05 --> 11:05area.
11:06 --> 11:07And so what we're working
11:07 --> 11:09on now throughout the country
11:09 --> 11:11is on the de intensification of
11:13 --> 11:14treatment. If we have a
11:14 --> 11:15cancer with
11:15 --> 11:17a eighty, ninety percent cure
11:17 --> 11:17rate,
11:18 --> 11:19do we need to
11:20 --> 11:21operate on them plus give
11:21 --> 11:23them radiation, plus give them
11:23 --> 11:24chemotherapy? And the answer to
11:24 --> 11:26that is no.
11:26 --> 11:27And that's what we're trying
11:27 --> 11:28to figure out. How can
11:28 --> 11:29we give less treatment
11:30 --> 11:30without
11:32 --> 11:33compromising cure rates?
11:34 --> 11:35And, you know, we'll
11:35 --> 11:36talk more about this in
11:36 --> 11:38in the second half of
11:38 --> 11:40our interview. But,
11:40 --> 11:41of course,
11:41 --> 11:43oftentimes, people are afraid of
11:43 --> 11:45backing off on treatment.
11:46 --> 11:48But here, the consequences of
11:48 --> 11:49treatment are often
11:50 --> 11:53significant enough and severe enough
11:53 --> 11:53that
11:54 --> 11:55the whole reason to do
11:55 --> 11:57this is, of course,
11:57 --> 11:58to give people
11:59 --> 12:00an equally long life and
12:00 --> 12:02a better quality of life.
12:02 --> 12:04Absolutely. And this comes back
12:04 --> 12:05to one of my reasons
12:05 --> 12:06for going into ENT. It's
12:06 --> 12:07a lot of this
12:07 --> 12:09is about quality of life,
12:10 --> 12:11and treatment
12:11 --> 12:12for back of throat cancers
12:12 --> 12:14can impact a lot of
12:14 --> 12:16aspects of quality of life,
12:16 --> 12:17most importantly, swallowing,
12:18 --> 12:19but also speech,
12:21 --> 12:21breathing,
12:22 --> 12:22appearance,
12:23 --> 12:25a lot of consequences to
12:25 --> 12:25treatment.
12:29 --> 12:30Years ago,
12:31 --> 12:32one would see people who
12:32 --> 12:33had been treated for head
12:33 --> 12:35and neck cancers, and oftentimes,
12:36 --> 12:38they really couldn't speak.
12:39 --> 12:39And,
12:40 --> 12:41of course, difficulty with swallowing
12:41 --> 12:42is still something
12:42 --> 12:43that people have.
12:44 --> 12:45But the treatment
12:46 --> 12:47for this particular
12:48 --> 12:49type of cancer,
12:50 --> 12:51at times,
12:54 --> 12:55is maybe not worse than
12:55 --> 12:56the cancer, but it's pretty bad.
12:56 --> 12:58Yeah. At times, definitely,
12:58 --> 12:59patients are probably saying that
12:59 --> 13:00in the middle or towards
13:00 --> 13:01the end of radiation, if
13:01 --> 13:02they're getting chemo,
13:03 --> 13:05you're absolutely right. They're definitely
13:05 --> 13:06saying that.
13:06 --> 13:07And we'll talk more
13:07 --> 13:08about that when
13:08 --> 13:09we talk about,
13:09 --> 13:11sort of the multidisciplinary
13:12 --> 13:13nature of the work.
13:17 --> 13:18So I think that at
13:18 --> 13:20this point, maybe we should
13:20 --> 13:21take a little break, and
13:21 --> 13:22we'll be back.
13:23 --> 13:25We'll pick up with our
13:25 --> 13:27guest, doctor Saral Mehra, associate
13:27 --> 13:29professor of surgery at
13:30 --> 13:31Yale School of Medicine,
13:33 --> 13:34and chief of head and
13:34 --> 13:35neck surgery.
