surgery

Complex cancer decisions, no easy answers

Source: blogs.biomedcentral.com
Author: Jeffrey Liu

With the many different options now available for the treatment of cancer, it can be very difficult for both clinicians and patients to decide on the best possible treatment strategy, particularly when faced with a complicated cancer. In this blog, Dr Jeffrey C. Liu reflects on the challenges encountered in cancer decision making, particularly when presented with difficult cases.

When treating cancer, sometimes the treatment decisions are straightforward and unambiguous. For example, surgery is the treatment of choice for an early, uncomplicated tongue cancer. However, many times, the recommendation for cancer treatment is not straightforward and requires combination treatment – one or more of surgery, radiation or chemotherapy.

As a head and neck cancer surgeon, I work with a team to make these treatment decisions, and usually team consensus is achieved. However, when we are faced with the choice of multiple treatments that all have the same chance of cure available, it seems to result in a never ending discussion amongst our team.

Take for example an advanced tonsil cancer. These cancers can sometimes be removed first with surgery, a process which removes both the primary cancer and the lymph nodes in the neck. Then, depending on the pathology results, patients may need radiation treatment, chemoradiation or sometimes no further treatment at all. Meanwhile, chemoradiation alone, and no surgery, is an excellent option. Whether the patient receives surgery or no surgery, the chance of cure is pretty much the same. However, based on the need for additional treatment after surgery, the patient may have better, equivalent, or worse function than chemoradiation alone.

How then can a patient make a decision with imperfect data? I wish I could help my patients better with these complex decisions. Most patients will make this decision only once in their lives. With the increased emphasis on patient autonomy, there is sometimes a feeling to just “present the options and let the patient decide.”

However, when a group of smart experienced doctors who all treat the same cancer, cannot reach an agreement, how is a patient with no experience expected to make the right decision? There is not enough time to explain to patients the observations of hundreds of such decisions and their thousands of outcomes. Some patients are so overwhelmed by the decision, that they just want someone to tell them what to do. Others have so many questions and concerns that they get lost in the details and paralyzed by the process. I don’t know the right answer for such patients.

Unfortunately, there is no option but to choose a treatment strategy and move forward. We all carry the hope that one day, with more research and better understanding, such complex decisions for the treatment of cancer, will become the easy ones.

October, 2017|Oral Cancer News|

Penn surgeons become world’s first to test glowing dye for cancerous lymph nodes

Source: www.phillyvoice.com
Author: Michael Tanenbaum, PhillyVoice Staff

Surgeons at the University of Pennsylvania have achieved a global first with the use of a fluorescent dye that identifies cancerous cells in lymph nodes during head and neck cancer procedures.

The study, led by otorhinolaryngologist Jason G. Newman, seeks to test the effectiveness of intraoperative molecular imaging (IMI), a technique that illuminates tumors to provide real-time surgical guidance.

More than 65,000 Americans will be diagnosed with head and neck cancers in 2017, accounting for approximately 4 percent of all cancers in the United States, according to the National Cancer Institute. About 75 percent of these cancers are caused by tobacco and alcohol use, followed by human papillomavirus (HPV) as a growing source for their development.

Common areas affected by these cancers include the mouth, throat, voice box, sinuses and salivary glands, with typical treatments including a combination of surgery, radiation and chemotherapy.

Lymph nodes, which act as filters for the immune system, are often among the first organs affected by head and neck cancers as they spread or resurface. Initial surgeries may leave microscopic cancerous cells undetected in the lymphoid tissue, heightening the risk that a patient’s condition will return after the procedure.

“By using a dye that makes cancerous cells glow, we get real-time information about which lymph nodes are potentially dangerous and which ones we can leave alone,” Newman said. “That not only helps us remove more cancer from our patients during surgery, it also improves our ability to spare healthy tissue.”

With the aid of a fluorescent dye, surgeons are able to key in on suspicious tissue without removing or damaging otherwise healthy areas. Previously adopted for other disease sites in the lungs and brain, the practice now allows Newman’s team to experiment with indocyanine green (ICG), an FDA-approved contrast agent that responds to blood flow.

Newman explained that since tumor cells retain the dye longer than most other tissues, administering the dye prior to surgery singles out the areas where cancer cells are present.

