If you've been diagnosed with a head and neck cancer, talk to us about treatment options. At City of Hope, our dedicated team of experts take a patient-centered approach to diagnosing and treating this group of cancers.
In this segment, Dr. Thomas Gernon discusses the latest advances in head and neck cancers and the treatment options available at City of Hope.
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The Latest Advances in Head and Neck Cancers
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Learn more about Thomas J. Gernon, MD
Thomas Gernon, MD
Thomas J. Gernon, M.D., is an associate clinical professor in department of surgery, specializing in head and neck surgery. Dr. Gernon came to City of Hope from the University of Arizona College of Medicine, where he was an assistant professor in the department of surgery, division of otolaryngology.Learn more about Thomas J. Gernon, MD
Transcription:
The Latest Advances in Head and Neck Cancers
Melanie Cole (Host): Head and neck cancers are particularly unique and complex requiring a personalized treatment plan for optimal clinical, quality of life and cosmetic outcomes. My guest today is Dr. Thomas Gernon. He’s a head and neck surgeon in the division of otolaryngology head and neck surgery in the Department of Surgery at City of Hope. Welcome to the show Dr. Gernon. Let’s just start by sort of a broad overview of head and neck cancers and what encompasses these types of cancers and then we will get into some specifics.
Dr. Thomas Gernon, MD (Guest): So, head and neck cancers are any cancers really of the face and upper aero digestive tract so it can include anything from skin cancers including run of the mill basal cell cancers, squamous cell cancers to melanomas and then you move inside into the upper aero digestive tract and we can have tumors of the sinuses or the oral cavity which is the anterior part of the tongue, the jaw bone and then you can get into the oropharynx which are tumors of the tonsils and the back of the tongue. You can have tumors of your voice box. You can also have tumors of the salivary glands. You have the parotid glands which are major salivary glands and your submandibular glands as well as minor salivary glands. And then also a number of tumors that we treat are tumors of the thyroid gland. So, it is really quite a broad array of tumors and there are also other tumors which are less common that can also pop up which we deal with intermittently.
Melanie: So, Dr. Gernon, people hear oropharyngeal cancers or oral cavity cancers and it really, I mean of all of the cancers you think about, the ones that involve your mouth and head and neck freak people out pretty much. Tell us a little bit about these cancers and who would be at risk.
Dr. Gernon: So, those are two different very different areas but I can speak in depth about both of those because I treat a lot of those. So, tumors of the oral cavity are tumors of the anterior tongue. So, the anterior tongue is pretty much the anterior two thirds of your tongue and then the oropharynx tumors include the posterior one third of your tongue and that also includes the tonsils which we typically have removed as a child. The posterior one third of your tongue also has tonsil tissue on the back of it which we don’t ever get treated as a child. So, patients who get tumors of the anterior part of the tongue, are typically smokers and typically people who consume a significant amount of alcohol and those are the more traditional squamous cell cancers that we have treated throughout the years. Interestingly, in the anterior tongue, the largest population that is growing is young white women who have not smoked so it is really becoming a pretty common thing in women who have not smoked and we don’t know why that is at this point but that specific population is on the rise. It is also in men in young white men who are nonsmokers as well. In contrast to that, tumors of the back of the tongue and tonsil are typically related to the HPV virus which is the same virus that causes cervical cancer in women. And typically, those patients are males greater than females, they typically are nonsmokers and they occur in patients in their fifties to sixties. So, that is really a large group of patients that we are treating now. Specific people that are known in the media specifically are Michael Douglas had a base of tongue tumor and I believe George Karl did as well. So, those are tumors that are related to likely the HPV virus. So, I am not specific in their certain cases but typically we are all subjected to that virus at some point in our adolescence and it lays dormant in our system and then reactivates when we are in our fifties or sixties.
Melanie: So, Dr. Gernon, as we are talking about HPV and we hear about it with cervical cancer and now the vaccine and do you think and this is just your opinion, that with this vaccine, with Gardasil, that you might be seeing less oropharyngeal cancers if they are directly related to HPV infection?
