Bob Underwood, M.D. (Host): Head and neck cancers can affect vital functions: How you breathe, talk, eat, hear, see or swallow. These are some of the basic ways we experience life. Today on the Cancerwise Podcast, we are talking with an internationally recognized head and neck cancer surgeon about managing these unique challenges. I'm Dr. Bob Underwood and joining us today is professor of Head and Neck Surgery at MD Anderson Cancer Center, Dr. Ehab Hanna, who specializes in the treatment of patients with skull base tumors. Dr. Hanna, thank you for being with us today. 

Ehab Hanna, M.D.: Thank you, Dr. Underwood. It's a pleasure to be here. 

Bob Underwood, M.D. (Host): Absolutely. I've really been looking forward to this discussion. So, why don't we start by talking about what are some of the quality-of-life issues that are more common for patients with head and neck cancer? 

Ehab Hanna, M.D.: Well, you've summarized it really well at the beginning of this podcast, and I would say that it really depends on what area of the head and neck. So, in the mouth area,for example, it would affect talking, chewing, eating, breathing. Some other really vital functions in the head and neck area with some of the other tumors would be seeing, hearing, swallowing. And as you have mentioned, these are essential functions not just for enjoying life, but for living altogether. And we, when we think about treating patients with head and neck cancer, it is front and center. Not only that, our prime focus is to cure the disease, meaning save lives, but also, what do these lives look like after they have been saved? And are the patients who survive head and neck cancer able to enjoy life to the fullest as we know it? 

Bob Underwood, M.D. (Host): And some of the issues that we're not, that we're talking about are not just related to the disease, but also related somewhat to the treatment of the disease. 

Ehab Hanna, M.D.: Absolutely. The disease itself can affect some of these functions, and the treatment by itself can either bring new deficits or handicaps or aggravate some of the handicaps that were present before the treatment. And I would add one more issue with head and neck cancer that is unique to this patient population, which is form or appearance. As you know, a lot of the other parts of the body are hidden under our clothes, whether it's the chest or the abdominal area or the limbs, but the head and neck area, that's our face. And as they say, we face the world with our face. So deformity, is another area where we are laser focused on preserving how patients look after treatment. 

Bob Underwood, M.D. (Host): I think those are absolutely incredibly important for these patients. How would these issues maybe differ based on the particular type of cancer or diagnosis, the disease stage and the site, which we've kind of already talked about. 

Ehab Hanna, M.D.: Of course. So, you know, the head and neck is essentially from the top of the head to the collarbone. And to give you an example about site, skin cancers can be pretty small and very minor, but they can also be very aggressive and in advanced stages affect things like the cheek, the nose, the eyelids, the ear, the lips. And that obviously would have great impact on the appearance of the face. The more deep-seated cancers that affect, for example, the jaws or the sinuses would affect the, not just the skin and the soft tissues covering the face, but the actual skeletal structures of the face, the mouth and the skull itself. 

Bob Underwood, M.D. (Host): So, what can people do to kind of optimize their quality of life before, during, of course, and then after treatment? It's almost like there's three phases that they've got to be concerned about. 

Ehab Hanna, M.D.: Absolutely. I think the key finding that we come back to every time we study this is the earlier the diagnosis, the less impact the disease and or the treatment will have on the quality of life of the patient. So I would say my number one advice to patients is not to neglect any symptom or any appearance of a lump or a sore or a discolored mole or a skin lesion, or anything that affects their swallowing or their speech and their hearing or their vision for more than a couple of weeks. I'm not saying that any sort of nasal congestion should cause alarm and freak people out that it could be head and neck cancer, but certainly some of these symptoms, if they persist for more than a couple of weeks, and particularly if they don't respond to the usual, you know, customary treatments of, let's say, you know, decongestants or a course of antibiotics or something of that nature, then they, that would, should alert the patient to seek medical attention immediately. And I would say that the second thing for the treatment part is to choose wisely where you get your treatment, because where you go first, when it comes to head and neck treatment, matters a great deal not only in curing the disease, but maintaining the quality of life. 

Bob Underwood, M.D. (Host): That's great advice. And so what about caregivers? So for example, I'm an emergency physician. So what do we other caregivers need to know about helping someone with head and neck cancer to help manage these quality-of-life issues? 

