Head and Neck Cancer: Discussion on Endocrine Oncology Research Innovations - Moffitt
Head and Neck Cancer: Discussion on Endocrine Oncology Research Innovations - Moffitt
Moffitt Cancer Center
Host: Caitlin McMullen, MD, Member, Department of Head and Neck-Endocrine Oncology
Kedar Kirtane, MD
Assistant Member, Department of Head and Neck-Endocrine Oncology
Sarimar Agosto Salgado, MD
Assistant Member, Department of Head and Neck-Endocrine Oncology
Barb Wampler, RN
Welcome, everyone! Thank you so much for taking the time to be here this evening. I'm Dr. Kayla McMullen, a head and neck surgeon and member of the Department of Head and Neck Endocrine Oncology here at Moffitt. I'm excited to introduce my colleagues to you in just a moment. I'm confident that you'll find the information we share with you tonight very valuable. Before we begin, I'd like to say one thing as a little disclaimer: This content is not intended to be medical advice. If you have any specific questions, please consult your physician. Viewers should not rely on the information contained in this presentation/webinar for immediate or urgent medical needs. Additionally, if you have a medical emergency, call your physician, go to the nearest emergency department, or call 9-1-1 immediately. Never disregard professional medical advice or delay seeking care because of the information contained in this webinar presentation. Tonight, we're so pleased to have you with us, and before we introduce our presenters, I'd like to remind you that after we hear from our speakers, you'll have the opportunity to have your questions answered by these experts. We invite you to type your questions into the Q&A box located at the bottom of your screen. You can see it right in the bottom middle of your Zoom screen. We'll be able to answer those later in the session. Now, let's introduce Dr. Kadar Kirtane. I'm pleased to announce him. He is a medical oncologist in our department at Moffitt, specializing in head and neck endocrine oncology. Dr. Kirtane, take it away.
Kedar Kirtane, MD - Moffitt Cancer Center on Head and Neck Cancers
Thanks, everyone, for joining. I know it's late on a Thursday evening, so I'm excited to talk with all of you and answer any questions that may come up. Mine is a very brief presentation, and I'll be discussing what's new in head and neck cancers. We can go to the next slide. Just to give everyone an idea of head and neck squamous cell cancers, which is the predominant part of this talk, it is the seventh most common cancer worldwide, with approximately 900,000 new cases and about half a million deaths each year. Squamous cell cancers are the most common type, although we do see many other types of head and neck cancers, including salivary gland cancers. While I'll only briefly discuss thyroid cancers, that's obviously a significant portion of what we take care of here at Moffitt in the Department. When it comes to head and neck squamous cell cancers, it represents approximately three percent of U.S. cancers, although that rate is rising. Sixty percent of the time, patients are newly diagnosed when we first meet them at Moffitt. Forty percent of the time, we're seeing patients for trial options and second opinions. We are very well tapped into clinical trials at Moffitt, and we work with national organizations across the country and the globe for leading some of these clinical trials.
So, we treated many patients on a study protocol from 2020 to 2021. Next slide. Now, the main thing that we've realized over the last decade is that there are many different types of head and neck cancers. In particular, there's one particular type that's caused by the human papillomavirus (HPV). Many of you may have already heard about it, but it's obviously a virus that many of us are exposed to in our younger age. It's the same virus that can cause cervical cancer. Over the last decade or so, it was found that it causes a particular type of head and neck cancer. The rate of HPV-associated oropharynx or tonsillar cancers is actually increasing in the United States, as you can see on the right part of the slide. On the other hand, the incidence of HPV-unrelated oropharynx cancers is decreasing. Next slide.
This is becoming important for studies and clinical trials for a variety of reasons. One reason is that HPV actually presents a better prognosis, generally speaking, for many patients who unfortunately have been diagnosed with this cancer compared to patients whose cancers are unrelated to HPV. This is important because it provides an avenue for us to figure out if we really need to give very aggressive treatments to everyone, like we've been doing for years and years. Additionally, for those patients for whom the standard of care does not work and who have HPV-related oropharynx cancers, it allows us to try to develop a target that we can attack with new treatment options that would hopefully help cause regression of the cancer. Next slide.
For early stage disease, it is highly curable, approximately 90% or higher for most patients. However, we do encounter patients for whom this doesn't work, unfortunately, in our highly specialized department at Moffitt. In such cases, we have a variety of other options that we try to use to cause tumor regression. The top part of the slide is an example of a de-escalation trial. As I mentioned, much of what we do for head and neck cancers is based on studies that were done decades ago, involving various treatments like chemotherapy and radiation. Nationally, we are trying to figure out whether we really need to do as much as we do for patients who have HPV-related disease, which often has a much better prognosis. The example above is a randomized clinical trial that's ongoing through a national organization called NRG. This trial involves chemotherapy and radiation, comparing it to a lower dose of radiation, as well as comparing it to immunotherapy, which I'll discuss in a few slides. The bottom part of the slide acknowledges that not all HPV-related neck cancers are the same. There are more aggressive HPV subtypes and patients who have a higher stage of disease at initial diagnosis. For these cases, de-escalation is not appropriate, and we try to determine whether adding immunotherapy early on would help these patients. In the bottom study, we also have Mafia patients who are receiving standard of care chemotherapy and radiation. They are randomized to one of two different groups: observation, which is what we would normally do outside of a clinical trial, or the other group, which receives immunotherapy, specifically a drug called nivolumab.