Dr. Gernon: I think we will but that is going to be many years to come because if you think about it, I, myself, I’m forty years of age and even people younger than myself, we were not vaccinated and we still have the period of time to hit our fifties so there is a thirty-year gap like my children will be vaccinated. Most children this day and age are vaccinated. So, there has been a gap though of 20-30 years where people have typically been exposed to the HPV virus and that virus lies dormant in their systems. But it’s absolutely correct that hopefully the Gardasil vaccine is now being offered to boys and girls and that will immunize them against the HPV virus and this type of disease in the future.
Melanie: So, if someone has been tested for HPV, maybe a woman who goes to her gynecologist and gets that test because they want to know if they are supposed to get their PAP smears every year, or a man and as you say we are giving our kids this vaccine so it’s going to be a while before we see if that takes hold. If you tested negative for HPV then does that decrease your risk of this type of cancer?
Dr. Gernon: It does. So, if you are negative for HPV your chance of getting this cancer is significantly decreased. What they are finding is that it’s not, interestingly in women, you commented about cervical cancer. So, what the belief is is that researchers have looked at this and they feel that women who are exposed to the virus in the cervix are actually able to immunize themselves against the virus and that’s why we think that we are seeing fewer incidences in women who present with head and neck HPV related tonsil or tongue base cancer in comparison to men. Because the men are exposed supposedly in the oropharynx and they are exposed to a larger amount of virus and then that virus kind of lays dormant and the thought is that the immune system drops off and then it reactivates in your fifties, middle fifties to sixties as a cancer.
Melanie: How interesting. So, then what do you do? How is this diagnosed? What would somebody notice for an oropharyngeal I mean are they going to notice pain in their throat or hoarseness, trouble swallowing, any of these things that you think about when you think about checking for these cancers?
Dr. Gernon: Definitely. So, I would say probably one of the most common ways that patients present is typically a male as I said, in their fifties or sixties and they present to their primary care provider because they have a lump in their neck that has been there for a couple of months and they have tried a couple of courses of antibiotics and it hasn’t gone away. So, a lot of patients don’t have any other symptoms other than a neck mass. And that is typically what happens is that the tumor is fairly small in the back of the tongue or the tonsil and then it – but it has a propensity to spread into the lymph nodes in the neck and typically it is one or two lymph nodes and they kind of grow rapidly and then they hang out there for a while. So, oftentimes we do see that patients are treated with antibiotics when in actuality, they have a tonsillar or a tongue base tumor which is there so that’s something to be aware of. And then the other type of patients that we do see is exactly what you talked about. Patients who are developing increased difficulty with swallowing, they feel that solid foods don’t pass as easily into the esophagus when they eat, typically have a harder time with solids than they would with liquids and other times patients will have pain particularly referred to their ear. You know when you were a kid and you had a sore throat the pain oftentimes you felt like you had an earache but it is because there is referred pain which is from the back of the tongue into the ear. So, that is how patients typically will present. Sometimes they present with changes in their voice, their voice is muffled or they sound like there is something in the back of their throat. But those are the typical presentations that patients have.
Melanie: And one of the things people worry about of course, with these type of cancers is eating, talking, and you know and it’s not vanity, but their looks because you are dealing with the face the neck, the head. So, what do you tell people about treating these types of cancers and their ability to live a somewhat normal life?
