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Melanie Cole, MS (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're offering updates in head and neck cancer with Dr. Peter Dziegielewski. He's the Chief of Head and Neck Surgical Oncology and Microvascular Reconstructive Surgery at the University of Florida College of Medicine and he practices at UF Health Shands Hospital.

Melanie Cole, MS: Dr. DZ, thank you so much for joining us today. I'd like to start by asking you if you've seen the incidence of HPV-related head and neck cancer change in recent years. What have you seen in the trends and how does it compare to other head and neck cancers? Where in that continuum of diagnostic criteria is HPV a factor in this trend?

Peter Dziegielewski, MD: Well, thank you very much, Melanie. We've certainly seen an increase in the proportion of head and neck cancers caused by HPV over the last 20 years, and especially in the last 10 years. Traditionally, the vast majority of these cancers were caused by smoking and excessive drinking. And those cancers still occur, but now the proportion of cancers caused by HPV has dramatically increased, and we sort of see it as almost an epidemic in our specialty.

Melanie Cole, MS: Wow. That's so interesting, doc. So, describe the current status of the smoking-related head and neck cancer and its prevalence. So, HPV has risen above the prevalence of smoking-related cancer, yes?

Peter Dziegielewski, MD: Well, I would say still the majority of head and neck cancers are caused by smoking. But if you take a hundred head and neck cancers, for example, it used to be that maybe 90% of them were caused by smoking, the other 10% by HPV. And now, it's almost 50/50. So, we're still seeing a lot of smoking-related cancers. But because the number of smokers in our population has dramatically gone down over the last 20 years, we certainly see a lot less of those cancers. So, the HPV ones are almost you could say taking over the vast majority of the causes.

Melanie Cole, MS: Dr. DZ, head and neck cancers are so unique and challenging. Speak a little bit about some of the effects of this type of cancer and its treatment; how it affects the daily lives and the quality of life really of patients and their families, eating, self-esteem, speech, appearance, all of those things.

Peter Dziegielewski, MD: Yes. Certainly, head and neck cancers are ones that you cannot hide from. Most people who have a head and neck cancer or have been treated for one, you can often tell. They can have changes in their speech, changes in their swallowing and their ability to eat and, for many people, that affects how they interact socially. So, many of these patients have a hard time eating in public, and you can certainly see that. It can also affect patient's appearance. And because of that, because of the way it affects their functional outcomes of swallowing and speech and appearance, it can definitely affect their own self-esteem and how they interact with the world. So, these cancers can have certainly effects on the patients. It's not something that's easy to disguise.

Melanie Cole, MS: Please tell us about some of the emerging technologies and state-of-the-art treatments that have been made that could allow surgeons to access hard-to-reach areas of the mouth and throat.

Peter Dziegielewski, MD: So for the cancers we see that are caused by smoking, the major advances have come in surgical technology. Major differences we've seen is, in the past when we used to remove a cancer, we didn't have a great ability to reconstruct the structures and organs we're removing, such as part of a tongue or a jaw or the face. We now have much more sophisticated means of reconstruction using other parts of the body as transplants from the patient themselves. And with our technology, our surgeries have decreased in time significantly. Things that used to take 20 hours, now only take 10 hours. And so, that means that patients can recover quicker, they can start additional treatment as needed, for example, radiation treatment or immunotherapy or chemotherapy. And because they get to those treatments quicker, their chance of surviving the cancer goes up and because of the more sophisticated surgical techniques we have, patients are able to live longer and also have better function with their speech and swallowing, which often translates to better quality of life. So, our goal is no longer to only improve survival, it is to improve survival with a life that's worth living, one that patients can adapt to and still have a very good life.

We've also had advances in minimally invasive technologies such as robotic surgery, which is very useful for treating HPV-related cancers. Those cancers tend to occur in the tonsils or the back of the tongue, or as we call it the base of the tongue, so kind of at the back of the mouth, the top of the throat. And those areas were very difficult to access in the past. And we used to make incisions through the lip or split the jaw to get back there. Now, we can do it all through the mouth with robots and our most sophisticated robots now can access cancers we used to not be able to get to.

