Evolving Role of Surgery in Multidisciplinary Care for Head and Neck Cancer

Joseph A. Califano, MD

Even with the advent of systemic therapeutic advancements to the armamentarium of head and neck cancer, surgery and novel techniques continue to rapidly evolve to effectively treat patients and leave less opportunity for adverse events (AEs).

Additionally, the role of the surgeon has changed to be a more integrative role in patient care.

“We are more precise and more integrated with other therapeutic modalities,” said Joseph A. Califano, MD. “Together, we work as a team and that is the best way that patients can receive their optimal outcomes. We do not just want to cure their cancer but to get back to function and wellness.”

OncLive: Please provide an overview of your presentation on surgery for patients with head and neck cancer.

In an interview during the 2017 OncLive State of the Science Summit^TM on Head and Neck Squamous Cell Carcinoma, Califano, a professor of surgery at the University of California, San Diego, discussed how surgery factors into modern multidisciplinary care for patients with head and neck cancer.Califano: I discussed the fact that the surgery that we do now for head and neck cancers is very different from what used to be done 15 to 20 years ago. Our ability to do effective surgery is good, but now we can do it in a way that leaves patients with excellent function and cosmetic results.

Can you discuss robotic surgery in this space?

How do you believe surgeons fit into multidisciplinary care in head and neck cancer?

When you see someone walking down the street who has had major head and neck surgery, you wouldn't know it because we are doing new techniques that are going through natural orifices to do major significant surgeries. Robotic surgery is part of what we do as head and neck surgeons. It is effective in terms of taking care of tumors—particularly in the throat, the tonsils, the back of the tongue, and perhaps even in the nasopharynx. Ordinarily, we cannot get to them unless we have robotic instrumentation. The beauty of robotic surgery in this setting is that we can have patients with excellent function, good swallowing, good voice, and rapid recovery from a significant procedure that was not available 10 years ago. Multidisciplinary care is one of the most important things that we practice when we take care of patients with head and neck cancer. It is not just medical professionals who do chemotherapy or radiation surgery; it is a whole host of other people, such as speech pathologists, dentists, dieticians, social workers, nurses, occupational therapists, and physical therapists.

What is your message to community oncologists who do not understand the importance of surgery when systemic therapies are available?

The reason this is so important is that the effects of our therapy combined are good in terms of curing cancers. The AEs need to be treated. We need to get people back to not just curative cancer, but functioning and happy, as well. Together as a team, we can do much more effective therapy and leave people with much better functions than we could in isolation. The second message is that surgery has rapidly evolved in the past 5 to 10 years. If you are a community oncologist or a community radiation oncologist, you do not realize that we can treat diseases that 10 years ago were treated with radiotherapy alone. We can very effectively treat with surgery alone or in combination with radiation therapy to reduce the AEs. Those AEs are what our patients are going to feel 10 or 15 years down the road.

What are some big concerns in head and neck cancer and what would you like to see addressed in the next 5 to 10 years?

For example, the risk of stroke after radiotherapy long term is as high as 6% at 12 years. If we can treat people effectively with surgery alone, then we can eliminate that risk of stroke and eliminate some of the long-term effects of other therapies. Some of the newer targeted therapy and immunotherapy approaches are going to blend in well with surgery; it will be one way we can tell whether someone responds to a systemic agent. For example, if a patient receives immunotherapy alone and has a complete response, we can do a minimally invasive surgery to not only make sure that we clear the disease but even to document that there is no disease and spare the patient additional therapy.

How is surgery an integrated part of the team?

The second thing I would say is that we are going to have a host of imaging technologies available. They are just starting to become clinically applicable. We are going to know exactly where the tumor is so that when we do surgery, we can make sure that we get all the cancer [out] most of the time and reduce the need for additional therapy, such as debilitating combination therapy. We can choose who is good for surgery, who is not, and who is better treated with other therapeutic approaches, such as radiation, chemotherapy, immunotherapy, and targeted therapy. Historically, we are unlike a lot of other surgeries. We follow our patients throughout the rest of their lifetimes and we are an integrated part of the care team. There are other things we can do as surgeons, for example. We can move salivary glands out of the way of radiation for patients with good saliva function to swallow better and have a better quality of life.

We do not think of ourselves as an isolated [group] to take out the cancer, but we are also there to reconstruct, rehabilitate, and help people get on their way to being well.

The head and neck is all about who we are, how we interact socially, and how we feel about ourselves. Social things that we do with other people are eating, talking, and communicating. There are many who now have these functions after head and neck cancer.