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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we discuss radiation therapy for oral cancer. Joining me in this thought leader panel today is Dr. Michael Kase. He's an Assistant Director of the Advanced Education in Maxillofacial Prosthodontics and Dental Oncology Fellowship. Dr. James Snider. He's a Radiation Oncologist and an Associate Professor and Dr. Christopher Willey, he's a Hale Stephens ROAR Endowed Professor for Distinctive Radiation Research and a Radiation Oncologist.

And they're all at UAB Medicine. Doctors, thank you so much for joining us today, Dr. Willey, I'd like to start with you. Can you tell us what oral cancers we're discussing here today? The current standard of care. Do the current therapies have a measurable effect on the course of the disease? Speak a little bit, just give us a broad overview of oral cancers.

Christopher D. Willey, MD, PhD (Guest): Sure. The main idea for oral cancers are basically the front part of the mouth. So, the very visible, the very sensitive part of the mouth that patients may become aware of eating food, seeing a dentist, seeing a primary care provider. Basically the areas we're talking about are areas along the lip, along the gum lines, both top and bottom, and really the tongue and the floor of mouth.

So, basically the area between where the gum and the tongue meet. And so, in general, really like for a lot of cancers, oral cancer is managed by really three major modalities and those include surgery, radiation treatment, and potentially chemotherapy. And so, in general, surgery, if possible is, the first step. And then that is typically followed by radiation and chemotherapy. A lot of it depends on when we diagnose it and that's basically called the stage. That's knowing where the tumor is when the disease is found. And then the management is usually based on many factors, which include some factors related to the patient themselves, and then some factors related to the extent of the disease and the available treatment.

So, I would say that's the big thing. But the idea is that surgery, is typically used to try to remove as much as possible, involves any potential reconstruction of the area. And then, radiation is used to essentially mop up after the surgery, often where you get, high risk factors, that can be hopefully controlled by radiation to the tumor bed, with or without chemotherapy based on, really the level of risk for the tumor coming back in that patient.

Host: Thank you so much for that, Dr. Willey and Dr. Snider, can you speak a little bit about how radiation for oral cancer affects the mouth, some of the side effects and how does it really, because I think this is one of the bigger issues in oral cancers. How does it affect the quality of life for the patient?

James Snider, III MD (Guest): Sure. I think radiation therapy to the head and neck is one of the more sophisticated things we do as Radiation Oncologists. And certainly is one that comes with a high payoff. Often these patients can be cured of their cancers and can do very well long-term, but the side effects of therapy can be relatively severe.

Most patients come to us, having had a big surgery to the front of their mouth, like Dr. Willey has stated. And certainly that's a very sensitive area, like he stated as. And then we're telling them that they're going to get six, seven weeks of radiation therapy, of daily treatments Monday through Friday, that are small treatments, small doses of radiation that add up to a total dose we want to get to, by the end. You know, each treatment is not something that the patient particularly feels, it's such a small dose of radiation. But as they start to build, as they get more and more dose throughout the course of radiotherapy, they certainly feel side effects. The most common side effects are taste changes, dry mouth, pain with swallowing and pain in the mouth. Some ulcer formation that we call mucositis. Most of these are short-lived and they will heal after the course of radiotherapy. Some of the side effects like dry mouth can be long-term and some of the effects on the bone in the mouth, and especially the dentition can be long-term.

And so that's why it's particularly important as patients go through this rigorous course of radiation and sometimes chemotherapy after they've had a major surgery, that they see a multidisciplinary team that is highly integrated and work together closely about making sure each of the steps is kind of checked off in the right order and that all the boxes are filled by the time we get to the end of the course of therapy. And that's why one of the most important steps we take is making sure that their teeth and dentition and oral health is well taken care of both upfront before we do the radiation therapy, as well as outback.

And that's why we work with people like Dr. Kase who I know can speak to after this, a lot of, sort of how we screen patients for their dental, before a course of radiotherapy and then how we follow them long-term and take care of their dentition and their jaw and the bones in their mouth long-term after a course of radiotherapy to the head and neck.

