Head and Neck Cancer Care with Evan Graboyes, M.D.

There are many new treatments for head and neck cancers, yet survival outcomes are poor, especially among Black Americans. In this episode, Dr. Evan Graboyes, a head and neck oncologic surgeon and director of survivorship and cancer outcomes research at MUSC Hollings Cancer Center, shares how a team of specialists are trying to catch this cancer earlier and offer more cutting-edge treatments for patients.

Topics Covered in This Show

• Head and neck cancers typically present within the mouth and throat. They can also include cancers in the salivary glands and melanoma that affect the face in functionally critical areas.
• Early indicators of head and neck cancer can include the voice changing or a sore on the side of the tongue. Ear issues can also be an indicator of head and neck cancer. An important early sign is often a lump on the neck.
• Treatments can affect people in life-altering ways, including their breathing, swallowing, eating, and speech.
• While excessive tobacco and alcohol use are leading causes of head and neck cancer, the human papillomavirus (HPV) has become very prevalent in head and neck cancer diagnoses as well. This affects men more than women, typically in their 40s and 50s. HPV screening to prevent cervical cancer has been very successful in this country, but there is less attention on its relation to head and neck cancer.
• Gardasil, a vaccine to prevent specific strains of HPV, is available to youth ages 9 to 14 and males and females only up to the age of 45 for three doses. The hope is that this will help bring down the prevalence of HPV-related head and neck cancer.
• Doctors think that HPV-related head and neck cancers are caused by HPV infections from much earlier in life. There are usually no symptoms, so people don’t even know they have it. HPV can be detected with a cheek swab, and doctors are looking into more methods of early detection for those who may be at risk.
• Reliable tests for early detection of head and neck cancer have not been developed yet, but there are other methods of early detection, particularly through routine dental check-ups.
• White men are getting this cancer more, but Black men have worse outcomes. Alcohol and tobacco-related head and neck cancers have a much worse survival rate than HPV-related head and neck cancers. HPV-related head and neck cancers seem to affect White men more than Black men, though it is not clearly understood why. Black men are more likely to suffer from tobacco and alcohol-related head and neck cancer. There is some information about different racial subgroups’ response to treatment, but this may also be explained by lack of access to timely treatment. The field is aware of this disparity and is working to try and improve outcomes for Black men.
• Doctors who treat head and neck cancer generally rely on three treatment methods: surgery, radiation, and systemic therapies. The right combination will depend on the patient and their stage of diagnosis.
• MUSC Health offers a holistic treatment approach for its head and neck cancer patients, including access to a team of a variety of oncologists, surgeons, speech and occupational therapists, and dedicated administrative staff that can help patients navigate making a variety of appointments and managing their overall treatment.
• Doctors at MUSC Health are using transoral robotic surgery to treat some head and neck cancers. It is minimally invasive, allowing for less morbid outcomes. They are also looking at using stronger treatments such as immunotherapy to treat alcohol and tobacco related head and neck cancer to try and improve outcomes.
• Graboyes asserts that head and neck cancer is a very preventable cancer, and things like smoking cessation, decreasing alcohol intake, and the HPV vaccine can all help.

Read the Show Transcript

Erin Spain, MS [00:00:03] Welcome to advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Head and neck cancers are typically caused by tobacco and alcohol use and the human papillomavirus. And while there are many new treatments for these cancers, survival outcomes are poor, especially among Black Americans. Here at MUSC Health, a team of specialists are trying to catch this cancer earlier and offer more cutting edge treatments for patients. Here with details is Dr. Evan Graboyes, a head and neck oncologic surgeon and director of survivorship and cancer outcomes research at the Hollings Cancer Center here at MUSC Health. Welcome to the show, Dr. Grayboyes.

Evan Graboyes, M.D. [00:00:53] Hi. Great to be here. Thanks so much for the opportunity, Erin.

Erin Spain, MS [00:00:56] Well, I'd love to talk about some examples of head and neck cancer. Tell me, what are some common head a neck cancers that you see in patients that come to see you for treatment.

