- Head and neck cancers what you should know coming up next on Call The Doctor.

- [Narrator] The region's premier medical information program Call The Doctor.

- Head and neck cancer account for about 4% of all cancers in the United States.

Experts estimate that more than 14,000 people died from the disease last year alone.

Symptoms of head and neck cancer vary depending on where the cancer starts.

They can include a lump in the neck, jaw or mouth, difficulty swallowing, speech problems, mouth ulcers that won't heal or a sore throat.

There are several treatment options for head and neck cancers including radiation, surgery and chemotherapy drugs designed to kill the cancer cells.

Many factors can affect patient's survival rates.

Head and neck cancers, what you should know now on Call The Doctor.

Welcome to Call The Doctor here on WVIA I'm Paola Giangiacomo thank you for joining us for our discussion on head and neck cancers.

Joining us on the panel, Dr. Christopher Peters.

He is the Medical Director of Northeast Radiation Oncology Centers.

Dr. Shreya Sinha is a board certified and fellowship trained cancer physician specializing in medical oncology and hematology at Geisinger.

And Dr. David Horvick, he is a Radiation Oncologist and Director of Commonwealth Health Cancer Center.

And I would like to remind our viewers that you can participate in the conversation at wvia.orgs/ctd.

You can also submit your questions for future shows by emailing ctd@wvia.org or using the #WVIACTD and be sure to check our website for a listing of future programs and watch Call The Doctor episodes any time on the WVIA app.

Now we'll begin our discussion.

Thank you all for joining us to talk about head and neck cancers.

Dr. Peters, I'll start with you how do neck cancers... What part of the body are we exactly talking about?

- That's a good question Paola.

Head and neck cancers are an umbrella term for a variety of sub-sites of the head and neck.

Starting in the mouth we have the oral cavity, the lips, the front part of the tongue, the gums.

If we work our way up to the nose and nasal cavities and then back in the mouth we get into what's called the pharynx and that has different sub-sites.

And as we go down the throat we get into the larynx and the larynx is the voice box and then there's structures above it and around it which are different sub-sites of the larynx.

And then the last commonly structure we see is called the hypo-pharynx.

These are the.. And those are tissues that support the actual swallowing apparatus.

The cancers typically start in the lining of the gums the kind of pink tissue you see when you look in the mouth and they can spread to the neck and that's why it's called head and neck cancer.

- Okay.

Is our head and neck cancer is it common in Northeastern and Central Pennsylvania Dr. Sinha?

- So in the United States the incidents of head and neck cancer is about 65,000 people which consists of like you mentioned three to 4% of all (indistinct).

The global word and that the disease is much larger though Around 650,000 cases globally are expected to occur annually.

- And Dr. Horvick, what would cause head and neck cancer?

- Well, the strongest associations with head and neck cancer are tobacco use, cigarette smoking chewing tobacco, pipe cigarettes of any type of tobacco.

Alcohol has an association and also a virus called the HPV virus.

- Okay, the HPV virus but there is a vaccine could that prevent head and neck cancer Dr. Peters?

- Yeah, it's timely.

We're in the midst of this pandemic talking about vaccines for COVID and we shouldn't forget to remind ourselves that vaccines also prevent lots of diseases.

And in oncology, HPV, human papilloma virus is a very common virus we all encounter and there are vaccines available to get as a preteen typically your pediatrician or family doctor's office that can prevent development of many cancers including HPV associated head and neck cancers which most commonly occur in the oral pharynx, the tongue base, the tonsils and the back of the mouth called the posterior pharyngeal wall.

And these are cancers now, HPV associated head and neck cancers that are more common than they were let's say, 10 or 15 years ago.

So it's a welcome conversation to have with your family doctor or pediatrician to try to prevent these cancers.

- And what causes head and neck cancer?

We've talked about tobacco use and alcohol use but are there any other risk factors Dr. Sinha that we should know about?

- Sure.

Just like Dr. Horvick mentioned, tobacco use can increase the risk of head and neck cancer by 5 to up to 25 fold same with excessive alcohol use as well and the chewing tobacco use as well.

Some viruses that Dr. Horvick mentioned as well, HPV human papilloma virus and also EBV, which is not very common in the North American continent but it's seen very commonly in Asia is the EBV virus, the Epstein-Barr virus and that's associated with the incidents of nasal pharyngeal cancer.

In addition to that, there's also radiation exposure in the past, which is linked to development of head and neck cancers in the future and other chemical or occupational exposure like Asian Orange has also been linked.

