robotic surgery: a better option for many head and neck...

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Robotic Surgery: A Better Option For Many Head and Neck Cancers Webcast April 11, 2011 Neal Futran, M.D., D.M.D. Eduardo Mendez, M.D. Charles Ross Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you. Chuck’s Story Andrew Schorr: Head and neck cancers are often difficult to diagnose and also can be hard to treat. Fortunately, advances in robotic surgery are changing the landscape of surgery for head and neck cancers. Coming up, two UW Medicine Health System head and neck surgeons and their patient will discuss the advantages of the latest in robotic surgery, next on Patient Power. Hello. Welcome to Patient Power, sponsored by UW Medicine Health System. I'm Andrew Schorr. Well, as a cancer survivor of course I know how traumatic it can be emotionally. Sometimes you need chemo, radiation, surgery. Well, imagine if you have cancer of the head and neck and need surgery, that can be quite traumatic of course. But what if there's a less invasive way, a more precise way, and to allow the doctors to get at cancers that maybe they otherwise could not get at with other types of surgery. We're going to hear about that in this program today. And I'd like you to meet someone who has benefitted from robotic surgery for head and neck cancer, specifically cancer that was found on his tongue. And that's Chuck Ross, who is 64 years old, from Wenatchee. He was in materials handling for many years there, and then back in 2009 he was diagnosed with prostate cancer, and he had robotic surgery for that. Well, while he was having the surgery the surgeon noticed that there was a spot on his tongue and said, you know, I don't like that. You need to get that checked out. And when the conclusion was that it was cancer on his tongue he came to the University of Washington and the head and neck surgeons there who by then had been doing robotic surgery to help people in a much less invasive way. Chuck, you had robotic surgery for prostate. The idea of having it for a second cancer, and nobody wants a second cancer, that seemed to be the way to go for you? Chuck: Oh, absolutely, and the way Dr. Mendez explained it to me, that was the best way to go that I could see.


Andrew Schorr: Now, the advantage would be, am I right, to get it and do the surgery and maybe spare you in your case radiation and chemo and kind of the precision of getting in a small place, right? Chuck: Yes. And I was very fortunate. I had a level one cancer, and it was caught early which I think saved me a lot of pain and agony. Andrew Schorr: So the fact that the prostate cancer surgeon spotted something unusual on your tongue, that was, can we say, fortuitous? Chuck: Oh, absolutely. It may have gone a lot longer in not noticing it. Andrew Schorr: And you understand that if head and neck cancer advances it's a rough deal. Chuck: Oh, yes. And as Dr. Mendez explained to me what they may or may not have had to do without the robotics would have been a lot more severe. Andrew Schorr: So you had the robotic surgery. And how long were you in the hospital for that? Chuck: I was in the hospital two days. Andrew Schorr: And then I know they went back and had lymph node surgery, and that was a hospitalization of a few more days? Chuck: Yes. That was four days in the hospital. Andrew Schorr: Now, this was in 2010. We're doing this program in 2011, many months later. How you are you doing? Chuck: I'm doing excellent. It couldn't be better. I've got--my swallowing is good. My taste is back. Yes, everything is very good. Andrew Schorr: Now, with any kind of surgery, and certainly surgery on the tongue, you did have some swallowing issues for a short time, correct?


Chuck: Yes, that's correct. About two weeks' period of time that I was on liquids, and there was some pain, especially the first, oh, I'd say week, and swelling, but after that it subsided and it went well. Andrew Schorr: So, Chuck, do you feel that you were a lucky guy, maybe with the prostate surgery as well as now with the tongue surgery, that robotic surgery was available? So if you were going to have these cancers that, in a way, bad thing to have but good time to have them? Chuck: Oh, I think the stars were in align for me when all this transpired, with the prostate surgery and what happened there and then with the da Vinci robot being available with the laser surgery was the best thing that could have happened as far as I'm concerned with what happened to me. The Advantages of Robotic Surgery Andrew Schorr: Okay. Well, we'll hear more from you in a minute. The chairman of the department of head and neck surgery and the department of otolaryngology at the University of Washington is Dr. Neal Futran. Dr. Futran, so you have an overview of what's been happening in your field. How big a deal is it, and maybe you can help us understand why the ability to do robotic surgery for somebody like Chuck. Dr. Futran: I've been an otolaryngologist for 15 years and have concentrated my work on the treatment of head and neck cancers, and in the tongue this includes that area. And when I first started training and in practice when we think about treatment for these cancers obviously the first goal of treatment is to get rid of the cancer, but also we need to think about a patient's quality of life, which in this case is speech, swallowing and appearance. And when we used to have to do surgery especially for the back of the tongue it was currently doable, but it was very invasive, could be disfiguring, but most importantly even with some modern reconstructive techniques swallowing and speech could be severely affected. We also have nonsurgical treatment, such as radiation and chemotherapy, which are very good tools in certain cases, and we started using that for these tumors, and again they can get rid of some of these tumors but there are both short- and long-term side effects on speech and swallowing that can be severe. What robotics has really done for us is to have a new tool that we can effectively surgically remove the tumor without those significant side effects, potentially reduce or eliminate the need for radiation and/or chemotherapy and solve those two goals of getting rid of the cancer, preserving speech and swallowing, easing the patient's recovery and maintaining excellent quality of life for our patients.


Andrew Schorr: Wow. Sounds like quite an advance. Dr. Futran: Yes. Andrew Schorr: Let's hear from a colleague of yours who has been on Patient Power before, Dr. Eduardo Mendez, who is an assistant professor of otolaryngology and head and neck surgery at the University of Washington. Dr. Mendez, so you performed the surgery on Chuck. So it sounds like this approach with robotics allows you to get to places that may be just with your hands it would be much more difficult to do or maybe there would be jaw surgery or other disfiguring things as Dr. Futran said that you would have to do to get to where you had to get to. Dr. Mendez: That's correct. We have the ability with robotic surgery to perform the operation through the mouth without having to make any external incisions. In many of these tumors the surgery, the open surgery that you described can be quite morbid, and for many of those patients they choose not to have a surgical option. And in many ways what robotics has done is now broadened the options that patients have. And for candidates like Mr. Ross it could be a win-win situation where, as Dr. Futran stated, we can remove the cancer and either avoid chemotherapy and radiation altogether or reduce the need for those two significantly. Andrew Schorr: Now, and also if we're comparing open surgery versus this, I imagine less blood loss, you tell me if it's shorter surgery time, less anesthesia, shorter hospitalization. Help me understand if you compared surgery to surgery, the benefits. Dr. Mendez: Yes. The traditional open surgical approaches would entail a, like you described, a big resection where the jaw would need to be split or big neck surgery with the incisions would need to be made and the tumor would be hard to access. Once the tumor was out then there is a chance--there is a challenge of having to reconstruct that, and that adds on yet another level of complexity. Altogether, it could be about a 12-hour surgical procedure. The patients then typically go to the surgical ICU with tube in their mouth and a tube--hose through their nose so that they can feed, and it--the recovery time can be about 10 days or so. And although some of these patients do quite well eventually and long-term, it is quite a bit for the patient to go through. Compare that to what Mr. Ross went through, which was about a 44-, 45-minute operation. The patient went directly to the regular floor and was discharged from the hospital in about 48 hours. The pain can be significant, but we can keep that under control. And the recovery time is also done in the comfort of your home as you're starting to swallow again, so by the end of two weeks or so the patients are swallowing almost normally.


Andrew Schorr: Help me understand, Dr. Futran, why it may offer an advantage too where radiation or chemo can be avoided. How does that work out? How does this surgery do the whole job? Dr. Futran: So when we think about surgery for any of these tumors we obviously want to take out the tumor but we also want to take out a rim of normal tissue all the way around, and the more tongue tissue you need to take away the more it can affect speech and swallowing. And so if you have a tumor that you can get to through the mouth with, as Dr. Mendez stated, less morbidity but get those clear margins, if there are no unusual features in the tumor we can observe that patient with clinical exam and periodic CT scans or other imaging. The--part of the reason why the kind of pendulum swung away from surgery to radiation therapy with or without chemotherapy was this issue of function. The whole goal is how can we get rid of the tumor with the minimum amount of side effects. With robotic surgery we're starting to get the both--best of both worlds in that we can get the tumor out, get back to normal activity and in many cases not need that an additional nonsurgical treatment because we've gotten rid of the tumor. The other issue is even if we need radiation after surgery a lot of times the dosages can be reduced a bit because instead of having to use radiation to get rid of the whole tumor or that big bulk of tumor we're just dealing with microscopic disease, and if we can lower the doses again those side effect issues are mitigated. Andrew Schorr: Okay. One other question for you, Dr. Futran. Dr. Futran: Yes. Andrew Schorr: So we talked about the surgery on the tongue for Chuck, but give me other examples in the head and neck where this offers advantages. Dr. Futran: So right now the most significant advantages are in the back of the tongue and also the tonsil region and side of the throat. The other interesting area folks are looking at for this in the head and neck are for thyroid surgery. Typically again a thyroidectomy is done through an open incision in the neck, and for small tumors you can actually make an incision in the armpit and use the robot to get to the neck, take out the tumor and eliminate a scar in the neck. The third area which is really under development is occasionally we do see tumors that are in the sinuses, which are right between the eyes, so to speak. And typically with open approaches these tumors can be removed, again with significant side effects, but if we're


able to do these surgeries with minimal incisions and a lot of times through the nose or the oral cavity, not only the recovery is quicker but the side effects are less, and the patients return to function much more quickly and with less discomfort. Quality of Life Following Surgery Andrew Schorr: Dr. Mendez, you've been doing this for a while now, one of the early adopters. So what are you seeing in your patients? Like Chuck comes back for checkups, other patients, they come back, you see them, how are they doing? I know everybody is different, and there's a continuum, if you will, people fighting their cancer, but compared to what you used to see before you did robotics about someone's quality of life? Dr. Mendez: Well, we've been very fortunate. It is important to be able as you're launching your robotic program to be appropriate in your case selection, so we have made sure that the patients were fitting the right profile, and because of that we have enjoyed so far very good outcomes. It is not only what you see, but it's also what you hear, and in head and neck cancer how you hear a patient speak is also evidence of what the long-term toxicities and side effects are of all these treatments. Sometimes big surgeries or radiation and chemotherapy can invoke this sense of slurred speech, and clearly, as you hear Mr. Ross speak, you cannot tell that there is--that he has gone through any sort of treatment. So that is--when you're meeting your cancer patient you have all your senses to follow them and not only how they interact, not only how they swallow but also how they speak, and with Mr. Ross and other patients that have enjoyed robotic surgery, I have to say the difference is quite remarkable. They're enjoying their food through mouth. They're not dependent on a tube or having to go through significant speech therapy to recover back to baseline. The speech is fantastic, intact, essentially. And they're able to put the cancer behind them without having to think about every day having a reminder of what they just went through. Andrew Schorr: Chuck, I want to see if you agree with everything your doctor said. Is that the way you see it too? Chuck: Oh, absolutely. My speech was minimal invasive. I believe I was talking probably, oh, right after surgery. I had a little, like anybody is when you have surgery a little hard time swallowing, and once in a while I would cough or gag a little bit from that, but that is, that was a long time ago, and now it's--everything is actually very, very good. The taste has come back. It was, oh, probably about four months or five months before I could really, really taste certain foods. That's all come back now. I don't have a problem speaking or swallowing. Andrew Schorr: I might ask you to sing for us.


Chuck: Well, you wouldn't want that. Andrew Schorr: Okay. But no, no. And so do your friends, families, this is all out of mind for them too, that this is in the past? Chuck: Yes, it is. And of course Dr. Mendez keeps a good eye on me. Every three months we get checked to make sure that nothing is coming back, and that eases my mind and Janice's mind and the family, that it's basically put behind it. I mean, it's like any other cancer. You get checked and make sure, but I feel very good about myself and what's transpired, and I feel very good that it's not ever going to come back. Andrew Schorr: Well, I sure hope so. Now, you're retired now, so the point is you want to enjoy your retirement, enjoy every day, go out to eat, interact with your family and feel good, and it sounds like you have that right now. Chuck: I do, and I'm a very fortunate person the way things went. I enjoy golfing and stuff like that, and it's just amazing. Who Could Benefit from Robotic Surgery? Andrew Schorr: Well, Dr. Futran, so we talked about who it's right for, but there are times, there's somebody who may be listening or somebody is going to come see you and you say yes, we have robotics but in your case we need to do it differently. So, Dr. Mendez talked about patient selection is the term doctors use. Dr. Futran: Yes. Andrew Schorr: Help us understand. Dr. Futran: Yes, so actually one of the issues with robotics is, you know, this is an expensive technology. It's very technically demanding, and you need, you know, special training to use it, and the question is is this a technology looking for a purpose or does it really have value. And again as clearly as you can see in this case and many others, it does have value. And so every time we see a patient we talk about options because the patients are partners in the decision-making in their care. And so when we see patients a lot of it depends on the size of the tumor, the location in the mouth of the tumor, whether or not we see evidence of spread of the tumor to lymph nodes in the neck, which is most common. And that's how we determine what types of treatment are best for the particular case.


The advantage we have here at the University of Washington is we have wonderful expertise in all facets of head and neck care, from radiation oncology to medical oncology as well as all the supportive services such as speech pathology and nursing, etc., and so we--even though one of us may see the patient we meet every week as a group to look at the problem to try to assess the best treatment in the best order for the patient, discuss it with them and their family and come up with the appropriate treatment plan. Andrew Schorr: Well, that was the next thing I wanted to ask you about. What you just described doesn't happen everywhere. Robotic surgery for head and neck cancer is not available everywhere, so it would seem like someone in our area, maybe they could be in Alaska, they may be in Wenatchee over the mountains where Chuck lives or further away, that this is a situation where they might want to have a consultation with a major center like yours, University of Washington, to see could this technique apply. Dr. Futran: Yes, no, I think that's of extreme value. We do see patients from all over the Northwest and beyond. Not all of them have to be treated in Seattle, especially for various parts of their care. We have wonderful partners in the community and there's great expertise, but by at least having an evaluation with us it's another set of eyes, it's having the whole team looking at the problem, and I think it really helps direct the therapy as best as we possibly can. You know, as you know, you know, with cancer we have certain tools, and we know really the first shot is the best shot. Obviously if we have to play catch-up we do, but if you can get the appropriate plan, use the tools we have as wisely as we can, I think that ultimately gets us to the best patient outcome. Andrew Schorr: Dr. Mendez, people ask you probably now, they say, well, you're talking about robotics, how many of these surgeries have you done. Now, that answer is going keep changing, but you have a good bit of experience for this now, right? Dr. Mendez: We started in April or the end of April 2010, and by now we've probably done over 50 or so of these cases, so we definitely have been able to expand our expertise and have become much more familiar with the technique. And so we're growing as a program. We're seeing more and more what the benefits are, what the limitations are also. And one other point we should mention is that one of the advantages that I have seen is that with chemotherapy and radiation therapy, although effective, they can only be given once, and the toxicities are such that the patient wouldn't be able to tolerate repeated treatments of that. With robotic surgery, or surgery in general, all tools remain on the table. Mr. Ross was talking about whether or not he--you know, we're following him to make sure that the it doesn't return, and although I'm comfortable, I'm confident that it won't, if for some reason, god forbid, it would, all tools remain on the table. And that is


extremely important, an extremely important option that we continue to preserve and have in the treatment of cancer. So we've made an advance, and the advance opens more doors and it doesn't shut them. The Importance of Early Detection Andrew Schorr: Dr. Futran, I want to give you a chance to go on your soap box about early detection because, you know, Chuck said some--his doctor spotted something unusual, he followed up, which was great, but what if he hadn't noticed it. Or--and I know my dentist every time I go they check, the dental hygienist checks my mouth and if there was something unusual I know we'd follow-up. That early detection is critical in head and neck cancer, isn't it? Dr. Futran: Absolutely. Like many things, the smaller the problem the--usually the smaller and easier the solution. And, you know, typically, you know, head and neck cancers are slow growing. It may start with a sore throat. It may start with a little ulcer on the tongue, which we all get. The key things about these cancers are typically those type of things that come and go come and go within a couple of weeks, but if there are persistent areas that last beyond two or three weeks they should be checked out and should be addressed. Because if we address these things early we can usually take care of them much more easily and not have to use a lot of the aggressive tools. And so I think, you know, as with, you know, all cancers early detection is one of the most critical aspects of achieving a good outcome, and people should just pay attention to their bodies and not be shy about seeking help when necessary. Andrew Schorr: Right. And now we have this approach, robotic surgery that can help many people when it's done with the experience of folks like Dr. Mendez and Dr. Futran and their program at the University of Washington. So I urge people to, first of all, be vigilant about their own body, and should they need treatment for head and neck cancer to certainly have a consultation with a renowned center such as that. And that's what I wanted to ask you about, Chuck. So you could have just stayed in Wenatchee and maybe had surgery there, or, you know, maybe it wouldn't have been caught so early. Are you glad that you went over the hill to the University of Washington? And wherever somebody may be listening, would you recommend they go that extra mile when it comes to something like that? Chuck: I absolutely would. The personnel there, including doctors and everybody, the hospital nurses, they were fantastic. They made you feel like they cared, and they did. And, yeah, I would recommend that to anybody at any time. Andrew Schorr: And the robotics again made a big difference for you?


Chuck: Oh, absolutely. Dr. Mendez and I both talked about that, what could have happened if they hadn't had robotics, and it scares the life out of me, I mean, to realize how much pain and agony I'd have had to go through compared to what minimal I did with the robotic. Andrew Schorr: Amen. Well, I have, you know, burned in my mind, in my memory a friend who a few years ago this wasn't around and didn't have that and how traumatic it was. So hopefully early detection, going to a skilled center and now with the option of a robotic approach that can offer so many advantages. Chuck Ross, I want to wish you a happy retirement and eating and tasting everything you like and maybe not singing but speaking a lot to anybody you want. But thank you for being with us. Chuck: Thank you. It was very enlightening. Andrew Schorr: Okay. Well, thank you. Yeah, we learned a lot, and you're helping inspire so many other people. Dr. Eduardo Mendez, thanks for being back on Patient Power. Thanks for what you do every day, and I'm glad that you can have full conversations with your patients who have had robotics and a lot of clear speech and probably good feelings as well. Dr. Mendez: Thank you for inviting me. It's a pleasure to be here. Andrew Schorr: Okay. And Dr. Neal Futran, you're the chair of the department. You got to feel really good about how a tool like this is helping you all provide better care. Dr. Futran: It's extremely proud, but it's also proud to have wonderful faculty members like Dr. Mendez, who learn about this, champion this cause and bring this to not only to our community but the entire Northwest. Andrew Schorr: There you go. Well, thank you so much for being with us and thanks for what you do at the University of Washington. This is what we do on Patient Power is connect you with imminent doctors like this who are continuing to use the best tools available for patients and then Chuck Ross, who benefitted but also inspired us all today. Thank you for joining us. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.


Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you.

robotic surgery: a better option for many head and neck...

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