Host: Well, that leads very well into Dr. Kase. So, does the patient see a dentist before or even after radiation treatment, throughout that treatment course? Is this a general dentist that evaluates the patient? Do they need a specialist? Explain a little bit about your role in this topic.

Michael Kase, DMD (Guest): Sure. All those points are fantastic that Dr. Willey and Dr. Snider have made. First, I'm just going to emphasize a little about some of those side effects that that they mentioned just a little bit more depth from my perspective. So, they mentioned the dry mouth, the xerostomia, the hyposalivation.,Well, that has big problems for the patient because they lose the protective elements those of us who have not had head neck radiation have. So the mechanical ability to use the saliva, to wash stuff away from our teeth. The enzymes that we have on our teeth that protect or have in our saliva that protect the teeth tend to be decreased. So, all that leads to this increased chance of cavities and increased rate of progression of these cavities.

Which all lead to big problems if they're unchecked, which kind of leads us into that next question that you had involving, when do these patients see me and generally that we want it to have happened as soon as they seen the radiation oncologist, or as soon as they know they're going to need radiation. Sometimes that can occur even at the surgical visit that the surgeons can pretty much assume or know that if the cancer is advanced to a certain point, they're going to need radiation.

So, if I could even see them before, surgery, that offers the best opportunity to help them out and streamline their care. Because as Dr. Snider alluded to, the patients have this very large risk of something called osteoradionecrosis, which is essentially dead bone and that can be, extraordinarily life changing even after the cancer therapy and we try and avoid that as much as possible. So, if the patient tends to need teeth extracted, we like to do that at the time of surgery. And definitely before the radiation. As far as a specialist, I tend to believe they need to see a specialist. I did a whole fellowship in this material. So, I'm very well versed in all this information. And if the patient doesn't get the right information, the rest of their life can be severely affected by it. So, they need to see a specialist before the radiation. And at times after it's all completed as well, but once they get back to the routine care, they can see their general dentist.

Then I always offer my contact information, to help them out with information if they have any questions.

Host: Can you expand a little bit Dr. Kase on, you mentioned extraction, is this necessary in all cases? Why is. that?

Dr. Kase: It's not necessary in all cases. More frequently than not. THe problem relates to the side-effect I mentioned previously called osteoradionecrosis oftentimes just called ORN. And the reason this is important is, the patient, once they've had radiation, especially to the effected area, they cannot have extractions anymore due to this risk of osteoradionecrosis. And what happens and unfortunately, we see it more than we like, is the patient either doesn't hear this information or forgets, and then five years down the road, when all else is well, they have a tooth that goes bad. The tooth needs to be extracted and the bone does not heal. The bone dies. And then the patient has to have another big surgery to fix that problem.

And that's not something we want the patient to have to go through. So, if we can get the teeth that are questionable out before the radiation, the patient is in a much, much better situation for their future.

Host: What a great point to note for other providers, Dr. Kase. So, Dr. Willey, let's speak about the latest radiation techniques. Evaluate for us the currently available radio therapeutic modalities that are available for oral cancer and any that have really changed the landscape for you. Any that you find really exciting right now for your diagnostic and therapeutic capabilities.

Dr. Willey: I guess historically there have been predominantly what we call external beam, which is like the general category of a therapy that comes from outside of the patient, shining on them. So, typically x-rays and proton therapy, which, we will talk about a good bit. The other approach has been more of a brachy therapy, which is basically stands for short therapy. And that's implantable radiation, typically utilizing a needle. I would say that's kind of fallen out of favor a good bit because it's, fairly difficult. And really more of a rare one-off type of therapy, at least certainly where we practice.

So in general, this external beam radiation is the key. And so, really what has changed how we utilize this is our ability to really focus the radiation and sculpt it individually to the patient. And so, every patient is different. And so every therapy we do is customized for our patients. And so we, utilize basically 3D imaging information from a CAT scan, when the patient is immobilized inside of a mask. This is, done through what's called the planning session. And once we have that information in the computer, we can design a custom therapy to them and, and we use computer optimization to optimize, really something that even a human really can't do as well as a computer can and design a treatment that really maximizes dose to the intended target and then, reduces the dose, dramatically to the areas we want to avoid. And once again, an ounce of prevention is worth a pound of cure. So, it's critical that the patient gets any of their teeth taken care of prior to radiation.

