As a head and neck surgical oncologist at NYU Langone Health’s Perlmutter Cancer Center, Umamaheswar Duvvuri, MD, PhD, focuses on understanding the biology of head and neck cancer to improve minimally invasive techniques, such as robotic surgery, and develop and test novel therapies for this disease. His goal is to change the way head and neck cancer is treated, with the aim of curing patients while maintaining their functional outcomes.
Dr. Duvvuri, who is the Mendik Foundation Professor of Otolaryngology in and chair of the Department of Otolaryngology—Head and Neck Surgery at NYU Grossman School of Medicine, discussed advances in the treatment of head and neck cancer and his vision for the department.
Given your experience with treating people with head and neck cancers, what trends have you seen in these cancers?
Head and neck cancer is better described as a subdivided entity rather than one major disease. Head and neck cancer has two main types that we look at right now. One type is carcinogen driven, specifically by smoking and drinking alcohol, and the other is driven by the human papillomavirus (HPV). This is important, because while the treatments for both of these two subtypes are not that different, the treatment goals are different. We only have three approaches for treatment of head and neck cancers that we can do. We can surgically remove the cancer, we can burn the tumors with radiation, or we can poison the cancer with chemotherapy.
What we understand, though, is that HPV-driven head and neck cancers are much more sensitive to treatment, so the cure rate for people is typically on average 90 percent for stage 1 cancers (those that are small and haven’t yet spread to the lymph nodes). So because of this, we have an opportunity to reduce the amount of treatment we give people and try to maintain their survival and therefore improve their quality of life.
So that is the trend with HPV-positive cancers, which are now one of the fastest-growing cancers in America and the rest of the Western world. We are not a hundred percent sure why, but it is probably because of exposure to HPV. But on the flip side, for HPV-negative cancers, those driven by smoking and drinking, we have a very bad cure rate, unfortunately, of 50 percent. For HPV-negative cancers, we are trying to figure out how to treat them in different ways to improve the oncological outcome, because it doesn’t really matter if we save someone’s swallowing or their voice if they are going to die from the cancer.
In summary, it’s a complicated question, but the essence of it is that there is an opportunity to put together treatment paradigms and protocols that allow us to optimize a patient’s quality of life and the length of their life.
With that said, what research is currently underway to help do that?
Perlmutter Cancer Center is leading the charge with a clinical trial looking to de-escalate, that is, reduce, the radiation that is given to patients with HPV-driven cancers. Some of the early results of that trial were presented recently and received an award at the annual meeting of the American Society for Radiation Oncology (ASTRO). The trial is being led by Dr. Kenneth S. Hu, professor in the Departments of Radiation Oncology and Otolaryngology—Head and Neck Surgery and co-director of the Head and Neck Center.
We have another important trial opening for people with HPV-negative cancers, which are typically tumors of the mouth and voice box, oral cavity, and larynx. (HPV-positive cancers are almost exclusively tumors that occur at the back of the throat, in the tonsils and tongue base.) For oral cavity cancers, we usually remove the cancer by removing many or all of the lymph nodes in the neck, a procedure called a neck dissection. In the trial, which is opening in partnership with NRG Oncology, we are removing only the sentinel lymph nodes and looking at whether sentinel lymph node resection, which is a less invasive surgery, is just as good as open surgery, which is major surgery.
From a basic science perspective, there are several investigators at Perlmutter Cancer Center who are very active in researching head and neck cancer, and I am putting together a more robust infrastructure for us to work together. We have investigators such as Dr. Markus Schober, associate professor in the Ronald O. Perelman Department of Dermatology and the Department of Cell Biology; Dr. Amanda W. Lund, associate professor in the Ronald O. Perelman Department of Dermatology and the Department of Pathology; Dr. Mark Yarmarkovich, assistant professor in the Department of Pathology, who was recently recruited; Dr. Michelle Krogsgaard, associate professor in the Department of Pathology; and Dr. Brian L. Schmidt, professor in the Dr. Anthony S. Mecca Department of Oral and Maxillofacial Surgery at the NYU College of Dentistry and director of the NYU Oral Cancer Center.