13:35 --> 13:36And we'll be talking more
13:36 --> 13:37about this, I think, very
13:39 --> 13:39interesting
13:40 --> 13:41topic of head and neck
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14:53 --> 14:54You're listening to Connecticut Public
14:54 --> 14:55Radio.
14:57 --> 14:58This is Eric Winer again
14:58 --> 15:00here with Yale Cancer Answers.
15:01 --> 15:03And I'm speaking with my
15:03 --> 15:05guest, doctor Saral Mehra, who
15:05 --> 15:06is an expert in
15:07 --> 15:08the treatment of head and
15:08 --> 15:09neck cancers,
15:10 --> 15:12and specifically in the surgical
15:12 --> 15:14aspects of that treatment. But
15:14 --> 15:16as a surgeon, you have
15:16 --> 15:17to know a lot more
15:17 --> 15:18than just the surgery
15:19 --> 15:21because this is a type
15:21 --> 15:21of cancer
15:22 --> 15:24where you are dependent upon
15:24 --> 15:26your colleagues in other disciplines.
15:27 --> 15:29And maybe we can start
15:29 --> 15:30off talking about that.
15:31 --> 15:32Who else do you interact
15:32 --> 15:33with? When a patient comes
15:33 --> 15:34to see you
15:35 --> 15:36and says, you know,
15:37 --> 15:38doctor Mehra, can
15:38 --> 15:40you take care of me?
15:40 --> 15:42Your first answer is
15:42 --> 15:43probably, well, I can take
15:43 --> 15:43care of you, but I
15:43 --> 15:44need the rest of my
15:44 --> 15:45team.
15:46 --> 15:48Absolutely. And this comes back
15:48 --> 15:48to what we were talking
15:48 --> 15:50about earlier. The reason I
15:50 --> 15:51got in to head and
15:51 --> 15:52neck cancer is it really
15:52 --> 15:54is a team sport.
15:55 --> 15:56I think the team I
15:56 --> 15:56like to break it down
15:56 --> 15:58into a few different
15:58 --> 15:59groups.
15:59 --> 16:01Basically, you have your doctors,
16:01 --> 16:03which are one part of
16:03 --> 16:04your team, and that's a
16:04 --> 16:06surgical oncologist, which is what
16:06 --> 16:07I do. But you absolutely
16:07 --> 16:09need a medical oncologist
16:10 --> 16:11and a radiation
16:11 --> 16:12oncologist.
16:12 --> 16:14Now medical oncologists are responsible
16:14 --> 16:16for talking with patients about
16:16 --> 16:17the disease, the
16:18 --> 16:18the process,
16:19 --> 16:21and they administer chemotherapy and
16:21 --> 16:22immunotherapy
16:22 --> 16:23when it's given and help
16:23 --> 16:24manage a lot of the
16:24 --> 16:27medical aspects of care. They
16:27 --> 16:27also get
16:28 --> 16:29extremely involved
16:29 --> 16:32when the cancer may spread
16:32 --> 16:33beyond the head and neck
16:33 --> 16:34and into other parts of
16:34 --> 16:36the body. That's when surgeons
16:36 --> 16:38and radiation oncologists are not
16:38 --> 16:40the answer. And our colleagues
16:40 --> 16:42in medical oncology, that's when
16:42 --> 16:43they really step up.
16:44 --> 16:45And then radiation oncologists, we
16:45 --> 16:47work hand in hand with
16:47 --> 16:48radiation doctors
16:49 --> 16:51to identify and personalize the
16:51 --> 16:53treatment for patients. Like I
16:53 --> 16:54was saying before, we wanna
16:54 --> 16:56minimize the amount of treatment
16:56 --> 16:57we give these patients, specifically
16:57 --> 17:00HPV associated cancers, and that's
17:00 --> 17:01where we'd all three of
17:01 --> 17:02us have to talk about
17:02 --> 17:04the optimal treatment for the
17:04 --> 17:05patient in front of us.