Next slide, now immunotherapy has really taken the cancer world by storm. Everybody has probably heard about it on some level, but really, what it is, is a therapy that has been approved for many different types of cancers, not just head and neck cancers. It's a drug that's given through an IV, and the intention of that drug is to try to get your own immune system to attack the cancer. In the same way that if you were to get a virus or a bacteria entering your body and your immune cells recognize those things as foreign invaders, they cause a reaction like a cold, a cough, or a fever. What cancer cells have done is they're really smart; they have figured out a way to invade and avoid capture. So what these immunotherapies do is try to take off that disguise and really stimulate your immune system to attack the cancer. It has worked remarkably well. As you can see, this is a list of different drugs that have been approved for the last several years for different types of head and neck cancers. In particular, the one on top, pembrolizumab, is now approved for patients who are initially diagnosed with recurrent or metastatic disease, which means the cancer has spread elsewhere. This is a remarkable paradigm shift for cancer treatments.
The unfortunate reality is that this only works for approximately 20 percent of our patients. For example, while those 20 percent do really well and experience a significant reduction in their tumors, the majority of the time it doesn't work. As you can imagine, there are lots of different clinical trials that are being conducted in Moffitt and Nationwide to try to enhance these responses.
Next slide, we have a few clinical trials that I would like to talk about. I'll mention them mostly because we lead some of these trials and have also participated in others. I've been at Moffitt since 2018, and through our involvement in clinical trials, we have contributed to the development of new treatment guidelines for patients with head and neck cancers. What I mean by that is, before we joined the study, there was a standard of care. However, after conducting the study, a new standard of care emerged. So, part of what we do is try to push the boundaries of scientific knowledge and make continuous improvements in helping patients with these potentially incurable diseases.
The first clinical trial at the top involves something called flx475, which is a drug administered in combination with pembrolizumab, an immunotherapy. The goal of flx475 is to help the immune system infiltrate the tumor and stimulate an immune response. The second study at the bottom follows a similar approach, but it adds inflammatory hormones to enhance the effectiveness of immunotherapy. These studies are still ongoing and being monitored closely.
Next slide. We recognize that, unfortunately, right now, immunotherapy doesn't work for many patients. While it's really helpful for some patients, that's actually a small minority. So, we have clinical trials here specifically intended to treat patients whose cancers have not responded to immunotherapy. "Parlosive" is a drug that we combine with chemotherapy called paclitaxel in an attempt to improve the outcomes.
Moving on to the bottom part of the slide, we have another clinical trial which involves a novel compound that blocks certain overexpressed receptors in neck cancers. We combine this compound with immunotherapy, aiming to increase the response rate and help the majority of our patients.
Next slide. This is a vaccine clinical trial that was previously conducted on mice. As I mentioned before, HPV is the target we focus on. Similar to preventative vaccines like the flu shot, this vaccine is intended to treat patients who already have HPV-related cancers. By targeting a specific protein on the cancer cells, we aim to stimulate an immune response and help the patients experience regression of their cancer.
Next slide. The last topic I'll mention is something that's really novel and unique to Moffitt. It's called tumor infiltrating lymphocytes. Many of you may have heard of a treatment called CAR-T. CAR-T is a special type of treatment approved for patients with lymphomas or cancers of the lymph system. In these patients, their T cells, which are a particular type of white blood cell, are extracted and re-engineered in the lab to target a specific cancer. These modified T cells are then reintroduced into the patients. This approach has shown remarkable success, leading to several new FDA-approved treatments for these patients.
We haven't seen the same successes for solid tumor cancers, but we're working on it. One way to do that is to take a tumor, get a biopsy, isolate those lymphocytes (which are special types of white blood cells), re-energize them, kick-start them outside of the body, and then give them back to see if they can cause cancer to regress. We call these skills, and Moffitt is a high-volume center for these types of cellular therapy and cellular immunotherapies, arguably one of the best centers in the country. So, we have a dedicated service for this, and our head and neck department is an active part of this novel treatment as well. We're working on pushing the needle of science forward with these new treatments. Next slide.
One thing I'll mention before Dr. Augusto takes over is that obviously, there have been meaningful changes in the treatment of thyroid cancers. There are now options for patients with certain mutations that weren't available before. Additionally, for salivary duct and salivary gland cancers, chemotherapy hasn't worked really well. We're trying novel targeted therapies to target mutations that help those cancers grow. There's a lot to be done, but we're really making headway, and we hope to continue to do so over the next several years.
Thank you so much, Dr. Cortani, for informing us about all the exciting research happening at Moffitt, especially during Head and Neck Cancer Awareness Week. I'm looking forward to seeing some new headway in this difficult disease. Thank you again for your remarks.
Next up, I'm incredibly excited to introduce Dr. Sarah Augusta Salgado, one of our Moffitt experts, who possesses a distinct expertise in systemic therapy for advanced thyroid cancer and is an endocrine oncologist. Without further ado, please take it away, Dr. Augusto.
Sarimar Agosto Salgado, MD - Moffitt Cancer Center on Head and Neck Cancers
Thank you for your kind introduction, Dr. McMillan. It is an honor to be here tonight. These are my disclosures from collaborations with pharmaceutical companies in order to find better options for our patients. Next slide, please.
To provide a background on why I am speaking about advanced thyroid cancers, it is relevant to us. We estimate that each year there are nearly 50,000 new cases of thyroid cancer in the United States, and Florida actually ranks among the top states with a higher prevalence. As an amorphic Cancer Center, the Comprehensive Cancer Center in Florida, we know that the more advanced cases are likely to seek additional options here. For our patients at all stages, we offer multidisciplinary care.
