Head and Neck Cancers

October 19, 2020

Information

October 18, 2020

Yale Cancer Center

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email: canceranswers@yale.edu

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00:00Support for Yale Cancer Answers comes from
00:03AstraZeneca, committed to researching
00:06innovative treatments to address
00:08unmet needs in head and neck cancer.
00:11Learn more at astrazeneca-us.com.
00:14Welcome to Yale Cancer
00:16Answers with your host
00:17Doctor Anees Chagpar.
00:19Yale Cancer Answers features the
00:21latest information on cancer care by
00:23welcoming oncologists and specialists
00:24who are on the forefront of the
00:27battle to fight cancer. This week
00:29it's a conversation about head and neck
00:31cancers with Doctor Benjamin Judson.
00:33Doctor Judson is a professor of
00:35surgery in Otolaryngology and the chief
00:37of the division of Otolaryngology
00:38at the Yale School of Medicine,
00:41where doctor Chagpar is a
00:43professor of surgical oncology.
00:47I always think about head
00:49and neck cancers as this
00:52very large bucket
00:54of heterogeneous diseases.
00:55Can you talk a little bit
00:57about how you classify them,
00:59how you think about them?
01:02Well your impression is actually on target. Head
01:05and neck cancers make up about four to
01:085% of cancers in the United States,
01:11but when you really zone in on them,
01:14they are not common,
01:17but they're not rare either.
01:19And then when you really begin
01:21to look more closely, they
01:23are made up of a lot of different
01:25cancers in the mouth throat area.
01:28One of the phrases we use to describe
01:30it in the medical lingo is it's
01:32between the dura and the pleura, so
01:34any cancer that's not brain cancer,
01:36but it's above the lung
01:39falls into that bucket of being a head and neck cancer.
01:44Are there things that
01:46kind of make these similar?
01:48So when we think about risk factors for
01:51example of getting head neck cancers,
01:53granted that all of these cancers
01:56are a little bit different,
01:58but do they share some of
02:00the same risk factors?
02:01Some of them do and some of them don't.
02:05Some of the cancers we see in this area
02:07just don't have strong risk factors,
02:11They are uncommon,
02:13but they they can happen out of the
02:15blue without any sort of exposure.
02:18That's probably a minority
02:19of the cancers in this area.
02:21Historically,
02:21the biggest risk factor has been smoking,
02:23and you know,
02:24with the decrease in smoking rates
02:26in the United States since World War
02:28Two we're beginning to see some slight
02:31decrease in smoking related cancers.
02:33But the big sort of change or
02:35the big story in this area
02:38is the rise of cancers in the throat
02:40that are a result of infection
02:43with the human papilloma virus.
02:45I want to dig into HPV in a minute,
02:49but I want to talk about
02:51a couple of other things before we get there.
02:55One is a little bit about alcohol.
02:58Is alcohol a major risk factor
03:01for head and neck cancers, and if so,
03:04is there a quote safe amount of alcohol?
03:08It's a great question and I'm
03:10saying a little because we don't
03:13know some of this,
03:16but what we do know about
03:19the role of alcohol is that it has a
03:22synergistic role with tobacco so that
03:24if alcohol is a risk factor,
03:28a low risk factor for developing
03:30head neck cancer,
03:31smoking is a larger risk factor,
03:34but if someone smokes and drinks
03:36it isn't an additive effect,
03:39it's a multiplicative effect.
03:43So if you smoke and drink,
03:44your risk is significantly higher.
03:46So I guess the biggest role of alcohol
03:48is in people who smoke because it
03:51amplifies that risk of smoking.
03:53I think that although we say that
03:56alcohol is a risk factor for
03:58developing a head neck cancer
04:00A low level of alcohol.
04:02The risk of developing head
04:04neck cancer with that
04:06is quite low. OK, an my next question.
04:09It has to do with race and ethnicity.
04:12Are there particular racial and
04:14ethnic groups that are more at risk?
04:16I know that I have sent you in the last year.
04:21At least a number of people that I
04:24can think of off the top of my head
04:27who are of South Asian descent,
04:30which is which is a racial and ethnic group
04:33that we rarely think about in this country.
