Few malignancies are more complex or require a greater level of interdisciplinary cooperation than head and neck cancers. The addition of maxillofacial, head and neck surgical oncologist Al Haitham Al Shetawi, MD, DMD, to the Vassar Brothers Medical Center and Health Quest team allows patients with those malignancies to receive comprehensive, personalized, multispecialty care in the Mid-Hudson Valley.
“Microvascular reconstruction is one of the most advanced surgical options we are able to provide to our patients to reconstruct defects that are caused by the removal of head and neck tumors,” says Al Haitham Al Shetawi, MD, DMD, maxillofacial, head and neck surgeon at Health Quest Medical Practice.
Health Quest Medical Practice (HQMP) welcomed maxillofacial, head and neck surgical oncologist Dr. Al Shetawi last August following his completion of a fellowship in head and neck oncologic surgery and microvascular reconstruction at the University of Florida. Dr. Al Shetawi specializes in treating benign and malignant tumors of the oral cavity, jaw, pharynx, larynx, neck, thyroid gland, parathyroid gland and salivary glands, as well as skin cancers. He also performs advanced microvascular reconstruction for the head and neck.
Dr. Al Shetawi completed a six-year residency in oral and maxillofacial surgery at Mount Sinai Beth Israel in Manhattan. During that time, Dr. Al Shetawi was struck by the number of patients who traveled from the Mid-Hudson region for treatment of head and neck cancers, and he recognized in Health Quest’s already-expansive capabilities a golden opportunity to treat them closer to home.
“There was a huge need for maxillofacial, head and neck surgical oncology in the Mid-Hudson Valley,” he says. “At Health Quest’s Vassar Brothers Medical Center, I saw all of the elements that are necessary to provide the best care to patients, including specialists in medical oncology, radiation oncology, otolaryngology, neuroradiology, pathology, endocrinology, dermatology, gastroenterology and dentistry, as well as important services, such as nutrition support, speech and swallow therapy, and physical therapy.”
The diversity of head and neck cancers makes every clinician on the team indispensable to the diagnosis, treatment and survivorship of these patients.
A Kaleidoscope of Challenging Cancers
Cancer can affect multiple structures in the head and neck, including the nasal cavity, oral cavity, sinuses, pharynx and larynx. These varied malignancies most often arise from the lining of the upper aerodigestive tract in the form of squamous cell carcinomas, according to Dr. Al Shetawi. The American Cancer Society estimates 51,000 new cases of oral and oropharyngeal cancer in 2018.
“The etiology varies from case to case, but most head and neck squamous cell carcinomas in the U.S. are associated with tobacco and alcohol exposure,” Dr. Al Shetawi says. “HPV is a significant cause of cancer of the oropharynx. The incidence of oropharyngeal cancer as a result of HPV has been trending up over the past decade.”
A lack of symptoms — or the presence of symptoms, such as oral pain or sore throat, that patients may mistake for signs of common illnesses — makes head and neck cancers difficult to diagnose in the early stages. By the time more telling symptoms manifest, like difficulty swallowing and breathing, advanced disease is usually present, Dr. Al Shetawi says.
Detecting head and neck tumors, especially early in the disease course, requires coordination among several specialists.
“Often, head and neck tumors are not obvious,” Dr. Al Shetawi says. “History and physical exam remain the cornerstones of early detection and diagnosis. Finding precancerous or cancerous lesions requires clinical expertise. At Health Quest’s Vassar Brothers Medical Center, we provide oral cancer screenings and management of precancerous and cancerous lesions. We also have the most advanced equipment and scopes to examine the nasal passages, nasopharynx, oropharynx and larynx.
“When patients require imaging, such as CT, MRI or PET, we have experienced neuroradiologists to interpret these images,” he continues. “We also collaborate with specialized pathologists to interpret some of the challenging lesions and tumors we see in the head and neck. Any workup that patients need, from a biopsy to advanced imaging, we can provide without delay.”
Dr. Al Shetawi examines a patient.
“There was a huge need for maxillofacial, head and neck surgical oncology in the Mid-Hudson Valley,” Dr. Al Shetawi says.
Vassar Brothers Medical Center’s collaborative approach to care is especially evident in its multidisciplinary head and neck tumor conferences, which include clinicians representing head and neck surgery, radiation oncology, medical oncology, otolaryngology, pathology, and radiology, as well as speech and swallow specialists and a nutritionist. Participants consider each patient’s case prospectively in the context of the latest data and therapeutic advances, and then create a personalized, evidence-based treatment plan.
“Treatment is based on the anatomical location and stage of disease,” Dr. Al Shetawi says. “Surgery, for example, is the preferred method of treatment for oral cavity tumors, whereas chemoradiation is the preferred treatment for most oropharyngeal, hypopharyngeal and laryngeal tumors to preserve the function of those organs. Many patients, however, present with locally advanced disease, so they often require multimodal treatment that includes surgery, radiation and chemotherapy.”
Leveraging the Benefits of Microvascular Surgery
Few therapeutic advances have had as significant an impact on the treatment of head and neck cancer as microvascular surgery — harvesting flaps of living tissue from another part of the patient’s body and connecting their small blood vessels to vessels at the sites of head and neck tumor resection.
“In the past, patients who had ablative surgery for head and neck cancers experienced significant cosmetic and functional deformity,” Dr. Al Shetawi says. “In the past two decades, however, microvascular surgery has made a major impact on patient outcomes. We are now able to reconstruct defects at the time of tumor removal with tissues from the patient’s body, thereby restoring cosmetic form and function.”
