The site was created by Itzhak Brook MD a physician and a laryngectomee. It contains discussions of informative topics related to head and neck cancer and life as a laryngectomee. It also contains Dr. Brook's books, manuscripts and videos about his personal experience as a patient with throat cancer.
Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.
The 170 pages guide is aimed at providing practical information that can assist laryngectomees and their caregivers in dealing with medical, dental and psychological issues. The guide contains information about the side effects of radiation and chemotherapy; the methods of speaking after laryngectomy; and how to care for the airway, stoma, heat and moisture exchanger filter, and voice prosthesis. In addition it addresses eating and swallowing issues, medical, dental and psychological concerns, respiration and anesthesia, and travelling as a laryngectomee.
papillomavirus (HPV)-positive tumor status is associated with a significantly
better rate of overall survival in patients with oropharyngeal squamous cell
carcinoma (OPSCC) that has progressed, according to Carole Fakhry, MD, and colleagues
of Johns Hopkins Medical Center, Baltimore, Maryland.
studies has shown reduced risk of cancer progression in patients with newly
diagnosed local-regionally HPV-positive OPSCC. However, no information was
available regarding the role of the HPV status in overall survival after cancer
retrospective study evaluated 181 patients with stage III-IV OPSCC, and
included 105 who were HPV-positive and 76 who were HPV-negative.
though no difference was found in the median time to progression in relation to
the HPV tumor status (8.2 vs 7.3 months; P = .67), HPV-positive OPSCC had
significantly improved rates of overall survival at 2 years compared with
HPV-negative patients (54.6% vs 27.6%; P< .001).
significantly associated with increased risk of death included high tumor stage
(T4 vs T2-3) at diagnosis, fewer cisplatin treatment cycles (≤1 vs 2-3), and
distant versus local/regional recurrence. Smoking was also an important risk
factor, with the risk of death after progression increased by 1% per cigarette
pack-year at diagnosis (P = .002).
reductions in the risk of death were associated with HPV-positive tumor status
and undergoing salvage surgery. The overall rate of mortality was reduced by
50% in individual with HPV-positive tumors.
cell carcinomas of the oropharynx (SCCOP) associated with human papillomavirus
(HPV) usually have better outcomes that those not associated with HPV. Patients with these cancers experience a
later onset of distant metastasis and more metastatic sites in atypical
locations, according to a new study by Samuel Trosman, MD and colleagues, of the
Cleveland Clinic, Cleveland, Ohio.
study illustrated that even though the rates of distant metastasis is similar
between patients with HPV-positive and HPV-negative SCCOP, distant metastases
occur significantly later and involves more body sites. The researchers
evaluated 285 patients with Stage III to IV SCCOP who were treated with
chemo-radiation therapy between 2002 and 2013. Among the patients, 27 of 245
(11%) HPV-positive and 8 of 40 (20 %) HPV-negative patients developed distant
radiation therapy regimen for the patients was either 3-dimensional
radiotherapy or intensity modulated radiation therapy with doses from 66 to 79
Gy. Concurrent chemotherapy consisted of cisplatin, cisplatin/5-fluorouracil,
though the distant metastasis rate between the HPV-positive and HPV-negative
groups was similar, the mean time to develop the distant metastasis was
significantly longer after the completion of treatment for HPV-positive
patients (21.6 months) than for HPV-negative patients (7.0 months; P = .03).
most common site of metastasis in both HPV-positive and negative individuals
were the lung followed by bone. Patients who were HPV-positive had
significantly higher average numbers of involvement in metastatic subsites
compared with HPV-negative patients (2.0 vs 1.1; P = .026).
HPV-positive patients, 21 of 27 (78%) had
>1 metastatic site, and 12 (44%) had distant metastases involving
>1 organ system, compared with only 1 of 8 (12.5%) HPV-negative patients.
Spread to less typical metastatic sites occurred more often in HPV-positive patients, and included liver
(6), intra-abdominal lymph nodes (3), brain (2), pleura (2), and peritoneum
treatment failure occurred more often in HPV-negative patients (3 of 8or 38%) compared to HPV-positive patients (4
of 27 or 15%).
