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Head and Neck Cancers Awareness Month

April 12, 2021
  • 00:00Support for Yale Cancer Answers
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  • 00:14Welcome to Yale Cancer Answers with
  • 00:16your host doctor Anees Chagpar.
  • 00:18Yale Cancer Answers features the
  • 00:20latest information on cancer care by
  • 00:22welcoming oncologists and specialists
  • 00:24who are on the forefront of the
  • 00:26battle to fight cancer. This week
  • 00:28it's a conversation about head and
  • 00:30neck cancer with Doctor Aarti Bhatia.
  • 00:33Doctor Bhatia is assistant professor
  • 00:34of medicine and medical oncology
  • 00:36at the Yale School of Medicine,
  • 00:38where Doctor Chagpar is a
  • 00:41professor of surgical oncology.
  • 00:43Aarti, maybe you can start off by telling us a
  • 00:46little bit more about head neck cancers.
  • 00:48It seems like there would be a lot of
  • 00:52cancers in that bucket.
  • 00:53It is actually a pretty wide bucket.
  • 00:56You know if you think about it,
  • 00:58the head and neck is a
  • 01:00pretty concise structure,
  • 01:01but diagnosis, treatment follows
  • 01:03like the site of origin of the
  • 01:05tumor within the head neck region.
  • 01:07So broadly it encompasses a lot
  • 01:10of tumors which arise from the
  • 01:12mucosa within the head and neck.
  • 01:14But you know, they could arise in the mouth,
  • 01:17so that would be oral cavity tumors.
  • 01:19They could arise in the back of the throat,
  • 01:22so that would be oropharyngeal
  • 01:24tumors or tonsillar tumors.
  • 01:25They could arise in our voice box
  • 01:27that would be laryngeal tumors.
  • 01:29The back of the nose is nasal
  • 01:31pharyngeal tumors.
  • 01:32You could also have salivary gland cancers,
  • 01:34and each of those sites is treated
  • 01:37differently in terms of how we
  • 01:39work it up and how we manage it.
  • 01:42And are they all lumped together?
  • 01:45Basically because they're all
  • 01:48pretty rare, or I wouldn't say
  • 01:50they are rare, together head neck
  • 01:53cancers always come within the top 10
  • 01:56most common cancers in the United States.
  • 01:58You know there's also a much larger
  • 02:01proportion of tumors that arise
  • 02:03outside of the United States,
  • 02:05so for instance, Asia has a very
  • 02:07large number of new head neck cancers
  • 02:10that are diagnosed every year, but
  • 02:13the reason they are lumped together is
  • 02:16because they share a common Histology.
  • 02:18So when we look at
  • 02:20tumors under the microscope,
  • 02:21most tumors arising from the head and
  • 02:24neck region tend to have what we call
  • 02:26a squamous Histology and based off
  • 02:28that they are clubbed together as one
  • 02:30entity. But they are different in
  • 02:32terms of how they're treated and we're
  • 02:35going to get into that in a second,
  • 02:37but just take one step back,
  • 02:40what is the etiology or the
  • 02:42cause of these head neck cancers?
  • 02:44Why are they more common in
  • 02:46Asia than they are for example,
  • 02:48in the United States and what
  • 02:50are some of the risk factors that
  • 02:52people should be watching for?
  • 02:55So the common etiologies worldwide is,
  • 02:58you know, tobacco exposure,
  • 02:59alcohol exposure. In Asia
  • 03:01there are a couple additional risk factors
  • 03:04that increase the incidence of these cancers.
  • 03:07So for instance, in Southeast Asia you
  • 03:10know people tend to chew a lot of tobacco.
  • 03:14They tend to chew betel nut and those
  • 03:17natural substances can also increase their
  • 03:20risk of acquiring head and neck cancers
  • 03:23in countries like China. In Hong Kong,
  • 03:25there is an incidence of nasal,
  • 03:28pharyngeal cancers which are caused by
  • 03:31the Epstein Barr virus or EBV virus.
  • 03:33It's almost endemic,
  • 03:34endemic proportions in those countries,
  • 03:36so a lot of head neck cancers
  • 03:39tend to be nasopharyngeal.
