Audiences were stunned to learn first-hand on the David Letterman show that the actor, Michael Douglas had cancer of the larynx (or voice box, or throat). The audience reaction to Mr. Douglas became even more dramatic when he stated he had stage IV (or stage 4). The immediate reaction from the host, audience and then amazingly the newswire services was that he was in fact “incurable” since he had stage IV cancer. As oncology specialists with extensive expertise in head and neck cancer, all we could do, was scream into our identical computers in Colorado and Delaware at the lack of information not only given by Michael Douglas (who I might add was very brave to go public with his fight) about what stage IV head and neck cancer really means, but the misinformation provided to the public by the news outlets.
So, time for head and neck cancer 101: Throat cancer or larynx cancer as it is normally called in our circles, is different than other cancers that can occur in the head and neck such as oral tongue cancer (more towards the front of your mouth), base of tongue cancer (which is very different then tongue cancer) tonsil cancer (which is part of the oropharynx like base of tongue and soft palate cancers) cancers of the hypopharynx (below or to the sides of the larynx) cancer of the nasopharynx (where the back of the nose meets the back of the throat), and cancers of the salivary glands, and skin and finally cancers of the lymph glands called lymphoma. Each one has a different prognosis and depends on a lot of things including if the patient is a current or former smoker and if the cancer is positive for the Human Papilloma Virus (HPV). There are specific strains of the HPV that can contribute to the development of head and neck cancers (primarily in the tonsil and base of tongue) and these are the same strains associated with the development of cervical cancer (more on this below!). Stage “IV” head and neck cancer is NOT the same as …say, Stage IV lung cancer or Stage IV pancreatic cancer. Stage IV head and neck cancer can be subdivided into Stage IV a, IVB or IVC (and the latter is the one that means the cancer has spread out of the head and neck region to other parts of the body). Most likely, Mr. Douglas has Stage IVA cancer and the stage can be related to the size of the main cancer in the base of tongue or based on lymph node spread, how many lymph nodes and the size of the lymph nodes. This is also true if you have a Stage IV cancer of the vocal cords or the larynx tissue above the vocal cords.
Some cancers of the “throat” arise from years of smoking and drinking. From what we can tell (again speculating since we have not examined Mr. Douglas), this chronic insult probably contributed strongly to Mr. Douglas’ cancer. There are now head and neck cancers arising in younger men and women with no past history of smoking primarily from HPV. HPV can be transmitted through oral contact and oral sex. The good news is, Stage IV head and neck cancers from HPV have a very high cure rate approaching 70-80% (if the patient has a light history of smoking), and even as high as 90% for never smokers. Many patients when facing the diagnosis of stage IV head and neck cancer are despondent, because they don’t understand, and they don’t know what questions to ask or how to ask them. It becomes vital that a patient with advanced head and cancer understand their options, go to experienced places that treat a high volume of cases and seek out all the options from surgeons, medical oncologists and of course MOST IMPORTANTLY, radiation oncologists! (like us). We always strongly urge cancer patients to seek second opinions at National cancer Institute designated cancer centers (a special designation) or seek out physicians that were trained specifically to treat this disease, publish on their outcomes and toxicities and have national reputations. We are continually surprised at how many patients do not do this.
Not to belabor this issue; however, a recent study showed that cure rates for head and neck cancer can vary by 10-20% depending on the doctor you end up with. In a nutshell…experience really matters. Smoking at the time of diagnosis and continued during/after treatment can change the chances of cure by 10-20% as well. Nicotine causes blood vessels to constrict and potentially make tumor cells more resistant to radiation therapy and chemotherapy. We generally advise not to go on a nicotine replacement before or during treatment. Smoking right before treatment or during also upregulates a tiny receptor on cancer cells called EGFR that also makes them more resistant to treatment. Cure rates can go down by 20%. In fact, head and neck cancer patients who are heavy smokers and lack HPV can have survival rates at 2 users less than 45%. So nicotine and upregulation of EGFR leads to a bad outcome. Now combine this with an inexperienced Medical Oncologist or Radiation Oncologist and you see where this is going. The typical approach for Mr. Douglas would involve some type of chemotherapy combined with radiation. Patients may be offered surgery followed by radiation or chemo-radiation or an organ preserving approach. Regarding the latter, generally a drug such as cisplatin is offered alone or combined with another drug called a taxane – both help the radiation kill head and neck cancer cells more effectively. Sometimes, a patient will be offered chemotherapy BEFORE radiation (many times inappropriately for earlier stage or less advanced disease) and this may be reasonable for patients with big lymph nodes and big primary cancers. More recently, special antibodies that block the EGFR pathway can be administered weekly and have been shown to improve cure rates when given with radiation. This approach is less toxic to the patient and may be appropriate in heavy tobacco users where cancers tend to have high expression of this EGFR pathway that drives cancer cells to grow faster. This antibody, which is FDA approved, can be given to stop head and neck cancer cells from repairing themselves during radiation. In addition, experienced radiation oncologists (make sure they are board certified!) can offer Intensity Modulated Radiation Therapy or IMRT that can help spare important salivary tissue and swallowing muscles that can truly impact the quality of the life of the head and neck cancer survivor. Again, experience in this area is REALLY important. These are questions that patients must ask their oncologist. Heck, asking the right questions is just as important. Nutrition counseling, psychological support, speech and swallowing help and exercises to maintain the function of the throat are also vital. It takes a village to cure this disease.
Finally, if you have a persistent sore throat ort notice a lump in your neck, urge your primary cancer doctor to refer you for more careful evaluation. Do not sit on this for 6-12 months. The earlier you detect a head and neck cancer the better. We wish we could end the habit of smoking as well – what an easy preventative measure! In terms of HPV and vaccinations, our young ladies are undergoing this procedure and it may be that we should advise our young men to get vaccinated as well. A debate for another day.
Drs’ Adam and David Raben