Radiation in the Care of Head and Neck Cancers

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer answers with
00:08 --> 00:10your host, doctor Aneese Chappar
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care by
00:14 --> 00:16welcoming oncologists and specialists
00:16 --> 00:18who are on the forefront of the
00:18 --> 00:20battle to fight cancer this week.
00:20 --> 00:21It's a conversation about radiation
00:21 --> 00:23in the care of head and neck
00:23 --> 00:24cancers with Doctor Melissa.
00:24 --> 00:27Young Doctor Young is an assistant
00:27 --> 00:28professor of clinical therapeutic
00:29 --> 00:31radiology at the Yale School of Medicine,
00:31 --> 00:33where Doctor Chappar is a
00:33 --> 00:34professor of surgical oncology.
00:36 --> 00:38Melissa, maybe we can start off by you
00:38 --> 00:39telling us a little bit more about
00:39 --> 00:41yourself and what it is that you do.
00:43 --> 00:44Thank you yes.
00:44 --> 00:46So I am a radiation oncologist with the
00:46 --> 00:49Yale Department of Therapeutic Radiology,
00:49 --> 00:52otherwise known as Radiation Oncology,
00:52 --> 00:55and we are a team that uses radiation
00:55 --> 00:58to help address cancer care,
00:58 --> 01:00either actually treating tumor and
01:00 --> 01:02eradicating tumor where surgery is
01:02 --> 01:04not the right option or using it in
01:04 --> 01:06what we call an adjuvant setting.
01:06 --> 01:08So I'm part of the head and neck
01:08 --> 01:11team and I'm the chief of the head
01:11 --> 01:13and neck radiation oncology team.
01:13 --> 01:14As part of our.
01:14 --> 01:15Practice throughout all of Connecticut
01:15 --> 01:17and the Yale Department of Radiation
01:17 --> 01:19and my role is to really help lead
01:19 --> 01:21our radiation team in the care of
01:21 --> 01:23specifically head and neck cancer patients.
01:24 --> 01:26So let's talk a little bit more
01:26 --> 01:29about head and neck cancer patients
01:29 --> 01:32and the role that radiation plays.
01:32 --> 01:34Tell us a little bit more about
01:34 --> 01:36how common head neck cancer is
01:36 --> 01:39and and who gets it and why. Yeah
01:39 --> 01:41so well, head and neck cancer is
01:41 --> 01:44the majority of what I treated.
01:44 --> 01:46It's one of the.
01:46 --> 01:48Less common cancers that might exist,
01:48 --> 01:51although it is about 5 to 8% of cancers
01:51 --> 01:53in the United States and classically
01:53 --> 01:56we used to consider head and neck
01:56 --> 01:59cancers largely in patients who had very
01:59 --> 02:01strong smoking or alcohol histories.
02:01 --> 02:04Typically cancers of the tongue, the throat,
02:04 --> 02:08tonsils and radiation is 1 modality
02:08 --> 02:13in which we can address cancer cure.
02:13 --> 02:16Radiation can be used to cure
02:16 --> 02:19certain types of cancers and is
02:19 --> 02:21commonly employed in larynx cancer,
02:21 --> 02:24throat cancers, tonsil cancer,
02:24 --> 02:26and base of tongue cancers is is
02:26 --> 02:28kind of the primary modality of cure,
02:28 --> 02:30although it can be used in the
02:30 --> 02:33what we call an adjuvant setting.
02:33 --> 02:35So after someone has had surgery may
02:35 --> 02:36have risk factors that indicate there
02:36 --> 02:38might be a higher risk of cancer
02:38 --> 02:40coming back if nothing more is done,
02:40 --> 02:42and so radiation may be employed
02:42 --> 02:45in that capacity. As well now.
02:45 --> 02:46More commonly,
02:46 --> 02:48we're starting to see a lot of
02:48 --> 02:50cancers in a non smoking population,
02:50 --> 02:52so a lot of people may have heard
02:52 --> 02:54about the human papilloma virus
02:54 --> 02:56and its association with cancers
02:56 --> 02:58and cervical cancer for women,
02:58 --> 03:00but we are starting to see quite an
03:00 --> 03:02uptick of this cancer for nonsmokers
03:02 --> 03:04who don't fit the classic criteria
03:04 --> 03:07for head and neck cancer who are
03:07 --> 03:08developing cancers either in their
03:08 --> 03:11tonsil or the base of tongue kind of
03:11 --> 03:13being the common areas and radiation
03:13 --> 03:15plays a large role in helping.
03:15 --> 03:17Your cancer for those patients.
03:18 --> 03:21So talk a little bit more about
03:21 --> 03:24HPV related cancers versus non
03:24 --> 03:26HPV related cancers. Are these?
03:26 --> 03:28Are these different in terms
03:28 --> 03:30of the anatomic sites in the
03:30 --> 03:32head and neck that they affect?
03:32 --> 03:35Are they different in the way in
03:35 --> 03:38which they present in their biology?
