Head and Neck Cancers Awareness Month 2021

Transcript

00:00 --> 00:02Support for Yale Cancer Answers
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00:14 --> 00:16Welcome to Yale Cancer Answers with
00:16 --> 00:18your host doctor Anees Chagpar.
00:18 --> 00:20Yale Cancer Answers features the
00:20 --> 00:22latest information on cancer care by
00:22 --> 00:23welcoming oncologists and specialists
00:23 --> 00:26who are on the forefront of the
00:26 --> 00:28battle to fight cancer. This week
00:28 --> 00:30it's a conversation about head and
00:30 --> 00:32neck cancer with Doctor Aarti Bhatia.
00:32 --> 00:34Doctor Bhatia is assistant professor
00:34 --> 00:36of medicine and medical oncology
00:36 --> 00:38at the Yale School of Medicine,
00:38 --> 00:40where Doctor Chagpar is a
00:40 --> 00:42professor of surgical oncology.
00:42 --> 00:45Aarti, maybe you can start off by telling us a
00:45 --> 00:48little bit more about head neck cancers.
00:48 --> 00:51It seems like there would be a lot of
00:51 --> 00:52cancers in that bucket.
00:52 --> 00:55It is actually a pretty wide bucket.
00:55 --> 00:57You know if you think about it,
00:58 --> 01:00the head and neck is a
01:00 --> 01:01pretty concise structure,
01:01 --> 01:02but diagnosis, treatment follows
01:02 --> 01:05like the site of origin of the
01:05 --> 01:07tumor within the head neck region.
01:07 --> 01:09So broadly it encompasses a lot
01:09 --> 01:11of tumors which arise from the
01:11 --> 01:14mucosa within the head and neck.
01:14 --> 01:17But you know, they could arise in the mouth,
01:17 --> 01:19so that would be oral cavity tumors.
01:19 --> 01:22They could arise in the back of the throat,
01:22 --> 01:23so that would be oropharyngeal
01:23 --> 01:25tumors or tonsillar tumors.
01:25 --> 01:26They could arise in our voice box
01:26 --> 01:28that would be laryngeal tumors.
01:28 --> 01:31The back of the nose is nasal
01:31 --> 01:31pharyngeal tumors.
01:31 --> 01:33You could also have salivary gland cancers,
01:33 --> 01:36and each of those sites is treated
01:36 --> 01:38differently in terms of how we
01:38 --> 01:40work it up and how we manage it.
01:41 --> 01:44And are they all lumped together?
01:44 --> 01:47Basically because they're all
01:47 --> 01:50pretty rare, or I wouldn't say
01:50 --> 01:52they are rare, together head neck
01:52 --> 01:55cancers always come within the top 10
01:55 --> 01:58most common cancers in the United States.
01:58 --> 02:00You know there's also a much larger
02:00 --> 02:02proportion of tumors that arise
02:02 --> 02:04outside of the United States,
02:04 --> 02:07so for instance, Asia has a very
02:07 --> 02:09large number of new head neck cancers
02:09 --> 02:13that are diagnosed every year, but
02:13 --> 02:15the reason they are lumped together is
02:15 --> 02:17because they share a common Histology.
02:17 --> 02:19So when we look at
02:19 --> 02:21tumors under the microscope,
02:21 --> 02:23most tumors arising from the head and
02:23 --> 02:25neck region tend to have what we call
02:25 --> 02:27a squamous Histology and based off
02:27 --> 02:30that they are clubbed together as one
02:30 --> 02:32entity. But they are different in
02:32 --> 02:34terms of how they're treated and we're
02:34 --> 02:37going to get into that in a second,
02:37 --> 02:40but just take one step back,
02:40 --> 02:42what is the etiology or the
02:42 --> 02:44cause of these head neck cancers?
02:44 --> 02:46Why are they more common in
02:46 --> 02:48Asia than they are for example,
02:48 --> 02:50in the United States and what
02:50 --> 02:52are some of the risk factors that
02:52 --> 02:54people should be watching for?
02:55 --> 02:57So the common etiologies worldwide is,
02:57 --> 02:59you know, tobacco exposure,
02:59 --> 03:01alcohol exposure. In Asia
03:01 --> 03:03there are a couple additional risk factors
03:03 --> 03:07that increase the incidence of these cancers.
03:07 --> 03:10So for instance, in Southeast Asia you
03:10 --> 03:13know people tend to chew a lot of tobacco.
03:13 --> 03:17They tend to chew betel nut and those
03:17 --> 03:19natural substances can also increase their
03:19 --> 03:22risk of acquiring head and neck cancers
03:22 --> 03:25in countries like China. In Hong Kong,
03:25 --> 03:28there is an incidence of nasal,
03:28 --> 03:30pharyngeal cancers which are caused by
03:30 --> 03:33the Epstein Barr virus or EBV virus.
03:33 --> 03:34It's almost endemic,
03:34 --> 03:36endemic proportions in those countries,
03:36 --> 03:38so a lot of head neck cancers
03:38 --> 03:40tend to be nasopharyngeal.
