Head and Neck Cancer Treatments

Transcript

00:00 --> 00:33Welcome to Yale Cancer Center answers with your hosts doctors in East Shag par. Susan Higgins and Stephen Gore Doctor Jag Power is associate professor of surgical oncology and director of the breast center at Smilow Cancer Hospital, Yale, New Haven Dr Higgins is professor of therapeutic radiology and of obstetrics gynecology and reproductive Sciences and doctor. Gore is director of human illogical malignancies. It's Milo, an an expert on Milo Dysplastic Syndrome's Yale Cancer Center answers features weekly conversations about the research diagnosis and treatment of cancer.
00:33 --> 00:58And if you'd like to join the conversation. You can submit questions and comments to cancer answers at yale.edu or you can leave a voicemail message at 888-2344 Y CC tonight. You'll hear a conversation about head and neck cancer with Doctor Hari Dish Pondy Doctor Despond, A's assistant professor of Madison in the section of medical oncology at Yale School of Madison. Here's doctor in East Shag par.
00:59 --> 01:32Hurry you know, unlike breast cancer, colon cancer lung cancer where there's a defined organ. That's involved with these malignancy's head and neck cancer is a rather large area. What exactly do we mean when we're talking about heading that cancers? Well, we mean cancers of what we call the arrow digestive tract and that's everything from the front of the mouth. The lips all the way down to the Larynx and the upper esophagus.
01:32 --> 01:52So, in other words, we not talking about the brain that eyes and generally not cancers of the skin, although in our clinics for head and neck cancer. We do see people with very aggressive skin cancers that occur on the face and also cancers of the thyroid.
01:53 --> 02:23So these cancers of the upper aero digestive tract are not things that a lot of people know about or talk about at least tell us more about how common they are, and how they present well there. Actually, not uncommon. So we see about 50,000 cases. New cases of these cancers every year in this country. They present with symptoms, however, that all of us kept so we're always.
02:23 --> 02:53Complaining in the winter, especially horse voices or sore throats and sometimes there lamp or a lymph node in the neck and these are the most common ways. They present there are a little more sinister ways. They present so if you're coughing up blood that could be a sign of a malignancy, but generally if you have a horse voice or a sore throat or especially a lump in the neck that doesn't go away by the time you would expect it too. And that's usually after a couple of weeks.
02:53 --> 03:25It's worth getting checked to see whether it's something else going on. And when you say checked? What does that mean? Is that a blood test is that an X Ray is that somebody saying open your mouth and say all how exactly or people checked for these cancers well. Initially it's a test that is a visit to your primary care physician an they will probably say open your mouth and say, Oh, that's the best way to look at what we call the oral cavity so that's
03:25 --> 03:55Everything in the mouth back to the start of the tonsils. Unfortunately, you can't see much further back than that and so the E NT Surgeons or ear nose and throat, surgeons have devices that they can look further back with so either a special mirror that they'll push to the back of the mouth or a fiber optic laryngoscope, which is a very small flexibel telescope with the camera at the end, that can see all the way down.
03:56 --> 04:26Into the larynx into the upper esophagus and see whether there any malignancy's there and so if you see one of these? How do you make the diagnosis? Can you actually take a biopsy through these little scopes? Yes, you can obviously if the cancer is in the front of the mouth and the EMT surgeon can see it right there in the office. They can easy take a biopsy just by looking at it, but these cameras these laryngoscopes.
04:26 --> 04:35Are able to do biopsies as well? And so they can very quickly make a diagnosis after the specimens being sent out to the pathologist.
04:36 --> 05:07And so how bad are these cancers. I mean, let's suppose you had a sore throat or a cough and it didn't go away. You went and saw your primary care. Doctor who referred you to the E&T specialist who did the fiber optic laryngoscope and saw something biopsied it and now you're sitting in their office and they say guess. Wat you have heading that cancer should you be very scared is the prognosis terrable? What is that like?
05:07 --> 05:38Well just like with most of the cancers that we see the prognosis depends on the stage and we come up with a stage based on how big the cancer is whether or not any lymph nodes are involved, and whether or not. It spread to other parts of the body. The staging of head and neck cancer is a little bit complicated for most cancers when you hear stage for it means it spread all over the body for head and neck cancer. It's slightly different.
