For people with head and neck cancer, retaining the ability to speak, swallow, or smile after treatment is as much a concern as managing the disease. If detected early, head and neck cancer is more responsive to treatments, but the treatments can leave people with lingering conditions, such as an inability to speak or swallow and facial paralysis.
The multidisciplinary team at the Head and Neck Center at NYU Langone Health’s Perlmutter Cancer Center continually innovates procedures, treatments, and clinical trials to offer patients optimal survival with the best quality of life possible.
“Our team of medical, radiation, and surgical oncologists has been on the leading edge of developing effective treatments for patients with head and neck cancers,” says Adam S. Jacobson, MD, associate professor in the Department of Otolaryngology—Head and Neck Surgery at NYU Grossman School of Medicine and director of the Head and Neck Center. “We offer top-level care for the management of all of the different head and neck cancers, and we provide a unique experience that enables patients to be cared for in a Comprehensive Cancer Center where all of our specialists are in one place.”
For people with head and neck cancer, this means that they will be seen by surgical, medical, and radiation oncologists who occupy offices on the same floor of the Head and Neck Center at Perlmutter Cancer Center—34th Street.
“There is no other head and neck cancer center in New York City, to my knowledge, where patients with these cancers are seen in a very highly coordinated fashion,” says Kenneth S. Hu, MD, professor in the Departments of Radiation Oncology and Otolaryngology—Head and Neck Surgery at NYU Grossman School of Medicine. “This is a unique patient-centered treatment approach that patients love because when they come here, their evaluation and treatment are vertically and horizontally integrated in one stop.”
In addition to the various experts and specialists who assist with diagnosis, treatment, and follow-up imaging, oncologists work closely with rehabilitation specialists at Rusk Rehabilitation at NYU Langone Orthopedic Hospital to help people recover function and return to their routines after they have completed their treatment.
Beyond the care that patients can receive in Manhattan, the head and neck cancer team is expanding care for patients in Brooklyn and on Long Island. Lindsey Moses, MD, who completed her residency in otolaryngology at NYU Langone, will return in September 2022 to spearhead head and neck cancer service at Perlmutter Cancer Center—Sunset Park. Alec E. Vaezi, MD, PhD, clinical associate professor of otolaryngology—head and neck surgery at NYU Grossman School of Medicine and chief of head and neck surgery at NYU Langone Hospital—Long Island, recently came on board to develop the service at Perlmutter Cancer Center at NYU Langone Hospital—Long Island. Moses M. Tam, MD, clinical assistant professor in the Department of Radiation Oncology at NYU Long Island School of Medicine, a radiation oncologist dedicated to head and neck cancer treatment, recently moved from the Brooklyn location to Long Island.
“We want to mirror the multidisciplinary care that we offer in Manhattan at our other network locations in Brooklyn and on Long Island,” Dr. Jacobson says.
Restoring Quality of Life After Facial Paralysis
Dr. Jacobson leads a team of surgeons who specialize in facial reanimation, a field focused on preserving—and in some cases, restoring—nerve function in a patient’s face after head and neck cancer treatment. Dr. Jacobson’s team includes Jamie P. Levine, MD, associate professor in the Hansjörg Wyss Department of Plastic Surgery at NYU Grossman School of Medicine and chief of microsurgery; Judy W. Lee, MD, clinical associate professor of otolaryngology—head and neck surgery and director of the Division of Facial Plastic and Reconstructive Surgery at NYU Grossman School of Medicine and director of the Facial Paralysis and Reanimation Center; and Danielle Eytan, MD, clinical associate professor of otolaryngology—head and neck surgery.
Facial reanimation surgery is performed as a single-stage surgery, meaning that Dr. Jacobson’s team operates after surgical oncologists remove a tumor—without waking the patient up from anesthesia—during any surgery that might result in the loss of or damage to a facial nerve. In some cases, in which facial paralysis has occurred as a result of surgery for a non–cancer-related problem, the facial animation team conducts the surgery in a separate procedure.
Providing care for a patient with head and neck cancer is very involved, says Allison Most, DNP, FNP-BC, nurse practitioner manager, because of the changes in function and appearance that they experience.
“I love working with facial reanimation patients because we can only make them better,” says Dr. Most. “It’s always wonderful when patients come in and tell us that they attended a child or grandchild’s wedding and they were able to smile better or were just happier with how they looked.”