03:39 --> 03:42Absolutely. So I kind of alluded
03:42 --> 03:44to this earlier, but classically
03:44 --> 03:47we used to consider head and neck
03:47 --> 03:49cancers largely only exist in people
03:49 --> 03:51who had very strong risk factors,
03:51 --> 03:53such as smoking or drinking,
03:53 --> 03:56but the human papilloma virus cancers,
03:56 --> 03:58or the HPV cancers are actually cancers
03:58 --> 04:01that seem to have a different driver,
04:01 --> 04:05likely from a history of infection that laid
04:05 --> 04:08silent somewhere within the body, often and.
04:08 --> 04:10What's called the oropharynx,
04:10 --> 04:13so these seem to be more associated
04:13 --> 04:16with causing cancers of the tonsils
04:16 --> 04:19or the base of the tongue and
04:19 --> 04:20people who may have never smoked.
04:20 --> 04:23And often if we meet a new patient who
04:23 --> 04:25has a new cancer diagnosis and gives us
04:25 --> 04:27a history of never having smoked our,
04:27 --> 04:30our highest concern is that this
04:30 --> 04:33likely represents a hate HPV associated
04:33 --> 04:35cancer in terms of prognosis over
04:35 --> 04:37the last 10 to 20 years.
04:37 --> 04:39It's been well established.
04:39 --> 04:42Now that the HPV cancer is actually
04:42 --> 04:44can be cured at much higher rates,
04:44 --> 04:47the and in fact about four years ago
04:47 --> 04:49the staging system for head and neck
04:49 --> 04:51cancer was it was actually changed
04:51 --> 04:54to reflect the better prognosis for
04:54 --> 04:56people with HPV associated cancers,
04:56 --> 04:59and so we are finding that we were
04:59 --> 05:01curing patients at much higher
05:01 --> 05:03rates with HPV cancers.
05:03 --> 05:05Even if they presented with rather
05:05 --> 05:07large bulky disease for people who
05:07 --> 05:09have never smoked or have been non.
05:09 --> 05:10HPV associated cancers.
05:10 --> 05:13While they can exist in the tonsil,
05:13 --> 05:15the back of the tongue,
05:15 --> 05:17we typically see these more
05:17 --> 05:18in the oral cavity,
05:18 --> 05:19so that would include things
05:19 --> 05:21like the front of the tongue,
05:21 --> 05:22the gum line,
05:22 --> 05:24the areas along the the mandible
05:24 --> 05:27or the jawbone and also in the
05:27 --> 05:29larynx or the the vocal cord area.
05:29 --> 05:30The voice box.
05:30 --> 05:32Those tend to be a little
05:32 --> 05:34bit more difficult to cure,
05:34 --> 05:36usually require maybe some sort
05:36 --> 05:37of intensification of therapy.
05:37 --> 05:39And there are a lot of clinical
05:39 --> 05:40trials looking to see how we
05:40 --> 05:41might be able to intensify.
05:41 --> 05:45Therapy for the non HPV associated
05:45 --> 05:48cancers to improve cure in terms
05:48 --> 05:51of differences in presentation,
05:51 --> 05:51classically,
05:51 --> 05:53people who present with an HPV
05:53 --> 05:55associated virus may actually present
05:55 --> 05:57with a lymph node mass rather
05:57 --> 05:59than anything causing any throat
05:59 --> 06:01discomfort or swallowing difficulty.
06:01 --> 06:03The the classic picture is someone
06:03 --> 06:05presents with a enlarged lymph node in
06:05 --> 06:08their neck that didn't seem to get go away.
06:08 --> 06:11It may even be noticed after a cold perhaps,
06:11 --> 06:12but the lymph node.
06:12 --> 06:14Doesn't really resolve and continues
06:14 --> 06:16to stick around and persistent lymph
06:16 --> 06:18node is not typically a normal
06:18 --> 06:21behavior for a typical virus,
06:21 --> 06:23so therefore patients often present to
06:23 --> 06:25their physicians and then subsequently
06:25 --> 06:27undergo the workup that identifies
06:27 --> 06:30that they likely have a an HPV cancer.
06:32 --> 06:34So one of the things that many
06:34 --> 06:36people might be asking themselves
06:36 --> 06:39is that you know many times we hear
06:39 --> 06:41that everybody has been exposed
06:41 --> 06:43to HPV at one point or another.
06:43 --> 06:44It's pretty ubiquitous.
06:44 --> 06:49Why is it, then, that some people get HPV
06:49 --> 06:52related cancers and other people don't?
06:52 --> 06:54I mean, if head and neck cancers
06:54 --> 06:56are only 5 to 8% of all cancers
06:56 --> 06:59and yet over 80 to 90% of the
06:59 --> 07:01population has been exposed to HPV?
07:01 --> 07:04Which is an etiologic factor.
07:04 --> 07:06Why is there that disconnect?
07:06 --> 07:08Why do some people get HPV related
07:08 --> 07:10cancers versus others don't even
07:10 --> 07:12though they've been exposed?
07:13 --> 07:14It's an excellent question
07:14 --> 07:17in the area of active study.
07:17 --> 07:20It's it's really thought that for some small,
07:20 --> 07:21unfortunate group of people,
07:21 --> 07:24they may have had the virus actually
07:24 --> 07:26integrate into cells in such a way that
07:26 --> 07:29the immune system isn't able to detect.