Oscar-winning actor Dustin Hoffman, has been successfully
treated for throat cancer and is "feeling great," his spokeswoman
confirmed to People magazine. His publicist said the actor had been "surgically cured" after his cancer was detected at an
early stage. No further details were provided though Hoffman is thought to be
recovering well and is in good health.
The two-time Oscar winner and director, 75, will undergo
doctor-recommended preventative treatments to minimize the chance of a
recurrence of cancer in the years ahead.
Human papilloma virus (HPV)-related oral cancers are rising
in prevalence among white men in the US, and fear of transmitting the virus can
lead to anxiety, divorce, and curtailing of sex and intimacy among couples.
Persistent oral HPV infections are a risk for developing oropharyngeal cancers,
located at the base of the tongue, tonsils, pharynx and soft palate.
A multicenter, pilot study performed by Johns Hopkins
investigators found that spouses and long-term partners of patients with mouth
and throat cancers related to infection with the HPV appear to have no
increased prevalence of oral HPV infections. The study’s results suggest that
long-term couples need not change their sexual practices.
The researchers conducted surveys and took oral rinse
samples from 166 male and female patients with HPV-related oropharyngeal
cancers and 94 spouses and partners. More than half of patients had at least
one type of HPV DNA detectable in their oral rinses, including HPV16, the viral
type most commonly associated with oral and other cancers. After a year, only
seven patients (6%) still had oral HPV16 DNA detectable.
Of the 94 spouses/partners, six had oral HPV infections (6.5
%). These infections were not detectable one year later. No oral cancers were
detected among 60 spouses/partners who underwent a visual oral examination.
The investigators concluded that oral HPV prevalence among
partners was comparable to rates observed among the general population, and
even though long-term spouses and partners have been exposed to HPV they
cleared the virus. They also concluded that more research is needed to
determine the timeline of progression for HPV-related oral cancers and how HPV
is transmitted and suppressed by the immune system.
recent study by Nisa and colleagues from Sion, Switzerland, evaluated the value
of patients' reported symptoms as an indicator of tumor recurrence after
definitive treatment for head and neck squamous cell carcinoma. Cancer
recurrence occurred in 30 of the 101 patients included in the study had local
and/or regional recurrences.
of all patients had early stage, and two-thirds had advanced-stage tumors;
two-thirds received only single treatment modality (i.e., surgery, radiation)
and one-third had multiple treatment modalities. Most patients were male, with
a mean age of 61.5 years (range, 29-85 years), and had at least one risk factor
(tobacco and alcohol).
symptoms had the best correlation with cancer recurrences. Localized pain, pain
on swallowing (odynophagia), and impaired ability to produce voice (dysphonia)
were independently correlated with recurrences. Correlation was better between
6 to 12 and 18 to 21 months after therapy and in patients initially treated
with only one type of therapy (i.e., surgery or radiation alone). Primary stage and tumor site had no effect on
study underlines the importance of close and continuous follow-up after
treatment of head and neck cancer especially during the first 2 years. It also
illustrates that patient input and vigilance in reporting new symptoms are
instrumental in diagnosing cancer recurrence. Close follow-up has other
important goals, especially the identification and management of
treatment-related complications and psycho-social support.
constituents of marijuana smoke, have been recognized to have potential
antitumor properties. A study by Liang and colleagues from Brown University, Providence, RI, found that
long-term marijuana smokers were roughly 62 % less likely to develop head and
neck cancers than people who did not smoke pot.
study featured 434 patients with head and neck cancers, which include tumors in
the mouth, tongue, nose, sinuses, throat and lymph nodes in the neck, and 547
individuals without these cancers seen in the Greater Boston area from 1999 to 2003. After adjusting for potential confounders (including
smoking and alcohol drinking), 10 to 20 years of marijuana use was associated
with a significantly reduced risk of HNSCC even in those who smoked or consumed
alcohol. Among marijuana users moderate weekly use was associated with reduced risk.
