Oral, Head and Neck Cancer Awareness Week and the early detection of head and neck cancer

The 15th annual Oral, Head and Neck Cancer Awareness Week occur April 22-28, 2012.  This weeklong series of events is aimed to educate the public about these potentially life-threatening but eminently treatable cancers and to promote prevention, screening and early detection. It is highlighted by the free screenings and related activities held at participating medical centers across the country. The screenings are quick, painless, and designed to advance early diagnosis, which can lead to better outcomes. The locations of the free screening sites are available at the Head and Neck Cancer Alliance internet site which also sponsors the event.

According to the American Cancer Society, an estimated 40,250 new cases of cancer of the oral cavity and throat, and an estimated 7,850 deaths from these cancers, are expected in 2012. 

Most oral cancers arise on the lips, tongue or the floor of the mouth. They also may occur inside your cheeks, on your gums or on the roof of your mouth.

Some signs and symptoms include:

·        A sore in your mouth that doesn't heal or that increases in size

·        Persistent pain in your mouth

·        Lumps or white, red or dark patches inside your mouth

·        Thickening of your cheek

·        Difficulty chewing or swallowing or moving your tongue

·        Difficulty moving your jaw, or swelling or pain in your jaw

·        Soreness in your throat or feeling that something is caught in your throat

·        Pain around your teeth, or loosening of your teeth

·        Numbness of your tongue or elsewhere in your mouth

·        Changes in your voice

·        Bad breath

·        A lump in your neck

Tobacco (including smokeless tobacco) and alcohol use are the most important risk factors for oral, head and neck cancers, particularly those of the tongue, mouth, throat and voice box.  People who use both tobacco and alcohol are at greater risk for developing these cancers than people who use either tobacco or alcohol alone.

Anyone can develop thyroid cancers, although a family history or exposure to radiation is often a factor. Salivary gland cancers do not seem to be associated with any particular cause.

The increase of oral cancer incidence in young adults, a group traditionally at low risk, is attributed to the rise of the human-papillomavirus (HPV), a cancer-causing virus that can be transmitted through oral sex.  Currently 70% of oropharyngeal cancers are caused by HPV infection. According to researchers, patients with HPV-positive oral cancers are more responsive to treatment and have better survival rates than HPV-negative patients. 

The effect of surgeon and hospital volume on short-term outcomes and cost of care of laryngeal cancer

The increase of use of chemotherapy and radiation in the treatment of laryngeal cancer has increased in the past two decades. The decline in surgery may affect the experience of performing surgeries in many centers and consequently the outcome and costs of the procedures. A study by Gourin and Frick sought to characterize the contemporary patterns of laryngeal cancer surgical care and the effect of volume status on surgical care and short-term outcomes.


Using the Nationwide Inpatient Sample database, the investigators evaluated the temporal trends in laryngeal cancer surgical care in 78,478 cases performed between 1993 to 2008. Relationships between volume and mortality, complications, length of stay, and costs were evaluated in 24,856 cases performed in 2003 to 2008 using regression analysis, with adjustment for patient and provider characteristics.

Laryngeal cancer surgery in 2001 to 2008 was done more often in high-volume hospitals. The author noted also s significant decrease in partial and total laryngectomy procedures, an increase in flap reconstruction, prior radiation, comorbidity, and wound complications, compared to 1993 to 2000. High-volume hospitals and high volume surgeons were significantly associated with more partial laryngectomy and flap reconstruction. The length of hospitalization and cost of hospitalization were both lower at a high-volume hospital.

These data reflect changing trends in the primary management of laryngeal cancer, with meaningful differences in the type of surgical care provided by high-volume providers. It also illustrates a shorter hospitalization time in hospitals that perform more laryngeal surgeries.

 

 

Can erectile dysfunction drugs ( Cialis, Viagra ) cure head and neck cancer?

Preliminary studies at John Hopkins suggest that an erectile dysfunction drugs (e.g. Cialis, Viagra) can stimulate the immune systems of patient’s with head and necks cancers so they can better battle cancer cells. This is interesting information because it is a new approach of treatment with agents so far not used to treat cancer.