- And what about, we've talked about risk factors.

What about the symptoms?

How would one know that they might have cancer of the head or neck Dr. Horvick?

- It's interesting because we're dealing with a relatively small area primarily from the mouth to the voice box but the variety of symptoms is pretty vast.

So if it's oral cavity, it might be a non-healing ulcer, it might be a lump, it could be pain with talking or swallowing, sometimes a loose tooth.

If it's farther back, you can have a sore throat often the sore throat will be just on one side and will linger longer than it should and a little progress over time.

If the cancer advances further, it can cause an earache.

As you go down the throat and the cancer involves the voice box, hoarseness, breathing problems, difficulty swallowing can occur.

So there were a number of symptoms.

Less common in the United States are nasal and nasal pharyngeal cancers but that can be a stuffy nose or even nosebleeds can occur from that.

- They all sound like pretty common symptoms but what's scary is if you were to get a cancer let's say in your oral cavity that would really affect your quality of life, your way of life, your every day.

Can you talk a little bit about how that would affect someone physically, emotionally, mentally.

- These structures that we briefly discussed are the important structures in communicating with others.

Eating, talking, communicating with your family members, even as said earlier, even hearing can be affected.

So it's critically important to have good primary care.

One of the things that we always say when we see patients in our office is, geez I wish this patient had had regular dental visits or had seen their primary care more regularly.

Good dental care, good primary care checks at the oral cavity oral pharynx simple office visits can often prevent locally advanced disease which is when people run into problems that really affect their ability to eat, swallow and interact with the others.

- So treating issues early.

Dr. Sinha, how would you treat a head and or neck cancer?

- Sure.

Because the disease is so heterogeneous the treatment becomes varied as well.

Most of the time the treatment planning starts in what we call a multidisciplinary team which includes the ENT surgeons and radiation oncologists, like Dr. Peter and Dr Horvick and medical oncology like myself, dentist, speech and swallow evaluation nutritionists.

All of us really kind of get together and make plans for the patient being treated.

Usually treatment includes a combination of surgery, radiation therapy or chemotherapy given concurrently with radiation therapy sometimes.

So in the earlier stage disease it is either surgery or using concurrently chemotherapy and radiation to treat the patient and the latest stages of the disease it becomes mainly primarily chemotherapy or immunotherapy based treatment.

- It sounds like you need a large team of doctors to treat this type of cancer.

Let's talk about the differences.

Dr. Sinha, you're a medical oncologist and Dr. Horvick and Dr. Peters you are radiation oncologist.

How do those differ when it comes to treating head and neck cancers?

I'll start with you Dr. Sinha.

- So in terms of treatment, radiation oncology is a more anatomic based specialty.

So really delivering radiation to the structures of the head and neck and doing so safely would be really their forte.

In medical oncology, chemotherapy mainly is used in three different settings for head and neck cancer.

The first setting is in the induction phase, if you will.

And in that setting, the role of chemotherapy is to shrink down the size of the tumor to make it more amenable to surgery or more amenable to chemotherapy and radiation.

The second setting where chemotherapy is used is given directly with radiation concurrently with radiation therapy and that's most of the times in the curative setting.

And the third place where chemotherapy or immunotherapy is used in the advanced stages of head and neck cancer where the tumor has already metastasized to different parts of the body or spread to different parts of the body and then the treatment really becomes more symptom relief driven and chemotherapy or immunotherapy is given to most of these patients.

So three different phases where we use systemic treatment and radiation oncology is more of anatomic specialty.

And I'll let Dr. Horvick or Dr. Peters take that.

- Dr. Peters.

- Yeah, I agree.

So typically for a solid tumor like head and neck cancer or let's say lung cancer, you need some type of local therapy to cure the patient.

If it's localized and that's where radiation or surgery is important.

And Dr. Horvick and I do share that specialty of trying to localize the tumor and we use physical exam, scopes in the office, we call that nasal endoscopy and scans.

Cat scans, pet scans, MRIs to stage the patient.

We work with our head and neck cancer surgery colleagues if it's early stage just localized to a certain site then often the local therapy can include surgery or radiation.

Sometimes both, sometimes we'll take out a cancer of let's say the front part of the tongue and it needs postoperative or agilent radiation treatments.

And then when the cancer becomes more advanced we definitely get systemic therapy involved whether that be chemotherapy or there are some immune therapies that our colleagues like Dr. Sinha give.

