Chapters Transcript Video Transforming Cancer Care: The Role of Technology in Head and Neck Oncology It's a privilege to be here today to discuss a critical area of oncology, head and neck cancers, including oral cancer. These malignancies, while diverse in their presentation and complexity, share common challenges in diagnosis, treatment and long-term management. Over the years, a better understanding of disease biology has broadened our treatment landscape beyond conventional surgical and radiation strategies to now include more patient specific treatments. The integration of AI, robotic surgery, and biomarker driven therapies is not just enhancing survival rates but also preserving function and quality of life. Yet despite these strides, our work is far from done. Welcome to Baptist Health. Doc, a podcast built for innovation and collaboration by physicians for physicians. Thank you for joining us. I'm Doctor Jeffrey Young, Chief of head and neck surgery at Baptist Health Miami Cancer Institute, and joining us for discussion today is Doctor Alessandro Villa, Chief of oral medicine, oral oncology, and dentistry with Baptist Health Miami Cancer Institute and Baptist Hospital. Alessandro, thank you so much for joining in this topic that is near and dear to both of our hearts. Thank you, very excited, um, to be here and looking forward to our discussion today. But why don't we just dive in and I know you get asked this a lot, but how do we define head and neck cancers? Yeah, you're right. That, that is a common question. Um, I always tell everyone it's pretty much anything above the collarbone, but outside of the brain. So, you know, inside the brain and spine, that's really left for the neurosurgeons, but we pretty much treat everything else. So these would be cancers. Of the throat, cancers of the thyroid gland, cancers of the salivary glands, uh, some skin cancers of the head and neck, etc. um, you know, but today we're gonna be concentrating a little bit more on oral cancers and what we call mucosal cancers, and those come from the lining of the upper arrow digestive tract, so the throat, the mouth, the tongue, etc. So one of the things that I get asked a lot also is what are the risk factors for head and neck cancers as, as you know, as a dentist, lots of my colleagues um do cancer screening, so I think it's important also for prevention and risk reduction. So maybe we can talk more about that. Sure, so um I think that. Traditional risk factors have been tobacco related, so smoking, oral tobacco use, etc. have have been traditional risk factors for head and neck cancers, as well as excessive alcohol consumption. Um, we do know that those are tied into development of um not only pre-cancerous but cancerous lesions. In the upper a digestive tract and also um in the most recent decades, we've known uh HPV to be fundamentally involved in the uh process of driving tumors um in the upper aero digestive tract. Now these are mainly in the oropharynx which you know is really the tonsilar base of tongue area. um, but we have seen HPV biology in a variety of different uh head and neck cancers and, um, you know, that really. Lends itself to to different presentations because there are certain signs and symptoms that people should look out for, right? And so pain in the mouth, a painful lesion, lesions that won't heal, um, and we can talk a little bit more about this because, you know, I'm sure you see a lot of these and and when people should be concerned. But the other thing is, um, a lot of the HPV related tumors present painlessly. So they'll present when there's a lump in the neck and the patient will not have ever felt their tonsil tumor, but when it metastasized to a neck lymph node and they find a lump in the neck, that's when there's some concern. And we always say any neck mass in an adult that wasn't there before really should be worked up and is cancer until proven otherwise. Um, difficulty swallowing, changes in voice, um, changes in hearing, pain behind the ears, pain in the back of the throat, all of those things, um, you know, can be warning signs. But in your area of expertise, I'm sure you see a lot of oral lesions, and, and what really makes you concerned when you see an oral lesion. Um, that will have you worried that it might be cancer? Yeah, that, that's a great question. There's some red flags that everybody should be aware of, um, an ulcer that doesn't heal, a sore that is persistent, um, a mass that develops over time. And a variety of these oral cancers, uh, actually develop from what we call oral potentially malignant disorders. And in particular, in the US there are, there is one that is the most common and it's present in about 4% of the population depending on the study that we consider, which is leukoplachia. And uh leukoplachia is defined as a white plaque that doesn't go away. So it's, it's persistent. Um, in the mouth, a lot of lesions can be white, but typically, leukoplachia has certain clinical characteristics that include demarcation of the margins, um, the tongue is the most commonly affected site, and a large proportion of oral squamous cell carcinomas, which