Dr. Gernon: So, fortunately, these tumors are fairly well-treated. So, some of the head and neck cancers that we treat, I feel you know you get the diagnosis and it is not a great thing, cancer is never a good thing, but the possibility that they do well when I get a diagnosis for certain types of cancer, in my own heart I feel like oh this a tough diagnosis but fairly typically HPV related tonsil and tongue base and oropharynx cancers you know patients for the most part do very well and so that has really changed our approach to treatment because we are really focusing on knowing that patients are going to live into their later ages, and we want to focus on their quality of life 10 years after their treatment has been performed. So, there are two main types of treatment and there is either a nonsurgical treatment which can be with chemo and radiation therapy and then there is also a treatment with trying to investigate less invasive surgery with either a robotic surgery through the mouth and then with the hopes of giving the patient less radiation or no chemotherapy or potentially no additional treatment at all. So, treatment is really moving towards de-escalation of therapy for these types of tumors meaning that trying to decrease the amount of treatment they are getting overall. So, decreasing the radiation dose because radiation ten years down the road can have significant effects on the jaw function, the jaw viability, also the swallowing function. So, we are really trying to decrease therapy overall for these patients.
Melanie: So wrap it up for us Dr. Gernon with your best advice about these oropharyngeal cancers and kind of summarize everything that we have been discussing, the HPV, and how somebody might find it and who is at risk and why they should come to City of Hope for their care.
Dr. Gernon: It’s hard to really know, you know we oftentimes have patients come into clinic and they are very concerned that you know maybe they had an HPV exposure at some point in life. I would say, the majority of us being normal adults probably have been exposed to it at some point. So, there is nothing really to do or to prevent it at this point. I think it is being proactive if you do notice that there is lump in your neck, something feels odd, you are having difficulty swallowing or whatnot then you present as quickly as you can. Because as I said, routinely these things are pretty well treated. I think as far as our treatment at City of Hope, we really focus on treating the patient, each individual patient based on how they present to us. So, we aren’t super pro surgery, we aren’t super pro chemo and radiation. We really prioritize each patient into how we feel they are going to do the best, based on the disease stage that they have when they present. So, if we feel that the patient can potentially get through treatment with surgery and nothing afterwards, we will offer that and then we try to do that with a surgical approach that is through the mouth, so we aren’t making any incisions – huge incisions in the neck to open the jaw or anything of that nature which decreases their morbidity and then we would remove the lymph nodes through the neck and if a patient has a tumor stage that is too great for that, then we would move towards possibly chemo or radiation or both together to treat the tumor if we felt that the surgical approach was going to be too much and wasn’t going to benefit them. We really are focusing on decreasing overall therapy so that patients can get through the treatment with as little treatment as possible and the fewest side effects as possible, so that patients can move towards a normal life down the road.
Melanie: Thank you so much for being with us today Dr., it’s really great information. You are listening to City of Hope Radio and for more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
The Latest Advances in Head and Neck Cancers
Melanie Cole (Host): Head and neck cancers are particularly unique and complex requiring a personalized treatment plan for optimal clinical, quality of life and cosmetic outcomes. My guest today is Dr. Thomas Gernon. He’s a head and neck surgeon in the division of otolaryngology head and neck surgery in the Department of Surgery at City of Hope. Welcome to the show Dr. Gernon. Let’s just start by sort of a broad overview of head and neck cancers and what encompasses these types of cancers and then we will get into some specifics.
Dr. Thomas Gernon, MD (Guest): So, head and neck cancers are any cancers really of the face and upper aero digestive tract so it can include anything from skin cancers including run of the mill basal cell cancers, squamous cell cancers to melanomas and then you move inside into the upper aero digestive tract and we can have tumors of the sinuses or the oral cavity which is the anterior part of the tongue, the jaw bone and then you can get into the oropharynx which are tumors of the tonsils and the back of the tongue. You can have tumors of your voice box. You can also have tumors of the salivary glands. You have the parotid glands which are major salivary glands and your submandibular glands as well as minor salivary glands. And then also a number of tumors that we treat are tumors of the thyroid gland. So, it is really quite a broad array of tumors and there are also other tumors which are less common that can also pop up which we deal with intermittently.
Melanie: So, Dr. Gernon, people hear oropharyngeal cancers or oral cavity cancers and it really, I mean of all of the cancers you think about, the ones that involve your mouth and head and neck freak people out pretty much. Tell us a little bit about these cancers and who would be at risk.