03:45 --> 03:47In the United States and in
03:47 --> 03:49the Western world at large,
03:49 --> 03:52we also see several head and neck cancers
03:52 --> 03:55arising in Association with the human
03:55 --> 03:57Papilloma virus or the HPV virus.
03:57 --> 03:58Most commonly,
03:58 --> 03:59people associate that with
03:59 --> 04:00cervical cancer in women,
04:00 --> 04:03but there's a rising incidence of HPV
04:03 --> 04:05head and neck cancers in the Western world.
04:07 --> 04:10And so when we think about risk
04:10 --> 04:13factors for developing these cancers,
04:13 --> 04:16and we often think about primary prevention,
04:16 --> 04:19so how can we reduce getting these
04:19 --> 04:21risk factors and thereby reduce
04:21 --> 04:24our risk of getting these cancers?
04:24 --> 04:28It seems that the two that you've
04:28 --> 04:31mentioned right off the top would be
04:31 --> 04:34reduce your smoking or tobacco consumption,
04:34 --> 04:36whether that's chewing tobacco
04:36 --> 04:37or smoking tobacco,
04:37 --> 04:40and getting an HPV vaccine. Is that right?
04:40 --> 04:42That is right, so you know,
04:42 --> 04:44the HPV vaccine is something
04:44 --> 04:46that still doesn't have a lot
04:46 --> 04:48of uptake in the Community,
04:48 --> 04:51and it's good to be aware
04:51 --> 04:54that the sooner you get it in life,
04:54 --> 04:56ideally in your preteen years before
04:56 --> 04:59you have a chance of being exposed
04:59 --> 05:01to the virus and the infection,
05:01 --> 05:03the much better protection that the virus
05:03 --> 05:05offers you against multiple cancers.
05:05 --> 05:07So for women it protects you
05:07 --> 05:08against cervical cancer,
05:08 --> 05:10head and neck cancer, anogenital cancers.
05:10 --> 05:13And for men it protects you from the head and
05:13 --> 05:15neck cancers and the anogenital cancers.
05:15 --> 05:18So yes, and another thing
05:18 --> 05:20to be aware of is that the FDA
05:20 --> 05:22has recently increased the age
05:22 --> 05:24limit to which you could actually
05:24 --> 05:26be eligible to get the vaccine.
05:26 --> 05:29So previously it used to be about 26 years.
05:29 --> 05:32Now it's up to 45 years so you
05:32 --> 05:34know people who did not meet the
05:34 --> 05:36initial cutoff for the vaccine are
05:36 --> 05:38now eligible to get the vaccine.
05:39 --> 05:41And so why do you think that
05:41 --> 05:43there is so much hesitancy
05:43 --> 05:46about getting the HPV vaccine?
05:46 --> 05:48I mean, it seems that it would
05:48 --> 05:52be a no brainer if it can reduce
05:52 --> 05:54your risk of getting cancer.
05:54 --> 05:57Certainly HPV vaccines
05:57 --> 05:59have been around for awhile and right
05:59 --> 06:02now during the covid epidemic
06:02 --> 06:04we've seen some hesitancy with
06:04 --> 06:06regards to vaccination for covid,
06:06 --> 06:08based primarily off of the speed
06:08 --> 06:11and the rapidity with which
06:11 --> 06:13those vaccines were developed.
06:13 --> 06:15But the HPV vaccines have
06:15 --> 06:18been around for a while,
06:18 --> 06:20so why aren't people getting vaccinated?
06:20 --> 06:24Is it that this isn't really something
06:24 --> 06:26that's been established in school programs?
06:26 --> 06:29When kids get their usual measles,
06:29 --> 06:31mumps, and rubella vaccine?
06:31 --> 06:33Is it celebrity endorsement
06:33 --> 06:34against vaccination?
06:34 --> 06:37Why do you think that there is
06:37 --> 06:38this hesitancy?
06:39 --> 06:42I think it's a combination of factors.
06:42 --> 06:45One is the lack of awareness.
06:45 --> 06:47A lot of people do not know
06:49 --> 06:53about the Association with HPV.
06:58 --> 07:00The second is that it's not a part of
07:00 --> 07:03the national immunization schedule,
07:03 --> 07:05unlike the MMR vaccine, which then
07:05 --> 07:07gets offered to all pediatric patients.
07:07 --> 07:09But this one doesn't,
07:09 --> 07:11and the third is, I think,
07:11 --> 07:12a cultural hesitancy.
07:12 --> 07:15You know, HPV is a sexually acquired
07:15 --> 07:16infection,
07:16 --> 07:18and I think people worry that getting
07:18 --> 07:21teenagers a vaccine against a sexually
07:21 --> 07:23transmitted infection will in turn then
07:23 --> 07:24promote promiscuity so
07:24 --> 07:27I think a lot of people worry
07:27 --> 07:29about that reason as well.
07:30 --> 07:33And so is that why it's not part of
07:33 --> 07:36the national vaccination schedule?