Innovating Surgical Techniques to Minimize Side Effects
Treatments for head and neck cancer include surgery, radiation therapy, and chemotherapy and targeted drugs. Thyroid cancer, for example, can be treated by completely removing the thyroid gland with a surgical procedure called a thyroidectomy, if the cancer is detected early. Thyroidectomy, however, requires an incision in the central lower neck area, which may leave thick, raised scars called keloids or hypertrophic scars in some patients. To avoid potential scarring, Michael J. Persky, MD, clinical associate professor of otolaryngology—head and neck surgery and director of head and neck robotic surgery, is collaborating with Insoo Suh, MD, associate professor in the Department of Surgery at NYU Grossman School of Medicine, and performing a new technique at Perlmutter Cancer Center called the transoral endoscopic thyroidectomy-vestibular approach (TOTEVA). Studies have shown that this minimally invasive procedure, which avoids scarring of the neck by allowing surgeons to remove the thyroid via three incisions in the lip, is safe for patients.
“People with thyroid cancer should be aware that TOTEVA is not standard of care nor is it a conventional thyroid removal procedure,” Dr. Persky says. “However, the procedure is safe, and it probably will, at some point in the future, become the standard of care for removing the thyroid.”
Dr. Persky recommends TOTEVA for people with thyroid nodules that are small cancers or for people with indeterminate nodules that might be cancer and who do not have extensive disease. TOTEVA is also recommended for people with early-stage thyroid cancer, which comprises the majority of thyroid cancer cases.
To minimize side effects of chemotherapy and radiation therapy in treating oropharyngeal cancer, which forms in the back of the throat, Dr. Persky has adopted the approach of performing primary, or curative, robotic surgery for patients with early stages of the disease to avoid using radiation. If radiation is needed after surgery, lower doses are used to minimize side effects.
“Radiation and chemotherapy applied to the back of the throat can lead to profound, long-lasting, and increasing difficulties with swallowing and dry mouth,” Dr. Persky says. “While we can’t eliminate these side effects, if we can offer primary surgery and can avoid radiation, morbidity can be much less than for patients who require radiation.”
Clinical Trials Aim to Decrease Radiation Side Effects, Improve Outcomes
Radiation therapy and chemotherapy—often delivered in combination for head and neck cancers—can result in side effects that affect a person’s ability to swallow or cause dry mouth or hearing loss. Clinical trials for people with head and neck cancer focus on reducing these side effects and improving outcomes.
For human papilloma virus (HPV)–associated oropharyngeal cancer, researchers at Perlmutter Cancer Center are studying how to reduce, or de-escalate, the amount of radiation and chemotherapy a patient receives during treatment. The goal of de-escalation is to reduce the toxicity of the treatment, which can induce a painful side effect called oral mucositis (inflammation of mucous membranes in the mouth).
“People with HPV-induced oropharyngeal cancer have a very good prognosis, especially if the cancer is confined to the head and neck area,” says Zujun Li, MD, clinical associate professor of otolaryngology—head and neck surgery at NYU Grossman School of Medicine. “We want to de-intensify radiation and chemotherapy in these patients to reduce side effects without affecting the cure rate.”
Some head and neck cancers, such as laryngeal cancer, are associated with smoking tobacco products and drinking alcohol and have a poorer prognosis. Laryngeal cancer is often treated with surgical removal of the voice box, which destroys the patient’s ability to speak. An alternative treatment, Dr. Li says, uses radiation and chemotherapy, which has a cure rate of 60 to 70 percent. A clinical trial is now underway testing whether the addition of immune-modulating agents, which enhance the body’s immune response against cancer, can improve outcomes in these patients.
HPV-associated cancers secrete biomarkers—which can be measured in the blood using a commercially available test—and show the presence of active disease. Dr. Hu is leading a clinical trial at Perlmutter Cancer Center aimed at using this test to adjust radiation dose based on the level of circulating tumor DNA during treatment. Patients in the trial will have HPV DNA measured before treatment and then after four weeks of radiation treatment. Dr. Hu says the level of circulating HPV DNA can guide radiation oncologists to adjust the amount of radiation needed to kill the tumors.
“There has been a lot of interest in a commercially available test to see whether we can use this as a way to monitor patients,” Dr. Hu says. “There are some exciting data that support using this test for HPV-positive patients who have detectable HPV DNA in their blood before they get any treatment.”
Ultimately, Dr. Hu hopes that the test can be used for surveillance of the patient after their treatment, reducing the need for PET/CTs, MRIs, and endoscopies to evaluate whether the cancer has recurred.