17:05 --> 17:06And sometimes,
17:07 --> 17:09particularly with surgery and radiation
17:09 --> 17:11oncology, there's a trade off
17:11 --> 17:13in terms of more surgery,
17:13 --> 17:16less radiation, more radiation, less
17:16 --> 17:17surgery.
17:17 --> 17:19Absolutely.
17:19 --> 17:21We have shifting
17:21 --> 17:21paradigms
17:22 --> 17:23in this, and new information's
17:23 --> 17:24coming out all the time.
17:26 --> 17:28But there's a recent trial that
17:28 --> 17:29showed that if we can
17:29 --> 17:31operate, remove all the cancer
17:31 --> 17:33for a oropharynx or tonsillar
17:33 --> 17:34based at tongue cancer,
17:34 --> 17:36we can actually lower the
17:36 --> 17:38dose of radiation by more
17:38 --> 17:39than ten
17:39 --> 17:41percent, almost twenty percent, and
17:41 --> 17:43get the exact same cancer
17:43 --> 17:43outcomes
17:44 --> 17:45with a better quality of
17:45 --> 17:46life. So these are the
17:46 --> 17:47boundaries
17:47 --> 17:48we're pushing in the field.
17:49 --> 17:50And, you know, ten or
17:50 --> 17:51twenty percent may not sound
17:51 --> 17:53like that much to people
17:53 --> 17:53listening,
17:54 --> 17:54but
17:55 --> 17:56the side effects
17:56 --> 17:57increase,
17:58 --> 18:00not in a linear
18:00 --> 18:01fashion as you increase the
18:01 --> 18:02dose of radiation.
18:03 --> 18:04So
18:04 --> 18:06that by eliminating
18:06 --> 18:07twenty percent of the dose,
18:07 --> 18:08you may eliminate
18:09 --> 18:10fifty percent or eighty percent
18:10 --> 18:11of the side effects.
18:12 --> 18:13That's what we're
18:13 --> 18:15trying trying to do. Any
18:15 --> 18:16major cancer center in the
18:16 --> 18:17country who sees a lot
18:17 --> 18:17of this
18:18 --> 18:19is exactly
18:19 --> 18:20doing that. So you have
18:20 --> 18:22the doctors and probably
18:22 --> 18:24worth mentioning that in addition
18:24 --> 18:25to the surgical oncologist and
18:25 --> 18:27radiation oncologist and medical oncologist,
18:27 --> 18:29you know, supporting all of
18:29 --> 18:30us are the pathologists
18:31 --> 18:31and the
18:32 --> 18:32radiologists
18:33 --> 18:34who we can't really live
18:34 --> 18:35without.
18:35 --> 18:37But then you have
18:37 --> 18:38all the other people.
18:39 --> 18:41And who else do you
18:41 --> 18:42rely on? Because,
18:42 --> 18:43you know,
18:44 --> 18:45patients may
18:45 --> 18:47come to a center because
18:47 --> 18:48they have a doctor's name.
18:49 --> 18:49But in the
18:50 --> 18:51end, a lot of the
18:52 --> 18:53care they receive is
18:56 --> 18:57as a result of all
18:57 --> 18:59the efforts that non
18:59 --> 19:01doctors put into the care
19:01 --> 19:02of patients.
19:03 --> 19:05Definitely. I think this cancer
19:05 --> 19:06may be more than others.
19:06 --> 19:07I'm a little biased. It
19:07 --> 19:09requires a lot of therapists.
19:09 --> 19:11We're talking
19:11 --> 19:12speech,
19:12 --> 19:14language, and swallow therapists. We're
19:14 --> 19:15talking lymphedema
19:16 --> 19:17physical therapists.
19:18 --> 19:19We're talking
19:19 --> 19:19about
19:21 --> 19:23social workers and mental therapists.
19:23 --> 19:24Some
19:24 --> 19:26not talked about often, but
19:26 --> 19:27head and neck cancer
19:28 --> 19:29patients who've recovered from that
19:29 --> 19:30actually have some of the
19:30 --> 19:32highest rates of depression
19:32 --> 19:33following treatment.
