Laryngeal (Voice Box) Cancer

Head and neck cancers can present a wide variety of symptoms. At UChicago Medicine, our team works to provide the best outcomes for patients while preserving as much speech and swallowing function as possible. UChicago Medicine otolaryngologist Dr. Nishant Agrawal and oncologist Dr. Ari Rosenberg will share what you need to know about head and neck cancers. From early detection and symptoms to treatment options in clinical trials, our experts will tell you about the latest in care and they'll take your questions live. That's coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not meant to take the place of an actual visit with your physician. We also want to remind our viewers that you can type in questions for our experts. Do that in the comments section. We'll get to as many of those as possible over the next half hour.

First of all, let's just start with having each of you introduce yourselves and tell us a little bit about what you do here at UChicago Medicine. Dr. Agrawal, we're going to start with you since you're right here at the desk.

Thanks, Tim. My name is Nishant Agrawal I'm head and neck surgical oncologist, which basically means I cut out cancers in the head and neck. Nice to meet everyone.

And Dr. Rosenberg?

Thanks, Tim. Ari Rosenberg, I'm a medical oncologist. So that means that I use medicines to treat head and neck cancer, and also running research on using new drugs to improve outcomes for patients with head and neck cancer.

I want to remind our viewers, too, that we are social distancing as much as possible. So we have our physicians kind of scattered around in here. Usually we'd have everybody at the desk. But we can't do that just yet. One of these days soon, hopefully we'll be back to normal.

Let's start off with the basics. And Dr. Agrawal, we're going to start with you and just have you talk to us a little bit about head and neck cancer. What is it and what do people need to know?

Sure. So the most common type of head and neck cancer is this thing called squamous cell carcinoma, or SCC. And it basically arises from the lining inside our mouth, our throat, and our voice box. A lot of times the patients are asymptomatic or they present with a lump in their neck.

But other things to look out for is chronic pain in the head and neck area, ear pain that doesn't improve, changes in swallowing, in your voice or speech or breathing and unintentional weight loss.

So Dr. Rosenberg, I would imagine a lot of the symptoms that Dr. Agrawal just talked about would probably fool people, because they would think, oh, I've just got a sore throat, maybe allergies or a cold or something like that. Does that make it difficult to diagnose these types of cancers?

Yeah, I would say yes. Oftentimes we see patients who present to our clinic after they've received a course of treatment for an infection or something like that. But like Dr. Agrawal mentioned, I think it is important if you have those symptoms to get it checked out and to diagnose it if it's present.

So what are some of the biggest risk factors of head and neck cancer? I would imagine probably the one that I would think of right off the bat would be smoking. But there are other risk factors as well.

Sure, Tim. So just back to the previous point, so the other thing, so the chronicity of the symptoms makes a major difference. So if anything lasts greater than two weeks, have a fairly low threshold to see your doctor for further evaluation. There have been a lot of high-profile head and neck cancers in the news that had a delayed diagnosis, just as you mentioned, because it's a very nonspecific complaint.

In terms of the risk factors of head and neck cancer, the major risk factor is smoking. Other risk factors include alcohol, heavy alcohol use, and HPV, or the human papillomavirus. Those are the three major risk factors for head and neck cancer.

What about the smokeless tobacco that some folks use?

Sure. So yes, sort of under the tobacco, the smokeless tobacco, chewing tobacco is another major risk factor, more so in other parts of the world, including Asia, less so in the United States. Just the incidence of oral tobacco product is as much less in the United States versus the rest of the world. But more common is tobacco smoking in the United States.

That makes sense. It's interesting, and I think a lot of times whenever we do a program and we talk about cancer, people immediately get that fear and that feeling that if they're diagnosed that it's a death sentence. And that's not the case. We want to stress that.

And I want to play a video. And John, we'll play the video here in just a moment. But this kind of, I think, demonstrates some of the work that can be done to help people. And again, to your point, Dr. Agrawal just you've always got to be aware of your body. So let's go ahead and roll that video. And then we'll talk about that afterwards, John.


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- Pardon me.

- [INAUDIBLE]

- No, she's going to go. We're going to square up right underneath. These become super symmetrical at that point in time.

- [INAUDIBLE].

- We've got an hour and a half.

- [INAUDIBLE]

- About six years ago, I was diagnosed with stage four neck and throat cancer. So it was a shock to me. Of course, it was a huge, huge shock. You're just into your 50s. You still feel a bit indestructible. You're not thinking that cancer is going to be part of your life.

