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Melanie Cole, MS (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And today, we're discussing oral, head and neck cancer with Dr. Anthony Morlandt. He's a Head and Neck Surgeon in Head and Neck Surgical Oncology, Oral and Maxillofacial Surgery. He's also an Associate Professor at UAB Medicine. Dr. Morlandt, it's a pleasure to have you back with us. You're always such a great guest. And as we get into this topic, why don't you start by telling us what makes oral, head and neck cancers unique in the field of medicine?

Anthony Morlandt, MD, DDS, FACS (Guest): Oh, thank you, Melanie. It's great to be back. Good to speak with you. Oral cancer is unique. Oral cancer is, you know, in some ways patients who suffer from oral cancer are the unsung heroes of medicine and especially of oncology practices. These are individuals who when undergoing treatment, have scars that are visible to the world, have radiation treatment effect and fibrosis that everyone can see that exists outside of their clothes. The facial appearance, the cosmetic outcome of a patient who's had cancer like this huge. And then quality of life outcomes when these are studied in the literature; sight, speech, chewing and swallowing as some of the most important aspects of getting through head neck cancer care.

So, we always talk about survival as kind of the key component, but it's not just survival, it's quality of life. It's helping a patient get back to their normal activities. Being able to face society, face the world, kiss their family members, talk to one another and even eat. I mean, eating is such a huge part of our lives socially, in addition to our nutritional intake requirements.

And so all of that has to be kept in mind. And just think it's a very unique patient population. There's a lot of, there's a lot of pride. There's a lot of sadness when patients have to suffer some of the disfiguring effects of the treatments that are available. So, you know, we have to be very sensitive to those issues and keep all of that in mind.

And the last thing I'd mention is one thing that also makes oral cancer unique is there is no widespread screening modality for oral cancer. And any of you who've been to your dentist, know that a good dental exam is about all that a patient can receive. There's no, mammography, there's no colonoscopy. We don't have a PSA. We don't have any other bloodborne or even tissue born biomarkers at this time to know whether a lesion is going to become cancerous, if it's dysplastic, if it's precancerous or know an individual's risk. Some of that's improving with biomarker options for screening in the saliva or in tissue, but for right now we really don't have a lot of options that our colleagues who treat breast cancer or even thyroid cancer and other cancers have. So it does depend on a good relationship with the primary care doctor or especially a dentist, 75% of patients who were seen with oral cancer are initially screened by their dentist.

It is important to maintain those relationships. It's a bit of a challenging field for sure. It's part of what attracted me to the field initially. My personal stories of my grandfather who passed away from head and neck cancer the 1990s. And an awful thing to watch where he went around to all of his primary care physicians, dentists. He had antibiotics, he had what was thought to be just a sore throat. Just thought to have a viral issue for months, but really had a stage four head and neck cancer and ultimately died from it. And this story is all too common.

Host: Wow, Dr. Morlandt. First of all I agree completely as somebody who has done a lot of podcasts on various types of cancers and the field of oncology, I agree with you about oral head and neck cancers. And thank you so much by the way, for sharing that story that you did. So, based on the intricate nature of this type of cancer, and as you say, the quality of life compared with so many others, and we're not diminishing any other cancers, but there is a difference when it's right out there for the public to see. And when it does involve swallowing, eating, talking, all of those things; how has medicine and in fact dentistry changed in recent years to improve those outcomes and help patients live longer, better quality lives?

You're doing so many exciting things at UAB Medicine. Tell us about how that's evolved and changed.

Dr. Morlandt: No. That's great. Yeah you're absolutely right. And how it impacts the patients in those visible ways. That the changes can be summarized into a few categories. It's diagnosis and detection, treatment and then reconstruction, right? So the reconstruction is probably where some of the most exciting changes have been made. It wasn't long ago, really in the 1990s, when a patient could have a cancer removed and maybe some local tissue brought in place, maybe a piece of the pectoralis major muscle, or a bit of the skin from th2e shoulder, that deltopectoral flap, Kamjian flaps as they were called. But very tight, lots of tethering, lots of limited range of motion and pretty awful surgery.

And so in the 1990s, microvascular surgery came of age. It was really developed and perfected by our colleagues in plastic surgery. And then otolaryngologists and oral maxillofacial surgeons began also perfecting the field of head and neck reconstruction. So instead of just taking a piece of someone's jaw out, for example, and filling it with a piece of their chest muscle and all of the morbidity that goes along with taking that large muscle from the front of the chest, now we can take a piece of bone, a piece of fibula bone, non-weightbearing, or a piece of iliac crest, that's vascularized, or a piece of scapula, actually put dental implants in situ that are guided with 3D navigation, actually temporize that piece of bone with teeth on top of the implants and transfer that piece of hard tissue with a soft tissue lining, a custom printed titanium reconstruction plate and the implants and the teeth all at once. So we are still using the patient's own tissue for the most part, but it's much more specialized.