Ehab Hanna, M.D.: Oh, that is a very important question, because nowhere else in the body where a disease process or its treatment will make the patient absolutely critically dependent on their caregiver for some of these things we've talked about. In the treatment phase and shortly after the treatment phase, there will be challenges with communication. There will be challenges with eating and nutrition. There will be challenges with mobility, maybe with vision, maybe with hearing. And these may be temporary as the patient goes through their journey of healing and recovery. And the caregiver will be essential in facilitating some of these, either facilitating communication with the care provider team, helping the patient with simple things as meals and nutrition, helping them with mobility, vision and hearing, by providing this assistance in perceiving what's going on around them. But I would say that equally important is that human connection, the support, the emotional support, in particular. Patients who are going through head and neck cancer treatment are going through nothing short of a hurricane in their life. It's a pretty life-altering journey, and luckily, we now have all the tools to land this ship through the storm, through the hurricane, safely into harbor and into better times. But during that storm, the emotional support, the human connection from the caregiver would be absolutely essential. 

Bob Underwood, M.D. (Host): That's huge. And there was a wonderful analogy. I really like it. Now, you made mention that deciding where to seek cancer treatment is pretty important. So are there certain things that patients, their loved ones that they really need to look, look at and they need to look for to make sure that their quality-of-life needs are being met? 

Ehab Hanna, M.D.: Absolutely. When it comes to head and neck cancer, it's a very, uncommon relative to the others disease. Therefore, the expertise in diagnosis, getting the right diagnosis, which is really the beginning of getting the right track, the right treatments and the right treatment combinations, the right treatment sequences with experts who do this every day, and then the right rehabilitation team that will pick up the pieces for the quality-of-life components and puts them together so that the patients return to their work, to their social environment, to their family, to eating out, to their hobbies. And all of that requires a deeply experienced, dedicated team that is also multidisciplinary. And what I mean by multidisciplinary, it's not just that you have a specialist in each area, but these specialists talk to each other. Sometimes you will have all the different specialists, but for some reason, the care is not integrated and that makes a huge difference in the final outcome. 

Bob Underwood, M.D. (Host): Yeah, I think it really does. And that's really, some of the special things that your team does at MD Anderson, just to make sure that these needs are met for the head and neck patient. 

Ehab Hanna, M.D.: Absolutely. 

Bob Underwood, M.D. (Host): So what are some of the newest advances in head neck cancer treatment? Let's start with surgery. 

Ehab Hanna, M.D.: So surgery, which is a main weapon against head and neck cancer, has evolved in the last several decades. In the beginning, it was let's do bigger, let's do more radical surgery because that's going to increase the cure rate. And as we have built a tremendous amount of experience, we have now developed these minimally invasive techniques that are delivering equal, if not better, survival and cure rates, but far less damage and far better maintenance of form and function. I'll give you a couple of examples. One of them would be endoscopic surgery for removing skull base tumors. In the past, this required a craniotomy, which is essentially opening the skull like brain surgery. And now these tumors are removed through endoscopes, really nifty high-definition cameras going through the nose or the mouth to remove the tumor without having any incisions or openings on the skull or on the face. The second example I would give you is a robotic surgery. A robotic surgery, uses the arms of the robot with microinstruments through the mouth to remove cancers in the back of the throat, the tongue, the swallowing apparatus, the swallowing tube, or the throat, and without making any external neck incisions, causing some pretty significant deformity. So these are just two quick examples of the surgical techniques that have evolved to minimize the radicality of surgery. 

Bob Underwood, M.D. (Host): Yeah, those are great examples. How about radiation? How does radiation now minimize quality-of-life issues? 

Ehab Hanna, M.D.: My goodness, radiation has evolved even in my own lifetime through different phases, and these are pretty big milestones. So for example, in the beginning, there is what they called 2D, then it became 3D, which means two dimensional became three dimensional, where the beams are coming to hit the cancer. And then it evolved into what we call conformal radiation. Conformal radiation is where the radiation beam conforms to the very shape of the specific cancer of this patient and where it's located. An example of that would be intensity-modulated radiation therapy or IMRT. Now the newest kid on the block and the newest advance is proton therapy. And proton therapy not only is conformal, but I'll give you an analogy: If the radiation beam is like a bullet, proton therapy hits the target without an exit wound. In other words, it goes in, kills the cancer and stops right there and does not continue the path of destruction as it exits the body. So in terms of treating cancers, for example, around the eye, the advantage is obvious. You can treat the cancer pretty hard and not cause vision damage. Cancers at the base of the skull, you can hit the cancer pretty hard and not damage the brain tissue and so on. 