And so that's kind of the difference.

Now, like we said earlier, it's a team.

We also have dieticians involved, we have speech and swallow therapy involved, sometimes there are specialties- - Plastic surgeons.

- Plastic surgeons.

Sometimes there are specialties that are you wouldn't think of maybe pulmonary medicine or GI some patients can't swallow so they might need help with a feeding tube.

So you have to have a lot of...

It's all hands on deck to try to get the patient through the treatment with the best quality of life and survival afterwards.

- And Dr. Horvick I would imagine that organ preservation is a big deal when it comes to head and neck cancer.

- It's very important.

It's also very, site-specific.

It's interesting that oral cavity cancers tend to be surgical diseases.

Studies have shown that surgery as a first step in treatment tends to be the best in terms of overall patient outcome.

But subsequently many of the patients will need radiation and or chemotherapy.

When you're dealing with the voicebox for example, that's a major quality of life.

So an early tumor of the vocal cord although surgery has a slightly higher cure rate we'll often treat it with radiation because the surgery might involve removing most or all of the voice box and the patient will never talk normally again.

There are devices that can be done or surgical procedures to create artificial voice boxes but the quality of life is simply different.

So we'll start with radiation, sometimes radiation with chemotherapy if it's not effective, surgery becomes the backup and that's totally a quality of life issue.

- Wow, what about robotics?

Is robotic surgery used a lot in this type of cancer Dr. Sinha?

- Yes.

So the expertise in the area is very important to kind of get a handle on before the patient undergoes a surgery like this but robotic surgery of the base of the tongue is becoming more and more of the first-line treatment.

- And I would imagine rehabilitation is a big part of the followup care in treating these patients.

- It is, again, depending on the sub site, some are either easier to treat than others.

For example, if the tongue is affected, as it often is speech swallow taste is paramount to the patient's quality of life.

So colleagues that we're working with in speech and swallow therapy become important.

There are exercises that they can do with the guidance of a speech pathologist that are critical and they help people.

So same is true with dieticians and clinical nutritionists very important to get the patient well-nourished, get through their treatments and try to preserve their functional quality of life.

- And what is the cure rate?

- That again depends on the sub-site.

So take, for example, the HPV associated base of tongue cancers or tonsil cancer is very common.

We have very high cure rates for the HPV associated ones.

Patients who have those cancers do better than if it was not an HPV associated oral pharynx cancer.

So you can get into as high as 90% cure rates even with lymph node positive disease.

If you take on the other hand a hypo pharynx cancer or an oral tongue cancer that is locally advanced cure rates are much lower and there's frankly more morbidity with treatment.

So it really just depends on the sub-site and the stage.

- You were saying earlier that tobacco is a huge cause, a main cause for head and neck cancer but you're also seeing it in patients who don't smoke or chew tobacco?

- Yeah, that's primarily in your human papilloma virus associated oral pharynx cancers.

And we've actually seen, you could see it in the lay press you see celebrities sometimes get it, you're seeing a difference in the population.

30 years ago if you got tongue-based cancer primarily you were older, you were a heavy smoker and probably a heavy drinker that still exists.

However, you can also be younger have no medical problems have never smoked and still get the disease which is why we're advocating for vaccines and regular dental checkups and things like that to catch your disease early.

- Yeah.

Dr. Horvick, what else can people do to try to prevent this type of cancer because it sounds horrendous.

- Well, first of all, if you smoke stop smoking, if you haven't started never smoke, never use tobacco that's number one.

Number two is alcohol consumption should be minimized.

Number three is for the younger generation they should be vaccinated against HPV.

Dentists are vital here although there are 65,000 cases of head and neck cancer annually in the US the majority of them are oral cavity and oral pharynx.

You can visualize a lot of those areas directly on examination.

And a good dentist every time you go in will be looking at those structures and a lot of the early detection that we have relates to dentists seeing it and the patient can be treated when it's stage one and has the really high cure rate rather than when it's more advanced - So oral cavity, oral pharynx what are we talking about?

The tongue, the throat, the gums.

- Great.

Well, the inner part of your lips, the moist part of your lips through the tongue, the bottom part of the mouth which we call the floor of mouth, the walls of the mouth and the hard palate or the oral cavity, the back third of the tongue and the tonsils and the wall of the pharynx surround the tonsils is the oral pharynx.

So it's a division doctors use basically front two thirds of the tongue defines for physicians the oral cavity.

