Advances in surgical treatment in head and neck cancers.

Transcript

00:00 --> 00:22Announcer Funding for Yale Cancer Answers is provided by Smilow Cancer Hospital. Welcome to Yale Cancer Answers with the director of the Yale Cancer Center, Doctor Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Doctor Winer.
00:22 --> 00:50Eric Winer Tonight, I'm very pleased to be joined by my colleague, Doctor Ben Johnson, who is professor of surgery at Yale School of Medicine and chair of the Department of Surgery, also at the Yale School of Medicine and surgeon in chief in the Yale New Haven Health System. So, Ben, thank you so much for being here with us tonight.
00:50 --> 00:57Ben Judson Thank you. Eric, it's my pleasure to be here. I actually was here about 14 years ago on this show, so it's nice to be back.
00:57 --> 01:14Eric Winer I should should have been part of my introduction. Told the audience that you're also a cancer surgeon because you have spent much of your career specializing in the treatment of head and neck cancers from a surgical perspective.
01:14 --> 01:15Ben Judson That's correct.
01:15 --> 01:40Eric Winer Maybe we could actually just start off briefly with, I mean, you tell us how it is that you you ended up going into head and neck cancer surgery. You first had to make the decision to become an ear, nose and throat doctor. And I think a lot of people think of ear, nose and throat doctors as, you know, taking out tonsils and looking in people's ears.
01:40 --> 01:52Eric Winer There's much more to it than that. But how is it that you ended up focusing on what's probably one of the most complicated parts of of ENT, which is head neck cancer surgery?
01:52 --> 02:17Ben Judson I will say that ending up in this career for me was not a straight line. I went to medical school when I was in my late 20s, and so I made this deal with myself that I would only train a short amount of training after school. And so my plan was to be a family practice physician. And then once I was in anatomy and in medical school, I realized I love surgery.
02:17 --> 02:47Ben Judson And so I renegotiated with myself and said, okay, I won't do a three year residency training program. I'll do five years. But the deal I made with myself is that I would not do any further training. I wouldn't subspecialties within a surgical area. But as you're laughing, predict, you know, points out, once I was training and I got exposed to multidisciplinary care of patients with head neck cancer, it really resonated for me and became very meaningful.
02:47 --> 02:55Ben Judson Me, for me. And so I sort of broke the deal that I had made with myself and pursued further training to become a head and neck cancer surgeon.
02:55 --> 03:22Eric Winer And what the audience may or may not appreciate is that some of the most complicated anatomy actually exists in this whole area where head and neck cancers occur. So in the throat, in the mouth, and the sinuses, I mean, this is anatomy that the rest of us just don't even begin to appreciate. The rest of us physicians, that is.
03:23 --> 03:45Ben Judson There's a lot going on in that in this area in the head and neck. And, you know, I think we it's something that as people, we it's easy to take for granted. Just like we walk around and think, think we think, oh, we're just walking, you know. But there's a lot that goes into walking. Similarly, things like swallowing and speech are really sophisticated, complex things that our bodies do.
03:45 --> 03:58Ben Judson And we do it generally without having to think about it, which is which is a blessing that sometimes is challenged when patients are facing treatment for head and neck cancer.
03:58 --> 04:13Eric Winer Just success isn't just survival. Success also means that those body parts that are supposed to swallow and speak and do all those things, that we don't think about it on a day to day basis, need to keep functioning after treatment.
04:13 --> 04:44Ben Judson That is correct. And really, when taking care of patients with, you know, when taking care of a patient with a head and neck cancer. This is what my and the team's focus is really on. It's, you know, of course, on ensuring that patient survival. But we're really, you know, appropriately obsessed with how can we, you know, tailor treatment or how can we treat this patient in a way that will preserve those, those different ways of functioning?
04:44 --> 04:55Eric Winer So years ago, the surgery for head neck cancers was pretty debilitating. How have things evolved?
04:55 --> 05:29Ben Judson Yeah, I think the two two of the biggest areas were surgery for neck cancer has advanced is the first is in reconstruction. And now oftentimes when a patient is undergoing a surgery to treat a head neck cancer, there's also a reconstructive team, not just a surgeon, but multiple surgeons. Sometimes it includes an oral surgeon and the techniques and technologies that are used to reconstruct whatever is being treated surgically have come so far, and they continue to be new advancements.