04:36We usually think about race in
04:39terms of African Americans,
04:40and we think about ethnicity
04:42in terms of Hispanic people,
04:44but if we think globally,
04:46are there particular racial and
04:48ethnic groups that are more at risk?
05:03Head and neck cancer is significantly
05:05more common in the rest of the world,
05:08and that probably has to do
05:10with tobacco and alcohol
05:12and betel nut exposure,
05:13which are higher elsewhere,
05:15especially in Asia.
05:16The other thing that's at play
05:18is that there is a particular
05:20type of head neck cancer
05:22called nasopharyngeal cancer that
05:24is much more prevalent in parts of
05:27Asia and it's related to Epstein
05:29Barr virus infection and
05:30we see when individuals from that part
05:33of the world move to the United States,
05:36their risk of developing those
05:38cancers goes down significantly,
05:39but not to the same level,
05:41and so we're sort of figuring out why that is.
05:44It is unclear exactly how
05:46the risk factors work,
05:48but we do see different types of
05:50head neck cancer more frequently
05:52in other parts of the world, like in
05:55Asia.
05:57And that brings me to this whole virus phenomenon,
05:59because now you've mentioned two viruses,
06:02both of which are risk factors for
06:04various head and neck cancers.
06:06One being HPV and one
06:09being Epstein Barr virus,
06:10and certainly right now,
06:12in the midst of a global pandemic,
06:15a lot of us have got viruses on the brain.
06:19Talk a little bit about the differences
06:24between different viruses and
06:27how exactly these viruses cause
06:30cancer and what we can do about it.
06:36I think what we're seeing the
06:38most in the United States by far
06:41is the rise in throat cancers
06:43that are caused by exposure
06:45to the human papilloma virus,
06:47and it's been happening
06:49over the last 15 or 20 years,
06:52and it's still an emerging story.
06:54We're still learning more about
06:56what's happening and how this works,
06:59but we certainly know a lot,
07:01and one of the key takeaways
07:03is that these are preventable
07:05cancers, and they're preventable
07:06if an individual is vaccinated against the
07:09human papilloma virus when they were younger.
07:11It's going to take 10
07:14to 20 years for that to play out.
07:16Teens today are
07:18getting vaccinated many of them,
07:20but not probably as many as we'd
07:22like in the United States,
07:24and that's going to prevent these
07:26cancers in those individuals
07:2715-20-30 years down the road.
07:31When we think about HPV,
07:35I think that many of our listeners may
07:38think about HPV and think about it being
07:42really primarily for women for cervical
07:45cancer being sexually transmitted.
07:48They don't think about it as much or
07:51perhaps at all for people of both
07:54genders in throat cancer.
07:55Talk a little bit about that.
07:59I mean, is this the same virus?
08:02Is it a different virus?
08:04Is it spread through sexual
08:07means or other means?
08:09And what do you say to the people
08:13who say, my child won't
08:17engage in oral sex and therefore
08:20will not be at risk of HPV in their
08:24throat and therefore if not female,
08:27does not need to be
08:30vaccinated?
08:32That is a question that people ask for sure
08:35and what we know is
08:38that human papilloma virus,
08:39the type of HPV that causes
08:43throat cancer is the same type that
08:46can cause cervical cancer in women.
08:49And in the throat
08:51it predominantly causes cancer in men
08:53and we don't know why that's the case.
08:56What we've learned is that the
08:58vast majority of Americans are
09:00exposed to this virus at some point.
09:03Estimates put it in the 80 to 90% range.
09:06So almost all of us get exposed
09:09to the virus at some point.
09:11Usually our bodies clear the virus.
09:14For some people,
09:15the virus hides out in the
09:17back of the throat.
09:19And it's it's there,
09:20sort of evading our immune
09:22system for decades.
09:23And it's that exposure of sitting
09:25there that is a risk factor for
09:28developing a cancer later on.
09:33There is some evidence that suggests
09:35that people who are more active,
09:37more sexually active are at higher
09:39risk for developing these cancers.