The current trial at Penn will enable researchers to determine whether ICG is the most suitable dye for head and neck cancers and provide oncologists with a deeper understanding of how cancer spreads in the lymph nodes.

October, 2017|Oral Cancer News|

Magnolia man joins exclusive trial in battle against cancer

Source: www.cantonrep.com
Author: Denise Sautters

Rich Bartlett is looking forward to getting back to his hobbies — woodworking and nature watching — and enjoying a good steak and potato dinner. Until then, though, he is in a fight for his life, one he plans to win.

Bartlett is a cancer patient and the first participant in a clinical trial at University Hospitals Seidman Cancer Center in Cleveland to test the safety of an immunotherapy drug — Pembrolizumab — when added to a regimen of surgery, chemotherapy and radiation therapy.

Back to the beginning
Bartlett went to the dentist in October for a checkup.

“He had a sore in his mouth he thought was an abscess,” explained his wife, Nancy Bartlett, who pointed out that, because radiation and chemo treatments cause the inside of the mouth to burn and blister, it is hard for Bartlett to talk.

“When the dentist looked at his sore, he sent Richard to a specialist in Canton, and in early November, he had a biopsy done. It came back positive for cancer.”

From there, he was referred to Dr. Pierre Lavertu, director of head and neck surgery and oncology at University Hospitals, and Dr. Chad Zender from the otolaryngology department, who did Bartlett’s surgery.

“They let us know it was serious,” said Nancy. “It had gone into the bone and the roof of the mouth, but they were not sure if it had gone into the lymph nodes. By the time we got through that appointment, it was the first part of December and (they) scheduled him for surgery on Dec. 22.”

The cancer tripled in size by then and the surgery lasted 10 hours. Doctors had to remove the tumor, all of the lymph nodes and parts of the jaw and the roof of Bartlett’s mouth.

“They harvested skin from his hand to rebuild the inside of his mouth, and took the veins and arteries and reattached everything through his (right) cheek,” she said. “He could not even have water until February because of the patch. He uses a feeding tube to eat now.”

The tube is temporary until Bartlett heals.

Clinical trial
Just before he started chemo and radiation therapies, the hospital called him about the clinical trial.

The trial is the first to use quadra-modality therapy — or four different types of therapy — against the cancer, according to Dr. Min Yao, the principal investigator.

Yao said Bartlett has squamous cell carcinoma of the oral cavity, with only a 50 percent chance of survival.

“Patients have surgery, then followed by six weeks of radiation and chemotherapy and immunotherapy,” Yao said in an email interview. “That is followed by six more months of immunotherapy, one dose every three weeks.”

Bartlett currently is in the radiation, chemotherapy and immunotherapy part of the study.

“It is too early to tell how he is responding,” said Yao. “His tumor has been resected. After the treatment, we will see them periodically with scans. Cancer often recurs in the first two years after treatment.”

Pembrolizumab originally was developed to activate the body’s immune system in the fight against melanoma. Former president Jimmy Carter was treated with the drug for his brain metastases from melanoma in 2015.

A truck driver by trade, Bartlett will undergo daily fluoride treatments for the rest of his life to protect his teeth.

“We did not realize until we got to Cleveland just how bad this was,” said Nancy. “When you have oral cancer, and they are getting ready to do radiation and chemo, you have to go have your teeth cleaned and examined and get anything done that needs to be done because radiation tends to compromise your blood flow in your mouth. That was a step we didn’t know.”

Although he was shocked to hear the outcome of that sore in his mouth, Bartlett is grateful to be a part of the trial.

“Who wouldn’t feel good about something like this? I mean, you got something that was used on Jimmy Carter, who is recovered and is now making public appearances again,” said Bartlett, who is looking forward to June when hopefully he can start eating again and enjoying his hobbies.

“I am very hopeful about this. The whole thing has been a trial. I have a dentist in Cleveland who said I was going to be in the fight of my life, and I am. I am in a huge fight. The chemotherapy is what has knocked me down the most, but I am very positive about the outcome of this.”

March, 2017|Oral Cancer News|

Imaging method has potential to stratify head and neck cancer patients

Source: www.eurekalert.org
Author: press release

Manchester researchers have identified a potential new way to predict which patients with head and neck cancer may benefit most from chemotherapy.