Come over here for a second. Look, look right here, my hand.

- [INAUDIBLE] in front of this camera. But you can get behind me.

- It was very scary, very difficult for me. We went up to our cabin in Michigan. We actually made dinner and everything and just and we started talking about it, just a lot of different things. And all of a sudden, I noticed how emotional he was.

And I said, what's going on? And that was when he actually told me what he had discovered. And it was heart wrenching. And I was just so upset.

- The answer that we got was you don't have to travel far. You've got the very, very, very best in your backyard. They said University of Chicago's got this amazing program. And there's a doctor there by the name of Dr. Everett Vokes who is breaking ground, who is the number one in his field. And he is your guy.

- For all we can tell, it had a good outcome because we were able to minimize surgery. And he is here doing important work for us here at the University of Chicago.

- Oh wow, you know, honestly, I really love the team there very, very much. I remember the nurse, the main nurse at the time, Denise. She was absolutely wonderful. Just any questions that we had, they would answer immediately.

- I got a call from an advertising agency out of New York. They had a hospital who they couldn't speak about yet because the client didn't-- because we hadn't had the job yet. But they wanted me to do a campaign for them that would help bring recognition to this hospital.

Well, little known to them, I had just left this hospital. I had just been cured of stage 4 cancer from this hospital. And once they found that out, just the serendipity, the coincidences just became a natural.

- We're shooting 60 frames per second.

- Yes, sir.

- Let's burn some film.

- What we really want to show is that the University of Chicago, first and foremost, has probably some of the best doctors in the world. They are getting the best of the best. And that's what we wanted to show in these spots, that you are dealing with the most innovative technology possible to me. And you're going to come out the other end. And you're going to get right back to your life. And you're going to enjoy your life.

- Try to enjoy life to the fullest. I mean, if we could travel somewhere just for a day, if we could take a road trip somewhere, we'd do it. And we'd do it together.

- You learn to make every minute count. Every bit of time with your wife, your children, your grandchildren become more important. I knew at this point that it was time for me to really take the challenge and push everything to the limit and do the absolute best work I could do.


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So the story behind the story, he's actually done two campaigns for us now. And great guy, a lot of fun to meet. His wife is a wonderful, wonderful person as well, and a lot of fun to work with on both of those campaigns. And it just seemed the story behind it was just awesome, that he had actually been here. So I think that made-- it even the connection even that much better. But again, it shows that there's hope out there and a great team.

Definitely.

So let's talk about some of the risk factors. And we touched on that just a moment ago. But Dr. Rosenberg, from your standpoint with the work you do, what do you see when patients come in? Is HPV-- I know we've talked about that. We've talked about that in the past. Where does that rank on the risk factors? And how important is it for folks to get their children inoculated?

Sure. No, absolutely, Tim. So a number of throat cancers can be associated with HPV, human papillomavirus. And we're actually seeing more and more of that, so an increasing incidence. More and more patients are being diagnosed with HPV-associated throat cancer. Fortunately, there is an HPV vaccine for children and teens that is approved and being administered in primary care doctors that essentially prevents people from developing HPV-associated cancers. So it's highly effective and strongly recommended.

And I think they've actually-- they've kind of changed the guidelines a little bit on that in recent years as far as ages, too. I don't know if you can talk a little bit about that.

Sure, that's changed. And initially it was teenage boys and girls and then went into the 20s, and now, actually, less than 45. And my wife and I-- I'm still less than 45-- got the HPV vaccine. It has been proven to be very effective in preventing HPV-associated cancers, both in the head, neck, and other areas. So we really are strong proponents of it.

So that's news to me right there, which is interesting. I hadn't realized that they'd increased it that much. So that's good news you can use.

Yeah, so the reason, Tim, is people's social situations change. And most people are exposed to HPV fairly early in life, but not everyone. So it's really to accommodate that changing landscape and people's personal social lives.

Great. That's really good to know. So let's talk about some of the treatments for head and neck cancer. We have both of you on. And you do very different things when it comes to that.

And Dr. Rosenberg, I'm going to start with you. Tell us how you treat and some of the basic treatments from your standpoint.

Sure. No, absolutely, Tim. So whenever a new patient comes to the clinic, The first thing we characterize is that the diagnosis, we confirm the diagnosis. And we do that oftentimes with a biopsy and work closely with Dr. Agrawal or our other surgical colleagues to make sure-- and our pathology colleagues to make sure that we have the right diagnosis.

