Treating Head and Neck Cancer Requires Extraordinary Coordination Among Disciplines Researchers Seek to Understand the Mysteries of Uterine Cancer and to Find Better Treatments Mammography vs. Magnetic Resonance Imaging: A Breast Cancer Prevention Specialist and a Radiologist Weigh in on the Recent Debate House Call: The Role of Alcohol and Tobacco in Head and Neck Cancer DiaLog: Sexuality after Gynecologic Cancer, by Karen Basen-Engquist, PhD, Associate Professor, Department of Behavioral Healthhttps://openworks.mdanderson.org/oncolog/1133/thumbnail.jp

Basen-Engquist, Karen, PhD, MPH

Chalaire, Dawn

Galloway, David

Hosemann, Sunni

English

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University of Texas MD Anderson Cancer Center OpenWorks @ MD Anderson OncoLog MD Anderson's Report to Physicians (All issues) OncoLog MD Anderson's Report to Physicians 2004 OncoLog Volume 49, Number 10, October 2004 Dawn Chalaire Sunni Hosemann David Galloway Karen Basen-Engquist PhD, MPH Follow this and additional works at: https://openworks.mdanderson.org/oncolog  Part of the History of Science, Technology, and Medicine Commons, and the Oncology Commons 2    OncoLog • October 2004Treating Head and Neck Cancer Requires Coordination(Continued from page 1)with cosmetic deformities or speech orswallowing impairments. It became clearthat combining or replacing surgery withother types of treatment to preserve formand function would require a great dealof coordination among different indi-viduals, departments, and disciplines.And so it was that in the treatment ofhead and neck tumors, the concept ofmultidisciplinary care was first conceivedand practiced at The University of TexasM. D. Anderson Cancer Center in thelate 1960s. “There was a lot of resistance tomultidisciplinary care when it wasdeveloped because treatment 30 yearsago was very territorial,” said Randal S.Weber, M.D., professor and chair of theDepartment of Head and Neck Surgery.“The true multidisciplinary teamconcept really grew out of the need toachieve the two goals in cancer care,which are to maximize survival andpreserve or restore form and function.”Changes wrought bymultidisciplinary careThe advent of multidisciplinarycare has led to many changes in thetreatment of head and neck cancer.For example, tumors of the posteriortongue and tonsil once often necessi-tated removal of part or all of thetongue, which frequently left patientsunable to swallow properly or speak.Now, these tumors can often be treatedwith radiation therapy alone or incombination with chemotherapy.In disease sites where surgery is stillthe principal treatment approach, newtechniques may allow surgeons to limitthe amount of tissue they remove.For example, laser surgery can now beperformed on patients with cancers ofthe larynx to avoid a tracheostomyand permanent loss of the voice.However, conventional surgery isstill required to treat some very advancedcancers, or those of the skin, thyroid,salivary glands, and front part of thetongue, because other treatment modali-ties for these cancers are not as effective.“So we’re left with the problem thatsurgery may still create cosmetic andfunctional loss,” Dr. Weber said.To minimize and restore the deficitscreated by surgery, head and neck sur-geons consult with plastic surgeons toplan combined extirpative and complexreconstructive procedures using thepatient’s own soft tissues and bone, whichare harvested with blood vessels from avariety of donor sites in the body andattached to blood vessels and othertissues in the head and neck region.In some cases, when immediatereconstruction is not feasible or desir-able, resected facial structures such asthe nose or an ear are replaced withprosthetics created in the Departmentof Head and Neck Surgery’s Section ofOncologic Dentistry and Prosthodon-tics. Researchers in the Department ofPlastic Surgery are also investigating theuse of engineered tissue that can growand differentiate around a scaffold toreplace missing structures.Pros and cons of chemotherapyand radiation therapyTreating head and neck tumors withchemotherapy, radiation therapy, orboth has enabled physicians to leavecertain organs and structures intact,but organ preservation often comes ata significant cost—acute toxic effectsthat can create scar tissue and damagenerves, adversely affecting the functionof the tongue and the larynx.“What we’ve done over the pastdecade is intensify radiation therapyusing a twofold approach. One approachis to deliver hyperfractionation, or morethan one radiation treatment a day.The other approach we’ve taken isadding radiotherapy sensitizers to thetreatment regimen, and that is wherechemotherapy comes in. Chemotherapyenhances the effect of radiation, but thedownside is that it is toxic. So we arepreserving organs, but some of thoseorgans don’t function so well becauseof the toxic effects,” Dr. Weber said.In a recent study led by Moshe Maor,M.D., a professor in the Department ofRadiation Oncology at M. D. Anderson,investigators found that patients withlaryngeal cancer who were treated withradiation therapy and chemotherapyconcurrently were less likely to requiresurgical removal of the voice box withintwo years after treatment than werepatients treated with chemotherapyfollowed by radiation therapy or radia-tion therapy alone.Radiation therapy and chemotherapycan also be used after surgery to improvelocal-regional control and survival inpatients with advanced head and necktumors. In the May 6, 2004, issue of theNew England Journal of Medicine, similarresults were reported from two random-ized clinical trials comparing