A University of Southern California professor made an appointment with his primary care doctor at USC after a twinge in his neck became an ache, and then a lump. He was immediately referred to Uttam Sinha, MD, a head and neck cancer surgery specialist for the USC Norris Comprehensive Cancer Center.
A PET CT scan and needle biopsy confirmed squamous cell carcinoma of the head and neck. Head and neck cancers account for ~4% of all cancers in the United States--impacting almost 67,000 Americans annually.1 Human papillomavirus (HPV) types are implicated in many oropharyngeal cancers—specifically, HPV-16 and HPV-18.2 Diagnostics revealed the tumor expressed P16.
Head and neck tumors are unique—no two cancers tend to be alike. Therefore, having an integrated team of oncology specialists solely dedicated to this tumor type is optimal. At USC Caruso Department of Otolaryngology-Head and Neck Surgery, the approach to cancer treatment is multidisciplinary, including a weekly head and neck tumor board to discuss treatment approaches to each patient's care. The patient's care team included a surgical oncologist, radiation oncologist, medical oncologist, oncology nursing team, nutritionist, physical therapists, lifestyle modification coach, and psychologist.
Since the patient's treatment plan would involve surgery, chemotherapy, and radiation, the team designed a pre-surgical program to maintain muscle cells and muscle function that involved vocal exercises along with physical therapy, speech transforming therapy, and neuromuscular electrical stimulation. He was also encouraged to gain weight to prepare for the inevitable weight loss associated with post-surgical chemotherapy and radiation.
Adam Garsa, MD
"There can be a lot of collateral damage with surgery and radiation," Dr. Sinha, professor of otolaryngology-head and neck surgery at the Keck School of Medicine of USC, says, "which can cause scar formation, which in turn can compromise quality of life in terms of the function of the muscles. If the patient does therapy before and during treatment to combat this, there is less scar formation, resulting in a better functional outcome."
In January of 2020, Dr. Sinha performed a transoral robotic surgery procedure to remove the tumor in the throat and modified radical neck dissection to remove the lymph nodes in his neck affected by the cancer. The complex surgery was successful, and the entirety of the tumor was extracted. Lymphedema therapy was initiated as part of rehabilitation.
"One of the main reasons our patients have great outcomes is our team approach," says radiation oncologist Adam Garsa, MD, an assistant professor of clinical radiation oncology at the Keck School. "We work together to develop the optimal approach to treat the cancer and minimize the effects of treatment."
Jorge Nieva, MD
Dr. Garsa and medical oncologist Jorge Nieva, MD, led the next phase of the treatment plan. Dedicated solely to treating head and neck cancer, Dr. Garsa is highly skilled at delivering radiation to this patient population. As Dr. Nieva acknowledges of his colleague, getting the radiation fields properly aligned so that only the areas of risk are radiated with the most advanced equipment—sparing normal tissue where possible—is critical.
One of the benefits of being at an academic medical center like Keck Medicine is access to clinical trials that can lead to better outcomes. Dr. Nieva invited the patient to join a novel clinical trial designed to address the side effects of chemoradiotherapy in patients with locally advanced, non-metastatic head and neck cancer.
"Patients with head and neck cancer often need the combination of chemotherapy and radiation given at the same time," says Dr. Nieva, associate professor of clinical medicine at the Keck School. "That's because with surgery in many of the areas of the head and neck, it's difficult or undesirable to remove too much tissue from an area because there are so many vital structures nearby. Chemotherapy and radiation help to clean up any cancer cells that may be around after surgery."
The clinical trial involved GC4419—also known as avasopasem manganese—an investigational, highly selective small-molecule superoxide dismutase mimetic. Dr. Nieva reports that this drug class helps make the effects of the radiation even more pronounced on the tumor but protective of the normal tissue, so the patient has less pain, less adverse side effects, and more therapeutic effects.
Dr. Neiva reports that "when the radiation beam is delivered, we want to alter the balance between superoxide and hydrogen peroxide in favor of hydrogen peroxide. The experimental molecule GC4419 helps accelerate that conversion… it is a way of causing more injury to the cancer and less injury to the normal lining of the throat."
Chemoradiotherapy is well-known for causing losses in appetite, weight, and taste. By the nature of their location in the body, head and neck cancers can increase these side effects and impact smell and hearing as well. The pre-surgical therapy program put in place by the multidisciplinary team made a significant difference in the patient’s outcome.
After treatment, the patient had no sense of taste or smell, there was a chance that only a small percentage of his taste would come back, and there was also a chance he would lose his hearing and use of his voice. For a educator, this would have been particularly devastating.
The physical therapy and rehabilitation programs, coupled with the patient’s inclusion in the novel clinical trial, made a significant difference. A year after treatment the patient has his smell, voice and 99% of his taste back, and never lost his hearing.
"During my treatment, whether I would be able to teach again was a big part of my anxiety," reports the patient. "At first, I couldn't talk before noon because my voice was gravelly. But then I started getting my voice back and doing the exercises, and it came back so quickly that I knew I could teach again."
About USC Caruso Department of Otolaryngology – Head and Neck Surgery
The head and neck cancer team at the USC Caruso Department of Otolaryngology – Head and Neck Surgery, part of Keck Medicine of USC in Los Angeles builds strong relationships with patients to meet both the physical and emotional demands of fighting head and neck cancers. We work with patients every step of the way—from diagnosis to rehabilitation—in treating tumors of the mouth, nose, throat, larynx, sinuses, lymph nodes and salivary glands. Our surgeons are also leading experts in parathyroid and thyroid surgery, and we offer the finest diagnostic tools and endoscopic and open surgery removal techniques.
The team, which includes head and neck surgeons, as well as medical oncologists, radiologists and radiation oncologists from the USC Norris Comprehensive Cancer Center, is involved through the entire cycle of care from pre-surgery to rehabilitation and can offer patients the full range of options from robotic surgery, open surgery with reconstruction and chemo-radiation. The team also works very closely with speech and language pathologists who are essential to the patient’s post-surgery rehabilitation. Our therapists and pathologists help patients regain muscle strength and coordination, powers of speech and other functional necessities like swallowing.
To refer a patient for a consultation, please call (323) 442-0118.