07:29 --> 07:32So it basically lies dormant and somewhat
07:32 --> 07:34undetected for some period of time
07:34 --> 07:36and may exist then within the cells,
07:36 --> 07:40and they seem to hone in the non smoking
07:40 --> 07:43population to tonsil and base of tongue area.
07:43 --> 07:46Umm and over some period of time,
07:46 --> 07:48likely decades, induce some set of
07:48 --> 07:50mutations that kicks off a cancer.
07:50 --> 07:53Some people their immune system at
07:53 --> 07:54the time of diagnosis completely
07:54 --> 07:57eradicates all evidence of of the virus,
07:57 --> 07:59and there's never a chance for
07:59 --> 08:01it to incorporate into some cell
08:01 --> 08:03and lay dormant for decades,
08:03 --> 08:04so they subsequently never
08:04 --> 08:06develop a head and neck cancer,
08:06 --> 08:08but for some small cohort of persons
08:08 --> 08:10who were exposed early in their
08:10 --> 08:12lifetime are unfortunate enough to
08:12 --> 08:14basically have it rear its head.
08:14 --> 08:15Decades later,
08:15 --> 08:19so there's a lot of interest in,
08:19 --> 08:21and how the immune system may play into
08:21 --> 08:24this and how we might be able to boost
08:24 --> 08:27the immune system to maybe eradicate
08:27 --> 08:29any low levels if that's possible,
08:29 --> 08:31versus use the fact that this
08:31 --> 08:33is a virus associated cancer in
08:33 --> 08:35terms of how we treat it,
08:35 --> 08:38and maybe even someday being able to
08:38 --> 08:41screen people much like women with.
08:41 --> 08:43You know who have Pap smears?
08:43 --> 08:44Is there any way to, perhaps,
08:44 --> 08:45you know,
08:45 --> 08:47with Pap smears we're trying to
08:47 --> 08:49identify people who may have persistent
08:49 --> 08:51infection and therefore higher risk
08:51 --> 08:52of developing a cancer someday.
08:52 --> 08:54Right now there's no screening
08:54 --> 08:56tests or anything currently employed
08:56 --> 08:57in standard of practice,
08:57 --> 08:59but it is an area of of active
08:59 --> 09:00investigation across the country
09:00 --> 09:01and the world.
09:02 --> 09:04So do we find that the people who
09:04 --> 09:06get HPV related cancers tend to
09:06 --> 09:09have a lower level of immunity,
09:09 --> 09:11like they may be immunocompromised?
09:11 --> 09:13In some sort of way, it's
09:13 --> 09:15not typically what we have seen,
09:15 --> 09:16so we have not been able to pinpoint
09:16 --> 09:18that as being a specific risk factor.
09:18 --> 09:21We don't find it seems to be only in
09:21 --> 09:23the immune suppressed population.
09:23 --> 09:25Hmm, so that's interesting,
09:25 --> 09:28especially when you think about
09:28 --> 09:30the you know why it is that some
09:30 --> 09:32people get this HPV that turns
09:32 --> 09:35into a cancer versus not it it it.
09:35 --> 09:38You know what the the one hypothesis
09:38 --> 09:41of you know your immune system
09:41 --> 09:43might not be strong enough to kind
09:43 --> 09:45of Kick It Out at at the time.
09:45 --> 09:49Might not, might not play.
09:49 --> 09:51Might not be as central kind
09:51 --> 09:53of factor at play there I.
09:53 --> 09:56I wonder, you know when you were
09:56 --> 09:58talking about the immune system
09:58 --> 10:00and and HPV related cancers,
10:00 --> 10:02do we find that HPV related cancers are
10:02 --> 10:05are more immunogenic such that they
10:05 --> 10:07may respond better to immunotherapy?
10:07 --> 10:09Or is that not been found
10:09 --> 10:12to be the case either?
10:12 --> 10:15It's also a very active area investigation.
10:15 --> 10:17UM it's there can be some signatures
10:17 --> 10:19that indicate that by using
10:19 --> 10:21immune modulating drugs that there
10:21 --> 10:23may be some improved response,
10:23 --> 10:25but it really hasn't been proven and and
10:25 --> 10:28the you know up front kind of initial
10:28 --> 10:30phase of treatment setting but there
10:30 --> 10:31are many active clinical trials all
10:31 --> 10:33across the United States and the world
10:33 --> 10:36looking to see if this would play out.
10:36 --> 10:38We are still trying to understand
10:38 --> 10:40the true interplay of the immune
10:40 --> 10:42system and and how that May.
10:42 --> 10:44Maybe utilized for head and neck
10:44 --> 10:47cancer and if there's any greater
10:47 --> 10:49role for immune modulating therapies
10:49 --> 10:51for HPV cancer specifically,
10:52 --> 10:55you know when we think about getting back
10:55 --> 10:58to your particular area of expertise
10:58 --> 11:00in terms of radiation oncology.
11:00 --> 11:03Is there synergy between
11:03 --> 11:07immunotherapy and radiation therapy,
11:07 --> 11:09particularly in the head and neck?