The basic science aspect of this is really quite exciting. What we are interested in as a group is thinking about how we optimize the utility of these treatments. For example, about 50 percent of the people who are given chemotherapy respond to it. Can we find ways to make that response rate higher if we give people immunotherapy? We also know that only about 20 percent of patients actually respond to immunotherapy. Can we find a way to bump that 20 percent to 30 or 40 percent? Even though that might not seem like a big number, that would be a huge improvement when you consider the number of patients being treated. So we are studying, as a group, the mechanisms that regulate the response to these immunotherapies and then looking at ways to target those mechanisms so that we can improve the efficacy of the drug.
What advances have you seen in the diagnosis of head and neck cancers?
The diagnosis of this disease is often driven by some kind of symptom that gets the patient in to see their doctor. A patient feels a lump in their neck or they become hoarse or they start having pain when they swallow or eat or chew. We are working very closely with patient advocacy groups to try to do screening for these patients. For example, if we know that someone is a smoker or a drinker, maybe we should screen them for head and neck cancer so we could, ideally, catch a precancer or a very early cancer and avoid having it treated at a later time. The concept is not unlike what we do for colonoscopy, which is recommended to be done beginning at age 50. And, hopefully, the result is clean, but if it is not, at least we found a small polyp that might have turned into cancer and is able to be removed before it turns into something worse.
These are the kinds of initiatives we are working on, and because smoking and drinking are key contributors to this disease process, we need to do these initiatives in communities where there is a high incidence and prevalence of smoking and drinking. We do need to be mindful that we are not incriminating anyone or being prejudiced, because that’s not the goal. But clearly there are some groups where the use of tobacco and alcohol is higher than others, and we want to be optimum in targeting that demographic.
What do patients with head and neck cancers want, and what do they deserve, in terms of care?
There is a lot to unpack in that question. Addressing what patients want, there was a research group that found that when patients are initially diagnosed with head and neck cancer, they just want to be cured of cancer, almost at all costs. The group then looked at those same patients three to five years after they were treated and asked them, What are your priorities now? And the answer was if they had known back then what life would be like now, their priorities would have been slightly shifted. They would have tried to optimize their functional outcomes even more so. In other words, if the chance of cure by getting a lower dose of radiation might be 2 percent less than getting a high dose of radiation, but if they knew that their functional outcome was going to be two times better, they would take that trade-off.
That’s hard to describe to patients. What I think patients deserve is to have that kind of information together, have a comprehensive analysis and understanding of all the different treatment options, and allow patients to make goal-directed care decisions. We need to include the patients in their own decision-making, not just the doctor saying, “Well, you have cancer, you need this treatment.”
But “you have cancer, you need surgery” might not be right for a 92-year-old. It may very well be right for a 52-year-old. So having those sorts of conversations is what we are really excited about. What I am trying to do now is to create a comprehensive head and neck cancer program where we go from soup to nuts: from the screening before the diagnosis, to diagnosis, to making a decision plan for the care for the patient, to then prehabilitate these patients.
Prehabilitation aims to introduce rehabilitation to patients before a major medical intervention, like surgery, to improve their outcome. If a patient is a heavy drinker and a heavy smoker, chances are likely that he or she might be malnourished and might not have been taking good care of themselves from a whole-body perspective. They may have heart disease, they may not have been to a doctor for a long time. We want to prehabilitate, or optimize their condition, as much as possible before surgery. If we rush this person into the operating room, we can do a great surgery. But if the patient then has a heart attack or develops pneumonia, we haven’t provided a service.
Part of prehabilitation is a complex discussion about goals of care. What do you want as an individual? What are your desires and what do you want to get out of this? And what are the trade-offs you are willing to make to be able to get those? If I could tell you that radiation is going to increase your percentage chance of cure by 10 or 15 percent, but it is going to increase your rate of complications by 100 percent, are you willing to take that risk?