To provide a background on how we treat what we call differentiated thyroid cancers, which include papillary and follicular thyroid cancers, we initially perform surgery on these patients. We then evaluate the pathology report to estimate the chances of the cancer recurring. After surgery, we monitor tumor markers, including thyroglobulin levels. Based on a combination of restratification, we determine if there is a need for radioactive iodine. Differentiated thyroid cancers have the property of still being able to capture iodine, similar to normal thyroid cells. We take advantage of this and prepare patients in a certain way with a special diet. We then treat them with a dose of radioactive iodine, depending on the risk of recurrence. This is followed by keeping their thyroid hormone replacement after surgery at specific targets and monitoring them every certain amount of months or every year, depending on an individualized approach.
Moving on to medullary thyroid cancer, which is another rare type of thyroid cancer that can occur from neuroendocrine cells, all patients undergo genetic testing to determine if it is associated with a familial syndrome from a RET mutation. In those patients, we monitor calcitonin levels and CEA levels after surgery and perform surveillance based on the response. While the majority of patients do well with these types of therapies, thyroid cancer is definitely not the "good cancer." There is a subset of patients who can develop metastatic disease, and these patients might require additional therapies. Next slide.
These additional therapies may depend on how quickly the tumors are growing and whether the cancer has spread beyond the neck and lymph nodes. Which tends to occur in 10 to 15 percent of all thyroid cancers. In those cases, we periodically perform imaging of the chest, abdomen, and pelvis to look for cancer spread. Sometimes, we can treat it by simply keeping the thyroid hormone medication, while in other cases, we use localized therapies like surgery to remove a metastatic site or radiation ablation therapies. Additionally, we have certain chemotherapies that have been approved for the management of both differentiated thyroid cancer and medullary thyroid cancer.
In the upper corner of this slide, you can see a list of medications such as lambatim and seraphinif, which were approved for differentiated thyroid cancers when they have become resistant to radioactive iodine. These treatments are used when tumors are growing rapidly, spreading quickly, or located where there's no other reasonable alternative for treatment. These treatments have shown some positive responses. In fact, lymphatene has shown to improve survival in patients with radioactive iodine refractory thyroid cancer who are over 65 years of age.
However, these treatments are initiated at a specific time because they are not a hundred percent curative. They work for a certain duration. In addition, kinase inhibitors like lambatinum and seraphim orbend (capitalary thyroid cancer) not only act on multiple receptors of tumor cells, as seen in this slide, but also affect the surrounding blood vessels. Therefore, the field of thyroid cancer is now shifting towards targeted therapies. Targeted therapies aim to specifically target the driver of the cancer responsible for tumor growth. For instance, when we analyze tumors, we sometimes find a B-RAF alteration in differentiated thyroid cancers, or less commonly, fusions in the red gene or intra gene. Fortunately, we now have more specific chemotherapies that can elicit profound responses. Furthermore, studies have shown that by blocking the B-RAF and MEK steps in the internal signaling pathway that drives cancer cell growth, tumors can potentially regain sensitivity to radioactive iodine.
Next slide, please. Redifferentiation therapy is an approach that aims to re-sensitize tumors to radioactivity. This approach was developed based on the observation that chemotherapy is only effective in thyroid cancer for a limited period. Therefore, we are cautious in determining the right time to initiate chemotherapy. We have asked ourselves, both here at Moffitt and in other locations, if there is something we can do to delay the initiation of systemic therapy. That's where the concept of resensitizing tumors to radioactive iodine comes in. To achieve this, we evaluate patients as if they are about to start chemotherapy. We assess their medical conditions, conduct laboratory tests, and determine how much radioactive iodine they have previously received. Afterward, we treat them with an oral chemotherapy for an average of 4 to 12 weeks. We then perform a diagnostic scan to assess the effectiveness of the radioactive iodine and administer an additional treatment if necessary. Finally, we conduct a post-treatment scan to ensure that the radioactive iodine has targeted all the disease sites we intended to treat. This approach potentially allows us to discontinue chemotherapy and keep patients off systemic therapy for a period of time. This not only avoids the financial toxicities associated with chemotherapy but also mitigates the impact on patients' quality of life. Next slide, please. This approach has been evaluated in various studies. The data presented here is from a study conducted by one of my colleagues in the Houston group. They assessed patients who had been on chemotherapy for an extended period and observed indications of redifferentiation to radioactive iodine. As shown in the graph, some tumors not only reduced in size during chemotherapy but also responded positively to an additional course of an average of 200 milligrams of radioactive iodine. As a result, many of these patients were able to remain on systemic therapy for an additional 20 months on average.
And in these pictures on the left, you can see that at the lower end of the images, there were patients who did not have the ability to uptake iodine before the treatment. After the treatment, the tumors were able to light up, indicating a positive response to radioactive iodine. Next slide, please. Furthermore, other fusion therapies available on the market, such as those for red-driven differentiated thyroid cancers or NTRK fusions, have not only shown promising results for patients with thyroid cancer, with nearly 70 to 80 percent experiencing profound responses, but they have also demonstrated the potential to be re-sensitized to radioactive iodine. This can be observed in the case of this patient who had diffuse lung metastasis and experienced significant tumor shrinkage, enabling them to receive an additional course of radioactive iodine and sustain a favorable response. Currently, we are collaborating with other sites to participate in multi-institutional studies in order to validate this approach on additional patients with different mutations. Can you please move to the next slide? Thank you so much. For our patients with the most aggressive form of anaplastic thyroid cancer, we have observed that a combination of bureaucracy and MEK inhibitors has improved overall survival, providing a significant glimmer of hope. However, at a national level, there are efforts to explore whether oral chemotherapies can further reduce tumor size, making surgery more feasible. This would allow for consolidation with subsequent treatments, including potentially immunotherapy, which is known as a neoadjuvant approach. The goal is to not only achieve local control, as these tumors can cause significant neck symptoms, but also to reduce the tumor burden, leading to less aggressive tumors and better response to systemic therapies. Thus, we need more treatment options for these patients, as anaplastic thyroid cancer still remains an incurable disease. As someone who has lost a loved one to this terrible disease, I understand the urgency and importance of finding effective solutions.