19:34 --> 19:35And
19:35 --> 19:37we need psychiatrists, psychologists
19:38 --> 19:39in the survivorship aspect of
19:39 --> 19:41this. So really a lot
19:41 --> 19:42of key
19:42 --> 19:44we call them ancillary, but
19:44 --> 19:46really they're absolutely critical to
19:46 --> 19:47the quality of life and
19:47 --> 19:47rehabilitation
19:48 --> 19:49of patients.
19:49 --> 19:50And then there are the
19:50 --> 19:52nurses, of course, who are,
19:52 --> 19:53you know, front and center
19:53 --> 19:54in that group.
19:54 --> 19:56Absolutely. We're dealing with tracheotomy
19:57 --> 19:59tubes sometimes, feeding tubes. And
19:59 --> 20:00when there's a problem, who
20:00 --> 20:01do I call?
20:02 --> 20:04The nurses to help manage
20:04 --> 20:04them,
20:04 --> 20:06counsel patients, teach patients.
20:08 --> 20:10And
20:10 --> 20:12it's oftentimes a hard course
20:12 --> 20:13of treatment to go through
20:13 --> 20:13getting
20:14 --> 20:15chemotherapy
20:16 --> 20:17and maybe radiation
20:18 --> 20:19and surgery in
20:20 --> 20:21varying orders.
20:25 --> 20:26And oftentimes, you have to take
20:26 --> 20:28special steps to make sure
20:28 --> 20:28that people are gonna get
20:28 --> 20:29through this. So you have
20:29 --> 20:31to worry about how people
20:31 --> 20:32are gonna nourish themselves,
20:34 --> 20:34and
20:34 --> 20:36how they're gonna remain hydrated
20:36 --> 20:38if they're having trouble swallowing.
20:38 --> 20:40So these are the things
20:40 --> 20:41you consider as well, I'd assume.
20:43 --> 20:44Absolutely. And I think not
20:44 --> 20:46only are they getting through
20:46 --> 20:47a lot of different types
20:47 --> 20:48of treatment, it's in a
20:48 --> 20:50relatively short amount of time.
20:51 --> 20:53Ideally, in an ideal world,
20:53 --> 20:54if we're gonna operate and
20:54 --> 20:56give radiation or chemo,
20:57 --> 20:58we like to get that
20:58 --> 21:00radiation chemo started within about
21:00 --> 21:01six weeks
21:01 --> 21:03of recovering from what's often
21:03 --> 21:04a major
21:04 --> 21:06surgery. And that's different than
21:06 --> 21:07other cancers where you can
21:07 --> 21:08you have a little bit
21:08 --> 21:09more time to start the
21:09 --> 21:11chemo or the immunotherapy or
21:11 --> 21:13the systemic therapy or the
21:13 --> 21:13radiation.
21:15 --> 21:16And so a big part
21:16 --> 21:17of that is getting them
21:17 --> 21:17through it,
21:18 --> 21:19having them not give up,
21:20 --> 21:21making sure they're
21:23 --> 21:25taking enough nutrition,
21:26 --> 21:28and optimizing their swallowing function
21:28 --> 21:29in the end.
21:29 --> 21:30A lot of things to think about
21:30 --> 21:31during treatment.
21:31 --> 21:32So how do you talk
21:32 --> 21:35to patients about doing less?
21:36 --> 21:37You know, there are a
21:37 --> 21:39lot of people who will
21:39 --> 21:40come in and will say,
21:42 --> 21:44doctor, I want everything that
21:44 --> 21:45I can get to make
21:45 --> 21:46sure that this cancer is
21:46 --> 21:48never gonna show up again.