05:29 --> 05:56Ben Judson We're now using virtual surgical planning, so it's basically AI to design exactly what's going to happen to a patient and then to before the surgery, you know, create plates and models to to guide and to support the reconstructive team. So that I would say reconstruction has come a long way, thankfully, and that the other area where surgery has advanced is in minimally invasive techniques.
05:56 --> 06:34Ben Judson And so a big one is the use of the robot to perform trans oral robotic surgery. So it sounds alarming, but when a patient's asleep, we can actually introduce robotic arms through the patient's mouth to access areas in their throat that we would not otherwise be able to get to, and we can do as possible to do minimally invasive surgery to remove tumors or growths from farther down in in areas that we wouldn't otherwise be able to see or get to without, like opening things up in a way that you know, has significant impact.
06:34 --> 06:39Eric Winer And these arms are like little tiny fingers. I mean, they're very small.
06:39 --> 07:06Ben Judson Their tiny little fingers. And they it's when you're as a surgeon, you sit at a console that's next to the patient and they're asleep. And the visualization is phenomenal. It's like the highest definition you can imagine. There's actually binocular vision. So you have depth perception, and you've got these tiny little arms that can that have risks. And they can do almost everything and more than your own risks can do.
07:06 --> 07:11Ben Judson And so you feel like you're a tiny person in someone's throat doing whatever it is that you need to be doing.
07:11 --> 07:17Eric Winer And and what's the role of plastic and reconstructive surgery and all of this.
07:17 --> 07:42Ben Judson Usually if some those are that's the other part. You know, that's the reconstruction. So you know plastics sometimes. Well, if I think if someone's going having a minimally invasive trans or a robotic surgery, that usually is not the need for a reconstructive team or plastic team, but if they're having more sort of traditional open surgery, that's when that team is so critical.
07:42 --> 08:11Eric Winer Now, the other piece of all of this is that you are totally integrated with other medical disciplines. So not just other surgeons, but medical ecologists who focus on giving medical or systemic treatments and radiation oncologists. And you may choose to back off on one treatment and give more of another one. And, you know, how does this all play out?
08:11 --> 08:18Eric Winer And of course, I realize that clinical trials is are critical here.
08:18 --> 08:42Ben Judson Yeah, I like to think of head neck cancer as being not a one doctor problem. To get a good treatment for Edna cancer, you need multiple. As you just pointed out, you need multiple team members that are working together. And so, you know, every patient that comes to see me also, as you pointed out, also sees the medical oncologist, radiation oncologist, usually a speech pathologist, sometimes a nutritionist.
08:42 --> 09:04Ben Judson And I'll give an example of a patient I saw about a month ago who was a snowbird. And so he spent some of his time in a warmer state, shall we say. And unfortunately, it was diagnosed with the head neck cancer and saw someone there that was just in one discipline. And so they recommended their discipline as the treatment.
09:04 --> 09:33Ben Judson And he came to Connecticut and saw the whole team, you know, everyone. And we all went over everything, different treatment options for him. And we offered him a significantly different treatment than he had been recommended. We actually felt that he was a candidate for a surgery only treatment option, which is ironically, it's like a way to deny the treatment because it could be a minimally invasive surgery.
09:33 --> 09:51Ben Judson And so, you know, he had surgery and was in the hospital for a couple of days and went home. And I think that's going to be his only treatment, which was really different than the treatment plan that had been previously outlined. And this can go in different ways. Oftentimes I'll see a patient that's referred to me and I'll say, oh, I don't think surgery is the best treatment for you.
09:51 --> 10:11Ben Judson I think you should get this. You know, this other combination of treatment treatments, and that really is the key, I think, to making sure that we're providing good care for each patient is to having them see the whole team and having the team really think about what's going to give them the best functional outcome, as well as the best survival outcome.
10:11 --> 10:24Eric Winer And to what extent are you using systemic therapy. So chemotherapy, immunotherapy, other sorts of treatments to reduce the amount of surgery you need.
10:24 --> 10:53Ben Judson This is such a good question. I gave an example of using surgery as a way to avoid using chemotherapy and radiation. But we're also doing the exact opposite, which we're using the targeted therapies that you spoke about as a way to reduce or avoid surgery sometimes that this is where it's, you know, I think in the future, we're having all these advances in surgery and advances in types of radiation that can be given and advances in targeted therapy.
10:53 --> 11:16Ben Judson And figuring out how to integrate all of these is like the next chapter for us in providing care for patients with head neck cancer. And I you know, I'll, I have this a patient that I remember so well who was treated this is almost 8 or 9 years ago. And, you know, she was treated with standard therapy. And unfortunately she developed a recurrence.