  • 03:45In the United States and in
  • 03:47the Western world at large,
  • 03:49we also see several head and neck cancers
  • 03:52arising in Association with the human
  • 03:55Papilloma virus or the HPV virus.
  • 03:57Most commonly,
  • 03:58people associate that with
  • 03:59cervical cancer in women,
  • 04:01but there's a rising incidence of HPV
  • 04:03head and neck cancers in the Western world.
  • 04:08And so when we think about risk
  • 04:11factors for developing these cancers,
  • 04:13and we often think about primary prevention,
  • 04:16so how can we reduce getting these
  • 04:19risk factors and thereby reduce
  • 04:22our risk of getting these cancers?
  • 04:25It seems that the two that you've
  • 04:28mentioned right off the top would be
  • 04:31reduce your smoking or tobacco consumption,
  • 04:34whether that's chewing tobacco
  • 04:36or smoking tobacco,
  • 04:38and getting an HPV vaccine. Is that right?
  • 04:40That is right, so you know,
  • 04:43the HPV vaccine is something
  • 04:45that still doesn't have a lot
  • 04:47of uptake in the Community,
  • 04:49and it's good to be aware
  • 04:52that the sooner you get it in life,
  • 04:55ideally in your preteen years before
  • 04:57you have a chance of being exposed
  • 04:59to the virus and the infection,
  • 05:01the much better protection that the virus
  • 05:04offers you against multiple cancers.
  • 05:06So for women it protects you
  • 05:08against cervical cancer,
  • 05:09head and neck cancer, anogenital cancers.
  • 05:11And for men it protects you from the head and
  • 05:14neck cancers and the anogenital cancers.
  • 05:16So yes, and another thing
  • 05:18to be aware of is that the FDA
  • 05:21has recently increased the age
  • 05:22limit to which you could actually
  • 05:25be eligible to get the vaccine.
  • 05:27So previously it used to be about 26 years.
  • 05:30Now it's up to 45 years so you
  • 05:32know people who did not meet the
  • 05:35initial cutoff for the vaccine are
  • 05:37now eligible to get the vaccine.
  • 05:40And so why do you think that
  • 05:42there is so much hesitancy
  • 05:44about getting the HPV vaccine?
  • 05:46I mean, it seems that it would
  • 05:49be a no brainer if it can reduce
  • 05:52your risk of getting cancer.
  • 05:55Certainly HPV vaccines
  • 05:57have been around for awhile and right
  • 06:00now during the covid epidemic
  • 06:02we've seen some hesitancy with
  • 06:04regards to vaccination for covid,
  • 06:06based primarily off of the speed
  • 06:09and the rapidity with which
  • 06:11those vaccines were developed.
  • 06:13But the HPV vaccines have
  • 06:16been around for a while,
  • 06:18so why aren't people getting vaccinated?
  • 06:21Is it that this isn't really something
  • 06:24that's been established in school programs?
  • 06:27When kids get their usual measles,
  • 06:30mumps, and rubella vaccine?
  • 06:32Is it celebrity endorsement
  • 06:34against vaccination?
  • 06:34Why do you think that there is
  • 06:38this hesitancy?
  • 06:40I think it's a combination of factors.
  • 06:42One is the lack of awareness.
  • 06:45A lot of people do not know
  • 06:50about the Association with HPV.
  • 06:58The second is that it's not a part of
  • 07:01the national immunization schedule,
  • 07:03unlike the MMR vaccine, which then
  • 07:05gets offered to all pediatric patients.
  • 07:08But this one doesn't,
  • 07:09and the third is, I think,
  • 07:12a cultural hesitancy.
  • 07:13You know, HPV is a sexually acquired
  • 07:15infection,
  • 07:16and I think people worry that getting
  • 07:19teenagers a vaccine against a sexually
  • 07:21transmitted infection will in turn then
  • 07:24promote promiscuity so
  • 07:25I think a lot of people worry
  • 07:27about that reason as well.
  • 07:30And so is that why it's not part of
  • 07:33the national vaccination schedule?
