Transcription:
HPV-Related Head and Neck Cancer: The Silent Threat

Melanie Cole, MS: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Urjeet Patel. He's a Professor of Otolaryngology and Head and Neck Surgery at Northwestern Medicine. And he's here to highlight advances in HPV-related head and neck cancer care.

Dr. Patel, it's such a pleasure to have you join us today. How have you seen the incidents of HPV-related head and neck cancer change in recent years? How does it compare to other head and neck cancers and where in the continuum of diagnostic criteria is HPV a factor in this trend?

Urjeet Patel: Good morning, Melanie. Thanks for having me. It's a real pleasure to be here. It is sort of a very interesting and exciting time in the world of head and neck cancer, specifically related to HPV. And head and neck cancer is sort of a mixed bag. Historically, the two main risk factors were tobacco and alcohol use. And that's sort of what we imagined to be the head and neck cancer patient for the last, you know, 50 years. But HPV or human papillomavirus is obviously a very well-established and well-known risk factor now.

Getting to your question about the incidence, they're going in different directions. Fortunately, for the country, tobacco use is on the decline. So, tobacco-related cancers are actually trending down ever so slightly, that's great. HPV is going in the other direction. It's actually on the rise over the last two decades. And so, head and neck cancer as a whole is sort of a mixed bag. It may be about even, because we have two different trend lines.

Now, the hope with HPV though is that as vaccine programs are becoming more widespread and as the younger population is aging and they have been vaccinated, we expect there will be a peak to that incidence, and then that will also be on the decline.

Melanie Cole, MS: Such an interesting topic and the trends are interesting as well, Dr. Patel. So, I'd like you to speak for just a minute about what makes head and neck cancers so challenging and unique, some of the after effects of the treatments and the daily lives, quality of lives of patients and their families, eating, self-esteem, speech, appearance, so much complexity in these types of cancers.

Urjeet Patel: You know, Melanie, you've kind of touched on all the things I would say about it. And the head and neck, there's a lot going on. Four of our five senses are housed in the head and neck. It's how we communicate with one another in society, and that's true whether you're online on cam or out at a restaurant with your friends. In terms of function, probably every body part claims to have unique functions, and then they probably do, but it's certainly no truer than in the head and neck. You know, our mouths and our throats, everything from eating, speaking, communicating. And then, there's an undeniable importance of facial appearance. This is literally our face. This is how we communicate with one another in society. A lot could be hidden under clothes for the rest of your body. But when we're interacting as social beings, it's with our faces.

So as we think about cancer of the head and neck, a lot of those functions become deranged or impaired. Speaking, swallowing, chewing, seeing with your orbit position, facial bones, those are some of the areas of complexity that we deal with as cancer impacts the head and neck.

Melanie Cole, MS: Well, I certainly agree with you there. And so, let's talk about the standard treatments that we have seen for HPV-related head and neck cancers, how those have evolved in recent years. And due to, after what we were just discussing, the intricate nature of these cancers, how has medicine changed in recent years to improve those outcomes and help patients live longer, better lives?

Urjeet Patel: We have three main tools for treating cancer in general and that's also true for head and neck. So, we have surgery, radiation therapy and what I'll call, you know, chemotherapy or systemic therapy. And those three generally come together to treat advanced stage cancers, and certainly true for head and neck.

Historically, surgery was really the primary modality. And by historically, you know, I'm talking 30, 40 years ago. Over the past 20 years, the role of radiation has really grown. And we're able to avoid large scale surgeries on lots of patients and still achieve high cure rates, but radiation has its side effects too. And so, we're, sort of swapping certain kinds of morbidity for other morbidity. Chemotherapy also plays into the mix.

So if we think about how we're making progress or how are we doing things better than we used to, probably deescalation is sort of the big word we're using these days to try to tone down our therapies, still achieve good cure rates, but try to impact or negatively impact the tissue as little as possible. So, trying to drop or refine the radiation dose in certain areas of the head and neck, trying to use minimally invasive surgery instead of what used to be, I think, what we call maximally invasive.

