Smoking During Head & Neck Cancer Radiation Therapy Contribute to Poor Outcome

Patients with head and neck cancer who continue to smoke while receiving radiation treatments have a much lower long-term survival rate than those who do not smoke, according to a new study. The study was published in the February 2011 issue of the International Journal ofRadiation Oncology/Biology/Physics.

In the study of patients with squamous cell carcinoma of the head and neck, 23 % of 101 patients who continued to smoke were still alive five years after treatment, compared with 55 percent of patients who quit smoking before they began radiation treatment.

Furthermore, 53 of the patients who continued to smoke suffered cancer recurrence, as compared with 40 patients in those who stopped smoking. Those who kept smoking also experienced more treatment-related complications such as the hoarseness,difficulty in eating and scar formation.

The poorer long tern outcomes for persistent smokers were found both in those who had radiation alone and in those who also had surgery prior to radiation.

A presentation on Fox News on Dr Brook's story as a physician who is a throat cancer survivor

A TV presentation about Dr Brook's challenges of returning to work as a pediatrician after losing his vocal cords was shown on Washington DC channel 5 Fox News on February 11.

A successful larynx transplant

In one of the most complex transplant surgeries ever performed, an international team of surgeons at UC Davis Medical Center has restored the voice of Brenda Charett Jensen  who had been unable to speak for more than a decade. The surgical team replaced the larynx (voicebox), thyroid gland and trachea (windpipe) in a 52-year-old woman who had lost her ability to speak in 1999 after her larynx was injured by a tracheal tube during surgery and became non-functional. BecauseBrenda's own larynx had not been removed prior to the transplant, the surgeons were able to identify all of the veins, arteries, muscles and nerves that enable the larynx to survive and function, and connect them to the transplant. The 18-hour operation, which took place in October 2010, is the second documented case of its kind in the world. The patient voiced her first words in 11 years 13 days after the surgery and is currently able to speak easily and at length.
Currently, transplantation is not an option for everyone who suffers from a missing or nonfunctioning larynx because it requires a lifelong regimen of immunosuppressant medications to prevent organ rejection. These medications are not something that cancer patients should take because they can interfere with their immune system's ability to fight the cancer. As a kidney-pancreas transplant recipient four years ago and already taking anti-rejection medications, Jensen was a unique candidate for the procedure. 

Larynx front view

Medical and surgical errors

Medical and surgical mistakes are very common in the hospital setting. They increase malpractice lawsuits, the cost of medical care, patients’ hospital stays, and morbidity and mortality. Being a physician did not spare me from being exposed to many errors in my medical and surgical care. A manuscript describing my personal experiences facing medical and surgical errors in my care was published in Disabled-World.com

The best way of preventing errors is to be your own advocate:

1. Decrease chances of medical errors by being informed and not hesitating to challenge and ask for explanations 

2. Become an “expert” in your condition 

3. Have a family or friend(s) with you in the hospital to act as you advocate 

4. Get a second opinion 

5. Educate your medical caregivers about your condition and needs (prior to and after surgery) 

It is my hope that greater vigilance by the medical community will reduce these errors.

The steps in my opinion that medical personal need to implement to prevent errors are:

1. Implement better and uniform medical training

2. Adhere to well established standards of care

3. Perform regular records review to detect and correct medical errors

4. Employ only well educated and trained medical staff

5. Counsel, reprimand, educate and when necessary dismiss staff members who make errors 

6. Develop and meticulously follow algorithms, set procedures and bedside checklist for all procedures

7. Increase supervision and communication between health care providers

8. Investigate all errors and take action to prevent them

9. Educate and inform the patient and caregiver(s) about the patient condition and treatment plans

10. Have family member and/or friend be patient advocate to ensure the appropriateness of the management.

11. Respond to patients & family complaints. Admit responsibility when appropriate and discuss these with the family and staff and take action to prevent them.