Many years ago, I embarked on a personal mission to work towards improving this field. Next slide, please. This not only involves considering anaplastic thyroid cancer patients for better hope but also our patients with medullary thyroid cancer, as both are rare types of tumors. Although more specific and highly effective red inhibitor therapies have become more tolerable, there are still patients without that alteration who are left to be treated only with multi-kinase inhibitors. For these patients, we need additional therapies. Next slide, please.
As you can see on this slide, each of these bars represents the profound responses we observe with these treatments. The patient shown on the left experienced a significant decrease in tumor size, along with a response in a paraneoplastic hormonal syndrome. Next slide, please.
This brings us to our goal of not only improving our patients' lives in terms of symptoms and measuring significant tumor reduction but also gathering information about who the ideal candidates for differentiation are. We want to identify the patients who will have more prolonged responses and those whose tumors will develop resistance sooner. This way, we can provide more aggressive upfront therapies to those patients. Additionally, we aim to incorporate patients' voices into quality of life studies and simple management research. While a cure is still elusive, we all hold onto hope and pray for that day to come. Hence, we must consider all our patients who have participated in clinical trials, both here at Moffitt and beyond, as well as our philanthropic donors who have made this research possible. Thank you for your attention.
Thank you so much, Dr. Augusto. I sincerely appreciate your work on this. You know, thyroid cancer—everyone says it's a "good" cancer, but there is definitely a subset of patients who have aggressive disease. It's good to know that we have some options that work pretty well for aggressive thyroid cancers. Thank you again.
Next up, I am so excited to introduce Barb Wampler, one of our wonderful colleagues here at Moffitt who plays a critical role on our head and neck cancer team, serving as a nurse navigator for our patients. So, welcome, Barb. Thank you so much for participating tonight. I'm looking forward to hearing what you have to say about this critical part of our care for head and neck cancer patients here at Moffitt.
Barbara Wampler, BSN, RN, OCN - Moffitt Cancer Center on Head and Neck Cancers
Thank you so much for the opportunity to share about my role as a navigator. I wanted to briefly start off by giving you an idea of what the Navigator role means for those who may not be familiar with it. Next slide, please.
The role of the navigator actually dates back to the 1990s when Dr. Harold Freeman in Harlem, New York, noticed that women coming to him for breast cancer were usually at a more advanced stage when they sought his help. He investigated why this was occurring and based on his observations, he identified different factors that contributed to it, such as access to care resources. From that observation, he developed the role of the navigator. We are very fortunate here at Moffitt to have 14 navigators throughout our institution covering various cancers. We can focus on our individual groups and provide resources to make it as easy as possible for patients to go through their cancer treatment. Next slides, please.
So, what do we do as navigators? I would like to list a few things that we focus on. Our primary goal is to promote and encourage self-advocacy, helping patients and their families be successful in their treatment and make decisions regarding treatment that align with their treatment goals and priorities. We also help facilitate communication and coordination of care. At Moffitt, we are fortunate to be able to address all modalities, whether it's surgery, radiation, or chemotherapy, under one roof. Unlike in some community settings where patients may have to go to various sites for different treatments, we provide comprehensive care in a single facility.
So, my job is to facilitate communication, which is very easy because at least a few times a week, all the doctors are in the same clinical setting. They talk frequently about patients and any issues that may come up. Another role for The Navigators is to identify barriers to care, such as challenges that may hinder patients from accessing treatment options. Financial and insurance concerns are common. Many of our patients may be the sole or primary financial support for their families. If they have to undergo radiation or a combination of radiation and chemotherapy, which can take multiple weeks, they may be unable to work and support their family or pay the bills that continue to come in. Insurance concerns are also frequent. I often encounter patients with ten-thousand-dollar deductibles, and most of us don't have that amount in our bank accounts. So, we explore available resources, including philanthropic organizations and outside assistance programs that they can apply to.
Transportation is another challenge. Many of our patients live outside of Tampa and have limited transportation options, either relying on someone to drive them or having a reliable car themselves. Lodging becomes an issue for those who need to come in for radiation treatment from Monday through Friday for five, six, or seven weeks. Commuting back and forth for one to two hours every day can become cumbersome and tiring. We also address the emotional needs of our patients. Being diagnosed with cancer is extremely stressful for both the patients and their families. As a holistic institution, we aim to address not only their physical needs but also their emotional needs and the stress that comes with the diagnosis and the anticipation of starting treatment.
