Surgery in the Care of Head and Neck Cancers

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer answers with
00:08 --> 00:10your host, Doctor Annise 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 the
00:21 --> 00:23surgical care of head and neck
00:23 --> 00:24cancers with Doctor Avanti.
00:24 --> 00:26Vermont Doctor Verma is an
00:26 --> 00:28assistant professor of surgery and
00:28 --> 00:30otolaryngology at the Yale School
00:30 --> 00:32of Medicine where Doctor Chappar is
00:32 --> 00:34a professor of surgical oncology.
00:35 --> 00:37Maybe we can start off ivanti by you
00:37 --> 00:39telling us a little bit more about
00:39 --> 00:41yourself and what it is that you do.
00:42 --> 00:45Yes, so I am a I like to describe
00:45 --> 00:47myself as a surgical oncologist within
00:47 --> 00:50the field of ENT and particularly
00:50 --> 00:54head and neck surgery so you know as
00:54 --> 00:56surgical oncologists we work very
00:56 --> 00:57closely with the multidisciplinary
00:57 --> 01:00team and we often are some of the
01:00 --> 01:02initial people within the oncology team
01:02 --> 01:05to see patients with head and neck
01:05 --> 01:07cancer because these patients tend to
01:07 --> 01:09have symptoms related to the head and
01:09 --> 01:11neck region and then present to ear,
01:11 --> 01:12nose and throat.
01:12 --> 01:15Doctors who would then refer patients over
01:15 --> 01:17to us if they're concerned about cancer,
01:17 --> 01:22and so, so in managing these patients,
01:22 --> 01:24maybe we can start off by you
01:24 --> 01:26telling us a little bit more about
01:26 --> 01:28who exactly these people are.
01:28 --> 01:29I mean, when we think about
01:29 --> 01:30head and neck cancers,
01:30 --> 01:31the head and the neck,
01:31 --> 01:33although a small space,
01:33 --> 01:36has got a lot of stuff in it.
01:36 --> 01:38So tell us a little bit more about the
01:38 --> 01:41types of cancers that you deal with.
01:41 --> 01:44Yes, the. Most common type of head
01:44 --> 01:47and neck cancer arises from the
01:47 --> 01:50lining of the aerodigestive tract.
01:50 --> 01:53As we say, so it could be in the nose,
01:53 --> 01:56the sinuses if we go further down the
01:56 --> 01:58oral cavity where the tongue, lips,
01:58 --> 02:01cheeks are the inside of your cheeks and
02:01 --> 02:04then even further down into the throat.
02:04 --> 02:08So the voice box and even the upper
02:08 --> 02:11esophagus and the vast majority
02:11 --> 02:13of cancers come from these areas.
02:13 --> 02:15But head and neck cancers can also
02:15 --> 02:18arise in the neck in the lymph nodes
02:18 --> 02:19or in the salivary glands as well,
02:20 --> 02:23and so are there particular patients who
02:23 --> 02:26are at risk of these types of cancers.
02:27 --> 02:29Yes, the most common risk factor
02:29 --> 02:32that is talked about traditionally
02:32 --> 02:34is tobacco use, smoking,
02:34 --> 02:37chewing, tobacco, even cigar use,
02:37 --> 02:39but something that also sometimes goes
02:39 --> 02:41along with this and has a synergistic
02:41 --> 02:44effect with this in terms of causing.
02:44 --> 02:45Answers is alcohol use as
02:45 --> 02:49well and so is there a demographic
02:49 --> 02:52that's more prone than than others?
02:52 --> 02:54I mean is this mainly older people?
02:54 --> 02:55Younger people.
02:55 --> 02:59Do we see a racial or a gender
02:59 --> 03:01or an ethnic variation?
03:01 --> 03:04Yes, so generally
03:04 --> 03:07as people use these substances,
03:07 --> 03:09you know there's an increased effect
03:09 --> 03:12over time and so the traditionally
03:12 --> 03:14the majority of our patients.
03:14 --> 03:16Or older, but we do see head
03:16 --> 03:18and neck cancers in younger
03:18 --> 03:20patients sometimes as well.
03:20 --> 03:23And I know that you know in the past
03:23 --> 03:25decade or two there's been a big rise,
03:25 --> 03:27particularly in North America and
03:27 --> 03:29in Northern Europe of squamous
03:29 --> 03:31cell carcinomas of the throat,
03:31 --> 03:32in particular being related
03:32 --> 03:34to the human papilloma virus,
03:34 --> 03:36so that tends to manifest
03:36 --> 03:38in younger patients.
03:38 --> 03:41It it's interesting that you you
03:41 --> 03:43note that HPV related cancers
03:43 --> 03:46tend to occur in younger patients.