Dr Brook presented a lecture on medical errors at the American Society of Clinical Oncology  in June 2012. The contents of the lecture was published in the ASCO Educational Book. A news release about the symposium was published at the ASCO Daily News.

Update about Michael Douglas' condition

Mike Douglas was diagnosed with cancer in August 2010. After months of radiation and chemotherapy for late-stage throat cancer, actor Michael Douglas announced today that he is tumor-free. To hear Mike Douglas describe his condition watch the interview on the NBC Today Show.  No trace of the stage 4, walnut-size tumor at the base of his tongue could be detected on medical imaging, according to Douglas which is a sign complete response to treatment. He discussed the radiation side effects that he suffered which including losing 32 pounds and reduction of saliva production.

However, even in the absence of detectable disease, there is at risk for recurrence and prognosis depends significantly on the biology of the tumor. The risk of recurrence is the highest in the first 2 years after diagnosis and treatment. Regular follow up examinations that includes CT and PET scans are very important in ensuring early detection of cancer recurrence.

Tongue-base cancers that are caused by human papillomavirus (HPV) infection have generally excellent cure rates with a five-year survival ranging 70-80%. It is, however, It is unclear whether Douglas' cancer was positive for HPV.

Three new publications about my experiences as physician who is also a cancer patient

The first article was published in the journal "Surgical Oncology". It describes my experiences undergoing surgery for cancer and illustrates the difficult challenges a patient faces. Unable to speak, eat, and breathe normally, while dealing with a potential fatal illness, makes the patient extremely vulnerable, both physically and emotionally. The manuscript explains why a proficient, competent, compassionate and caring approach should be practiced during this difficult and challenging time. An Editorial By Surbone & Rowe adds insight to the manuscript.
The second article was published in the journal "Clinical Otolaryngology" and describes my experiences at the otolaryngology ward after surgery. It details some of the nursing errors that were made in my care. It is my hope that this communication will improve patient care.
The third article was published in KevinMD which is a popular web site for health related issues.

Blood test to capture cancer

A new blood test that has the potential of aiding in cancer screening is being currently evaluated. The test is claimed to be able to show if cancer cells are invading the blood system even in very small quantities. It may one day change the approach to treatment of several types of cancer especially those of the breast, prostate, colon and lung. Hopefully, the test may offer a way to screen for cancer besides the mammograms, colonoscopies, biopsies and other less-than-ideal methods that are presently utilized. All these tests require referring the patient to a specialist and take time. 

The new may enable clinicians to predict what treatments would be best for each patient's tumor and find out quickly if they are working. Currently the response to chemotherapy or radiation treatments is monitored by performing CT or MRI scans. Having a rapid and convenient way to evaluate treatment efficacy may help clinicians in managing their patients. 

The test uses a microchip that resembles a lab slide covered in 78,000 tiny posts, like bristles on a hairbrush. The posts are coated with antibodies that bind to tumor cells. When blood is forced across the chip, cells ping off the posts like balls in a pinball machine. The cancer cells stick, and stains make them glow so researchers can count and capture them for study. 

Mass General, Sloan-Kettering, University of Texas M.D. Anderson Cancer Center in Houston and Dana-Farber Cancer Institute in Boston will start using the test this year. Studies of the chip have been published in the journals Nature, the New England Journal of Medicine and Science Translational Medicine. 

Complications of radiation therapy for head and neck cancer

The early and long term side effects of radiation therapy for head and neck cancer can be difficult to endure and some may be a life long challenge. To read the recent updated description of these complications and their management see the Side effects of radiation treatment of head and neck cancer page.

Radiation face mask

Sinusitis after irradiation therapy for head and neck carcinoma

Patients who undergo radiotherapy for nasopharyngeal carcinoma tend to suffer from sinusitis because irradiation causes damage to sinonasal tissue. There is very little information about the organisms causing sinusitis after radiation therapy. Two recent studies provided important information about the unique microbiology of sinusitis in these patients.