09:41But I think anyone just the vast majority,
09:44almost all Americans are
09:45exposed at some point,
09:47and so we do see these cancers in
09:50everyone.
09:51And so this opens the
09:55question of vaccination and as
09:58we sit here in 2020,
10:02the remarkable year that it has been,
10:06it really does bring to light
10:09the question of vaccination.
10:10And historically there have been
10:14people in this country who have been what
10:18have been called anti-vaxers who have
10:22concerns about autism due to vaccination and
10:25perhaps there are more people who worry
10:28about how vaccines actually get approved
10:31in this country and whether they are safe.
10:37Can you speak to that and really
10:40allay our listeners fears?
10:42Because right now people might have
10:45all kinds of concerns with regards
10:48to not just the Covid vaccine,
10:50but vaccines in general.
10:53I think with
10:55HPV we have the benefit of this
10:58not being a new vaccine.
11:01Over 120 million doses have been
11:03given in the United States and I
11:06think it's now over 300 million doses
11:09across the world over the last decade.
11:12and this is a safe vaccine.
11:15It also is an effective vaccine.
11:18It eliminates 90 to 100%
11:21of the infections and cancers
11:23that this virus can cause down the road.
11:34It's safe and
11:36it's effective and you know,
11:38in the past the rationale for
11:40getting the vaccine was sometimes
11:42it was described as to avoid
11:44genital warts or things like that,
11:47and I think that there's not as great a
11:49perception or understanding that this
11:51is really a cancer prevention vaccine,
11:54and so there's new survey
11:56data and studies going on that
11:58really shows that if more
12:01people appreciate that this
12:02vaccine has the potential
12:05and the ability to prevent cancers,
12:07those people are more likely to
12:10have their children vaccinated,
12:11so I think that there is some
12:14work to do in this area to explain
12:17the benefits of
12:18the vaccine.
12:21The other point that comes up is
12:24the fact that this cancer
12:27is not terribly common.
12:28As you said, it's not terribly rare,
12:31but it's not terribly common,
12:33and so I'm playing Devil's advocate
12:36here for the benefit of our listeners,
12:39who may have similar concerns.
12:42To really think about the risks of
12:45the vaccine versus the benefit in
12:47preventing a cancer that occurs
12:49in 4 to 5% of the population,
12:52can you speak to the data
12:54with regards to autism,
12:56which is something that
12:59Jenny McCarthy and other
13:01figures active in the anti vax
13:03movement have really promulgated.
13:05Is there any truth to that?
13:08I know certainly not with the HPV vaccine.
13:11There's really been no
13:14signs whatsoever over hundreds
13:15of millions of people that
13:17there is any association like that.
13:19The data that
13:22led to some of those claims has
13:24really been debunked as false data
13:26at this point for other vaccines.
13:29So I think that that's
13:31not really\ up-to-date
13:33with where we are in terms of
13:35understanding the side effects.
13:38I think that given its safety and
13:40the fact that it's been around for
13:43a long time and seems to almost
13:45completely eliminate cancer,
13:46whether it's cervical cancer
13:48for girls, head and neck cancers
13:50for both genders, it reduces the risk.
13:53general towards for what that's worth.
13:58Vaccine is really important.
14:00We're going to take a short
14:02break for a medical minute,
14:04and when we return,
14:06we'll talk more about treatment
14:08and diagnosis for head and neck
14:10cancers with my guest doctor Ben
14:12Judson.
14:14Support for Yale Cancer Answers comes from AstraZeneca,
14:16a biopharmaceutical business
14:18with a deep rooted heritage in
14:21oncology and a commitment to
14:24developing cancer medicines for
14:27patients. Learn more at astrazeneca-us.com.
14:30This is a medical minute about survivorship.
14:34Completing treatment for cancer
14:35is a very exciting milestone,
14:38but cancer and its treatment can be a life
14:41changing experience for cancer survivors.
14:43The return to normal activities and
14:46relationships can be difficult and
14:48some survivors face long term side
14:50effects resulting from their treatment,
14:53including heart problems,
14:54osteoporosis, fertility issues,
14:55and an increased risk of 2nd cancers.