is the most common oral cancer, uh, arise from pre-cancerous lesions like leukoplachia. So if a patient presents with a white spot or an ulcer that doesn't heal in 23 weeks, a biopsy becomes necessary. And, uh, unfortunately, we have been seeing an increase in oral pre-cancers as well, which also translates in an increase in tongue cancers, for example, in the US, in North America in general. Uh, and the diagnosis, uh, is with an incisional biopsy. Um, when we look at under the microscope, uh, leukoplachia can be a hyperkeratosis not reactive, and recent data show that even an hyperkeratosis is not reactive as the potential, uh, to transform into cancer, usually around 4, 5% of these patients can develop cancer in a 10-year period. Um, mild, moderate, and severe dysplasia are more common. And the higher is the grade of dysplasia, the higher are the chances for patients to transform into squamous cell carcinoma. So, for example, a leukoplagia that under the microscope shows as severe dysplasia, these patients have a risk of about 50 to 60% of transforming into cancer in a 5, 10 year period, depending on the study that, that we consider. Uh, so there is definitely an opportunity to do prevention, to detect early, uh, these changes in the mouth. I think that, um, physician, dentists have the opportunity to do a routine. Oral examination. Uh, there was a recent Lancet editorial that came out many years ago now, and it was titled 5 Minutes to Save a Life. It takes just a few minutes to do an intraoral and extraoral examination to detect some of these pre-cancers or even some of the lesions that are already cancerous. And I would imagine that many of these lesions are found by the dentist during. You know, even routine cleanings or most dentists, I think when they see a patient on regular basis will perform a screening exam, you know, once a year, and I imagine a lot of what you see is, is, is found by dentists. Absolutely. Our, um, major referrals, um, comes from dentist and dental hygienist as well. And it's interesting because when you look at the numbers, uh, patients tend to see more often their dentist and dental hygienist than a primary care physician. And, and therefore, you know, patients have their unique relationship with their dentist that they may have seen for many, many years. And the mouth being so accessible, um, it's really part of the examination of the dental exam, the oral exam. And so when, when a dentist detect a lesion, typically they refer the patient to uh have the neck surgeons like you or specialized oral medicine physicians like, like us, and, and then the workup starts for these patients. So, so let's take, you know, 33 different cases. So the lesion comes to you, you know, area of leukoplachia, you know, uh, it's been there for, you know, greater than 23 weeks, 30 days. You biopsy it, it comes back atypia. Mild dysplasia. What are, what are the next steps in your mind for that? Yeah, so there's a couple of um factors and other things that we should consider. One is how large is the size of the lesion? Are we talking a 1 cm leukoplachia or are we talking a leukoplagia that involves half the tongue of a patient? And, and there's two different types of leukoplaas. Um, one, it's what we call localized, leukopplegia, which is a small white patch in the mouth. The other one, which is the most challenging to treat is called proliferative leukopplechia, that involves many sides in the mouth. So imagine that patient that you were mentioning walks in, as a little leukopplechia, we take a bite. Biopsy, mild dysplasia. Typically, surgical excision is, um, the treatment of choice. And, and it's pretty successful. Uh, the recurrence rates vary from 0% success, up to 30, 35%. Um, the problem is when we have a proliferative leukoplachia, that really poses a challenge for patients, for clinicians, because these are pre-cancer. They're not cancer yet. And they may affect multiple areas in the mouth or a very large lesion, as I mentioned, like half the tongue. So, in, in that case, there's different approaches. One is what we call active surveillance. So patients are seen every 4 to 6 months and they may undergo a 1 year biopsy to make sure that the lesion has not progressed. Um, there's laser ablation, uh, which is something that, uh, you and I do, and, and we collaborate. It's a team effort many times for these patients, uh, which is a good option, um, to laser la, CO2 laser some of these lesions, although they can also recur because there is a genetic predisposition. And then more recently, there are some new, uh, treatment options available with topical chemotherapeutic agents. Um, Emiquimo is, is one of them. Uh, there's a couple of studies now that they show some promising results in the treatment of some of these lesions. So it's definitely an area that it's evolving. There's a lot of research going on and, and we are hoping to find an effective treatment option for our patients. And I, and I think that's, that's very. Important because you know, as we mentioned, you know, these, these lesions tend to recur, they tend to be multi, some, some patients, you know, will come in with