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Cancer Answers: Understanding the Risk Factors for Head and Neck Cancer, April 11, 2010

July 20, 2019
Dr. Benjamin Judson, Understanding the Risk Factors for Head
and Neck Cancer
April 11, 2010Welcome to Yale Cancer Center Answers with Drs. Ed Chu and
Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy Director
and Chief of Medical Oncology at Yale Cancer Center and Dr. Foss is
a Professor of Medical Oncology and Dermatology specializing in the
treatment of lymphomas.  If you would like to join the
conversation you can contact the doctors directly.  The
address is canceranswers@yale.edu and
the phone number is 1888-234-4YCC.  This evening Francine
welcomes Dr. Benjamin Judson.  Dr. Judson is an Assistant
Professor of Surgery and an active member of the Yale Cancer Center
Head and Neck Cancer Program.  Here is Francine Foss.Foss
 Can you tell us a little bit about your background and what
brought you to Yale?Judson
 Absolutely, I am a head and neck surgeon and I specialize in
taking care of patients with any neck tumors, so any tumor either
benign or malignant that is anywhere between the brain and the
lungs.  I did my residency at Georgetown in Washington DC and
then I was at Memorial Sloan-Kettering in New York for the last two
and half years and just came to Yale in January of this year.Foss
 Ben, what are the different areas included in cancer of the head
and neck?  You mentioned the neck, but can you go through the
different areas that you cover?Judson
 Absolutely, it involves really any tumor in the neck and it's
quite a diverse area. Patients can develop tumors in the mouth, the
tongue, the tonsils, the throat, and the voice box.  We also
see patients with tumors that arise in the saliva glands; the
parotid, submandibular, and sublingual glands.  We see
patients with advanced skin cancers if there is a question of
whether it's spread to the lymph nodes in the neck or involves any
deeper structures. We see thyroid cancer patients and also patients
who have tumors that arise in the sinuses or the skull base, so
it's quite a diverse group of patients with a diverse set of
problems.Foss
 Are most of these patients referred to you by a primary care
doctor or oncologist?Judson
 Different ways, sometimes people just walk in to see us, but most
frequently, as you pointed out, we see patients who are referred to
us by their primary care doctor or dentist, an oral surgeon, or a
medical oncologist.  Usually people see someone else first and
then they get sent to see us.Foss
 This might be a good time for us to let the audience know how
common head and neck cancer is.Judson
 There are just under 50,000 cases a year of new patients in the
United States who have some sort of head and neck cancer.2:45 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3Foss 
            
 And that includes cancers of the thyroid and the sinuses as
well?  That includes all of the different types of head and
neck cancer?Judson
 That number is mostly patients with head and neck cancer that's a
squamous cell cancer, it arises somewhere in the mouth or, as I
mentioned, the tongue, the tonsils, or the throat and that's the
majority of the patients that we see.Foss
 What are the risk factors for head and neck cancer?Judson
 It's a great question.  Classically the risk factors have
been smoking and drinking.  We know that patients who smoke
have a slightly increased chance of developing head and neck cancer
and that's also true for patients who drink, and there seems to be
a synergistic effect for patients with a long history of smoking
and a long history of alcohol use; those are the patients who are
at highest risk, but we do see all kind of patients.  Even
patients who don't have those risk factors come to us. 
Interestingly, in the last 10 years or so, as the smoking rates
have decreased, we expected to see a decrease in the number of
patients as we saw with lung cancer, and unfortunately, that has
not happened.  There has actually been an increase in patients
with tonsil and tongue base cancers, both here and in the United
States and abroad, and there has been some really interesting
science done to figure out why that is. It's implicated that the
human papilloma virus, the HPV virus, which has been known to be
involved in cervical cancer, also turns out to be able to cause
tonsil and tongue base cancer.Foss
 How does one acquire this HPV virus?Judson
 It's an excellent question as well.  There are certain high
risk types of HPV and having some sort of HPV infection is very
common; the majority of Americans have had one at some point. 
