342 - Head and Neck Cancer (Dr. Madia Russillo)

Dr. Madia Russillo, otolaryngologist with Physicians' Clinic of Iowa Ear, Nose & Throat, joins Dr. Arnold to discuss the signs, symptoms and risk factors of head and neck cancer, as well as how the HPV vaccine plays an important role in preventing it.

For more information on ENT services provided at PCI call (319) 399-2022. For more information on services and resources available for cancer patients, call (319) 558-4876 or visit communitycancercenter.org 

If you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Transcript

Dr. Arnold 0:07

This is LiveWell Talk On...Head and Neck Cancer. I'm Dr. Dustin Arnold, Chief Medical Officer UnityPoint Health - St. Luke's Hospital. Today we're discussing the signs, symptoms, and risk factors for head and neck cancer, as well as how the HPV vaccine plays an important role in preventing head and neck cancer. Our guest today is Dr. Madia Russillo from Physicians Clinic of Iowa, Ear, Nose, and Throat. Dr. Russillo, welcome.

Dr. Russillo 0:32

Yeah, thank you very much, Dr. Arnold. I appreciate you having me here.

Dr. Arnold 0:35

It's nice to have you. Um let's just start, I mean, head and neck cancer, that's a lot, right? You know. Uh, but just kind of give us an overview of what is head and neck cancer um and what why should it concern patients?

Dr. Russillo 0:48

Yeah. So I think head and neck cancer is kind of like a very big blanket category, but within the head and neck, there are many different types of cancers that can actually occur. So if we think about some of the different locations, so you can certainly have things like skin cancers that can impact in the head and neck area. And then if you go by different anatomic subsites, you can have cancers in the nose, you can have cancers in the mouth. Mouth can particularly include the lip, upper lip, lower lip, tongue, and then you can have cancers that can affect the throat area. So within the throat, you have your tonsils, you can have the side walls of the throat, the back of the tongue, and then certainly cancers of the voice box can also happen. And if you travel down in the neck area, then we're certainly including things like thyroid cancer, for example. So there are many different subsites, and so while head and neck cancer is a big blanket category depending on what type of cancer and in what location we're talking about, the diagnosis and treatment plans can be a little bit different. I guess one of the things I forgot to mention is actually saliva glands, also. So we have salivary gland cancers that can also come up in the head and neck area.

Dr. Arnold 2:05

I think you know, head and neck, one of the reasons why it's such a complex surgical procedure is you have a lot of structures crammed in a small space. Correct. You know, you think about other organs of the body, lung cancer, you you know, there's it's in a big space, it's in the lung. Yeah. Colon cancer is in the colon. Right. But really, the head and neck, you have a lot of anatomical structures in a very small space. Exactly. Exactly. And that's why these are big procedures, right? Sometimes, correct?

Dr. Russillo 2:35

Sometimes, depending on again, ultimately, it comes down to kind of knowing what type of cancer we're dealing with, what location it is at. Um, and absolutely you're right. Sometimes the treatment, if it involves surgery, um, surgery can be extensive again, depending on the extent of that.

Dr. Arnold 2:54

Well, some of the common ones, um, let's just focus on the you know, the skin cancers and sun exposure, uh radiation exposure. Uh but let's talk about the throat, oral and throat cancer. I think that's a scary one. Yeah. Um, particularly because it can affect young people. Absolutely. And uh what are some risk factors for that?

Dr. Russillo 3:15

Yeah, so uh great question. And um, the risk factors for head and neck cancer to some degree are actually very similar to what are some other risk factors for other cancers. So I think about it in uh kind of like in my mind, I have big three categories. So you can have genetic predisposition. So if there's a family history of some kind of cancer, particularly head cancer, head and neck cancer in the family, that's something that you know we should be aware of. Um, and then other things would be some lifestyle risk factors, which again is very similar for different types of cancers. And this is your um uh correlation with history of smoking or significant um alcohol use. Um diet, to some degree, there is enough research that actually encourages you know, um, healthy diets to include things like your raw fruits and vegetables and all of that stuff, because there have been studies that have seen association of, I guess, like poor dietary intake with development of cancer, not just head and neck cancer, but cancer in general. Um, and then other factors that could be there are your history of uh radiation exposure, interestingly, can sometimes cause what we call secondary cancers. So if somebody had a history of radiation exposure, particularly at a very young age, they just have time to develop things that can happen in the future. So thyroid cancer in the head and neck is one of those that does have an association with um ionizing radiation exposure. And then the other category that I kind of think about is sort of your association of viral exposures, which plays a little bit into that HPV-related risk factor, which I guess we can talk a little bit about here.