The magnitude of reduced risk was more pronounced for those who started use at
an older age.
contrast a pooled analysis from nine case-control studies from the US and Latin
America by Marks and colleges, found that as compared with never marijuana smokers, ever marijuana smokers had an elevated risk of oropharyngeal and a
reduced risk of oral tongue cancer. Evaluated were 1,921 oropharyngeal cases,
356 oral tongue cases, and 7,639 controls.The risk of oropharyngeal cancer remained elevated among
never tobacco and alcohol users. The risk of oral tongue cancer was reduced
among never users of tobacco and alcohol. These results suggest that the
association of marijuana use with head and neck carcinoma may differ by tumor
Human papillomavirus (HPV) can cause serious health
problems, including genital warts and certain cancers. However, in most cases
HPV goes away on its own before causing any health problems. The same types of
HPV that infect the genital areas can also infect the mouth and throat. Some
types of oral HPV can cause cancers of the head and neck. Other types of
oral HPV can cause warts in the mouth or throat.
HPV can cause cancers in the back of the throat (oropharynx),
most commonly in the base of the tongue and tonsils. These cancers are called “oropharyngeal cancers.” Cancer caused by HPV often takes years to develop after
initially getting an HPV infection. It
is unclear if having HPV alone is sufficient to cause oropharyngeal cancers, or
if other factors interact with HPV to
cause these cancers.
Signs and symptoms oropharyngeal cancers
may include persistent sore throat, earaches, hoarseness, enlarged lymph nodes,
pain when swallowing, and unexplained weight loss. Some individuals have no signs or symptomsor may only have a lump in the neck as the initial presentation.
Knowing whether ones cancer was caused by HPV may help
physicians determine the prognosis for survival. Head and neck cancers caused by HPV infection respond better to current treatments as compared to head and neck
cancers caused by tobacco or alcohol use.
There are also new treatment options such as vaccine clinical trials and
de-intensification radiation protocols available to patients whose cancers are
caused by HPV.
About 7% of people in the USA have oral HPV. But only 1% of them
have the type of oral HPV that is found in oropharyngeal cancers (HPV type 16).
Oral HPV and cancers of the oropharynx are about 3 times more common in men than in women. About 8,400 people
are diagnosed in the USA with cancers of the oropharynx caused by HPV.
It is uncertain how
people get oral HPV. Some studies suggest that oral HPV may be passed on
during oral sex (from mouth-to-genital or mouth-to-anus contact) or
open-mouthed (“French”) kissing, others have not. The likelihood of getting HPV
from kissing or having oral sex with someone who has HPV is not known. One can reduce the risk of getting HPV by using
condoms and dental dams during oral sex, since they serve as barriers, and can
stop its transmission from person to person.
There is no FDA-approved test to diagnose HPV in the mouth
or throat, and medical and dental
organizations do not recommend screening for oral HPV.
HPV vaccines that
are now on the market were developed to prevent cervical and other genital
cancers. It is possible that HPV vaccines might also prevent oropharyngeal
cancers, since the vaccines prevent an initial infection with HPV types that
can cause oropharyngeal cancers, but studies have not yet determined if HPV
vaccines will prevent oropharyngeal cancers.
The loss of voice and a decrease in physical functioning due
to breathing through a stoma are known to result in long-term changes in daily
and professional life. There is growing evidence that head and neck cancer
patients including laryngectomees are more often anxious and distressed than
other cancer patients. Prevalence rates of psychiatric problems in laryngeal cancer
patients vary from 20% to 60 %, if nicotine dependence is taken included. Studies
reported depression in 4-20% of head and neck cancer patients, anxiety disorder
and phobia in 2 - 6%, adjustment
disorder in 4 - 13%, post traumatic stress disorder (PTSD) in 1 -2% and alcohol
dependence in 5-33%.
Several recent studies from the University of Leipzig in Germany explored the role of psychological problems in laryngectomees.
Psychological disorders were diagnosed in about a quarter of patients during the first year after laryngectomee according to a new study by Keszte et al. These were evenly distributed among males and
females. However, women suffered more often from PTSD and generalized anxiety disorder. Alcohol dependency developed in 80% of the
patients who had acquired no voice 80% following laryngectomy. Only 7% of individuals
with any mental disorder received psychotherapy one year after laryngectomy.
None of the patients diagnosed with alcohol dependency received psychotherapy
or psychiatric treatment.
