Melanie Cole, MS (Host): There are so many advancements in head and neck cancer care, including clinical trials and high risk clinics. And we're here today to highlight the AHN Head and Neck Center of Excellence.

Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And joining me today is Dr. Warren Swegal. He's an otolaryngologist, head and neck surgeon at the Allegheny Health Network.

Dr. Swegal, thank you so much for joining us today. And since we're coming up on head and neck cancer awareness month, I'd like you to start by telling us how the landscape of head and neck cancers have changed over the course of your career. How have you seen the incidence of HPV-related head and neck cancer change? How does this compare to other types of head and neck cancers? Where in the continuum of diagnostic criteria? Has HPV even become a factor? Speak about this landscape a little bit.

Warren Swegal, MD: Hi, good morning. Thank you for having me on the podcast today. I mean, you hit the nail right on the head in terms of the changing landscape in head and neck cancer. And, you know, like most cancers, traditional head and neck cancer of the mouth, the throat, and the tonsil area overall in the past 30 years has been decreasing in the number of cancers we see for traditional smoking and alcohol-related head and neck cancer, but specifically HPV-related cancer of the tonsils and the back of the tongue or the base of the tongue have been increasing unlike the other types of cancer and will, we expect, continue to increase over the next 20 to 30 years as the incidence goes up.

And what that means is we're seeing more and more patients who don't have traditional risk factors like smoking and alcohol abuse. They tend to be on the younger side, more in the 50s and 60s as opposed to 70s and 80s. And oftentimes, they're healthy. And so, we're finding patients much younger with cancer.

Luckily though, having HPV-related cancer does mean that these cancers are more sensitive to treatment overall. And so, our success rates with cancer therapy has only gone up in that time period as well. But that also means our focus in treatment has also shifted, specifically with less invasive treatments if possible, and also really focusing on the quality of life of patients after cancer care.

Melanie Cole, MS: Well, thank you for that. And Dr. Swegal, what makes these cancers so challenging and unique? Some of the after-effects of the type of cancer, the treatments we used to hear about, tell us a little bit about how it affects the daily lives of patients, their families, eating, self-esteem, speech, appearance, all of these things. And then, we're going to get into some really exciting advancements in techniques.

Warren Swegal, MD: Wow. So, as discussed, these cancers, HPV cancer in general is a little bit easier to treat, or I should say more susceptible to treatment than non-HPV-related cancer. But cancers of the head and neck in general can kind of have outsized effects on patient's quality of life. You can have a very small cancer of the vocal cord, or a small cancer of the tongue and have pretty significant symptoms, either changes in your speech, difficulties breathing, and most importantly, especially for HPV-related cancers, problem swallowing. And so, even after the cancer is gone, patients can be left with pretty significant side effects from treatment or the cancer itself, such as problem swallowing. The number of patients I have who have problems eating a normal meal and have to either prepare their food differently or make different food choices because of the difficulties, either because the muscles of the throat don't work well or their mouth is so dry that the food sticks. It can also lead to changes in taste. That tend to be temporary, but sometimes permanent.

And then, other effects, especially with treatment of the lymph nodes, either radiation or surgery, patients can have significant lymphedema after surgery or radiation, which can have lifelong effects either with neck fibrosis and stiffening, or as you mentioned, cosmetic defects that cause swelling of the neck and face. And what we see is patients with head and neck cancer have a pretty high rate of post-treatment depression. And that is also something that we need to focus in on and make sure that, yes, we can cure these patients of their cancer many times, but it's those long-term side effects that we also need to treat and hopefully prevent.

Melanie Cole, MS: What good points you've made. So, what does it mean to be a center of excellence in head and neck cancer care? It's not something that every hospital, Dr. Swegal, or medical center can claim. So, tell us a little bit about the primary mission, the overarching goal of the Cancer Care Program, what this means for patients. Tell us a little bit about wait times and screening and that sort of thing.

Warren Swegal, MD: Yeah. So, just being able to treat cancer is great, but being a center of excellence means going above and beyond what we can offer patients. You know, not just the standard of care, but taking that next step and that's really what it means to be a center of excellence.

You know, we know that time in terms of cancer treatment is very critical. And so with regard to wait times, our goal is to have patients seen at least on the ear, nose, and throat side five business days of a concern. They had not necessarily a cancer diagnosis, but you may be coming in with a neck mass or a lump you feel in your throat, all of those symptoms that may be a sign of cancer. And so, helping reduce the amount of time until patients are seen is critical in order to get an early diagnosis.

And then, once you start treatment, having kind of a multidisciplinary approach to that, one, we're all on the same page, but like we talked about, treating some of those side effects, things like swallowing therapy before treatment to help prevent swallowing problems long-term or screen for patients who already have some swallowing problems, upfront physical therapy to help with some of that lymphedema post-op. Dental problems can be pretty significant in patients with head and neck cancer, both from the cancer or from the radiation. And so, integrating with dental clinics and our Oral Surgery colleagues in order to take care of any dental issues.

And so, we consider ourselves a center of excellence, not just because we can treat cancer well, but we're treating more than the cancer, we're really trying to treat the patient. And then, on top of that, providing other opportunities like research studies that patients can be part of so that if we have better treatment options that we can offer those to patients or patients who may need a second or third-line treatment, that we have those options for them.

Melanie Cole, MS: Well, thank you for bringing up the multidisciplinary care team and how that utilization of a multidisciplinary team has been ideal for managing these complex patients. And Dr. Swegal, I'd like you to speak about patient-reported outcomes, how your doctors treat the patient, not just the cancer, how novel treatment approaches such as targeted therapies, immunotherapy, personalized medicine are really integrated into that patient care.

