>> Welcome to Facebook Live
from Johns Hopkins Medicine.
I'm Elizabeth Tracey.
This is Head and Neck Cancer Awareness Week
and we are so privileged to have here with us
in the studio two experts in that field.
And I'm gonna ask them to introduce themselves.
>> Sure, so I'm Rina Abrams.
I'm a speech pathologist.
I specialize in speech and swallowing disorders,
specifically with patients who have head and neck cancers.
>> My name is Christine Gourin.
I'm a specialist in head and neck cancer surgery.
>> Thank you so much for taking the time to be here today.
I deeply appreciate it.
I'd like to start first by asking
a question about head and neck cancers.
It seems like there's an awful lot more
head and neck cancer out there.
>> Christine: You're correct.
The incidence of head and neck cancer
is rising for several reasons,
but we can expect to see more cases in the future.
>> I think we have a graphic we'd like
to take a look at that describes this thing
incidence or the number that are taking place.
>> Elizabeth: 70,000.
Wow that seems like an awful lot.
Are you surprised by this number?
>> I'm not surprised.
We know that in the last two decades
the number of head and neck cancer cases
that are seen in the developed world
is increasing.
So it's not just a phenomenon unique to the United States.
And projections suggest that those numbers
are gonna increase even further
in the next several decades.
>> Elizabeth: Are there populations that are
disproportionately affected?
Specifically are men more affected than women?
I think we have a graphic about that also.
[Elizabeth] So my goodness.
Way more men than women.
Why is that?
>> Christine: It's true.
And there are several reasons for that.
You asked about populations at risk.
Class historically, head and neck cancer
or most head and neck cancers not all
are related to tobacco and alcohol use.
And historically men have always used
those substances at greater numbers than women have.
But we also know that men are at a
particular increased risk for reasons
that are incompletely understood.
But we do see more head and neck cancers
in men than women.
It's true.
Not to say that women are not at risk though.
>> There's a virus.
Human papillomavirus or HPV frequently abbreviated
that at least as far I've been able to determine
is also involved with head and neck cancers
pretty often.
Is that right?
>> Christine: It's true.
HPV is the newest thing in head and neck cancer.
I say thing because about 20 years ago
we weren't really aware of its role
in carcinogenesis or causing a head and neck cancer.
It has always been known to be a causative virus
in the development of cervical cancer.
But in the head and neck about 20 years ago
we started to see more patients who didn't
have the risk factors of tobacco or alcohol use.
And who seemed to be younger.
Getting cancers that they did very well
as a result of treatment from.
And subsequent research has shown
that this is related to the human papillomavirus.
That is right now what's considered an epidemic.
The numbers of HPV related cancers is rising
and that accounts for the greatest increase
that we see in head and neck cancer today.
>> Can you help me to understand how
a viral infection might be related
to the development of a cancer.
>> I don't pretend to be able to understand
the exact pathogenesis,
but we know that people
that are exposed to the HPV virus,
and that's most of us.
Most of us contract an HPV type infection in our lifetimes,
and the majority of us clear it.
But in some small percentage of people the virus persists.
And when the virus persists
after about a historically 10 year period
when we look to cervical cancer guidelines.
Even smaller percentage of patients will
develop cancer related to viral infection.
I don't pretend to understand the reasons why that happens,
but that is a known association.
>> Are there specific strains?
Because I know right now we have a vaccine
against HPV that are related to the development of cancer.
>> Christine: Yeah so there are what are called
high-risk strains of HPV in the head and neck area
primarily it's 16
that is the most common strain of HPV virus
associated with cancer.
But there are some other high-risk strains too.
And there are two vaccines available now.
One covers two strains
and the other covers four strains.
>> Elizabeth: And would it be your guess then
that when we give that vaccine to more adolescents
that we're gonna see a decline ultimately
in head and neck cancers?
>> That is the hope.
It has been shown in countries like Australia
that the incidence of cervical cancer
can be almost entirely eliminated in women
because of early vaccination.
And so our hope is that if enough people get vaccinated,
we'll see a decrease or perhaps elimination
of head and neck HPV related cancers.
But not only young people should get vaccinated.
The current FDA guidelines are
for anyone up to the age of 46.
>> Elizabeth: Rina let's turn to you for a second.
What about HPV infection and rehabilitation
of someone who's been treated for head and neck cancer?
>> Sure so a lot of these patients
that have head and neck cancers require
some degree of rehabilitation
whether it be speech or swallowing or both.
And one of the, I guess, good things
about the HPV virus is that their prognosis
for, prognosis for cure and survival is much better
than the non-HPV related cancers.
And so what that means is that the
rehabilitation process is even more important
because these patients are living so much longer.