03:46 --> 03:49Why is that? I mean, one would
03:49 --> 03:53think that younger people would be.
03:53 --> 03:57In an age group where they would have been
03:57 --> 04:00able to avail themselves of the HPV vaccine,
04:00 --> 04:05did we find that HPV related cancers
04:05 --> 04:08are a different biological beast that
04:08 --> 04:11tend to affect younger people? Yeah,
04:11 --> 04:13that's a that's a great question.
04:13 --> 04:16The mechanisms are definitely different.
04:16 --> 04:19The vast majority of the population does
04:19 --> 04:21get exposed to the human papilloma virus.
04:21 --> 04:24I think the numbers about 85% and it
04:24 --> 04:27does happen at a relatively young age.
04:27 --> 04:30It is associated with sexual activity,
04:30 --> 04:31and that's why you know that when
04:31 --> 04:33we speak about vaccinations,
04:33 --> 04:36we try to target, you know.
04:36 --> 04:41Preteens, mostly for the for vaccination,
04:41 --> 04:45but anyway, we've seen these cancers manifest
04:45 --> 04:47in patients even as young as their 30s,
04:47 --> 04:50but traditionally 40s, fifties, 60s,
04:50 --> 04:53and that that happens even decades,
04:53 --> 04:54potentially after they've
04:54 --> 04:56been exposed to the virus
04:57 --> 05:00and and so you know,
05:00 --> 05:02certainly a good thing to keep
05:02 --> 05:05in mind for parents who may be
05:05 --> 05:08listening to us so that. You know,
05:08 --> 05:11we think that HPV can cause cancers,
05:11 --> 05:13particularly in young adults,
05:13 --> 05:16and so it's really important to
05:16 --> 05:19vaccinate your children against HPV,
05:19 --> 05:21because potentially that can
05:21 --> 05:23prevent a cancer.
05:23 --> 05:23Is that right?
05:24 --> 05:25Yes, exactly it.
05:25 --> 05:28You know it took some time for the
05:28 --> 05:31vaccination to be available to young boys,
05:31 --> 05:34and I know initially it was girls
05:34 --> 05:35because of cervical cancer,
05:35 --> 05:37but we do actually.
05:37 --> 05:40More commonly, we don't know exactly why,
05:40 --> 05:42but more commonly, see this in men late,
05:42 --> 05:44you know in those decades that
05:44 --> 05:46I mentioned 30s, Forties, 50s,
05:46 --> 05:49even in 60s and beyond as possible too.
05:49 --> 05:52So it's very important for both boys and
05:52 --> 05:54girls to get vaccinated against HPV.
05:55 --> 05:57And so you know when you think
05:57 --> 06:01about how people present.
06:01 --> 06:04You know, we know that for many other
06:04 --> 06:07more common cancers, breast cancer,
06:07 --> 06:09colon cancer, cervical cancer,
06:09 --> 06:11even lung cancer we have.
06:11 --> 06:13We have good screening tools that
06:13 --> 06:17help us to find these cancer early.
06:17 --> 06:18What about for head and neck cancer?
06:19 --> 06:22Yes, you know there isn't really a
06:22 --> 06:24great screening test that has been
06:24 --> 06:27shown to improve survival or outcomes.
06:27 --> 06:29We do, you know now that it's head
06:29 --> 06:31and neck cancer Awareness Month we do.
06:31 --> 06:33And I've participated in cancer screenings
06:33 --> 06:35that we offer to the Community,
06:35 --> 06:37and I think that's great.
06:37 --> 06:40But the reality is that a lot of
06:40 --> 06:42these cancers do present relatively
06:42 --> 06:45early because of the effect that
06:45 --> 06:47it causes on the patient.
06:47 --> 06:49Like you said, the the head and neck is
06:49 --> 06:51a region that just has so much going on,
06:51 --> 06:53so sometimes patients will notice,
06:53 --> 06:55you know, a change in their voice,
06:55 --> 06:58or even a lump in the neck or some other
06:58 --> 07:01change in their day-to-day that might.
07:01 --> 07:03Prompt a closer look at that.
07:04 --> 07:07Yeah, so important, you know,
07:07 --> 07:08and I think the other.
07:08 --> 07:14The other issue is this is another.
07:14 --> 07:17Prompt for people to make their
07:17 --> 07:19annual appointment to see their
07:19 --> 07:21dentist because oftentimes a
07:21 --> 07:23dentist looking in your mouth
07:23 --> 07:25can often find things that may
07:25 --> 07:27make them curious about whether
07:27 --> 07:28something could be a cancer.