And then the next thing we do is we stage the cancer. We find out where it's spread to. Is it very small and localized to one spot? Or has it spread to lymph nodes in the neck, for example, or other parts of the body? And a lot of that information is very important to determining what the right treatment approach is.

And then after that, it's actually very important that patients meet a number of different doctors that treat head and neck cancer. So I'm one of those doctors, a medical oncologist that uses medicines, like I mentioned, to treat head and neck cancer. But all patients will ultimately need a surgeon a head and neck surgeon, like Dr. Agrawal, as well as a radiation oncologist, a doctor that uses radiation.

And these are the three tools that we use to treat head and neck cancer. And it's very important with a new diagnosis that we all take a look at the case, discuss it as a group, and figure out what the right personalized approach is for an individual patient, whether it's a patient that would benefit from surgery first, followed by other types of treatment if needed, or whether a patient benefits from a nonsurgical approach first by combining chemotherapy or radiation, for example, and sometimes even new medicines to treat cancer as well. So it really depends on the situation. And we discuss it to figure out what the right approach is for a given patient.

So Dr. Agrawal, I think this-- what Dr. Rosenberg was just talking about is so important. It's this team effort that we see. And it's kind of that one-two-three punch, even, for treatment. And it's just so important. And it really is. You all get together. You discuss different patients. And it's a big process, but it's an important process.

I think it's the most important process. So what makes this fairly unique in head and neck oncology across the world is really the fact that it's become a multidisciplinary discipline, where there's engagement with medical oncology, radiation oncology, and surgical oncology. And we really keep our egos aside and we all meet, discuss the patient at a multidisciplinary tumor board, and optimize what's best for the patient. And multiple studies have shown that a multidisciplinary approach to the treatment and management of head and neck cancer makes a dramatic difference in both outcome and function.

And beyond medical oncology, radiation oncology, and surgical oncology, there are other medical teams that are involved in the care, including speech language pathologists, a dietitian, physical therapist, occupational therapist. It's a big team, pathologists, radiologists. And again, we all come together really to find the best option for the patients.

It makes such a huge difference. And I just think that is so critical. So I'm glad both of you talked about this. We do have some viewer questions and comments coming in. So I do want to remind our viewers, just type them in the comment section and we'll get to those.

Here's a nice one. Beth says Dr. Stenson removed her cancer. She's been cancer free for seven years. Thank you, University of Chicago. So that's very nice.

I have a few others coming in. How do we know when a lump or a bump in your neck is more serious? And I think as we all age, because I've got these as well, you get lumps and bumps in places where you didn't have lumps and bumps before, unfortunately. And it's difficult to know, do I need to go see my physician or is this just part of life?

Yeah, absolutely, Tim. So lumps and bumps all over our body are very common. Generally more often happen in younger patients and it's inflammatory or reactive. But as we get older, those lumps and bumps shouldn't happen as frequently.

So again, if something comes and goes or resolves after a couple of weeks, it's probably innocuous thing. But if something persists, grows, or spreads two to four weeks or longer, then it's something that requires additional attention. And the next steps are generally a combination of an examination, some sort of imaging, and usually a needle biopsy.

And it never hurts just to go see your physician if you have a question. It's better safe than sorry. It doesn't take that much time. And you'll sleep better, obviously, that evening if you find out some good news.

Absolutely, Tim. So one thing we haven't discussed is the survival for head and neck cancer is very dependent on stage. So if we can identify early-stage cancer, stage 1 and 2, the survival is much superior compared to advanced stage 3 and 4 cancers. So early diagnosis is key in both outcomes and decreasing the morbidity, some of the side effects, both from the treatment and the tumor itself.

Great. So Dr. Rosenberg, can you talk to us a little bit about immunotherapy? Actually, I'll throw this open to each of you. You can both answer this one. But immunotherapy is something we hear more and more about when it comes to cancer treatment. And it's a fascinating area. I don't know if you can address that.

Sure, absolutely. Yeah. So immunotherapy, there's a number of different types of immunotherapy. But the one that's most commonly talked about in a number of cancers, in particular head and neck cancer, are actually medicines that are immunotherapy. These are medicines that don't kill cancer cells directly, like chemotherapy or radiation do, but rather medicines that release the brakes, if you will, on the immune system, the immune cells, your own body's immune system, so that your immune system can then go and attack cancer.

And immunotherapy has improved survival in a number of different cancer types. And one of those cancer types is, indeed, head and neck cancer. And we use it very commonly in the more advanced situation, where head and neck cancer spreads to other parts of the body, because we know in that type of situation that either by itself or with other types of treatments that they help patients live longer.