14:58Resources are available to help
15:00keep cancer survivors well and
15:02focused on healthy living.
15:04More information is available
15:06at yalecancercenter.org.
15:07You're listening to Connecticut public radio.
15:11Welcome back to Yale Cancer Answers.
15:13This is doctor Anees Chagpar and I am
15:16joined tonight by my guest doctor Ben Judson.
15:20We're talking about patients with
15:22head and neck cancer and right before
15:25the break we were talking about the
15:27fact that HPV is actually
15:30causing a lot of throat cancers
15:32that we see and this is entirely
15:34preventable with the HPV vaccine now.
15:37We talked a little bit about risks
15:39and benefits and it seems to me that
15:42with millions and millions
15:45of doses being given over many,
15:48many years, we really do have
15:50the data that suggests that this
15:53vaccine is safe and effective.
15:55But I wanted to
15:59ask who should be
16:02vaccinated and when?
16:03Terrific question, so the guidelines
16:06now for males and females who are
16:09under the age of 26 to be vaccinated.
16:12Usually the recommendation is
16:14for the first dose to be given
16:17when someone is around 11 or 12
16:19years old with one second dose.
16:22And the thought for that timing is that
16:24the vaccination then has
16:27time to work before
16:29they are potentially exposed,
16:31likely years down the road.
16:33The change in this area has
16:35been that the CDC
16:37broadened the recommendation
16:38to consider vaccination for
16:40anyone up to 45 years old.
16:43I think that that's so important,
16:46but one of the
16:49issues that I always ask is,
16:51many of our listeners
16:54who may be hearing this show,
16:56may be saying, I'm 47,
16:59I'm 48, I'm 52.
17:00I'm outside that window,
17:02but I really want to
17:05get vaccinated because I'm not
17:07particularly keen on getting cancer.
17:09What do you do in that older population?
17:15We don't know for sure the benefit,
17:20I mean the benefit is
17:22overwhelming for those that are under
17:2426 in terms of preventing
17:26cancers and the issues
17:28or side effects from
17:30treatment as well as the risk of death.
17:33So that is for sure.
17:34I think in that group that are 27 to 45,
17:38there is a suggestion that
17:40there's a real benefit there.
17:41That's where we have this
17:43sort of soft recommendation
17:45to consider vaccination in that
17:47age group and we just don't know
17:50beyond that whether the size
17:52of the benefit to getting vaccination
17:55and is the reason why we've kind of
17:58looked at those particular age ranges
18:01as being the age ranges
18:04where people are most likely to
18:07be sexually active.
18:10So you would imagine that people
18:12who are in their 50s may have
18:15already come in contact with
18:17the virus and therefore
18:19vaccination may be less effective.
18:20That is absolutely
18:21right. The idea is to vaccinate
18:23people before they could possibly
18:25be exposed to the virus.
18:27That's why it's as young as the
18:29recommendations are
18:31for the initial vaccination and
18:33it's less known as we get
18:36older and we're more likely,
18:38as I mentioned, 80 to 90% of us
18:41have been exposed to the virus.
18:43The potential benefit of the
18:44vaccination later on is less
18:46understood or less known.
18:49I mean if you have people who have
18:53not been sexually active until their 50s
18:56for example, maybe they were
18:59for religious reasons or other reasons
19:01really did not engage but wanted to
19:04be vaccinated before they started.
19:06Whether that's something to consider.
19:08But it sounds like we're not there
19:11yet in terms of the data,
19:13it sounds very reasonable,
19:15but we just don't know yet
19:18based on the data.
19:24Let's suppose you weren't vaccinated.
19:26What are the signs and symptoms
19:29that you should look out for in
19:32terms of head and neck cancers?
19:34And I mean we talked at the
19:37top of the show about this being
19:40a basket of really heterogeneous
19:43diseases right?
19:46I would
19:49imagine that there are so many
19:53varied symptoms that could
19:56be signs of head and neck cancer.
20:00I think that's right.
20:04In some ways,
20:05one of the pitfalls that we've
20:07seen is that with HPV related
20:10cancers these cancers are arising
20:12in younger otherwise very healthy
20:14individuals without real risk factors.