And so we don't want to design a custom made plan for the patient, then they get a tooth removed or something happens that changes their anatomy. In terms of things that are very exciting for us, really, I think, Dr. Snider will be best able to discuss since he really leads this program for us. It's really our proton therapy, which is a particle based therapy and has some very special physics that allows the dose to essentially stop on a dime, as compared to x-ray therapy, which does have what we call entrance and exit dose as it passes through tissue. So, proton therapy has allowed us to really spare, basically more far away target tissue and normal tissue, on the other side of what we're trying to hit with our therapy.

And so, that particle based therapy, is very specialized. We have the only center in the state of Alabama, but, Dr. Snider, really leads that effort. And I think he probably, could expound on that a good bit.

Dr. Snider: Yeah, I appreciate it Dr. Willey. I, think, the proton center here at UAB or Proton International at UAB Proton Center is a very unique center. There's only 30, some odd proton centers in the United States and only a handful more around the world. It does deliver what, is kind of our newest, latest and greatest as far as a new modality of radiation therapy that has changed our game to some extent. As Dr. Willey alluded to protons, do something different inside our body, x-rays go in one side of us and out the other, which means they have both entrance and exit dose. Whereas, and I always liken it to, if we're shining x-rays onto a patient it's like shining a hundred flashlights onto their tumor. Unfortunately the light passes through the tumor and onto the other side of them with each flashlight. Now it's very bright where all the flashlights meet, but around in all their normal tissues, in the rest of their mouth, in their salivary glands, on the other side, in tissues that we're not trying to target, there's some dose of radiation that's being deposited by just trying to get our dose into the patient.

In proton therapy instead, the dose goes to a certain depth inside the patient and stops and where it stops or where the particle actually stops inside the body is where it delivers almost all of its dose along its path. And so I always tell patients, I liken it to almost like a light saber in star wars. It goes to a certain depth and just stops, and that allows us to more finely target our radiation inside the human body and reduce the exposure of the rest of the normal human body to radiation therapy. Which can therefore reduce the side effects associated with what is a fairly rigorous course of radiation therapy to the head and neck region. For patients with oral cavity cancers, that means sometimes reduced dose to salivary glands, reduced dose to the other side of their body if we only need to treat one side of their oral cavity, reduced dose to their swallowing tissues or their voicebox tissues or their swallowing tube called their esophagus. All those things can make what is a tough course of radiotherapy, less severe them and as the Associate Medical Director of this center at UAB, it's been my pleasure to bring that here.

We only opened that center in 2020 with the technology that I was very familiar with in my last job in Maryland. And we got that center up and running and now we're at capacity most of the time treating as many patients as we can. And over half of our patients in the center, are normally head neck cancer patients, often oral cavities or, oropharynx, the back of the throat cancers. Or nasopharynx or nasal cavity tumors, all things around the oral cavity that we treat with radiation very frequently, either instead of surgery or with a surgery as we do in the oral cavity. But it's really changed our game as radiation oncologists, about how much we can spare and how little damage we can cause to a patient while still giving them adequate radiation therapy.

Host: Dr. Snider, is there an optimal surgery to radiotherapy interval that you work with patients? Because I understand that these things, you know, as you've said can cause complications. Is there something you'd like to let other providers know about what you use as those clinical indicators for when it's time to start and a little patient selection.

Dr. Snider: Yes, Ma'am and I think one of the things that I would, maybe expound upon that Dr. Kase mentioned, and reinforce, and maybe use a little bit stronger words than he did is that I wouldn't just recommend, but instead I, strongly recommend that patients see somebody who's trained, especially for their dental care, who's trained specifically in looking at this issue around radiation therapy and things like that. And to speak to that timeline. I think that, that's very important about the dental timeline as well. That's one of our biggest holdups that we can run into between surgery and radiation is if we don't have an integrated team, this multidisciplinary team that can quickly act on a patient and do what needs to be done for their dental care to get them to radiation therapy, it can often delay their care overall.

And there is a critical what we call package time. That's a term that we use, but basically it means time from when they get their surgery to when they complete their radiation, that, that package of therapy needs to be completed in a certain period of time to give them the best chance at a great oncologic or cancer outcome, as well as a side effect profile and toxicity outcome.