11:10 --> 11:13Again, it hasn't been proven,
11:13 --> 11:15but there are clinical trials looking
11:15 --> 11:19to see if there might be ways to combine
11:19 --> 11:21immune mediated therapies and radiation
11:21 --> 11:24to maybe even offer lower doses of
11:24 --> 11:26radiation to potentially reduce side
11:26 --> 11:29effects of the radiation or classic
11:29 --> 11:31chemotherapy that may be utilized.
11:31 --> 11:33On the other hand,
11:33 --> 11:34it's not clearly proven,
11:34 --> 11:36and sometimes the concern might
11:36 --> 11:38be is that radiation actually
11:38 --> 11:39does also affect immune cells.
11:39 --> 11:42And if if you recruit immune cells
11:42 --> 11:43and then give them radiation,
11:43 --> 11:46are we kind of working against ourselves?
11:46 --> 11:48So it's it's a very active.
11:50 --> 11:52Arena of investigation.
11:52 --> 11:54When there are clinical trials
11:54 --> 11:57that have been looking to see if
11:57 --> 11:58immunotherapy instead of chemotherapy
11:58 --> 12:00and radiation may be utilized,
12:00 --> 12:03can immunotherapy and maybe lower
12:03 --> 12:06doses with chemotherapy be utilized?
12:06 --> 12:08I think we're going to learn a lot
12:08 --> 12:10over the next 10 years in terms of
12:10 --> 12:11of which combination of therapies
12:11 --> 12:13may prove to be most efficacious and
12:13 --> 12:16and improve an already high cure
12:16 --> 12:18rate for HPV associated cancers.
12:20 --> 12:22In you know when you start thinking
12:22 --> 12:24about combinations of therapy,
12:24 --> 12:27whether we use chemotherapy or immunotherapy,
12:27 --> 12:29and radiation therapy,
12:29 --> 12:31and sometimes surgery,
12:31 --> 12:34it really brings to mind the whole
12:34 --> 12:36aspect of multidisciplinary care.
12:36 --> 12:38Can you kind of talk about the
12:38 --> 12:40importance of that and head and
12:40 --> 12:41neck cancer and how that really
12:41 --> 12:43helps you to decide what you're
12:43 --> 12:45going to do in the management
12:45 --> 12:47of any particular patient?
12:48 --> 12:49Oh, absolutely so.
12:49 --> 12:51I couldn't do anything that I do
12:51 --> 12:53without the multidisciplinary team
12:53 --> 12:55which incorporates our medical
12:55 --> 12:58oncologists who administer chemotherapy.
12:58 --> 12:59The surgical oncologist,
12:59 --> 13:01specifically the head and neck surgeons,
13:01 --> 13:05who specialize in and assessing if a
13:05 --> 13:06patient is appropriate for surgery,
13:06 --> 13:10and if that may be a good modality.
13:10 --> 13:12To offer for upfront treatment so it
13:12 --> 13:14is a very important aspect of having
13:14 --> 13:17all team members really evaluate the
13:17 --> 13:20patient depending on a certain disease site,
13:20 --> 13:21it may be standard of care
13:21 --> 13:22to offer surgery up front,
13:22 --> 13:24which is classically of of
13:24 --> 13:25specifically oral cavity.
13:25 --> 13:27So front of the tongue cancers.
13:27 --> 13:29But for our HPV associated population
13:29 --> 13:31where it's typically tonsils or
13:31 --> 13:33the base of tongue or or maybe even
13:33 --> 13:35larynx cancer patients where a
13:35 --> 13:37comment you know where either surgery
13:37 --> 13:39or radiation may be appropriate,
13:39 --> 13:40having that multidisciplinary.
13:40 --> 13:43Team evaluate the patient is critical.
13:43 --> 13:45Our goal is to not only provide cure but
13:45 --> 13:47also to reduce side effects of treatment.
13:47 --> 13:49And if there's a way to offer only
13:49 --> 13:51one or two modalities rather than all
13:51 --> 13:53three modalities of cancer treatment,
13:53 --> 13:56we we feel we're offering good quality of
13:56 --> 13:58life for our patients after their cure.
13:58 --> 14:01So our multidisciplinary team is critical.
14:01 --> 14:02We often try to meet patients all
14:02 --> 14:04on the same day and we certainly
14:04 --> 14:06discuss our patients as part of a
14:06 --> 14:07team so that we can have a nice,
14:07 --> 14:10cohesive plan that is evidence based to
14:10 --> 14:12provide the best opportunity for cure.
14:12 --> 14:14But also for excellent functional outcomes.
14:15 --> 14:17Great, well, we're going to take a
14:17 --> 14:18short break for a medical minute,
14:18 --> 14:20but please stay tuned to learn more
14:20 --> 14:22about radiation oncology in the care
14:22 --> 14:23of head and neck cancer patients
14:23 --> 14:25with my guest doctor Melissa Young.
14:26 --> 14:29Funding for Yale Cancer answers comes
14:29 --> 14:31from Smilow Cancer Hospital presenting
14:31 --> 14:34the Susan Barrass MD brain tumor webinar
14:34 --> 14:37May 18th register at Yale Cancer Center.
14:37 --> 14:42Org or email cancer answers at yale.edu.
14:42 --> 14:44Genetic testing can be useful for
14:44 --> 14:46people with certain types of cancer
14:46 --> 14:48that seem to run in their families.