Dr. Arnold 5:06

Yeah. Thyroid cancer is kind of a worrisome one uh in younger people. And you know, I have in my career I've probably diagnosed a half dozen uh young women. Yes. Routine thyroid examination lump. And uh I I think we probably should note that thyroid lumps or cyst are pretty common and as we age. Very common. But uncommon when we're younger.

Dr. Russillo 5:29

It is uncommon, yes, exactly. And so um thyroid cancer is also one of those, you know, again, like how do you a do you routinely screen for these, right? And a lot of these, it just comes out to basically if there's something that gets recognized on an exam, um, it probably will prompt an evaluation because the truth is that if you scanned or screened somebody who is asymptomatic, you probably would uncover or discover things that may or may not be concerning, right? And it triggers a number of uh of things whether we should look into or not. Um, but you're right, thyroid cancer, especially in younger folks, essentially I think the take the take-home that I would give on this is if there's any type of abnormal mass or lump that somebody feels if they feel and palpate their neck area, especially if it is uh an asymptomatic mass, meaning it is painless, not actually causing any symptoms, but it is there when it's not supposed to be there. I would say that that should get evaluated.

Dr. Arnold 6:38

That's good advice on any lump or bump exactly have. But um while when we're talking about thyroid cancer, just this is more of a curious question. Uh the uh GLP1s are ubiquitous um and the commercial worms, you know, of multiple endocrinineal plasia. Yeah. Um have you seen more uh thyroid cancer in your practice with the GLP1s?

Dr. Russillo 7:01

It's a good this is, I think, a great, great question. And um to kind of like shortly answer that question, so far I I have not seen it yet. However, it doesn't mean that it is not there to come. I think that association, and I'm actually glad that the research about it has been made public knowledge very quickly. And so this is something that patients are aware of. And so if an asymptomatic neck mass does come up in a patient who is actually taking a GLP1 medication, then I would certainly prioritize screening for the possibility of thyroid nodules or thyroid cancer. Uh, but you're right, I think there's more, there is more that we will probably uncover as most people are um as a lot as a lot more people are actually coming on these medications.

Dr. Arnold 7:51

I mean, we're getting close to the five-year mark they've been on the market. So now you're gonna have enough time to see that relationship really, really is there.

Dr. Russillo 8:00

Yeah. I do have a few patients who have had a history of thyroid nodules, and these are benign nodules. We know they've been benign from their previous workup, who have been started on, say, GLP1 medication. So I'm already monitoring them in general for their history of thyroid nodules anyway. And so it would be interesting to see how that actually changes. Yeah.

Dr. Arnold 8:23

Yeah. Interesting. Um if a patient doesn't have their tonsils out when they're younger, I'm one of them, um, is there a risk for cancer later in life?

Dr. Russillo 8:34

You know, it's this is, I think it's a very hard, I think that's a hard question to say yes or no to. So uh generally, again, right, like, and even from a surgical perspective at this, at this time, just because somebody has their tonsils even at a younger age doesn't mean if there's no indication to take them out, we would not just take them out. Now, does leaving them in place put them at risk for cancer in the future? The tonsils themselves don't necessarily have anything to do with, I think, the development of cancer. It's more the exposure that, you know, and specifically again, we're going to come back to the topic of viral-driven exposures with HPV that may put them at risk of, you know, developing tonsil cancer because it just happens to be one of the locations, right? So it's nothing necessarily from the structure of the tonsils themselves as opposed to just what exposures could have predisposed somebody to getting cancer.

Dr. Arnold 9:33

Interesting.