one, you treat it, it shows up on the other side, and then there are those that progress to cancer. So let's talk about really now the uh the cancer aspect of so you get a diagnosis of cancer, um, I think that people um often will. Sort of come to a pause at that diagnosis with what do I do next? And who do I go see? Because there are so many different treatment options in the head and neck landscape, and I think that's one of the reasons why a multidisciplinary team is very important in treating this disease. And you know, I think it's amazing that we have such uh access to um a multidisciplinary team, because as you know, you know, you you're talking about critical areas of anatomy, right? So patient's tongue, that's where they speak, you know, their communication, uh eating, taste, all of these things that your upper airway is responsible for breathing. It's how you interact with the world, right? So we want to preserve as much of that as we possibly can when treating these diseases. So, yes, there are surgical approaches, but there are also radiation approaches. Some patients may benefit from a combinational approach where we have surgery and radiation and so I can't, I, I can't really stress enough the importance of having that multidisciplinary evaluation, not just for the medical providers. But also for the speech language pathologists who need to help these patients learn how to maybe swallow differently while they're being treated or after their treatment, nutritionists to make sure that the patients are maintaining their caloric intake to have the calories that they need to fight this disease as, as they're moving through treatment. So, um, nurse navigators, you know, when you're a patient that's faced with all of these appointments, you're having daily radiation or weekly chemo infusion. And you need to, you know, have all of these things timed perfectly to be successful. Nurse navigators are very, very important in that process. I think we're actually very blessed to be at an institute, uh, like Miami Cancer Institute where we have all of that under one roof and um can offer that to our patients. And one of the roles that I know you've been really involved in in this is that there are dental. Effects of treatment of these diseases, because we are treating these areas where, um, you know, where where we speak, chew, eat, etc. So what can you say about, you know, the importance of a good dental evaluation. Prior to starting any kind of, you know, treatment in the head and neck landscape. Yeah, so you know, our goal is to really minimize side effects that can affect the teeth or the mouth in general and the American Cancer Society guidelines on. Um, prevention of dental disease and oral diseases, uh, require patients are waiting to start radiation therapy to see their dentist, and the goal is to minimize any sources of dental infection. So if a patient has poor dentition. Uh, the dentist should make sure that restorative work is completed. Uh, teeth with poor prognosis are extracted before starting chemo or radiation because radiation specifically can cause problems to the jaw bones. It's a complication that we call osteoradialcrosis, which can develop spontaneously, but most cases are really triggered by a surgical procedure like a Tooth extraction in a patient following radiation therapy. So actually, at Miami Cancer Institute, we have developed, um, a program for our patients to see their, uh, local dentist. We provide educational guidelines for the community dentists to prepare these patients in an effective way, in a timely manner so that they can start their cancer therapy, uh, as early as possible. And we also provide consultation during treatment for, for our patients. And unfortunately, many of the new treatment options, including radiation, targeted agents, come with side effects that affect the mouth of our patients. So you mentioned difficulty swallowing, difficulty speaking, dry mouth is a very Common side effects from radiation therapy and can be very morbid for the patient because if somebody doesn't have saliva, taste is affected, the speaking is affected, patients complain of difficulty swallowing. So it has a big impact on the quality of life of patients that underwent head and neck cancer treatment. And you can They have a study on that, right? They're looking, you know, trying to reverse some of the effects of, uh, dry mouth or stone. We have an open clinical trial, which is a multi-site, and we are looking to, with gene therapy to restore the function of the salivary glands that are compromised, uh, following radiation therapy. So I'm curious to see how the results will be in the future. Um, and we're actually open also a new study on the management of some of those challenging pre-cancers that we were talking about. But, but to your point, again, the role of the dentist in multidisciplinary care really is important for the best care possible of our patients with neck cancer. You know, it's interesting because, you know, one of the, I, I see a lot of head and neck cancer patients longitudinally years after their treatment and that dry mouth really, you know, is, is