05:38 --> 06:10We have a stage for a stage 4B and the stage for C and 4A even though it sounds like a very aggressive stage is kind of in the middle of the head and neck staging and we still treat those cancers for cure. So I would tell people if they first hear that they have cancer of the head and neck and by cancer. I mean, something called a squamous cell cancer. These are what the pathologist looks at under the microscope and the appearance is called a squamous cell cancer.
06:11 --> 06:41Those cancers can have very, very good survival rates, even for Stage 3 in for a disease so how do you know what stage you're at, I mean you know for many cancers at least not for Stage 4 but for earlier stages. It's made on the basis of pathology where the you take the cancer out and you send it to the pathologist and the pathologist tells you exactly how big it is, and you sample some lymph nodes and they tell you whether those.
06:41 --> 06:42Have got cancer in them or not.
06:43 --> 07:15But in head and neck cancer do you do do that first or is this image Ng and and if so D image? Everybody we tend to image everybody and the reason for that is. Unlike some of the other parts of the body. Most people when they have had a net cancer. They want to limit the amount of surgery. They have they don't want to lose their ability to swallow they don't want to lose their voice box or larynx and lose their ability to talk. So we typically do a pet scan and sometimes a cat scan and an MRI.
07:15 --> 07:43To see exactly what you asked how big is the cancer whether or not any lymph nodes are involved, and with that information. We can come up with? What's known as a clinical stage? What you were talking about with the surgery and looking at the lymph nodes in the pathology lab is also done in head and neck cancer for some patients and we call that the pathological stage, but we based most of our treatment decisions on the clinical stage.
07:43 --> 07:51So you have all of these X Rays that tell you how big the cancer is how many lymph nodes look like they're involved.
07:52 --> 08:22How do you decide how to treat these cancers that depends partly where the cancer is so generally we split the head neck region into different subsites. The first site. We call the oral cavity. That's everything from the lips. All the way back to the front of the part of the tongue where the front and the back join and just before the tonsils and for those cancers. We tend to remove them with an operation.
08:23 --> 08:55And then follow it with radiation or score chemo and radiation if it's a little more advanced a little further back is the oropharynx. That's the base of the tongue and the tonsil. Now the cancers in the oral cavity. The anterior turn cancers that cheat cancers. Those are very heavily related to cigarettes and alcohol, but cancers of the tonsil in the base of tongue are related to HPV or 70% or more of them related to HPV this is a virus.
08:55 --> 09:25The human papilloma virus, which is the same virus that causes cervical cancer and people with tonsil in base of tongue cancers tend to do really very well and 90% cure rate if their HPV positive with chemo and radiation without having any surgery so the treatments as you can imagine a very different depending on the site of the disease. So 2 questions 1st question is most people when they hear.
09:25 --> 09:57HPV they think about cervical cancer and they think about it as being sexually transmitted is it the same thing in the Oro pharynx. I mean, is this sexually transmitted. It is a sexually transmitted virus the way it was found was people noted that ever since the 1970s, the incidence of base of tongue in tonsil cancers have been going up. Every year and they feel this is the change in the sexual preferences of people over the last few decades.
09:57 --> 10:23And possibly an interaction between the virus and cigarettes that may have made it less common previously in more common now but either way. These cancers are very common in the base of tongue in tonsil area and appear to be increasing in incidents so the 2nd question is this.
10:23 --> 10:49HPV causes these cancers and so one would hypothesize that people should get an HPV vaccine so that they can reduce the incidence of these head and neck cancers. But on the other hand, people whose cancers are HPV positive tend to do really well with a 90% cure rate. So maybe it's good to get a cancer that's related to HPV should people get vaccinated, or not.
10:50 --> 11:20I think they should get vaccinated. I think the evidence for reduction in cases of cervical cancer is one of the best public health benefits that has come out of Madison in recent years and one of the added benefits. We feel will probably be a reduction in the number of oropharyngeal cancers and I agree the outcomes for these HPV cancers seem to be better than than an HPV related cancers.
11:20 --> 11:27But even so, who wants to go through chemo and radiation. I think if we can prevent them. It's much better than trying to treat them.
11:28 --> 11:58So how do you know whether your cancer is HPV positive or not is that something that is done on all biopsy's when the you take them out, so until recently. I'd say, this was a test that we had to ask for in particular, however, over the past 10 years or so any cancer. That's found in the back of the tongue of the base of the tongue or the tonsils are automatically checked for HPV.