07:28 --> 07:29Is that right?
07:30 --> 07:31Yes, that's very important.
07:31 --> 07:34A lot of patients who come to us
07:34 --> 07:36with lesions in the oral cavity,
07:36 --> 07:38in particular their first found by
07:38 --> 07:40their dentist during routine screenings.
07:40 --> 07:42So it sometimes patients don't
07:42 --> 07:44always prioritize seeing the dentist.
07:44 --> 07:47And I think it's very important because
07:47 --> 07:49that's how things can get caught early.
07:49 --> 07:52Yeah, so do you
07:52 --> 07:55think that the majority of head
07:55 --> 07:57neck cancers present at a later
07:57 --> 08:00stage or or are we actually
08:00 --> 08:02picking these up earlier? I think
08:02 --> 08:04the the majority actually do
08:04 --> 08:06present at an earlier stage
08:07 --> 08:09because of the impact on function.
08:09 --> 08:12And the that kind of prompts the patient
08:12 --> 08:16to to seek further attention. You know,
08:16 --> 08:18different cancers behave differently,
08:18 --> 08:20though some some behave more
08:20 --> 08:21aggressively than others.
08:21 --> 08:23Once they are found. So we do.
08:23 --> 08:25When we do see patients with cancer,
08:25 --> 08:28we do a full work up,
08:28 --> 08:30including imaging of the head and neck,
08:30 --> 08:31with careful attention to the lymph
08:31 --> 08:33nodes in the neck and even the chest.
08:33 --> 08:36Also to make sure that we know
08:36 --> 08:38the extent of the disease.
08:38 --> 08:40So tell us a little bit more.
08:40 --> 08:43About the role of surgery in the
08:43 --> 08:46management of these patients is surgery
08:46 --> 08:48one of the mainstays of therapy? Yes,
08:48 --> 08:50I would say it is the interesting
08:50 --> 08:52thing about the head and neck is
08:52 --> 08:54that in itself is not a very you
08:54 --> 08:56know a smaller area of the body,
08:56 --> 08:59but it's divided into many sites within
08:59 --> 09:03the head and neck and our treatment often
09:03 --> 09:07depends on where this cancer is presenting.
09:07 --> 09:11So for example, cancers in the oral cavity.
09:11 --> 09:14Involving the gums. The lift,
09:14 --> 09:17the inner lining of the cheek, the tongue.
09:17 --> 09:19Those are predominantly treated
09:19 --> 09:22surgically up front and then thought,
09:22 --> 09:23you know, we could consider
09:23 --> 09:25following it with either radiation or
09:25 --> 09:27chemotherapy depending on the results,
09:27 --> 09:29but there's other other sites of the
09:29 --> 09:32head and neck that are not necessarily
09:32 --> 09:34treated upfront with surgery.
09:34 --> 09:37Some of the early cancers of the voice box,
09:37 --> 09:38for example,
09:38 --> 09:41there's a notion of organ preservation.
09:41 --> 09:42For example,
09:42 --> 09:45where we could treat those potentially
09:45 --> 09:46with chemotherapy and radiation
09:46 --> 09:48combined and try to preserve
09:48 --> 09:50structures of the voice box.
09:51 --> 09:52But one would think even
09:52 --> 09:54for things like the tongue,
09:54 --> 09:58the lips that that really preservation
09:58 --> 10:00of function is really important.
10:00 --> 10:01I mean, because when we think
10:01 --> 10:03about the head and neck,
10:03 --> 10:05there's so many structures that are
10:05 --> 10:07so vital for everything that we do
10:07 --> 10:09from speaking to eating, to smiling.
10:09 --> 10:13So how do you do that as part
10:13 --> 10:17of a multidisciplinary team,
10:17 --> 10:20even when surgery is going to be one of
10:20 --> 10:23the modalities that's going to be used.
10:24 --> 10:25Yes, so first of all,
10:25 --> 10:28when we do see a patient with cancer of
10:28 --> 10:30the head and neck no matter where it is,
10:30 --> 10:33we do always make sure that we have
10:33 --> 10:35a multidisciplinary evaluation.
10:35 --> 10:37So our colleagues that we work very
10:37 --> 10:38closely with the radiation oncologists
10:38 --> 10:41and the medical oncologists will
10:41 --> 10:42evaluate the patient as well.
10:42 --> 10:44And we have a, you know,
10:44 --> 10:47huge team of speech and swallow therapists,
10:47 --> 10:48nutritionists,
10:48 --> 10:51social workers who also get involved.
10:51 --> 10:52And so the patient often is
10:52 --> 10:54flooded with a lot of appointments.