Warren Swegal, MD: Yeah, excellent point there. In terms of targeted therapy and treating the patient, in the head and neck cancer landscape, targeted therapy is, I don't want to say a newer treatment, but it is becoming more and more common in terms of where we integrate it into the process. And so, more and more patients were starting to integrate it early in terms of things like immunotherapy, especially in research studies, doing immunotherapy potentially before treatment, before things like radiation and surgery.

In terms of other targeted treatments or at least targeted care, I should say, again, that's where I think our multidisciplinary team, being able to preoperatively or pre-treatment evaluate the patient and determine, "Okay, this patient has this stage cancer, but also has these problems we need to focus on so that once their cancer is treated, they're not left with long-term side effects." Again, that's where having the patient see the speech and swallow therapist before any treatment starts makes a big difference. Understanding, again, dry mouth as one of the main components of long-term quality of life issues for these patients and working with patients to help treat things like dry mouth or change in taste.

Melanie Cole, MS: And I'd like you to highlight care close to home for us, Dr. Swegal, multiple locations for radiation, chemo clinics that make it easier for patients that have to travel for treatment.

Warren Swegal, MD: Yeah. So, that has been a strong mission from the Cancer Institute in general is we know patients come from all over the western side of the state and even sometimes the eastern side of Ohio and West Virginia. And it's not easy. I think anybody who's driven in Pittsburgh realizes it's not necessarily easy to get downtown, especially if you have to do daily radiation treatments.

And so, one of our missions has been to have a central core within the head and neck center of excellence, however, being able to provide that care more locally. So, the radiation, having multiple different radiation centers so that patients don't have to drive on a daily basis down into Pittsburgh; having chemotherapy options closer to home. Surgery still tends to be pretty centralized. But then, we also partner with local ENTs, dental providers, so that those patients can still get some of that care closer to home. Again, this is where we're trying to treat not just the cancer, but the patient as well. And if transportation is an issue, that's where our excellent cancer care navigation team can come into play as well to help organize rides and things for the patients so that they can make it to treatment if need be.

Melanie Cole, MS: Dr. Swegal, before we wrap up, I'd like you to speak about some of the state-of-the-art surgical practices for other providers to let them know some of the exciting advancements in head and neck cancers, as these can have devastating effects, as you've said, on appearance, function of the patient, and are among some of the most disabling and socially isolating defects, really affecting quality of life. But this is also a very exciting time in your field, Dr. Swegal. So, speak to the listeners about some of the reconstruction technology, the surgical planning that's involved, anything you'd like to talk about.

Warren Swegal, MD: Yeah. That's when you talk about head and neck cancer, and for those who've seen patients with head and neck cancer, I think they understand how disfiguring sometimes it can be, traditionally speaking. We interact with the world through our face and our mouth and our nose. And to have a cancer that's really kind of upfront that everybody can see can be very hard for patients.

And so, while radiation can help in many types of head and neck cancer, sometimes surgery is by far the best treatment therapy. And so, minimizing cosmetic defects and functional defects, things like transoral robotic surgery, traditionally to get to the tonsil or the back of the tongue, you'd have to split the jawbone in half and move it away, move it out of the way in order to get to the cancer, now using kind of the most up-to-date single-port robot systems. We can get into the oropharynx and back of the tongue and remove these cancers without any incision on the neck or the face. Trying more cosmetic techniques for removing lymph nodes through the neck; reconstruction, especially for patients who have tumors of the mouth that require removing parts of the jawbone. Those surgeries traditionally would take anywhere from 12 to 20 hours.

Now, with precise, you know, 3D printing and pre-surgical planning, we can go in with a plan of we're going to make our bone cuts here and here. We can pre-print a plate and pre-bend a plate and cut down that surgery time to six to eight hours instead of 12 to 20 and have a much better both cosmetic and functional outcome at the end.

So, that's really where from a surgery standpoint, especially in the last five to ten years, we've made absolutely fantastic gains to be able to really reduce, again, those cosmetic and functional defects.

Melanie Cole, MS: As we wrap up, I'd like you to summarize the key takeaways that you would like other providers to take away from this episode today on Head and Neck Cancer Center of Excellence at the Allegheny Health Network and any clinical trial portfolio that you have that you'd like to mention to better address those patients with recurrence or difficult-to-treat cancers.

Warren Swegal, MD: Yeah. To kind of highlight the key points, number one, I think, is access. We understand it's hard to get appointments. And when you're dealing with a cancer diagnosis, we do not want any difficulty getting access to us. And so, again, really trying to reduce that wait time to see a provider, but also reduce the amount of time it takes to a patient, number one.

Number two is the wide-ranging multidisciplinary care. Again, it's more than just the surgeon, the medical oncologist, the radiation oncologist. At our tumor board, we have a Speech and Swallow therapist, an Onc Rehab specialist, we have the research team, we have the dental team, we have kind of that wide-ranging group so that we can have coordinated care. Again, not to treat just the cancer, but to treat the patient as a whole so that we can get them through their cancer and then have them get back normal life afterwards. And then, from a clinical trial standpoint, especially those patients who've had recurrence or advanced disease, again, our portfolio, we draw from both the national studies that take place throughout the country, as well as some internal studies throughout the Cancer Institute, things like the TILS trial, to give patients multiple different options when it comes to, like I said, either advanced or metastatic disease.

Melanie Cole, MS: Thank you so much, Dr. Swegal, for joining us today and sharing your incredible expertise and really telling us about the AHN Center of Excellence for Head and Neck Cancers. Thank you again for joining us. And to learn more or to refer your patient to Dr. Warren Swegal, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. I'm Melanie Cole.