Head and neck cancer remains one of the most challenging clinical presentations faced by the oncology community. Patients must not only face a potentially lethal disease, but must also cope with treatments that often result in significant side effects. To gain a better understanding on the treatment-associated psychological issues faced by patients with head and neck cancer, The ASCO Post spoke with head and neck cancer specialist Andrew Shuman, MD, Assistant Professor in Head and Neck Surgery at the University of Michigan Medical School. He is also Chief of the Clinical Ethics Service in the Center for Bioethics and Social Sciences in Medicine.
Diverse Academic and Clinical Practice
Please tell our readers a bit about your background and current work.
I am a head and neck surgical oncologist who has trained in otolaryngology. I completed my surgical oncology fellowship at Memorial Sloan Kettering Cancer Center and in medical ethics at Weill Medical College of Cornell University. My current role involves work as a practicing head and neck surgical oncologist along with helping to run the clinical ethics service at the University of Michigan. I’m privileged to have a very diverse academic and clinical practice. I also teach medical ethics to undergraduate and medical students at the University of Michigan and at the postgraduate level.
Clinical Balancing Act
In a nutshell, what are the ongoing challenges faced by surgeons in this specialty?
Head and neck cancer is among the most difficult malignancies with which doctors and their patients grapple, particularly related to its intimate association with who patients really are as people. The surgical interventions impact how people look, and it disrupts functions such as eating, swallowing, breathing, and speaking. It also can be stigmatizing and impact psychosocial health.
We are constantly balancing who people are with our efforts to control their cancer, which is what makes this such a difficult but incredibly rewarding field.— Andrew Shuman, MD
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Moreover, there are frequent trade-offs in regard to oncologic control with related treatment side effects. We are constantly balancing who people are with our efforts to control their cancer, which is what makes this such a difficult but incredibly rewarding field.
Another interesting aspect of this field is the close relationship among surgical oncologists and medical/radiation oncologists and how every treatment-related decision involves a balance between those services to maximize oncologic control and minimize treatment-related toxicity.
Genetic Biomarkers and HPV
How are head and neck cancer therapies positioned in the new genetically driven therapeutic paradigm?
In many ways, we are actually behind other solid tumors in how we think about the role of biomarkers and genetic information. That said, I feel the next decade in head and neck cancer will be particularly exciting as we are better able to personalize our treatment modalities.
What is the current status of human papillomavirus (HPV)-related head and neck tumors?
We are currently at an epidemic level of HPV-associated oropharyngeal cancers, which are becoming the predominant malignancies we see. The challenges in HPV also represent opportunities, in that these tumors tend to be more responsive to treatment, and novel paradigms are emerging.
Advances in Larynx Preservation
What have been the primary advances in this field?
The biggest development over the past couple of decades has been our ability to personalize treatment and preserve organ function in advanced head and neck cancer, particularly in the larynx. The role of nonsurgical modalities that are delivered in a thoughtful manner has, in many ways, revolutionized the treatment of laryngeal cancer while allowing patients to maintain oncologic control and still be able to maintain their voice box.
The biggest development over the past couple of decades in head and neck cancer has been our ability to preserve the larynx in advanced laryngeal cancer.— Andrew Shuman, MD
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At our institution, one of our main motivations is to determine how best to predict which patients will do well by using bioselective treatment paradigms. From a surgical standpoint, the advent of minimally invasive technologies is certainly an exciting development. There are several ongoing prospective clinical trials that hopefully will better define how new technology can be adapted to optimize the effect in head and neck cancer.
But I would also argue that the new frontier in technologic advances does not obviate the need for us to take a step back and make sure that every intervention is appropriate, such that we do not assume that every nail requires a hammer.
Leader in Clinical Ethics
Please tell our readers about your role as Chief of the Clinical Ethics Service in the Center for Bioethics and Social Sciences in Medicine at the University of Michigan.
The Center for Bioethics and Social Sciences in Medicine is a multidisciplinary collaboration that brings together decision scientists and experts from fields as diverse as sociology, public policy, and philosophy to provide both clinical ethics service to patients as well as support normative and empiric research. The Clinical Ethics Service involves rounding within key units within the hospital, coupled with clinical ethics consultation, education, and outreach. My ability to serve as one of the leaders of that service is one of the highlights of my current career.
Are you involved with any research projects?
Yes. My current research examines the overlap and interface between clinical ethics and delivery of head and neck cancer care. I’m focusing on how patient and provider perspectives can be integrated into a precision oncology platform, looking specifically at how to design therapies and put them into practice in a way that patients’ needs are consonant with the physicians’ treatment goals and our goals of advancing the science.
What is the most important aspect of communication in this difficult clinical area?
It is vital to fully understand and respect a patient’s expectations and limitations when it comes to treatment decisions. Doing so requires a sustained effort, and in my opinion the most important outcome is to truly understand each patient on a deeply personal level. It is also vital to be honest and forthright about what is achievable, which helps patients make appropriate decisions that align with their personal goals.
Future Challenges
What are the main challenges in head and neck cancer going forward?
The biggest challenge we face is how to integrate the advances in the genomic frontier into routine clinical care, not just research platforms. Another challenge is how to enhance an even more complicated decision-making paradigm, involving many different providers and perspectives in a manner that allows patients to truly understand their options and to make decisions that reflect their own preferences. The science is only truly “advanced”—as opposed to simply moved forward—when we help improve the lives of the patients sitting in front of us. ■
DISCLOSURE: Dr. Shuman reported no conflicts of interest.
