Head and neck cancer: developments in endoscopy, reconstructive surgery and patient care

Prof Dennis Kraus - North Shore-LIJ Cancer Institute, New York, USA

Can you discuss your talk on quality of life for head and neck cancer?

My specific talk is about swallowing dysfunction in patients with advanced oral cavity cancer who undergo major surgical resection and then have chemo and radiation as part of their treatment. Again, it’s a good story and it’s a bad story. So if you look at what we’ve been able to do since the time of my training, we can completely reconstruct your jawbone. You can have your jawbone removed from here to here, take the lower bone in your leg, we’ll reconstruct a new jawbone, you’ll look very much the way you did. But the problem is that over time, and this is the real difficult part of it, in the chemoradiated patients they develop worse and worse swallowing function. The muscles stop working, the sensory mechanism stops working and these patients really develop significant impact in terms of their ability to eat. If you think about it, in terms of all of our social function, one of the most significant social functions is the ability to sit down with someone else and break bread and when you lose that it can have an extraordinary impact upon your social function, upon your ability to be in a work environment, to interact with your family. Again, we’re continuing to try to develop strategies where we can help patients be able to swallow better over a longer period of time.

How can you tackle this issue?

One of the transitions that we made in our healthcare system is that all of the head and neck cancer patients are seen jointly with a speech and swallowing specialist. So we actually have baseline data on patients and we understand what their level of ability to swallow and not swallow is, even prior to any treatment. They are continued to be followed by these people post-operatively, they’re offered exercises. One of the things that can have a huge impact upon your ability to swallow is whether you can open your mouth or not. The inability to open your mouth is a term called trismus and if you can’t open your mouth think about your inability to do something like bite an apple, eat a sandwich. So we actually have mechanical devices that can help patients exercise their jaw.

So these are one of many things that we’re still understanding. We’re also understanding the central mechanisms that occur in the brain and we’re trying to put all of that together to come up with more effective rehabilitative strategies for swallowing function.

Can you describe your initial treatment techniques at North Shore?

It’s fair to say that, really, surgically one of my raison d’êtres during the course of my career has been to create different mechanisms of minimally invasive surgery. Minimally invasive surgery can mean many, many things. So, for example, we do a lot of robotic surgery so, again, we’re removing a lot of these oropharyngeal cancers, removing some larynx cancers, some nasopharynx cancers, utilising the robot. So that avoids many of the disfiguring operations that we used to perform where we would have to make incisions in people’s lips, cut their jawbone; I don’t do that any longer. So that’s one aspect of it. There’s a lab surgery that we can now do endoscopically through the nose where we would have had to make an incision along your nose and along your eye to remove a tumour. We no longer need to do that in the majority of patients, we’re now able to do that endoscopically through the nose.

Then, lastly, something as simple as using a small incision for thyroid and parathyroid surgery. I’ve had a pretty compelling experience that many of my patients are able to return to work sooner, they have a reduction in need for pain medication, they don’t have the long-term numbness in their neck and they just overall have an improved quality of life.