10:54 --> 10:56Up front and we do, you know,
10:56 --> 10:57inform the patient that that's
10:57 --> 10:58what they should expect,
10:58 --> 11:01and then after that we reconvene.
11:01 --> 11:04We discuss at our multidisciplinary
11:04 --> 11:06tumor board about what the
11:06 --> 11:08best treatment would be,
11:08 --> 11:10and so even before we go to
11:10 --> 11:12surgery we we talk about all
11:12 --> 11:14these other options and all these
11:14 --> 11:16other considerations and the
11:16 --> 11:19impact on function in particular
11:20 --> 11:22and has surgical techniques
11:22 --> 11:24evolved to a point.
11:24 --> 11:27Where either you're using more
11:27 --> 11:30minimally invasive techniques where
11:30 --> 11:34you can preserve a lot of the organ
11:34 --> 11:36function and or have the ability
11:36 --> 11:39to to reconstruct so that people
11:39 --> 11:41don't lose a lot of function.
11:42 --> 11:44Yes, I think you know.
11:44 --> 11:46In the past several decades there's been
11:46 --> 11:49a lot of advances on in both areas,
11:49 --> 11:52reconstruction and minimally
11:52 --> 11:55invasive surgery in the.
11:55 --> 11:571970s, that pectoralis flap,
11:57 --> 11:59which is the muscle from the chest
11:59 --> 12:01that was invented at Yale and that
12:01 --> 12:04has been one of the the mainstays
12:04 --> 12:06of head and neck reconstruction.
12:06 --> 12:08But in addition to that,
12:08 --> 12:11a lot of reconstruction to
12:11 --> 12:12preserve function is performed
12:12 --> 12:15by using a free tissue transfer,
12:15 --> 12:17which is essentially tissue that
12:17 --> 12:20is transplanted from one part of
12:20 --> 12:22the body and brought to the head
12:22 --> 12:25and neck region to reconstruct.
12:25 --> 12:27That defect that is left behind
12:27 --> 12:29and to help restore function
12:29 --> 12:30along with rehabilitation.
12:32 --> 12:34And and tell us a little bit more about
12:34 --> 12:36the minimally invasive techniques.
12:36 --> 12:38I mean because when people are thinking
12:38 --> 12:40about surgery for the head and neck,
12:40 --> 12:42oftentimes you know the pictures that
12:42 --> 12:45go through people's head may be things
12:45 --> 12:47that seem really quite gruesome,
12:47 --> 12:50where large segments of of the
12:50 --> 12:53face of the mouth of the tongue
12:53 --> 12:56of the jaw have been removed.
12:56 --> 12:57And potentially reconstructed,
12:57 --> 13:00but are there minimally invasive
13:00 --> 13:02techniques that can address certain
13:02 --> 13:04kinds of cancers and and talk to
13:04 --> 13:07us a little bit more about that?
13:07 --> 13:09Yes, there's two major
13:09 --> 13:11minimally invasive techniques that exist.
13:11 --> 13:14One is using the laser with a microscope,
13:14 --> 13:16and that has been around longer.
13:16 --> 13:18That's particularly useful in the voice
13:18 --> 13:21box and in the back of the throat too,
13:21 --> 13:24but robotic surgery has been
13:24 --> 13:26a big development since the.
13:26 --> 13:28Early 2000s it's been used and that
13:28 --> 13:31really helps us access areas that
13:31 --> 13:33are otherwise difficult to see,
13:33 --> 13:34including the base of the
13:34 --> 13:36tongue and the tonsils,
13:36 --> 13:38and that's used commonly in in
13:38 --> 13:40the cancers that develop in
13:40 --> 13:41these regions related to HPV.
13:42 --> 13:44Great, well you know we need to
13:44 --> 13:46take a short break for a medical
13:46 --> 13:48minute but please stay tuned to
13:48 --> 13:50learn more about the surgical
13:50 --> 13:52care of head and neck patients
13:52 --> 13:55with my guest doctor Ivanti Verma
13:55 --> 13:57funding for Yale Cancer Answers
13:57 --> 13:59comes from Smilow Cancer Hospital
13:59 --> 14:01presenting the Susan Barras,
14:01 --> 14:04MD brain tumor webinar May 18th.
14:04 --> 14:07Register at yalecancercenter.org or
14:07 --> 14:10email cancer answers at yale.edu.
14:12 --> 14:15Over 230,000 Americans will be diagnosed with
14:15 --> 14:18lung cancer this year and in Connecticut
14:18 --> 14:21alone there will be over 2700 new cases.