At some point, what does that mean? Um, I'm making sure that the patient is scheduled with the appropriate provider based on their diagnosis. Do they need to see a surgeon or do they need to see a radiation specialist? We want to ensure that they are seeing the right person for their appointment because they are investing their time to come and see us. We want to make sure that their time is well spent in terms of receiving feedback and information about the available options. We also look at their test results to see if any necessary tests have been conducted or if there are any missing tests that could make their appointment with us less beneficial. In addition, we investigate internal resources and referrals. Do they need support from a social worker? Do they need information about smoking groups or our smoking cessation program? Providing these resources can significantly impact outcomes, especially if the individual is encouraged to stop smoking. We also offer financial counseling to ensure that necessary financial resources are available for the patient and their families. Furthermore, we determine if there are any external resources that can be utilized, such as the American Cancer Society, particularly for lodging. Next slide, please.
In my role here at Moffitt, I work in our multi-disciplinary clinic. We have designated times three days a week when both medical oncologists and radiation oncologists come together for appointments. This setup saves patients from making multiple trips, and since many patients require multiple types of treatments, they can have their questions answered in one session instead of coming back multiple times. My role is to reach out to individuals assigned to a multi-disciplinary clinic within 24 hours of them making an appointment. I begin the process of finding out what has been done and what their goals of care are. We strive to ensure that we have access to thorough and appropriate records so that our physicians can provide them with feedback on the available treatment options.
We want to ensure we provide as many options as possible for our patients to consider, so we need to know what clinical trials are available. Additionally, we want to determine their expectations for this visit. Sometimes, patients may not understand what the visit will entail, especially if they have never been through appointments like this before. Therefore, we aim to provide them with information about what to expect and address any questions they may have.
I frequently encounter patients who have unfortunately turned to the internet and received misinformation. They may have also received information from relatives or friends who have had similar experiences, but it may not necessarily apply to their specific situation. Hence, we try to clarify what is accurate and answer any questions or concerns they may have heard. Our goal is to alleviate the stress of the unknown before their appointment.
When patients arrive at the clinic, I meet them in person. I believe it is best to have a face-to-voice interaction so that they know there is someone behind the phone working for them. While I may not always see them in the clinic, I am there to assist them if they need me. Therefore, I call them within one to two days, based on their availability after the appointment, to review what has been discussed and ensure their understanding. We often say that the best questions arise on the ride home, so we make sure to address all their questions or provide clarification on what they thought they heard. Sometimes, due to stressors, they may not accurately hear or misinterpret what has been said. Thus, it is crucial to receive feedback from the patients and their families to ensure they understand the possible treatment options and to answer any questions that may arise after their visit.
I also assist with scheduling treatments, especially if multimodality is required. We want to ensure that these treatments are appropriately coordinated.
I tell my patients that I'm sort of like the general contractor. I may not do the drywall, I may not do the plumbing, but I know that you have to get the electrical and plumbing in before you put the drywall up. So, same thing with our scheduling. I don't do the infusions, the chemotherapy. I'm not in the radiation department, but I am able to coordinate those, making sure that they're in the right sequence. But also, I try to condense them as much as possible because I feel that individuals' time is valuable. We want to try to limit the amount of time that you have to spend here, allowing them to be with their families or doing whatever normal activity they can throughout the day. They don't have to be here in our facility all the time.
I work with clinical nurses around the institution who may also be involved with their care to help reinforce education, making sure that they understand and the individual understands the side effects of treatment and when to call the physician. We give them those building blocks, those tools, again to make their treatment successful and limit any challenges that may interfere with their ability to go through treatment from start to finish. Because that's going to give them the best outcomes, to be able to start and have no stoppage in between the treatments.
Lastly, I am a resource for patients and their families. Some of them have my direct number at my desk, so I'm available when they call me with questions or concerns, or sometimes just to talk. I want to make sure that they have the ability to contact someone. Sometimes in the clinic, of course, the nurses in the clinic are seeing patients on a day-by-day basis, so I'm an extra set of ears. If they have any questions, challenges, or concerns about anything, I'm also a resource for them as well. So, that globally is what I do as a navigator here at Moffitt. It has always been my pleasure to work with my patients, and hopefully, I'm able to make a positive impact on their time with us as they go through treatment. So, I thank you for the opportunity of sharing.
Thank you so much, Barb. We are truly grateful to have you as part of the team and for taking care of our patients with us. Thank you for joining us tonight. Now, we have some great questions coming through in the chat box. I'm really looking forward to addressing those. But before we do, I'd like to quickly introduce David Curry. He is one of our partners here at Moffitt and works with the Moffitt Foundation. David collaborates with the Head and Neck Endocrine Program to secure the research funds necessary to initiate clinical research and make advancements in cancer treatments. If you're interested in learning more about how you can help, please contact David for further information. David, would you like to say a few words to our attendees?
David Curry - Moffitt Cancer Center on Head and Neck Cancers
Yeah, that would be great. Thank you so much, Dr. McMullen. I want to thank everybody for their time this evening. There are so many things that you could be doing, but you chose to be with us. So, I hope this has been informative and that you are enjoying it. I know that the Q&A is very popular, so that will be coming up in just a minute.
I also want to thank the participants, our presenters: Dr. McMullen, Dr. Kirtane, Dr. Augusto, and Barb. You know, the work that they're doing not only benefits our patients locally, but especially the research that's happening here at Moffitt in head and neck endocrine is going to have a global impact. So, what they're doing is vitally important, and we just really appreciate them and their giving their time tonight and providing us with this great insight.
And then I've got two colleagues I need to thank quickly, Brielle Humphreys and Tiffany Hughes. They're working behind the scenes tonight and just making sure that everything goes smoothly. I will say that unfortunately, head and neck endocrine research is underfunded, and that's across the board. So, there are some projects that are happening at Moffitt and some ones that are on the board, and we'd like to pursue them. They're just in need of funding. So, if you have any interest in exploring ways that you can provide philanthropic support for these projects, please, I look forward to talking to you and maybe seeing if we can work something out.