It then clears, but there definitely are risk factors that are
related to sexual activity, so people who are sexually active and
have a higher number of sexual partners over their lifetime are at
higher risk for obtaining one of these high risk HPV infections,
and are at risk for developing a cancer like this.Foss
 Just for the sake of our audience, if there are folks out there
who know that they have HPV infections say in the cervix, are those
people at high risk for head and neck cancer or is it a separate
set of risk factors?Judson
 It's connected, so patients who have had high risk HPV infection
in the cervix, those patients, and also their sexual partners, are
at a slightly increased risk for developing an infection with one
of these high risk HPV types in the oral cavity as well.5:47 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3Foss             
 As a parent, and I am sure that there are other parents out there
who are thinking the same thing, more kids now are smoking and
drinking earlier, are you seeing more head and neck cancers in
younger people as result of this?Judson
 We are, classically we would see patients would present to us with
a history of heavy smoking and drinking, usually in their 60s and
70s, and what's happening is we are seeing more and more patients,
and younger patients who are never smokers, never drinkers, who had
HPV related cancers. The peak age of those patients when they come
to us is people in their 40s.  It is really a very different
patient population for us, and we say that the face of head and
neck cancer is changing. We still see all the patients that we used
to see, but we are also seeing this new subset of patients who
don't have classic risk factors and we haven't known what's causing
this until relatively recently when HPV infection has been
implicated.Foss
 How do most patient present? Do they present with lesions in their
mouth or swellings, what is the typical thing?Judson
 Patients with head and neck cancer frequently have symptoms that
are very common, symptoms that we all have at some point, sore
throat, earache, problems swallowing, swollen glands in the neck or
a lump in the neck, but those symptoms, when most of us have them,
go away, they are related to a cold or an infection and they
usually go away after a week or two.  If they stick around for
three to four weeks, or longer, that's somewhat concerning and
worth having it checked out, and that is usually how patients
present.Foss
 A lot of patients must also present to the dentist, because a lot
of people think if they get a sore in their mouth, perhaps the
dentist is the first place to start.Judson
 That's true and that's a good way to start.  If there is a
question and there is something that you can see, seeing a dentist,
an oral surgeon, an ear nose and throat doctor, or your primary
care doctor is a great way to start because they are usually able
to make an initial evaluation and if you need to be referred to
someone else they are able to do that.Foss
 In fact, having just had my annual dental appointment, I know that
the dentist now-a-days does a very careful head and neck
check.  They put on gloves and they really feel all of these
glands and these nodes that you are talking about and that's now
part of routine screening for most folks going to a dentist.Judson
 Yes, the American Dental Association has made a big push to do
that because we know, as with other cancers, that if we detect
these things early, people do much better. Just like other
screening modalities have been used such as colonoscopy and
mammogram, the dental8:50 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3
 community is recognizing that its really important to do careful
examinations to find these things early so that patients can have
them taken care of before they are more involved.Foss
 Ben, once the patient has identified a lesion that is suspicious,
or there are lymph nodes or a sore throat that has not gone away,
what's the next step?  How do you actually make a diagnosis of
head and neck cancer?Judson
 Diagnosing these things really starts by a physician or a dentist
doing a careful history, talking to the patient, examining the
patient very closely, those are sort of the cornerstones.  If
there is something there that is suspicious, the next step is
usually doing some sort of biopsy.  Sometimes based on what we
see and feel, we need to get some imaging or radiographic studies
to help us as well.Foss
 What kind of studies do you typically get? We talk a lot about CAT
scans and PET scans on this program, what's the right imaging
study?Judson
 The imaging study that is done first is generally a CAT scan of
the neck to  look at the tumor itself and also to evaluate the
lymph nodes in the neck, which is where these cancer can go
first.  Another scan which can be very useful is a PET
scan.Foss
 When you see these tumors in the head and neck, and you have made
a diagnosis based on biopsy I presume, do you have to worry about
these spreading to other parts of the body?Judson
 Yes, generally there is always a concern and that's an important
part of our evaluation and affects the treatments that we
give.  The tumors spread usually first to the lymph nodes in
the neck and then there is also a chance it can spread elsewhere in
the body.Foss
 So when you get your scans initially, you are getting CAT scans of
the head and neck, then in most patients do you get scan of the
rest of the body as well, or is that only in certain
circumstances?Judson
 In certain circumstances, we routinely get a chest x-ray. 