Dr. Russillo 9:34

Yeah. I still have my tonsils. I still I have mine. And and if there's no reason to get them out, if there's no indication for it, if it hasn't caused problems with at least sleep apnea or recurrent infections, you haven't had problems with developing abscesses in the neck, uh, I would not recommend anyone to undergo a tonsilectomy just prophylactically. I mean, it's a big, big thing to go through.

Dr. Arnold 10:00

Now, for head and neck cancers, you mentioned, you know, the lifestyle alcohol is a big one on that list too.

Dr. Russillo 10:07

Yeah. So smoking and alcohol are probably the two, so they're the two big drivers that I would say are the modifiable drivers that we can look at. So if there are some behaviors that we can look to say, well, how can we prevent cancer, right? Ultimately, sometimes cancer just happens. You can have, there are patients that we see that have been very healthy with no known risk factors and just develop that, right? So that can happen. But at the same time, we do know that these are the high-risk behaviors. So it is the um increase in smoking, um, or actually more like it's cigarette exposure specifically. So it could be smoking tobacco or chewing tobacco, and then um excessive alcohol use that are one of the known um drivers towards um uh uh throat cancer specifically as well. Yeah.

Dr. Arnold 10:59

What do you recommend as the screening process for head and neck cancer?

Dr. Russillo 11:04

Right.

Dr. Arnold 11:04

So generally we have colon cancer, we have colon oxpheme, mammogram, cerebrass. Exactly. What is the screening cancer? Uh so the screening modality.

Dr. Russillo 11:14

Yeah, so head and neck cancer screening is a little bit unique because there is not one standardized test that can be done. So you're absolutely right. So, for example, cervical cancer, you have your pap smears, breast cancer, you have your mammograms, you can do CTs every so often for lung cancer, right? Head and neck cancer, unfortunately, so far, does not have anything that has been developed quite yet that we can consider to be an early screening tool. There is something on the horizon. There are some, there is a blood test, and this is not, again, this is still in the preliminary roles of um research where there is, especially for the HPV-driven drivers of head-neck cancer, there is a blood test that they're looking at to see can we detect HPV much earlier within the bloodstream before it even develops into malignancy. So until we get there though, ultimate essentially it just comes down to needing to have good head and neck examination. And I think part of that does fall to start with on the shoulders of our primary care providers to just do a good skin examination, um, oral cavity examination, look at the tonsils. And obviously, again, if somebody has, it just comes down to also symptom recognition. So if you had a cough, cold, viral illness, or something like that, you get a sore throat, um, you know, uh nasal congestion or something just is out of the ordinary. But if those symptoms don't recover, I would say three weeks is probably a good time frame.

Dr. Arnold 12:55

Three weeks.

Dr. Russillo 12:56

Yeah. About a two and a half to three weeks. And if you continue to have persistence of symptoms, especially if there is pain in the throat, swallowing changes, for sure, breathing problems, voicing changes, right? Um, and it's lagging and not improving, or if anything, getting worse, um, I would say that's probably not a symptom to be ignored. Um, and it may require your a referral to and your nose and throat doctor or somebody who can do a more comprehensive examination than just looking inside the mouth. One of the things that would be different, so when patients come to see me for let's just say a symptom of uh trouble swallowing or pain with swallowing. One of the things that I would do in addition to looking at the uh at the head neck and just feeling, I would actually do something called a laryngoscopy exam, which is using a thin fiber optic camera that can go through the nose and through the mouth. It's a little bit unpleasant to go through. It's kind of like getting a COVID swab in the nose, it's a similar sensation, but it gives a really good direct visualization of back of the nose area, back of the throat area, and really back of the tongue and where the voice box lies to make sure that all the anatomy is actually normal. And if any of these symptoms, are they actually caused by something that is like an abnormal mass or a polyp in that location? Um so certainly, if there are long-lasting symptoms, usually I would say I think two and a half, three weeks is a good gauge. Um, then examination should probably be done.

Dr. Arnold 14:34

Yeah, I think it's like a lot of things in medicine, the uncomfortability of that test is you know much better than something like uh exactly. You're talking as a speak and spell. Right. You're not old enough to know what a speak and spell is, are you? Kind of kind of, yeah. Um we talked about human papillomavirus and ATV vaccine. Yeah. Which when it first came out, I was like, okay, yeah, cervical cancer, APV, that was a bored tech question, you know. Um but it it really the the evidence or the data on head and neck cancer is really pretty impressive. I was pleasantly surprised when I when I've read that. Tell us about that.