20:17The vast majority of patients
20:18with an HPV related cancer
20:21present with a painless neck mass,
20:24a physical lump in the neck that they can
20:27see and feel and they otherwise feel fine,
20:30and so there's a little bit of a tendency to
20:35put that off like
20:36I feel fine and
20:41living my life and
20:43so they might not seek
20:45medical care early,
20:47but that is the
20:49leading presentation of this cancer.
20:50And so one of the
20:52recommendations is that
20:54someone who has a mass in the neck,
20:57even if you otherwise feel great
20:58and have no other symptoms,
21:00and if it's there for more than four weeks,
21:02you should see your
21:04physician about it.
21:05See someone about it.
21:07And what's the age range that
21:09we typically see these cancers in?
21:12You mentioned if you're
21:14an otherwise healthy young person,
21:16are young people really the
21:18ones getting this disease,
21:20or are they at lower risk and this
21:22is really something that people
21:24should worry about when they're
21:26pushing into their 70s and 80s?
21:29I think that the smoking drinking
21:31related head neck cancers that
21:32we saee happen most frequently
21:34in people who are in their 60s,
21:38somewhat later in life,
21:42having a longer time
21:44of exposure to
21:46the risky effects of tobacco
21:48and alcohol. With HPV we're seeing
21:51these cancers younger and younger,
21:52and so the peak age of these cancers is
21:55actually in their 40s and we see it
21:58at all ages we can see younger and older,
22:01but it definitely isn't
22:02happening in younger patients,
22:04and I think that that's so critical for
22:06people to really understand because,
22:08being in my 40s, I can tell you that
22:12you do kind of feel invincible, right?
22:16You're healthy, you don't
22:17really need to go to the doctor.
22:21Everything is good.
22:22And you certainly don't think you're
22:24gonna get cancer, but it can occur.
22:26That's so true.
22:26And so often peoples in their
22:2840s are busy with life.
22:30You know they've got jobs and whatever it is,
22:33and so their time for cancer,
22:34they don't have time for this and
22:36they are less likely to go get it
22:38checked out 'cause they're just too busy.
22:47What are the other other symptoms
22:49that people should look for?
22:51I mean a painless lump in the neck
22:53is certainly something that
22:55should be a red flag for people,
22:57even though it's painless,
22:59and I think that's the other
23:01thing is that people say
23:03if it's not causing me pain,
23:05it can't be bad,
23:06but we know that with so many
23:09cancers that simply is not the case.
23:11That's right, and
23:22one of the symptoms, potential
23:24symptoms, is a sore throat or pain
23:26or difficulty with swallowing.
23:28Obviously this happens to
23:30all of us as a result of an infection
23:34or tonsillitis or something like that,
23:36but if that persists for more
23:38than three to four weeks,
23:40that is another reason to
23:42seek medical attention.
23:44Similarly, hoarseness of voice again,
23:46usually not cancer.
23:47We all get that at one point or another,
23:50but if it persists for more than four weeks
23:54that probably makes sense to seek
23:56medical attention for that as well.
23:57Yeah, it seems
23:58like that four week mark is really
24:00when people should start saying,
24:02you know, something
24:04that you get out of the blue if
24:06it's been persistent, it's really
24:08something that you need to look for.
24:16I had a
24:19friend who had a nosebleed,
24:22really young guy, 20-22 years old.
24:25I think you may have heard about him
24:29because I sent him to you who
24:32presented with a nosebleed.
24:35So simple things like that,
24:37you think
24:40it's a nosebleed but
24:42things like that can happen.
24:47It goes back to what we
24:49were talking about before.
24:50It's the patients who are
24:52young and healthy and feel fine.
24:54They're more likely to
24:55blow off these things.
24:56And most likely
25:0099% of the time,
25:01it's nothing.
25:03But sometimes it's something,
25:04and so it is just a reminder,
25:06if something is not going
25:08away or not getting better,
25:10it's ertainly worth
25:10having someone take a look.
25:12And sometimes
25:12there's some things that are really bad
25:14like what happened
25:15to my friend. so can you talk
25:17a little bit about the
25:20prognosis for head and neck cancers,
25:23and I realized that again it's a
25:26heterogeneous bucket of diseases,
25:28but in general, how
25:30do people fair?