Bob Underwood, M.D. (Host): It is phenomenal in terms of how technology has really advanced us in these ways. And finally, let's talk about medical therapies. 

Ehab Hanna, M.D.: Let me just add one more thing on radiation. Before we move on to medical therapy. The second advance in radiation is what we call adaptive radiation therapy, and we're studying this at MD Anderson very hard. Adaptive radiation is different from the standard radiation that has been used forever and ever. The standard radiation is you decide before the treatment about the dose and the field of radiation. What am I going to hit, and how much am I going to hit it with? Adaptive radiation changes those parameters (how much dose is needed and the field of radiation) based on how the cancer is responding. So if you start with a cancer this big and then it goes half the size, there is no reason to continue hitting hard on that wider field. And you can narrow the field and reduce the dose, and that minimizes collateral damage. 

Bob Underwood, M.D. (Host): That's phenomenal. And again, the technology to be able to do that is amazing. OK, so how about medical therapies. What are some new things and new innovations there? 

Ehab Hanna, M.D.: That is also an explosive field of discovery and innovation. I'll give you a couple of examples on that. One of them is what we call in medical jargon neoadjuvant therapy. And in layman's terms, what that means is that you get drug therapy before you start the next treatment, which could be surgery or radiation, with the goal of shrinking the cancer. So if you start with a cancer that is, you know, ten centimeters in its size, and then you start with neoadjuvant chemotherapy and it goes half the size, then the next phase of treatment, let's say surgery, is far less in its scope than had you not shrunk the tumor. So neoadjuvant chemotherapy is an area where we are making great strides in several of these cancers and preserving organs, preserving vital structures that otherwise could have been sacrificed to get rid of the cancer. This second example is something I'm sure a lot of the public has heard about, which is immunotherapy. Immunotherapy unshackles the immune system. When cancers develop, they're trying to outsmart us. And what they do is they put the brakes on the immune system. They shackle the immune system, both the surveillance part of the immune system, which is what I call the police. These are the cells that are roaming around the body looking for any mischief or any misbehavior. And the killer cells, which I call the Army or the Air Force or the Marines, depending on where your background takes you. And these cells, when they are notified by the surveillance cells, which is the police, that there is some problem, they attack and kill. Now, cancers will put the blocks on these two systems. Immunotherapy unshackles both. The greatest area where immunotherapy has transformed the treatment is skin cancers. A lot of the skin cancers that required massive surgery to remove them with sacrificing facial structures like we talked about before, ears, eyes, noses, lips, skin on the face, now, a great deal of these patients will respond to immunotherapy with minimal surgery or no surgery at all. 

Bob Underwood, M.D. (Host): So you're highly motivated. So what is it that motivates you to really move the ball forward for patients with head and neck cancer? I mean, you can hear it in your voice. So what is it that motivates you? 

Ehab Hanna, M.D.: My patients. No question, no hesitation. I go to work every day excited. I go to work every day with one mission. How can I serve my patients? For three goals, I have three goals in mind every single day. Number one: Maximizing treatment efficacy. What that means in layman's terms: Save more lives. Cure more cancer. Number two: Maintain their form and function. What that means in layman's terms: I want them to look as good as they did before the cancer, and I want them to function as good as they did before the cancer. Number three: Have the best quality of life after they have been cured. And that means going back to all the things that they love doing, whether it's work, family, society, hobbies, what have you. 

Bob Underwood, M.D. (Host): That's awesome. Thank you so much for being with us today and for sharing your great wisdom and your great experience. 

Ehab Hanna, M.D.: Thank you so much, Dr. Underwood. It's my pleasure. 

Bob Underwood, M.D. (Host): It's been wonderful. 

Ehab Hanna, M.D.: Thank you. 

Bob Underwood, M.D. (Host): For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MD Anderson.org. I'm Dr. Bob Underwood. Thanks for listening to the Cancerwise Podcast from MD Anderson Cancer Center.