Evan Graboyes, M.D. [00:01:06] Head and neck cancer probably isn't appropriately named since it's a little bit confusing. So often what we start by saying is what cancer is not so it's not the spine, it's not the brain, it's not teeth, it's not the esophagus. Most of the cancers we take care of our inside the mouth and throat. And so they come from the lining of the tissue inside the to the upper air digestive tract. So inside the jawbone, inside the back part of the throat, the tonsils, the back part of the tongue, the voice box, which was predominantly the cancers we see. There are a number of other types of cancers that we also see in our clinic. So in South Carolina especially, we see lots of patients with skin cancers. So from sun exposure, people can also get cancers that arise from the salivary glands. So these lines are located in front of the ear. They're called the prodded gland or underneath the jawbone, the sub -- gland. And often we also see patients sometimes who have melanoma as another type of skin cancer we see. So they're very, I think, different in their presentation, but all occur in sort of cosmetically and functionally critical areas of the face and throat.

Erin Spain, MS [00:01:56] This is your face, this is your neck, this is your voice box. I mean, these cancers really impact patients. Can you tell me about that?

Evan Graboyes, M.D. [00:02:02] The signs of head, neck cancer can be subtle. And so sometimes patients either through lack of awareness or inability to access care present at late stages. And so sometimes the early symptoms can be things like voice changing or sore on the side of the tongue. And depending upon how advanced cancer is, treatments can involve really critical and life altering and permanent changes to things that are critical for our identity and our social function. So these may be things related to breathing. So sometimes patients love to temporarily breathe or breathing tube in their neck or tracheostomy tube will impact their swallowing functions. They may not be able to eat the food that they used to eat or eat as much of it. Sometimes patients have to have their teeth removed just part of cancer. Sometimes their facial structure changes. Cancer may go into their lower upper jawbone. And we've made tremendous, tremendous progress in our ability to treat these cancers in a way that helps improve survival, decreases the likelihood of cancer coming back, and improve outcomes for patients long into survivorship. But I think we also have a long way to go on each of those fronts.

Erin Spain, MS [00:02:52] While catching this cancer early is so important and like you said, it can be difficult to catch it early. What are some of the common early signs of head and neck cancer and who is the most at risk?

Evan Graboyes, M.D. [00:03:03] Yes, the signs are often very nonspecific. And so there are things that during cold season happen all the time. And so some of the clues that we use to figure out whether this is concerning or not concerning, I think really depends upon how long the signs or symptoms are there for. Some patients might come to see us because I notice a sore on the side of their tongue and so they may think that they just bit their tongue, but actually the disorder was there sort of all along. It may be growing. That's why they bite your tongue sometimes. Actually, patients come in and say their dentures don't fit anymore or there's like a sore under their dentures and they think the thought might be like the dentures rub the sore. But really the sore itself is, is the cancer and is the reason the dentures don't fit or bodies are sort of wired funny for some reason, the nerve that does sensation to the back part of the throat also goes towards the ear. So sometimes cancer is going in the back part of the throat can actually show up, causing ear pain. So people will say like, oh, my ear hurts and overlooking the ear and they'll be nothing wrong there because the cancer is actually the back part of the throat. You know, for cancers that happen in the voice box, patients may notice a change in their voice early on or potentially late having trouble breathing if the cancer occupies a space where they need to breathe and then especially with cancers related to the human papillomavirus, they start sort of inside the tonsils in the back part of the tongue and don't really have a lot of symptoms there, but they spread the lymph nodes in the neck early. So one of the really important signs are these cancers, maybe a lump in the neck. And so it's very, very common that someone may say, like, oh, I was shaving, I know some lump on my neck in that lump on the neck as cancer that started inside the throat and then spread to a lymph node.

Erin Spain, MS [00:04:18] And you mentioned human papillomavirus there. And at the beginning of the show, we mentioned tobacco and alcohol use. Are those the main causes of these cancers and what preventative measures can people take to avoid developing these cancers?

Evan Graboyes, M.D. [00:04:32] That's a great question. So historically, tobacco and alcohol were the two major reasons people develop head neck cancer, especially cancers sort of inside the mouth and throat area. We were called squamous cell carcinoma. And over the past 20 years, we've seen an epidemic of human papillomavirus related head neck cancer. These are predominantly affect males more than females. When we first noticed this trend, it was mostly males in their forties or fifties who often didn't have really any any smoking or alcohol history. And over time, that group has changed a little bit more and more common in elderly males, but still males much more than females, predominantly white males. And from a public health perspective, more people in America each year have human papillomavirus related cancer inside their oropharynx, so the back part of their throat and in their cervix. And so while it's, I think, amazing and that the public health community has made so much progress preventing cervical cancer through screening and early detection, we haven't had that same benefit for head, neck cancer. Actually, it's much more common now that people get papillomavirus related cancer in their throat and cervical cancer across the US.