Thanks again for joining us tonight. I'm going to turn it back over for the very popular Q&A part of our session and take it away, Dr. McMullen.
Q & A Session in Head and Neck Cancers
Awesome, thank you so much, David. I really appreciate your time and help in facilitating and organizing tonight's event. So, let's get to the questions. Ladies and gentlemen, please add some more to the chat box. We'll address those right now. I think there's a bit of a theme here, so we have a couple of different groups of questions for Dr. Curtani and Dr. Augusto Barb. Let's see here. I think the first set of questions will be directed to Dr. Curtani, asking about the prognosis of HPV-related throat cancer. People are asking if treatment many years ago increases the risk of long-term recurrences after treatment for HPV-related oropharyngeal cancer. Can you tell us about the recurrence rates?
Usually, recurrence rates are highest within the first two years after completing treatment. They start to decline with every passing year from the completion of treatment. Ten years is a long time, and it's great. There are always risks with anything, but the risk is relatively low. However, it depends on the specific case.
Excellent. In my experience as well, after the first couple of years, the risk of recurrence is very low. Of course, it depends on the stage of presentation and specific patient risk factors. HPV is an important feature. A couple of years ago, the entire staging system for oropharyngeal cancer was revised, dividing it between patients with HPV and those without HPV. Patients with HPV had a better prognosis, so they were downstaged even with similar tumor sizes. Overall, I believe that addresses a few questions about HPV-related throat cancer.
Alright, doctor. Oh, yeah, I want to add one more thing that I didn't mention in my talk. One of the types of cancers we treat here at Market is adrenal cancer. Adrenal cancers are considered a form of rare cancers, and they are very uncommon. There is a lack of standard treatment options for them. That's why we recently opened a clinical trial for adrenal cancer. Since it's a rare cancer, many patients from all over are interested in participating. I just wanted to highlight that because we were already discussing relatively rare cancers. Only three percent of U.S. cancers are head and neck endocrine cancers, and this is an even rarer type. There's still much work to be done, and we would like to have available options for patients with these rare cancers as well. Awesome. Thank you.
Dr. Augusto, I have lots of questions about thyroid cancer. Are you ready? Yes, alright. I have a couple of questions regarding treatments for advanced thyroid cancers. I'll name two of them now because I think they have similar features. So, besides TKIs, what are the new treatments for advanced thyroid cancer? I know you touched on that a bit, so if you could summarize, that would be great. Additionally, what are the latest treatments for metastatic thyroid cancer other than TKIs? Definitely, whenever we have advanced thyroid cancer, we look at the sites of the disease to see if there's anything new, like doing a short course of an oral targeted agent to decrease tumor burden and enable a summary. We've talked today about redifferentiation therapies, but for the more aggressive variants of advanced thyroid cancers, studies have also been conducted on combinations of targeted agents and immunotherapy. Dr. Kirtani mentioned this in his talk. Cancer tricks our immune defense system and hides from it, but immunotherapy aims to make our body capable of fighting the cancer. In the case of more aggressive forms of thyroid cancer, combining targeted agents with immunotherapy could potentially yield positive responses. Some studies have already investigated combining TKIs and immunotherapy, and other institutions are also exploring similar combinations for anaplastic thyroid cancers. There's also a discussion about the potential role of CAR-T cell therapies in medullary thyroid cancer. Furthermore, when considering non-TKI options, it's important to highlight the individualization of care. For example, when talking about long meds, treatment can range from TSH suppression to exploring minimally invasive surgery with our great thoracic team or focal radiation therapy with our knowledgeable radiation oncology team. The patient's needs are at the center, and we aim to personalize the treatment accordingly. Thank you for the excellent question. Now, moving on to another question about advanced thyroid cancer. I'm aware that several different cancers have recently seen interesting research on therapeutic vaccines. Trials have been conducted for head and neck cancers. Are there any therapeutic vaccines being developed for thyroid cancer? Not that I am personally aware of. I have heard some interest in the role of CAR-T and immunotherapy, but there is still much more to explore. That's certainly a good question. Hopefully, developments in this area will arise in the future. Next, is there anyone at Moffitt engaged in and practicing metabolic therapies for the suppression of cancer? That's an interesting question. At Moffitt, we have a whole department dedicated to metabolism and physiology as they relate to oncology. I wonder if your question is related to diet. I know many patients often inquire about cancer-specific diets. For head and neck cancer, in general, we advise patients not to follow any unusual diets prior to treatment, as most patients tend to lose weight due to the difficulties in eating and drinking throughout therapy. Currently, our department is not conducting any specific studies on diets like the ketogenic diet during cancer treatment or for long-term disease suppression. Our main focus is to ensure that patients maintain their weight.
Dr. Kirtane, are you familiar with anything related to metabolism and neck cancer at Moffitt? Right now, I mean, I think it's extraordinarily difficult to develop a randomized controlled trial or a very controlled diet at home. You can control the administration of drugs or radiation, but controlling the diet is challenging. Therefore, I don't know anything about that at Moffitt currently. However, we do have a wonderful Nutrition department. I refer almost every patient with head and neck cancer to them for consultation. They are extremely knowledgeable and help calculate intake to maintain a healthy diet during cancer treatment. Our nutritionists at Moffitt exclusively serve cancer patients, so they specialize in that expertise. We can definitely facilitate that for patients who are interested.