concurrentchemotherapy and radiation therapyversus radiation therapy alone inpostoperative patients with advancedhead and neck cancer. In both studies,disease-free survival was longer in thepatients who received concurrenttherapy; however, patients treated withboth radiation therapy and chemo-therapy were much more likely to havemoderate to severe side effects such asnausea, vomiting, pain, and difficultyswallowing.Even patients treated with radiationtherapy alone may suffer from long-termeffects, especially a decrease in salivaproduction. Besides causing discomfortand making it more difficult to speakand swallow, a decrease in saliva canmake the teeth more susceptible tocavities, necessitating long-termprophylaxis, including daily fluoridetreatments.To avoid damaging the salivaryglands during radiation therapy, differ-ent approaches are under investigation.Intensity-modulated radiation therapyis used to focus the treatment beamson the tumor with less damage tosurrounding tissues, such as the salivaryglands, than that caused by conven-tional radiation therapy deliverymethods.Follow-up care of patientstreated for head and neck cancerPatients who have been treated forcancers of the head and neck requirefrequent and extensive follow-up aftertreatment. Patients with a history ofsmoking or alcohol abuse are at highrisk for a second primary tumor, includ-ing lung cancer, esophageal cancer, or4    OncoLog • October 2004Fortunately, most localized uterinecancers have a high (>90%) cure rate.However, the prognosis is grave forwomen with metastatic or aggressiveforms of uterine cancer. Fewer than 20%of women whose disease has spread intothe pelvis will survive five years. “Wejust don’t have very effective treatmentsfor advanced or recurrent uterinecancers,” said Lois Ramondetta, M.D.,an assistant professor in the Departmentof Gynecologic Oncology at TheUniversity of Texas M. D. AndersonCancer Center.More than 40,000 women in the U.S.will be diagnosed with uterine cancer in2004. While most women are 60 years orolder at diagnosis, 20% to 25% arepremenopausal. “For some reason thatwe don’t yet understand, we are seeingmore women with this disease at ayounger age, in their 30s and 40s,” notedAnuja Jhingran, M.D., an associateprofessor in the Division of RadiationOncology, whose research focuses ongynecologic tumors. “And one of theother mysteries of the disease is thatolder women [>70 years] have a poorerprognosis than younger women whencompared stage-for-stage. This is unlikemany other cancers.”To solve the mysteries of uterinecancer and to develop more effectivetreatments for metastatic and aggressiveResearchers Seek toUnderstand the Mysteriesof Uterine Cancer and toFind Better Treatmentsof pelvic or vaginal recurrence. Inten-sity-modulated radiation therapy, whichdelivers very focused radiation only tothe target area, is a promising newdevelopment. “In small studies so far,we have seen much reduced lower boweltoxicity,” said Dr. Jhingran. “This mayseem like a small advance, but forwomen who suffer posttreatmentdiarrhea, it is a huge improvement inquality of life.” This technique will bepart of a large, upcoming RadiationTherapy Oncology Group study.Vaginal cuff radiation is a patient-friendly advance that can be used to treatpatients with intermediate-risk diseasethat has been fully staged or as a boost forpatients with high-risk disease that hasbeen treated with external-beam radiationtherapy to the pelvis. In this therapy, atampon-like device called a vaginal domecylinder is inserted into the vagina whereit delivers high-dose radiation.Chemotherapy options with a goodchance of cure or palliation are notyet available for patients with uterinecancer.Risk factors for uterine cancerFor most women, the lifetime riskof uterine cancer is 3%, but for womenwith hereditary nonpolyposis colorectalcancer (HNPCC), the lifetime riskjumps to 40%.Obesity is another significant riskfactor; the risk of endometrial cancertriples for a woman who is 30 poundsoverweight and increases five times fora woman who is 50 pounds overweight.“Of all cancers, endometrial cancer ismost strongly linked to obesity,” saidKaren Lu, M.D., an assistant professorin the Department of GynecologicOncology. “Any obese woman whohas irregular periods should have anendometrial biopsy.”Prolonged exposure to unopposedestrogen—either endogenous or exog-enous—significantly increases awoman’s risk of uterine cancer. Thisincludes obese women, those treatedwith hormone replacement therapyconsisting of estrogen without progester-one, and women who have had anearly menarche (before age 12) orlate menopause (after age 52).According to a recent NationalSurgical Adjuvant Bowel and BreastProject (NSABP) trial, uterine cancerdisease, researchers at M. D. Andersonare investigating new treatment andprevention strategies as well as thedisease’s biology.Treatment updatesThe majority of cancers arising inthe uterus are endometrioid adenocarci-nomas. These have an excellent progno-sis compared to more aggressive typessuch as uterine sarcomas, papillaryserous and clear cell carcinomas, andmalignant mixed mullerian tumors.