Erin Spain, MS [00:05:28] Well, here in the southeast, this seems to be sort of a focal point for this growing epidemic of HPV and head and neck cancer is related to HPV. Can you tell me about what's happening here in South Carolina?

Evan Graboyes, M.D. [00:05:39] Yes, I think South Carolina in some sense is a little behind, but catching up relative to the rest of the country. For a long time, we thought it made sense to us that the vaccines that can be given to prevent cervical cancer and, you know, genital warts and anal cancers caused by human papillomavirus. It seems like they should have also been able to prevent head neck cancer due to human papillomavirus. And then in 2019, the FDA agreed and granted an indication to Merck for Gardasil, their nine valent human papillomavirus vaccine for the prevention of head and neck cancer. And so now people ages 9 to 14, both males and females, a boys and girls ages 9 to 14, can get two doses of Gardasil. And we think that that will help prevent HPV head neck cancer. It's also approved for males and females only up to the age of 45 for three doses. So there's been a renewed emphasis within our professional community to make sure that message is out there that HPV causes head, neck cancer. This is very common, in fact, more common in cervical cancer. And it's potentially a preventable cancer through vaccines that can be given in early childhood and onto even early adulthood. You know, despite what we know about why human papillomavirus is cause head, neck cancer, how we can prevent it, there's a lot that we don't know yet. We think most of the infections happen many, many years before the cancer. So if someone shows up with cancer in their forties, their fifties, it doesn't mean that they had human papillomavirus infection. Then the infection probably happened far, far sooner. And there's just a very long period between the initial infection and when the cancer develops. We don't know why some people go on to develop cancer and some people don't do infections very, very common inside the mouth from humanpapilloma virus. It generally has no symptoms, actually, as it always has no symptoms. So people are really never aware that they have it, but it can be detected with a swab inside the cheek. So I think we're moving towards spaces where we hope that we can only prevent human papillomavirus related cancers in the future by vaccinating the next generation, but also move to methods of early detection so that cancers can be caught at a really early stage, or even to a screening program, which we clearly don't have yet.

Erin Spain, MS [00:07:25] What is the gold standard for early detection and screening?

Evan Graboyes, M.D. [00:07:29] Screening has really revolutionized cancer outcomes in the sense that it's given many cancers breast, colon, recently lung a chance to get cancers caught at an earlier stage where they're more localized and more treatable and outcomes are better. Sadly, we don't have any screening tests that are recommended for head and neck cancer. Part of this is because the head neck cancer is not common enough to make it a worthwhile public health screening initiative. And part of it is because we don't have the right test yet. So that doesn't mean that there's nothing that can be done. Often dentists in the dental community are a fantastic source of early detection. And so while there's not a official recommendation from the USPSTF to go get a dental exam to prevent head neck cancer, when people do get routine dental evaluations, the dental providers often will notice abnormalities inside the mouth that may be cancer caught at a very early stage. So I think we are hopeful for the future that we can develop a screening program. But for now, the best that we recommend is that people regularly check in with their dentists and that when they do dentist perform an examination to see if there's anything that might be an early cancer inside the mouth.

Erin Spain, MS [00:08:27] You mentioned before the white men seem to be the ones that are getting this cancer most often. But black men, black Americans in general seem to have the worse outcomes with had a neck cancer. Can you tell me about that?

Evan Graboyes, M.D. [00:08:41] This answer, I think, is multifactorial. One of the major things that we have noticed about the human papillomavirus related head neck cancer is that the outcomes are much, much, much better. So historically, patients with tobacco and alcohol related had neck cancer. Maybe only 50% or less would be alive at five years, whereas with human papillomavirus they'd had no cancer upwards of 95% are alive at five years. So the survival is much, much, much better. The HPV-related cancers disproportionately seem to affect white males as opposed to black males for reason to understand. So part of it is that African Americans are more likely to get the more aggressive form of head neck cancer caused by tobacco and alcohol, less likely to get the less lethal form that's caused by human papillomavirus. There are also some things that we think potentially about the underlying biology of the tumors that may be different among different racial subgroups in how their bodies respond to treatments. And then we certainly know that access to care and timely care across the cancer care continuum. So getting in for initial treatment all the way through the combinations of surgery and radiation and chemotherapy, certain groups don't get the timely care that other groups do due to lack of access, maybe potentially to insurance or other barriers to care, and as a result of that, disproportionately worse outcomes. And so this is an area of research we spend a lot of time thinking about, but MUSC and are working on trying to understand more how the care delivery system fails African American patients head neck cancer and how we can help improve timely care delivery to help improve the very disparate outcomes. And they're very real. So for the past 20 years, we've seen that African Americans are approximately 50% more likely to die of their head and neck cancer compared to white patients. This is even after adjusting for a number of other things that could potentially explain the differences. So we hadn't made any progress in this very stark and racial difference of the many cancers that have well documented racial differences in survival between white and black patients head and neck cancer is probably the second strongest difference. So it's, I think, something we're aware of as a field and we're I think we're moving it was in the last really five or so years to documenting and describing the problem and really understanding at a mechanistic level why this is happening and the many different parts that are related to the underlying biology of the tumor and immune system. And then also, I think the structures and processes of cancer care delivery and how different social determinants of health and social needs may impact different communities.