These patients commonly receive pre-treatment induction chemotherapy, before either surgery or radiotherapy, to reduce the risk of disease spread. However the effectiveness of such treatment is reduced in tumours with poor blood flow.

Previous studies have shown that CT scans can be used to assess tumour blood flow. Now researchers at The University of Manchester and The Christie NHS Foundation Trust – both part of the Manchester Cancer Research Centre – have explored the use of MRI scans in predicting which patients would benefit from induction chemotherapy.

Professor Catharine West, who led the study, said: “It’s also important to identify those patients who are unlikely to respond to induction therapy so that we can skip ahead in the treatment pathway and offer them potentially more effective treatments and hopefully improve their outcome.”

The team used an imaging technique known as dynamic contrast-enhanced MRI (DCE-MRI), where a contrast agent tracer is injected into a patient’s vein whilst they have a series of MRI scans taken. This allows scientists and doctors to investigate the blood flow and vessel structure of a patient’s tumour.

They found that the blood flow of a patient’s tumour before they received induction therapy could predict response to treatment. In a paper recently published in the journal Oral Oncology, the group report that those with high tumour blood flow were more likely to respond.

Jonathan Bernstein, a co-author on the paper, said: “Delivery and effectiveness of chemotherapy appears to be better in tumours with higher blood flow. However, amongst those patients with lower measured tumour blood flow, more work is needed to determine those who will and won’t respond.”

Source: ‘Tumor plasma flow determined by dynamic contrast-enhanced MRI predicts response to induction chemotherapy in head and neck cancer’, Bernstein et al. (2015) Oral Oncology

September, 2015|Oral Cancer News|

Critical Outcome Technologies and MD Anderson Cancer Center to evaluate COTI-2 in treating head and neck cancers

Source: www.marketwatch.com
Author: press release

Critical Outcome Technologies Inc. (“COTI”), the bioinformatics and accelerated drug discovery company, announced today that it recently executed a material transfer agreement (“MTA”) with Dr. Jeffery Myers, MD, PhD, FACS of The University of Texas MD Anderson Cancer Center for the continued evaluation of COTI-2 in the potential treatment of patients with head and neck squamous cell cancer (“HNSCC”).

There are approximately 500,000 new cases worldwide of HNSCC a year, making it the sixth leading cancer in terms of new cases. In the United States, HNSCC is considered to be a rare disease and therefore represents a second “Orphan Disease” opportunity for COTI-2.

If HNSCC is caught at an early stage, current therapies, which include surgery and radiation followed by chemotherapy, can be effective. Unfortunately, HNSCC tumors with p53 mutations tend to be more difficult to treat with such mutations occurring in 30-70% of HNSCC tumors. These mutations are associated with poorer patient outcomes as traditional chemotherapy, using the current first line chemotherapy, cisplatin, is often ineffective. The overall five-year survival rate of patients with HNSCC is 40-50%.

As a small molecule activator of misfolded mutant p53 protein, COTI-2 has demonstrated in preclinical studies its ability to restore p53 function and thus induce cancer cell death for many common p53 mutations. As previously announced, the Company is planning a Phase 1 study in gynecological cancers (ovarian, cervical and endometrial) at MD Anderson with Dr. Gordon Mills and his team and these studies in HNSCC with Dr. Myers will seek to extend the understanding of COTI-2’s ability to treat p53 mutations across multiple cancer types.

Dr. Jeffrey Myers, leader of MD Anderson’s Multi-Disciplinary Head and Neck Cancer Research Program, has been studying the impact of p53 mutation, a common event in HNSCC, on tumor progression and response to therapy. His group has evaluated a number of single agent and combination treatments for p53 mutant tumors, and his preliminary findings with single agent COTI-2 in HNSCC in vitro tumor models show tremendous promise. In addition to seeing sensitivity of HNSCC cells to COTI-2, his group has found that this drug sensitivity is associated with activation of p21, an important mediator of p53’s response to cellular DNA damage. This response is consistent with the p53-dependent mechanism of action studied by Dr. Mills in ovarian cancer. Dr. Myers and his colleagues are planning more extensive studies of COTI-2 and its dependence on p53 re-activation for its effects in both in vitro and in vivo HNSCC tumor models.