Moving on to the next question, is there anything at Moffitt regarding the impact of head and neck cancer treatment on fertility? I know this concern also arises for patients with thyroid cancer. Dr. Augusto, Dr. Kirtane, any thoughts on how we address this at Moffitt? Do you discuss it with your patients?
It's a great question. We could certainly do a better job of providing resources for fertility preservation. Currently, we don't have dedicated fertility preservation experts at our center. Usually, we refer our patients to community partners who specialize in this area. While it's not a common concern for the majority of my patients, it's crucial for the small minority who prioritize fertility. We need to improve in this area and establish internal resources for referral. Dr. Augusta, any thoughts?
The individualization and importance of the Race certification in thyroid cancer are particularly relevant here. It's crucial to have discussions with patients interested in having children about balancing the timing of radioactive iodine treatment to minimize the impact on their fertility treatment. We closely monitor their thyroid hormone levels as well. If any patients are interested in fertility preservation and are receiving therapies that may affect fertility, Moffitt has a system to connect them with community partners who can assist.
Next, we have some kudos for Dr. Kirtane and Barb for their care of a patient. Thank you. Moving on to Dr. Augusto, there's a question about TSH suppression and thyroid cancer. How do you balance quality of life and suppressing thyroid cancer? Is there a point where you stop suppressive therapy with thyroid hormone?
After monitoring patients for a certain period, we assess the response based on neck ultrasounds, scans, and tumor markers. If we observe an excellent response, we start aiming to keep the TSH on the lower end of the range, up to two, without suppressing it completely. Long-term TSH suppression can have side effects, so it's important to balance the patient's quality of life. Depending on other medical conditions and symptoms, there may be circumstances where we adjust the target and range of TSH suppression to find a suitable balance.
Let's move on to the remaining questions. We have a couple more minutes, and hopefully, we can address them all.
Dr. Kirtane, I have two questions for you about HPV. Again, regarding what is the correlation between HPV and tonsil and cervical cancer? And is esophageal cancer HPV-related? So, um, esophageal cancer is not HPV-related. The correlation between cervical cancer and oropharynx cancer is the common virus, obviously HPV. Um, it's not that the cancers themselves are related, but it's the cause. So, in general, if someone's immune system did not take care of HPV and unfortunately HPV caused cancer, there is still a risk of that HPV causing cervical cancer. For example, my head and neck patients that have HPV-associated cancers still need to keep up with all of their standard, you know, pap smears and things like that that need to be done to just monitor for HPV-assisted cervical cancer. It's not that you're at a higher risk necessarily, but because HPV has already caused one cancer, it's always possible to cause that other cancer. Awesome, thank you, a great question about an important issue that affects a lot of head neck patients. Any research being done on the regeneration of taste buds after radiation therapy? So, we don't have a radiation oncologist with us tonight, but um, I can just comment briefly on that. It depends on the etiology. It is a common thing that can affect head neck cancer patients undergoing radiation. Sometimes taste can be affected by the surgery as well, based on the nerves that are near the surgery site. But fortunately, the majority of patients who do experience dysgeusia have recovery of their taste, although some still have a persistent metallic taste. I'm not aware; we don't actually have any studies for that at Moffatt at the moment. I am aware of potentially a role for acupuncture or some vitamin supplements, but unfortunately, nothing really that's proven to be super helpful. That's a really important question because it's obviously a long-term side effect for many of our patients and is pretty understudied but has a major impact on life quality of life. So, I'm just saying that to her, I agree with whoever asked the question that it needs to be studied more and better. Yep, for sure, Barb. I have a question for you: Can anyone have access to a Nurse Navigator? So, um, yes. Um, primarily, as I shared before, my role is with our multi-disciplinary team. But the clinic nurses are aware that if they see someone that comes in that may not be in that particular clinic, they can always reach out to me if they feel like an extra person may help them get through the treatment or have those resources. They're always welcome to reach out to me, and I can help as well. Awesome, thank you. We're so glad to have you as a resource. Um, okay, question about Keytruda. Are there any new clinical trials for head and neck patients, except Keytruda, after it has metastasized to the lungs?
Dr. Kirtane, yeah, so, um, you know, temporalism. Keytruda is, as I mentioned, the standard of care as a first-line treatment. So, it's hard to develop a trial when you're not giving the standard of care as part of the first-line treatment. So, most of the time, when I say "first sign," I mean the first treatment that a patient gets when they're first diagnosed. So, most trials include concatruda plus, you know, a new combination of drugs. I mentioned one of those trials where we have patients from Katrina, and it didn't work, so we use chemotherapy and add to it a pill. That pill is a blocker of a certain receptor that's overexpressed, and I had neck cancer. That pill is called buparlo sip. So, that's a clinical trial we have for patients for whom Katrina didn't work. Um, there are other trials where we have a similar paradigm, you know, patients get gertruda, it doesn't work, and then we add something else to try to stimulate the immune system to work better. But as a first-line treatment, most of those patients usually have Keytruda as some aspect of that combination of treatments. If they're ineligible for Katrina due to, you know, autoimmune diseases or things like that, there are potentially other options, but that is a less well-studied area of the astonished. Thank you. All right, we have one more question here. I'll answer quickly. Um, thyroid cancer in 2012, surgically removed, um, calcium numbers, um, are off, and can this be a symptom of parathyroid problems? So, when you have thyroid surgery for thyroid cancer or for any other thyroid disease, there is a small chance of ending up with low parathyroid hormone levels, which can cause low calcium levels. Um, and usually, in the vast majority of patients, those symptoms resolve after a few weeks. But there are about four percent of patients who end up with permanent parathyroid issues after having a total thyroidectomy, unfortunately needing calcium supplements. But it's very unusual to experience new problems with that long-term. Dr. Augusto, any thoughts about a relationship between parathyroid problems and thyroid cancer down the road after surgery? No, not necessarily. I think if somebody is having problems long-term after thyroid cancer surgery, they would definitely need additional evaluation to try to sort out where the calcium disturbance is coming from. Is it a primary parathyroid problem or is it a non-parathyroid related issue? And there are certainly certain blood work laboratories that, from an endocrinology standpoint, can be obtained in that scenario. Fine, thank you. Well, that will do it. Thank you so much for being with us tonight. Thank you so much to David Curry, Tiffany Brielle, for helping us put this together. Thank you so much to Dr. Kirtane, Dr. Augusto, and Barb Wampler for participating tonight and sharing your expertise. And thank you to all of our patients. We are so appreciative of you and your continued support as we go through treatment with you. We're working towards revolutionizing Cancer Care here at Moffitt, and we are so happy you could come and listen to us tonight. So, thank you, and have a wonderful night.