11:16 --> 11:39Ben Judson The cancer had spread to elsewhere in her body, which previously at that time was thought to essentially be an incurable problem. And she was treated on a clinical trial and she received immunotherapy, and she got so sick she had to go into the intensive care unit. And I think we all thought that this was going to, you know, really was a big threat to her.
11:39 --> 12:03Ben Judson But she recovered and it completely eliminated the cancer that had recurred. And she I still see her regularly and she's cured all these years later. And so that was like such a remarkable thing to recognize that these new targeted therapies like immunotherapy are really active in head neck cancer. It's an effective treatment for now at this stage of figuring out, you know, so the example I gave was treating after to come back.
12:03 --> 12:14Ben Judson But clearly it's also got an important role in earlier on in the treatment. But figuring out when and how to give it is what a lot of the clinical trials are focusing on now.
12:14 --> 12:42Eric Winer Yeah, no, it becomes incredibly important. And it's this balancing act of the various modalities and figuring out, you know, what you can emphasize for which patients and what you can eliminate. And finally, before we take a break, let me just quickly ask you, these cancers that occur in the oral cavity and the throat and the nasal sinuses, they're quite different from one another.
12:42 --> 12:59Eric Winer So the prognosis and the natural history and behavior of cancer that's in your tonsil is different from a cancer that's in your that arises in your time. You have to be an expert in like 15 different kinds of cancers.
13:00 --> 13:21Ben Judson Yeah. There's it's a lot of subtleties. And this is why it takes a whole team of specialists. But to your point, historically, a lot of the majority of had neck cancers were thought to come from smoking and alcohol exposure. And as smoking rates in the United States have decreased, we've seen the number of patients with those types of cancers decreased.
13:21 --> 13:44Ben Judson Unfortunately, we're seeing a real increase in patients with throat cancers that are thought to be caused by the human papillomavirus. And we also still see sort of out of the blue cancers, where someone just does not have a good reason to get it. And they it can still happen. So there's not always a, there's not always a good, you know, thing to point at being like, this is why it happened.
13:44 --> 14:00Ben Judson Those happen as well. But those two types of cancers, those that are head neck cancers, those that are caused by smoking and drinking, compared to those that are caused by that human papilloma or HPV virus behaviorally differently. And the treatments are really different for sure.
14:00 --> 14:13Eric Winer Well, we're going to have to take just a brief break. We'll be back in just a minute with our guest tonight, Doctor Benjamin Judson, chair of surgery at the Yale School of Medicine. Be right back.
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15:26 --> 16:02Eric Winer Welcome back to the second half of Yale Cancer Answers. I'm Eric Winer the director of the Yale Cancer Center. And I'm here tonight with Ben Judson who is professor of surgery and chair surgery at the Yale School of Medicine. Then let's keep talking about head and neck cancers for a few more minutes. And I used this line earlier, but in fact, it was one that you fed me in a few minutes before we we got on the show, which is that success.
16:02 --> 16:22Eric Winer Success is not all about survival. And there's more to life than just being alive. And one of the things that I know you're trying to accomplish, along with your colleagues, is making sure that the lives people have after treatment for cancer is as good as that life can be.
16:23 --> 16:57Ben Judson That's right. And that balance of making sure that we're ensuring survival but maintaining function and long term function, really because some of the treatments can have late side effects. That is that's the goal to make that to strike that balance. And in some ways I think, you know, the patient care is a science applying science. But this is where there's an art as well, you know, to balance what's going on with each patient and what's important important to them as well.
16:57 --> 17:21Ben Judson Sometimes you can't take that for granted. Sometimes people will have a strong preference for one thing or another. And so I think having that, creating that relationship with the patient so that you can understand what it is, it's important to them is important. But I think for everyone at some extent function is is really important. So that definitely is a the other goal of treatment for patients with this kind of problem.
17:21 --> 17:50Eric Winer As I think about this, there really sort of three waves of side effects with head and neck cancer treatment. There's the very acute side effects than maybe from chemotherapy or immunotherapy or surgery or radiation. And then there's, you know, what someone's left with in the next few years. And then there are these late side effects that you were referring to.
17:50 --> 17:58Eric Winer That's a little bit about the challenges of of the initial treatment.
17:58 --> 18:21Ben Judson And I think the initial I think I like the categorization of, of the, of the side effects. And, you know, you're asking me about the initial and let's talk about that. One of the problems we have is that the cure rates are rising. So we have more patients that are surviving. And so we have to think more about those longer term, because, you know, we have so many patients that are cured.
