Robotic surgery and oropharyngeal cancer

Prof Terry Day - Medical University of South Carolina, Charleston, USA

We are hosting a panel on robotic surgery and oropharyngeal cancer. A lot of people aren’t familiar with this type of cancer but it is one of the fastest rising cancers in the world. It’s of the base of tongue and tonsils; it seems to be related to human papilloma virus, so the same virus that can cause cervical cancer. It is now estimated that cancers of the throat are going to bypass cervical cancer in number of cases around the world. The utility of robotic surgery for cancer of the oropharynx really has come on the stage in the last ten years and now it’s probably the most common procedure used to treat these types of cancers. The cancers arise in the back of the throat, most patients that come in have either a lump in their neck that they didn’t realise was a sign of the cancer. Some of them will have a sore throat or trouble swallowing or an earache and oftentimes they’ll see a physician and the physician may or may not diagnose it. They may be treated with antibiotics a number of times and eventually they’ll get to a head and neck surgeon, they’ll get the diagnosis and get recommended for treatment.

People can generally, depending on where they are in the world, they can generally be treated with either surgery or radiation or a combination of surgery and radiation or a combination of chemotherapy and radiation therapy. So when they have surgery one of the common ways to treat that now is with robotic surgery. We can now go through the mouth without any cuts on the face or the neck; we don’t have to split through the lip or the jawbone to get to these tumours like we used to. Robotic arms can go into the mouth, we have a high intensity camera that’s three-dimensional and we get a view of cancers in the back of the throat like we’ve never had before. So actually we’ll be sitting at a console, kind of like a video game, doing the surgery via a robot that is at the patient’s side doing the surgery on the patient. We’re obviously directing and guiding the surgery and we can take out these cancers now with the robot through the mouth and reduce the need for long-term swallowing and chewing and eating and dry mouth and difficulties like that that people used to have with some of the more complicated surgeries that we used to have to do. So robotic surgery many times is shorter, it’s cheaper and there are better outcomes for people with throat cancer than the other treatments we used to have.

Could you tell us a little about staging?

Cancers of the head and neck area are staged and in the United States we use the AJCC criteria for staging. It gives us a stage, usually a 1, 2, 3 or 4, and 1 and 2s are the better, earlier stage cancers, the 3 and 4s are the higher or worse cancers. So when you find out that somebody has a cancer you give it a stage and you can do that by examining the patient, measuring the tumour. You can also do it by a scan, like CAT scans or MRI or PET scans. That gives you information about how big the tumour is, where it is and if it’s spread or not. Once you know that you give it what’s called a TNM stage: T stands for tumour, N stands for nodes or lymph nodes and M stands for spread or metastasis. So once you get a TNM stage you then know the stage of the cancer and you can give somebody a general percentage chance that this will be cured. We also know over the last several decades of experience that what the best treatment is, based on the stage. So we really want to know the exact stage.

One of the research studies we’re presenting today is on how we use the stage and we’re comparing the stage that we get from looking at the patient and from the scans to a stage we actually get when the tumour is taken out. What we’ve found is that those stages don’t always correlate, so when you do the surgery you might find something different than you found on the CAT scan. So the surgery or the pathologic stage becomes the final, definitive, accurate stage and then you decide on whether or not somebody needs radiation or chemotherapy. So it’s important to get the right stage and we’re trying to find the best way to predict what the right stage is before we put somebody through surgery.

Are there mathematical models that can be used?

Not yet, it would be ideal to have a mathematical model and I think that will come. But for now we’re finding out that the pathologic stage at the time of surgery is different from the stage we thought was right for people that don’t get surgery in about a third of the cases. So what we’re trying to figure out is who is going to need more treatment and who is going to need less treatment, based on a stage. So we’re trying to identify those factors. It’s going to take a few years and we’re going to need some more detailed information to get the right answer to that but that’s going to be important. So anybody that gets these cancers or any physicians treating these cancers, they should look at this closely to make sure they’re giving the patient the accurate stage up front or some people may get too much treatment, treatment they didn’t need, or other patients may not get enough treatment to cure the cancer.

What about prevention?

Prevention of cancer, there are multiple types of prevention. Primary prevention is really stopping people from being exposed to the factors that cause cancer. So in mouth cancer, which is called oral cavity cancer, the most common cause worldwide is tobacco use. There are different types of tobacco, whether it’s chewing or betel nut or smoking and we don’t know the effects now in e-cigarettes, but in different parts of the world there are different types of tobacco that people are using. So the ideal situation would be in primary prevention is you would stop people from being exposed to these factors.