14:48 --> 14:50Genetic counseling is a process
14:50 --> 14:52that includes collecting a detailed
14:52 --> 14:54personal and family history,
14:54 --> 14:55a risk assessment,
14:55 --> 14:58and a discussion of genetic testing options.
14:58 --> 15:01Only about 5 to 10% of all cancers
15:01 --> 15:03are inherited, and genetic testing
15:03 --> 15:05is not recommended for everyone.
15:05 --> 15:07Individuals who have a personal
15:07 --> 15:09and or family history that includes
15:09 --> 15:11cancer at unusually early ages.
15:11 --> 15:12Multiple relatives.
15:12 --> 15:14On the same side of the family
15:14 --> 15:16with the same cancer,
15:16 --> 15:18more than one diagnosis of
15:18 --> 15:20cancer in the same individual.
15:20 --> 15:22Rare cancers or family history of a
15:22 --> 15:25known altered cancer predisposing gene
15:25 --> 15:28could be candidates for genetic testing.
15:28 --> 15:30Resources for genetic counseling and
15:30 --> 15:32testing are available at federally
15:32 --> 15:33designated comprehensive cancer
15:33 --> 15:36centers such as Yale Cancer Center
15:36 --> 15:38and its Milo Cancer Hospital.
15:38 --> 15:40More information is available
15:40 --> 15:41at yalecancercenter.org you're
15:41 --> 15:43listening to Connecticut.
15:43 --> 15:44Public radio
15:44 --> 15:47welcome back to yield cancer answers.
15:47 --> 15:48This is doctor Anish.
15:48 --> 15:50Chegg Park and I'm joined tonight
15:50 --> 15:52by my guest doctor Melissa Young.
15:52 --> 15:54We're learning about radiation oncology
15:54 --> 15:56in the care of head neck cancers and
15:56 --> 15:59right before the break there a couple
15:59 --> 16:01of points that I wanted to revisit.
16:01 --> 16:03The first is you know,
16:03 --> 16:07you mentioned that in some situations there
16:07 --> 16:12might be a role to escalate care and to
16:12 --> 16:15escalate the the radiation therapy that.
16:15 --> 16:17You're offering these patients,
16:17 --> 16:19and in other situations there
16:19 --> 16:21may be a role to deescalate.
16:21 --> 16:23Can you talk a little bit more
16:23 --> 16:25about how those decisions are made?
16:25 --> 16:27What factors go into it?
16:27 --> 16:29I I would surmise that a lot of that has to
16:29 --> 16:31do with that multidisciplinary team that
16:31 --> 16:33we talked about right before the break.
16:33 --> 16:35But what are the factors that
16:35 --> 16:36are considered when you think
16:36 --> 16:38about one way versus the other
16:38 --> 16:42in terms of the non HPV associated cancers?
16:42 --> 16:45While we provide excellent treatment?
16:45 --> 16:48And outcomes there are a group of patients
16:48 --> 16:50that tend to just have higher risks
16:50 --> 16:53of recurrence or lower survival rates.
16:53 --> 16:55So while we often initially provide
16:55 --> 16:59excellent whether it be surgery or radiation,
16:59 --> 17:02is the initial curative treatment.
17:02 --> 17:03These patients unfortunately are
17:03 --> 17:05still at higher risks of recurrence
17:05 --> 17:07and still sit around sometimes in the
17:07 --> 17:09range of only 60 to 80% cure rate.
17:09 --> 17:10Even without you know,
17:10 --> 17:12metastatic disease at diagnosis,
17:12 --> 17:13so our multidisciplinary team
17:13 --> 17:15is really geared towards.
17:15 --> 17:18Being able to provide the best in
17:18 --> 17:20terms of outcomes first of all,
17:20 --> 17:23so cure rates and if things of the tongue
17:23 --> 17:26might be first addressed by surgery,
17:26 --> 17:27but as a radiation oncologist and and
17:27 --> 17:29part of that multidisciplinary team
17:29 --> 17:31after a surgery has been performed,
17:31 --> 17:33we meet as a group to determine
17:33 --> 17:36whether or not there are risk factors
17:36 --> 17:38that weren't consideration of
17:38 --> 17:39potentially radiation and or addition
17:39 --> 17:42of chemotherapy as well to to try
17:42 --> 17:44to provide additional treatment to
17:44 --> 17:46reduce the risk of that recurrence.
17:46 --> 17:47Whether that be within the head and
17:47 --> 17:49neck area or elsewhere in the body,
17:49 --> 17:52so depending on certain factors,
17:52 --> 17:53we carefully evaluate all of these
17:53 --> 17:55patients to determine whether or not
17:55 --> 17:57they may be eligible for clinical
17:57 --> 17:59trial that might look to actually
17:59 --> 18:00potentially escalate treatment for
18:00 --> 18:02higher risk diseases where we know
18:02 --> 18:03the outcomes aren't quite as good.
18:03 --> 18:06And this is where exploring whether or
18:06 --> 18:08not immunotherapies may be of utility
18:08 --> 18:10and and help provide better chance
18:10 --> 18:12of long term cancer free survival and
18:12 --> 18:14and these are all things that are
18:14 --> 18:16determined as part of our multidisciplinary.
