Head, neck cancer surgeons offer highly specialized care
Mays Cancer Center Annual Report
Traditionally head and neck cancer was thought to be a disease primarily of elderly men who smoked and consumed alcohol heavily. In many cases, long-term prognosis was poor, and treatment options for these complicated cancers were often limited to large, invasive surgeries that altered how they looked, talked and swallowed. However, contemporary changes in the patient population and significant advancements in treatment have changed the landscape in head and neck cancer.
The steady decline of smoking over the last several decades is contributing to debunking this misconception, explained Jay K. Ferrell, M.D., who joined UT Health San Antonio in 2017 as one of two fellowship-trained head and neck cancer surgeons serving the people of South and Central Texas.
Today head and neck cancer is the sixth most common cancer in the U.S. It is an umbrella term for tumors arising between the collarbone and the base of the skull. The main subtypes of head and neck cancer are squamous cell carcinoma of the mouth, throat and voice box; salivary gland cancers; thyroid cancers; and complex skin cancers involving the scalp, face and neck. Each of these different types of cancers can require a unique combination of surgery, radiation therapy, or chemotherapy. A multidisciplinary team approach — like that offered at UT Health San Antonio Physicians and the Mays Cancer Center — is key to the successful treatment of these complex diseases.
Despite the decline in smoking, there has been an unusual increase of tumors in the back of the throat, he said. This new epidemic of head and neck cancer is impacting younger, healthier people from all walks of life. “These are patients who, many times, never smoked or might have smoked briefly in their teens or twenties,” he said.
“For many years, physicians wondered, ‘Why are they now getting throat cancer?’”
The answer came from groundbreaking research performed over the last two decades that identified the human papillomavirus (HPV) —which also causes cervical cancer in women — as the cause of this rise in the incidence of throat cancer. This important discovery resulted in a paradigm shift in the collective thinking about head and neck cancer.
The Centers for Disease Control estimates that at least 75 percent of adults have been exposed to HPV at some point in their lifetimes, said Dr. Ferrell, assistant professor in the Department of Otolaryngology in the Long School of Medicine. For many, the virus may not manifest as cold sores or genital warts, because the body flushed the virus out of their system. Unfortunately, the virus still leaves it genetic imprint, a mutation, in the cells of the back of the throat, he explained.
“As these patients age, that genetic information continues to cause damage in those cells. At around age 40 to 60, they then present with tumors in those areas, which used to be associated only with heavy smoking and drinking,” Dr. Ferrell said.
“This shift in patient demographics raised the ante about the impact of our treatments,” he said. “These patients are in the prime of their lives, and we as physicians want to maintain their quality of life in addition to treating their cancer.”
In the mid-20th century, treatment of these tumors often involved time-intensive, aggressive surgeries, which required resections of the jawbone, throat, neck and tongue. The after-effects of these procedures often altered a patient’s appearance and frequently required a tracheostomy and feeding tube for prolonged periods of time.
Toward the end of the 1990s, physicians started using chemotherapy and radiation therapy instead of surgery to treat tumors in the voice box and hard-to-reach areas of the throat.
“The goal was to try and spare normal tissue and preserve function. We now destroy the tumor and save normal tissue. Combinations of radiation and chemotherapy proved to be especially effective in patients with HPV-associated cancers of the base of the tongue and tonsils. Almost 90-plus percent are permanently cured of their cancer with these treatments,” Dr. Ferrell said.
However, high dose chemoradiation therapy can cause significant side effects, such as severe dry mouth, taste changes, and long-term swallowing difficulty. This can be particularly problematic for the younger patients presenting with HPV-related throat cancer. Their improved survival expectation also means that they will have many more years to potentially suffer the long-term side effects of chemoradiation therapy.
The emphasis on not only curing but also improving the post-treatment quality of life of head and neck cancer patients has prompted the development of less invasive ways to remove tumors such as Trans-Oral Robotic Surgery (TORS), Dr. Ferrell said. Started about 10 years ago at the University of Pennsylvania, TORS has become a valuable tool in head and neck cancer surgery as it is often requires less time under anesthesia, preserves critical functions, such as speech and swallowing, and avoids the disfiguring facial scars of older procedures.
Dr. Ferrell is one of the few fellowship-trained head and neck surgeons in Central and South Texas routinely performing TORS. During the procedure, he controls a sophisticated surgical robot via a surgeon-driven console in order to safely and effectively operate in hard-to-reach areas of the throat that traditionally were only accessed with aggressive, open surgical approaches.
“Another major benefit of up-front robotic surgery is that I am able to fully remove the primary tumor,” he explained. “Then I remove any metastatic lymph nodes in the neck so the pathologist can more fully assess and stage a specific patient’s cancer and help us, as a Head and Neck Cancer Team, determine how much post-operative radiation therapy a patient may need. In many cases, we can actually de-escalate their treatment by removing chemotherapy from the equation.
“In certain select cases, we may also enable them to either avoid radiation therapy altogether or at least reduce the total amount of radiation they receive.”
Dr. Ferrell and Frank Miller, M.D., FACS, professor and chair of the Department of Otolaryngology, are the only two fellowship-trained, academically focused head and neck surgeons in the large swath of South Texas west of Houston, south of Dallas, and east of El Paso.
The surgeons are patient focused in a specialty that has many complex moving parts.
In order to provide a true, multidisciplinary approach to treating patients fighting head and neck cancer, the surgeons meet weekly with the Mays Cancer Center Head and Neck Team consisting of radiation oncologists, medical oncologists, neuroradiologists, and other medical professionals to review and discuss the unique needs and treatment plan of every new head and neck cancer patient. In addition, Drs. Ferrell and Miller both run high-volume thyroid surgery practices and perform over 100 procedures for both benign and cancerous thyroid conditions annually.
“Treatment of head and neck cancer involves multiple disciplines because it impacts those senses that make us human and allow us to interact with the world around us. During and after treatment, patients may need psychological and spiritual services, dental care, speech pathology, and swallowing support,” he said.
In order to meet these needs and help deliver patient-focused care, the Mays Cancer Center recently added a dedicated nurse navigator to the growing head and neck program. She serves as a point of contact for patients and their families and helps them to successfully manage all of the appointments, imaging studies, transportation, and other complex intricacies of their treatment plans.
“Supportive care can make or break a patient’s experience. No two patients are the same. You’re treating the whole patient, not just a tumor,” said Dr. Ferrell, a Texas native who found his calling in head and neck cancer surgery during his residency rotations at MD Anderson Cancer Center and subsequent fellowship training at Oregon Health and Science University in Portland, Oregon.
“Every patient comes in with unique fears, concerns and values. Some may say, ‘If a particular treatment compromises this part of my life, I’m not okay with that.’ Some may need more psychological or family support than others. That’s where patient-focused care comes in. We’re treating the entire patient and ensuring that the treatment pathways we choose not only successfully treat head and neck cancer but also respect and value the unique personal, cultural, and spiritual needs of each patient that entrusts us with their care.”