And normally we want that timeline from surgery to radiation to be at or under about six weeks, which means there's a lot that has to happen in that six weeks. And if you don't have a team, that's all on the same page, that does this regularly, that does it with a lot of head neck patients that timeline could get protracted in a way that we don't want it to be. From surgery, they need to start healing. They need to see their surgeon post-op and make sure they're healing correctly. There can always be little revisions, like little wash outs and things like that, that need to be done. They need to see the radiation oncologist.

They might need to see the medical oncologist about chemotherapy. They need to see Dr. Kase or somebody from our prosthodontics team or oral surgery team to talk about extractions, if they are need it or dental work, if they need it. That dental work needs to be done, then we need to do the CT simulation or planning process that Dr. Willey mentioned for radiation therapy, where we make a mask and custom molded pillow for the patient that they'll lay in every day for treatment, they need to do their CAT scan for treatment planning for radiation. Then we have to plan the radiation, which in the case of something like proton therapy, that means we're taking a subatomic particle speeding up two thirds the speed of light, shooting it up a story in a building back down a story in a building through a 300 ton machine and landing it in the patient within a two to three millimeter space.

If we're doing that, that takes a lot of planning. It takes a lot of people and it takes a lot of work. And so having all those steps laid out by a team that does it every day, that is used to doing it in a concerted fashion, that everybody knows, it's almost like a dance and everybody knows their next step. And everybody has to know that next step for the patient. Otherwise the whole dance falls apart.

And so, for us having this multi-disciplinary team and working with Dr. Kase and his ilk, they're very ready to take our patients and know what we want from him. Know what we're asking him every time we send him a patient and can manage them quickly and expeditiously is highly important.

Host: Dr. Kase, would you like to expand a little bit on what Dr. Snider and by the way, Dr. Snider, what an excellent explanation. That was fascinating, really. Dr. Kase, speak to this just a little bit in your role in this setting this interval, and any interventions that happen during this time that you'd like to mention.

Dr. Kase: It kind of relates back to my previous statements in that it's best for me to see the patient as early as possible because these interventions that are mainly I'm referring to the extractions need to be done as soon as possible. So, if this happens at the time of surgery, when there's that hypothetical six week window where the extraction sites will be healed up much sooner than the large surgery the patient had.

So, the rate limiting step does not have to be the extractions. Whereas if an outside institution sends me a patient that has had surgery and seen radiation oncology, and now I have to see the patient, we have to evaluate them. They need extractions. And once those extractions occur, it's generally, 10 days, 14 days before it's healed enough to move forward with the simulation. So, that can delay time, a lot more than if we see the patient as Dr. Snider said, this well-orchestrated dance well before the surgery, so we could plan everything to happen at the same time.

Host: I'd like to give you each a chance for a final thought before we end this very informative podcast. So, Dr. Snider, why don't you start? I'd like you to please just tell other providers what you would like them to know about this multidisciplinary team that you've got, this approach that you described and how it really helps with your clinical decision making.

Dr. Snider: I think the proof is in the pudding for us. We can say all we want that we think having a concerted team and a multidisciplinary team in one place matters, but instead I think in the head and neck space in particular, in cancers of the head and neck region, time and time again, we've seen clinical trials, large clinical trials with thousands of patients who are being treated for head and neck cancer. And they show over and over again, one of the most important prognostic factors for how they will do both from a cancer standpoint, as well as from a toxicity and side effect management standpoint with their therapy, that multidisciplinary teams at major academic facilities, like UAB make a difference for these patients. Whether it's the timing or how concerted their efforts are, people that are trained in looking at things like oral health, like Dr. Kase are, whatever it is, there's magic in that mixture and magic in that recipe, and I think that's what we try to be here, for the head and neck team at UAB is one team that works closely together, that understands the calling that is in front of us, which is that these patients go through a very severe course of therapy that has a lot of side effects, but can be managed appropriately and get them to the other side of that with a very good long-term prognosis, if we dot all our I's and cross all our T's correctly and in a concerted fashion with the right timing and all those things for the patients. So that's, I think I hope the difference that we offer at UAB, not just technologies. And we do have fancy things like protons and so on and so forth. But I think the biggest thing we offer is this one team mentality around head and neck and understanding that, hey, patients are going to flow into this system.