07:36 --> 07:39I mean, it seems as though if the
07:39 --> 07:42CDC and other public health officials
07:42 --> 07:45recommend getting the HPV vaccine,
07:45 --> 07:48and certainly cervical cancers,
07:48 --> 07:49head, neck cancers,
07:49 --> 07:52anogenital cancers are significant in
07:52 --> 07:55terms of their public health consequences.
07:55 --> 07:59Why isn't it part of the national schedule?
07:59 --> 08:01I think one because it's
08:03 --> 08:05been maybe within the last decade
08:05 --> 08:07or so that we've started to see
08:07 --> 08:09results from clinical trials
08:09 --> 08:10establishing the efficacy of the
08:10 --> 08:12vaccine against these cancers.
08:12 --> 08:14And two, I think just a cultural
08:14 --> 08:16uptake hasn't been that much,
08:16 --> 08:18but it would be great to see it
08:18 --> 08:20become a part of the national
08:20 --> 08:22immunization schedule so
08:22 --> 08:25people have to opt out of getting
08:25 --> 08:27the vaccine instead of opting in to get it.
08:27 --> 08:30And so for the people who are
08:30 --> 08:33listening to this show and are thinking,
08:33 --> 08:35it seems as though
08:35 --> 08:37this vaccine is safe.
08:37 --> 08:40It's highly efficacious as I understand it,
08:40 --> 08:41can prevent over 90%,
08:41 --> 08:44maybe even higher, of these cancers,
08:44 --> 08:46especially cervical cancer.
08:46 --> 08:49But also other forms of cancer.
08:49 --> 08:51Why wouldn't I get it?
08:51 --> 08:54How do they go about doing that?
08:54 --> 08:56Is that something that they can
08:56 --> 08:58get through their doctors offices?
08:58 --> 09:00Is it covered by insurance?
09:01 --> 09:04What are the other potential barriers
09:04 --> 09:06that people can address?
09:06 --> 09:08It shoud be fairly straightforward to get
09:08 --> 09:10it so it is covered by insurance
09:10 --> 09:12right from the preteen years.
09:12 --> 09:15So age 9-10 until someone gets to
09:15 --> 09:18the age of 45 years and it should be
09:18 --> 09:20fairly straightforward to call your
09:20 --> 09:23pediatrician or your primary care doctor,
09:23 --> 09:26and you know, go in and get the shot.
09:26 --> 09:28Most clinics offer the vaccine.
09:29 --> 09:31And really it's been efficacious
09:31 --> 09:33and minimal side effects, right?
09:33 --> 09:35Well, there are some side effects. Nothing
09:35 --> 09:36like the covid vaccine.
09:36 --> 09:39So you know right off the bat,
09:39 --> 09:41that's something a little bit better
09:41 --> 09:42tolerated than the covid shot so
09:42 --> 09:44if people could deal with the covid shot,
09:44 --> 09:46they can definitely deal with
09:46 --> 09:48the HPV vaccine,
09:48 --> 09:49but there are minimal side effects.
09:49 --> 09:52Most of them are short term, they
09:52 --> 09:54dissipate within a day or two.
09:55 --> 10:00OK, great so aside from getting the
10:00 --> 10:02HPV vaccine the other risk
10:02 --> 10:03factors are really tobacco,
10:03 --> 10:06which has gone down in this country,
10:06 --> 10:09at least in terms of smoking.
10:09 --> 10:11The other question that people may
10:11 --> 10:14have is with regards to E cigarettes.
10:14 --> 10:16We found that
10:16 --> 10:18as people's smoking in terms
10:18 --> 10:20of smoking tobacco has gone
10:20 --> 10:22down in the United States,
10:22 --> 10:25E-cigarettes seem to have gone up.
10:25 --> 10:27Does that increase your
10:27 --> 10:29risk of head and neck cancers?
10:30 --> 10:32There isn't a lot of data
10:32 --> 10:33that's looked at that.
10:33 --> 10:35Again, E cigarettes are a new phenomenon.
10:35 --> 10:36It's really only been
10:36 --> 10:38within the past few years.
10:38 --> 10:40It theoretically would have a lower
10:40 --> 10:42risk than regular cigarettes and
10:42 --> 10:43causing head and neck cancers,
10:43 --> 10:45but I'm not sure that it totally
10:45 --> 10:47eliminates the risk altogether.
10:48 --> 10:50And then the other
10:50 --> 10:52thing that people often put
10:52 --> 10:54together is smoking and alcohol.
10:54 --> 10:56What's the impact of alcohol
10:56 --> 10:58on head and neck cancers?
10:59 --> 11:01Almost the same as smoking,
11:01 --> 11:05so you know smoking.
11:05 --> 11:07when you inhale the smoke,
11:07 --> 11:09it goes down all the way from your head
11:09 --> 11:12and neck passages down to your lung
11:12 --> 11:14passages and with alcohol, similarly it goes
11:14 --> 11:16down your mouth, the back of your
11:16 --> 11:18throat and then into the food pipe.