It's much more specific based on their needs. If it's a bony defect, we try to replace the bony defect with bone. If they're missing teeth, we try to replace those teeth with implants and prosthetic teeth. And in the past that just wasn't an option. I think the other huge advance is in treatment. So patients now have access to proton therapy. We're the only proton therapy center in the state of Alabama. And it has made a huge difference in patient outcomes. And we have some highly skilled radiation oncologists here, and we're also seeing some opportunities with immunotherapy in head and neck cancer things like the PDL1 inhibitors, for example that are allowing patients to live a longer life.

So years ago when head and neck cancer treatment really wasn't associated with long-term survival, now we're seeing these patients do live longer, so it really speaks to the importance of good reconstruction. We've got to give that patient years of of good jaw form and of good chewing and of good facial appearance, and facial aesthetics.

And then on the screening and detection side, there are a few diagnostic adjuncts that are available even in the dental office to help, but ultimately now we still need that patient to receive a biopsy. We still need an office based punch or scalpel biopsy. It's a simple procedure. It's simpler than having a filling in your tooth done in a dental or an oral surgeon's office or an ear nose and throat doctor's office.

And that procedure helps a physician understand whether or dentist, helps the clinician understand if that patient has oral cancer, so they can be referred to a cancer center like ours for treatment. So there, there are some advances, I'd say in general, most of it centers around the use of 3D rendering and for surgical planning and also the use of intraoperative navigation with which helps us be better surgeons. Just helps us do a better. What's coming in the future? Well, I hope we can really use, really leverage the immune system with things like checkpoint inhibitors and more robust immunotherapy options and really understand the role of inflammation in oral cancer. You know, Melanie, if you think about the mouth is filled with teeth and we get bacteria around our teeth. The mouth is filled with about 200 types of normal bacteria that help us start digesting our food. Well, all of those bacteria play a role in inflammation. And so if there's an imbalance in healthy and unhealthy bacteria, we might see things like gum disease, for example.

Well, it's pretty well known that those same inflammatory mediators are overly expressed in patients who have cancer. So a mouth cancer is similar in its fundamental basis. And I'm not speaking as a scientist here, but the fundamental basis of mouth cancer is still based on some of the things that are very commonly seen in dentistry.

So, it maybe an option in the future to, to leverage the immune system to fight cancer even more in that way. One of the big challenges for the the physicians in the audience, is that genome level mutations are not thought to be implicated in oral cancer progression as much as epigenetic changes or post-translational modifications. And that may be due to the fact that we're constantly putting things in our mouth. We constantly have mechanical and contact related trauma, contact related mutagens. Because we put things in our mouth constantly, all sorts of preservatives and toxins even. And that may be make proteins and inflammatory mediators, the driving process of carcinogenesis more than just a DNA or genome level change. So lots of interesting things are being understood more as we get further along.

Host: I agree with you. And I think we're going to learn more about inflammatory markers and the immune system. I completely agree with you there, Dr. Morlandt, and I'd like you to tell us about Jaw in a day because you started about it just a little bit. I want you to expand for other providers that are not at UAB Medicine to hear the exciting things that you're doing and how you're really using instrumentation, coupled with improved imaging and these localization techniques to really provide minimum damage to surrounding tissue. You're able to do really cool things.

Dr. Morlandt: Oh, yeah. Yeah, absolutely. Thank you. We've put together some media on that topic, things like videos on YouTube that are available and we've had some local news stories with some really good human interest in patient related stories. But Jaw in a day and it's in its core is exactly that, instead of waiting six months or even a year to have normal functioning teeth after a part of the lower or upper jaw is resected using 3D navigation and patient specific implants that are custom fabricated through a number of techniques.

But the most common is a process called selective laser centering. Everything can be built from titanium. And so a custom plate is custom fabricated based on the patient's CT scan. And that plate is used at the leg. For example, if we're harvesting a fibula flap, with the blood vessels attached to put dental implants, just the same dental implant you might have, if you'd lost a tooth to gum disease or lost a tooth to trauma or a cavity, the same dental implants can be put into the leg.

And as long as they're positioned the right way, those four or five implants can then be, can be fixed with a temporary bridge that then is replaced with a permanent bridge. And those teeth are then all transferred to the mouth with the implants and the leg bone and the titanium custom plate and the blood vessels.

