It’s well understood that cancer treatment can be incredibly hard on the body, but it’s necessary to beat this aggressive and life-threatening disease.
Cancers of the head and neck, which account for about 4 percent of all cancers in the United States, are no exception. These cancers—particularly those caused by HPV—are typically treated with radiation and chemotherapy. This combination can be effective, but the side effects of radiation can be debilitating.
Radiation can cause damage over time to the body’s blood supply in the tissues, which can result in new side effects that emerge years after treatment ends, says UNC Health head and neck cancer specialist Trevor G. Hackman, MD. For example, the nerves, muscles and vessels in the area that received radiation can shut down and stiffen, disrupting normal functions, such as speech and swallowing.
People who have had radiation to the head and neck also face a higher lifetime risk of carotid artery stenosis, or narrowing of the carotid arteries, because of damage to the microscopic blood supply to these major arteries. This leads to inflammation and thickening of the vessel walls, which restricts blood flow.
Treatment Side Effects in Younger Patients
Over the past decade, more people are getting HPV-associated head and neck cancers and at a much younger age (ages 30-50) than those affected by the traditional, tobacco-related head and neck cancer (typically a population older than age 60). This means the side effects of treatment also affect patients at a younger age. Scientists have yet to fully grasp the long-term impact of treating this younger population with radiation as they also have greater overall life expectancies.
“When we were treating people 20 years ago, it was an elderly population getting cancer, and they were not usually surviving another 20 to 30 years. But now you have a growing population of 20- to 40-year-olds who are getting head and neck cancer, and we don’t really know what the long-term consequence is going to be of radiating those patients,” Dr. Hackman says. “We just don’t have the data because we’ve not been doing it long enough.”
This is what prompted Dr. Hackman and other researchers at the UNC School of Medicine to start a clinical trial in 2011 that explored options to adjust the intensity of treatment patients receive based on their risk factors. Some patients could potentially avoid radiation without risking their chances for a cure.
A Clinical Trial to Reduce or Eliminate Radiation
Although surgery has long been a mainstay of cancer therapy, particularly for lesions in the oral cavity (part of the mouth that can be seen), a combination of chemotherapy and radiation became a preferred option in the late 1990s and early 2000s for treating cancers in the lower throat (oropharynx, hypopharynx and larynx). With this treatment combination, patients could potentially avoid the destructive side effects of surgeries that affected speech, swallowing and appearance.
The growth of transoral surgery and improved reconstructive techniques opened the door for minimally invasive management of the cancer without those side effects. Transoral surgery uses a robot and sometimes a laser to reach cancers of the lower throat through the mouth, avoiding the need to enter the throat through neck incisions. This minimally invasive technique also avoids visible, disfiguring incisions, and more importantly allows surgeons to preserve the muscles and bones in that part of the body that are so critical for speech and swallowing.
“We now have improved surgical techniques and are able to remove tumors from the inside so we don’t take out the muscular support or destroy the skeletal framework,” Dr. Hackman says. “Transoral surgery has grown as an accepted way to remove the primary tumor with very minimal side effects to speech and swallowing function.”
In addition, there have been significant advances in chemotherapy and immunotherapy in the past 10 years.
“Before, the options we had for chemotherapy were pretty toxic, and the launch of immunotherapy has been a game changer with a great response rate,” Dr. Hackman says.
Immunotherapy for head and neck cancer primes the immune system to attack the cancer. One of the greatest defenses cancer cells have is their ability to hide from the immune system. Immunotherapy sheds light on the cancer cells and, when given in conjunction with chemotherapy, increases the effectiveness of treatment.
Given the advances in surgery, chemotherapy and immunotherapy, Dr. Hackman and Jared Weiss, MD, a UNC Health medical oncologist, partnered to launch a clinical trial that married these advances with the goal of reducing or eliminating the need for radiation after surgical removal of the tumor.
Patients qualified for the trial if their primary tumor could be removed using transoral surgery and the overall cancer stage was high (stage 3 or 4—this is usually driven by the presence of cancer in lymph nodes). First, the patients had combination immunotherapy/chemotherapy once a week for six weeks. Then they would heal for two weeks and have repeat scans, followed by surgery. Additional therapy depended on the pathology report from the surgery.
“We had excellent response rates from our five-year study, and 75 percent of patients who would have otherwise received radiation avoided it. It’s been five years out, and those who completed trial therapy have not had any recurrences,” Dr. Hackman says.
Retired school secretary Sandra Wasserman, 75, was a clinical trial participant. Diagnosed with oral cavity cancer, Wasserman was able to avoid radiation because of her participation in the clinical trial.
“I did not have to have radiation—the chemo and immunotherapy did the trick. And then, Dr. Hackman did my surgery on Dec. 15, 2015, and I was home for Christmas,” Wasserman says. “And I’ve been cancer-free now for almost six years.”
Testing the Approach on Tougher Tumors
The success of the first clinical trial motivated Dr. Hackman and the research team to initiate a second trial in 2017 that uses a different chemotherapy/immunotherapy drug combination and expanded the criteria for the trial to include more aggressive and larger tumors. This trial recently completed its goal for patient accrual.
“Some of the patients in this new trial have tumors so large and advanced that they’re having a hard time eating and swallowing due to the size and pain of the lesion, and one of the things we noticed is that some of these patients have had such a good response to the induction trial portion of it (the chemotherapy/immunotherapy prior to surgery) that their lesions shrink, their pain goes away and they can actually eat again,” Dr. Hackman says. “They then go into surgery more functional and capable to heal than they were before.”
This was the case for 47-year-old firefighter Jeremy Meares, who had a tumor in his mouth that was almost too large to remove.
“He was in debilitating pain and losing weight,” Dr. Hackman says. “After chemotherapy, he had such a great response that his pain resolved, and he could eat again. He gained 15 pounds prior to surgery, which is unheard of, usually, in the cancer population, and he did great with the surgery.”
Although Meares did not completely avoid radiation, the induction therapy before surgery “was instrumental in his ability to tolerate surgery and the great results he received,” Dr. Hackman says.
Meares completed treatment at the end of May and is back to work. He says he is glad he participated in the clinical trial.
“I entered the clinical trial and had no problems. It really shrunk the cancer, and it stopped growing,” Meares says.
If you’re experiencing any symptoms of head or neck cancer, talk to your primary care provider or find an ENT doctor near you.