14:21 --> 14:24More than 85% of lung cancer diagnosis are
14:24 --> 14:27related to smoking and quitting even after
14:27 --> 14:30decades of use can significantly reduce your
14:30 --> 14:33risk of developing lung cancer each day.
14:33 --> 14:35Patients with lung cancer are surviving
14:35 --> 14:38thanks to increased access to advanced
14:38 --> 14:39therapies and specialized care.
14:39 --> 14:40New treatment options.
14:40 --> 14:42And surgical techniques are giving
14:42 --> 14:44lung cancer survivors more hope
14:44 --> 14:46than they have ever had before.
14:46 --> 14:48Clinical trials are currently
14:48 --> 14:50underway at federally designated
14:50 --> 14:51Comprehensive cancer centers,
14:51 --> 14:54such as the battle two trial at Yale
14:54 --> 14:55Cancer Center and Smilow Cancer Hospital
14:55 --> 14:58to learn if a drug or combination of drugs
14:58 --> 15:01based on personal biomarkers can help
15:01 --> 15:04to control non small cell lung cancer.
15:04 --> 15:07More information is available at
15:07 --> 15:08yalecancercenter.org you're listening
15:08 --> 15:10to Connecticut Public Radio.
15:11 --> 15:13Welcome back to Yale Cancer answers.
15:13 --> 15:16This is doctor anise Chappar and I'm joined
15:16 --> 15:18tonight by my guest Doctor Avanti Verma.
15:18 --> 15:20We're learning more about the surgical
15:20 --> 15:22management of head and neck cancer
15:22 --> 15:25patients in honor of head and neck
15:25 --> 15:27Cancer Awareness Month now Avanti,
15:27 --> 15:29right before the break you started
15:29 --> 15:31talking about robotic surgery and you
15:31 --> 15:33know here on this show we've heard a
15:33 --> 15:36lot about robotic surgery and the fact
15:36 --> 15:38that it helps surgeons to kind of get
15:38 --> 15:41a little bit more dexterity and get
15:41 --> 15:43into areas where they normally can't.
15:43 --> 15:46Get talk to us a little bit more
15:46 --> 15:48about how that really is playing a
15:48 --> 15:51role and and whether you think that
15:51 --> 15:54that's going to become more and more.
15:54 --> 15:56You know with technique of choice.
15:57 --> 16:00Yes, I I think robotic surgery has
16:00 --> 16:03been and continues to become more and
16:03 --> 16:06more a technique of choice and even the
16:06 --> 16:09technology is improving with new models.
16:09 --> 16:11The the head and neck and and
16:11 --> 16:12the mouth and the throat.
16:12 --> 16:15It's a narrow area and traditionally
16:15 --> 16:18to access the back of the throat
16:18 --> 16:21involved a big approach through the
16:21 --> 16:24the jawbone to be able to see back
16:24 --> 16:27there and and so with the robot.
16:27 --> 16:29There's flexible arms that can go into
16:29 --> 16:31the mouth and into the throat with a camera,
16:31 --> 16:34and you can really see things you
16:34 --> 16:37know up close and in a better
16:37 --> 16:39way than than previously.
16:39 --> 16:42And so the this helps us with as
16:42 --> 16:44surgeons do what we need to do,
16:44 --> 16:47which in general is to remove the tumor
16:47 --> 16:50and get negative margins without causing
16:50 --> 16:52damage to surrounding structures or
16:52 --> 16:56nerves or blood vessels that are important.
16:56 --> 16:59And so I think that's really revolutionized.
16:59 --> 17:01Our ability to take care of patients
17:01 --> 17:03who have cancers in these areas.
17:03 --> 17:06It's been particularly used for patients
17:06 --> 17:10with the HPV related cancers of the throat,
17:10 --> 17:13and there's been trials and data that
17:13 --> 17:17have shown that it's it's a great way
17:17 --> 17:20to to treat patients that should be
17:20 --> 17:22considered that successful surgery can
17:22 --> 17:25sometimes even result in patients not
17:25 --> 17:27needing additional therapy in earlier
17:27 --> 17:30stages and even in intermediate stages.
17:30 --> 17:32Maybe reduced dose of
17:32 --> 17:34radiation after surgery?
17:35 --> 17:35That's interesting.
17:35 --> 17:37I mean that you mentioned
17:37 --> 17:39that it's particularly useful
17:39 --> 17:42for HPV related cancers.
17:42 --> 17:43Why would that be?
17:43 --> 17:47I mean, I can understand why robotic
17:47 --> 17:50surgery may be particularly useful
17:50 --> 17:53in a very narrow kind of relatively
17:53 --> 17:55inaccessible anatomic site,
17:55 --> 17:58but why would the etiologic
17:58 --> 18:01factor HPV versus not?