“We look forward to further exploring COTI-2’s impact on HNSCC tumors,” said Dr. Wayne Danter, President and CEO. “We continue to believe that COTI-2 represents a potential breakthrough treatment given the central importance of p53 gene mutations in many cancers, including HNSCC. This second indication would broaden the treatment opportunities for our lead oncology asset, which has already been granted the Orphan Drug Designation from the U.S. Food and Drug Administration for the treatment of ovarian cancer.”

October, 2014|Oral Cancer News|

Blood test could predict oral cancer recurrence

Source: www.livescience.com
Author: Rachael Rettner, Senior Writer

A new blood and saliva test that looks for traces of the human papillomavirus (HPV) can predict whether some people with oral cancers will have their cancer come back, early research suggests.

It helps to know as soon as possible that cancer has returned, because tumors that are caught early are easier to treat.

In the study, the researchers analyzed blood and saliva samples from 93 people with head and neck cancers; about 80 percent of these patients had cancers that tested positive for HPV. All of their cancers had previously been treated with surgery, radiation or chemotherapy.

The researchers looked for fragments of DNA from HPV-16, a strain of the virus that is strongly linked with head and neck cancer. The virus may be found in cancer cells that linger in the body after treatment, the researchers said.

Among people with HPV-positive tumors, the new test identified 70 percent of those whose cancer returned within three years, the researchers said.

“Until now, there has been no reliable biological way to identify which patients are at higher risk for recurrence, so these tests should greatly help [to] do so,” study researcher Dr. Joseph Califano, professor of otolaryngology at Johns Hopkins School of Medicine, said in a statement.

Patients with head and neck cancer typically visit the doctor every one to three months during the first year after their diagnoses to check for cancer recurrence. But new tumors in the tonsils, throat and base of the tongue can be difficult to spot, and are often not detected early, the researchers said.

Still, more research is needed to confirm the findings, Califano said. Because HPV infection is common, the test may identify HPV infections that are not related to the cancer. “We can’t be sure our test results are cancer-specific, and not due to other forms of HPV infection or exposure,” Califano said.

The researchers are now looking for additional genetic markers that would increase the accuracy of their test.

Note:
The study is published today in the journal JAMA Otolaryngology–Head & Neck Surgery.

August, 2014|Oral Cancer News|

Researchers find way to diagnose aggressiveness of oral cancer

Source: www.news-medical.net
Author: staff

Studying mouth cancer in mice, researchers have found a way to predict the aggressiveness of similar tumors in people, an early step toward a diagnostic test that could guide treatment, according to researchers at Washington University School of Medicine in St. Louis.

“All patients with advanced head and neck cancer get similar treatments,” said Ravindra Uppaluri, MD, PhD, associate professor of otolaryngology. “We have patients who do well on standard combinations of surgery, radiation and chemotherapy, and patients who don’t do so well. We’re interested in finding out why.”

Reporting in Clinical Cancer ResearchK/em>, the investigators found a consistent pattern of gene expression associated with tumor spreading in mice. Analyzing genetic data from human oral cancer samples, they also found this gene signature in people with aggressive metastatic tumors.

“We didn’t automatically assume this mouse model would be relevant to human oral cancer,” said Uppaluri, who performs head and neck surgeries at Barnes-Jewish Hospital. “But it turns out to be highly reflective of the disease in people.”

Rather than use genetic methods to induce tumors in the mice, the research team repeatedly applied a known carcinogen, in much the same way humans develop cancer of the mouth.

“Patients often have a history of tobacco and alcohol use, which drive the development of these tumors,” Uppaluri said. “We felt that exposing the mice to a carcinogen would be more likely to produce similar kinds of tumors.”

The researchers, including first author Michael D. Onken, PhD, research assistant professor of cell biology and physiology, showed that this exposure sometimes produced tumors in the mice that did not spread, but other times resulted in aggressive metastatic tumors, similar to the variety of tumors seen in people. Uppaluri’s team then collaborated with Elaine Mardis, PhD, co-director of The Genome Institute at Washington University, to find out whether the mouse and human tumors also were genetically similar. They compared their mouse sequences to human data sets from The Cancer Genome Atlas (TCGA).