Dr. Gernon: So, those are two different very different areas but I can speak in depth about both of those because I treat a lot of those. So, tumors of the oral cavity are tumors of the anterior tongue. So, the anterior tongue is pretty much the anterior two thirds of your tongue and then the oropharynx tumors include the posterior one third of your tongue and that also includes the tonsils which we typically have removed as a child. The posterior one third of your tongue also has tonsil tissue on the back of it which we don’t ever get treated as a child. So, patients who get tumors of the anterior part of the tongue, are typically smokers and typically people who consume a significant amount of alcohol and those are the more traditional squamous cell cancers that we have treated throughout the years. Interestingly, in the anterior tongue, the largest population that is growing is young white women who have not smoked so it is really becoming a pretty common thing in women who have not smoked and we don’t know why that is at this point but that specific population is on the rise. It is also in men in young white men who are nonsmokers as well. In contrast to that, tumors of the back of the tongue and tonsil are typically related to the HPV virus which is the same virus that causes cervical cancer in women. And typically, those patients are males greater than females, they typically are nonsmokers and they occur in patients in their fifties to sixties. So, that is really a large group of patients that we are treating now. Specific people that are known in the media specifically are Michael Douglas had a base of tongue tumor and I believe George Karl did as well. So, those are tumors that are related to likely the HPV virus. So, I am not specific in their certain cases but typically we are all subjected to that virus at some point in our adolescence and it lays dormant in our system and then reactivates when we are in our fifties or sixties.
Melanie: So, Dr. Gernon, as we are talking about HPV and we hear about it with cervical cancer and now the vaccine and do you think and this is just your opinion, that with this vaccine, with Gardasil, that you might be seeing less oropharyngeal cancers if they are directly related to HPV infection?
Dr. Gernon: I think we will but that is going to be many years to come because if you think about it, I, myself, I’m forty years of age and even people younger than myself, we were not vaccinated and we still have the period of time to hit our fifties so there is a thirty-year gap like my children will be vaccinated. Most children this day and age are vaccinated. So, there has been a gap though of 20-30 years where people have typically been exposed to the HPV virus and that virus lies dormant in their systems. But it’s absolutely correct that hopefully the Gardasil vaccine is now being offered to boys and girls and that will immunize them against the HPV virus and this type of disease in the future.
Melanie: So, if someone has been tested for HPV, maybe a woman who goes to her gynecologist and gets that test because they want to know if they are supposed to get their PAP smears every year, or a man and as you say we are giving our kids this vaccine so it’s going to be a while before we see if that takes hold. If you tested negative for HPV then does that decrease your risk of this type of cancer?
Dr. Gernon: It does. So, if you are negative for HPV your chance of getting this cancer is significantly decreased. What they are finding is that it’s not, interestingly in women, you commented about cervical cancer. So, what the belief is is that researchers have looked at this and they feel that women who are exposed to the virus in the cervix are actually able to immunize themselves against the virus and that’s why we think that we are seeing fewer incidences in women who present with head and neck HPV related tonsil or tongue base cancer in comparison to men. Because the men are exposed supposedly in the oropharynx and they are exposed to a larger amount of virus and then that virus kind of lays dormant and the thought is that the immune system drops off and then it reactivates in your fifties, middle fifties to sixties as a cancer.
Melanie: How interesting. So, then what do you do? How is this diagnosed? What would somebody notice for an oropharyngeal I mean are they going to notice pain in their throat or hoarseness, trouble swallowing, any of these things that you think about when you think about checking for these cancers?