Now, on the other hand, oropharyngeal cancer, and people often get these two terms mixed up, that oral cancer is not oropharyngeal cancer - oral cancer is mouth, oropharyngeal cancer is throat. Oropharyngeal, or throat cancer of the base of tongue and tonsil, are usually caused by a virus, the HPV or human papilloma virus. That’s the same virus that causes cervical cancer. This has really dramatically increased in incidence, especially in the United States and developing countries, in that the HPV virus is just about everywhere and not very many people were vaccinated when they could be vaccinated as teenagers. So now people are getting these cancers ages 40-60 that didn’t know they’d ever been exposed to a cancer-causing agent. So they’re arising in the back of the throat, in the tonsil and the back of the tongue. So to prevent those obviously the only thing we know about right now is a vaccine. Unfortunately I don’t know of any country the vaccine is approved to give to prevent throat cancer. Hopefully logic will win in this scenario and we’ll have this vaccine to prevent these cancers because sometimes the treatment for these cancers can cause people a lot of problems.

Robotic surgery and oropharyngeal cancer

Prof Terry Day - Medical University of South Carolina, Charleston, USA

We are hosting a panel on robotic surgery and oropharyngeal cancer. A lot of people aren’t familiar with this type of cancer but it is one of the fastest rising cancers in the world. It’s of the base of tongue and tonsils; it seems to be related to human papilloma virus, so the same virus that can cause cervical cancer. It is now estimated that cancers of the throat are going to bypass cervical cancer in number of cases around the world. The utility of robotic surgery for cancer of the oropharynx really has come on the stage in the last ten years and now it’s probably the most common procedure used to treat these types of cancers. The cancers arise in the back of the throat, most patients that come in have either a lump in their neck that they didn’t realise was a sign of the cancer. Some of them will have a sore throat or trouble swallowing or an earache and oftentimes they’ll see a physician and the physician may or may not diagnose it. They may be treated with antibiotics a number of times and eventually they’ll get to a head and neck surgeon, they’ll get the diagnosis and get recommended for treatment.

People can generally, depending on where they are in the world, they can generally be treated with either surgery or radiation or a combination of surgery and radiation or a combination of chemotherapy and radiation therapy. So when they have surgery one of the common ways to treat that now is with robotic surgery. We can now go through the mouth without any cuts on the face or the neck; we don’t have to split through the lip or the jawbone to get to these tumours like we used to. Robotic arms can go into the mouth, we have a high intensity camera that’s three-dimensional and we get a view of cancers in the back of the throat like we’ve never had before. So actually we’ll be sitting at a console, kind of like a video game, doing the surgery via a robot that is at the patient’s side doing the surgery on the patient. We’re obviously directing and guiding the surgery and we can take out these cancers now with the robot through the mouth and reduce the need for long-term swallowing and chewing and eating and dry mouth and difficulties like that that people used to have with some of the more complicated surgeries that we used to have to do. So robotic surgery many times is shorter, it’s cheaper and there are better outcomes for people with throat cancer than the other treatments we used to have.

Could you tell us a little about staging?

Cancers of the head and neck area are staged and in the United States we use the AJCC criteria for staging. It gives us a stage, usually a 1, 2, 3 or 4, and 1 and 2s are the better, earlier stage cancers, the 3 and 4s are the higher or worse cancers. So when you find out that somebody has a cancer you give it a stage and you can do that by examining the patient, measuring the tumour. You can also do it by a scan, like CAT scans or MRI or PET scans. That gives you information about how big the tumour is, where it is and if it’s spread or not. Once you know that you give it what’s called a TNM stage: T stands for tumour, N stands for nodes or lymph nodes and M stands for spread or metastasis. So once you get a TNM stage you then know the stage of the cancer and you can give somebody a general percentage chance that this will be cured. We also know over the last several decades of experience that what the best treatment is, based on the stage. So we really want to know the exact stage.