21:49 --> 21:50And you may have a
21:50 --> 21:52clinical trial or you may
21:52 --> 21:53actually,
21:54 --> 21:55just know,
21:56 --> 21:57based on trials that have
21:57 --> 21:59been done, that sometimes a
21:59 --> 22:00little less is
22:01 --> 22:02every bit as good, or
22:03 --> 22:04if not every bit as
22:04 --> 22:05good,
22:05 --> 22:07very close and maybe worth
22:07 --> 22:09the trade off. So what
22:09 --> 22:10what are those conversations like?
22:10 --> 22:11And do people
22:12 --> 22:13can you tell when you
22:13 --> 22:14see somebody if they're gonna
22:14 --> 22:15be comfortable doing a little
22:15 --> 22:16bit less?
22:16 --> 22:17Totally. When I see a
22:17 --> 22:18new patient with head and
22:18 --> 22:19neck cancer, I kinda talk
22:19 --> 22:21to them about the journey
22:21 --> 22:22of cancer. And during that
22:22 --> 22:23time, you kinda get to
22:23 --> 22:25know them and their personality.
22:25 --> 22:26And I tell them the
22:26 --> 22:27journey for head and neck
22:27 --> 22:28cancer is threefold. One,
22:29 --> 22:30get all the information.
22:30 --> 22:32That's getting the scans, getting
22:32 --> 22:34the consultations done with the
22:34 --> 22:36multidisciplinary team, getting everything ready
22:36 --> 22:37to go. I tell them
22:37 --> 22:38this is probably the most
22:38 --> 22:39frustrating part of your journey
22:39 --> 22:40because you have
22:40 --> 22:41cancer.
22:41 --> 22:43You think we're not doing
22:43 --> 22:44anything, but you're actually in
22:44 --> 22:45the most important
22:46 --> 22:47part of your journey.
22:47 --> 22:49And this, I tell them,
22:49 --> 22:51is really important. I could
22:51 --> 22:52operate on you tomorrow,
22:52 --> 22:53but
22:54 --> 22:55what if I do an
22:55 --> 22:57unnecessary operation, impacts your swallowing,
22:57 --> 22:58and you coulda just gone
22:58 --> 22:59straight to radiation in a
22:59 --> 23:01few weeks and had the
23:01 --> 23:02exact same outcome with less
23:02 --> 23:04side effects? Once I start
23:04 --> 23:05telling talking to them about
23:05 --> 23:06that, I think they realize
23:06 --> 23:07it's worth
23:07 --> 23:09the trade off to do
23:09 --> 23:10the right work up, to
23:10 --> 23:11see all the multidisciplinary
23:12 --> 23:12team,
23:13 --> 23:15and get less treatment if
23:15 --> 23:17it's the right thing for
23:17 --> 23:18you. Interestingly, I think I
23:18 --> 23:19have less of that problem
23:19 --> 23:21than maybe other cancers because
23:21 --> 23:22people
23:23 --> 23:25read, I guess, on Google,
23:25 --> 23:27the Internet, whatever, about the
23:27 --> 23:28side effects of head and
23:28 --> 23:29neck cancer treatment, and most
23:29 --> 23:31of them are happy
23:31 --> 23:32to take less treatment
23:32 --> 23:33as long as they have
23:33 --> 23:35the confidence it's not gonna
23:35 --> 23:37impact their cure rates.
23:37 --> 23:38Sure.
23:40 --> 23:42These are often
23:42 --> 23:43hard discussions.
23:43 --> 23:43And,
23:44 --> 23:45you know, it's interesting.
23:47 --> 23:49When someone's first diagnosed,
23:50 --> 23:51they're often willing to
23:53 --> 23:54or say they will go
23:54 --> 23:55through anything
23:56 --> 23:58to absolutely minimize the chance
23:58 --> 23:59of a recurrence of the
23:59 --> 24:00cancer.