One study evaluated 25 patients with acute sinusitis and the other evaluated 30 with chronic sinusitis. Both studies found higher recovery of Staphylococcus aureus in irradiated individuals.  Because of the high prevalence of methicillin resistant S. aureus (MRSA) these individuals may need to be treated with antimicrobials effective against these organisms.

These studies underscore the need to obtain appropriate cultures from patients with chronic sinusitis who were irradiated so that proper antimicrobials can be administered to them.

X rays film showing right maxillary sinusitis: 

Hyperbaric oxygen treatment: is it working?

Irradiation treatment for cancer of the head and neck can cause permanently reduction in the blood supply to the mandibular and maxillary (jaw) bones. The mandible is more frequently affected. This places treated individuals at risk of developing bone necrosis (osteoradionecrosis ) especially after dental manipulations such as tooth extraction, surgery, and implant placement. The risk of developing bone necrosis depends on the amount of radiation delivered. When possible it is advisable that if needed tooth repair, extraction or restoration is done before radiation.
Hyperbaric oxygen therapy (HBO) has been suggested as a beneficial therapeutic maneuver in head and neck cancers patients who developing osteoradionecrosis after radiation treatment. HBO is a medical treatment during which the entire body is placed in an airtight chamber at increased atmospheric pressure and the patient breathes 100% oxygen.
Theoretically HBO has the potential of preventing and improving osteoradionecrosis because it increases oxygen supply to the affected area which enhances collagen synthesis and vascular density. The schedules for prevention and treatment of osteoradionecrosis generally include 20 to 30 preoperative HBO sessions followed by 10 postoperatively.
A recent review suggested that HBO may be beneficial for those with late radiation tissue injury to the head and neck, and promote healing of irradiated sockets after dental extraction (Bennett et al. Cochrane Database Syst Rev 2005; :CD005005). Unfortunately, the available data are conflicting, and the benefit of using HBO to prevent or treat osteoradionecrosis of the jaw in irradiated patients is uncertain. Because randomized trials have not been done, questions persist about the ultimate utility of this approach.

Are Probiotics Safe and Effective?

Probiotics are defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. In the USA, probiotics are marketed as foods or dietary supplements. For dietary supplements, premarketing demonstration of safety and efficacy and approval by the Food and Drug Administration are not required; only premarket notification is required and the manufacturer is responsible for determining its safety.

The live organisms commonly used as probiotics are: Lactobacillus spp. (eg, L. acidophilus , L. casei , L. rhamnosus , L. bulgaricus), Bifidobacterium spp. (e.g., B. bifidum , B. longum), Saccharomyces boulardii , and Streptococcus salivarius.

Common uses of probiotics include treatment of acute/infectious diarrhea, antibiotic-associated diarrhea, immunity/allergy, respiratory and urinary tract infections, and vaginosis. Each agent or preparation may have unique actions. The mechanisms of action of probiotics are production of pathogen-inhibitory substances, inhibition of pathogen attachment and toxins production, stimulation of immunoglobulin A, and nutrient effect on intestinal mucosa.

Oral preparations of probiotics (tablets/capsules/liquid) can deliver billions of live bacteria in each ingested dose. Many yogurt brand contain live probiotic bacteria. However, the quantity of these bacteria in yogurt is much smaller than in oral probiotic preparations.

Despite the widespread availability of probiotic products, few commercially available preparations are supported by placebo-controlled, double-blind studies, and the results of in vitro studies cannot be extrapolated to in vivo situations.

Although generally believed to be safe with few side effects, oral preparations of probiotics should be avoided in people with intestinal damage, a weakened immune system, or with overgrowth of intestinal bacteria. This may include individuals who are receiving chemotherapy. In these patients these bacteria can cause serious and sometimes life threatening complications. This is why individuals should consult their physician whenever live organisms are ingested. This is especially important in those with the above conditions.

Oral preparations of probiotics (Tablets/capsules/liquid/) can deliver billions of live bacteria in each dose. Many yogurt brand contain live probiotic bacteria. However, the quantity of these bacteria in the yogurt is much smaller than in oral probiotic preparations.