So, technology has certainly increased. And with that, we've also learned that the HPV-related cancers don't often need as much treatment as their non-HPV counterparts. For example, we used to think that in order to cure one of these cancers, we had to give them the highest dose of radiation possible or do the maximum amount of surgery possible. We now know we can use lower doses of radiation and less surgery to cure these patients, and we can use combinations of the two, less surgery and less radiation to achieve equivalent survival rates with much better outcomes in terms of side effects from treatment.

One other technology I'll mention that's really emerging right now. We don't have all the answers yet, but we have blood tests that can detect HPV DNA, and we think that this DNA comes from active cancers. So, the way you can think of it is that cancer is shedding this DNA and it ends up in the bloodstream. So while there's an active cancer, the blood test can show that by detecting HPV DNA. Once the cancer is gone, that DNA should go down to zero. Preliminary studies show that that is actually what's happening. We don't have enough data yet to completely rely on this, but we are engaged in clinical trials that are using this to measure patients' DNA as they go through treatment. So, for example, if a patient is getting radiation treatment for an HPV cancer, let's say about halfway through the treatment they get a blood test and that blood test shows that the HPV DNA is zero, well then they might be done with treatment. They may not need any more radiation after that.

Likewise, we're hoping that it'll also show us that once a patient has gone through surgery, if their DNA level in the blood is zero, then they may not need additional radiation treatment or chemotherapy like we once thought they would need. So, we're starting to really tailor treatment, not just to the disease, but to the patient themselves and trying to use as little treatment as possible to maintain survival rates at a very high level, but also to decrease the side effects patients experience.

So, I know that was a long and wordy answer, but there's a lot of things going on in head and neck cancer and we're certainly pushing the envelope every day.

Melanie Cole, MS: No, it certainly wasn't. It's fascinating, Dr. DZ. And what an exciting time in your field. It's moving so quickly. And as we're speaking about these treatments and these exciting innovations, discuss just a little bit about reconstruction. What's exciting as far as the intricate nature of these procedures and how they're preserving the patient's quality of life after treatment.

Peter Dziegielewski, MD: Absolutely. So, one of the exciting parts of being a head and neck cancer surgeon is that we get to mix science and art together. We use scientific data to develop our surgical approaches to maximize removal of cancers. So once we remove the cancer, we then get to use our artistic side a little bit. So for example, if we need to remove a portion of a patient's jaw and tongue, we need to reconstruct those structures and we have the ability to use various parts of the body to do that. We can take pieces of a person's forearm or bone from the leg or bone and tissue from the back. And we can then use that to shape a new tongue and shape a new jaw. That definitely involves definitely some science, but also some art to get the right shape, to get the right movement afterwards. And a lot of that comes with time and experience.

And over the years, as more and more surgeons have developed these techniques, we've been able to share experiences, share scientific data and we've exponentially got better at these. And now, patients are able to swallow and speak much better than they used to be able to after these types of surgeries. In the past, it used to be that the majority of patients were stuck with a feeding tube for the rest of their life and they couldn't speak very well. Now, it's the complete opposite. Most of these patients can speak very well. Very few of them are reliant on a feeding tube for the rest of their life. And this all just comes from experience and more and more advances in our instrumentation and the sharing of knowledge around the region, around the country and around the world.

Melanie Cole, MS: Well, I think one of the most important aspects other than all of this technology and the exciting work that you're doing is the importance of having a robust care team when treating these types of cancers. How has that introduction of therapy involvement of multiple subspecialists, utilization of that multidisciplinary team been really ideal for managing these complex patients? Speak about that just a little, Dr. DZ.

Peter Dziegielewski, MD: Yes. Certainly. The importance of a multidisciplinary team cannot be stressed enough. When you're taking care of a cancer patient, let alone a head and neck cancer patient, you need a whole village to take care of these patients. It's not just about getting through a good operation, but it's also about having the opinions of multiple specialists like radiation oncologists and medical oncologists, radiologists and pathologists all coming together to individualize treatment, to make sure that we are recommending and choosing the best option for that particular patient. And then, using that expertise to treat the patient, get them through treatment and get them to our rehabilitation folks, and that's going to be physical therapists, speech language pathologists, dieticians, and it is incredibly important for these patients to undergo rehabilitation.

And the way I tell patients to think about this is, let's say you were a high performance athlete, you tore your ACL, you had your ACL repaired, well, no matter how good the surgery is, your outcome is only going to be as good as the effort you put into the rehabilitation physical therapy afterwards. So, I tell patients think of your mouth as the area that needs that physical therapy. You're going to need speech therapy and swallowing therapy as the physical therapy for your mouth. You're going to need physical therapy for your body. And this goes on for many months and having these experts focus on patients that have gone through head and neck cancer, knowing what they need to accomplish gets them the best possible goals, because this is an incredibly long journey. Just going through an operation or an operation and radiation therapy is just the beginning. Afterwards, the survivorship and trying to get the best function to improve quality of life takes many months. So, the journey goes on and on.

I tell patients, I try to emphasize this, that when you get cancer care, you want to be at an institution, at a place that has the whole team, that has the experience, because this is not the type of disease you want someone dabbling in. You need experts who are very focused on this to get you the best possible results.

Melanie Cole, MS: Dr. DZ, as we get ready to wrap up here, how do you see the field of head and neck cancer evolving in the coming years, and specifically HPV-related cancers? I mean, we now have a vaccine for this. So, do you feel that the next generation may see a lower incidence of this? And how do you want other providers to stay current with some of the developments and exciting innovations that you've discussed here today?

Peter Dziegielewski, MD: Great questions. So, I see if things continue going the way they are in our society, the trends of smoking are going down. However, the one concerning trend is the increase in use of vaping. We still don't know how bad vaping is for someone. We don't know if it does cause cancer or not, but we have seen some young people in their 20s get head and neck cancers. And the only reason we can think of is because of the use of vaping. So, that is concerning. We don't have all the data yet to make a definitive conclusion on that, but I'm hoping those trends go down and we don't see that.

With respect to HPV, as vaccines become more and more available and hopefully used and not shunned by society, we will see a decrease in HPV-related cancers. For those people who do get HPV-related cancers, the way our field is going is we are trying to use less and less therapy while keeping survival rates high so that patients have less side effects. One of the most difficult things about going through any cancer treatment is after you're cured and the adrenaline rush is gone, now you're left with a new normal. And that in head and neck cancer can mean many side effects that impair speech and swallowing, dry mouth, stiff muscles in the neck, difficulty swallowing. And a lot of these side effects get worse over time, especially the more treatment a patient has, the more surgery, the more radiation, the more chemo. And so with HPV, the less treatment we use, the better these side effects will be.

And so, we're still trying to find that balance and having some state-of-the-art blood tests are going to help guide us. And so, I see a lot more individualization of treatment coming from that. And then, I think, you know, the best way to keep abreast of what's going on in our field is just to follow the literature. Every few months, there's typically updates in our journals about HPV-related head and neck cancers. It's a very hot topic and it's often published about. We tend to put out some information on our website as well every few months to update folks. Those are probably the best ways to keep current about the treatments. But the most important things are making sure that the patients get to the providers they need to and that means going to multidisciplinary institutions that really specialize in the treatment of these types of cancers. So, NCI-designated institutions are great locations for these patients.

Melanie Cole, MS: Thank you so much, Dr. DZ, for joining us today, and it is so important, and the experience of the surgeon and treatment team matters so much here. Thank you again for sharing your expertise. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.