We, as doctors, are sort of paternalistic. We tell people they have to cure the cancer, but we are not the ones who have to live with the dry mouth or other complications. You can’t be a very productive member of society and go to work if you have to give yourself tube feedings every four hours, for example. So we need to take that into account.
And then finally after that, we go through the treatment, which is where we all have traditionally focused for a long time, trying new drugs, new ways of delivering radiation, introducing new types of surgery. But we often neglect all of that in the beginning, which I think is really important. And then once the treatment is done, we also often neglect survivorship care. How do you help people go back to their lives? How do we help people be better adjusted to the new normal? Because once you’ve had cancer, and you’ve had surgery or treatments, you will never be normal again.
Patients always ask, “Doc, will I be normal?” The answer is, “No, you are never going to be normal because you’ve had cancer. This is going to be your new normal.” We hope to get the patient back as close to normal as possible, but we can’t guarantee 100 percent. This is a long answer, but it’s a complicated question.
What expertise do you bring to Perlmutter Cancer Center to augment its strength in head and neck cancer?
Perlmutter Cancer Center is a great place, and a lot of exciting science has been done here over the years. I think one of the reasons that I was brought in is because I have a translational science background, where I am both an active practicing surgeon as well as a scientist. Finding ways to incorporate science into the care for patients with head and neck cancer is extremely important. And the best way to do that would be to create a team of individuals who can play key roles within all of this. Part of my task is to build upon the existing strengths of the program and augment some of the areas in which we could be better, namely research and, specifically, translational research—the bridge between the bench and the bedside—which is what I am passionate about.
Another reason relates to surgery. The field is constantly evolving. When I was in training, there was no such thing as the robotic surgery that we do to operate on people now. Today, if you are not doing robotic surgery, it’s like you are in the dark ages. I was one of the first people in the country to be doing robotic surgery for head and neck cancer. I still have a huge expertise in it, and I want to continue to push the boundaries on what we can do with it.
One of the specific things that I am working on is minimally invasive surgery using the robot to minimize scars and to maximize patient function. A very tangible example of this is the typical surgery we do for these cancers, the neck dissection I mentioned earlier to remove lymph nodes. Patients usually get a scar across their neck that extends from behind the ear down to the throat. Using the surgical robot, we can now make an incision that looks like a facelift and hide it. This is not only more aesthetically pleasing, but it prevents the buildup of fluid that often accompanies a neck dissection. When you cut through the skin horizontally, as in the neck dissection, the lymph channels that drain the skin get backed up and patients can get swelling in the neck from fluid buildup. In addition to looking bad cosmetically, it also affects swallowing, because there is fluid pressure. By doing this alternate approach, we can save the lymphatics, and the appearance as a whole is much better. And we think the function is better as well. This is something we are studying right now.
For people with head and neck cancer who come to you for care, what should they expect in terms of how they would be treated and how their concerns will be addressed?
I can sum up my philosophy by saying that I believe every patient deserves to be treated as I would treat my own family members. That means I listen to their concerns and give them the advice that I would give my own family member. We are not here to just do surgery as a surgeon. When a patient sees me, they receive a multidisciplinary approach. I have clinic at the same time as my medical and oncology colleagues. We are all there together, so when a patient comes to see me, they will see all three of us, get the opinions of all three experts, and then together we formulate a treatment plan for the patient. Patients will get a holistic, comprehensive approach to treatment.
NYU Langone Health is ranked No. 1 in the nation for quality and patient safety by Vizient Inc., a leading healthcare performance improvement organization. We have excellent outcomes for head and neck cancer care, and we are on par with any other cancer center in the country. I attribute that to a number of things, including the excellent way cancer care at Perlmutter Cancer Center is designed. This is something I intend to build on.
As an example, patients get followed by our advanced practice providers—nurse practitioners and physician assistants—over the continuity of their treatment to make sure that they are getting the best quality of care that they can and that they are being checked in on and not forgotten. We take great care to not have treatment breaks, to not miss people during the course of their treatment so that we can ensure that they get through the process smoothly and effectively.