Biomarkers hold promise for early detection of head and neck cancer

New research holds promise for early detection of head and neck cancer using simple testing. The newly developed tests will be able to detect “biomarkers” which are biologic factors found within a tumor. (Chang & Califano, 2008)
Candidate biomarkers for head and neck squamous cell carcinoma include the p53 gene and its protein; microsatellite regions throughout the genome; human papillomavirus; proteins involved in cellular proliferation, apoptosis, angiogenesis, and intracellular adhesion; epithelial growth factor receptor; and various measures of immune response to cancer. (Edwards et al, 2010) Biomarkers many have potential clinical applications because they can facilitate detection of primary or recurrent cancer. These tests can be performed in saliva which is easy to obtain.
However, before these tests are used in actual clinical settings, they have to be carefully validated.

Study shows greater survival at medical centers with more experience

A recent study by Chen and colleagues from the Department of Surveillance and Health Policy Research, (Cancer. 2010 ;116:4744-52.) American Cancer Society showed improved survival of patients with advanced laryngeal cancer is the highest when they are treated at high-volume teaching facilities for patients with this type of cancer.
A total of 19,326 patients who were diagnosed with advanced laryngeal cancer (stage III and IV) between 1996 and 2002 and who received treatment chemoradiotherapy, total laryngectomy, or radiotherapy were analyzed from the National Cancer Database.
Patients were treated with total laryngectomy (37.6%), chemoradiotherapy (29.4%), and radiotherapy alone (33%). Overall, 36.2% of patients were treated at high-volume teaching/research centers (average, 17.1 cases per year). The author found that receiving treatment at high-volume teaching/research facilities was associated with improved survival. Undergoing total laryngectomy also was associated with improved survival.
This findings support what most people had assumed to be the case, that patients with cancer have the best chances for long term survival if they get care at centers with the greatest amount of experience. This is particularly important when the cancer is a relatively infrequent one such as laryngeal cancer.

Smoking and sinusitis

Smoking is one of the most important causes of head and neck cancer.
Another important untoward result of active and second hand smoke exposure is the increased risk of respiratory bacterial infection. These include sinusitis, ear infections, bronchitis and pneumonia. Recent studies we and others did show that smokers harbor more pathogenic bacteria that are resistant to antibiotics, can be a source of spread of these bacteria to others (including their household members), and when smokers get respiratory infections treating them may be more difficult than treating non-smokers. These changes are reversible once smokers stop smoking.

A recent study of smokers with sinusitis we have just completed shows that sinusitis in smokers is often caused by antibiotic resistant bacteria including methicillin resistant Staphylococcus aureus (MRSA).

Since many head and neck cancer survivors are engaged in educating young individuals about the risks of smoking this information may be useful to them in encouraging them to stop smoking.

Radiation exposure at the airport full-body scanners. Are they dangerous to those who had received radiation treatment for cancer ?

I wanted to clarify misconceptions regarding exposure to radiation by airport scanners in people who received radiation therapy.

These full-body scanners fall into two main categories: millimeter wave and backscatter. The first directs radio waves over a body and measures the energy reflected back to render a 3D image. The latter is a low-level X-ray machine that creates 2D images. The scanners can detect items such as nonmetallic weapons and explosives not picked up by metal detectors.

Millimeter wave scanners produce 30 to 300 gigahertz electromagnetic waves, and reveal explosives if they are denser than other materials. This means that these scanners emit less radiation than a typical cell phone, according to Transportation Security Administration (TSA).

The backscatter machines are low-level X-ray machines that expose bodies to as much radiation as about two minutes of flying in an airplane does. In other words, if you already use a cell phone and you already fly, you are already exposing your body to more radiation than these scanners will.