often their main complaint. And it's very interesting because the treatment landscape and head neck we've already described is a very complex, you know, multiple physicians are usually involved in these decision making processes, um, you know, initially everything was treated with surgery and these surgeries were extremely morbid. You had to, you know, divide somebody's jaw, move it out of the way to get to the base of the tongue. You know, you remove the base of the tongue. People couldn't speak very well. They had to have tracheostomies hospital for weeks. And so, you know, when radiation started to, to grow and become an alternative treatment, a lot of people just swung away from that surgery and went straight to radiation. So you had this many decades where radiation alone was what treated everything. Very few surgeries were ever done, um, and then. You started getting more advanced modern surgical techniques that allow surgery to be done without the tracheostomies, without the 2 weeks stays in the hospital. And one of the biggest ones that, you know, I'm very intimately familiar with this transoral robotic surgery. So, you know, we have these surgical platforms, these robotic surgical platforms, which basically provide better visualization. They get small tools into a hard to reach area and make you able to see it better. That's perfect for the back of the throat, right? So this was an easily adaptable, um, you know, surgery. Again, these instruments were not designed for head and neck, they are now, but the initial instruments were designed for abdominal surgery, etc. but the head and neck surgeon saw the utility of this, this advanced visualization, being able to see around corners, and you can use it to remove tonsil tumors, base of tongue tumors, etc. with minimal morbidity in the right patients. And um, so that has taken off and you know we offer that uh in our practice and we have the newest robot that's actually the the the um single port robot is actually the only robot that's FDA approved for trans robotic surgeon. We we're lucky to have that, uh, in our practice at Miami Cancer Institute. But interestingly, these patients tend to be those HPV positive patients we've been talking about because the disease behaves differently. It tends to respond very well to treatment. It tends to be um more surgically accessible in, in most cases, but there are some that are beyond what's where surgery can reach and get treated with radiation and do very, very well. And so I think, you know, that is one of these advances that we've been lucky to have. You've shared another one, laser surgery. So, um, laser surgery has been useful in the upper airway for a while, but I think, you know, you mentioned. These patients with this proliferative leukoplachia, right? We're not necessarily dealing with cancer, but we're dealing with a potential for cancer and we wanna control it without creating a significant morbidity. So having the availability of the CO2 laser to ablate that tissue, um, you know, like you said, up to 33% recurrence rate, but you and I have both seen patients that have come out of laser surgeries and had, you know, no recurrence. So I think that these technologies really allow, um, Individualized approaches to treatment. Um, and, uh, you know, I don't know if you have any more comments on the laser aspect for leukoplachia, but, um, and it's a relatively, you know, newer concept. It's been around for a while, but it's been tested and tried and true in the literature. Yeah, and I, and I think that um the healing also following a laser ablation is, um, is faster in some cases for this patient. And for proliferative leukoplacias that are so challenging to treat because of the multifocality of the actual pre-cancer. I think the laser is a, is a great approach, um, especially if the patient has a pre-cancer of the tongue, a pre-cancer of the Bcal mucosa that are easily accessible, far from the teeth. Um, and, and we're doing a lot of these cases together, it's a multidisciplinary care again. And the goal is really to prevent the malignant transformation of, of these pre-cancers, yeah. And we're gonna step a little bit outside of our comfort zones for this next segment. I'm a surgeon, you're a uh oral medicine specialist, but one of the most, I think, um, you know, greatest advances that we've seen in the past decade is the ability to more target treatments. Now, we talked a little bit about targeting the surgical patient because of these surgical techniques we have. Now, radiation, I don't deliver radiation, you don't deliver radiation. We deal with the side effects of radiation, but radiation can be profoundly helpful to our patients and I think one of the radiation. Um, uh, advancements that we've seen recently is really proton radiation. Proton, um, you know, from my experience with our radiation oncologists, provides a, a very targeted radiation where they can avoid some of the what I call, uh, you know, um, collateral damage, right? So we all know radiation has collateral damage because when you radiate an area, it has to go through those tissues and it affects everything in the