11:18 --> 11:21So we do see a significant proportion
11:21 --> 11:23of patients who've never smoked but
11:23 --> 11:24have a significant alcohol history
11:24 --> 11:27who then go on to develop head and neck cancers.
11:27 --> 11:30So I would say the risk is about the same.
11:30 --> 11:31It's also cumulative,
11:31 --> 11:33so the more the exposure to either
11:33 --> 11:35substance or both substances,
11:35 --> 11:37the higher your chance
11:37 --> 11:39of developing a cancer.
11:39 --> 11:41The next question that
11:41 --> 11:44everybody is going to ask is,
11:44 --> 11:48is there a safe limit? Is it okay to have 1
11:48 --> 11:51drink at dinner or is there
11:51 --> 11:54a certain threshold at which
11:54 --> 11:57people should really be cautious?
11:58 --> 12:00Of course you want to avoid
12:00 --> 12:01binge drinking,
12:01 --> 12:03and there are these thresholds
12:03 --> 12:05that are set by the CDC as well.
12:05 --> 12:07and that
12:07 --> 12:08needs to be double checked,
12:08 --> 12:11but maybe it's 2 drinks a day for women
12:11 --> 12:14and three drinks at a time for men.
12:14 --> 12:16The safest is to minimize though,
12:16 --> 12:18'cause I think everyone has a personal
12:18 --> 12:19body threshold that's different,
12:19 --> 12:22we see some people
12:22 --> 12:24who've smoked 100 pack years and
12:24 --> 12:26do not get head and neck cancers,
12:26 --> 12:28and then we see some people have
12:28 --> 12:29smoked just ten years and then
12:29 --> 12:31have a head and neck cancer
12:31 --> 12:33that's not virus associated,
12:33 --> 12:34so is presumably smoking associated.
12:34 --> 12:36So I think everyone just has
12:36 --> 12:37a different threshold.
12:37 --> 12:39Doing away with smoking altogether
12:39 --> 12:40is healthy for everyone,
12:40 --> 12:41and minimizing how much alcohol
12:41 --> 12:44you drink is also the best thing
12:44 --> 12:45you could do for yourself.
12:47 --> 12:49And so when we move away
12:49 --> 12:51from now primary prevention,
12:51 --> 12:54we've kind of talked about the risk factors
12:54 --> 12:57and things we can do to minimize that.
12:57 --> 13:00The next thing that people often talk
13:00 --> 13:03about is secondary prevention or screening.
13:03 --> 13:05Now, unlike a lot of other cancers,
13:05 --> 13:07breast cancer, colon cancer,
13:07 --> 13:10where we really have good screening tests,
13:10 --> 13:13do we have good screening tests
13:13 --> 13:15for head and neck cancer?
13:15 --> 13:17So screening hasn't shown to
13:17 --> 13:20save lives for patients who
13:20 --> 13:22go on to develop head neck cancer,
13:22 --> 13:24but in our own experience,
13:24 --> 13:27the way head neck cancer
13:27 --> 13:29is most commonly diagnosed is
13:29 --> 13:31when someone notices a lesion,
13:31 --> 13:34say in the oral cavity or in the back
13:34 --> 13:37of the throat and is then referred
13:37 --> 13:38to the oncology team.
13:38 --> 13:41So that tends to be found
13:41 --> 13:43serendipitously by somebody's doctor or
13:43 --> 13:46dentist who looks in their mouth.
13:46 --> 13:48Yes, but I hear that
13:48 --> 13:50you were about to say that you
13:50 --> 13:52organize community screening
13:52 --> 13:54programs that might be helpful,
13:54 --> 13:56and I'd love to delve a little
13:56 --> 13:58bit more into that.
13:58 --> 14:01But first we need to take a medical minute,
14:01 --> 14:03so please stay tuned to learn
14:03 --> 14:05more about head and neck
14:05 --> 14:07cancers with my guest doctor
14:07 --> 14:09Aarti Bhatia.
14:09 --> 14:11Support for Yale Cancer Answers comes from AstraZeneca, working
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14:14 --> 14:17Learn more at astrazeneca-us.com.
14:17 --> 14:20This is a medical minute about lung cancer.
14:20 --> 14:23More than 85% of lung cancer diagnosis
14:23 --> 14:26are related to smoking and quitting, even
14:26 --> 14:28after decades of use can significantly
14:28 --> 14:31reduce your risk of developing lung
14:31 --> 14:33cancer. For lung cancer patients,
14:33 --> 14:35clinical trials are currently underway
14:35 --> 14:37to test innovative new treatments.
14:37 --> 14:40Advances are being made by utilizing
14:40 --> 14:42targeted therapies and immunotherapies.
14:42 --> 14:44The BATTLE II trial aims to learn
14:44 --> 14:47if a drug or combination of drugs
14:47 --> 14:49based on personal biomarkers can help
14:49 --> 14:52to control non small cell lung cancer.
14:52 --> 14:55More information is available
14:55 --> 14:56at yalecancercenter.org.
14:56 --> 14:59You're listening to Connecticut Public Radio.
15:00 --> 15:03Welcome back to Yale Cancer Answers.