“When we sequenced these tumors, we found that a lot of the genetic mutations present in the mouse tumors also were found in human head and neck cancers,” Uppaluri said.

Further analysis identified a common signature in the expression of about 120 genes that was associated with the more aggressive tumors, whether in mice or people. The researchers confirmed this signature using data collected from 324 human patients. Subsequently, using oral cancer samples from patients treated at Washington University, they developed a proof of concept test from their signature that identified the aggressive tumors with about 93 percent accuracy.

Working with the Washington University Office of Technology Management, Uppaluri has a patent pending on this technology and recently received funding from the Siteman Cancer Frontier Fund to develop a laboratory test that predicts aggressive disease and would be easily available for any patient diagnosed with head and neck cancer.

“These kinds of tests are available for other types of cancer, most notably breast cancer,” he said. “They are transformative genetic tests that can alter the clinical management of patients, tailoring therapies especially for them. It’s our goal to develop something like that for head and neck cancer.”

Source:
Washington University School of Medicine

Jim Kelly’s toughest game: Fighting oral cancer

Source: www.foxnews.com
Author: Dr. Manny Alvarez

Jim Kelly, the Hall of Fame quarterback who played for the Buffalo Bills until 1996, is one of the greatest football players that I have ever seen. During his football career, I followed him closely and was always in awe of his athletic abilities, his leadership qualities and his love of family.

Unfortunately, Jim Kelly is currently battling a second recurrence of oral cancer and has been scheduled to undergo surgery in an attempt to control the disease. His wife, Jill, told the Associated Press that her 54-year-old husband’s cancer is aggressive and beginning to spread.

I’ve been following Jim Kelly’s health struggles and have been thinking about him, praying that he gets better. It is easy to think of some humans as immortal – especially when you’re looking at an individual as physically fit as Jim Kelly. But we tend to forget that sometimes nature has a unique plan for all of us.

However, Jim Kelly’s struggles can serve as a reminder for us all to be vigilant about our health. Jim Kelly is suffering from oral cancer, which doesn’t get the attention that it deserves, despite the fact that 42,000 new cases will be diagnosed in 2014, according to the National Cancer Institute.

Oral cancers are any cancers occurring in the oral cavity, which starts in your throat and extends all the way to your lips. The sad part about this disease is that oral cancers are typically not identified early, which severely reduces survival rates.

The early signs of oral cancer are often missed because lesions are small, painless and often not irritating – especially in tongue cancers or cancers of the gums. But, as the cancer grows, these lesions become ulcerated, causing burning and severe tenderness in the affected areas. Because of the vascular nature of the mouth and throat, many of these cancers tend to metastasize, making matters much worse.

Some risk factors for oral cancer include tobacco use, excessive alcohol consumption and exposure to some strains of the humanpapilloma virus (HPV). HPV has also been linked to cervical cancers in women.

One very important fact to know about oral cancer is that diagnoses of the disease have increased every year for the past five years, according to The Oral Cancer Foundation. That is why it’s so important for people to schedule regular appointments with their dentist – and to make sure they get examined for signs of oral cancer.

If you catch oral cancers early, the survival rate can be over 80 percent. Treatments for oral cancer often include surgery, in addition to radiation and chemotherapy. Yet, once the tumor has metastasized, it can be very challenging for doctors to control or remove it.

Please join me in wishing Jim Kelly all our love and support, and keep his family in our hearts.

March, 2014|Oral Cancer News|

Recurrent mouth and throat cancers less deadly when caused by HPV

Source: www.oncologynurseadvisor.com
Author: Kathy Boltz, PhD

People with late-stage cancer at the back of the mouth or throat that recurs after chemotherapy and radiation treatment are twice as likely to be alive 2 years later if their cancer is caused by the human papillomavirus (HPV), suggests new research. This study was presented at the 2014 Multidisciplinary Head and Neck Cancer Symposium, held in Scottsdale, Arizona.

Previous studies have found that people with so-called HPV-positive oropharyngeal cancers are more likely to survive than those whose cancers are related to smoking or whose origins are unknown.