Erin Spain, MS [00:10:38] Walk me through the treatment. Once somebody is diagnosed, what treatment is given for the best outcomes?

Evan Graboyes, M.D. [00:10:46] So treatment depends a little bit on where the cancer is located and what stage the cancer is. Generally, we have three sort of major tools in our armamentarium surgery, radiation and systemic therapies. Those may be things like chemotherapy or immunotherapy for localized or early stage cancers. So stage one or stage two will often recommend either surgery or radiation, but just one one type of treatment. And that's the best when people can only have one type of treatment for more advanced cancer. So stage three or stage four, which are still curable for the most part, then we recommend combinations of of treatments that may be radiation and chemotherapy together and then surgery afterwards. If the radiation and chemo don't make the cancer go all the way away, or maybe surgery first, followed by radiation and chemotherapy afterwards. So we sort of mix up the combinations of sequences of those three tools, and we're still learning how to use immunotherapy. It's really revolutionized cancer care within the past five years, and it's still finding its place within head, neck cancer, four ways in which it might be able to improve outcomes and decrease the toxicity of treatment. Sometimes we're sort of equivalent between whether surgery is the best option or radiation's the best option, except for cancers that are in the front part of the mouth, fairly close to the jawbone. And we think that surgery is a better option there because radiation can lead to some long term damage to the jawbone and potentially worse cancer outcomes. But radiation is a very important part of the treatment modality, and I think we're blessed to have a very multidisciplinary and collaborative team of oncology providers here for surgery, radiation, medical oncology to make sure each person gets the right treatment.

Erin Spain, MS [00:12:10] And MUSC Health and the Hollings Cancer Center really offer this holistic approach where it's from the beginning to the end. Like you mentioned, if you're dealing with some common issues after treatment, you have specialists in place to help people. Just walk me through the experience at MUSC Health and how you're able to help patients get through the treatment stage and the survivorship as well.

Evan Graboyes, M.D. [00:12:33] Yeah, I think the concept that there is a very large team starts really right up front. So that's not until the end of treatment where we help on the back side. But really from the very beginning to have patients have, I think the best outcomes in terms of being alive and being cancer free and having the quality of life that they want. There's many, many providers involved and like you mentioned, this is because the cancers occur in such, I think cosmetically and functionally critical areas. So in addition to surgeons and radiation oncologist and medical oncologist who work very closely with our dental colleagues, so the dental oncologists and oral surgeons who are involved in maintaining oral health for patients who either have teeth or need teeth replaced as part of treatment. We work very closely with our speech language pathologists, and so they work with patients before treatment, during treatment and after treatment to help optimize speaking and swallowing function. Our patients will work with physical therapists and occupational therapists to help get strength back and range of motion back as part of treatment that they may go through. What are the side effects that patients will also encounter? Is lymphedema so fluid that sort of doesn't drain from the head back towards the body the way it needs to because of either combinations of surgery, radiation therapy. And so I think both speech therapists and physical occupational therapists can help teach patients massage to help reroute their fluid or get some compressive maks. In addition, I think because treatment involves so many different types of providers, it is a very large support team I think involved in coordinating care. So Nurse Navigators, referral coordinators to help make sure that patients get so many different appointments scheduled was all the right patients really along the continuum. And it's very hard. You know, patients travel from a great distance to have all these appointments. And so we do our best here, I think, to make sure that there's a very patient centered referral and scheduling process in a way that's not overwhelming because this is a lot of appointments, even when patients are healthy and in this situation they're dealing with really a devastating cancer. Sometimes they come without caregivers or support, so it's a lot for them to go through. And I think I would also add that those two providers that I didn't cover before, we worked very closely with our colleagues in behavioral medicine in the cancer center. And so patients had neck cancer, have very high rates of substance abuse and substance dependence in the beginning. So alcohol, tobacco being common things and because treatment is so toxic and devastating, depression, anxiety, concerns about body image to body image lead to stress and then suicide are all very real concerns among our patient population. And so so cancer survivors, we know generally have twice the rate of suicide compared to the general population and that cancer survivors compared to other survivors of cancer, they have twice the risk of suicide. So they're really a very uniquely vulnerable population to, I think, mental health concerns.