11:58 --> 12:29Or, a protein called P 16. This is a we call this a tumor suppressor gene. That's over expressed in patients who have HPV related cancers in other words, if their cancer is related to that virus. Then they make more of this protein which seems to affect the way that the cancers grow and also the way that they respond to treatment. So I'd say it's an automatic test for the tongue base of tongue in tonsil cancers.
12:29 --> 12:58If you have a cancer in the front of the tongue or in the Larynx. It's not a test. It's automatically done. We often have to ask for that. In particular for that patient but that's because those cancers tend not to be related to HPV right? That's correct. Some estimates put the instance of HPV related cancers in those other parts of the head and neck at less than 20% and we don't know if they behave better or worse they're just not as common right now.
12:59 --> 13:31And so is this test done on the initial diagnostic biopsy because one would think that if you have a cancer at the base of the tongue or in the tonsil. That's HPV positive then maybe you Forego surgery completely 'cause. You know that these people will do well with chemo radiation rather than having a surgery to find out the HPV status well. That's a question that we're trying to answer in one of our clinical trials were part of a big consortium called there.
13:31 --> 13:36Ikago Eastern Cooperative Oncology Group, which is come up with a trial.
13:37 --> 14:08Headed by Doctor Burtness, who I work with here at Yale and Doctor Judson, who's one of our surgeons who are looking at whether or not, we can cut back on the surgery as well as cutting back on the chemo and radiation for these patients well. It certainly sounds really exciting and could have potential huge impact for patients were going to learn more about that, after we take a short break for a medical minute. Please stay tuned to learn more information about heading that cancers with my guest doctor Hari Dish Banday.
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15:07 --> 15:38Welcome back to Yale Cancer Center answers. This is doctor in East Shag Baran. I'm joined tonight by my guest doctor. Hari dish bonding. We're talking about head and neck. Cancers now hurry right before the break. We were talking a little bit about a really exciting clinical trial. That's ongoing that's trying to see whether we can cut back on some of the side effects of surgery, particularly in such a vital area of the head, neck, where people are using vital organs to swallowed to speak and so on.
15:38 --> 16:11Tell me more about other clinical trials that are going on in this area. We have clinical trials. Now, for different stages of the disease so for people who have very early stage disease where we imagine there only going to need an operation. They have a small cancer that if it's taken out. It's probably going to be cured. We're looking now to see whether or not. We can use some of the information from the biopsy beforehand and the specimen that they get from the operation.
16:11 --> 16:27At the end to make decisions on what best treatments. We can give to people with more advanced disease. We call these window trials, so people get a biopsy initially if they find that they have a cancer in the floor of the mouth or the?
16:27 --> 16:43Anterior part of the tongue that can be relatively easily removed then will offer those patients 7 days of chemo therapy with an agent that one of my colleagues doctor Yarbrough has found that in his labs.
16:43 --> 17:15Produce really good changes in the test tubes in cancer cells that suggest it might be very useful for treating those kinds of cancers. This particular chemo is called 5. Asus I did in it's been around for awhile we treat people with certain blood cancers and Milo Dysplastic Syndrome's with it and in the lab it seems to work in favor of treating head and neck cancer cells as well. So what these patients would have to do, if they agree to go on the study.
17:15 --> 17:41Is they get 7 days of this treatment and then? After that on the 8th day? They get their operation and then we look at it in the pathology lab. Hopefully it will help them, but it will also help patients who have more advanced disease. If it turns out that this is a good treatment. What are the side effects of this drug? I mean one can imagine that if patients would not normally get this drug that they might be worried about the side effects of treatment.
17:42 --> 18:13That's true and there are side effects. As with any chemotherapy. Luckily, with this one. They tend to be much less frequent. But there the similar side effects. That probably you've all heard of nausea, sometimes vomiting. It can cause tiredness and sometimes it can cause low blood counts. So we follow these people. Once a week just to check their blood to make sure that they're not reacting unfavorably to their chemotherapy.
18:13 --> 18:43But we only give the treatment once and then they don't get it again. So luckily any of the long term side effects that we might see with some chemotherapies when they're given over and over again. We don't see on this particular trial because they only get it for 7 days. That's correct do they get it 7 days consecutively in this particular trial. They do and that's a drawback to the way this particular treatment is given. It has to be given intravenously daily for 7 days.