And based on our knowledge of dentistry and occlusion and orthodontics, all the things you spend years in dental school studying, you can put that jaw into exactly the right position. So when that patient wakes up, they can chew. And as you can imagine if any of those parts are put in the wrong position, nothing works.

So if a leg bone is slightly out of alignment and doesn't, doesn't meet the other jaw, then you can't chew. And if the teeth are not in alignment then if the implants are angulated poorly, so it's one of those things that we've been able to execute only because we have an excellent team. And as in, in many aspects of medicine, it takes people from different disciplines, different backgrounds, our prosthodontist Dr. Case trained at Memorial Sloan Kettering, has a dental background and also a prosthodontic background. And so is able to bring that training to UAB and our surgeons have extensive training in 3D surgical planning and partner with several industry groups to bring that into practice.

The latest thing we've started to do is actually custom 3D print our own teeth at UAB. And the reason that's important, is cost. Everything I described as is exciting, but is very expensive. It's all customized for a typical case that doesn't have any customized implants or any customized parts.

The cost is in the hundreds of dollars. But it can be many thousands of dollars to, to customize the entire process. We've been able to print 3D teeth here at UAB for about $10. And because they're temporary, we can do that. The patient can wake up, have a beautiful cosmetic result have some chewing function on temporary teeth.

And then those are replaced with porcelain or acrylic teeth later that are permanent, but that low cost really improves access to care for patients who may have dental coverage or good medical coverage. We have a lot of patients at UAB who are underfunded. So it allows us to give those patients the best we can offer.

Host: What a great educator you are. And I can hear the passion and yes, of course, Dr. Case has certain specialties that we haven't seen really anywhere else. You're very lucky to have him and obviously UAB with all of you. So as we wrap up, Dr. Morlandt, since cancers of the head and neck region can have, as well discussing devastating effects on appearance and function of the patient and are really among the most disabling and socially isolating cancers that really impact the patient's quality of life. I'd like you to speak now to primary care physicians, nurse practitioners, advanced practice providers, dentists to help their patients better understand those unique needs of oral cancer patients and their families.

Dr. Morlandt: Absolutely. I think the most important thing Melanie to remember is if someone has suffered from oral cancer, they've suffered not only physically. But also emotionally and psychologically. There is a component of PTSD with the treatment. And it has to do, I think with the fact that it's a very public illness, it's a public disease. You can't hide it under your clothing. There are no scars that are hidden underneath your clothing. It's the same for people who have disfigured hands. You know, these are out in the community, they're available at some of the exposed skin, along with the head and neck. And the problem with the face, good or bad as it makes up our identity.

You know, when we have patients who suffer from facial nerve injuries and our colleague, Dr. Green and Dr. Myers who run the facial nerve clinic could tell you, these are patients who really suffer from an identity crisis because they've lost their ability to function with facial animation. And they've lost their ability to function in that fundamental human mode of expression. So I think every primary care doctor and advanced practice needs to understand that these patients deserve a special level of compassion. On the other hand, patients who might have an oral cavity cancer really need to be evaluated by someone with some degree of specialty experience, they don't all need to come to the head and neck cancer clinic. But what we see in a busy primary care practice or urgent care clinic is a good examination of the throat, a good examination of the tonsils, sort of bypassing the tongue, bypassing the mouth and oral cavity. And these patients you know, many times have a long delay in diagnosis. And because there's no diagnostic adjunct available because I can't order a CT scan or order just an MRI and know if the patient has cancer, it relies on someone with experience. That person is usually the local dentist or dental specialist. And in some cases, the otolaryngologists or even dermatologist who, who spend a lot of their time looking at cutaneous lesions or mucosal lesions, but it really is important for that primary care physician to get someone involved who we might call a regional specialist in the care of the mouth. And some clinics are really excellent at that. And I think some have some opportunities and in various areas around the Southeast. We've had a lot of patients even lately with long delays in diagnosis up to a year. And unfortunately, a stage one cancer has about twice the survival over five years as a stage four cancer.

So, and all stage four cancers start off as stage one at some point. So there is an opportunity for early intervention if we have sharp eyes and are keenly looking for these patients in our clinics. So I think that's the message to our primary care colleagues for sure. Early diagnosis and detection absolutely saves lives. Oral cancer has a 65% five-year survival. Breast is 91, thyroid's 98, prostate's 90, oral cancer, 65. We've gotta be detecting these earlier if we're going to make a change.

Host: Well, if anybody can do it, you absolutely can. And your team at UAB Medicine. Dr. Morlandt, thank you so much for joining us. This was a great informative episode and a physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. For updates on the latest medical advancements, breakthroughs and research at UAB Medicine, please follow us on your social channels. I'm Melanie Cole.