area. So that's gets what gets you the dry mouth, right? Because those salivary glands get hit. So protons allows um a little less collateral damage. It's great when you only wanna treat one side because it tends not to flow over to the other side, like other forms of radiation. And again, that's something that they will often take into consideration with our patients that we have this availability for protons. And if it's helpful, or if it's gonna make a difference, or it's gonna potentially reduce side effects, then they will offer it. Um, the other Side of things is the medical oncology side and I think that immunotherapy has really been one of the most talked about things in all forms of cancer, and I do a lot of melanoma and skin cancers and immunotherapy is pervasive in melanoma and does very, very, very well. Unfortunately, we haven't seen the results of immunotherapy in head and neck tumors that we have seen in other sites like melanoma. Um, and again, I think there's a lot of ongoing clinical trials, ongoing research and we maybe just have not reached the right combination or the right, uh, um. You know, right, um, decision making strategy for that yet. But there is one area, and we just wrote a consensus statement that's going to be published in, um, in the literature here uh shortly about neoadjuvant therapy using immunotherapy. Now this is something that um is for patients with very advanced disease where maybe they're surgically resectable resectable, but the surgery will be morbid or maybe they're surgically not resectable. And you give the patient immunotherapy, see if there's a response. Maybe it shrinks, maybe it shrinks significantly, and maybe it completely goes away. And then you decide, do we radiate? Do we do surgery? So we're we're giving an added layer of potential treatment and potential tumor response, um, to the patients. And I think that that is something as these clinical trials continue to progress, um, that we're going to see a definite, um, you know, uh, usefulness. In treating some of our more aggressive tumors. And again, it doesn't work for every patient. I think that's where we need to figure out how do we either combine it with other therapies or what do we need to do more genomic analysis to find out if that potential tumor is going to respond or not. So we have some homework to do, but I think that that's a very promising uh area. Um, interestingly, immunotherapy has its consequences as well, and you've seen some of those in the dental aspect. Yeah, so definitely has changed the landscape of how many cancers are treated. You mentioned melanoma, potential also for metastatic at the neck cancers, uh, but unfortunately, as for many of the new drugs that, that are FDA approved, they do come with side effects that affect the mouth and And we did a large study looking at about 4000 patients um that were that received the immunotherapy. And looked at what are the side effects that can affect the oral cavity. And about 8% of patients develop some sort of toxicity that affects the mouth. And the most common, once again, is hyposalivation. So a reduction of the saliva and the salivary flow in, in our patients, a common side effects that we already talked about from radiation therapy. We see it also with immunotherapy. And this is because of an autoimmune destruction of the salivary glands. The second most common are, um, mucosal lesions, which is different from the conventional oral mucositis with the large ulcers that you see from radiation therapy or chemotoxic regimens. In immunotherapy, the lesion That affect the mouth are similar to an autoimmune disease that we call lichen planus. So patients develop white reticular changes, almost a spider web, erythemas, or redness of the mucosa, pain. A small subject of patients develop, uh, lesions that resemble erythema multiforme. So like crusting of the lips, very, very painful. This is a smaller subset of patients. And the third most common side effects of immunotherapy is taste changes. So patients may complain of a metallic taste, uh, difficulty eating regular food because of the taste changes. Again, it's 8 out of 100 patients, but still very, very morbid. And, and we are here to help these patients. And so we follow patients who develop side effects, uh, we help them and typically they do, they do pretty well. Um, and after the discontinuation of the agents, some of all these side effects also resolve. Uh, and again, multidisciplinary care, we need to, uh, talk with our medical oncologist, colleagues, and we really work hand in hand to ultimately improve the quality of life of patients with other neck cancers. So as our time is, you know, coming to an end, I think one of the topics that I'd I'd like to close out with is something both near and dear to our hearts that we've worked on a lot together as well with different societies, and it's often a question we get asked by our patients, but also our family and friends. How do you prevent this? What can you do? To prevent this disease. Now we already talked about the importance of oral screenings, right? Um, you know, seeing your dentist, primary care on a regular