18:16 --> 18:16Team,
18:16 --> 18:18so whenever we're thinking about
18:18 --> 18:19escalation of therapy,
18:19 --> 18:21it's it's trying to determine whether or
18:21 --> 18:23not is that adding additional systemic
18:23 --> 18:26therapy from the medical oncology side,
18:26 --> 18:29whether that be additional types of
18:29 --> 18:30chemotherapy or immunotherapies,
18:30 --> 18:33and how does that interplay with radiation
18:33 --> 18:37therapy and also doses of radiation.
18:37 --> 18:39In terms of the concept of deescalation,
18:39 --> 18:41this is really more false into the
18:41 --> 18:44arena of the HPV associated cancers.
18:44 --> 18:46So earlier in the segment I mentioned
18:46 --> 18:49that the the cure rates are much
18:49 --> 18:51higher in in the HPV associated
18:51 --> 18:54population such that even the the
18:54 --> 18:56cancer staging was adjusted to reflect
18:56 --> 18:59that significantly better prognosis.
18:59 --> 19:01So patients who five years ago would have
19:01 --> 19:03been told they had stage four disease,
19:03 --> 19:05we told them we're still curing
19:05 --> 19:07you at 90% of the time.
19:07 --> 19:08Five years out,
19:08 --> 19:10so now we're able to tell these
19:10 --> 19:12patients they have stage one disease,
19:12 --> 19:13but our treatments really
19:13 --> 19:15hadn't changed much.
19:15 --> 19:17So the idea behind Escalation is
19:17 --> 19:19trying to figure out in a very careful,
19:19 --> 19:22safe kind of evidence based way on
19:22 --> 19:24clinical trials on are we able to
19:24 --> 19:27reduce some component of that treatment?
19:27 --> 19:30Are we able to offer shorter courses of
19:30 --> 19:32radiation with the same chemotherapy?
19:32 --> 19:32Alternatively,
19:32 --> 19:36can we adjust the chemotherapy that
19:36 --> 19:37we provide?
19:37 --> 19:39Are some some have proposed,
19:39 --> 19:40maybe immunotherapies,
19:40 --> 19:42maybe of utility here,
19:42 --> 19:45to avoid having to offer chemotherapies that
19:45 --> 19:47may have some component of side effects?
19:47 --> 19:50Alternatively, is there a way of
19:50 --> 19:53perhaps incorporating a surgery that
19:53 --> 19:55might be minimally invasive and lower
19:55 --> 19:57doses of radiation and still being able
19:57 --> 20:00to provide very high levels of cure?
20:00 --> 20:01A lot of our patients,
20:01 --> 20:03especially in the HPV setting,
20:03 --> 20:05are perhaps in their 40s or 50s,
20:05 --> 20:07and so have decades of of life.
20:07 --> 20:10Ahead of them still and we want to make
20:10 --> 20:12sure that they're able to enjoy that
20:12 --> 20:15time and not have a lot of difficulty
20:15 --> 20:17with their ability to taste food
20:17 --> 20:19the way they want or the ability to
20:19 --> 20:21produce saliva to induce and enjoy
20:21 --> 20:23the foods that they normally enjoy.
20:23 --> 20:25Could we reduce scar tissue
20:25 --> 20:27by lower doses of radiation,
20:27 --> 20:28if at all possible,
20:28 --> 20:31that might help reduce tightness in the neck
20:31 --> 20:33that may develop in the decades to come,
20:33 --> 20:37so it's an active area again
20:37 --> 20:38of investigation.
20:38 --> 20:39We're wanting to be mindful of
20:39 --> 20:41this because the last thing that
20:41 --> 20:43we want to find out is that by DE
20:43 --> 20:44intensifying or deescalating therapy,
20:44 --> 20:46now we're also providing lower
20:46 --> 20:47chances of cure,
20:47 --> 20:49so it's very important to do this
20:49 --> 20:51in a very controlled way and not
20:51 --> 20:52just make assumptions.
20:53 --> 20:55Yeah, and one would think that
20:55 --> 20:57you're multidisciplinary team beyond
20:57 --> 21:00having you know kind of the core
21:00 --> 21:02specialties of medical oncology and
21:02 --> 21:04radiation oncology and surgery who
21:04 --> 21:06really put their heads together to
21:06 --> 21:09figure out what might be the optimal.
21:09 --> 21:11Treatment plan also includes other
21:11 --> 21:15people who really are there to try
21:15 --> 21:17to improve quality of life, right?
21:17 --> 21:19So do you want to talk a little bit
21:19 --> 21:22more about the importance of those other
21:22 --> 21:24individuals and how they support that team?
21:25 --> 21:26Absolutely so I've I've spent
21:26 --> 21:29a lot of time talking about the
21:29 --> 21:30physicians or or medical providers
21:30 --> 21:32in that regard on the team,
21:32 --> 21:34but none of us can do what we do
21:34 --> 21:36and support our patients without
21:36 --> 21:38the assistance of our speech,
21:38 --> 21:39language pathology.
21:39 --> 21:39Departments,
21:39 --> 21:42so we sometimes we have providers
21:42 --> 21:44who are specialized in rehabilitation
21:44 --> 21:47of speech and swallow that may
21:47 --> 21:49be affected by either a surgical
21:49 --> 21:51procedure or the radiation treatment
21:51 --> 21:53that we use to cure cancer.