18:01 --> 18:04HPV make a difference to
18:04 --> 18:06the surgical approach. Yes.
18:06 --> 18:10I think a lot. A lot of this has to do
18:10 --> 18:14with how the HPV virus related cancers
18:14 --> 18:16behave and so most commonly patients
18:16 --> 18:19who develop this type of cancer actually
18:19 --> 18:21present not with throat symptoms but
18:21 --> 18:23amass a painless mass of the neck
18:24 --> 18:27when you talk about HPV related cancers
18:27 --> 18:31versus not HPV related cancers it it now.
18:31 --> 18:33Seems to suggest that
18:33 --> 18:35these behave differently.
18:35 --> 18:38Do we know anything about their
18:38 --> 18:42prognosis in terms of how well people
18:42 --> 18:45fare and whether you know even
18:45 --> 18:47whether they are more susceptible
18:47 --> 18:50to other modes of therapy as well?
18:51 --> 18:54Yes, we we do know that the HPV
18:54 --> 18:58related cancers of the throat do
18:58 --> 19:00have a better prognosis compared
19:00 --> 19:03to the ones that are related to.
19:03 --> 19:05Tobacco use or alcohol use,
19:05 --> 19:08and that's been shown and even
19:08 --> 19:12when we you know do have studies.
19:12 --> 19:14Looking at robotic surgery and different
19:14 --> 19:16levels of radiation afterwards,
19:16 --> 19:18plus or minus chemotherapy,
19:18 --> 19:22even the survivals that we see are,
19:22 --> 19:24you know 90% or higher.
19:24 --> 19:26So we do know that we can
19:26 --> 19:28treat and cure these patients.
19:28 --> 19:29Vast majority of the time.
19:31 --> 19:33And do we know why that is?
19:33 --> 19:37I mean from a molecular mechanism standpoint.
19:37 --> 19:39I know on this show we talk a lot about,
19:39 --> 19:42you know, kind of targeted therapies
19:42 --> 19:45and looking for particular mutations.
19:45 --> 19:49Do we think that HPV related cancers
19:49 --> 19:52have a different genetic profile
19:52 --> 19:55than non HPV related cancers?
19:57 --> 19:59Yes, I think there's still quite
19:59 --> 20:02a bit of research to do on this,
20:02 --> 20:06but you know, they they do have different
20:06 --> 20:09mechanisms of of genetic mechanisms of
20:09 --> 20:12of changing cells and and resulting
20:12 --> 20:14in in uncontrolled cell growth.
20:14 --> 20:18And I think you know one thing
20:18 --> 20:20is and and it's a challenge with
20:20 --> 20:23patients who do use tobacco and
20:23 --> 20:25alcohol is that sometimes it's it's
20:25 --> 20:27difficult to even have patients.
20:27 --> 20:29Cut down or stopped during treatment and
20:29 --> 20:31that's something we have to you know.
20:31 --> 20:32Do extensive counseling on so.
20:32 --> 20:35I think even those repeated you
20:35 --> 20:38know insults to the the lining of
20:38 --> 20:41the of the of the throat can also.
20:41 --> 20:42Make those patients higher risk
20:42 --> 20:44so some of it might be behavior,
20:44 --> 20:46but I think a lot of it is in
20:46 --> 20:48the genetic differences.
20:49 --> 20:52And so you know it's when you
20:52 --> 20:55mention alcohol and and tobacco,
20:55 --> 20:58and the fact that you know
20:58 --> 20:59after you get a cancer,
20:59 --> 21:02we know that these are two of the
21:02 --> 21:04main etiologic factors outside of HPV
21:04 --> 21:07for getting head and neck cancers.
21:07 --> 21:10Do you counsel your patients on on stopping?
21:10 --> 21:14And what proportion of people actually do?
21:15 --> 21:17Yep, that's a great question.
21:17 --> 21:18We do, you know,
21:18 --> 21:20the the first time I meet a patient?
21:20 --> 21:23If that is a risk factor, you know,
21:23 --> 21:26I do counsel then we have also the
21:26 --> 21:29smoking cessation counseling service.
21:29 --> 21:30You know that helps us too so
21:30 --> 21:32we can refer them for that.
21:32 --> 21:34And there are strategies like
21:34 --> 21:35nicotine replacement therapy
21:35 --> 21:38and and counseling in general.
21:38 --> 21:41But you know the success.
21:41 --> 21:42We actually.
21:42 --> 21:43I think quite a few patients
21:43 --> 21:45are able to stop.
21:45 --> 21:48But it it requires a lot of work.
21:48 --> 21:49You know, really,
21:49 --> 21:51exploring the reasons they'd like to stop.
