Dana-Farber / Brigham and Women's Cancer Center

Organ Preservation Techniques Improve Quality of Life for Patients

Specialists in the Head and Neck Oncology Center are employing advanced multidisciplinary approaches to achieve the best functional outcome for each patient, including a combination of radiation and medical therapies, as well as surgery when necessary.

"Preserving function for our patients is extremely important, as we treat structures that are essential for eating, speaking, swallowing, and many other critical roles," said Robert I. Haddad, MD, Center Director for the Head and Neck Oncology Center.

Novel approaches in the use of chemoradiation, including the use of lower doses of radiation and new chemotherapy agents, are designed to minimize side effects of curative therapy. In addition, Center specialists are offering less invasive surgical treatment options and novel approaches to the management of surgical morbidities in order to maintain quality of life.

New Findings in Induction Chemotherapy
Specialists in the Head and Neck Oncology Center pioneered the use of induction chemotherapy with docetaxel, cisplatin, and fluorouracil (TPF) in head and neck cancers and led the Phase III study that resulted in the FDA approval of this regimen (N Engl J Med. 2007;357(17):1705-1715). In this study, more than 500 patients were enrolled worldwide, and a clear survival advantage was noted with TPF. This finding has resulted in a significant change in treatment of patients with head and neck cancer.

Jochen Lorch, MD, who leads translational research at the Center, recently published the five-year survival update on this pivotal study and was able to show that the survival benefit of induction chemotherapy with TPF is maintained at five years (Lancet Oncol. 2011 Feb;12(2):153-9.). Median survival was 70.6 months in the TPF group versus 34.8 months in the PF group. Progression-free survival was also significantly better in patients treated with TPF (median 38.1 months) compared with PF (13.2 months).

TORS: A Revolutionary New Surgical Treatment
Dana-Farber/Brigham and Women's Cancer Center surgeons Donald J. Annino, Jr., MD, DMD, and Tom Thomas, MD, MPH, perform TransOral Robotic Surgery (TORS) – an innovative new surgical treatment for oropharyngeal,  pharyngeal, and laryngeal cancers. TORS offers many benefits compared with traditional surgery for head and neck cancers, including:

  • No external incisions;
  • No need for jaw splitting or tracheotomy;
  • Faster recovery;
  • Shorter hospital stay (three to four days compared with seven to 10 days);

TORS also provides a minimally invasive treatment option for patients who have had previous treatment – including surgery, chemotherapy, and radiation, as well as those with recurrent or second primary disease.

"Conventional surgery and reconstruction for head and neck cancers, while effective, have the potential for a longer and more difficult recovery period, and possible external deformities," said Charles M. Norris, Jr., MD, FACS, Surgical Director of the Head and Neck Oncology Center. "TORS represents a groundbreaking new surgical approach to treating selected head and neck cancers and other entities, especially for those patients with early-stage disease of  the oropharynx, hypopharynx, and larynx. TORS treatment of more advanced HPV-related oropharyngeal cancers may also prove to be effective in avoiding adjuvant radiation toxicity."

Pharyngeal Cancer Treated with Robotic Surgery

A 52-year-old woman was successfully treated for oral cavity cancer in October 2005, however, the treatment left her with scarring and limited ability to open her mouth (less than 3 cm).

In November 2010, a routine PET-CT scan revealed a lesion on the posterior pharyngeal wall which could not be treated with conventional surgery. She underwent transoral robotic surgery at Brigham and Women's Hospital in January 2011 with complete excision of the 1.1 x 1.2 cm lesion. A total area of 3.3 x 3.0 cm was removed. Margins were negative. She was discharged home on the third day following the procedure with no dietary restrictions or swallowing or speech difficulties.

Pharyngeal Cancer Treated with Robotic Surgery 01 A 2 cm margin is measured and marked around the tumor. Visualization and dissection are enhanced with the robot, allowing resection of the tumor with margins previously only achieved by invasive mandibulotomy.
Pharyngeal Cancer Treated with Robotic Surgery 02 The tumor is retracted medially. The internal carotid artery covered by the carotid fascia is lateral to the tumor.

Novel Technique to Restore Esophageal Patency
Occasionally, patients present with complete esophageal stenosis following head and neck cancer treatment. Head and neck surgeon Laura Goguen, MD, FACS, and her head and neck surgical colleagues, collaborating with thoracic surgeon Michael Jaklitsch, MD, FACS, are among few in the nation to perform combined antegrade and retrograde esophageal dilation (CARD), including patients who are referred from other centers. A retrospective review of 45 patients who underwent CARD at the Center between May 2001 and September 2008 supports this procedure as a viable option for patients with complete esophageal stenosis and an alternative to chronic gastric tube dependence or laryngopharyngoesphagectomy (Laryngoscope. 2010 Feb; 120(2):261-6).

Intraoperative esophageal patency was obtained in 91 percent of patients and resumption of oral intake occurred in 80 percent of patients. The majority of patients had their gastric tubes removed and resumed a soft or regular diet. Minor complications occurred in 29 percent of CARD procedures, including eight pneumomediastinum, seven GT site problems, two esophageal perforations, and one pharyngeal infection. All complications resolved spontaneously or with minimal interventions.

Pre-emptive Approaches to Swallowing Issues
Speech and Swallow Specialists Elaine Burke, MS, CCC-SLP, and Maria Puglia, MA, CCC-SLP, provide education and swallowing therapy for patients. Prior to the start of treatment, and during and after therapy, these specialists prescribe exercises for the jaw, tongue, tongue base, and the posterior pharyngeal wall to combat the effects of chemo-radiation on these structures. These exercises are designed to help stretch and strengthen muscles and maintain range-of-motion in the jaw, tongue, and tongue base.

"We have found that those patients who follow the exercises at the beginning and throughout treatment and continue to eat or drink even small amounts of liquid or pureed foods during treatment are able to reduce dependence on gastric tubes and have them removed much sooner than patients who do not continue to work these muscles," said Elaine Burke, MS, CCC-SLP.

Strategies related to diet, developed in conjunction with nutritionists in the Center, help patients to reduce the risk of aspiration when consuming foods or liquids. These include modifying types of foods and head positioning during swallowing. Patients also are evaluated using video swallow studies and fiberoptic endoscopic evaluation of swallowing (FEES), which are used to identify issues related to various stages of the patient's swallow. Video swallow studies also identify esophageal strictures that are referred for dilation.

Long-term Support for Treatment Toxicities
Long-term support for patients includes a range of efforts to address swallowing issues, hormone changes, cardiovascular toxicities, dental concerns, and other issues. Speech and swallow specialists continue to address swallowing issues that occur after treatment is concluded, sometimes several years or more following treatment.

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Current and New Concepts in the Biology and Treatment of Head and Neck Cancers
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Dana-Farber President Comments on National Cancer Report

Benz, Jr., MD comments on the Annual Report to the Nation

Dana-Farber president Edward J. Benz, Jr., MD, comments on the
Annual Report to the Nation on the Status of Cancer,
citing encouraging news as well as areas where improvement is needed.

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