Transcription:
Advances in Treatment of Head and Neck Cancer

Melanie Cole (Host): Here today to discuss the intricate nature of head and neck cancer, facial reconstruction and how it affects the daily lives of patients and their families, is my guest Dr. Sandeep Samant. He’s the Chief of Head and Neck Surgery and the Director of Northwestern Multidisciplinary Head and Neck Program. Dr. Samant, let’s start, please tell us a little bit about yourself and how you came to Northwestern Medicine.

Sandeep Samant, MD (Guest): Yeah, I have been practicing head and neck surgery for gosh, twenty years. I finished my training, fellowship training in head and neck surgery at the University of Miami and then also at the University of Tennessee in Memphis. I stayed on in Memphis, Tennessee for the first 15 years of my career and I was recruited to Northwestern four years ago now to be the Chief of Head and Neck Surgery and to be the Director of the Northwestern Medicine’s Head and Neck Program.

Host: Tell us a little bit about head and neck cancer. What’s the prevalence of it and are there different types?

Dr. Samant: Yes, so about half a million people worldwide will develop head and neck cancer on an annual basis. In the United States, too there is – there are two types of head and neck cancer that we are seeing. A steadily rising type of cancer that we are seeing these days is the cancer that is caused by infection with human papilloma virus. Most patients will contract the infection early on in their lives and while the majority of people will actually clear the infection; in a minority of folks, the infection will linger on only to cause the development of a cancer in the tonsil region, tonsil and base of tongue region, maybe ten to fifteen years later. And of course, the more common type of head and neck cancer that we’ve seen for a long time is the one that is associated with smoking and drinking. So, these are the two predominant types of cancers that occur in the head and neck that affect the mucosal lining of the mouth and throat and the sinuses. But of course, in addition to this, we also treat as head and neck surgeons, cancers that arise in the thyroid gland as well as in the salivary gland and then finally, cancers that arise from the skin of the face and scalp and that affect the skin as well as metastasize to the lymph nodes of the neck.

Host: Doctor, due to the sensitivity of these types of cancers and the intricate nature; are there any non-surgical treatment options people can look to? It certainly depends on the type of cancer someone is diagnosed with, but what typically do you tell patients about treatment options that might be non-surgical?

Dr. Samant: So, the treatment options that are given to the patient depend largely on the exact type of cancer. Head and neck cancer is a very heterogeneous disease so, what I mean by that is, cancers differ in where they arise so a tongue cancer arising in the mouth may be totally different than the tongue cancer that arises in the base of the tongue. Then there are larynx cancers, pharynx cancers, nasal cancers, sinus cancers. So, each of those have a different set of recommendations that are given.

Generally, though, when patients present with early cancer; we try to use a single modality of treatment whether it’s surgical or non-surgical, depending on the location. For instance, cancers of the oral cavity will typically be treated by surgery. Cancers in the voice box, if they can be treated surgically, we might treat early cancer surgically but at other times, we might recommend radiation treatment for larynx cancers. So, as far as non-surgical treatment is concerned; generally, it’s based on radiation treatment either alone or in combination with chemotherapy for more advanced cancers.

Host: Tell us about some of the advancements that have been made in the treatment of head and neck cancers as far as like minimally invasive technology that could allow you surgeons to access hard to reach areas of the mouth and throat. Speak about some of those for us.

Dr. Samant: The most exciting technology that has become available in the last ten to twelve years is the use of the surgical robot. So, know that cancers that occur in the throat are not very easily accessible to the surgeon’s hands without making big cuts in the neck or on the face or splitting open the jaw simply to access the area where the cancer is. So, in the past, these cancers that arose in the tonsil or back of the tongue or in the top of the larynx; where often accessed with open approaches which required long surgical stays, long operations, stays in the ICU. But nowadays, with the advent of robotic technology, we can use robotic instruments to remove many of these cancers through the mouth without having to do major disruption of the face and neck.

Host: And how does interoperative imaging help you with skull-based tumor resection, thyroidectomy and while you are speaking about robotics and some of these advancements; speak about the goals as you are finishing, of reconstruction for the patient. Because that’s really what all of these advancements are headed towards, correct, is to protect those vital structures for function and form. Because these can be devastating for patients.

Dr. Samant: Correct. So, let me start by taking up the most common type of cancer that we are seeing these days; the HPV associated tonsil cancer and HPV associated tongue-base cancer. These cancers typically occur in younger, fit otherwise healthy individuals and these cancers are highly curable. That also means that these patients will live a long life after completing their therapy and have to live with the consequences of their treatment. While the older method of surgery which required open surgical access by splitting the jaw was quite disruptive and left poor functional outcome; we started to use non-surgical treatment with a combination of radiation therapy and chemotherapy for treating some of these cancers. But remember, that high does of radiation, 70 gray given over seven weeks with concurrent chemotherapy is quite toxic to the mouth, the mucosal lining of the mouth and the throat, larynx, resulting in loss of saliva, xerostomia, loss of taste, scarring, difficulty swallowing and long-term G-tube dependence.