18:21 --> 18:45Ben Judson And now they go on ten, 20, 30 years and then they're facing the long term. But the short term mostly affect, you know, honestly, they mostly affect swallowing and speech. And and you know, they can there can, you know, the treatments can be uncomfortable and painful and cause fatigue. And so it's really helping people to get through those, those parts of the treatment and those side effects.
18:46 --> 19:20Eric Winer And assuming that, you know, you're successful and someone gets through those initial side effects and of course, you know, the chance of not making it through, it is very small. I mean, very few people experience, you know, any kind of truly life threatening complication up front. But what what what can people expect, you know, let's say, for, you know, treatment that has involved some amount of chemotherapy and immunotherapy and, you know, surgery.
19:20 --> 19:27Eric Winer And I'm actually not even sure this is radiation always a part of this or just sometimes.
19:27 --> 19:29Ben Judson Just sometimes.
19:29 --> 19:33Eric Winer And what are the kinds of side effects we see with radiation.
19:33 --> 20:03Ben Judson Yeah. Radiation. You know, I think of radiation like administering what looks on the outside of someone's neck like a terrible sunburn. And they unfortunately get that same thing in their throat, which makes it uncomfortable and painful to swallow. You know, it's interesting. 15, 20 years ago, we used to think that one of the best ways to manage that was to, for many patients, was for them to receive a feeding tube so that they wouldn't have to swallow during the treatment.
20:03 --> 20:23Ben Judson But what we've learned is that if you don't keep your swallowing active, those muscles and coordination atrophy, just like walking. I think, you know, if you if you imagine if you were not to walk for a month, you'd have a hard time getting up and walking around. Similarly, it's not very good for your one swallowing ability to not swallow for a month.
20:23 --> 20:43Ben Judson And so really now the focus is on treating the pain, encouraging them with nutrition and other things to have patients continue to do all the things that we normally do as much as possible during the treatment, which leads to a better functional outcome. On the other side of the treatment.
20:43 --> 20:55Eric Winer It's really important to consider all of these issues. And then in terms of the the kinds of late side effects that people have, I mean, what are you what are you most concerned about?
20:55 --> 21:22Ben Judson One of the conundrums with the late effects is that we have a poor understanding of why some patients do great long term, late, you know, and others have end up having real problems, particularly this is from radiation or the combination of radiation with chemotherapy. But you you described it. People can, you know, many years out can develop difficulty with swallowing.
21:22 --> 21:34Ben Judson That's the biggest one. And so again most patients many patients do do great long term. But some have this late problem where they have difficulty with swallowing.
21:34 --> 21:56Eric Winer You know I think many people don't realize, you know, how difficult some of these things can be. But, you know, like problems with a dry mouth, you think, oh, like having a dry mouth, big deal. But when your mouth is dry all the time and you're constantly needing to do something to keep it moist, it must be very challenging.
21:56 --> 22:11Ben Judson Yep. It's a it's it's an it is a tough problem. And you know, saliva is one of those things that we don't appreciate until it's gone. But you know, saliva as you suggest, we need saliva in our throat to speak clearly.
22:11 --> 22:12Eric Winer To to.
22:12 --> 22:33Ben Judson Yes. Yeah. If you don't have saliva, it makes it much harder to swallow. And so, you know, saliva also protect our teeth. So if patients whether it's through one of these treatments or for other reasons, if they have drive a patient has a dry mouth, not a lot of saliva. There are increased risk for developing cavities and other dental problems.
22:33 --> 22:40Ben Judson And so they require really more intensive dental care in that setting. If they have a dry, you know, if they have dry mouth.
22:40 --> 23:11Eric Winer Well, you know, this is really beyond the scope of, of what we're talking about tonight. But increasingly there's a lot of focus on what I'm going to broadly call cancer rehab. And it's trying to prevent the kinds of frailties that can develop after cancer treatment, oftentimes many years later. And, you know, I think I think people sometimes think they get through something and it's done.
23:11 --> 23:39Eric Winer And unfortunately, we often have to take steps to make sure that what's done really is done and that it's not going to lead to another complication, you know, many years down the road. And the more, as you pointed out, the more we continue to treat cancer effectively and the more the larger number of people who survive cancer, the bigger the problem this gets.
23:39 --> 24:02Ben Judson This is true. And I actually, you know, you brought up this topic of cancer rehab. And I think for me that also brings up the question of cancer pre had. And so like you know like when someone's having a knee replacement right. Like now it's understood that like the doing all this physical therapy before the surgery is actually really important to help them recover from that surgery.