Studies performed so far were test tube ones done in blood samples collected from patients. Although the results are promising, clinical studies are needed to evaluate if the administration of erectile dysfunction drugs can be helpful in treating head and neck cancers.

A new study demonstrate that Cialis (tadalafil) augments general and tumor-specific immunity in patients with head and necks cancers and has therapeutic potential in head and necks cancers. Evasion of immune surveillance and suppression of systemic and tumor-specific immunity is a significant feature of head and neck cancer development. This study demonstrates that a PDE5 inhibitor, tadalafil, can reverse tumor-specific immune suppression in patients with head and neck cancer, with potential for therapeutic application.

These results are very preliminary and more research is needed.  However, they offer hope for new type of treatment in the future.

Are individuals with human papillomavirus associated head and neck cancer still carrying the virus in their throat after treatment?

Oral human papillomavirus (HPV) infection a virus spread during oral sex is now the main cause of head and neck squamous cell carcinoma (HNSCC) in people under 50. Oral HPV infection is a concern for patients with HPV-positive HNSCC and their partners. Recent studies showed that the virus can stay in the throat of patients with NNSCC associated with the virus even after the cancer is treated by radiation and surgery.  (Agrawal et al, Clinical Cancer Research 2008). However, most individuals with the oral HPV virus infection do not develop cancer. After treatment, cases with HPV16-positive tumors had an estimated 14-fold increase of oral HPV16 infection when compared to cases with HPV16-negative tumors. The odds of a diagnosis of an HPV16-positive versus negative HNSCC increased with lifetime number of oral sexual partners.

This finding illustrates that many patients with this type of cancer are still carrying the virus in their body and can potentially spread it to others. However, since this virus is very prevalent in individuals ( can be found in almost half of adults ) the significance of this information is unclear.

The effect of the introduction of HPV vaccination (introduced to prevent cervical cancer) to girls and boys on the potential of development of HNSCC is unknown at present and requires further studies.

Oral HPV infection

The high incidence of suicide in head and neck cancer patients is highlighted in recent studies

The suicide rate in cancer patients is twice of that found in the general population according to recent US studies. These studies clearly point to the urgent need to recognize and treat psychiatric problems like depression and suicidal ideation in patients.

Suicide rates varied by type of cancer: The third highest rates are among patients with head and neck cancer, including the oral cavity, pharynx, and larynx. A high prevalence of depression or distress was found among patients with these types of cancers. This is explained by the devastating effects of the illness on patients’ quality of life, the effect on one's appearance and essential functions such as speaking, swallowing, and breathing.

Most studies have found high incidence of depressive mood disorders associated with suicide among cancer patients. In addition to major and minor depressive disorders, there is also a high rate of less severe depression in elderly cancer patients that is sometimes under recognized and treated. Even though studies have shown that in about half of all suicides among people with cancer, major depression was present, there are other important contributory factors. These include anxiety, lack of social support systems, and demoralization.

The results of these and other studies underscore the significant psychosocial impact of cancer. It is hopeful that health care providers will continue to be vigilant for signs of depression and suicidal thoughts and remain open to discussion of these topics. This will allow patients’ mental health needs to be addressed more readily, with referral to mental health specialists when appropriate.

To read more about these issues see the psychological issues page on this Blog.

A gift of a voice

The story “A gift of a voice” about my efforts to speak again was posted in the Georgetown University Homepage as a feature story. 

I hope that you will find it inspirational.
To read it click here.

  Dr Brook lectures at East Virginia School of Medicine on "Life as a laryngectomee" Nov 2009

Dr. Brook lectures to the University of Southern California Head and Neck Cancer Support Group August 2011 
 

Dr Brook lectures at Bnai Zion Medical Center at Haifa Israel on Jan 2, 2012

A patient with cancer receives an artificial tracheal transplant seeded with his own stem cells

The windpipe (trachea) transplanted into a terminal cancer patient in the Sweden is a major medical breakthrough. It promises the potential of perhaps other airway transplants in the future (such as larynx or voice box). The surgery is the first time that a trachea grown from a patient’s stem cells that were seeded onto a synthetic (plastic polymer), rather than a donor, structure has been transplanted in a human. This procedure was performed in a 36-year-old man who had tracheal cancer. 