We're going to take care of them from A to Z and make sure all the steps are done in the right order, on the right timing, to make sure they have the best chance at a great outcome, both from a cancer standpoint, as well as from a side effect of therapy. And long-term that their quality of life is as good as possible after this rigorous course of therapy for head and neck cancer.

Host: What an elegant description. And as you describe it as this dance and this multidisciplinary approach is just so important. Dr. Kase, I'd like you to go next and speak to other providers and specifically even to other maxillofacial prosthedontists or dentists about what you'd like them to know about their role in this, and even referral to you at UAB.

Dr. Kase: Well, I would just like to emphasize to any of the dentists out there that might be listening to this, that it's okay to not know all this information. And that's what I'm here for is to take the patients that they may have and guide them the appropriate way. But I'm also going to send the patient right back to them for the care afterwards. So, all the information that I have, I'm happy to talk to them about. I'm happy to discuss patient care with them. And that's usually what happens is I always give the patient my card and tell them to have their local dentist talk to me in the future if they ever have any questions. And that usually ends up taking the decreased risk for these big problems like osteoradionecrosis that are decreased because of our multidisciplinary care and decreasing it even further because we try and send this information into the community as best we can.

Host: Dr. Willey, last word to you, as you represent different specialties, all focused on treating oral cancer for the most part, different specialties. I just would like you to kind of summarize your combined clinic and why this is so important for the patients. They don't have to go to 8 million different places and how you all work together. And when you feel it's important to refer to the specialists at UAB Medicine.

Dr. Willey: I think a great way to finish this up, so, a lot of times when I'm talking to patients or even friends or people who just want to find out about this newly diagnosed head and neck cancer and how to manage it. I think the one thing that I, tend to bring up first is, really, we have amazing surgical specialists here. Okay. So, we have a huge catchment area because we have some of the highest volume surgeons, particularly the maxillofacial group, our ENT group is outstanding. And so really, a national leader and certainly regional leader. And so a lot of get introduced to the Cancer Center and UAB, actually through the surgical providers.

And we have an outstanding relationship with them, all of us. And so we consistently meet, a lot of us actually do research together as something we haven't talked about today is that, we actually have a number of clinical trials that are looking at what's the next best thing. Can we improve outcomes for patients through new research and we have some research that's geared just towards quality of life and just the toxicity that our therapies produce. So, a lot of those are multidisciplinary as well. And so once you're plugged into the UAB system, you're really connected to all these specialists, who meet regularly, who really come up with consensus best care plans for these patients. And it also involves obviously maxillofacial group, the prosthodontists. And so another thing we didn't really have time to talk about is not only, we're talking about teeth and management of that, but sometimes patients will have resections, have holes, let's say they have a pallet defects, something like that.

You're having Dr. Kase create prosthetics that allow the patient to eat, to talk, to communicate much better and all those things are really part of the care, not just the cancer control. On the radiation side, we have a very large group. And we have a lot of experience. We have a lot of providers that really tackle head and neck as their main gig.

And so, really all those things pulled together, when you get plugged in and then, certainly on the medical oncology team, we have a lot of experience Dr. Nabell, really leads that effort and so I think all together, we really want to attack this in a comprehensive manner because, in terms of side effects and difficulties to get through the care, this is really, I call the top three of radiation oncology in terms of most difficult. In fact, where I trained, the main head and neck provider used to tell patients, I'm going to take you to hell and back. And so be able to embark on a course, such as that, you really want a group that's able to tackle all aspects and all facets. We have had a neck cancer support team. We have really, providers that are even mainly focused on the supportive care management. And so all those things really come into play to get a patient through such a difficult course. And so I think with that, I would just say, we're willing and able to handle the head and neck cancer cases that, the people of Alabama are faced with.

And we really have an outstanding group that I love to work with everyday.

Host: Thank you gentlemen, for joining us today. What an interesting and so informative podcast. Thank you all for joining us and sharing your expertise. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast.

Please always remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.