Another study by Danker et al. found that more
than 40% of larngectomees withdrew from conversation. Only one-third of all
laryngectomees regularly took part in social activities. About 87% perceived stigmatization
because of their changed voice and more than 50% felt embarrassed because of
their tracheostoma. Almost one-third of the patients had increased anxiety and
These studies illustrates that only one in twelve patients
who suffered from psychological disorders following laryngectomy receive adequate
psychotherapeutic support. Because mental health seems to be
related to successful voice restoration, more effort is needed to promote
speech rehabilitation after laryngectomy. Also more programs are needed to combat alcohol
dependency. The studies also highlights the urgent need for psychological and
social support programs for laryngeal cancer patients.
Itzhak Brook MD gave aGrand Rounds lectureon May 16, 2012 for the Department of Surgery at Scott & White Medical Center, Texas A&M College of Medicine in Temple Texas. The lecture entitled " The patient Experience as a Laryngectomee" was about his experiences as a patient with head and neck cancer. The topics discussed include dealing with the medical and psychological issues, voice rehabilitation and life challenges as a laryngectomee.The presentationcan be watched on YouTube.
Dr. Brook delivered theJ. Conley Medical Ethics Lecture,the Scholar Award keynote lecture at the opening ceremony of theAnnual Meeting of the American Academy of Otolaryngology - Head and Neck surgery Foundation& OTO EXPOin Washington DCon September 9, 2012. His lecture is entitled "A Physician’s Perspective as a Throat Cancer Patient". A description of the presentation was published in theMeeting Daily Newsletter. The presentation can be watched on YouTube.
A Physician’s Perspective as a Throat Cancer Patient
A presentation entitled “ Patient Voices in Diagnostic Error in Medicine “ in Diagnostic Error in Medicine,5th international Conference of the Society to Improve Diagnosis in Medicine, John Hopkins School of Medicine, Baltimore Maryland, November 13, 2012.
A Grand Rounds lecture entitled "Preventing Medical Errors: a Physician's Personal Experience as a laryngeal Cancer" was delivered tothe Department of Medicine Louisiana State University on April 16, 2013. The lecture can be read on line and It can be viewed on YouTube.
Preventing medical errors
Keynote speaker University Hospitals Quality and Patient Safety Fair, Case Medical Center, School of Medicine Case Western University:“Preventing medical errors: a physician personal experience as a laryngeal cancer patient.” Cleveland, Ohio, March 5, 2014. The presentation can be watched on YouTube.
Personal experiences as a patient with laryngeal cancer: Medical errors. University Hospitals , Cleveland, March 5, 2014.
Signing copies of "My Voice"
A Grand Rounds lecture entitled “A Physician’s Personal Experience as a Head and Neck Cancer Patient” was delivered to the Department
of Medicine Veterans Administration Medical Center Washington DC, June 26,
2013. It can be viewed on YouTube.
Dr Brook presenting a lecture on October 10, 2014, about "Voice rehabilitation after laryngectomee" in the Humanism in Medicine seminar at Iona College New York.
Dr. Brook's interview on Feb. 2, 2014 about the power of a hug and human touch in patient care based on his personal experiences as a physician and a patient.
The power of a hug
Dr. Brook's was interviewed on iRadio on February 21, 2014, about life challenges as a laryngectomy,prevention of medical errors, patient's advocacy, and choosing the best treatment. To listen click here.
A presentation entitled "Life challenges as a laryngectomee" was delivered to the Lost Cord Club in Cleveland Ohio on September 28, 2012, and the Louisiana State UniversityFeist-Weiller Cancer Center in Shreveport, New Voice Club on April 17, 2013. The last lecture can be viewed on YouTube. Comments on the lecture are available.
Life challenges as a laryngectomee
Dr. Brook gave a talk at the 5th Annual David Nasto Memorial Oral Cancer Awareness Walk in New Jersey on September 22, 2012 . He also signed copies of his book "My Voice". All proceeding were donated to the Oral Cancer Foundation.
Dr. Brook presented a lecture at the 8th International Conference on Head and Neck Cancer in Toronto, Ontario, Canada on July 23, 2012. The talk's title was “ Putting the Personal Back in Personalized Cancer Therapy; A Physician’s Experience as a Head and Neck Cancer Patient”.