Surgical virtual planning for a patient with fibula free flap
Technology plays a major role in reconstructive surgery, especially for bony tumors. The process begins with preoperative planning. A CT scan of the patient’s face produces a 3-D image that Dr. Al Shetawi uses to perform the procedure virtually, from tumor resection to microvascular reconstruction. The same CT-based technology allows Dr. Al Shetawi to fabricate custom-made surgical guides for use intraoperatively, as well as individualized implants and plates for patients who require them.
Microvascular reconstruction produces remarkable results for a wide range of patients who, in the past, would have faced lasting deficits as a result of tumor removal.
Computer-generated, custom-made implant to reconstruct a patient’s orbit
“For example, for a patient who undergoes partial removal of the tongue, we can restore the tongue’s shape and form by using a free flap from the radial forearm,” Dr. Al Shetawi says. “If a patient has jaw resection, we’re able to transfer bone from the scapula, iliac crest or fibula to immediately reconstruct the shape and form of the jaw. In select cases, we’re able to place dental implants and teeth concurrent with jaw reconstruction so the patient is completely restored during the same procedure in which we treat the cancer.”
Head and neck cancer patients often require radiation therapy as part of their overall treatment due to the advanced nature of many malignancies at the time of diagnosis. A major challenge of treating head and neck cancers with radiation is minimizing sequelae.
“Patients can develop permanent dry mouth, loss of taste, difficulty swallowing and weight loss — side effects that will affect their quality of life indefinitely,” says Dimitrios Papadopoulos, MD, radiation oncologist with HQMP at Vassar Brothers Medical Center. “In the past, we had to irradiate tumors without being able to avoid normal tissues. Nowadays, we’re able to focus the beam to conform to the area of interest and modulate its intensity, which allows us to spare normal tissues.”
That approach, intensity-modulated radiation therapy (IMRT), does not take place in a vacuum. As with every other aspect of head and neck cancer treatment, IMRT involves a variety of other specialists, who coordinate with radiation, surgical and medical oncologists to optimize the therapy and mitigate potential side effects. These specialists include:
- A dentist to evaluate patients’ teeth and administer fluoride therapy or other treatments, as necessary
- A speech and swallow therapist, who sees patients before and after radiation therapy
- A gastroenterologist to evaluate patients for potential placement of a feeding tube for nutritional support after radiation therapy, when many patients struggle to obtain the nutrients they need due to difficulty with swallowing
Dimitrios Papadopoulos, MD, plans a radiation oncology case at the Dyson Center for Cancer Care at Vassar Brothers Medical Center.
Prior to each of the approximately 35 IMRT treatments that patients receive, they undergo a CT scan that serves as a guide for aiming the beam. That allows the radiation oncologist to precisely irradiate the tumor.
“We can’t do IMRT without first performing image-guided radiation therapy to ensure accuracy,” Dr. Papadopoulos says. “During IMRT, as the beam rotates around the patient, we modulate its intensity as it goes through an area we need to protect and then increase the intensity to full strength when we target the malignancy.”
The Present and Future of Treatment
Shorter courses of radiation therapy, and treatment plans that call for both radiation therapy and advanced targeted therapies, represent a significant part of the future of head and neck cancer treatment, Dr. Papadopoulos says. Other leaders in head and neck cancer care share that assessment, especially with regard to targeted therapies. As our understanding of immunology and tumor biology is improving, the practice of oncology is transforming, Dr. Al Shetawi says. Targeted and immune therapies are the next frontier in the treatment of cancers. A key to the future of treating these malignancies, he says, is the development of targeted therapies that attack cancer cells at the molecular level without causing significant side effects.
James Nitzkorski, MD, collaborates with a member of his team at the Dyson Center for Cancer Care at Vassar Brothers Medical Center.
Dr. Al Shetawi and Dr. Nitzkorski collaborate on a patient case at the Dyson Center for Cancer Care at Vassar Brothers Medical Center.
“The epithelial growth factor receptor monoclonal antibody cetuximab was the first such targeted therapy approved by the FDA to treat head and neck squamous cell carcinoma, and many more are currently under development,” Dr. Al Shetawi says. “Immunotherapy’s role in head and neck cancer is also emerging. Drugs such as pembrolizumab and nivolumab, which are monoclonal antibodies that target programmed cell death-1 receptors on lymphocytes, are now also FDA-approved treatments for certain head and neck squamous cell carcinomas.”
The more researchers and clinicians learn about the causes of head and neck cancers, the better they are able to refine treatments for maximum efficacy and minimum side effects. For patients with HPV-positive oropharyngeal cancer, for example, de-escalated therapy (scaled-back or conservative chemotherapy and radiation therapy) has emerged as a favorable option, according to Dr. Al Shetawi.
“There is a biological difference between people who have HPV-positive squamous cell carcinoma and those who have HPV-negative disease, and it has implications for prognosis and definitive therapy,” Dr. Al Shetawi says. “We are seeing more HPV-positive oropharyngeal cancer in young, Caucasian men who are nonsmokers. These patients have a more favorable prognosis and response to treatment, so in select patients, we choose de-escalated therapy to minimize the complications from traditional chemo-radiation.”
Leading-edge Care from Diagnosis to Survivorship
Cancer patients often choose to leave their community to find medical care that fits seamlessly into a comprehensive continuum of care. Dr. Al Shetawi is providing just that, close to where residents of the Mid-Hudson Valley live and work.
“We provide patients with the latest treatment options and all of the support they need, from the time they receive the diagnosis of cancer to the postoperative follow-up and surveillance,” he says. “Their providers in the community — whether primary care physicians, dentists, oral surgeons, otolaryngologists or other clinicians whom we consider to be part of our team — should know that we support their patients every step of the way.”
For information about the Dyson Center for Cancer Care at Vassar Brothers Medical Center, visit healthquest.org/cancer.