We wanna make sure that they have
what we call prehab
so they're getting rehabilitated upfront.
>> Elizabeth: And so there's no real difference
than whether they have HPV or not
in what you do for rehabilitation?
>> Correct. Yes.
>> But really important to get rehabilitation.
>> Yes. Very important.
>> Before we dive further into that topic
let's talk about treatment.
Treatment frequently of course does require surgery.
>> Well it's true that often times
a surgical procedure is required to make the diagnosis.
Head and neck cancers can involve anywhere
from the back of the nose to the opening of the esophagus.
So all those areas need to be inspected
for tumor development.
And we always confirm a biopsy site,
so you never want to treat somebody
based on your assumption that
that's where it's coming from.
So some degree of surgery in the form of biopsy
at a minimum is required.
And then the treatment options
consist of surgery, radiation, chemotherapy,
increasingly immunotherapy.
And these are given alone or in some combination.
And the exact treatment recommendation is
based on the stage, the site,
and patient's goals and wishes.
>> Well let's talk about that.
So let's factor back even a little bit further.
How is it that someone even suspects
that they have a head or neck cancer?
>> There are some symptoms that are unique
to the head and neck.
We always worry about anybody
with unilateral or one-sided ear pain,
trouble swallowing,
a change in your voice,
difficulty swallowing,
a lump in the neck.
These are the most common symptoms,
but the truth is,
particularly with HPV related cancers,
the only symptom one may have is a lump in the neck.
So we encourage everybody to get checked out
if they feel a new mass
or have any symptoms that are new
or formal to the head and neck.
>> Elizabeth: Do you get referrals from dentists sometimes?
Do they detect them?
>> Christine: Sometimes they do.
A good dental exam will pick up oral cancers
sometimes in their earliest stages,
so we never discount a referral from a dentist.
They know what they're looking for.
>> Is there a familial component or genetic component
to the development of these cancers?
>> There is one familial link in the form of a disease
called Fanconi's anemia.
People with Fanconi's anemia
are at risk of oral cancers
usually earlier in life in the teenage years.
Fortunately this disease is very rare.
We're not aware of any other genetic link
to head and neck cancer.
>> And how about staging?
We hear an awful lot about what stage a cancer is.
How is a head and neck cancer staged?
>> It's staged based on three things.
One is the size of the primary tumor.
And the primary tumor is somewhere in
the lining of the tissues,
the back of the nose,
back of the throat,
down near the voice box.
So that's the T stage.
The N stage refers to node status
and whether or not there are any
enlarged lymph nodes present
and how big they are and how many there are.
And then the M stage is for metastasis.
Is it anywhere else in the body?
An overall stage is assigned based on that combination.
So it's primarily the size of the tumor,
and whether or not there's lymph node involvement.
>> Rina, after somebody has staging.
Yes, staging, diagnosis, treatment,
that could be any one of these modalities
they come to you.
Can you give me an overview of the
kind of assessment that you do
and how you develop a treatment plan?
>> Rina: Sure so a lot of it varies
depending on what the plan is,
whether they get surgery upfront
or if they're getting radiation or chemoradiation
or a combination.
So usually if they're getting surgery upfront,
we evaluate them preoperatively
with some type of swallowing evaluation.
There's a few different types that I can get into
if we have enough time later.
But we are talking to them,
or counseling them really
on what to expect after surgery as well.
And then we usually see them postoperatively
depending on what the surgery is
and how extensive it is.
And then for patients that are getting
radiation or chemoradiation,
again we see them per baseline evaluation,
evaluate their swallowing.
Again, counsel on what side effects
we would anticipate going through their treatment.
And then we follow them,
usually for about five years after treatment,
because they can have changes postradiation
in their swallow function.
>> And even for five years, you would be involved
in that rehabilitation.
>> Yes.
>> Now that's impressive.
>> Yeah it's a long time.
They get to know us well.
(laughs)
>> But that sounds like that's also
some really great vigilance.
>> Yes.
>> Yeah. >> Yeah.
It's a lot of work that they put in,
but it's worth it in the end.
>> One fear I've heard people express
about treatment and subsequent rehabilitation
of head and neck cancers
is "oh gosh am I gonna need a feeding tube?"
>> Rina: Sure.
Yeah that's a tough question
and you're gonna get some variation
dependent on where you're going,
who your doctors are you know.
So from a surgery standpoint,
again it's totally dependent on the surgery
and the extent of resection.
So I think it's kind of impossible
to answer whether or not people need that,
but, you know we work closely with the surgeons
to determine preoperatively if we think they'll need one
and also postoperatively.