15:03 --> 15:04This is doctor Anees Chagpar
15:04 --> 15:07and I'm joined tonight by
15:07 --> 15:09my guest Doctor Aarti Bhatia.
15:09 --> 15:11We're talking about head and neck
15:11 --> 15:13cancers and right before the break,
15:13 --> 15:15you made a comment that
15:15 --> 15:16I found really interesting.
15:16 --> 15:18You said that
15:18 --> 15:20screening for head neck cancers has
15:20 --> 15:23not been shown to improve survival.
15:23 --> 15:25That for many people,
15:25 --> 15:27I think would seem counter
15:27 --> 15:28intuitive for most cancers.
15:28 --> 15:31We think if we pick it up early,
15:31 --> 15:33the earlier we pick it up,
15:33 --> 15:35the easier it is to treat,
15:35 --> 15:37the better the survival rate is.
15:37 --> 15:39So why do you think that is that
15:39 --> 15:41that screening really hasn't
15:41 --> 15:43been shown to affect survival?
15:44 --> 15:46Well, I think a large part of that
15:46 --> 15:48is because patients present with
15:48 --> 15:50symptoms pretty early on.
15:50 --> 15:53I mean, if you have a bleeding ulcer
15:53 --> 15:55in the mouth, you have sore throat,
15:55 --> 15:57you have trouble swallowing or chewing,
15:57 --> 15:59you notice a neck lump,
15:59 --> 16:01most people aren't going to
16:01 --> 16:03sit on it for months or years.
16:03 --> 16:05They're going to go see a doctor
16:05 --> 16:08and figure out what's going on.
16:08 --> 16:10So because of the
16:10 --> 16:12location of these tumors and how
16:12 --> 16:14early they present with symptoms,
16:14 --> 16:16most people are diagnosed early on,
16:16 --> 16:17and in early stages.
16:17 --> 16:19So the vast majority of our patients
16:19 --> 16:22come in with curable cancers,
16:22 --> 16:24so I think there isn't much
16:24 --> 16:25more that screening does.
16:26 --> 16:28Screening picks up early cancers,
16:28 --> 16:30but then people come in
16:30 --> 16:31with early cancers anyway,
16:31 --> 16:33so for that reason it hasn't
16:33 --> 16:35been shown to improve survival.
16:35 --> 16:38But we still think it's helpful to
16:38 --> 16:41engage in community wide screening efforts,
16:41 --> 16:43especially in the high risk population.
16:43 --> 16:45So in patients who have a significant
16:45 --> 16:47smoking exposure, alcohol exposure,
16:47 --> 16:48multiple partners,
16:48 --> 16:50it makes sense to have them
16:51 --> 16:53engage with their dentist or
16:53 --> 16:56oral surgeons, ENTs, to see if
16:56 --> 16:59they have any lesions that can be
16:59 --> 17:00intervened in an early
17:00 --> 17:02course in the disease
17:02 --> 17:05I think that's one of the
17:05 --> 17:08beauties of head neck cancers is that
17:08 --> 17:09because the lesions
17:09 --> 17:12in the head and neck are such that
17:12 --> 17:14they will present with symptoms,
17:14 --> 17:16it can be found earlier than,
17:16 --> 17:18for example, other cancers that
17:18 --> 17:20we've talked about on this show,
17:20 --> 17:23which tend to be pretty silent and
17:23 --> 17:25patients present quite late.
17:25 --> 17:29So you mentioned a few of the symptoms that
17:29 --> 17:32people should be looking out for, right?
17:32 --> 17:33Bleeding, ulcer, nosebleeds,
17:33 --> 17:35lump in the throat,
17:35 --> 17:36losing your voice,
17:36 --> 17:37hoarseness, cough.
17:37 --> 17:40Are there other things that people
17:40 --> 17:42should be looking out for?
17:42 --> 17:44And seeing their doctor about?
17:47 --> 17:49Sometimes you may even have
17:49 --> 17:52oral lesions which tend not to bleed,
17:52 --> 17:54but they've just been there for awhile.
17:54 --> 17:57Some of those can be precancerous,
17:57 --> 17:58some precancerous lesions will then
17:58 --> 18:00go on to transform into cancer,
18:00 --> 18:03so even if it isn't a very bothersome lesion,
18:03 --> 18:06but just has been there around for awhile,
18:06 --> 18:08you want to make sure
18:08 --> 18:10you see someone about it
18:10 --> 18:11and get it checked out.
18:11 --> 18:14Yeah, and for many people,
18:14 --> 18:16going to your doctor for
18:16 --> 18:18a regular checkup once a year,
18:18 --> 18:21or seeing your dentist once or twice a year
18:21 --> 18:23is a really good thing to
18:23 --> 18:25do because as you mentioned,
18:25 --> 18:27it's often on these visits that
18:27 --> 18:30people can pick up on lesions that may
18:30 --> 18:32not have been bothersome to you.
18:35 --> 18:38They can then see it as suspicious
18:38 --> 18:41and move on to the next step.