  • 07:36I mean, it seems as though if the
  • 07:39CDC and other public health officials
  • 07:43recommend getting the HPV vaccine,
  • 07:45and certainly cervical cancers,
  • 07:49head, neck cancers,
  • 07:50anogenital cancers are significant in
  • 07:52terms of their public health consequences.
  • 07:55Why isn't it part of the national schedule?
  • 08:00I think one because it's
  • 08:04been maybe within the last decade
  • 08:05or so that we've started to see
  • 08:08results from clinical trials
  • 08:09establishing the efficacy of the
  • 08:11vaccine against these cancers.
  • 08:12And two, I think just a cultural
  • 08:15uptake hasn't been that much,
  • 08:17but it would be great to see it
  • 08:19become a part of the national
  • 08:21immunization schedule so
  • 08:23people have to opt out of getting
  • 08:25the vaccine instead of opting in to get it.
  • 08:27And so for the people who are
  • 08:31listening to this show and are thinking,
  • 08:33it seems as though
  • 08:36this vaccine is safe.
  • 08:37It's highly efficacious as I understand it,
  • 08:40can prevent over 90%,
  • 08:42maybe even higher, of these cancers,
  • 08:45especially cervical cancer.
  • 08:46But also other forms of cancer.
  • 08:49Why wouldn't I get it?
  • 08:51How do they go about doing that?
  • 08:54Is that something that they can
  • 08:56get through their doctors offices?
  • 08:59Is it covered by insurance?
  • 09:02What are the other potential barriers
  • 09:04that people can address?
  • 09:07It shoud be fairly straightforward to get
  • 09:08it so it is covered by insurance
  • 09:11right from the preteen years.
  • 09:13So age 9-10 until someone gets to
  • 09:15the age of 45 years and it should be
  • 09:18fairly straightforward to call your
  • 09:20pediatrician or your primary care doctor,
  • 09:23and you know, go in and get the shot.
  • 09:26Most clinics offer the vaccine.
  • 09:30And really it's been efficacious
  • 09:32and minimal side effects, right?
  • 09:33Well, there are some side effects. Nothing
  • 09:36like the covid vaccine.
  • 09:37So you know right off the bat,
  • 09:39that's something a little bit better
  • 09:41tolerated than the covid shot so
  • 09:43if people could deal with the covid shot,
  • 09:45they can definitely deal with
  • 09:46the HPV vaccine,
  • 09:48but there are minimal side effects.
  • 09:50Most of them are short term, they
  • 09:53dissipate within a day or two.
  • 09:56OK, great so aside from getting the
  • 10:00HPV vaccine the other risk
  • 10:02factors are really tobacco,
  • 10:04which has gone down in this country,
  • 10:07at least in terms of smoking.
  • 10:09The other question that people may
  • 10:12have is with regards to E cigarettes.
  • 10:14We found that
  • 10:17as people's smoking in terms
  • 10:19of smoking tobacco has gone
  • 10:21down in the United States,
  • 10:23E-cigarettes seem to have gone up.
  • 10:26Does that increase your
  • 10:27risk of head and neck cancers?
  • 10:31There isn't a lot of data
  • 10:32that's looked at that.
  • 10:34Again, E cigarettes are a new phenomenon.
  • 10:35It's really only been
  • 10:37within the past few years.
  • 10:39It theoretically would have a lower
  • 10:41risk than regular cigarettes and
  • 10:42causing head and neck cancers,
  • 10:44but I'm not sure that it totally
  • 10:46eliminates the risk altogether.
  • 10:49And then the other
  • 10:51thing that people often put
  • 10:53together is smoking and alcohol.
  • 10:55What's the impact of alcohol
  • 10:57on head and neck cancers?
  • 11:00Almost the same as smoking,
  • 11:02so you know smoking.
  • 11:05when you inhale the smoke,
  • 11:07it goes down all the way from your head
  • 11:10and neck passages down to your lung
  • 11:12passages and with alcohol, similarly it goes
  • 11:14down your mouth, the back of your
  • 11:17throat and then into the food pipe.