One of the research studies we’re presenting today is on how we use the stage and we’re comparing the stage that we get from looking at the patient and from the scans to a stage we actually get when the tumour is taken out. What we’ve found is that those stages don’t always correlate, so when you do the surgery you might find something different than you found on the CAT scan. So the surgery or the pathologic stage becomes the final, definitive, accurate stage and then you decide on whether or not somebody needs radiation or chemotherapy. So it’s important to get the right stage and we’re trying to find the best way to predict what the right stage is before we put somebody through surgery.

Are there mathematical models that can be used?

Not yet, it would be ideal to have a mathematical model and I think that will come. But for now we’re finding out that the pathologic stage at the time of surgery is different from the stage we thought was right for people that don’t get surgery in about a third of the cases. So what we’re trying to figure out is who is going to need more treatment and who is going to need less treatment, based on a stage. So we’re trying to identify those factors. It’s going to take a few years and we’re going to need some more detailed information to get the right answer to that but that’s going to be important. So anybody that gets these cancers or any physicians treating these cancers, they should look at this closely to make sure they’re giving the patient the accurate stage up front or some people may get too much treatment, treatment they didn’t need, or other patients may not get enough treatment to cure the cancer.

What about prevention?

Prevention of cancer, there are multiple types of prevention. Primary prevention is really stopping people from being exposed to the factors that cause cancer. So in mouth cancer, which is called oral cavity cancer, the most common cause worldwide is tobacco use. There are different types of tobacco, whether it’s chewing or betel nut or smoking and we don’t know the effects now in e-cigarettes, but in different parts of the world there are different types of tobacco that people are using. So the ideal situation would be in primary prevention is you would stop people from being exposed to these factors.

Now, on the other hand, oropharyngeal cancer, and people often get these two terms mixed up, that oral cancer is not oropharyngeal cancer - oral cancer is mouth, oropharyngeal cancer is throat. Oropharyngeal, or throat cancer of the base of tongue and tonsil, are usually caused by a virus, the HPV or human papilloma virus. That’s the same virus that causes cervical cancer. This has really dramatically increased in incidence, especially in the United States and developing countries, in that the HPV virus is just about everywhere and not very many people were vaccinated when they could be vaccinated as teenagers. So now people are getting these cancers ages 40-60 that didn’t know they’d ever been exposed to a cancer-causing agent. So they’re arising in the back of the throat, in the tonsil and the back of the tongue. So to prevent those obviously the only thing we know about right now is a vaccine. Unfortunately I don’t know of any country the vaccine is approved to give to prevent throat cancer. Hopefully logic will win in this scenario and we’ll have this vaccine to prevent these cancers because sometimes the treatment for these cancers can cause people a lot of problems.

Are teenagers in the US vaccinated against HPV?

It is given to teenage girls and it was approved by the FDA in the United States. It took a while then to get it approved for boys and now it is approved for both boys and girls in the United States. But the last statistics I saw was that less than half of teenagers were getting all three doses of this vaccine. So you worry what’s going to happen in a few decades when people are at the age that these throat cancers are arising - are we going to continue to see the dramatic increase in numbers of cases that we’re seeing today?

Are there any trials looking at the potential damage caused by e-cigarettes?

I’ve heard that there are trials, I’m not aware of any specifics but obviously there is a lot of controversy surrounding e-cigarettes and their contents and if these are cancer causing agents or not. So we really don’t have enough information yet to give any conclusion. My feeling is if there’s something harmful we know the environmental effects of smoke in factories and things like that and if some type of smoke is going in your mouth that maybe is not intended to be there, that it could potentially cause a cancer. We just don’t know yet so I think studies are going to have to be done to determine that.

It is given to teenage girls and it was approved by the FDA in the United States. It took a while then to get it approved for boys and now it is approved for both boys and girls in the United States. But the last statistics I saw was that less than half of teenagers were getting all three doses of this vaccine. So you worry what’s going to happen in a few decades when people are at the age that these throat cancers are arising - are we going to continue to see the dramatic increase in numbers of cases that we’re seeing today?

Are there any trials looking at the potential damage caused by e-cigarettes?

I’ve heard that there are trials, I’m not aware of any specifics but obviously there is a lot of controversy surrounding e-cigarettes and their contents and if these are cancer causing agents or not. So we really don’t have enough information yet to give any conclusion. My feeling is if there’s something harmful we know the environmental effects of smoke in factories and things like that and if some type of smoke is going in your mouth that maybe is not intended to be there, that it could potentially cause a cancer. We just don’t know yet so I think studies are going to have to be done to determine that.