24:02 --> 24:03But what sometimes
24:04 --> 24:05is less apparent
24:06 --> 24:08is that dealing with side
24:08 --> 24:09effects that extend for
24:10 --> 24:11a year, two years, five
24:11 --> 24:13years, or in some cases,
24:13 --> 24:14a lifetime
24:14 --> 24:16can be pretty devastating. And
24:16 --> 24:17I suspect that's
24:18 --> 24:20partially related to the high
24:20 --> 24:21rate of depression in many
24:21 --> 24:23patients after treatment for head
24:23 --> 24:24and neck cancers. It's just
24:24 --> 24:26dealing with the chronic problems
24:26 --> 24:28that just never seem to
24:28 --> 24:29go away, which is what
24:29 --> 24:30you're trying to avoid.
24:30 --> 24:31I think you're right. If
24:31 --> 24:32you have a patient with
24:32 --> 24:33a cancer of the voice
24:33 --> 24:34box sitting in front of
24:34 --> 24:36you and you tell them,
24:36 --> 24:37I could remove your voice
24:37 --> 24:37box, but
24:40 --> 24:41I could try and save
24:41 --> 24:43your voice box, not operate,
24:43 --> 24:44give you other treatments
24:45 --> 24:46with the exact same cure
24:46 --> 24:47rate.
24:47 --> 24:49It's not a tough decision
24:50 --> 24:51for a lot of them.
24:52 --> 24:52Yeah.
24:53 --> 24:55So tell us a little
24:55 --> 24:56bit about
24:56 --> 24:58the research that you've been
24:58 --> 25:00involved in over these past
25:00 --> 25:02five to ten years.
25:03 --> 25:06My research is really
25:06 --> 25:07focused on the process
25:08 --> 25:09of cancer care delivery.
25:10 --> 25:12It's a field of
25:12 --> 25:13research called health services research.
25:14 --> 25:16It doesn't get all the
25:16 --> 25:17fame and glory of fancy
25:17 --> 25:19new drugs and medications,
25:19 --> 25:21but in my hypothesis and
25:21 --> 25:22theory and why I'm so
25:22 --> 25:23interested in it is I
25:23 --> 25:25think, as a health services
25:25 --> 25:27researcher, we can make just
25:27 --> 25:29a big an impact on
25:29 --> 25:29outcomes
25:30 --> 25:31and care of patients
25:32 --> 25:34throughout the world as the
25:34 --> 25:35next fancy blue pill.
25:36 --> 25:37And that's where if you
25:37 --> 25:39can't deliver that blue pill
25:39 --> 25:40to everybody,
25:42 --> 25:43and if people have trouble
25:43 --> 25:45taking it or people have
25:45 --> 25:46trouble accessing it,
25:47 --> 25:48it's not gonna do anyone
25:48 --> 25:49much good. So we
25:49 --> 25:50have to figure these things out.
25:50 --> 25:51Exactly. So I think
25:51 --> 25:52it tell us more about
25:53 --> 25:54what you do. Exactly. So
25:54 --> 25:55I think we need to
25:55 --> 25:56work hand in hand with
25:56 --> 25:58the researchers who
25:58 --> 25:59are making the fancy blue
25:59 --> 26:00pills because as you pointed
26:00 --> 26:01out, how do you get
26:01 --> 26:02it to people? How do
26:02 --> 26:03you
26:03 --> 26:05decrease variation in cancer care
26:05 --> 26:07delivery across the country?
26:07 --> 26:08Somebody in one part
26:08 --> 26:10of the country should have
26:10 --> 26:12the ability to get the
26:12 --> 26:13same quality of care with
26:13 --> 26:15the latest and greatest information
26:15 --> 26:17that somebody in another part
26:17 --> 26:17of the country
26:18 --> 26:19has access to. And that's
26:20 --> 26:21basically my research. We look
26:21 --> 26:23at national trends. We look
26:23 --> 26:24at regional trends, and we
26:24 --> 26:26look at barriers to accessing
26:27 --> 26:28that care and delivering that
26:28 --> 26:29care. And we've found some
26:29 --> 26:30really
26:30 --> 26:32interesting and drawn some interesting
26:32 --> 26:33conclusions about this. And most
26:33 --> 26:34importantly, I think, it's just
26:34 --> 26:35raised awareness
26:36 --> 26:37of the variability
26:38 --> 26:39and differences in care.