Generally, if cancer is not spread to the lymph nodes in the neck,
there is a very low likelihood that it has gone elsewhere in the
body.  Once it's going to the neck, then there is a little
more concern to look elsewhere and that is frequently where we will
get maybe a CT scan of the chest or a PET scan or something like
that.Foss
 Are there specific blood tests that would be enlightening for
patients with head and neck cancer? Are there blood tests, say,
that would predict for who is going to develop metastatic11:26 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3
 disease, or that could even be used as screening for head and neck
cancer?Judson
 There is a lot of research in that area, but there are no good
blood tests or tumor markers to help identify patients who have a
cancer or to monitor their progression afterwards.  The one
exception to that is there is a cancer that can arise behind the
nose called nasopharyngeal cancer and a subset of those cancers
have been related to Epstein-Barr virus.  This is a cancer
that is relatively uncommon in the United States but is endemic in
China and other parts of the world. Because nasopharyngeal cancers
are associated with Epstein-Barr virus infection, it has been shown
that you can do a blood test for Epstein-Barr virus markers and
that is useful in diagnosing these patients, predicting their
prognosis, and also helping to follow their response to
treatment.Foss
 A lot of folks out there have heard of Epstein-Barr virus with
respect to mononucleosis, and I just want to make our listeners a
bit more comfortable about the fact that this is not very common in
that setting.  Just because you have Epstein-Barr virus, you
don't need to worry necessarily about nasopharyngeal cancer.Judson
 Yes, thank you.  As I said, this is a very rare, and
uncommonly seen problem here.Foss
 Ben, you talked about nasopharyngeal as being a type of head and
neck cancer, are there other subtypes?Judson
 There are three classified cancers in terms of its anatomic
location, so whether it occurs in the oral cavity, that is the
front part of mouth, behind that is the tonsils and the base of
tongue, and we refer to that as the oropharynx.  Below that is
the larynx, sort of the voice box area.Foss
 Great, we have heard a little bit about some of the demographics
of head and neck cancer and when we come back after the medical
minute I would like to talk a little bit about the treatment of
this disease.13:58 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3treatments for prostate cancer.  Patients enrolled in
these trials are given access to experimental medicines not yet
approved by the Food and Drug Administration.  This has been a
medical minute and you will find more information at
yalecancercenter.org.  You are listening to the WNPR Health
Forum on the Connecticut Public Broadcasting Network.Foss
 Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss and I am here with Dr. Benjamin Judson, Assistant
Professor of Otolaryngology in the Department of Surgery at Yale
Cancer Center. We are here tonight discussing the treatment of head
and neck cancers.  We talked a little bit about the types of
head and neck cancer.  Let's launch into a discussion now
about how you treat this disease.Judson
 Thank you Francine.  The treatment varies a lot on the type
of tumor and the extent of the tumor.  The one thing that I
would say is that it is important to design and tailor our
treatments to the individual patient and the individual problem
that they have.  One of the reasons why I came to Yale was to
join the excellent multidisciplinary team that is already here, I
work with a medial oncologist and radiation oncologist as well as
others, with each patient trying to tailor a treatment that
individualized to them.Foss
 We talk a lot about multidisciplinary care, and I cannot think of
any area where that is more important then head and neck
cancer.Judson
 I think that is true.Foss
 Tell us a little bit about what the treatment options are for
patients.Judson
 For earlier tumors we try to use a single treatment, sometimes
that can be surgery, sometimes that can be radiation.  This
depends on where the tumor is and the patient.Foss
 Ben, can I just back up for second, unlike other cancers where we
do not cure many patients, is your primary goal for most of these
patients to actually cure them with your therapy?Judson
 Yes, frequently, especially for early stage cancer, but for any
one as long as it has not spread beyond the neck, our intention is
generally to cure the cancer.Foss
 So that is important when you think about long term side effects
of your therapy.Judson
 Yes, and that is one of the reasons why it is so important to come
up with a carefully tailored treatment approach, because we are
trying to balance getting the best outcome we can in16:24 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3
 terms of treating the disease, and also minimizing the side
effects that the patient experiences immediately after treatment
and long term.Foss
 Do all patients have a surgical excision of their tumor?Judson
 Not at all, as I said, it depends on what type of cancer it is,
its size, and its extent.  For the early stage, we try to do a
single treatment, so either surgery or radiation.  For more
extensive cancers, we generally combine treatments so it can be
radiation with chemotherapy or sometimes surgery followed by
radiation. For more advanced cancers, frequently we will combine
all three so it will be surgery with radiation and chemotherapy
together.Foss
 There are some novel ways now of giving radiation therapy. 