Dr. Russillo 15:23

Yeah. So HPV, just kind of again, big category, what is it? So HPV is a ubiquitous virus. This is something that as we go through life, many of us would probably have been exposed to it at some point. Um, and there are low-risk forms of the virus, and then there are high-risk forms of the virus. And it is really the high-risk forms of the virus that drive towards cancer potential. So this is where it can potentially cause cervical cancer, um, anal cancer, and then throat cancer. And the uh thing with the HPV vaccine, I mean, this is this is where the vaccine, I think, in my mind is very powerful because really it is the only vaccination that we have that we know has the potential to actually prevent the development of cancer. And it kind of comes down to the whole idea: well, why should we vaccinate, you know, young children? Because it is most effective prior to HPV exposure. So if you have been vaccinated, which again, the CDC recommendation is, you know, vaccination usually is around like 11 to 12 years of age. I want to say 11 to 12, but you can start as young as nine. But the recommendation for the vaccine is definitely up until age 26. And the whole idea of it is that if you're vaccinated prior to exposure to HPV, it does potentially minimize your risk of developing HPV that can sit in your system and then eventually transform into a malignancy. Yeah. Um now the actual FDA uh or I'm sorry, the uh CDC um age record guideline though has been raised to about age 45. So 27 to 45, there is a you can, you know, have a conversation with your primary care doctor to help decide and assess your risk of should you get vaccinated with the HPV vaccine if you're within that range. Um there uh the and the reasoning for that is because you don't, you know, there's no strong recommendation to push for it only because you probably already have been exposed to it by then.

Dr. Arnold 17:42

Well, one I know the listeners will relate to this, I will relate to it as a parent. Um the posterior lymph node that's enlarged in your child when you're giving them a bath at night and you feel it, how how would you handle that from an ENT specialist? Probably not cancer, right, you know, but stranger things happen, right? Uh, and you want to be sure you don't ignore it. What what's your recommendation to the listeners?

Dr. Russillo 18:10

Exactly. So um again, cervical, so the uh the term right for enlarged lymph node in the neck is cervical lymph adenopathy. And uh again, I like to think of things and categories in my mind, and there are a number of things that can cause cervical lymph adenopathy. So you can have infectious problems, you can have things like autoimmune conditions that can cause that, you can certainly have cancers that can cause that. Um, the important thing about cervical lymph adenopathy, so age is a big factor. So when I have an adult patient who comes to me with cervical lymph adenopathy, um while infection could cause that, um I actually have a much higher concern for ruling out the possibility of malignancy. Versus if a young child comes to me with cervical lymphadenopathy, while cancer could be a cause, it is much less likely in the pediatric population. Infection tends to be the more common thing. Again, um, it's the same the same statement I made before. Basically, if it's something that you have noticed, whether it's painful or painless, if it is something that persists for more than a few weeks, I do think it would warrant evaluation. And whether that's an evaluation with your primary care doctor or it gets a referral to an ENT to see that, then they can they can actually help guide and decide should this be something you should be concerned about or not be concerned about. There are some scenarios again, depending on what the exam feels like. What does the lymph node feel like? Is it on one side? Is it on both sides? Is the skin in that area? Is there any type of abnormality to it? Um, does it feel soft or does it feel firm? These are all clinical decisions that we make just by actually examining a patient. And then that may help us assess whether we should do something like an ultrasound or something like that to look at it further with imaging. Uh, and we then go through the decision of, well, should we do other things like lab work, for example, to see are there some infection-related markers that may help us understand why this is there, right? Um, and also again, in a young child, the decision to do things, for example, like biopsy of the lymph node and all that, I mean, these are, and as an adult, um, to go through that, you can you can tolerate going through these procedures, but these are big things in a pediatric patient. Sometimes it requires sedation. And so if you're going down that road of getting all of these testing done, it's because it's actually necessary and needed. So I would say if anything is persisting beyond a few weeks, then that's probably the simplest thing is just to check in with someone who can actually help you assess whether you should worry about it or not worry about it.