So, with the advent of robotic surgery, what we are able to do is to remove the cancer trans-orally with negative margins. That allows us to reduce the intensity of radiation treatment, if radiation has to be given at all and avoid the addition of chemotherapy which when added to radiation, certainly adds to the toxicity overall. So, fewer patients end up needing adjuvant radiation, fewer patients need the combination of chemotherapy and radiation and those that are treated with radiation after surgery; can usually receive a more precise and a lower dose of radiation treatment. This then leads to a significantly lower toxicity burden that the patient has to face long-term. So, patients will rarely ever need a G-tube. They will have lower incidence of loss of taste, loss of saliva and other complications that we see with definitive chemo-radiation such as osteoradionecrosis which is break down of the jawbone.

Host: Are you seeing less work for plastic surgeons as a result of all of these advancements?

Dr. Samant: No, so many patients unfortunately are not candidates for trans-oral surgery or minimally invasive surgery. These are patients with tumors - with very advanced tumors which still require major surgical resection or patients who have been treated with non-surgical treatment before, radiation therapy and chemotherapy and have recurrent disease. They require open surgical operations with removal of large amounts of tissue, perhaps in the oral cavity or pharynx or the mandible or maxilla and here, the recent advances in the reconstruction play a large role.

So, we can now reconstruct large defects with the use of microvascular surgical techniques where we borrow tissue from elsewhere in the body to replace the – to reconstruct the defect very precisely, the use of computer modeling and 3-D printing with virtual surgical planning has helped us a lot to develop very accurate methods of reconstructing bone and soft tissue in the head and neck which obviously, leads to a better cosmetic and facial outcome.

Host: What does current research indicate for future developments. Give us a little blueprint, ten years down the line. What do you see happening?

Dr. Samant: So, there’s a lot of research happening in understanding the mechanisms of head and neck carcinogenesis, identifying newer drivers that can be targeted. That area of research in tumor genomics and proteomics will obviously help us in the future to develop targets that can prevent head and neck cancers from forming or treat them with less long-term side effects.

The other research that is happening is understanding how immunotherapy can be incorporated in management of these cancers. There’s already very good data that has come out in management of recurrent metastatic head and neck cancers with the use of chemotherapy. Two drugs which are both checkpoint inhibitors, PD-1 blockers, were approved a couple of years ago in management of patients who have recurrent or inoperable disease, with immunotherapy as an alternative to traditional cytotoxic medications.

The future would involve moving chemotherapy more into the realm of upfront treatment or enhancing the effect of radiation and when patients are treated non-surgically. So, there’s a trial, RTOG3504 which is ongoing which is looking at adding the nivolumab which is one of the PD-1 blockers to the combination of chemotherapy and radiation, platinum in the case. There’s another trial RGHN003 which is looking at adding pembrolizumab another PD-1 blocker, to adjuvant chemotherapy and radiation in patients who have undergone surgery for their cancer but are considered at high-risk for recurrence.

So, immunotherapy will play a bigger and bigger part in the management of these cancers. And finally, a lot of research is being done in figuring out how we can de-intensify therapy after surgery in patients who have HPV positive cancers where they undergo surgical treatment and you want to minimize the long-term side effects by reducing the intensity of radiation, giving radiation more precisely so that patients do not have to suffer long-term consequences.

Host: So, in summary, Doctor, tell other physicians what you’d like them to know about head and neck cancer surgery, reconstruction, the advancements that have been made and when to refer to the specialists at Northwestern Medicine.

Dr. Samant: So, my message would be this, that head and neck cancer is a heterogeneous disease. It requires some very intensive combinations of different treatment approaches, chemotherapy, immunotherapy, radiation therapy and surgery. There is a lot of evidence that patients who are treated in busy head and neck surgery programs which are multidisciplinary, end up having much better survival outcomes than patients who are treated in centers that are not treating these in high volumes.

So, first thing to remember is refer the patients who have head and neck cancer to specialists. Patients should see head and neck surgeons who are fellowship-trained in head and neck surgery rather than a general surgeon or a general otolaryngologist who is treating not just head and neck cancer. I try to tell my primary care colleagues to identify cancers early, so if anyone has a lump in the neck that is not going away after a round of antibiotics, make sure that they get evaluated. They maybe need to do a fine needle biopsy to make sure this is not a cancer. Anyone that has a sore throat or change in voice again, symptoms of very common illnesses such as upper respiratory infection. But if it doesn’t clear in a week or two; make sure that you have the patient see a specialist to rule out a cancer. And similarly, any ulcers in the mouth that don’t go away, make sure that you have them evaluated.

Host: Thank you so much Dr. Samant, for coming on today and sharing your expertise, your incredible expertise about head and neck cancers and what’s going on with treatment and advances. Thank you again. This is Better Edge, a Northwestern Medicine podcast for physicians. For more information on the latest advances in medicine; please visit www.nm.org, that’s www.nm.org. This is Melanie Cole. Thanks so much for tuning in.