24:02 --> 24:25Ben Judson And so, you know, we don't have the luxury in cancer care to spend a lot of time getting ready for the treatment. But patients also oftentimes will ask me, you know, like what should I do in the, you know, weeks or month or month and a half or whatever from when they're diagnosed? Do they start treatment? And I think that, you know, the science is out, but I think that it's reasonable to think that pre helps.
24:25 --> 24:45Ben Judson So, you know, being active, getting swallowing exercises from a speech language pathologist, seeing a nutritionist, making sure one's diet is, you know, is a healthy is a healthy diet. These are all things that can come before treatment that I think can drive how people do in terms of getting through the treatment and in terms of how they do afterwards.
24:45 --> 25:09Eric Winer So maybe we can in the last oh, I don't know. We have we have somewhat less than five minutes, but we can just shift and talk for a minute about your role as chair of surgery. So, you know, you oversee far more than head neck cancer surgery. You oversee all aspects of surgery. And we'll stay focused on cancer surgery.
25:09 --> 25:42Eric Winer But there's lots of cancer surgery that happens outside of the head neck region. There's surgical oncology and there's thoracic surgery and on and on. And, you know, as part of this, you want to make sure that you're providing the very best care and doing great research. And as the next group of, of of physicians and scientists. So what's your biggest challenge in your job, boy?
25:42 --> 25:50Ben Judson First of all, I think that I love my job, and one of the things that I like about it is seeing.
25:50 --> 25:54Eric Winer I like my job too. So we share that.
25:54 --> 26:35Ben Judson Yeah. And it's, you know, it's seeing the advances happen and seeing teams come together and do good things is, you know, it's fun and rewarding. And so I love that part of it. And, you know, I think the challenges, you know, you called out that there are lots of other obviously lots of other kinds of surgeries that happen transplant surgery, heart surgery, vascular surgery, you know, on and on those some of the themes I think are across all these areas, one being that teen care is where it's going, you know, like as medicine becomes more subsub, sub specialized and, you know, that's how you get good outcomes, you get really, you know, working as a
26:35 --> 26:56Ben Judson team is really important. You know, whether it's cancer care or transplant surgery care and, and and I think also integrating the advances in all these different areas is sort of what we need to be focusing on so that advances in medical care are, you know, integrated with advances in surgical care and vice versa.
26:56 --> 27:18Eric Winer No. And I mean, that's critical. And of course, as you, as you were referring to translating the latest advances in science, whether that's surgical science or basic science into the care of people so that we continue to improve. It's just so very important.
27:18 --> 27:25Ben Judson Agreed. And you actually asked me what my biggest challenge is, and I sort of evaded the question, so maybe I'll come back. Oh, I was so, so, so.
27:25 --> 27:31Eric Winer As you will go back to that. So so what what keeps you up at night.
27:31 --> 27:50Ben Judson Boy, I guess, you know, listen, this the environment that we're in right now in health care is there are a lot of challenges. And, you know, I think the mission is so important to care for, provide, you know, provide outstanding care for the community. You know, the large community, the region that comes to us. That's the mission and being able to do so.
27:50 --> 28:01Ben Judson You know, they're they're sort of external forces that are making it hard, that are challenging our health care systems to do that. And so I think that's certainly something that keeps me up at night.
28:01 --> 28:27Eric Winer Yeah, it's it's it's the best and worst of times. I mean, it's the best of times because we have so much we can do. And yet at the same time we, we actually function within American, within an American health care system, I think is pretty deeply challenged. And, you know, we're going to we're going to have to keep pushing hard to make sure that we can deliver the kind of care we want to to everyone.
28:27 --> 28:38Eric Winer I've been speaking with Doctor Ben Judson, who is chair of surgery at the Yale School of Medicine. Ben, it's been a real pleasure having you on tonight. Thanks so much.
28:38 --> 28:57Announcer If you have questions, the address is CancerAnswers@Yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you'll join us next time to learn more about the fight against cancer. Funding for Yale Cancer Answers is provided by Smilow Cancer Hospital.

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Dr. Eric Winer and Dr. Ben Judson talk about the latest surgical advances in treating head and neck cancers.

Yale Cancer Center

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Dr. Ben Judson Chair of Surgery Yale School of Medicine, Surgeon-in-Chief, Yale New Haven Health, Chief of Surgery Yale New Haven Hospital, Yale Cancer Center.

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