(Serous and clear cell carcinomas—which tend to occur in older womenand are often at an advanced stage whenfound—behave the most aggressivelyand need to be treated differently thanother uterine tumors.)For early-stage endometrial cancersthat are considered medically inoper-able, radiation therapy is the primarytreatment; for all others, total abdomi-nal hysterectomy with bilateralsalpingo-oophorectomy and lymph nodedissection remains the standard treat-ment. At M. D. Anderson, some uterinelymph node dissections are performedlaparoscopically, with no increased risksand with reduced morbidity.Patients with intermediate- or high-risk uterine tumors may receive adju-vant radiation to the pelvis, dependingon the final pathology, to reduce the riskby Sunni HosemannAlthough uterine cancer is the most common gynecologicmalignancy in the United States—more common thaneither cervical or ovarian cancer—fallacies regardingthe disease abound. Some women mistakenly believethat their Papanicolaou’s test will screen them for uterine cancerwhen in fact there is no routine screening test for this disease.Others are unaware that heavier than normal menstrual bleedingand bleeding between periods may be symptoms of uterine cancer.Dr. Anuja Jhingran (1), associate professor in the Division of Radiation Oncology, explains vaginal cuff radiation to patient . In this therapy, a device called a vaginal dome cylinder (shown) is inserted into the vagina to deliver high-dose radiation. developed in some users of tamoxifen. However, this is not a reason to discon­tinue its use, said Dr. Ramondetta, because the benefits of preventing recurrent breast cancer outweigh the increased risk of endometrial cancer. In the NSABP trial, all cases of en­dometrial cancer were low grade and early stage (i.e., curable) and occurred in patients who had used tamoxifen for more than five years. Other risk factors are hypertension, diabetes type 1 and type 2, hypothyroid­ism, and nulliparity. Women with a family history of uterine cancer or a personal history of breast or colon cancer are considered to be at higher risk than women in the general population. Monitoring and reducing risk Because there is no recommended routine screening test for uterine cancers, all women should be queried by their gynecologists about unusual menstrual bleeding, irregular periods, or spotting, and women at high risk should be advised to report any unusual bleeding. Women who have HNPCC or a family history of uterine cancer should start being monitored between ages 25 and 35 years, with an annual pelvic examination, transvaginal ultrasonogra­phy, and endometrial biopsy. No large studies have produced guidelines for reducing or managing the risk of uterine cancer, but both surgical and medical options are available. Prophylactic surgery-a total hysterec­tomy and salpingo-oophorectomy-is recommended for women with con­firmed HNPCC who have completed childbearing or who are in their mid- to late 40s. For others, chemoprevention is an option that may be of interest; oral contraceptives and progestins have been shown to reduce uterine cancer risk. A National Cancer Institute (NCI) trial available at M. D. Anderson and two other sites will compare the effective­ness of contraceptive agents LoOvral and Depo-Provera in preventing uterine cancer. The question of how best to monitor women who are being treated with tamoxifen remains unanswered. • At M. D. Anderson, we do not routinelyscreen women treated with tamoxifenwho are asymptomatic," said Dr.Ramondetta. "We only recommendendometrial biopsy for those whohave vaginal bleeding." In addition,because of the submucosal edema thatcan develop in patients taking thismedication, many experts recommendthat a transvaginal ultrasound measure­ment of 8 mm-rather than the 5-mmcriterion used for other endometrialbiopsies-be used to determinewhether a patient should undergobiopsy.New research The NCI recently awarded a Special­ized Programs of Research Excellence (SPORE) grant-the first ever for uterine cancer-to researchers at M. D. Anderson, who plan to answer some of the many questions about this disease and its treatment. "We will study prevention, novel treatments, and gain a better knowledge of the biology of the disease with this funding," said Dr. Lu. The group is looking at new hor­monal therapies, including mifepristone (RU486), as well as new combinations of radiation therapy and chemotherapy. One crucial area of research that will be investigated is the molecular aspect of this disease. "We know that 75% of uterine cancers have a good prognosis and can be cured by surgery and/or radiation therapy," said Russell Broaddus, M.D., Ph.D., an assistant professor in the Division of Pathology. But for patients with aggressive variants, the outlook is poor. "We want to know more about aggressive versus nonaggressive types of this disease," Dr. Broaddus said. He noted that uterine cancer, unlike many other cancers, is not just an oncology problem; lipid metabolism, insulin biochemistry, and hormones also play a crucial role. "We must understand the endocrine and biochemical aspects," he said. Therefore, oncologists, endocri­nologists, internists, obesity specialists, and pharmacologists, among others, will contribute to the uterine cancer studies. In addition to receiving funding from the SPORE grant, researchers from M. D. Anderson's Uterine Cancer Research Program will also receive proceeds from sales of the cookbook From Home Plate to Your Plate, which was created by the wives of Houston Astros baseball players to benefit uterine cancer research. Thanks to these contributions, researchers may finally have the resources they need to defeat this disease.• FOR MORE INFORMATION, contact Dr. Ramondetta at (713) 745-0307, Dr. ]hingran at (713) 563-2347, Dr. Lu at (713) 745-8902, or Dr. Broaddus at (713) 745-2794. OncoLog • October 2004 5 

OncoLog, Volume 49, Number 10, October 2004

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OncoLog Volume 49, Number 10, October 2004

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