And then, in the area of chemotherapy, instead of some of our traditional chemotherapies that we've used in the past, which also have a pretty notable side effect profile, immunotherapy. So, these are a different class of drugs. They're essentially revving up our immune systems to participate in the battle against cancer. And this is sort of an exciting area for cancer all over the body, but also true for head and neck, that the drugs of immunotherapy are probably less toxic to humans and are actually showing more promise or more efficacy in certain areas.

Melanie Cole, MS: Really is an exciting time for the advancements in your field, Dr. Patel. So, discuss the use for us of robotic surgery for these types of cancers and how that technology is giving better results, specifically cancers of HPV and how is endoscopic instrumentation coupled with improved imaging and localization techniques, intraoperative imaging. These are all being used now to help resect tumors with minimal damage to that surrounding tissue, as you were just speaking.

Urjeet Patel: You're exactly right. And again, let me sort of paint the picture of how we did it back when I trained, which was quite a long time ago. You know, if you had a cancer of the throat or the base of tongue, we're going to go through the neck, where, you know, large incision splitting the mandible, resecting tumors. And then, those required really sophisticated reconstruction. Again, we're happy to do that, we're trained to do that and we're good at doing that. But you can imagine what that does to the patient. A lot of morbidity, long hospital stays, and even our surgeries cause a lot of dysfunction to the tissues and all the functions we spoke about earlier.

So as robotic surgery came online, we started using it in the head and neck, trying to work through the mouth. And as you can imagine, it's a tight space there, trying to get to the throat or down to the larynx. Going through the mouth, there's a limitation to what we could do endoscopically, you know, historically. As robotic surgery came online, initially, the instruments were still quite large. Eight-millimeter arms are pretty big, a 1.2-centimeter camera, trying to get all that into the throat, especially lower down by the larynx. We were seeing a proof of concept existed and it worked fine for higher up, like in the area of the tonsils, but less well for tongue base and larynx, for example.

Fortunately, I must admit the companies who provide robotic consoles and instrumentation have been refining as well. And instruments are becoming smaller, access is getting better. And now with current robotic platforms, we can really do, I guess, what I would call amazing work in the tonsil, in the tongue base, even getting down into the larynx. And so, our instrumentation is becoming smaller, narrower, more refined. It's allowing us to get deeper down or further along in the pharynx than we used to be able to go. And then on top of that, the next iteration of robotic consoles are including real-time imaging in the operating room, and even starting to look at augmented reality platforms, where right now we'd have a camera down the throat. We're looking at the tumor, for example. Now with an augmented reality platform, there can be phantom structures showing where perhaps the carotid artery or the jugular vein would be in relation to the tumor, obviously under the tissue. And that's done with a combination of imaging and a lot of software computing.

So, I hope to answer your question that, with advances in technology, we really are able to tackle tumors in a minimally invasive fashion, which I think it goes without saying, is going to be better for our patients. Now, it's trying to select which patients are appropriate for that kind of care. And I can say I think the pool of patients is growing for whom minimally invasive or robotic surgery is really coming to the front line as a great option to start with.

Melanie Cole, MS: Dr. Patel, I'm glad you made that point about patient selection being so important for this. But it's opening up, certainly, as we advance in this field. And as cancers of the head and neck region can have devastating effects on appearance and function of the patients and are among some of the most disabling and socially isolating defects with significant, as we've said, impact on patients' quality of life, you spoke about reconstruction and robotic surgery. Can you tell us a little bit about the learning curve for these as you're seeing these advancements happen so quickly, and some of them are so amazing and minute. Tell us a little bit about the learning curve. Any technical considerations in that learning process you'd like other providers to know?

Urjeet Patel: Yeah. Like any sort of new procedure or new technology, there is a learning curve. And I think I have to compliment the robotic surgery industry that as new advances come along, they really like surgeons to really get fully invested and sort of well trained on the latest technology. So when new platforms come online, it doesn't really give the surgeons the option to dabble, so to speak. We kind of go through certain training pathways, modules, and we get familiar with new technology, before we have to apply it on real patients.