The back part of the tongue, the tonsillar region and the walls that you can see when the doctor says, say, ah you're looking at the walls of the oral pharynx.

- So could you see or maybe feel a tumor in your mouth?

Would that be one symptom Dr. Peters?

- Sure, absolutely.

The graphic you put up earlier about a non-healing ulcer or something's wrong with your tongue, sometimes people can describe ear pain, a change in their voice.

Those can all be symptoms or signs that you can see.

Non-healing ulcer is a very common one for oral cavity and painless lump in the neck is probably the most common chief complaint we get for the oral pharynx especially for the virus associated ones.

- Now surgery in this part of your anatomy sounds very scary Dr. Sinha, what is recovery time like?

Or how long does the surgery take and what is recovery like for this type of surgery in these patients?

- Sure, you're right.

Surgery is very challenging for these patients especially because of not only the anatomical effects that it has, but also body image issue later on can become an issue as well.

So you're right.

Intense rehabilitation is definitely built into the treatment plan for these patients.

Sometimes reconstruction is required after the surgery is done especially if there's a major lymph node dissection or the jaw needs to be removed reconstruction becomes a huge part of it as well.

- Yeah and as a clinical research director, Dr. Peters, are there any... Is there any advancements in research when it comes to head and neck cancer?

- Yeah, so the exciting thing that I've seen even in the past five years is what's called deescalation of therapy.

And that comes into different varieties.

One would be limited surgery, the trans or robotic surgery that you've mentioned too before is a way of getting the right oncologic surgery but minimizing how much you have to take out of a person.

Radiation techniques research has shown you can deescalate the intensity of the radiation perhaps the dose.

There was a trial that was done (indistinct) that we're waiting for the results but that looked at deescalation using both the combination of limited surgery in limited radiation and reserving chemotherapy only for kind of the worst players on that trial.

So using less surgery, less radiation, less chemotherapy are often yielding similar results because of better staging that we have now and better biology especially in the patients who have the virus associated disease.

So research has shown us that we can deescalate therapy get similar survivals and really try to maximize that quality of life that's so important.

- Dr. Horvick, you work with advanced technology within the cancer field.

Are there any advancements in technology when it comes to treating head and neck cancers?

- All of us these days treat head and neck cancer with what's called an IMRT technique.

So in the old days we would treat kind of big open fields that exposed a lot of structures to radiation with IMRT we're sort of painting the dose in the machines have small led leaves that shape the radiation as it goes in, we can vary the angles, position and really give differential doses to different areas.

By doing that we can spare a lot more of the normal tissues still give appropriate doses to the cancer and have better outcomes with less side effects.

And is hereditary, is this hereditary if you have this in your family should you get genetic testing for this type of cancer Dr. Sinha?

- So there's a very small subset of head and neck cancer which can be genetically mediated.

Usually patients with things like Fanconi syndrome or Fanconi anemia can be predisposed to forming squamous cell carcinomas of the head and neck.

But most of the times this is not a family genetically predisposed condition.

- And Dr. Peters, what is the chance of it spreading if it starts in your oral cavity can this type of cancer spread to your head?

- So typically like many cancers we use what's called a TNM staging and that depends on the sub-site, but in general how large is the primary tumor?

Did it spread to lymph nodes?

Yes or no.

And did it spread anywhere else?

Most head and neck cancers if they spread outside of the area of curability, let's say below the clavicles.

So anything above the clavicles is potentially curable once it's spread somewhere else that typically would go to the lungs and that's why during our diagnostic imaging the doctor or provider will often order a pet scan or a CT or an MRI scan which includes the neck as well as the chest.

Cause that's the most common site of metastasis.

It can spread to other organs but typically it goes to lymph nodes first and then the lungs.

- And are you seeing it more in this area?

- I think we have.

As Dr. Sinha said at the start of the show, head and neck cancer in general is not one of the most common cancers we have about 60 - 70,000 a year.

Just to give you a perspective, you may have 250,000 cases of prostate and lung and breast cancer.

So it's less common, but in this area we've always had heavy smoking rates here.

So I think we see our fair amount and there's good data on this from the Northeast Regional Cancer Institute that's available but I don't have those memorized but I can tell you we see a good amount of it unfortunately.

- Well, thank you.

This was all very interesting.

I'd like to thank our panelists for participating in our discussion on head and neck cancers.

For more information and resources on this topic visit wvia.org/ctd.

I'm Paola Giangiacomo for Call The Doctor.

Thank you for watching.

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