basis. There are community health offerings where, you know, head and neck screenings are offered to the community. Baptist uh does them and we participate in those. Um, the other one that I think is often overlooked, we talked about HPV. And HPV driving some of these cancers. Now, there's a way to prevent HPV. It's a simple vaccine, a vaccine that's offered to all 9 to 11 year olds, um, that is a cancer prevention vaccine. And um I know I have done a lot of work with the American Cancer Society. I don't know if you want to speak on to this as well, but um you know we can't enough stress the importance of HPV vaccination. You agree? Absolutely. I mean, we talked about it over 70% of oropharyngeal cancers are HPV related. About 3 to 5% of mouth cancers are also HPV related and so we have only two cancer prevention vaccines that are approved. One is the one against hepatitis B, the other one is against human papillomavirus. It's safe, it's effective, million doses have been already given, um, and it not only prevents oropharyngeal cancer, it prevents also many others, right? And, and interestingly enough, um, in some states in the US dentists can administer the vaccine. Um, to prevent these HPV related cancers and in those states where we are not allowed to, to vaccinate patients, we can still discuss with patients. We can discuss the importance of a cancer prevention vaccine and, and this is given up to the age of 26 years, but after consultation with the primary care physician, patients at risk can also receive it up to the age of 45. Uh, either in 2 doses or 3 doses depending on the age, but I think it's amazing we have a cancer prevention vaccine. Why shouldn't everyone get it? Why isn't everyone in line, right? And um, you know, and pharmacists can give it, and you can get a prescription from your PMD, go to a pharmacist, get the shot if you're, you know, if your provider doesn't necessarily have it. You know, in in an adult practice, etc. and for the children, you know, the vaccination rates in children, if you look at Australia where they have a 95% vaccination rates, there are HPV related diseases that they do not see or have not seen in 5 years. And um that just goes to show the power of, you know, when you have these high vaccination rates, the elimination of these diseases, HPV related diseases and cancer, and I really hope that's in our future. I've always told people if I get put out of business because you eliminate the cancer that I take care of with good vaccination rates, and I think we have a win for the world, um. And uh one last thing because everybody talks about AI, right? So we've been talking about these lesions, you know, there's so many different types of lesions in the mouth, so forth and so on. Can AI be useful in helping the average Joe determine what might be worrisome and what might not be? How does AI play into screening? There's a lot of research right now on this, um, a lot that we learned from dermatology using AI, but Uh, again, the mouth is easily accessible. So now there are tools in which you can take a photograph and the uh machine algorithm, um, gives a differential diagnosis. Again, it's still in research, it's not using clinical practice, but I think That this tool will become fundamental for as a screening tool in the community. Even a practitioner that is not familiar with mouth lesions eventually will be able to use a simple, take a simple photo with the smartphone, uh, upload it into the app that has an AI algorithm and generates a differential diagnosis. So, I think, uh, this is an area that is Rapidly evolving. We are actually doing a study on it even at MCI, so more to come on this. Uh, but, um, I, I think it's gonna change the future of diagnostics and screening. So looking forward. We're not quite prime time yet. If you still have that lesion that's been there for 30 days and nobody's taking a look at it, I suggest see, uh, myself or Alessandro and make sure that, uh, you get a good opinion on it. So thank you so much for this discussion. I thoroughly enjoyed it. You know, these are topics that we, we profoundly care about and I think most people really. Uh, uh, care about as well. Our patients are profoundly grateful for the care that they receive and for the ability to participate in some of the clinical trials and everything we talked about. So I really am thrilled to be able to share this in this setting. As research progresses, combination therapies and novel drug developments offer hope for better survival rates and quality of life. Collaboration between researchers, clinicians, and technology will be key in transforming the landscape of head and neck cancer treatment, bringing us closer to more effective and less toxic solutions. Advances in immunotherapy, targeted therapies, and minimally invasive surgical techniques are improving outcomes while reducing side effects. AI and machine learning will enhance early detection and treatment planning and lead to more tailored care. Thank you again for joining us. To find out more about the topics covered on Baptist Health. Doc, please visit physicianresources. Baptisthealth.net. Created by