25:31You mentioned it varies.
25:33You know it varies on the type,
25:35the specific type and the
25:36stage at which they present.
25:37So all the more reason to come in
25:40and get it checked out and found earlier.
25:44Interestingly
25:44the prognosis with HPV related cancers
25:47is much better than with the other
25:50types of head neck cancers that we see.
25:52Like for example,
25:53the smoking drinking related cancer.
25:55So the vast majority of patients
25:57with HPV related cancers are cured.
26:00Cure rates are in the 70 to 90% range.
26:03There are certainly side
26:04effects from treatment and so
26:06our goal is really
26:08to maximize that cure,
26:10but also try to
26:12minimize the side effects of any
26:15treatment.
26:18And the prognosis can be
26:21across the board, it can be varied.
26:24It can be very good.
26:27It can be not so good.
26:30Talk a little bit about treatments.
26:32Now, granted, treatments are going
26:35to vary based on whether this is
26:38found at an early stage or whether
26:41it is spread and metastatic.
26:43But on this show we frequently talk about
26:47personalized medicine about a
26:49multidisciplinary approach about
26:50all of the things that have
26:53evolved overtime that can improve
26:55treatment and patients outlooks.
26:57So how do you approach patients
26:59who have had neck cancer?
27:01Well, one part of this
27:03that I'm just passionate about is that
27:06it's so apparent to me working in this
27:10field that how patients do
27:13depends on the team that surround them.
27:16And so you know, I'm a surgeon and
27:19that's one potential treatment for a patient.
27:22Other treatments are chemotherapy
27:23or immunotherapy, or radiation.
27:24But it's critical
27:26to have a nutritionist, a
27:28speech language pathologist,
27:29physical therapists,
27:30a social worker,
27:32all part of the team and really
27:35how people do depends on
27:38having that whole team around the
27:40patient to help get them through it and
27:44having the team is key and then as you said,
27:48just carefully tailoring
27:49treatments for each patient
27:51based on the specifics of what's going on
27:53with them in their situation is just key.
27:56Talk a little bit about that.
27:59I mean we talk on this show
28:01a lot about how there have been
28:04advances in various tumor types.
28:09So in some cancers you
28:11know they they look at,
28:13panels of hundreds of
28:15of genetic and genomic mutations,
28:18and have targeted therapies
28:20for each of these.
28:21In others it's not quite so advanced
28:24in terms of tailoring therapies.
28:26The idea of course being that you
28:29know with a more targeted therapy
28:31you can potentially reduce some
28:34of the side effects of treatment.
28:37So given what you had said earlier
28:39about the side effects of therapy,
28:42where are we in terms of personalized
28:44medicine in head and neck cancer?
28:47It's so interesting
28:49and one of the areas where personalized
28:52medicine, really
28:53is common day-to-day in treating patients
28:55in this area is that patients with head
28:58with HPV related cancers are now being
29:01treated differently than the other cancers.
29:03We know that their responses and
29:06the prognosis is different and
29:08so now the
29:09treatments are different as well.
29:12And like so much in
29:14medicine there are constant advances.
29:16We're doing transoral
29:18robotic surgery and now patients
29:20have the potential to get immunotherapy,
29:22potentially as part of their treatment,
29:24and so there's
29:27more targeted radiation treatment,
29:29so it's constantly evolving
29:31and we're seeing
29:33an overall gradual improvement.
29:35Slow, but gradual improvement in prognosis,
29:38and I think it's a result of
29:40all these little incremental
29:41steps and improvements.
29:44Dr. Benjamin Judson is a professor
29:46of surgery in Otolaryngology,
29:47and the chief of the division
29:50of otolaryngology at the
29:51Yale School of Medicine.
29:53If you have questions,
29:54the address is canceranswers@yale.edu
29:56and past editions of the program
29:58are available in audio and written
30:00form at Yalecancercenter.org.
30:01We hope you'll join us next week to
30:04learn more about the fight against
30:07cancer here on Connecticut public radio.