The Karolinska University Hospital in Stockholm said the surgery was performed June 9, and that the patient is on his way to a complete recovery. The patient, whose late stage cancer had almost fully blocked his windpipe, had no other options since no suitable donor for a windpipe was available.

To perform the surgery, an international team lead by Professor Paolo Macchiarini seeded a synthetic scaffold shaped as a trachea the patient's own stem cells. The new cells lined and covered the windpipe were grown on the scaffold for two days before it was transplanted into the patient. Because the cells used to regenerate the trachea were the patient's own, there was no rejection of the transplant and the patient does not have to take immunosuppressive anti-rejection drugs.

There were previous surgeries where donor’s windpipe and the patients' own stem cells were transplanted. However, the latest surgery is the first to use a man-made artificial organ. Several years ago, the same surgical team used a patient's bone marrow stem cells to coat a patient's new trachea, which was damaged from tuberculosis. A few years ago Belgian surgeons had implanted a donor windpipe into their patient's arm to restore its blood supply and grow new tissue before implanting it into her throat. In both transplants, because the patients' own cells were used to coat the windpipes, no anti-rejection medicines were required.

   

Artificial trachea

The medical and psychological effects of alcohol consumption after laryngectomy

Alcohol consumption after laryngectomy can cause medical and psychological problems. Danker and colleagues of the University of Leipzig, studied the drinking behavior in 225 laryngectomized patients and its effects on their quality of life and mental health.

Alcohol dependency was found in 7% of the patients. Half of the respondents showed a constant consumption of alcohol and only 6% of the patients wanted to change their consumption. Patients with alcohol dependence had increased anxiety, more problems in coping with illness, and increased psychosocial care needs, fatigue, shortness of breath, diarrhea and a worse emotional functioning level .

Alcohol intake was independent of tumor stage , employment status, social class, the time interval since laryngectomy, and type of voice substitute.

The authors concluded that alcohol dependency is associated with adverse psychosocial and medical consequences, which require treatment. Because socio-demographic and medical parameters do not assist in evaluating patients' alcoholism risk, an individual exploration of the patients' drinking behavior is needed which could prepare the ground to specific treatment.

The study was published in the June 2011  Clinical Otolaryngology.

Smoking and drinking did not effect survival from head and neck cancer but reduced overall survival

Head and neck squamous cell carcinomas are known to be associated with tobacco use and alcohol consumption. Farshadpour and colleagues from the Department of Otolaryngology, University Medical Center Utrecht, the Netherlands, evaluated the effects of these substances on patient’s survival. The prognostic relevance of these substances was evaluated in 1829 patients with and 183 without substance use.

The investigator found that head and neck squamous cell carcinoma-specific survival (death due to primary-or recurrent cancer) were not significantly different for patients who smoked and drank alcohol and those who did not. However, overall survival was significantly affected and was shorter in those who smoked and consumed alcohol.

The authors concluded that although tobacco and alcohol use are the main risk factors for development of head and neck squamous cell carcinomas, cancer outcome was comparable in patients who did or did not use these substances. They also emphasize the importance of substance use cessation because tobacco and alcohol use affected overall survival.

The study was published in the June 2011 issue of Head and Neck.

Adequate protein intake can reduce the severity of oral mucositis in patients with head and neck cancer receiving radiation therapy.

A study by Zhan and colleagues from the University of New Mexico Cancer Center, Albuquerque evaluated the relationship of caloric and protein intake to the severity of oral mucositis in 40 patients with head and neck cancer receiving radiation therapy over 2 years.   

 The researchers found that patients who met protein-related goals during radiotherapy had less severe oral mucositis. This was the only nutritional factor that effected the severity of mucostis. They recommended that patients with head and neck cancer receiving radiation get nutritional counseling during radiotherapy, with emphasis on protein.

The study was published in Head Neck in Jun 2011.

Touched by another human touch-the power of a hug

A short essay that I wrote entitled : "Touched by another human touch" was published in the My Turn section of the Los Angeles Times.  The assay describes my personal experience as a patient where I discovered the power of a hug in comforting an ailing patient.