18:44 --> 18:44Hurry.
18:45 --> 19:15In breast cancer when we give people chemotherapy up front as we do with many locally advanced cancers. One of the advantages to giving chemotherapy upfront is that sometimes we can get what's called a pathological complete response where we as surgeons. When we go in to take out the cancer find that you as medical oncologist have already wiped out the cancer and we know that those patients will have an outstanding prognosis is it the same in head and neck cancer and could that be.
19:15 --> 19:28A reason why patients should consider having this trial treatment where potentially this chemotherapy can tell them that their cancer responds very well and potentially that their prognosis is very good.
19:29 --> 20:00I think that's something that we might aim to do in the future. But the idea of this particular trial is only to give the 7 days of treatment to see what the effects are on the tumor in the lab under the microscope in the molecular level. So it's what we call a window trail. We're not really looking to see in this particular trail. If we can eradicate all of the cancer having said that we do the pre operative treatment if you like.
20:00 --> 20:30For head and neck cancer all the time, using chemotherapy and radiation. But unlike with breast cancer. We often don't do an operation at the end, especially if we don't see any sign of disease. So we try and avoid an operation altogether with chemo and radiation. And just like with breast cancer. There is some patients who will be completely cured of their disease using that approach of either radiation alone or chemo and radiation together, so how do you know that you?
20:30 --> 21:02Have eradicated the disease with chemo radiation if you can't have a pathologist tell you that you've eradicated the disease. That's a good question. And it's a question my patients ask all the time. How do we know if it worked and what we typically? Do is after the end of radiation. So the last day of radiation. We will count 12 weeks from that point and then do a pet scan a pet scan is a radiology test. It involves X Rays and also a nuclear Madison.
21:02 --> 21:37Die that will show up where cancers are fairly accurately in people with head and neck. Squamous cell cancers, so if their pet scan is very positive before they take the treatment and then 12 weeks after the radiation has become all all clear then that's a very good prognostic sign that their cancer is not going to come back, I agree. It's not the same as removing it and showing it under the microscope that I would say it's the next best thing right. I tell all my patients that there's only 2 people who can tell you anything for sure.
21:37 --> 22:08God in the pathologists and while pet scans are very good. They may not be got at least not for breast cancer. But maybe for head neck, so tell me more about other studies that are ongoing in head neck cancer. While we have some very exciting studies that my colleague Barbara brightness is brought to Yale. She's the head of the medical oncology had neck team and she's looking among other things at immunotherapy and this is something that has a long history at Yale.
22:08 --> 22:38Basically, we feel that some cancers can actually turn off your immune system and allow themselves to grow to progress and to metastasize and if you can turn back on the immune system then maybe you can treat those cancers. We know from work here at Yale and elsewhere that these are good for cancers such as Melanoma and non small cell lung cancer and it looks like for squamous cell had neck cancers.
22:38 --> 23:08That these medications the same ones that are being used for Melanoma and lung cancer might also be very useful in metastatic head and neck cancer. So we do have a couple of trials using these immune therapies and we also have the trials as we mentioned just before the break, where we're trying to actually get rid of some of our treatments. Do less surgery. Less chemo and less radiation for patients who we expect to do well these HPV positive cancers.
23:08 --> 23:39So immunotherapy is one of these really hot buzzwords. These days and the whole concept of revving up your immune system to fight cancer's I think is something that many people think is a good idea does it have less toxicity than standard chemotherapy. I'd say it has different toxicity so people don't tend to lose their hair. They don't tend to get the nausea and vomiting. But they can get some very strange side effects. They can if you like allow their immune system to.
23:39 --> 24:10Attack parts of the body that wouldn't normally be attacked typically. These are the lungs they can get something called a pneumonitis or inflammation of the lungs and basically they can get information of any part of the body if it's just a mild rash. We don't worry about it, too much. But if someone has difficulty breathing. We have to stop the treatment and give them steroids to try and allow the body to recover. You know it's interesting when we think about immunotherapy's and we think about immune systems many of us think about.
24:10 --> 24:26Vaccines because that's how a vaccine works. It primes, your immune system so that the next time it sees that antigen that sell your body says ha ha. That is something to attack and I wonder if particularly for.
24:28 --> 24:35Diseases cancers that are virally mediated whether immunotherapy's are particularly effective.
24:36 --> 25:09I think that's a very good question. And I know some of my colleagues who much more versed in immunology may be able to answer that question better, but I would say that some of the best responses that we've seen have been in these virally related cancers and possibly it's because of the fact that the immune system is being primed in some way do you think that in people who have been previously vaccinated with HPV vaccine?
25:10 --> 25:20If they then get a head neck cancer, presumably it would be an HPV negative cancer that immunotherapy's would work better.
25:21 --> 25:52I'm not sure that is a very good question. I don't know if we have enough information to look at it yet. But as more and more people are vaccinated. I think those are the sorts of questions that will be able to answer better. So is vaccines. Just for girls. HPV vaccines are has the guidelines changed with regards to that. They've never change. So you're correct. It used to be for girls and young women between the ages of 9 and 26.
25:52 --> 26:23But now it's for girls and boys of the same age range and the hope is that if you vaccinate girls boys young men and young women. Then you will get all of the population that could then cause, especially cervical cancers, but also these head and neck cancers to occur. It's felt that if you vaccinate people over the age of 26. The Efficacy goes down significantly and that's why it's not recommended for older people.
26:23 --> 26:42So that means that all other people who are our age range are you know out of luck. Well, I'd say that they are less likely to respond to the vaccine. Yes, OK, So what can we do aside from vaccines to prevent ourselves from getting head and neck cancers.
26:43 --> 27:15I think the main thing, even though we're seeing more of these virally related cancers is definitely not to smoke cigarettes. That's by far the number one cause have had a net cancers. Even with the rise in HPV cancers. The the interaction between alcohol and cigarettes is that alcohol by itself doesn't appear to cause these squamous cell cancers, although it can cause other cancers in other parts of the body but when you combine alcohol and cigarettes.
27:15 --> 27:30It does increase your risk of getting their squamous cell heading that cancers. So definitely don't smoke and drink would be my number one still my number one recommendation. Thank you so.
27:31 --> 27:33If you are a current smoker.
27:34 --> 28:05If you quit smoking are you still at risk for some period or do you start to get some risk reduction day one you pretty much will get a risk reduction very, very quickly. I think day one might be a little too soon, but it does continue to go down and it continues to go down over 10 or 20 years. So definitely stop smoking, but continue to stop smoking for a long period of time and your risk will.
28:05 --> 28:36Keep going down, we have a smoking cessation group at Yale, which is very popular and I've had a lot of patients who are very positive about it. But even if you can't get into that group. There are quit lines that you can call and hopefully a lot of your colleagues and family will be encouraging for you to stop smoking. 'cause most of the time, especially if they are nonsmokers. They'll want you not smoke as well right and when we think about.
28:36 --> 29:06Prognosis you mentioned that the HPV positive cancers are the ones that have the good prognosis. The ones that are not HPV related tend to have a worse prognosis and those are the ones that are caused by smoking and alcohol is that right? That's absolutely correct. And so how bad is the prognosis. Let's suppose you. You do smoke and you do drink and you have an HPV negative cancer. You know you mentioned that the prognosis with HPV positive cancers was over 90%? What is it?
29:06 --> 29:28For HPV negative cancers, so for the patients with a stage 3 and 4A disease. These are the people who get the aggressive chemo and radiation. HPV positive cancers have a 90% prognosis. It's 50% or less for the equivalent stage of HPV negative cancers. So it's a big difference probably even a different disease.
29:28 --> 29:59Doctor Hari Despond, A's assistant professor of Madison in the section of medical oncology at Yale School of Madison. We invite you to share your questions and comments. You can send them to cancer answers at yale.edu where you can leave a voicemail message at 888-2344 YCC and as an additional resource archived programs are available in both audio and written form at Yalecancercenter.org. We'd like to thank the Yale Cancer Center for providing production support for this program and we'd also like to thank Renee got debt.
29:59 --> 30:14Emily Fenton and the staff of the L Broadcasting Media Center. I'm Bruce Barber, hoping you'll join us again next Sunday evening at 6:00 for another edition of Yale Cancer Center answers here on W NPR, Connecticut public media source for news and ideas.

Information

Head and Neck Cancer Treatments with guest Dr. Hari Deshpande August 30, 2015 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095