21:51 --> 21:53I found that you know a lot
21:53 --> 21:54of success comes from family
21:54 --> 21:56members and and patients stopping
21:56 --> 21:58for their families who have
21:58 --> 22:00been asking them to stop also.
22:00 --> 22:02And and sometimes even this
22:02 --> 22:04diagnosis is is a wake up call.
22:04 --> 22:06You know that you know this is a.
22:06 --> 22:08This can be a harmful behavior.
22:08 --> 22:10Yeah, but I can imagine that
22:10 --> 22:13as with so many addictions,
22:13 --> 22:19it can be really hard. And so.
22:19 --> 22:22So, and especially because
22:22 --> 22:24what you're asking patients
22:24 --> 22:26is complete abstinence, right?
22:26 --> 22:28It's not like 1 drink is OK.
22:29 --> 22:33Yes, we do. We do recommend that it is
22:33 --> 22:35hard to ask someone to stop right away
22:35 --> 22:37the first time you're meeting them.
22:37 --> 22:41So I do, you know, say we can try,
22:41 --> 22:42you know, slowly over time,
22:42 --> 22:44you know when you when someone comes
22:44 --> 22:46to you with the cancer diagnosis.
22:46 --> 22:48We don't have lots of time
22:48 --> 22:50we we try to move on.
22:50 --> 22:53On treatment and addressing it, but yes,
22:53 --> 22:57it we do recommend abstinence because
22:57 --> 22:59it's hard to know exactly at what
22:59 --> 23:01quantity caused this in the 1st place.
23:01 --> 23:02There's no,
23:02 --> 23:04you know every patient is different.
23:04 --> 23:05Some people, I think,
23:05 --> 23:07are more susceptible to even
23:07 --> 23:08lower amounts of exposure,
23:08 --> 23:10whereas others seem to be smoking
23:10 --> 23:12for decades and don't have,
23:12 --> 23:12you know,
23:12 --> 23:14don't have a cancer diagnosis
23:14 --> 23:16or don't present with that.
23:16 --> 23:19Yeah, and so if you do
23:19 --> 23:21continue to smoke or to drink.
23:21 --> 23:23You're at higher risk of relapse.
23:23 --> 23:25Is that right or recurrence?
23:25 --> 23:27Yes, that is certainly true.
23:27 --> 23:29And you know, data has shown
23:29 --> 23:31that even outcomes and response
23:31 --> 23:33to treatment are are not as
23:33 --> 23:35good for patients who continue.
23:36 --> 23:39And so you know,
23:39 --> 23:43outside of of alcohol and and smoking,
23:43 --> 23:45are there other risk factors?
23:45 --> 23:49I mean? For many cancers,
23:49 --> 23:53we talk about diets and obesity and exercise.
23:53 --> 23:55Are those things that play into
23:55 --> 23:57head neck cancers or not so much?
23:57 --> 23:59Is it really more the the
23:59 --> 24:02smoking and alcohol?
24:02 --> 24:03Yeah, I think
24:03 --> 24:06with you know obesity and diet.
24:06 --> 24:09There's not been shown to be an
24:09 --> 24:11association and there are some
24:11 --> 24:13other potential risk factors.
24:13 --> 24:15Sometimes we see patients.
24:15 --> 24:17For example, we didn't mention it earlier,
24:17 --> 24:20but we sometimes treat skin cancers
24:20 --> 24:23of sun exposure without using
24:23 --> 24:26sunscreen and even a history of
24:26 --> 24:28having immunosuppression can also
24:28 --> 24:31lead to certain cancers or or.
24:31 --> 24:32Higher risk of certain cancers
24:32 --> 24:34in the head and neck region?
24:34 --> 24:38Yeah yeah. Just shifting gears a little
24:38 --> 24:40bit tell us a little bit more about some
24:40 --> 24:42of the exciting research that's going
24:42 --> 24:45on in the field of head and neck cancer.
24:45 --> 24:47We talked earlier about novel kinds of
24:47 --> 24:50surgery. Certainly there must be work
24:50 --> 24:53going on in terms of different biologies,
24:53 --> 24:56HPV versus not, and one would
24:56 --> 24:59assume that there may also be trials
24:59 --> 25:01looking at how we can best help.
25:01 --> 25:04Are patients in terms of lifestyle factors?
25:04 --> 25:06So can you kind of break down some
25:06 --> 25:08of the exciting advances that you
25:08 --> 25:10see in terms of clinical trials
25:10 --> 25:12and where the field is going?