  • 11:19So we do see a significant proportion
  • 11:21of patients who've never smoked but
  • 11:23have a significant alcohol history
  • 11:25who then go on to develop head and neck cancers.
  • 11:28So I would say the risk is about the same.
  • 11:31It's also cumulative,
  • 11:32so the more the exposure to either
  • 11:34substance or both substances,
  • 11:35the higher your chance
  • 11:37of developing a cancer.
  • 11:40The next question that
  • 11:42everybody is going to ask is,
  • 11:45is there a safe limit? Is it okay to have 1
  • 11:48drink at dinner or is there
  • 11:52a certain threshold at which
  • 11:55people should really be cautious?
  • 11:59Of course you want to avoid
  • 12:01binge drinking,
  • 12:02and there are these thresholds
  • 12:04that are set by the CDC as well.
  • 12:06and that
  • 12:07needs to be double checked,
  • 12:09but maybe it's 2 drinks a day for women
  • 12:12and three drinks at a time for men.
  • 12:15The safest is to minimize though,
  • 12:17'cause I think everyone has a personal
  • 12:19body threshold that's different,
  • 12:20we see some people
  • 12:22who've smoked 100 pack years and
  • 12:24do not get head and neck cancers,
  • 12:26and then we see some people have
  • 12:28smoked just ten years and then
  • 12:30have a head and neck cancer
  • 12:32that's not virus associated,
  • 12:33so is presumably smoking associated.
  • 12:35So I think everyone just has
  • 12:37a different threshold.
  • 12:38Doing away with smoking altogether
  • 12:39is healthy for everyone,
  • 12:40and minimizing how much alcohol
  • 12:42you drink is also the best thing
  • 12:44you could do for yourself.
  • 12:47And so when we move away
  • 12:50from now primary prevention,
  • 12:51we've kind of talked about the risk factors
  • 12:55and things we can do to minimize that.
  • 12:58The next thing that people often talk
  • 13:00about is secondary prevention or screening.
  • 13:03Now, unlike a lot of other cancers,
  • 13:06breast cancer, colon cancer,
  • 13:08where we really have good screening tests,
  • 13:10do we have good screening tests
  • 13:13for head and neck cancer?
  • 13:16So screening hasn't shown to
  • 13:18save lives for patients who
  • 13:20go on to develop head neck cancer,
  • 13:23but in our own experience,
  • 13:25the way head neck cancer
  • 13:27is most commonly diagnosed is
  • 13:29when someone notices a lesion,
  • 13:31say in the oral cavity or in the back
  • 13:34of the throat and is then referred
  • 13:37to the oncology team.
  • 13:38So that tends to be found
  • 13:41serendipitously by somebody's doctor or
  • 13:43dentist who looks in their mouth.
  • 13:46Yes, but I hear that
  • 13:48you were about to say that you
  • 13:51organize community screening
  • 13:52programs that might be helpful,
  • 13:54and I'd love to delve a little
  • 13:57bit more into that.
  • 13:58But first we need to take a medical minute,
  • 14:01so please stay tuned to learn
  • 14:03more about head and neck
  • 14:05cancers with my guest doctor
  • 14:07Aarti Bhatia.
  • 14:09Support for Yale Cancer Answers comes from AstraZeneca, working
  • 14:12to eliminate cancer as a cause of death.
  • 14:14Learn more at astrazeneca-us.com.
  • 14:17This is a medical minute about lung cancer.
  • 14:21More than 85% of lung cancer diagnosis
  • 14:23are related to smoking and quitting, even
  • 14:26after decades of use can significantly
  • 14:29reduce your risk of developing lung
  • 14:31cancer. For lung cancer patients,
  • 14:33clinical trials are currently underway
  • 14:35to test innovative new treatments.
  • 14:37Advances are being made by utilizing
  • 14:40targeted therapies and immunotherapies.
  • 14:42The BATTLE II trial aims to learn
  • 14:44if a drug or combination of drugs
  • 14:47based on personal biomarkers can help
  • 14:49to control non small cell lung cancer.
  • 14:52More information is available
  • 14:55at yalecancercenter.org.
  • 14:56You're listening to Connecticut Public Radio.
  • 15:01Welcome back to Yale Cancer Answers.
  • 15:03This is doctor Anees Chagpar
  • 15:05and I'm joined tonight by
  • 15:07my guest Doctor Aarti Bhatia.
  • 15:09We're talking about head and neck
  • 15:11cancers and right before the break,
  • 15:13you made a comment that
  • 15:15I found really interesting.
  • 15:17You said that
  • 15:18screening for head neck cancers has
  • 15:21not been shown to improve survival.
  • 15:23That for many people,
  • 15:25I think would seem counter
  • 15:27intuitive for most cancers.
  • 15:28We think if we pick it up early,
  • 15:31the earlier we pick it up,
  • 15:33the easier it is to treat,
  • 15:35the better the survival rate is.
  • 15:37So why do you think that is that
  • 15:40that screening really hasn't
  • 15:41been shown to affect survival?
  • 15:44Well, I think a large part of that
  • 15:47is because patients present with
  • 15:48symptoms pretty early on.
  • 15:51I mean, if you have a bleeding ulcer
  • 15:53in the mouth, you have sore throat,
  • 15:56you have trouble swallowing or chewing,
  • 15:58you notice a neck lump,
  • 16:00most people aren't going to
  • 16:01sit on it for months or years.
  • 16:04They're going to go see a doctor
  • 16:06and figure out what's going on.
  • 16:08So because of the
  • 16:10location of these tumors and how
  • 16:12early they present with symptoms,
  • 16:14most people are diagnosed early on,
  • 16:16and in early stages.
  • 16:17So the vast majority of our patients
  • 16:20come in with curable cancers,
  • 16:22so I think there isn't much
  • 16:24more that screening does.
  • 16:26Screening picks up early cancers,
  • 16:28but then people come in
  • 16:30with early cancers anyway,
  • 16:32so for that reason it hasn't
  • 16:34been shown to improve survival.
  • 16:36But we still think it's helpful to
  • 16:39engage in community wide screening efforts,
  • 16:41especially in the high risk population.
  • 16:43So in patients who have a significant
  • 16:46smoking exposure, alcohol exposure,
  • 16:47multiple partners,
  • 16:48it makes sense to have them
  • 16:52engage with their dentist or
  • 16:54oral surgeons, ENTs, to see if
  • 16:57they have any lesions that can be
  • 16:59intervened in an early
  • 17:01course in the disease
  • 17:03I think that's one of the
  • 17:06beauties of head neck cancers is that
  • 17:08because the lesions
  • 17:10in the head and neck are such that
  • 17:12they will present with symptoms,
  • 17:14it can be found earlier than,
  • 17:16for example, other cancers that
  • 17:18we've talked about on this show,
  • 17:20which tend to be pretty silent and
  • 17:23patients present quite late.
  • 17:26So you mentioned a few of the symptoms that
  • 17:29people should be looking out for, right?
  • 17:33Bleeding, ulcer, nosebleeds,
  • 17:34lump in the throat,
  • 17:36losing your voice,
  • 17:37hoarseness, cough.
  • 17:38Are there other things that people
  • 17:40should be looking out for?
  • 17:43And seeing their doctor about?
  • 17:47Sometimes you may even have
  • 17:50oral lesions which tend not to bleed,
  • 17:52but they've just been there for awhile.
  • 17:55Some of those can be precancerous,
  • 17:57some precancerous lesions will then
  • 17:59go on to transform into cancer,
  • 18:01so even if it isn't a very bothersome lesion,
  • 18:04but just has been there around for awhile,
  • 18:07you want to make sure
  • 18:08you see someone about it
  • 18:10and get it checked out.
  • 18:12Yeah, and for many people,
  • 18:14going to your doctor for
  • 18:16a regular checkup once a year,
  • 18:18or seeing your dentist once or twice a year
  • 18:22is a really good thing to
  • 18:23do because as you mentioned,
  • 18:25it's often on these visits that
  • 18:28people can pick up on lesions that may
  • 18:30not have been bothersome to you.
  • 18:36They can then see it as suspicious
  • 18:38and move on to the next step.
  • 18:41So when you do go to your
  • 18:43dentist or your doctor and they
  • 18:45find something,
  • 18:48what's the next step in terms of making a
  • 18:51diagnosis and moving on with treatment?
  • 18:54So if the dentist
  • 18:56finds something that's suspicious,
  • 18:58they will either refer you to
  • 19:00an oral surgeon or an ENT,
  • 19:02and both those kind of physicians
  • 19:04can make a diagnosis with a biopsy,
  • 19:06so we need to typically get some
  • 19:08of that tissue out with a needle.
  • 19:11Look at it under the microscope
  • 19:13and see what's going on,
  • 19:14and if that diagnosis is cancer,
  • 19:16the next step is usually
  • 19:18scans where we try to find out to
  • 19:21what extent has this cancer spread.
  • 19:23Is it involving adjacent structures?
  • 19:24Is it involving some neck nodes?
  • 19:27Is it a local tumor or has it
  • 19:30spread and then from
  • 19:32then on you get involved with the
  • 19:34rest of the oncology team so you
  • 19:37meet a radiation oncologist.
  • 19:38You made a medical oncologist,
  • 19:40which is someone like me,
  • 19:42and usually treatment will then be planned,
  • 19:44involving a course of radiation
  • 19:46or chemotherapy or surgery,
  • 19:47or a combination of these so
  • 19:50multidisciplinary management is
  • 19:51key to treating and formulating
  • 19:53a good treatment plan for head
  • 19:55and neck cancer patients and in
  • 19:57fact outcomes are tied to being
  • 19:59treated at large
  • 20:00volume centers,
  • 20:01so you want to make sure you see
  • 20:03someone who has many
  • 20:05head neck cancer patients and
  • 20:07has dealt with their treatment.
  • 20:10Yeah, and when
  • 20:13you talk about large volume centers,
  • 20:15I think part of that may have to do
  • 20:18with the expertise of the clinicians
  • 20:21themselves and the fact that they
  • 20:24see these cancers day in and day out.
  • 20:27But the other might be some
  • 20:29of the things that they have at
  • 20:31large volume centers that may
  • 20:33not be ubiquitously available.
  • 20:35So talk to us a little bit
  • 20:38about personalized medicine.
  • 20:39We find that in so many cancers now,
  • 20:43especially the large volume centers
  • 20:45really are tailoring care in terms of
  • 20:48the genomics of a particular cancer and
  • 20:51using that information, that molecular
  • 20:53information, to really tailor their
  • 20:56therapy in terms of that multi modality
  • 20:59care that you were talking about.
  • 21:01Can you talk more about that?
  • 21:05Yes, absolutely.
  • 21:06So you know that's valid for patients
  • 21:09who have more advanced disease or
  • 21:11incurable disease at our center.
  • 21:13And I'm sure at many other large
  • 21:16volume centers with expertise,
  • 21:17we do what we call molecular
  • 21:20sequencing or profiling of tumors.
  • 21:22So the biopsies are analyzed for their
  • 21:25genes that are present
  • 21:26in the tumor and
  • 21:29we then determine is this gene something
  • 21:32that was inherited by the patient,
  • 21:34or is it something that
  • 21:36originated in the oral cavity
  • 21:39or in the mucosa of the head neck
  • 21:42and then went on to cause a tumor,
  • 21:46and sometimes knowing what these genetic
  • 21:49defects or mutations are in the tumor,
  • 21:51help us identify drugs or
  • 21:54targeted therapies,
  • 21:55which then will specifically go and
  • 21:58target or inhibit that aberrant
  • 22:00protein or aberrant mutation so the
  • 22:03cancer can come under better control.
  • 22:05Some of these drugs are
  • 22:07FDA approved in these settings and
  • 22:09some of these drugs are available
  • 22:12on clinical trials and clearly more
  • 22:14clinical trials will be available
  • 22:16at the larger volume centers where
  • 22:18we have the patient still offer
  • 22:20these studies too,
  • 22:21but even for patients who have
  • 22:24curable disease,
  • 22:25like we mentioned,
  • 22:26head and neck cancers tend to present
  • 22:28most often in the curative stage,
  • 22:32Therapeutic modalities like
  • 22:34robotic surgeries,
  • 22:35advanced radiation techniques are
  • 22:37sometimes available only at the
  • 22:40large volume centers and
  • 22:45along with improving your prognosis or
  • 22:47outcomes for treating these cancers,
  • 22:49it also helps minimize the side
  • 22:51effects that you have and you
  • 22:53have to then live with for the
  • 22:55rest of your life as a result
  • 22:58of undergoing cancer treatment.
  • 22:59So there are
  • 23:00many advantages to being
  • 23:02seen at large volume centers.
  • 23:03One of the things I think that
  • 23:06you mentioned which many people
  • 23:08might find curious is that
  • 23:10when you talk about genomics,
  • 23:12and tailored therapy,
  • 23:14that's mainly for people who
  • 23:16present with advanced cancers.
  • 23:17So is it the case that in more
  • 23:20early stage cancers the systemic
  • 23:23therapy or the chemotherapies tend
  • 23:25to be uniform across patients?
  • 23:30That is probably true for
  • 23:32head and neck cancers.
  • 23:34That might change in the
  • 23:36future though, so for instance,
  • 23:38immunotherapy is currently approved only
  • 23:40in the treatment of advanced cancers.
  • 23:43But we now have many trials which
  • 23:45are looking to move immunotherapy
  • 23:47into the curative setting and see if
  • 23:50we can improve cure chances for our
  • 23:53patients with locally advanced disease.
  • 23:55So there are biomarkers which we
  • 23:57use to predict which patients
  • 24:00will respond to immunotherapy in the
  • 24:02advanced setting and that might become
  • 24:04standard of care for even patients who
  • 24:07are in the locally advanced settings.
  • 24:09So we're using chemo and
  • 24:11standard radiation for cure,
  • 24:13but we're maybe adding on a partner
  • 24:15drug like an immunotherapy drug based on
  • 24:17what trials show us in the next few years.
  • 24:21There is a chance that we may not
  • 24:23be using that for everyone but
  • 24:26personalizing it for patients
  • 24:28who have these positive biomarkers
  • 24:30which then predicts for a better
  • 24:32outcome with
  • 24:33immunotherapy.
  • 24:35In general, what is the prognosis
  • 24:37for patients who present with
  • 24:39early stage head neck cancers?
  • 24:42So a large part of that depends on whether
  • 24:45or not they are associated with HPV,
  • 24:48so having the HPV virus associated
  • 24:50cancer confers a much better
  • 24:52prognosis and in the early stage,
  • 24:5480 to 90% of these patients can be
  • 24:56cured five years out in patients
  • 24:59who have HPV negative disease,
  • 25:01that number is a little bit lower,
  • 25:03but if you compare with a lot of other
  • 25:06cancer types it's still pretty good.
  • 25:08You know we are able to cure about on
  • 25:12average 60% of HPV negative patients.
  • 25:14Early stage with curative intent treatment.
  • 25:16Of course, we're always trying to
  • 25:18do research and clinical trials to
  • 25:20see if we can move that bar up and,
  • 25:23you know, get a higher proportion
  • 25:25of our patients cured.
  • 25:26And that's also the advantage
  • 25:28of being seen at a
  • 25:29larger centers that
  • 25:30has these trials to maybe make
  • 25:32treatment more aggressive.
  • 25:33To intensify your treatment so we can
  • 25:36move that bar up for our patients.
  • 25:39That was going to be one of my questions,
  • 25:42which is, for many patients, they
  • 25:45hear about clinical trials and they think
  • 25:48I have a fairly early stage cancer,
  • 25:51prognosis is reasonably good,
  • 25:56clinical trials always sound a little scary.
  • 25:58Do I really want to be a
  • 26:01Guinea pig in the early stage?
  • 26:04So what do you say to patients who
  • 26:06might be contemplating whether they
  • 26:08really ought to be in a clinical trial?
  • 26:12If they have potentially curative
  • 26:14cancer or not?
  • 26:17Two things.
  • 26:18One, it's always good to remember
  • 26:20that what is standard treatment today
  • 26:22was a clinical trial some years ago,
  • 26:25so we would have not gotten to the
  • 26:28treatments that we are at today
  • 26:30if we had not
  • 26:32used some other patients in
  • 26:34the past on clinical trials.
  • 26:35The second thing is that we always try
  • 26:38to carefully match and screen patients
  • 26:40to the available trials that we have.
  • 26:43So we're always
  • 26:45thinking about what benefit does
  • 26:47it directly offer that patient.
  • 26:48And even if there is a chance
  • 26:51of some benefit,
  • 26:51then that's the ideal patient
  • 26:53to be matched to a clinical trial.
  • 26:56So of course,
  • 26:56if we think that there is no
  • 26:58possible benefit to someone,
  • 27:00we're not going to put them on a trial,
  • 27:02so we're
  • 27:03carefully screening patients.
  • 27:04It's also a mutual decision,
  • 27:06so it's not something that's
  • 27:07going to be forced on anyone,
  • 27:09but it's worth at least hearing
  • 27:11out your options and then
  • 27:13making an informed choice.
  • 27:14And I think it's so important for
  • 27:17people to realize that
  • 27:19on average patients who participate
  • 27:21in clinical trials tend to do
  • 27:23better than patients who don't.
  • 27:25Because we're always testing what
  • 27:27we think is tomorrow's therapy,
  • 27:28the next great therapy,
  • 27:30how we can move that bar,
  • 27:32as you said to standard
  • 27:34of care today and so on.
  • 27:36Average people tend to do better.
  • 27:38The other question that I want
  • 27:40to circle back to before the
  • 27:42show closes is an important one,
  • 27:45and that is,
  • 27:46you mentioned that people who have
  • 27:48HPV positive cancers tend to do
  • 27:50better than people who have HPV
  • 27:53negative cancers and I want you to
  • 27:55kind of dispel a misconception that
  • 27:58some people might have then, which is,
  • 28:01why should I get the HPV vaccine,
  • 28:03if that then would prevent me from
  • 28:06getting an HPV positive cancer.
  • 28:08So then I would be more likely to
  • 28:11get an HPV negative cancer and
  • 28:13do worse.
  • 28:16Getting the vaccine does not increase your risk of getting
  • 28:19the HPV negative cancer and HPV
  • 28:21Positive cancers actually tend to
  • 28:23occur earlier in life so where
  • 28:26HPV negative cancers need a certain
  • 28:29degree of tobacco and alcohol exposure
  • 28:31for them to develop and usually occur
  • 28:33in the 6th or 7th decade of life.
  • 28:36HPV positive cancers can occur
  • 28:38as early as the third, fourth,
  • 28:41fifth decades of life and think about it.
  • 28:44Now you have a highly curable cancer,
  • 28:46but the
  • 28:47treatment is just as aggressive
  • 28:49as HPV negative cancers by the
  • 28:51current standard of care,
  • 28:53so you're going to live out all
  • 28:55these decades
  • 28:56dealing with the side effects of
  • 28:58treatment and for anyone who's known
  • 29:00someone going through head and neck cancer
  • 29:02treatment or has gone through it themselves,
  • 29:05it's probably
  • 29:05a nightmare to live
  • 29:08through and something that stays
  • 29:10with you for the rest of your life.
  • 29:13The side effects can be
  • 29:14pretty disabling for many,
  • 29:16many years afterwards.
  • 29:17Doctor Aarti Bhatia is assistant
  • 29:18professor of medicine and medical
  • 29:20oncology at the Yale School of Medicine.
  • 29:22If you have questions,
  • 29:24the address is canceranswers@yale.edu
  • 29:25and past editions of the
  • 29:27program are available in audio and
  • 29:29written form at yalecancercenter.org,
  • 29:31we hope you'll join us next week to
  • 29:33learn more about the fight against
  • 29:35cancer here on Connecticut Public Radio.