26:39 --> 26:41Finally, in our last minute,
26:41 --> 26:43and maybe this is sort
26:43 --> 26:44of backwards, and I should
26:44 --> 26:45have asked you this to
26:45 --> 26:46begin with. But
26:47 --> 26:48can you just leave our
26:48 --> 26:49listeners with
26:50 --> 26:52a few comments about
26:52 --> 26:54the kinds of symptoms that
26:54 --> 26:56they may have that
26:57 --> 26:58should lead them to seek
26:58 --> 27:00attention for a possible head
27:00 --> 27:01and neck cancer?
27:01 --> 27:02Absolutely. And I think it's
27:02 --> 27:04a great way to end
27:04 --> 27:06because we are all about
27:06 --> 27:07awareness in head and neck
27:07 --> 27:09cancers. We don't have fancy
27:09 --> 27:11screening guidelines like lung cancer
27:11 --> 27:12and breast cancer and colon
27:12 --> 27:14cancer and prostate cancer.
27:14 --> 27:16We are all about awareness.
27:16 --> 27:19So symptoms that patients need
27:19 --> 27:20to be aware of,
27:20 --> 27:22when thinking about head and
27:22 --> 27:23neck cancers would be a
27:23 --> 27:24sore in the mouth that
27:24 --> 27:26doesn't heal after a few
27:26 --> 27:28weeks, maybe four to six
27:28 --> 27:29weeks. Everyone gets a sore
27:29 --> 27:30once in a while, a
27:30 --> 27:31canker sore, but they heal.
27:31 --> 27:33Something that doesn't heal, seek attention.
27:34 --> 27:36If you have a throat
27:36 --> 27:37pain,
27:37 --> 27:37one-sided,
27:38 --> 27:39not getting better after
27:40 --> 27:42four weeks, six weeks, seek
27:42 --> 27:43attention immediately.
27:44 --> 27:45Referred pain to the ear
27:45 --> 27:47can sometimes be associated with
27:47 --> 27:49deeper cancers in the throat
27:49 --> 27:50that you can't see, voice
27:50 --> 27:53changes, raspiness of voice, difficulty
27:53 --> 27:53swallowing.
27:54 --> 27:55And then for HPV cancers,
27:55 --> 27:57one of the most common
27:57 --> 27:57presentations
27:57 --> 27:59is actually a neck mass.
28:00 --> 28:01Before you even find anything
28:01 --> 28:02in your throat or have
28:02 --> 28:03a symptom in your throat,
28:04 --> 28:05a lump in the neck.
28:05 --> 28:07If you're above thirty five
28:07 --> 28:08and have a lump in
28:08 --> 28:09your neck develop,
28:10 --> 28:11go get that checked out
28:11 --> 28:13immediately and ask about the
28:13 --> 28:16possibility of an HPV associated
28:16 --> 28:16cancer.
28:17 --> 28:18Doctor Saral Mehra is an
28:18 --> 28:20associate professor of surgery and
28:20 --> 28:21otolaryngology
28:21 --> 28:22at the Yale School of
28:22 --> 28:23Medicine.
28:23 --> 28:24If you have questions, the
28:24 --> 28:26address is cancer answers at
28:26 --> 28:27yale dot e d u,
28:27 --> 28:29and past editions of the
28:29 --> 28:30program are available in audio
28:30 --> 28:32and written form at yale
28:32 --> 28:34cancer center dot org. We
28:34 --> 28:35hope you'll join us next
28:35 --> 28:36time to learn more about
28:36 --> 28:38the fight against cancer. Funding
28:38 --> 28:39for Yale Cancer Answers is
28:39 --> 28:41provided by Smilow Cancer Hospital.

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Advanced Reconstructive Surgery for Head and Neck Cancer with guest Dr. Saral Mehra March 9, 2025

Yale Cancer Center

visit: https://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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Dr. Saral Mehra

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