The new study shows that the longer survival pattern holds even if the cancer returns. Oropharyngeal cancers, which once were linked primarily to heavy smoking, are now more likely to be caused by HPV, a virus that is transmitted by oral and other kinds of sex. The rise in HPV-associated oropharyngeal cancers has been attributed to changes in sexual behaviors, most notably an increase in oral sex partners.

For the study, the researchers used data provided by the Radiation Therapy Oncology Group on 181 patients with late-stage oropharyngeal cancer whose HPV status was known and whose cancer had spread after primary treatment.

There were 105 HPV-positive participants and 76 HPV-negative ones. Although the median time to recurrence was roughly the same (8.2 months vs 7.3 months, respectively), some 54.6% of those with HPV-positive cancer were alive 2 years after recurrence, whereas only 27.6% of those with HPV-negative cancers were still alive at that point in time.

The researchers also found that those whose cancers could be treated with surgery after recurrence—regardless of HPV status—were 52% less likely to die than those who did not undergo surgery. Surgery has typically been done in limited cases, as doctors and patients weigh the risks of surgery against the short life expectancy associated with recurrent disease.

“Historically, if you had a recurrence, you might as well get your affairs in order, because survival rates were so dismal. It was hard to say, yes, you should go through surgery,” said study leader Carole Fakhry, MD, MPH, an assistant professor in the Department of Otolaryngology-Head and Neck Surgery at the Johns Hopkins University School of Medicine in Baltimore, Maryland. “But this study shows us that surgery may have a significant survival benefit, particularly in HPV-positive patients.”

Although it remains unclear why patients with HPV-positive tumors have better outcomes than those with HPV-negative tumors, researchers speculate that it may be due to biologic and immunologic properties that render HPV-positive cancers inherently less malignant or better able to respond to radiation or chemotherapy treatment.

“Until this study, we thought that once these cancers came back, patients did equally poorly regardless of whether their disease was linked to HPV,” she said. “Now we know that once they recur, HPV status still matters. They still do better.”

March, 2014|Oral Cancer News|

Surgery beats chemotherapy for tongue cancer, U-M study finds

Source: www.eurekalert.org
Author: press release

Patients with tongue cancer who started their treatment with a course of chemotherapy fared significantly worse than patients who received surgery first, according to a new study from researchers at the University of Michigan Comprehensive Cancer Center.

This is contrary to protocols for larynx cancer, in which a single dose of chemotherapy helps determine which patients fare better with chemotherapy and radiation and which patients should elect for surgery. In larynx cancer, this approach, which was pioneered and extensively researched at U-M, has led to better patient survival and functional outcomes.

But this new study, which appears in JAMA Otolaryngology Head and Neck Surgery, describes a clear failure.

“To a young person with tongue cancer, chemotherapy may sound like a better option than surgery with extensive reconstruction. But patients with oral cavity cancer can’t tolerate induction chemotherapy as well as they can handle surgery with follow-up radiation. Our techniques of reconstruction are advanced and offer patients better survival and functional outcomes,” says study author Douglas Chepeha, M.D., MSPH, professor of otolaryngology – head and neck surgery at the University of Michigan Medical School.

The study enrolled 19 people with advanced oral cavity cancer. Patients received an initial dose of chemotherapy, called induction chemotherapy. Those whose cancer shrunk by half went on to receive additional chemotherapy combined with radiation treatment. Those whose cancer did not respond well had surgery followed by radiation.

Enrollment in the trial was stopped early because results were so poor.

Ten of the patients had a response to the chemotherapy, and of that group, only three had a complete response from the treatment and were cancer-free five years later. Of the nine patients who had surgery after the induction chemotherapy, only two were alive and cancer-free after five years.

The researchers then looked at a comparable group of patients who had surgery and sophisticated reconstruction followed by radiation therapy and found significantly better survival rates and functional outcomes.

“The mouth is a very sensitive area,” Chepeha says. “We know the immune system is critical in oral cavity cancer, and chemotherapy suppresses the immune system. If a person is already debilitated, they don’t do well with chemotherapy.”

“Despite the proven success of this strategy in laryngeal cancer, induction chemotherapy should not be an option for oral cavity cancer, and in fact it results in worse treatment-related complications compared to surgery,” Chepeha adds.

December, 2013|Oral Cancer News|