Dr. Arnold 21:17

Yeah, well, that's great clinical uh wisdom for the young parents out there. Um I know we had that happen when my kids were little, you know. And uh meanwhile, I'm telling my wife about that's enough. And meanwhile, I'm scrambling through my head to get cancer board to make sure it's nothing concerning. Now we're we're very proud of the Helen G uh NASA Community Cancer Center. We have to do a lot of podcasts on that, the great team over there. Tell me your uh ENT's role and how do you work with the center?

Dr. Russillo 21:47

Yeah, um, I will say I've been very impressed with them myself. Um and very good team. I I also will say that uh we they do a fantastic job of providing a comprehensive. Network for patients in general. So coming down with a cancer diagnosis, it's a big deal. And there are a lot of factors that are involved. So it's not only about coming to terms with, you know, getting a diagnosis of cancer, but then ultimately how does it get treated? Which treatment modalities is very different. And a lot of times, especially when it comes to the head and neck area, you know, you have the aspects of breathing, of swallowing, of speaking. And as you go through treatments for head and neck related cancers, sometimes these very functions can actually become impacted. And so if it is expected that as a result of your head-neck cancer treatment, you're going to have trouble swallowing because of the treatment, right? We may actually work ahead of time with planning on patients getting things like feeding tubes or G tubes and the role of a dietitian, and what is the role of a dietitian to help us monitor how they are doing from a nutrition perspective, because in order to go through cancer treatment successfully to a degree, you also have to heal and you have to maintain and support your nutrition to do that. So there are a number of things that that play play a role there. And then certainly with so that's one aspect, but then you have things like if you're going through chemo, radiation, you have multiple different appointments for that itself. And so having somebody, I think the Cancer Center, they do a fantastic job of kind of having somebody who I think is, I think about them as like the um, what's the word for it, almost like a traffic controller where they can kind of help to um coordinate all of these different aspects of care. So you can actually go through what you need to go through and have peace of mind that if there's actually something that needs to be addressed, somebody's kind of in the back helping us out with that.

Dr. Arnold 24:06

Yeah.

Dr. Russillo 24:06

And and I think they do a phenomenal job.

Dr. Arnold 24:10

I'm always excited when first of all, they're they're very passionate and they care about what they do. So they're they're fun to bring on podcasts or and they're fun to work with just in general, but they're just really a great team over there. Andrew does a great job doing that. They're excellent. We we've talked about risk factors that can be modified. We've talked about diagnosis. Let's talk about treatment.

Dr. Russillo 24:33

Yeah.

Dr. Arnold 24:34

Um surgery is a big part of it. Uh tell us about the surgical procedures that might have to be done for head and neck cancer.

Dr. Russillo 24:42

Yeah, so again, I think uh kind of coming down on where it's located, right? So depending on is it a skin cancer, a lot of times, depending on the location, sometimes you can either do um, you can completely excise it, and usually that's all we need to do. Sometimes it might require some reconstruction depending on how extensive the removal process is. Sometimes there is a little bit of a balance between an ENT doing excision, especially if it's a skin lesion, versus a dermatologist doing something like MOSE surgery, depending on the cancer location, so things like the eyelid, things like the nose, for example, where you want to do more, we call it tissue-sparing type procedures, that's where the role of something like MOSE surgery could come into play. Now, let's kind of come back to maybe more of like the oral cavity and throat-related cancer. So again, depending on where the cancer and what is the clinical stage of it dictates how we address it. And so when a patient comes to us, comes to me and I diagnose them, let's just say with tongue cancer, there are a there are a few things first that actually has to come into the into play. A, we need to have a tissue diagnosis. So usually that requires some form of a biopsy. Um, and then a lot of times we will follow that up with some form of imaging studies to know how extensive is this cancer? Is it just located where we see it or has it gone beyond where we see it? Is it deeper in the muscle structures? Has it invaded anywhere else in the head and neck area? And when I say invasion, head neck-related cancers typically the spread of that will go towards the lymph nodes in the neck. So this is where, if again, you have someone who comes and they have a painless neck mass in the neck that has been there for several weeks, that is probably not normal and should require some additional screening because there is a possibility that maybe that neck mass may actually be malignant and it it may be a malignancy from somewhere within the mouth area, the lip area, or the back of the throat area. So, again, usually starting with a CT scan of some form, again, depending on a cancer diagnosis, we might do something called a PET scan to see has it gone anywhere else? Has it gone to the lungs or anywhere else? And then that helps us assess and decide. So that's the clinical staging. Then the next step is coming up with a plan on how to treat it. And treatment modalities can be very different, so you're absolutely right. Surgery is definitely one aspect of it. Um, and the other aspect is radiation or chemotherapy. Sometimes it's a combination of all three. And more recently, in the last couple of years, there's also been some uh there's been newer development with the role of immunotherapy, um, more from the oncologic side of things. We sometimes bring that on even upfront, especially if you have like an aggressive cancer or something like that, before you even do surgery. So many modalities, again, it comes down to what is the clinical stage ultimately and how what is the best way to treat it.