Erin Spain, MS [00:14:47] Tell me about some of the cutting-edge ways that MUSC Health is able to tackle head and neck cancer, especially in younger patients, and what you're seeing and what you're doing right now.

Evan Graboyes, M.D. [00:14:58] I think it was our multidisciplinary team. We, along with many other places around the country, have. Recognize that the really two two major problems to solve in the field. One is for patients with HPV-related head neck cancer. So those due to human papilloma virus where the patients are younger and the outcomes are really, really good, potentially treatment doesn't need to be as toxic to still achieve that very high cure rate. And so there's many different strategies that we're studying here that may help be able to deliver treatment that cures patients of their head, neck cancer, but doesn't leave them with some of the long term side effects related to all the toxic treatments. And so sometimes this may be trying to figure out the right way to use newer surgical approaches like robotic we call it transoral robotic surgery or TORs. It was allows for a much more minimally invasive and less morbid, less harmful way to treat cancers inside the back part of the throat, which are otherwise very hard to access with historical techniques. I think we're also part of a number of important clinical trials, looking at new radiation or chemotherapy or immunotherapy options that may be less toxic and harmful to patients than historical regimens. And so these are, I think, are very exciting things that we hope to be able to maintain that very high cure rate and then not have as much toxicity. On the flip side, I think we're also looking at ways to intensify treatment for the group of patients with tobacco and alcohol related head neck cancer, where that survival is really poor. And so now we're looking for new ways to add on things like immunotherapy, either before treatment or after treatment in a way that we hope will help teach the immune system to recognize and attack the cancer so that it's not coming back the way we we frequently see it doing. But I think in the survivorship period, you know, one of the major concerns for our patients is there is a relatively high rate of cancer coming back again. And so I think developing new ways to detect cancer coming back again early and in a way that doesn't cost too much stress to them is a really important. And so one of the radiation oncologists here, actually, Dr. Chera, helped developed a blood test that can detect circulating DNA from human papillomavirus and potentially catch patients earlier who have may have cancer coming back and allow for treatment otherwise wouldn't happen. So I think those are I think many of the ways and many of this happens in the context of clinical trials. That's probably, I think, what's special about getting care at Hollings, which is the only NCI designated cancer center in South Carolina, is we really have a robust clinical trial portfolio that offers the most cutting edge treatments for the many different kinds of head neck cancer that we talked about. And so some of them involve new quality of life surgical approaches that may minimize the toxicity of surgery, sort of new ways of delivering radiation or pairing it with new chemo or immunotherapy options. And then really in the supportive care and survivorship phase, too, I think we have a lot of interesting trials that help patients and caregivers get back to the quality of life that is meaningful to them after they've been through such a such a treatment. So that's really something that we is critical to our mission here. That's why we're all at MUSC and Hollings in way we hope that not only improve the outcomes for patients in South Carolina, but contributes something meaningful to the biomedical community that can improve outcomes nationally and internationally for these types of patients.

Erin Spain, MS [00:17:36] What do you do to optimize your health and live well?

Evan Graboyes, M.D. [00:17:40] Well, my wife and I have found exercise group that meets from 6 to 7 in the morning. It's called The Outsiders, and they do different group exercise activities around the peninsula. And I think the level of physical activity and social and camaraderie aspect that goes with it is perfect for us. And so it's something it's just a great way to start the day and a key part, I think, of being active and moving around.

Erin Spain, MS [00:17:58] Thank you so much, Dr. Evan Graboyes, for coming on the show.

Evan Graboyes, M.D. [00:18:02] So such a joy and thanks for the chance to share about head neck cancer with your audience.

Erin Spain, MS [00:18:09] For more information on this podcast, check out advance.muschealth.org.