We are constantly exposed to radiation from the environment. While no radiation is good the radiation used by airport scanners are miniscule and do not add much to the amount received in treatment. They are not concentrated at one area of the body as radiation treatment is-but the whole body. When a patient that received local radiation is told that they can not get any more radiation it means they can not get radiation treatment to the area that was treated before. This still does not mean that they can not get X rays CT and PET scans. This is because the radiation doses there are small compared to the one used in the treatment. However, whenever any radiation exposure is planned the benefit of the test should be weighted carefully against the potential risk of radiation exposure.

TransOral Robotic Surgery (TORS). An Update from A Symposium at Johns Hopkins on 10/16/10.

Trans Oral Robotic Surgery (TORS) is a new surgical technique that offers several advantages over the traditional surgical approaches to remove head and neck cancer. It was developed for surgery at all body sites and the robotic equipment is available in many medical centers. It is often used for prostatic surgeries.

TORP was pioneered in head and neck cancer surgery by Drs G. Weinstein and B. O’Malley from the Department of Otolaryngology Head and Neck Surgery in the University of Pennsylvania in Philadelphia. Currently other medical centers are also using this method in Head and Neck Surgery including John Hopkins and Greater Baltimore Medical Center.

This is a minimally invasive surgery where the surgeon uses robotic equipment. The surgeon controls the movement of the robot’ arms and delicate surgery is done by the robot’s arms. 

TORS offers significant advantages:
It significantly shortens the length of surgery, a more accurate handling of the patient’s tissues, a more accurate and agile instrumentation, ability of the surgeon to see better, use of an endoscope, and better ability to control the surgical motions. 

Other advantages are: quicker return of the patient to normal activities, shorter hospitalization, reduced risk of swallowing problems, fever complications, less scarring, less risk of infection, less risk of blood transfusion, and less use of tracheostomy compared to traditional surgery. In some patients the use of TORS obviates the need for radiation and/or chemotherapy treatment. 

The surgeon sees the operated area by a highly magnified three dimensional optic device.

TORS shortens the time of surgery, reduces damage to the normal tissues around the cancer as well as the operated tissues, the surgeon can reach where present endoscopy can not go, and it may improve cancer treatment outcome.

Results of studies done up to now by Weinstein and O’Malley show reduction in side effects compared to regular surgery, improved swallowing, and potential for improved overall survival compared to existing treatments strategies.

TORS received FDA approval for several head and neck cancer types of surgeries and awaits other indications. Newer instruments are under development that will enable surgeries at site that are difficult to reach using the current ones. It is good to be aware of this approach that can offer important benefit for patients who require head and neck surgery.

"My Voice" Book Signing Event in the News

A recent book signing event for "My Voice" took place recently in Bethesda Maryland. All the proceedings of the book's sale were donated to 9114HNC (Help for Head and Neck cancer). The fund grants financial aid to patients with head and neck cancer and is sponsored by the National Coalition for Cancer Survivorship (NCCS).

More information about the event can be found in the Internal Medicine News site.

Human papillomavirus (HPV) is now the main cause of head and neck cancer in the USA

There is a continuous increase in oropharyngeal squamous cell carcinoma (OSCC), due to Human papiloma virus (HPV) that accounts for over half of the new cases. HPV (most commonly type 16) was found in 45% to 100% of OSCCs in various studies. Most patients are in individuals younger than 50 years, are Caucasians, males that are non alcohol consumers and non smokers. The cancer associated with HPV is mostly oral, tongue and tonsils. New data suggests that changes in sexual practices are behind the surge in OSCC cases linked to sexually transmitted HPV. The key factors appear to be multiple sex partners, starting sexual activity at a younger age, and practicing oral sex.

According to the CDC about half of all sexually active Americans will get HPV at some point in their lives. In the US, oral cancer due to HPV infection is now more common than oral cancer from tobacco use, which is still the main cause of such cancers in the rest of the world. Scientists found a 225-percent increase in oral cancer cases in the US from 1974 to 2007, mostly among white men.  The single greatest factor associated with the cancer  is the number of partners on whom the person has performed oral sex. Individuals who had performed oral sex on six or more partners over a lifetime face an eight-fold higher risk of acquiring HPV-related head or neck cancer than those with less than six partners.