Actually, the University of Chicago, because it's worked so well in more advanced disease, we've actually brought it as part of some of our clinical trial research and some of our ongoing treatment protocols into the earlier stage. And so that that's something that we're currently investigating, to see if that's something that can also help patients with earlier stage cancer do better.

That's fantastic. And we'll talk more about some of our clinical trials, because that, to me, again, that's an area where I think UChicago does a wonderful job and it's a very important part of the work that happens here. You have a statement/question from a viewer, and this is important, wanting to know if nurses are part of that multidisciplinary team. They were not mentioned. Obviously, they are. Nurses are--

Oh, absolutely. So that's my oversight--a big part of what we do.

So the centerpiece is patients and their families. But the next foundation are all our amazing nurses. They are integral in every aspect of care of patients, including cancer patients. So absolutely.

And we do have a great nursing team here. It's fun to see them work and talk to them. And they do fabulous work here as well. So it is all truly, and I can't overstate this enough, I've heard this many times from patients. The entire team here is what really makes this a special place. And they do wonderful work. You all do wonderful work. I'll just add to that.

Go ahead.

Yeah, just real quick here, Tim, before we move on.

Sure.

It's not-- obviously, the nurses are an integral part of the team. But there are also nurses that have a lot of experience and specialization in head and neck cancer specifically. So it's also their expertise within the integrated program that allows it to be an important component as well of the multidisciplinary team that both you, Tim, and Dr. Agrawal mentioned.

Yeah, that's great. I'm glad you all both said that, because I think those are fantastic points. Let's talk a little bit about clinical trials, if we can for a moment. And I don't know who wants to take this. But again, this is work that's done here at UChicago Medicine. Dr. Rosenberg, let's start with you, because I think it's so important, and it really affords patients the chance to be on the leading edge of treatment. And it's pretty exciting stuff.

Yeah, absolutely. Thanks, Tim. Certainly, our clinical trials are an important part of the program. We try very much to not only cure patients and help patients live long, but also reduce the side effects of treatment. And so we have clinical trials across different situations for HPV-associated throat cancers, for non-HPV, patients with earlier stages, patients with more advanced disease, all in trying to improve patient outcomes.

One of the important situations that we see is new medicines, new drugs that are being investigated to treat head and neck cancer, in particular to making our treatments work better in combination or by themselves in various settings. We also do a lot of research to identify new tests that we can use to help patients receive the right personalized kinds of treatment. We do this kind of testing on blood, for example, or tumor tissue and things like that. And we do it all collaboratively within the group as well.

All right. So Susan has a question for us. And she wants to know, is there any research to support why, with no apparent risk or family history, young females with non-HPV oral cancer is growing? Is that a number that's growing?

Significantly. Yeah, there've been a few studies that have shown increasing incidence of oral cavity, so in the mouth, cancers that are not associated with smoking, heavy alcohol use, or HPV. It's really a mystery in our field. We have not been able to identify a carcinogenic source for that patient population.

There's some debate whether it's more common in women versus men. But we see it in both men and women. And we see it in younger patients, sometimes in their late 20s, early 30s, and spanning through the 80s and 90s, so patients who have no significant history of tobacco use. Our group and other groups are actively investigating this. But this is something we have to figure out.

Interesting. Yeah, it sounds like an area that a lot of work is being done, I'm sure, and needs to be done. We are having a lot of comments supporting various physicians and nurses at UChicago Medicine. And I'd love to read them all off, but we may be here for a while if we do. So suffice it to say you all have fans, which is nice.

Let's talk about-- I'm kind of curious as far as from your standpoint the various types of treatment, do we use robotic surgery at all in any of these treatments?

Yeah, sure. So as Dr. Rosenberg said, the mainstay of cancer treatment for most type of cancers is chemotherapy. And under that, there's things like immunotherapy and targeted therapy, radiation therapy, and surgery. Within surgery, we're technology driven. So we really are integrating robotic surgery into head and neck cancer management. And that really allows resection of inaccessible tumors 15 years ago, but now we can access them through an open mouth.

So it's really been very transformative in our field. And the robots continue to get better with each generation. So it's a very exciting area. Right now, robotic surgery is mainly used for HPV-associated tumors in the tonsil or the back of the tongue, and occasionally for tumors of the voice box. But the indications continue to grow over the next few years. And it's a very, very exciting area for head and neck cancer management.

The technology that you surgeons use is just unbelievable.