Dr. Gernon: Definitely. So, I would say probably one of the most common ways that patients present is typically a male as I said, in their fifties or sixties and they present to their primary care provider because they have a lump in their neck that has been there for a couple of months and they have tried a couple of courses of antibiotics and it hasn’t gone away. So, a lot of patients don’t have any other symptoms other than a neck mass. And that is typically what happens is that the tumor is fairly small in the back of the tongue or the tonsil and then it – but it has a propensity to spread into the lymph nodes in the neck and typically it is one or two lymph nodes and they kind of grow rapidly and then they hang out there for a while. So, oftentimes we do see that patients are treated with antibiotics when in actuality, they have a tonsillar or a tongue base tumor which is there so that’s something to be aware of. And then the other type of patients that we do see is exactly what you talked about. Patients who are developing increased difficulty with swallowing, they feel that solid foods don’t pass as easily into the esophagus when they eat, typically have a harder time with solids than they would with liquids and other times patients will have pain particularly referred to their ear. You know when you were a kid and you had a sore throat the pain oftentimes you felt like you had an earache but it is because there is referred pain which is from the back of the tongue into the ear. So, that is how patients typically will present. Sometimes they present with changes in their voice, their voice is muffled or they sound like there is something in the back of their throat. But those are the typical presentations that patients have.
Melanie: And one of the things people worry about of course, with these type of cancers is eating, talking, and you know and it’s not vanity, but their looks because you are dealing with the face the neck, the head. So, what do you tell people about treating these types of cancers and their ability to live a somewhat normal life?
Dr. Gernon: So, fortunately, these tumors are fairly well-treated. So, some of the head and neck cancers that we treat, I feel you know you get the diagnosis and it is not a great thing, cancer is never a good thing, but the possibility that they do well when I get a diagnosis for certain types of cancer, in my own heart I feel like oh this a tough diagnosis but fairly typically HPV related tonsil and tongue base and oropharynx cancers you know patients for the most part do very well and so that has really changed our approach to treatment because we are really focusing on knowing that patients are going to live into their later ages, and we want to focus on their quality of life 10 years after their treatment has been performed. So, there are two main types of treatment and there is either a nonsurgical treatment which can be with chemo and radiation therapy and then there is also a treatment with trying to investigate less invasive surgery with either a robotic surgery through the mouth and then with the hopes of giving the patient less radiation or no chemotherapy or potentially no additional treatment at all. So, treatment is really moving towards de-escalation of therapy for these types of tumors meaning that trying to decrease the amount of treatment they are getting overall. So, decreasing the radiation dose because radiation ten years down the road can have significant effects on the jaw function, the jaw viability, also the swallowing function. So, we are really trying to decrease therapy overall for these patients.
Melanie: So wrap it up for us Dr. Gernon with your best advice about these oropharyngeal cancers and kind of summarize everything that we have been discussing, the HPV, and how somebody might find it and who is at risk and why they should come to City of Hope for their care.
Dr. Gernon: It’s hard to really know, you know we oftentimes have patients come into clinic and they are very concerned that you know maybe they had an HPV exposure at some point in life. I would say, the majority of us being normal adults probably have been exposed to it at some point. So, there is nothing really to do or to prevent it at this point. I think it is being proactive if you do notice that there is lump in your neck, something feels odd, you are having difficulty swallowing or whatnot then you present as quickly as you can. Because as I said, routinely these things are pretty well treated. I think as far as our treatment at City of Hope, we really focus on treating the patient, each individual patient based on how they present to us. So, we aren’t super pro surgery, we aren’t super pro chemo and radiation. We really prioritize each patient into how we feel they are going to do the best, based on the disease stage that they have when they present. So, if we feel that the patient can potentially get through treatment with surgery and nothing afterwards, we will offer that and then we try to do that with a surgical approach that is through the mouth, so we aren’t making any incisions – huge incisions in the neck to open the jaw or anything of that nature which decreases their morbidity and then we would remove the lymph nodes through the neck and if a patient has a tumor stage that is too great for that, then we would move towards possibly chemo or radiation or both together to treat the tumor if we felt that the surgical approach was going to be too much and wasn’t going to benefit them. We really are focusing on decreasing overall therapy so that patients can get through the treatment with as little treatment as possible and the fewest side effects as possible, so that patients can move towards a normal life down the road.
Melanie: Thank you so much for being with us today Dr., it’s really great information. You are listening to City of Hope Radio and for more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.