10 Key Take aways from the Discussion on Head And Neck Cancers
Head and neck squamous cell cancers are the seventh most common cancer worldwide, with a high number of new cases and deaths each year.
Human papillomavirus (HPV) is a significant factor in causing certain types of head and neck cancers, particularly oropharynx or tonsillar cancers.
HPV-related head and neck cancers have a better prognosis compared to non-HPV-related cancers, which opens avenues for exploring less aggressive treatment options.
Clinical trials are underway to evaluate de-escalation treatments for early-stage HPV-related head and neck cancers, including lower radiation doses and immunotherapy.
Immunotherapy is a treatment approach that aims to stimulate the immune system to attack cancer cells. It has shown promising results in various cancers, including head and neck cancers.
Several immunotherapy drugs have been approved for head and neck cancers, such as pembrolizumab, but they only work for approximately 20% of patients.
Moffitt Cancer Center is actively involved in clinical trials to enhance the effectiveness of immunotherapy and develop new treatment options for patients who do not respond to it.
Clinical trials are exploring the use of combination therapies, such as adding flx475 or inflammatory hormones to immunotherapy, to improve treatment outcomes.
Vaccines targeting specific proteins on HPV-related cancer cells are being developed to stimulate an immune response and promote cancer regression.
Moffitt Cancer Center is conducting research on tumor infiltrating lymphocytes, a type of cellular therapy, to treat solid tumor cancers, including head and neck cancers.
What are the different types and subtypes of Head and Neck Cancers?
Squamous Cell Carcinoma: This is the most common type of head and neck cancer, accounting for the majority of cases. It originates in the squamous cells lining the various structures in the head and neck region, such as the mouth, throat, voice box, and nasal cavity.
Oropharyngeal Cancer: This type of cancer specifically affects the oropharynx, which includes the back of the throat, base of the tongue, and tonsils. Oropharyngeal cancer can be further classified into HPV-related and HPV-unrelated subtypes based on the presence or absence of human papillomavirus (HPV) infection.
Nasopharyngeal Cancer: This cancer develops in the nasopharynx, the upper part of the throat behind the nose. It is more common in certain populations, such as individuals of Asian descent.
Nasal Cavity and Paranasal Sinus Cancer: These cancers originate in the nasal cavity and the paranasal sinuses, which are hollow spaces around the nose and skull bones. They are relatively rare.
Salivary Gland Cancer: This type of cancer forms in the salivary glands, which produce saliva. There are different types of salivary gland cancers, including mucoepidermoid carcinoma, adenoid cystic carcinoma, and acinic cell carcinoma.
Thyroid Cancer: Although not exclusive to the head and neck region, thyroid cancer can affect the thyroid gland located in the neck. It includes different subtypes such as papillary carcinoma, follicular carcinoma, medullary carcinoma, and anaplastic carcinoma.
Laryngeal Cancer: Laryngeal cancer affects the voice box (larynx) and can be categorized into different subtypes, including squamous cell carcinoma, adenocarcinoma, and sarcoma.
Moffitt Cancer Center - About
The Moffitt Cancer Center, located in Tampa, Florida, is a renowned cancer research and treatment facility. Established in 1986, Moffitt has grown into one of the leading cancer centers in the United States. It is designated as a Comprehensive Cancer Center by the National Cancer Institute (NCI), recognizing its excellence in cancer research, patient care, and education.
At Moffitt, a multidisciplinary team of experts collaborates to provide personalized care and innovative treatments for various types of cancer. The center offers a wide range of specialized programs and clinics, including those focused on breast cancer, lung cancer, melanoma, and many other cancer types. Their team of physicians, surgeons, researchers, and supportive care professionals work together to ensure the best outcomes for patients.
Moffitt Cancer Center is committed to advancing cancer research and discovery. The center conducts extensive research in areas such as immunotherapy, precision medicine, cancer genetics, and early detection. Moffitt's scientists and clinicians work together to translate their research findings into clinical applications, aiming to improve patient outcomes and develop new therapies.
In addition to research and clinical care, Moffitt Cancer Center is dedicated to educating and training the next generation of cancer professionals. The center offers various educational programs, fellowships, and training opportunities for medical students, residents, and researchers, fostering the development of expertise in cancer care and research.
Overall, Moffitt Cancer Center stands as a leading institution in the fight against cancer, providing comprehensive, compassionate care to patients, conducting groundbreaking research, and educating future cancer professionals.