The Head and Neck Cancer Alliance (HNCA) booth in theInternational Society of Laryngectomee Annual Meetingin Durham NC June 6-8, 2012. Copies of the book " My Voice" by I. Brook MD were given out to the attendees. In the picture: from left to right: John Groves Director of HNCA, Itzhak Brook MD, member of the HNCA Board of Directors, and Doug Ulery Marketing Director of HNCA.
A study published in 2013 by Brook et al. evaluated the long-term use of HMEs
and other accessories by laryngectomized patient and especially on the use of
the Provox® Micron.
After laryngectomy, pulmonary protection is
mostly acquired by means of using a Heat and Moisture Exchanger (HME) that is
placed on an airtight seal around the stoma. The effects of HMEs on tracheal
climate have been well-described, and the filtration effect of an HME with
electrostatic filter has been described .
study investigated long-term use of HMEs in laryngectomees. A questionnaire was
sent to 195 laryngectomees of which 75 were returned. Over 85% of all
respondents used an HME, of which 77% were compliant users (i.e. >20
hrs/day). Incidence of pulmonary illnesses (either prior of post-surgery) was
about 25%. Over 90% of all respondents were heavy smokers prior to their
laryngectomy. One-third of all respondents are regularly exposed to dusty
environments. Compliant HME-users tend to use less external humidifiers and
vaporizers, showing a better pulmonary status and less health-care costs.
Regarding Quality of Life, patients using a FreeHands device tended to have the
most social contacts (r=.251;
p=.030).The prevalence of depression is high, pointing to an urgent need to recognize and treat psychiatric problems like
depression and suicidal ideation in this patient group.
Gastric reflux can reach the upper airway, inducing cellular damage in
the epithelial lining. This may be a risk factor for development of
laryngopharyngeal squamous cell carcinoma although the medical literature is inconclusive.Frequent heartburn caused by gastric reflux was found to
increase the risk for development of throat cancer, and over-the-counter
antacids medication may provide protection from it, according to a newstudy published in the journal of Cancer
Epidemiology, Biomarkers and Prevention.
Brown University studied heartburn incidence and medication use in 631 patients
with squamous cell cancers of the throat and vocal cords who were not heavy
smokers or drinkers, matching them with 1,234 healthy controls.
Theinvestigator found that individuals
who had reported a history of frequent heartburn were 78% more likely to have
cancer than those who did not. Those with frequent heartburn who took antacids
reduced their risk for cancer by 41%, compared with those whose heartburn was not
There was no reduced risk among those
taking proton pump inhibitors (i. e., Prilosec,
Nexium, Prevacid, Aciphex) or histamine
H2 receptor antagonists (i.e., Pepcid,
Tagamet, Zantac). However, this may be because
those who took such medications were likely to have had severe acid reflux, and
not because those drugs are ineffective. The authors recommended that further studies are needed to clarify the
possible chemopreventive role of antacid use for patients with gastric reflux.
Michael Douglas underwent chemotherapy and radiation treatment in 2011 for
stage four throat cancer. He described his difficult personal experiences on
the road to recovery in a recent interview. Douglas was shaken
when he was diagnosed with late-stage cancer in 2010 after it took his
physicians nine months to make the diagnosis. In an
interview with the Guardian newspaper, Michael Douglas said that the throat
cancer he was diagnosed three years ago was associated with HPV human
papillomavirus (HPV) which can be transmitted during
oral sex. Through this revelation Douglas pushed the disease onto the mind of millions of Americans who may
have become concerned about this cancer for the first time.
symptoms were a sore tooth that resembled a dental infection. He was seen by a
periodontist and an otolaryngologist who repeatedly gave him antibiotics without
any effect on the pain. After the clinicians assured him that he is better he
left to an overseas vacation and only upon his return did another physician discover
a walnut-size tumor at the base of his tongue. A biopsy of the tumor lead to the
diagnosis of a stage-four throat cancer.
immediately underwent a grueling eight-week program of chemotherapy and
radiation. He was able to avoid a feeding tube but still lost 45 pounds in the
process. During the radiation treatment, Douglas was too weak to move around,
and stayed confined to a sofa at his home. He currently feels rejuvenated with a
new lease on life and is be back at work making movies again.