Can you go through them a little bit and tell us what is available
at Yale Cancer Center?Judson
 Absolutely, in the past historically radiation to the head and
neck was administered in a way that it treats or affects the entire
neck and throat, but now there are incredibly sophisticated ways to
target the radiation so it is given just to the area it is
needed.  Just to the tumor and the areas around there, maybe
the lymph nodes in the neck, and the reason why this is important
for patients is that the radiation can cause lots of side effects
like dry mouth or problems swallowing.  It can affect the jaw
bone and cause problems with jaw bone weakening and even breaking
with the old style radiation that was given.  Now, those side
effects are really minimized and we rarely see that because the
radiation is targeted just to the area where it is needed.Foss
 That is called IMRT.Judson
 That is one important technique for doing it, for giving radiation
in that targeted way.Foss
 We talk about radiosurgery in other kinds of cancer.  Does
that apply to head and neck cancer as well?Judson
 Not routinely, but there are situations where we use it.Foss
 There also are some novel surgical techniques that are being
pioneered here at Yale Cancer Center in terms of minimally invasive
surgery.  Can you talk a little about that?Judson
 Absolutely, techniques using endoscopes to remove tumors through
the mouth so that we avoid an external incision were really
pioneered in Germany, but it is beginning to catch on here in the
United States, and we have been doing that here at Yale for the
last several years.18:53 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3
                     
Often we use a laser as part of that technique to remove these
tumors without making any external incisions.  An interesting
event recently in our field, is the FDA approved the use of the
robot to operate through the mouth as well, and so we are planning
to begin doing that here at Yale within the next year.Foss
 That sounds kind of space age.  Can you talk a little bit
about how that robot does the operation?Judson
 Often times these tumors are small, but if they are in the back of
the throat or down in the throat they are very hard to get to and
so in the past in order to remove the tumor with a nice, cuff of
normal tissue around it so we feel comfortable that the whole thing
is out and the patient is not going to have any problems, it
required making bigger incisions in the neck to get their. 
The robot allows us to go through the mouth and have great
visualization and then we can perform very sophisticated surgeries
just through the mouth using the robot.Foss
 It sounds like that is a tremendous advance for patient in terms
of side effects, long term sequelae from these kinds of
operations.Judson
 Yes, it is not for everyone but for those patients where it can be
done it can make a big difference.Foss
 Let us talk a little bit about chemotherapy.  Do all patients
require chemotherapy?Judson
 No, we try to tailor the use of our different types of treatment
to the patients needs and so sometimes chemotherapy is used in
conjunction with radiation alone, as a single treatment for a
patient, and in patients with even more advanced cancer sometimes
we combine surgery with radiation and chemotherapy that is given at
the same time as the radiation.Foss
 I know that you work closely with your colleagues in medical
oncology to treat patients with chemotherapy.Judson
 That is correct.Foss
 There are some drugs that actually sensitize to the effect of the
radiation.Judson
 That is correct.Foss
 I think that has been a major step forward in some of these
bulkier tumors.21:00 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3Judson
 Yes.Foss
 Can you talk about the Head and Neck Program here at Yale?Judson
 Absolutely, as I mentioned, there is a great head and neck team
that is already here that I have been really excited to join. 