21:53 --> 21:56And so we find it very important
21:56 --> 21:58to incorporate the the speech
21:58 --> 22:00Swallow team very early on,
22:00 --> 22:02even if at all possible before treatment.
22:02 --> 22:05So as a multidisciplinary team we
22:05 --> 22:07can make assessments based on speech,
22:07 --> 22:09swallow breathing function to make
22:09 --> 22:10best determinations.
22:10 --> 22:12About should someone have surgery
22:12 --> 22:14or radiation and what might be the
22:14 --> 22:16effect of either of those treatments
22:16 --> 22:19on a person's functional outcome and
22:19 --> 22:21specifically during radiation treatment,
22:21 --> 22:26we find it very critical in in
22:26 --> 22:27keeping patients connected to
22:27 --> 22:29the speech Swallow team.
22:29 --> 22:30Even throughout radiation treatment,
22:30 --> 22:32really encouraging the use of the
22:32 --> 22:34muscles that might otherwise get weak
22:34 --> 22:36because of the radiation treatment
22:36 --> 22:38so that as soon as treatment is done
22:38 --> 22:40and we've established cure patients.
22:40 --> 22:42And get back to their hopefully
22:42 --> 22:43normal baseline function shortly
22:43 --> 22:45after completing treatment to
22:45 --> 22:47keep and preserve that function
22:47 --> 22:49even after treatments been given.
22:49 --> 22:49Similarly,
22:49 --> 22:52our nutrition team is highly
22:52 --> 22:54critical to to what we do.
22:54 --> 22:55A lot of these treatments,
22:55 --> 22:58whether it be surgery or radiation,
22:58 --> 23:00require manipulation and potential
23:00 --> 23:03injury to areas of the mouth and
23:03 --> 23:05the throat and the swallowing areas.
23:05 --> 23:08So it's quite natural that
23:08 --> 23:10without aggressive management.
23:10 --> 23:12Patients may naturally start to
23:12 --> 23:14have a decline in their weight
23:14 --> 23:16because it becomes more difficult to
23:16 --> 23:18swallow a more painful to swallow.
23:18 --> 23:20And despite our best efforts,
23:20 --> 23:23sometimes even with our speech swallow team,
23:23 --> 23:24there can be some difficulty
23:24 --> 23:27getting certain types of food down.
23:27 --> 23:29And so without specific intervention
23:29 --> 23:31with our nutrition and dietary team,
23:31 --> 23:34patients are at very high risk of
23:34 --> 23:35developing malnourishment during
23:35 --> 23:37radiation treatment or after
23:37 --> 23:38a surgical procedure,
23:38 --> 23:40and these are difficult treatments to
23:40 --> 23:41get through, which are going to be made.
23:41 --> 23:43More difficult to get through
23:43 --> 23:44if malnourishment continues
23:44 --> 23:45throughout treatment.
23:45 --> 23:48So our dietitians and team is very critical
23:48 --> 23:51and providing nutritional guidance.
23:51 --> 23:53Whether it's different textures,
23:53 --> 23:55nutritional supplements such
23:55 --> 23:56as boost and shore,
23:56 --> 23:59but a little bit more nuanced than that.
23:59 --> 24:01To really help ensure we can try
24:01 --> 24:03to prevent malnourishment as much
24:03 --> 24:05as possible during any head and
24:05 --> 24:06neck cancer treatment,
24:06 --> 24:08and then also helping support
24:08 --> 24:10them through that recovery as
24:10 --> 24:12soon as treatment is complete.
24:12 --> 24:12It's natural,
24:12 --> 24:14a lot of people come to us and say Oh well,
24:14 --> 24:16I've got 20 or 30 pounds to lose.
24:16 --> 24:18But unfortunately any cancer
24:18 --> 24:20treatment requires a lot of
24:20 --> 24:22calories and proteins to heal,
24:22 --> 24:23so it's quite critical that we have
24:23 --> 24:25established a a very important goal in
24:25 --> 24:27terms of nutrition to prevent weight loss,
24:27 --> 24:28which can cause malnourishment
24:28 --> 24:30even in someone who might be
24:30 --> 24:33£300 at the start so that we can continue
24:33 --> 24:35their treatment on interrupted and provide
24:35 --> 24:38them the best chance first for cure,
24:38 --> 24:40but then also preservation of function and
24:40 --> 24:42quality of life after treatment is complete.
24:42 --> 24:44So all of these. All of these members,
24:44 --> 24:46not just the physicians, but our speech,
24:46 --> 24:48swallow, nutrition and social
24:48 --> 24:50work is also critical here too.
24:50 --> 24:52A lot of people may have to
24:52 --> 24:53take time away from work,
24:53 --> 24:57may have travel difficulties,
24:57 --> 24:59transportation issues,
24:59 --> 25:01and and really need a lot of
25:01 --> 25:03assistance in order to get through
25:03 --> 25:04this very complex treatment.
25:04 --> 25:06And so our social work team is a key
25:06 --> 25:08integral part in understanding what we
25:08 --> 25:10can do to help support our patients.
25:10 --> 25:12Again with the entire team.