Michael Douglas in 2011 while receiving chemotherapy and radiation
HPV Type 16, is also known to cause cervical cancer in women. Unfortunately
there no early oral screening test for HPV such as the Pap test. The lack of a
screening test for oral HPV means that a doctor should be seen as soon as
symptoms appear: a lump in the neck, a sore throat or ear pain that persists
for two weeks.
There are currently no studies showing that vaccines to
prevent cervical cancer from HPV Types 16 and 18, also prevent HPV
related oral cancer. However, these vaccines are recommend for boys and young men.
Most head and neck cancers are caused by tobacco and alcohol. The overall number of cancer caused by tobacco and alcohol are decreasing, while those associated with HPV are increasing. The cancer caused by HPV generally occurs near the base of the tongue; a difficult site to see and
saliva test can detect an oral HPV infection. However it is not very helpful
because 85% of individuals may be colonized with a variety of HPV types and less
than 1% of individuals with HPV 16 eventually develop throat cancer.
Currently about a quarter of head and neck cancer are caused by HPV and it is associated with 80% of tonsillar cancer. About 25,000 cases a year are diagnosed in the United States, compared with
226,000 lung cancers. However, it is growing in importance as smoking-related
oral cancers decline.Patients with positive cancer associated with HPV have a lower risk of dying compared to those with HPV-negative cancer.
growing frequency in oral sex may have contributed to the increase in cancer
caused by HPV. Men are twice as likely as women to get it, and it is more common
among whites than blacks. Straight men are more likely to get the cancer than
gay men perhaps because there may be more HPV in vaginal fluid than on the
Michael Douglas visiting Jerusalem for his son's bar-mitzva on May 20114
HPV-related head and neck cancers occur mainly in the
oropharynx ( tonsils and the back of the tongue ). However, a 2013 study from China found HPV infection, especially infection due to the high-risk typeHPV-16, was found to be significantly associated with the risk
oflaryngeal squamous cell carcinoma.
Knowing whether one’s cancer was
caused by HPV may help physicians determine the patient prognosis and
survival. Head and neck cancers caused by HPV infection tend to respond
better to current treatments as compared to head and neck cancers caused by
tobacco or alcohol use. There are also new treatment options available to
patients whose cancers are caused by HPV . These include vaccine
clinical trials and treatment protocols that use less radiation
and chemotherapy. These are easier for the patient to tolerate as they may
generate fewer side effects.
The only way that head and neck
cancers can be evaluated for the presence of HPV is to biopsy
the lesion and test it for the presence of HPV DNA. Patients who have
already completed surgery, for head and neck cancer, can find out if their
cancer is HPV related if the pathology sample is still available.
rehabilitation with voice prostheses is a standard therapy in laryngectomized
patients. Biofilm formation on the surface of the
voice prostheses causes device failure and requires frequent replacements.
Studies analyzing the biofilm
of voice prostheses have mainly focused on fungi and aerobic bacteria. Anaerobic bacteria as an integral part of the
biofilms on voice prostheses have not been
et al of the Department of Periodontology, Bernhard Gottlieb School of
Dentistry, Vienna, Austria, performed aprospective pilot study on the occurrence of anaerobic and microaerophilic pathogens in biofilm formation on voice prostheses.
samples of 15 voice prostheses were analyzed using a polymerase chain
reaction-based hybridization method, searching for the existence of 11 selected
anaerobic and microaerophilic pathogens.
80% of the voice prostheses, at least one and up to 10 of the tested bacteria were
identified. Fusobacterium nucleatum
was the most common isolate (73%). Other frequently occurring pathogens were Treponema denticola (40%), Tannerella forsythia (33%), and Eikenella corrodens (33%). There was no
correlation between the number of identified bacteria and the indwelling times
(mean, 127 days; maximum, 344 days; minimum, 22 days).
is the first study showing the presence of anaerobic and microaerophilic potential
pathogens as part of the biofilm
formation on the surface of voice prostheses. Further studies are warranted to
find out if these organisms may be responsible for accelerated biofilm formation and reduced lifetime of
the voice prostheses.