18:41 --> 18:43So when you do go to your
18:43 --> 18:45dentist or your doctor and they
18:45 --> 18:47find something,
18:47 --> 18:50what's the next step in terms of making a
18:50 --> 18:52diagnosis and moving on with treatment?
18:54 --> 18:56So if the dentist
18:56 --> 18:57finds something that's suspicious,
18:57 --> 18:59they will either refer you to
18:59 --> 19:01an oral surgeon or an ENT,
19:01 --> 19:03and both those kind of physicians
19:03 --> 19:05can make a diagnosis with a biopsy,
19:05 --> 19:08so we need to typically get some
19:08 --> 19:10of that tissue out with a needle.
19:10 --> 19:12Look at it under the microscope
19:12 --> 19:14and see what's going on,
19:14 --> 19:15and if that diagnosis is cancer,
19:15 --> 19:18the next step is usually
19:18 --> 19:20scans where we try to find out to
19:20 --> 19:22what extent has this cancer spread.
19:22 --> 19:24Is it involving adjacent structures?
19:24 --> 19:26Is it involving some neck nodes?
19:26 --> 19:29Is it a local tumor or has it
19:29 --> 19:31spread and then from
19:31 --> 19:34then on you get involved with the
19:34 --> 19:36rest of the oncology team so you
19:36 --> 19:38meet a radiation oncologist.
19:38 --> 19:40You made a medical oncologist,
19:40 --> 19:41which is someone like me,
19:41 --> 19:44and usually treatment will then be planned,
19:44 --> 19:46involving a course of radiation
19:46 --> 19:47or chemotherapy or surgery,
19:47 --> 19:49or a combination of these so
19:49 --> 19:51multidisciplinary management is
19:51 --> 19:52key to treating and formulating
19:52 --> 19:55a good treatment plan for head
19:55 --> 19:57and neck cancer patients and in
19:57 --> 19:59fact outcomes are tied to being
19:59 --> 20:00treated at large
20:00 --> 20:00volume centers,
20:00 --> 20:03so you want to make sure you see
20:03 --> 20:05someone who has many
20:05 --> 20:06head neck cancer patients and
20:06 --> 20:08has dealt with their treatment.
20:09 --> 20:12Yeah, and when
20:12 --> 20:15you talk about large volume centers,
20:15 --> 20:18I think part of that may have to do
20:18 --> 20:20with the expertise of the clinicians
20:20 --> 20:23themselves and the fact that they
20:23 --> 20:26see these cancers day in and day out.
20:26 --> 20:28But the other might be some
20:28 --> 20:31of the things that they have at
20:31 --> 20:33large volume centers that may
20:33 --> 20:35not be ubiquitously available.
20:35 --> 20:38So talk to us a little bit
20:38 --> 20:39about personalized medicine.
20:39 --> 20:42We find that in so many cancers now,
20:42 --> 20:44especially the large volume centers
20:44 --> 20:47really are tailoring care in terms of
20:47 --> 20:50the genomics of a particular cancer and
20:50 --> 20:53using that information, that molecular
20:53 --> 20:55information, to really tailor their
20:55 --> 20:58therapy in terms of that multi modality
20:58 --> 21:01care that you were talking about.
21:01 --> 21:04Can you talk more about that?
21:05 --> 21:06Yes, absolutely.
21:06 --> 21:08So you know that's valid for patients
21:08 --> 21:11who have more advanced disease or
21:11 --> 21:13incurable disease at our center.
21:13 --> 21:15And I'm sure at many other large
21:15 --> 21:17volume centers with expertise,
21:17 --> 21:19we do what we call molecular
21:19 --> 21:21sequencing or profiling of tumors.
21:21 --> 21:24So the biopsies are analyzed for their
21:24 --> 21:26genes that are present
21:26 --> 21:28in the tumor and
21:28 --> 21:31we then determine is this gene something
21:31 --> 21:33that was inherited by the patient,
21:33 --> 21:36or is it something that
21:36 --> 21:38originated in the oral cavity
21:38 --> 21:42or in the mucosa of the head neck
21:42 --> 21:45and then went on to cause a tumor,
21:45 --> 21:48and sometimes knowing what these genetic
21:48 --> 21:51defects or mutations are in the tumor,
21:51 --> 21:53help us identify drugs or
21:53 --> 21:55targeted therapies,
21:55 --> 21:57which then will specifically go and
21:58 --> 22:00target or inhibit that aberrant
22:00 --> 22:02protein or aberrant mutation so the
22:02 --> 22:05cancer can come under better control.
