Delivering the Best Outcomes, Fewest Side Effects

Cancers of the head and neck are relatively rare, accounting for less than 4% of cases in the United States, but they are extremely complicated to treat because they attack essential daily functions.

“People sometimes ask why I went into head and neck cancer. It’s because these cancers affect the basics of quality of life—eating, drinking, speaking, hearing, smiling, what a person looks like,” says Saral Mehra, MD, MBA, FACS, section chief of head and neck surgery and director of the head and neck tumor board. “So, it’s important to get the treatment right—to get the best possible outcome with the minimal amount of side effects.”

Getting the treatment right is a guiding principle of Yale’s Head and Neck Cancers Program. These diseases damage the mouth, lips, tongue, throat, larynx, sinuses, or salivary glands—fundamental structures jammed into a small area. For that reason, patients receive specialized care from experts, including medical oncologists, radiation oncologists, surgeons, reconstructive surgeons, dentists, speech-language pathologists, swallowing therapists, audiologists, physical therapists, nutritionists, advanced practice providers, and social workers. All of these caregivers in the Head and Neck Cancers Program specialize in the treatment or rehabilitation of patients with these difficult cancers.

Yale is committed to this all-encompassing approach, says Dr. Mehra, because studies affirm that head and neck patients who receive comprehensive multidisciplinary care have better cure rates, survival rates, and quality of life after treatment.

The growing program has added three new surgeons in the past year, bringing the total to seven, while advanced practice providers have more than doubled, from two to six, and the program has also added two medical oncologists and two radiation oncologists. The program now handles 10,000 patient visits per year, an increase of 33% in the last five years, as word spreads about the program’s commitment to a unsurpassed multi-disciplinary team approach for each patient.

WHEN DOES MULTIDISCIPLINARY CARE BEGIN?

After diagnosis, people with head and neck cancers who choose treatment at Smilow Cancer Hospital begin with a team approach from the very start. They meet with a medical oncologist, a radiation oncologist, and a surgeon. Next, each patient’s case is discussed by the Head and Neck Tumor Board, which includes representatives from the whole multidisciplinary team, including radiologists and pathologists sub-specializing in head and neck, a social worker, speech and swallow therapists, advanced practice providers, registered nurse coordinators, and a reconstructive surgeon. The tumor board designs a personalized treatment plan for each patient. This typically includes drug therapy, radiation, and surgery, or some combination of them, in addition to rehab programs. The treatment approved often includes clinical trial participation.

“Our goal is to optimize cure rates and functional recovery,” says Barbara Burtness, MD, division chief for head and neck/sarcoma oncology and director of the Yale head and neck specialized program of research excellence at the Yale Cancer Center. “We want to restore speech and swallowing function to as close to baseline as possible, minimize the risk of chronic pain, and minimize the risk of complications such as aspiration pneumonia.”

Dr. Burtness and the program’s other medical oncologists are among the world’s leading researchers in head and neck cancers. She has directed several clinical trials that led to new FDA-approved first-line treatments now being used nationally. Dr. Burtness and her colleagues are busy with “a very extensive portfolio of clinical trials,” that explore novel drugs to treat these cancers, including new targets for immune checkpoint inhibitors that help ensure a patient’s immune system can perceive and fight cancer and innovative combinations of cancer-fighting drugs.

REMOVING CANCER, REDUCING TISSUE TRAUMA

On the surgical side, Dr. Mehra and his colleagues are experts in advanced techniques such as transoral robotic surgery (TORS). In the past, to remove a tumor from far back in the throat, Dr. Mehra had to split the lip and the jawbone, swing the jawbone out, remove the tumor, rebuild the jaw with a titanium plate, and sew the lip back together.

“With the surgical robot,” Dr. Mehra says, “we can get a camera and three robotic arms in through the mouth and down into the throat, and with a 3-D super-magnified view we can remove tumors completely without having to split the jaw. It also helps preserve the swallowing function and lessens the need for chemotherapy or radiation.” Dr. Mehra and his colleagues now use 3-D printing to make titanium plates and cutting guides so that a new jawbone exactly matches the contour of the original and is aligned perfectly for new dental implants.

Cancer sometimes invades facial nerves, paralyzing the face and robbing patients of the ability to express themselves emotionally. The program recently hired facial plastic & reconstructive surgeon, Suresh Mohan, MD, who literally returns smiles to the faces of such patients. The procedure, called facial nerve reanimation, involves nerve transfers, muscle grafts from the thigh, and sling suspension of the face to restore smile, facial symmetry, and in some cases, even the ability to blink. “Seeing a patient smile again and face the world with confidence after everything they’ve gone through is incredibly rewarding,” Dr. Mohan says.

PROACTIVELY PREPARING FOR TREATMENT

The program’s multidisciplinary support begins even before surgery or chemoradiation, with a visit to the “prehab” clinic.

Jacqueline Dibble, APRN, who directs the program’s team of advanced practice practitioners (APPs), started the clinic in 2019 when she realized that newly diagnosed patients were often too overwhelmed to absorb all the information relayed by the doctor during that early visit. She began scheduling another 90-minute meeting during which patients met support staff who prepared them for treatment and life afterwards, and answered questions about all of it. These team members include an APP, a speech-language pathologist, a nutritionist, and a swallowing specialist who starts patients on an exercise program to strengthen the swallowing muscle, which often reduces the need for a feeding tube after radiation or surgery.

“We did a study and found that patients do better if they are prepped mentally and physically before surgery,” Ms. Dibble says. “When they know what to expect, they have less anxiety and recover better, and leave the hospital quicker.”

The second component of patient support is the “surveillance and rehabilitation clinic” run by the program’s APPs. After completing treatment, patients are seen at lengthening intervals for the next 10 years. Throughout this period they are directed to rehabilitation for speech, swallowing, lymphedema, nutrition, and any other issue. The APPs conduct routine examinations and also review scans, lab work, and other tests. Anything of concern is immediately brought to the doctors. “It allows more patients to be seen, in a more timely manner, which has allowed us to grow our practice,” Ms. Dibble says.