We have an event scheduled in April for free head and neck
screenings.  It will be at Smilow Cancer Hospital on April 16,
2010, from 11 a.m. to 4:30 p.m. and listeners who are interested
can go to www.yaleheadandneck.org to find out more details and
register.Foss
 Great, can we talk a little bit then about patients who have
already been through this?  Patients who have had their
surgery, their chemotherapy or the radiation therapy, how long does
it take people to recover from this disease?Judson
 It varies a lot and for smaller tumors patients sometimes will
have surgery and they're home the next day, if it also involves
some neck surgery, it is usually a couple days in the hospital and
then for the larger tumors people can be in a hospital for one to
two weeks. In those patients the healing process is one that can
take weeks to months as we work with them to restore their
swallowing and their speaking function.Foss
 During that period of time, when they are recovering, do patients
require say TPN or some other way of receiving nutrition, because
they cannot eat normally?Judson
 Yeah that can happen, if that is the case, if it is going to be
more than a week or two, we generally try to use the feeding tube
in the stomach to allow them to use their gut, which is still
working, for nutritional support.Foss
 I know that when you radiate the mouth you can sometimes lose
salivary gland function.  How difficult is that for
patients?Judson
 That can be quite difficult and that is one of the reasons why the
IMRT or the more targeted radiation therapy has been such a
breakthrough for these patients because you think that having a dry
mouth does not sound so bad, but it actually can be quite
bothersome and with the more targeted therapy that we're using now
it is much less common.Foss
            
 There are other supportive cure medications that can be used in
that setting as well to stimulate saliva. 23:11 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3Judson            
 There are and one of the things that is important for those
patients is that they take very good care of their teeth because
saliva has an important protective function in terms of protecting
the teeth, so it is important that they are followed closely by the
dentist and dentists work with us to make sure that they do not
have any dental problems.Foss
 Can you talk a little bit about the future for head and neck
cancers, are there new advances coming down the pike that we should
know about?Judson
 There are advances in all the areas that are used to treat head
and neck cancers, as I mentioned, there are increasingly minimally
invasive surgical approaches so that patients have less side
effects from the surgery.  There are new chemotherapeutic
agents in development and that have been developed in the recent
past which help in these patients and there continues to be
improvement in the radiation technology that is used to treat these
patients, and as with treating other cancers, really the most
important thing I think is to work as a team; have a team approach
and tailor a treatment for each person.Foss
 Are there biological therapies say like monoclonal antibody
therapy that are available?Judson
 Yes, one of the chemotherapeutic agents is an antibody that
targets EGFR that is relatively well tolerated compared to some of
the other chemotherapeutic agents and that we use routinely.Foss
 Are there specific therapies now for the HPV virus; are there ways
that we perhaps could prevent head and neck cancer in people that
carry the HPV virus?Judson
 It is a great question.  One of the things that we are
beginning to learn and some of the research that has been done here
at Yale is that patients with HPV related cancers have a better
prognosis then tumors related to smoking and drinking, but how to
tailor a treatment based on that is still an area of intense
research.  We do not want to lessen our treatment because we
are doing pretty well in those patients, but I think that's where
one of the futures is in terms of an area of research, trying to
tailor a treatment based on the risk status that a patient has.Foss
 We now have these HPV vaccines that young women are getting to
prevent cervical cancer.  Obviously we do not know yet whether
those are going to prevent head and neck cancers.Judson
 So there is no evidence to show that they are useful in treating
head and neck cancer, but the two types of vaccines that are
commercially available include HPV types 16 and 18 and25:59 into mp3 file 
http://yalecancercenter.org/podcast/apr1110-cancer-answers-judson.mp3those two are the types that are implicated in head and
neck.  There is every reason to believe that  as long as
they protect against those types of HPV infections, that they will
also protect against the associated head and neck cancer that they
can cause.Foss
 Great.  That's something for us to look forward to in the
future.Judson
 Absolutely.Foss
 Ben, I just wanted to ask a few other questions because we now are
looking more at the federal level issues of
disparities in terms of cancer incidence and cancer care, and we
did not touch on this at the beginning of the program, but could
you just talk a little bit about the frequency of head and neck
cancers in different racial groups and whether the disease is worse
say in one group versus another?Judson
 It's an area of intense investigation.  There have been some
studies that showed, for example, that African Americans with
oropharyngeal cancer were not doing as well as the rest of the
population.  What has come out more recently is that that may
be driven by HPV infection, so it may be that more of the African
American population does not have HPV related cancers, which may
explain why they are not doing as well.Foss
 That leads us to the whole issue of screening, which we talked
about, and perhaps people in certain disparities groups ought to be
screened more frequently?Judson
 Yes.Foss
 Excellent.  We have had a very good discussion here tonight
about head and neck cancer and I would like to thank you for coming
in and being my guest.Judson
 Thanks so much for having me.Foss
 Dr. Benjamin Judson is Assistant Professor of Otolaryngology in
the Department of Surgery at Yale Cancer Center.  Thank you
very much for joining us tonight, and have a pleasant evening.If you have questions or would like to share your comments,
visit yalecancercenter.org, where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.