22:05 --> 22:07Some of these drugs are
22:07 --> 22:09FDA approved in these settings and
22:09 --> 22:11some of these drugs are available
22:11 --> 22:14on clinical trials and clearly more
22:14 --> 22:15clinical trials will be available
22:15 --> 22:18at the larger volume centers where
22:18 --> 22:20we have the patient still offer
22:20 --> 22:21these studies too,
22:21 --> 22:23but even for patients who have
22:23 --> 22:24curable disease,
22:24 --> 22:26like we mentioned,
22:26 --> 22:28head and neck cancers tend to present
22:28 --> 22:30most often in the curative stage,
22:32 --> 22:34Therapeutic modalities like
22:34 --> 22:35robotic surgeries,
22:35 --> 22:37advanced radiation techniques are
22:37 --> 22:40sometimes available only at the
22:40 --> 22:44large volume centers and
22:45 --> 22:47along with improving your prognosis or
22:47 --> 22:49outcomes for treating these cancers,
22:49 --> 22:51it also helps minimize the side
22:51 --> 22:53effects that you have and you
22:53 --> 22:55have to then live with for the
22:55 --> 22:57rest of your life as a result
22:57 --> 22:59of undergoing cancer treatment.
22:59 --> 23:00So there are
23:00 --> 23:01many advantages to being
23:01 --> 23:03seen at large volume centers.
23:03 --> 23:05One of the things I think that
23:05 --> 23:07you mentioned which many people
23:07 --> 23:09might find curious is that
23:09 --> 23:12when you talk about genomics,
23:12 --> 23:13and tailored therapy,
23:13 --> 23:15that's mainly for people who
23:15 --> 23:17present with advanced cancers.
23:17 --> 23:20So is it the case that in more
23:20 --> 23:22early stage cancers the systemic
23:22 --> 23:25therapy or the chemotherapies tend
23:25 --> 23:28to be uniform across patients?
23:29 --> 23:31That is probably true for
23:31 --> 23:33head and neck cancers.
23:33 --> 23:36That might change in the
23:36 --> 23:38future though, so for instance,
23:38 --> 23:40immunotherapy is currently approved only
23:40 --> 23:42in the treatment of advanced cancers.
23:42 --> 23:45But we now have many trials which
23:45 --> 23:47are looking to move immunotherapy
23:47 --> 23:49into the curative setting and see if
23:49 --> 23:53we can improve cure chances for our
23:53 --> 23:55patients with locally advanced disease.
23:55 --> 23:57So there are biomarkers which we
23:57 --> 23:59use to predict which patients
23:59 --> 24:02will respond to immunotherapy in the
24:02 --> 24:04advanced setting and that might become
24:04 --> 24:06standard of care for even patients who
24:06 --> 24:08are in the locally advanced settings.
24:08 --> 24:11So we're using chemo and
24:11 --> 24:12standard radiation for cure,
24:12 --> 24:14but we're maybe adding on a partner
24:14 --> 24:17drug like an immunotherapy drug based on
24:17 --> 24:20what trials show us in the next few years.
24:20 --> 24:23There is a chance that we may not
24:23 --> 24:25be using that for everyone but
24:25 --> 24:27personalizing it for patients
24:27 --> 24:29who have these positive biomarkers
24:29 --> 24:32which then predicts for a better
24:32 --> 24:33outcome with
24:33 --> 24:34immunotherapy.
24:34 --> 24:36In general, what is the prognosis
24:36 --> 24:38for patients who present with
24:38 --> 24:41early stage head neck cancers?
24:42 --> 24:44So a large part of that depends on whether
24:44 --> 24:47or not they are associated with HPV,
24:47 --> 24:49so having the HPV virus associated
24:49 --> 24:51cancer confers a much better
24:51 --> 24:53prognosis and in the early stage,
24:53 --> 24:5680 to 90% of these patients can be
24:56 --> 24:58cured five years out in patients
24:58 --> 25:00who have HPV negative disease,
25:00 --> 25:03that number is a little bit lower,
25:03 --> 25:05but if you compare with a lot of other
25:05 --> 25:08cancer types it's still pretty good.
25:08 --> 25:11You know we are able to cure about on
25:11 --> 25:13average 60% of HPV negative patients.
25:13 --> 25:15Early stage with curative intent treatment.
25:15 --> 25:18Of course, we're always trying to
25:18 --> 25:20do research and clinical trials to
25:20 --> 25:22see if we can move that bar up and,
25:22 --> 25:24you know, get a higher proportion
25:24 --> 25:26of our patients cured.
25:26 --> 25:27And that's also the advantage
25:27 --> 25:28of being seen at a
25:28 --> 25:30larger centers that
25:30 --> 25:32has these trials to maybe make
25:32 --> 25:33treatment more aggressive.
25:33 --> 25:35To intensify your treatment so we can
25:35 --> 25:38move that bar up for our patients.
25:38 --> 25:41That was going to be one of my questions,
25:41 --> 25:44which is, for many patients, they
25:44 --> 25:47hear about clinical trials and they think
25:47 --> 25:51I have a fairly early stage cancer,
25:51 --> 25:55prognosis is reasonably good,
25:55 --> 25:58clinical trials always sound a little scary.
25:58 --> 26:00Do I really want to be a
26:00 --> 26:03Guinea pig in the early stage?
26:03 --> 26:06So what do you say to patients who
26:06 --> 26:08might be contemplating whether they
26:08 --> 26:11really ought to be in a clinical trial?
26:11 --> 26:14If they have potentially curative
26:14 --> 26:16cancer or not?
26:16 --> 26:18Two things.