25:12 --> 25:15Not just curing a cancer in a patient,
25:15 --> 25:17but also supporting a patient going
25:17 --> 25:18through cancer and we're really
25:18 --> 25:20trying to treat an individual,
25:20 --> 25:21just not a tumor.
25:22 --> 25:24And the other piece,
25:24 --> 25:26I think that you had mentioned
25:26 --> 25:29briefly when we were talking about the
25:29 --> 25:31multidisciplinary team is is really
25:31 --> 25:35clinical research and and clinical trials.
25:35 --> 25:37Before the break we were talking
25:37 --> 25:40about a number of areas where where
25:40 --> 25:42you were saying that there's active
25:42 --> 25:44areas of of investigation going on.
25:44 --> 25:46So talk a little bit about the
25:46 --> 25:49importance of of clinical trials and
25:49 --> 25:51some of the exciting clinical trials
25:51 --> 25:53that you see coming down the Pike.
25:53 --> 25:55That patients with head and neck
25:55 --> 25:58cancers should avail themselves of.
25:58 --> 26:01Right, so I think when we first sometimes
26:01 --> 26:03discuss clinical trials to patients,
26:03 --> 26:04I think the natural inclination
26:04 --> 26:05is thinking, oh, goodness,
26:05 --> 26:07you know that must be a bad sign if they
26:07 --> 26:09want to talk about a clinical trial,
26:09 --> 26:11but I can't emphasize enough that the
26:11 --> 26:13clinical trials are used in all phases
26:13 --> 26:15of cancer care and not just when all
26:15 --> 26:17things are lost and we have no other
26:17 --> 26:19options specifically and and head and
26:19 --> 26:22neck cancer because we are looking at
26:22 --> 26:24ways to either help improve outcomes
26:24 --> 26:26at the initial curative treatment.
26:26 --> 26:28Clinical trials are very critical.
26:28 --> 26:30Important part of helping move our
26:30 --> 26:32field forward so that we can, UM,
26:32 --> 26:37more carefully find what types of
26:37 --> 26:39treatments might be of utility to help
26:39 --> 26:41improve outcomes so whenever possible,
26:41 --> 26:43every patient is screened for
26:43 --> 26:45clinical trial eligibility.
26:45 --> 26:47Therefore that we know that we are
26:47 --> 26:48providing the highest quality of
26:48 --> 26:50care and providing every option
26:50 --> 26:52for a patient who is interested
26:52 --> 26:54in whatever options may exist.
26:54 --> 26:56Now. Sometimes patients may end up
26:56 --> 26:57just receiving standard of care,
26:57 --> 26:58so sometimes.
26:58 --> 27:00Clinical trials are designed such
27:00 --> 27:03that we're trying to compare what the
27:03 --> 27:05current standard of care is compared to
27:05 --> 27:08either a reduced treatment or a more
27:08 --> 27:10intense treatment depending on the
27:10 --> 27:13goal or or specific question being answered,
27:13 --> 27:18and so these are clinical trials that we
27:18 --> 27:20champion and feel are really important
27:20 --> 27:22for helping move our field forward,
27:23 --> 27:25but also ethically decided these are our
27:25 --> 27:28clinical trials that have been vetted.
27:28 --> 27:30Usually institutionally as well as
27:30 --> 27:33nationally to make sure that there were
27:33 --> 27:35not potentially withholding treatments
27:35 --> 27:37that that have established importance,
27:37 --> 27:40but also maybe not making great leaps
27:40 --> 27:42and assuming that something might be
27:42 --> 27:44better when it may not be so important.
27:44 --> 27:45Again,
27:45 --> 27:48therapies and and adjuvant treatments that
27:48 --> 27:50might be incorporated are immunotherapies.
27:50 --> 27:52I I will admit,
27:52 --> 27:53I'm not sure exactly where
27:53 --> 27:54immunotherapies are going to take
27:54 --> 27:56us in the head and neck cancer,
27:56 --> 27:57but they've been incredibly
27:57 --> 27:59promising in lung cancer.
27:59 --> 28:01And there's been a lot of excitement
28:01 --> 28:02of how immunotherapies may play
28:02 --> 28:04a role in head and neck cancer.
28:04 --> 28:07So certainly in our practice we have
28:07 --> 28:10patients who would be eligible for
28:10 --> 28:12potentially having immunotherapy
28:12 --> 28:14at some part of their treatment,
28:14 --> 28:16and we're trying to learn if it's going
28:16 --> 28:18to help improve outcomes down the line.
28:18 --> 28:18Also,
28:18 --> 28:19I anticipate some surgical
28:19 --> 28:21trials coming down the line.
28:21 --> 28:24It should be very exciting to see
28:24 --> 28:26if there's ways of also helping
28:26 --> 28:28modify how surgery is done,
28:28 --> 28:30but also help reduce toxicity of surgery.
28:30 --> 28:31On the line.
28:31 --> 28:34Doctor Melissa Young is an assistant
28:34 --> 28:36professor of clinical therapeutic
28:36 --> 28:38radiology at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu
28:42 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public radio
28:55 --> 28:57funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Radiation in the Care of Head and Neck Cancers with guest Dr. Melissa Young April 17, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095