While HPV cancer growth more rapidly it is easier to treat than non-HPV cancer and patient with HPV positive cancer have a lower risk of dying compared to those with HPV-negative cancer. These patients may need less radiation and chemotherapy to get better which means that they will have less side effects. However, studies that explore these issues are ongoing and there is not yet a consensus whether less treatment is best for these patients. A review of recent epidemiological studies can be found on this site.

There is promising research that may enable one day to treat those with HPV associated cancer by vaccinating them. Preliminary studies in animals show vaccination in conjunction with chemotherapy to be effective against the cancer.

It is yet unknown if the introduction of HPV vaccination during adolescence in boys and girls that was mainly done to reduce cervical cancer in women will decrease the rate of this cancer. It is possible now to find out if the cancer is caused by HPV or not which was not the case until recently.

All these new developments hold promise for better treatments in the future.
The CDC has informative site on HPV.

Michael Douglas recent diagnosis of throat cancer

The diagnosis of throat cancer in Michael (mike) Douglas is very sad news. The potential of losing his voice will be devastating to him as an actor. I wish him success in combating his illness. He is one of my favorite actors and I would like to see him continue his career.

From my own personal experiences I can imagine how devastating it was for Mike to learn about the diagnosis of throat cancer. This has ramifications on his ability to continue to act and his family. Face ones own mortality and the potential of losing ones voice are very difficult. Many people would like to keep their illness private as I did. However, as a celebrity this impossible. Hopefully the public’s support that he may receive will help him overcome the difficult period of radiation and chemotherapy that lies ahead.

As a celebrity whose career depends on his voice, Mike Douglas is facing difficult choices about what is the best treatment for him. I am wondering if the non surgical option that was offered to him was an attempt to spare his larynx. I hope that this treatment will work for him. To hear Mike Douglas describe his condition watch his interview with David Letterman on the Tonight Show.

As sad as this news is, it is an opportunity to remind everyone about the importance of avoiding smoking and excessive alcohol consumption. Unfortunately Michael Douglas had done booth.

It is also an opportunity to remind the public about the early signs of throat cancer so that it can be detected at an early stage. These include: sputum may appear bloody, lump may appear on the outside of the neck, abnormal-sounding breathing, chronic cough, neck pain or swelling, difficulty swallowing, persistent throat or ear pain and hoarseness. Individuals with these symptoms should be examined by their otolaryngologists as soon as possible.

After months of radiation and chemotherapy for late-stage throat cancer, actor Michael Douglas announced on January 11, 2011 on an NBC Today Show that he is tumor-free. No trace of the stage 4, walnut-size tumor at the base of his tongue could be detected on medical imaging, according to Douglas which is a sign complete response to treatment. He discussed the radiation side effects that he suffered that included weight loss and reduction of saliva production.

However, even in the absence of detectable disease, there is at risk for recurrence and prognosis depends significantly on the biology of the tumor. The risk of recurrence is the highest in the first 2 years after diagnosis and treatment. Regular follow up examinations that includes CT and PET scans are very important in ensuring early detection of cancer recurrence.

Tongue-base cancers that are caused by human papillomavirus (HPV) infection have generally excellent cure rates with a five-year survival ranging 70-80%. It is, however, It is unclear whether Douglas' cancer was positive for HPV.

Article in JAMA (Brook I. Rediscovering my voice. JAMA.2009; 302; 236.)

The article I wrote that describes regaining my speech was published in JAMA in the section: A Piece of My Mind.

To request a reprint contact the author.

Article in Archives of Otolaryngolgy Head and Neck Surgery ( Brook I. Neck Cancer- A Physicians’ Personal Experience. Arch Otolaryngol Head Neck Surg. 2009;135:118. )

The article I wrote about my personal experiences as a cancer patient was published in the Reflection section.

To request a reprint contact the author.