26:18 --> 26:20One, it's always good to remember
26:20 --> 26:22that what is standard treatment today
26:22 --> 26:24was a clinical trial some years ago,
26:24 --> 26:27so we would have not gotten to the
26:27 --> 26:29treatments that we are at today
26:29 --> 26:31if we had not
26:31 --> 26:33used some other patients in
26:33 --> 26:35the past on clinical trials.
26:35 --> 26:37The second thing is that we always try
26:37 --> 26:40to carefully match and screen patients
26:40 --> 26:42to the available trials that we have.
26:42 --> 26:44So we're always
26:44 --> 26:46thinking about what benefit does
26:46 --> 26:48it directly offer that patient.
26:48 --> 26:50And even if there is a chance
26:50 --> 26:51of some benefit,
26:51 --> 26:53then that's the ideal patient
26:53 --> 26:55to be matched to a clinical trial.
26:55 --> 26:56So of course,
26:56 --> 26:57if we think that there is no
26:57 --> 26:59possible benefit to someone,
26:59 --> 27:02we're not going to put them on a trial,
27:02 --> 27:03so we're
27:03 --> 27:04carefully screening patients.
27:04 --> 27:05It's also a mutual decision,
27:05 --> 27:07so it's not something that's
27:07 --> 27:09going to be forced on anyone,
27:09 --> 27:10but it's worth at least hearing
27:10 --> 27:12out your options and then
27:12 --> 27:14making an informed choice.
27:14 --> 27:16And I think it's so important for
27:16 --> 27:19people to realize that
27:19 --> 27:20on average patients who participate
27:20 --> 27:23in clinical trials tend to do
27:23 --> 27:24better than patients who don't.
27:24 --> 27:26Because we're always testing what
27:26 --> 27:28we think is tomorrow's therapy,
27:28 --> 27:29the next great therapy,
27:29 --> 27:31how we can move that bar,
27:31 --> 27:33as you said to standard
27:33 --> 27:35of care today and so on.
27:35 --> 27:38Average people tend to do better.
27:38 --> 27:40The other question that I want
27:40 --> 27:42to circle back to before the
27:42 --> 27:44show closes is an important one,
27:44 --> 27:45and that is,
27:45 --> 27:47you mentioned that people who have
27:47 --> 27:50HPV positive cancers tend to do
27:50 --> 27:52better than people who have HPV
27:52 --> 27:55negative cancers and I want you to
27:55 --> 27:57kind of dispel a misconception that
27:57 --> 28:00some people might have then, which is,
28:00 --> 28:03why should I get the HPV vaccine,
28:03 --> 28:05if that then would prevent me from
28:05 --> 28:07getting an HPV positive cancer.
28:07 --> 28:10So then I would be more likely to
28:10 --> 28:13get an HPV negative cancer and
28:13 --> 28:15do worse.
28:15 --> 28:18Getting the vaccine does not increase your risk of getting
28:18 --> 28:21the HPV negative cancer and HPV
28:21 --> 28:23Positive cancers actually tend to
28:23 --> 28:26occur earlier in life so where
28:26 --> 28:28HPV negative cancers need a certain
28:28 --> 28:30degree of tobacco and alcohol exposure
28:30 --> 28:33for them to develop and usually occur
28:33 --> 28:36in the 6th or 7th decade of life.
28:36 --> 28:38HPV positive cancers can occur
28:38 --> 28:40as early as the third, fourth,
28:40 --> 28:43fifth decades of life and think about it.
28:43 --> 28:46Now you have a highly curable cancer,
28:46 --> 28:46but the
28:46 --> 28:48treatment is just as aggressive
28:48 --> 28:51as HPV negative cancers by the
28:51 --> 28:52current standard of care,
28:52 --> 28:55so you're going to live out all
28:55 --> 28:55these decades
28:55 --> 28:57dealing with the side effects of
28:57 --> 29:00treatment and for anyone who's known
29:00 --> 29:02someone going through head and neck cancer
29:02 --> 29:04treatment or has gone through it themselves,
29:04 --> 29:05it's probably
29:05 --> 29:07a nightmare to live
29:07 --> 29:09through and something that stays
29:09 --> 29:12with you for the rest of your life.
29:12 --> 29:14The side effects can be
29:14 --> 29:15pretty disabling for many,
29:15 --> 29:16many years afterwards.
29:16 --> 29:18Doctor Aarti Bhatia is assistant
29:18 --> 29:20professor of medicine and medical
29:20 --> 29:22oncology at the Yale School of Medicine.
29:22 --> 29:23If you have questions,
29:23 --> 29:25the address is canceranswers@yale.edu
29:25 --> 29:27and past editions of the
29:27 --> 29:29program are available in audio and
29:29 --> 29:30written form at yalecancercenter.org,
29:30 --> 29:33we hope you'll join us next week to
29:33 --> 29:35learn more about the fight against
29:35 --> 29:37cancer here on Connecticut Public Radio.

Information

Head and Neck Cancers Awareness Month with guest Dr. Aarti Bhatia April 11, 2021 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095