To read it click here.

A new publication: A Physician’s Experience as a Cancer of the Neck Patient: The Importance of Patient Participation

Journal of Participatory Medicine has posted a new paper I wrote, 'A Physician’s Experience as a Cancer of the Neck Patient: The Importance of Patient Participation '

My hope is that relating my experiences as a physician who experienced medical care from the other side of the stethoscope will help other patients, their family members, and caregivers recognize the importance of active involvement in their own care. Active involvement can help prevent medical errors and facilitate recovery.

Dr Brook lectures to Veterans at the Veteran Administration Medical Center in Philadelphia

I gave a lecture at the Veteran Administration Hospital Laryngectomee Club in Philadelphia on April 15, 2011 about life challenges as a laryngectomee.

Catherine Zeta-Jones plight: the impact of cancer on a care giver

The recent revelation that Catherine Zeta-Jones  the wife of the actor Michael Douglas sought treatment for bipolar disorder underscores the potential impact of cancer on other family members. Michael Douglas was recently diagnosed and underwent radiation and chemotherapy treatment for base of the tongue cancer.

Being a caregiver for a loved one with a serious illness such as head and neck cancer is very difficult. It can be extremely hard to watch their loved one suffer especially if there is little that they can do to reverse the illness. It can be physically and emotionally very taxing.

Caregivers often fear the potential death of their loved one and life without them. This can be very anxiety provoking and depressing. Some cope by refusing to accept the diagnosis of cancer and believe that their loved ones illness is less serious in nature.

                                                   

Caregivers often sacrifice their own well being and needs to accommodate those of the person they care for. They often have to calm down their loved one’s fears and support them despite being often the target of their vented anger, frustrations and anxieties. These frustrations may be exaggerated in those with head and neck cancer who have often difficulties in expressing themselves verbally. Caregivers frequently suppress their own feelings and hide their own emotions so as not to upset the sick person. All of this is very taxing and difficult.

Unfortunately the well being of caregivers is frequently ignored as all the attention is focused on the sick individual. It is essential, however, that the needs of the caregivers are not ignore. Getting physical and emotional support through friends, family, support groups, and mental health professionals can be very helpful for the caregiver. Professional counseling can be an individual or joint one with other family members and or the patient.  They should find time for themselves to “recharge” their own batteries. Having time dedicated to their own needs can help them continue to be a source of support and strength for their loved ones. 

Treatment of recurrent laryngeal cancer following initial nonsurgical therapy

A recent study (Agra et al. 2011) found surgery to be the preferred modality for curative treatment of recurrent laryngeal cancer after failure of nonsurgical treatments. Patients with initial early-stage cancer experiencing recurrence following radiotherapy often have more advanced-stage tumors by the time the recurrence is recognized. About one third of such recurrent cancers are suitable for conservation surgery. Endoscopic resection with the laser or open partial laryngectomy. Transoral laser surgery is currently used more frequently than open partial laryngectomy for treatment of early-stage recurrence, with outcomes equivalent to open surgery but with less associated morbidity. Laser surgery has also been employed for selective cases of advanced recurrent disease, but patient selection and expertise are required for application of this modality to rT3 tumors. In general, conservation laryngeal surgery is a safe and effective treatment for localized recurrences after radiotherapy for early-stage glottic cancer. Recurrent advanced-stage cancers should generally be treated by total laryngectomy.

A new silent speech device under development

A new speech device that may enable laryngectomees and other voiceless individuals to speak is being developed. It is called “EMG-based Silent Speech Recognition”, and relies on a computer to construct words by reading the muscles in the face of the person who articulates. About 25 wires connect electrodes that are placed on the face to a computer. The person can silently articulate the words without speak them — and the computer interprets the muscle movements and turns them into sound. It is as if the computer is able to read the speaker’s lips.

At present the system is able to recognize approximately 2,000 words and is 90 percent accurate. It is hopeful that further improvements will eliminate the need for wires and the  electrodes and the software will be completely integrated into a smart phone that could be held on the side of the face and produce clear speech.

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: