Robotic Surgery: A Better Option for Many Head & Neck Cancers Neal Futran, MD, DMD Director of Head and Neck Surgery, Department of Otolaryngology UW Medicine Eduardo Mendez, MD Assistant Professor, Otolaryngology: Head and Neck Surgery UW Medicine Charles Ross Throat Cancer Survivor Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. [Editor s Note, May 11, 2016: In 2011, Andrew interviewed tongue and pancreatic cancer survivor, Chuck Ross, along with experts Drs. Neal Futran and Eduardo Mendez about robotic surgery, which continues to be used today as an approach to treatment. This is the transcript of that interview.] 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. In this interview, two UW Medicine Health System head and neck surgeons and their patient discuss the advantages of the latest in robotic surgery. Imagine if you have cancer of the head and neck and need surgery - that can be quite traumatic. But what if there's a less invasive way, a more precise way, to allow doctors to get at cancers that maybe they otherwise could not get at with other types of surgery. Meet 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. During surgery, the surgeon noticed that there was a spot on Chuck s tongue and said, You know, I don't like that. We need to get that checked out. The conclusion was that it was cancer on his tongue and Chuck came to the University of Washington, to the Head and Neck surgeons there who also used 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? Oh, absolutely, and the way Dr. Mendez explained it to me, that was the best way to go that I could see.
Now, the advantage would be to get it and do the surgery and maybe spare you radiation and chemo because of the precision of getting in a small place, right? 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. So the fact that the prostate cancer surgeon spotted something unusual on your tongue, that was, can we say, fortuitous? Oh, absolutely. It may have gone a lot longer in not noticing it. And you understand that if Head and Neck cancer advances, it's a rough deal. 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. So you had the robotic surgery. And how long were you in the hospital for that? I was in the hospital two days. And then I know they went back and had lymph node surgery, and that was a hospitalization of a few more days? Yes. That was four days in the hospital. Now, this was in 2010. We're doing this program in 2011, many months later. How you are you doing? I'm doing excellent. It couldn't be better. My swallowing is good. My taste is back. Yes, everything is very good. Now, with any kind of surgery, and certainly surgery on the tongue, you did have some swallowing issues for a short time, correct? Yes, that's correct. About two weeks' period of time that I was on liquids, and there was some pain and swelling, especially the first week, but after that, it subsided and it went well. 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? If you were going to have these cancers, this was a good time to have them?
Oh, I think the stars were in alignment for me when all this transpired: with the prostate surgery and what happened there, and then with the da Vinci robot being available for the laser surgery, this was the best thing that could have happened. 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, you have an overview of what's been happening in your field. How big a deal is it? I've been an otolaryngologist for 15 years and have concentrated my work on the treatment of Head and Neck cancers, and this includes the tongue. When we think about treatment for these cancers, 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. When we used to have to do surgery, especially for the back of the tongue, it was doable but it was very invasive, could be disfiguring, and 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. These are very good tools in certain cases, and we started using that for these tumors, but even though they can get rid of some of the tumor, 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 provided us a new tool that we can use to effectively remove the tumor surgically without those significant side effects, potentially reducing or even eliminating the need for radiation and/or chemotherapy. It also solves the dual 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. Sounds like quite an advance. 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, you performed the surgery on Chuck. It sounds like the robotics approach allows you to get to places that, with just your hands, would have been much more difficult or might have left disfigurements. 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 open surgery that you described can be quite morbid, and for many of those patients they choose not to have a surgical option. In many ways what robotics has done is broadened patients options. 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 significantly reduce the need for those two. If we're comparing open surgery versus robotics, I imagine with robotics there would be less blood loss, shorter surgery time, less anesthesia, and shorter hospitalization. Help us understand the benefits. The traditional open surgical approaches would entail a big resection where the jaw would need to be split. Or with a big neck surgery, the incisions would need to be made and the tumor would be hard to access. Once the tumor was out, 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 patient then typically goes to the surgical ICU with a tube in their mouth and another tube through their nose so that they can eat, and the recovery time would be about 10 days or so. Although some of these patients eventually do quite well in the long-term, it is quite a bit for the patient to go through. Compare that to what Mr. Ross went through: about a 45-minute operation, transferred directly to the regular floor, and 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 since you're starting to swallow again, so by the end of two weeks or so the patients are swallowing almost normally. Dr. Futran, why is it an advantage when radiation or chemo can be avoided. How does this surgery do the whole job? 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. The more tongue tissue you need to take away, the more it can affect speech and swallowing. If you have a tumor that you can get to through the mouth with, as Dr. Mendez stated, less morbidity but still get those clear margins and, if there are no unusual features in the tumor, we can observe that patient with clinical exam and periodic CT scans or other imaging. Part of the reason why the 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 best of both worlds. 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 radiation is required after surgery, the dosages can be reduced a bit because instead of having to use radiation to get rid of the whole tumor or a big bulk of the tumor, we're just dealing with microscopic disease. If we can lower the doses again, those side effects are mitigated. We talked about Chuck s tongue surgery, but give me other examples of the Head and Neck where this offers advantages. Right now, the most significant advantages are the back of the tongue the tonsil region, and the side of the throat. The other interesting area folks are looking at for this in Head and Neck are for thyroid surgery. Typically, a thyroidectomy is done through an open incision in the neck. 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 really under development is tumors in the sinuses, right between the eyes, so to speak. Typically, with open approaches, these tumors can be removed with significant side effects, but if we're able to do these surgeries with minimal incisions through the nose or the oral cavity, the recovery is not only quicker, but the side effects are less and patients return to function much more quickly and with less discomfort. Dr. Mendez, you've been doing this for a while now. What are you seeing in your patients? Chuck and other patients come back for checkups and you see them. How are they doing compared to what you used to see before you did robotics? We've been very fortunate. It is important to appropriate in your case selection, so we have made sure that the patients were fitting the right profile. Because of that, so far we have enjoyed 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 he has gone through any sort of treatment. 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 the 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. Chuck, I want to see if you agree with everything your doctor said. Is that the way you see it too? Oh, absolutely. My speech issues were minimally invasive. I believe I was talking right after surgery. I had a little hard time swallowing, and once in a while I would cough or gag a little bit from that, but that was a long time ago, and now everything is actually very, very good. The taste has come back. It was about four or five months before I could really, taste certain foods. That's all come back now. I don't have a problem speaking or swallowing. Is this is all out of mind for your friends and family? Yes, it is. And of course Dr. Mendez keeps a good eye on me. Every three months I get checked to make sure that nothing is coming back. That eases my, Janice's and the family s that it's basically put behind. I mean, it's like any other cancer. You get checked to make sure, but I feel very good about myself and what's transpired, and I feel confident that it's not ever going to come back. You're retired now, so the point is you want to enjoy every day, go out to eat, interact with your family and feel good, and it sounds like you have that right now. 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. Dr. Futran, we talked about who robotic surgery is right for, but there are times when you have to say, in this case, we need to do it differently. One of the issues with robotics is the expense. It's technically demanding, and you need special training to use it, so the question becomes, is this a technology looking for a purpose or does it really have value? You can see in Chuck s case and many others, it does have value. Every time we see a patient, we talk about options because the patients are partners in the decision-making process. When we see patients a lot of it depends on the size of the tumor, the location of the tumor in the mouth, and whether or not we see evidence of spread of the tumor to lymph nodes in the neck. That's how we determine what types of treatment are best for each particular case. The advantage we have here at the University of Washington is the 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. So 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 then come up with an appropriate treatment plan. Robotic surgery for head and neck cancer is not available everywhere, Patients and their families might want to have a consultation with a major center like the University of Washington to see if robotic surgery could apply. 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 is another set of eyes. It's having a whole team looking at the problem and I think it really helps direct the therapy as best as we possibly can. With cancer, we have certain tools, and we know really the first shot is the best shot. Obviously, if we have to play catchup, we do, but if you can get the appropriate plan from the start, using the tools we have as wisely as we can, that ultimately gets the best patient outcome. 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? Since April 2010 we've done over 50 of these cases, so we definitely have been able to expand our expertise and have become much more familiar with the technique. We're growing as a program. We're seeing more and more of what the benefits are and what the limitations are. One other point we should mention is that one of the disadvantages with chemotherapy and radiation therapy, although effective, is that they can only be given once and the toxicities are such that the patient wouldn't be able to tolerate repeated treatments. With robotic surgery, or surgery in general, all tools remain on the table. We're following Chuck to make sure that the cancer doesn't return. I'm confident that it won't, but if for some reason it did, all tools remain on the table. And that is an extremely important option that we continue to preserve and have in the treatment of cancer. We've made an advance, and the advance opens more doors and it doesn't shut them. Dr. Futran, I want to give you a chance to get on your soapbox about early detection because, as you know, Chuck said his doctor spotted something unusual and he followed up. Early detection is critical in head and neck cancer, isn't it? Like many things, the smaller the problem is, the smaller and easier the solution. Head and Neck cancers are slow growing. It may start with a sore throat. It may start with a little ulcer on the tongue. The key thing about these cancers is that they typically start with symptoms that 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 be addressed. 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. Early detection is one of the most critical aspects of achieving a good outcome and people should pay attention to their bodies and not be shy about seeking help when necessary. 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. I urge people to be vigilant about their own body, and should they need treatment for Head and Neck cancer to have a consultation with a renowned center. And that's what I wanted to ask you about, Chuck. So you could have just stayed in Wenatchee and maybe had surgery there and maybe it wouldn't have been caught so early. Are you glad that you went over the hill to the University of Washington? Would you recommend others go the extra mile? I absolutely would. The personnel there doctors, everybody, the hospital nurses - they were fantastic. They made me feel like they cared, and they did. I would recommend that to anybody at any time. The robotics made a big difference for you?
Absolutely. Dr. Mendez and I both talked about that: what could have happened if they hadn't had robotics. It scares the life out of me to realize how much pain and agony I'd have had to go through compared to what minimally I did with robotics. Early detection, going to a skilled center, and now the option of a robotic approach offers so many advantages. Chuck Ross, I want to wish you a happy retirement, eating and tasting everything you like, and speaking a lot to anybody you want. Thank you for being with us. Thank you. It was very enlightening. 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, clear conversations with your patients who have undergone robotic surgery. Thank you for inviting me. It's a pleasure to be here. Dr. Neal Futran, you're the chair of the department. You must feel really good about how robotic surgery is helping you provide better care. I m extremely proud. I m proud to have wonderful faculty members like Dr. Mendez, who learn about this, champion this cause, and bring it to not only to our community but the entire Northwest. 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. We connect you with imminent doctors who continue to use the best tools available for patients. We also bring inspiring stories from patients like Chuck Ross. Thank you for joining us. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you.