And studies have shown that as surgeons come out of training and they perform robotic surgery, this is good news. They might be slow at first in that learning curve process when the number of cases they've done is few. But it turns out their safety is very high. So, that's exactly what we'd like to see when we're launching new instruments or technology that we're okay with a little loss of efficiency. Anything new will take a little time to learn, but we certainly don't want to compromise safety. And so, again, the training pathway, even with already trained surgeons, as new technology comes online, we sort of refresh or we relearn on new consoles. And we've been able to show safety still remains high, and then efficiency improves as experience improves. Robotic surgery is something that I had to learn after training. I trained over 20 years ago. And today, the new trainees of today are learning that in their residencies or in their fellowships. It's just part of training now and its own specialty as it's coming online this way.

Additionally, as we talk about reconstruction and things that are either minimally invasive or what I call maximally invasive, reconstruction can be performed in either setting. Again, historically, large reconstructive or microvascular reconstructive surgery was needed for our typically open cases. We still do those kind of cases today. In fact, today, I'm doing, my third day in a row of microvascular reconstruction. Sometimes that's for recurrent tumors, often for HPV negative, and then often for oral cavity or larynx. So, our traditional large open surgeries are still being performed when needed. And again, microvascular reconstruction still plays a very important role.

As we look at TORS or transoral robotic surgery, there are some cases as we're tackling larger tumors or more difficult to access tumors, where reconstruction also plays a role in those cases, the role of reconstruction is sort of being modified as we make progress in a minimally invasive fashion.

Melanie Cole, MS: Yeah. Reconstruction of those kinds of defects has really been an extremely demanding challenge for surgeons. So, thank you so much for explaining a little bit about that learning curve. And can you discuss the importance of having a robust care team when treating head and neck cancers and how has that introduction of therapy, involvement of multiple subspecialists and the utilization of that multidisciplinary team been ideal for managing these complex patients?

Urjeet Patel: Yeah, that's an excellent point. As most people listening may know, cancer care is complex. It's multidisciplinary. Often, many specialties are cooperating to achieve the best outcomes for our patients. And I already mentioned the three modalities of surgery, radiation oncology, medical oncology, but that's just the beginning of the team. The whole cancer team goes far beyond that. We have specialized nurses in oncology. Our speech pathologists or speech therapists are critical, especially in the head and neck cancer realm when we're talking about speaking and swallowing.

We also have psychosocial support for our patients. Unfortunately, for many people, it can be a cause of psychological distress, maybe even leading to depression, that has also been studied. Our psychosocial support mechanisms are also important. The team is extensive not surprisingly. And like I said, the whole team comes together to cooperate to provide the best care for the patient. And I will say that it's probably one of the reasons why when patients seek care, they really do want to go to a tertiary care location where all of these facets of cancer care are often located.

Melanie Cole, MS: This is just such an interesting topic, Dr. Patel. As we wrap up, where do you see the field of head and neck cancer going in the coming years and specifically HPV-related cancers, how physicians can stay current with these developments and how that existing knowledge of the relation of HPV to these types of cancers we can now see as we look toward vaccines and awareness and more knowledge? Tell us where you see this going.

Urjeet Patel: I guess one of the good things about head and neck cancer, if there's such a thing as a good thing about cancer, is that we have known risk factors. And as I mentioned before, tobacco, alcohol, HPV are our three big ones. And HPV is sort of the one of focus right now. So by virtue of having known risk factors, we at least have a target of how to actually educate the population, take care of the population and raise awareness. And so, there are national campaigns on HPV vaccination and this interfaces with the pediatric world where a lot of our vaccines are given to our youngsters, as well as the adult world when we talk about tobacco cessation or even HPV vaccination in adults.

Certainly, we can always do better with those types of campaigns, but at least this cancer has a risk factor or two, that there's some amount of awareness. And our job as the specialist is to keep awareness high through podcasts like this, where we're raising awareness.

I think nowadays so much is established about HPV and head neck cancer, that at least in the medical realm, most providers at least are aware of that association, and it's our job as the specialist to keep them up-to-date. It's a much bigger question. How do we keep our public well educated and informed at large? How do we increase to nearly a hundred percent participation with HPV vaccination, which here we have the rare cancer that's actually preventable with a vaccine. What a shame if we don't take advantage of it. So, I think these are some of the mechanisms that we can try to keep awareness and education high. And hopefully, there'll come a day where we can talk about the decreasing incidence of HPV-related cancer.

Melanie Cole, MS: What an informative episode, Dr. Patel. Thank you so much for joining us today. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please always remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.