Dr. Arnold 28:18

Yeah, I would say we're at the just the beginning of immunotherapy. Very beginning. I mean it's very beginning. I I see that really blossoming in the next five years.

Dr. Russillo 28:28

Yes, yeah. This is it's very similar to I think um I think melanoma of all cancers has gone through a similar, um, a similar change where in the past a lot of melanoma, um, and it's still managed surgical to a degree, but immunotherapy has really taken over the course where um it is just not as common um to do upfront surgery right away, and there is a possibility that immunotherapy for these head and neck related cancers can change.

Dr. Arnold 29:04

Um yeah, I I mean, you know, for melanoma, when I trained, which is a long time ago, it it was surgery and interference. That's all that's all you had. And it was, you know, if it had spread, right, it was not good. Exactly. Um that's definitely changed with Keuda and all the other big time uh commercials that we see each evening as we're television. Right. Well, a fun question, why ENT?

Dr. Russillo 29:29

Yeah. Um, so as a first-year med student, I actually found the head and neck area. And this is like, you know, your first kind of like anatomy introduction and all that. And I actually just really enjoyed head and neck anatomy. Didn't really think too much of it at the time. Um, I kind of knew it about myself that I wanted to go into something that was more procedural, more surgical, um, and really through the clinical rotations. The thing that drew me towards ENT, what I appreciated a lot later in medical school, is there's a lot of complexity above the clavicle. There are a lot of things, a lot of um uh medical problems that can actually happen within the head and neck area. And um, it's a big combination of as specialists, I mean, as ENT specialists, we are surgeons, but there are a lot of things that we actually do that requires just medical management. And it's a really great combination of doing a bit of medicine with surgery. It's integrated, and for me, what drew me towards um continuing to stay on as a general ENT is that I really enjoy the wide variety of ages that I can take care of. So I take care of the really little babies and pediatric patients all the way to elderly, so it keeps it keeps it fun um and engaging.

Dr. Arnold 30:58

So now listeners may know your husband's an anesthesiologist. And you have how many children? Three, what are their ages?

Dr. Russillo 31:06

Four and a half, two and a half, and baby will be 11 months uh next week.

Dr. Arnold 31:12

So you you've had two of them since you've joined the medical staff for sure. Yeah, right. Yeah, yeah.

Dr. Russillo 31:16

Wow.

Dr. Arnold 31:17

Yeah. You went from man coverage to zone coverage. You guys got outnumbered.

Dr. Russillo 31:22

Exactly. Oh, we're outnumbered big time.

Dr. Arnold 31:24

Yeah, you should have yeah. Dr. Russill, thank you so much for joining me today. This has been great information. Once again, this is Dr. Medea Russillo from Physicians Clinic of Iowa, ear nose and throat. For more information on ENT services provided at PCI, please call 319-399-2022. For more information on services and resources available for cancer patients, call 319-558-4876 or visit communitycancer.org. Thank you for listening to Live Well Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcast. We're available on Apple Podcasts, Spotify, Pandora, or wherever you get your podcast. Until next time, be well.