25:13 --> 25:16Yes, so I think something that we
25:16 --> 25:17talked about before remains very
25:17 --> 25:20important for head and neck cancer,
25:20 --> 25:23which is organ organ preservation
25:23 --> 25:25or preserving function.
25:25 --> 25:28And like I mentioned to,
25:28 --> 25:30there are certain sites where up front
25:30 --> 25:32surgery is is usually considered and
25:32 --> 25:35I think within the field at large.
25:35 --> 25:39The most exciting thing has been the use
25:39 --> 25:43of immunotherapy and head neck cancers and.
25:43 --> 25:46It's been shown to be something
25:46 --> 25:47that we should consider,
25:47 --> 25:49particularly in advanced
25:49 --> 25:52disease or recurrent disease,
25:53 --> 25:55but now I think we're starting to
25:55 --> 25:57think you know what about using
25:57 --> 26:00this before surgery in what we call
26:00 --> 26:02the neoadjuvant setting to see if
26:02 --> 26:04it could minimize the effect of
26:04 --> 26:06surgery on the patient's function,
26:07 --> 26:10and is that for HPV related cancers?
26:10 --> 26:13Or all head neck cancers particular?
26:13 --> 26:15Anatomic sites of cancer.
26:16 --> 26:21Yes, so I think I think basically both kinds.
26:21 --> 26:25It's it's something that's being looked at.
26:25 --> 26:27And you know, I think oral cavity
26:27 --> 26:30cancers is is 1 area of interest too?
26:30 --> 26:32Because we do the, you know,
26:32 --> 26:34sometimes we have to consider
26:34 --> 26:36bigger surgeries. And like I said,
26:36 --> 26:38reconstruction with those free
26:38 --> 26:39tissue transfers which you know,
26:39 --> 26:41preserve function quite a bit.
26:41 --> 26:44But do also require a lot of recovery.
26:44 --> 26:46So I think that's that's something that is
26:46 --> 26:48becoming interesting to many oncologists.
26:49 --> 26:52Yeah, you know when we think about
26:52 --> 26:54the move towards shorter surgeries.
26:54 --> 26:55Robotic surgeries?
26:55 --> 26:58Are you finding that that's cutting
26:58 --> 27:00down on the length of the operation
27:00 --> 27:03as well as the length of stay
27:03 --> 27:05and the number of complications?
27:06 --> 27:09Yes, definitely you know patients after
27:09 --> 27:12robotic surgery if they're swallowing OK,
27:12 --> 27:15can even leave the next day,
27:15 --> 27:16whereas before when we had to
27:16 --> 27:18do big surgeries in this area,
27:18 --> 27:20patients would stay, you know,
27:20 --> 27:23a week or so and require a tube
27:23 --> 27:26in the nose to be fed or even a.
27:26 --> 27:29Tracheostomy tube to breathe and and recover.
27:29 --> 27:32And so, I think yes.
27:32 --> 27:33Shorter surgery terms,
27:33 --> 27:36but also shorter length of stay and shorter.
27:36 --> 27:37You know, recovery times at
27:37 --> 27:39large because even after the
27:39 --> 27:40patient goes home from surgery,
27:40 --> 27:42we do have regular follow up and
27:42 --> 27:45really rely on our our speech
27:45 --> 27:46and swallow therapist.
27:46 --> 27:49Also, to help us with
27:49 --> 27:51rehabilitation which takes longer
27:52 --> 27:54and you know, so it sounds
27:54 --> 27:55like robotic surgery is
27:55 --> 27:57certainly something that.
27:57 --> 27:59And people should be looking
27:59 --> 28:01into one final question.
28:01 --> 28:05Is it covered by insurance?
28:05 --> 28:08Yes, so robotic
28:08 --> 28:11surgery is is covered by insurance.
28:11 --> 28:13You know it was.
28:13 --> 28:14I think one of the downsides
28:14 --> 28:16that people reported earlier
28:16 --> 28:18on is is the cost, but we.
28:18 --> 28:20We know now that it can minimize the
28:20 --> 28:22cost down the road in terms of other
28:22 --> 28:24things that the patient might need
28:24 --> 28:26for recovery from the larger procedure,
28:26 --> 28:29or even chemotherapy and radiation.
28:29 --> 28:31So I think there haven't
28:31 --> 28:32been any issues with that.
28:33 --> 28:35Doctor Avati Verma is an assistant
28:35 --> 28:37professor of surgery and otolaryngology
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:46and passed additions of the program
28:46 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 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
28:55 --> 28:57radio funding for Yale Cancer Answers
28:57 --> 29:00is provided by Smilow Cancer Hospital.

Information

Surgery in the Care of Head and Neck Cancers with guest Dr. Melissa Young April 24, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095