Yeah, eventually we'll only push a button and it'll cut the tumor out. Yeah. We'll be there.

Yeah, yeah, it's pretty impressive stuff. And the robotic surgery, as you're talking about that, I've been lucky enough to actually get to look in through the little eyepiece during a surgery. And it's amazing what you can see. And the three dimensional aspect of it is fantastic.

Absolutely. The optics are better than our eyes. And we work on millimeters, so the thickness of it in the single hair. But the visualization, the magnification, the angles are what we're able to obtain with robotic surgery is really-- it's a breakthrough. And it's exciting because the technology is going to continue to get better.

So more questions from viewers. So let's get to those. Amanda asks if the two of you can talk about support for patients post-treatment in terms of survivorship. And I know we do a lot in that area. You even mentioned some of the work we do with patients from even from dietitians and on. But I know it's so much broader than that.

Yeah, absolutely. So survivorship is very important for head and neck cancer, of course. After completing treatment and when patients have no evidence of cancer, of course, we want their quality of life to be as good as it can be. And so that's sort of what we think about with survivorship.

We involve a number of different team members, depending on the specific situation. And Dr. Agrawal mentioned them a little bit early as well during treatment, but also after treatment, dietitians to help with nutrition, speech and swallowing specialists to focus on speech and swallowing and function afterwards, psychosocial support afterwards in terms of psychosocial issues related to being a cancer survivor, including social work, and, of course, physical therapy, occupational therapy. All these folks are involved in follow up afterwards.

And then I'll just mention also, because it's very important, is that when patients are undergoing active cancer treatment, they're seeing us a lot, right? We're seeing them frequently. For those getting medicines to treat cancer, we're getting blood tests. We're seeing them. We're very active in their treatment.

And as patients get farther and farther out from completing their treatment without any evidence of cancer that we can see, then they start seeing us less frequently, which is a great thing. And a lot of times we work with primary care doctors and other types of health-care providers in order to make sure that the optimal support and all the preventative treatments that are so, so important for all patients, but in particular cancer survivors, are things that are happening for patients.

That's great. The psychosocial aspect of it, which you mentioned and you talked about pretty extensively, is-- I think that's so critical, because again, it's life changing. This is a huge, huge thing that's happening in your life. And it does have a pretty significant impact. And we have some wonderful support groups that work with people for potentially years on out.

Yeah, absolutely. So survivorship is critical. So once patients and their family members are done with the acute treatment, survivorship really kicks in. And again, it's a multidisciplinary approach with nurses, physicians, and, as Dr. Rosenberg mentioned, speech and swallow therapists and other medical staff. There's also a lot of support system that's around and organizations, both medical organizations and patient-centered organizations, such as Head and Neck Cancer Alliance, Oral Cancer Foundation.

So there are a lot of resources out there. A few decades ago, this was probably underappreciated. But now survivorship really draws a lot of attention. There's a fair amount of resources dedicated to it, at individual institutions and also centrally across the nation.

We're just about out of time, but I've got a couple more questions I'd like to get to quickly if we can. Karen wants to know how you can check for HPV. Would either one of you want to take that one?

Yeah, absolutely. So for cervical cancer, there are screening that women do in order to monitor for cervical cancer. And that's worked quite well.

For throat cancer related to HPV, we're not quite there yet. We hope to be. And there's a number of evaluations trying to see how we can best screen or check for HPV-associated cancer in the throat.

But as of now, we're not quite there. So hopefully we will be at some point. For now, I think the main thing is keeping an eye out for some of those symptoms that Dr. Agrawal had mentioned a little bit earlier. That should certainly bring you to see your doctor and get checked out.

All right. Technically, we are out of time. I do have to read one more, though, because I think this is really nice. So this is from Jamie. And Jamie says, "Dr. Agrawal and the entire head and neck team are phenomenal physicians. The level of care provided is above and beyond. They truly treat patients like family. And that makes going through this difficult time much easier."

To me that's so nice to hear that kind of thing. So kudos to the two of you, wonderful work. And we are out of time. I apologize we couldn't get to more questions. But this went pretty quickly. You guys did a great job.

Thank you, Tim. Thank you, Tim. Great. Thanks very much.

So thank to our physicians, obviously, for being with us today. And a thank you to those of you who watched and participated in the program. Please remember to check out our Facebook page for a schedule of programs that are coming up in the future. To make an appointment, go online at uchicagomedicine.org or you can call 888-824-0200. Thanks, again, for being with us today. And I hope everyone has a great weekend.