For patients that are getting radiation,
our general kind of thought or knowledge is
that we want patients to keep swallowing.
So we encourage them to try to get through
treatment without a feeding tube
unless they need it.
And that's again something that we do here.
People may go to other facilities
and find that they're recommending a
feeding tube upfront.
And we know that by using those muscles
they have a lower risk of long-term
dysfunction of those muscles.
So using the muscles,
whether it be by doing swallowing exercises
by continuing to swallow,
are both two really important factors.
>> I imagine that could be quite troublesome
though sometimes isn't it?
>> Rina: Oh absolutely.
So radiation especially is very difficult
and you know having a team,
a multidisciplinary team,
to help work through that,
with the radiation oncologists,
the dietitians,
the medical oncologist,
speech pathologist,
the surgeons,
you know everyone needs to get involved in that care.
>> There's also a consequence of treatment
sometimes that develops this stiffness of the jaw.
Trismus.
How 'bout that?
>> Rina: Yeah so trismus can come from surgery.
It can come from radiation therapy.
And so again we treat that prophylactically
with the radiation patients
and then also reactively for radiation and surgery.
So there are gentle stretches that people can do.
There are devices out there
to work on stretching the jaw.
Basically the earlier that it's caught,
the easier it is to treat.
So it becomes more of an issue
if people let it go.
>> I love this concept of prehabilitation.
Are there other things that people can do
previous to their treatment
that would aid in their recovery?
>> So aside from doing swallowing exercises
and jaw stretches
that's you know for
that's again for radiation patients.
Usually the surgical patients
they don't need to do anything before surgery.
>> Chris would you answer that also.
Are there things that people can do
to try to make sure that they're going
to achieve the best outcome that they can
from their seat in the bleachers?
>> There are some things patients can do.
If you smoke, quit.
If you abuse alcohol, stop that as well.
Because both of those things interfere
with wound healing after surgery.
But also during radiation and chemotherapy
those things interfere with your tissues
handling the effects of radiation
and recovering from that.
And then I just wanna second what Rina said about
the swallowing therapy.
Wherever you get your care you should see,
make sure that your team has recommended
you see a speech and language pathologist.
This is as critical to you as seeing
a surgeon or a radiation oncologist
because the exercises that Rina prescribes are key.
Key in preventing late complications
from treatment.
>> Is there a role for robotic surgery here?
>> There is.
We actually do a fair amount of robotic surgery.
The surgical robot allows us to see around corners.
It's not suitable for all cancer types,
but where it's really shown is,
or where it really shines is in HPV related cancers
involving the base of the tongue.
Because the robot allows us to go take out that tissue
while minimizing disruptions to normal tissue.
So if patients swallow pretty well,
we've published our data that 95% of patients
are home the next day eating on their own.
They see Rina and her team afterwards
for swallow therapy,
but it's really remarkable how TORS
has allowed us to still offer surgery to some patients
and reduce the odds of needing chemotherapy
when the tumor is suitable for TORS.
>> You both identified not just each other
but other professionals as really pivotal
to your approach to a comprehensive strategy
for managing people with head and neck cancer.
Of course all those folks are available
right here at Johns Hopkins.
And why do we need to come to an
academic medical center to be treated?
>> So we know that outcomes are better at larger centers
because of that team approach.
I mean we all meet together once, sometimes twice,
sometimes more than that every single week.
And so I think just having that collaborative team
to work through whatever issues each person is having
makes it, you know, gives them a much better outcome
and allows them to get through treatment easier.
>> It takes a team.
It really does.
Because if you see a surgeon
you're gonna get a surgical opinion
and if you see a radiation oncologist
you'll get their opinion.
And what you really need is to have
the entire team weigh in
and decide collectively what the best options are.
The other factor is that it really matters
where you get your care.
So we know that volume matters.
Places that treat a high volume of
head and neck cancer patients
have better outcomes.
And that's not opinion, that's fact.
So it's very important to see a team
that is knowledgeable about head and neck cancer.
Is aware of the role of speech and language pathology
and rehabilitation and prehabilitation.
That is aware of the importance of ongoing
swallowing therapy during treatment.
And really is up to date on the newest advances
such as using the robot when that's indicated.
And some of the newer treatments as well.
>> We do have an event that's taking place
here at Johns Hopkins at the end of this month
[Elizabeth] we'd like to advise you about.
If you need to learn more about head and neck cancer
and also meet with some survivors
on April 27th as you can see
there's an event taking place here
and you are certainly welcome.
Thanks to both of you for joining me here today.
You've both been so informative
and I know what your academic schedules are like.
So this was really a big gift.
Thank you so much.
>> Thank you for having us.
>> Thank you.
It's been a pleasure.