Teamwork

Kentucky has more adult smokers per capita than any other state in America, according to Centers for Disease Control and Prevention, with nearly 28 percent of residents saying they light up regularly.

This unfortunate fact also places the commonwealth near the top of the list for cancers of the head and neck. While these diseases are far less common than lung or colon cancers, affecting about 16,000 people annually in the United States, their impact on patients can be unusually debilitating.

That's because so much of what makes people human is centered in the head and neck, says Jeff Bumpous, M.D., associate clinical director of UofL's James Graham Brown Cancer Center.

When cancer strikes this area, it can rob patients of precious functions like speech or taste.

"A lot of how we relate to society occurs in the head and neck: our facial appearance, our ability to talk and communicate, our ability to make eye contact and see, our sense of smell and taste, our hearing and our other senses," says Bumpous, UofL's J. Samuel Bumgardner Professor and director of the Division of Otololaryngology.

"These are all things that allow us to have a happy life. When one of them is compromised, it can be quite devastating to a patient."

Head and neck cancers also are anatomically complex, frequently involving multiple tissues like the tongue, larynx, sinuses and salivary glands, says Liz Wilson, multidisciplinary program coordinator at the Brown Cancer Center. This complexity further complicates the treatment of demanding cases.

In response to these challenges, UofL has established the Head and Neck Multidisciplinary Clinic, a state-of-the-art facility that focuses the expertise of more than 30 health-care professionals on the treatment of patients with cancers in this region of the body.

Since its inception in 2002, the clinic's patient base has climbed from 24 new patients annually to more than 200 last year, Wilson says. An additional 100 were treated in follow-up care in 2006, with some commuting from as far away as Virginia.

One of the primary goals of the clinic was to create a multidisciplinary team of practitioners who can offer patients "one-stop shopping," Wilson says.

Traditionally, cancer patients are referred by their primary-care physicians to see a cancer specialist. That specialist -- say, a surgical oncologist -- would then make additional referrals to a medical oncologist, a radiation oncologist and any number of other practitioners like dieticians or psychologists.

Each referral meant yet another appointment for the patient, often at different physical locations, resulting in care that was difficult to coordinate and sometimes contradictory.

"The patient ends up going here and there and everywhere," Wilson says. "And they may get different advice from each of the specialists. The surgeon might want to operate, but the radiation oncologist might want to treat it with radiation, or the medical oncologist says he can treat it with chemotherapy. It's a confusing and frustrating experience for the patient. Often, they're just overwhelmed."

In contrast, UofL's clinic offers specialists from all three treatment modalities -- surgery, chemotherapy and radiation therapy -- under one roof, as well as the full spectrum of support services, including cancer nurses, speech pathologists, dieticians, psychologists and social workers. No other facility in Kentucky offers such complete multidisciplinary care for patients with head and neck cancer, Bumpous says.

The full team meets once a week to examine patients, determine tailored courses of treatment and discuss each individual's progress, including any social or psychological issues that may be impacting care. Another day is set aside each week to follow up on patients whose cancer has been eliminated but who still need care or referrals for speech therapy, physical therapy and dietary counseling.

By seeing patients as a group, the team can discuss multiple treatment options and easily arrive at a consensus about the best approach for each individual, Bumpous says.

"Our individualized treatment plans really are superior to anything you could come up with if you were trying to coordinate care among three or four physicians in different physical locations," he adds. "It's a very collaborative environment. Sometimes, it's the speech pathologist or the nutritionist who provides a key piece of information that has a massive impact on the way the patient is ultimately treated."

William J. Spanos Jr., M.D., chair of the Department of Radiation Oncology, agrees.

"Because of our multidisciplinary approach, the patient is going to hear a consensus from very well-trained experts about the best way to manage their problem," he says. "They're also going to hear about alternatives, and they're going to get support information from all the allied health professionals involved in their case.

"Some of the treatments we put patients through are very intense, and if they need speech therapy, dietary counseling, dental support or psychological counseling, those are all going to be available for them simultaneously."

State-of-the-art care

Another factor that set's UofL's clinic apart is its ability to offer "combined therapies" -- treatments that mix surgical, radiation and chemotherapy techniques.

"In the past, surgery or surgery and radiation therapy might have been the only option, but we can now offer novel combinations for treatment," Bumpous says.

Besides increasing the effectiveness of therapy, these new combinations offer the possibility of preserving more healthy tissue, thus allowing the patient to retain more functionality.

"We have a goal of eliminating the cancer, but we want to get rid of it in a way that the patient can still do the things they enjoy as much as possible," Spanos says.

Bumpous notes, for example, that some people like singers or teachers depend on their voices to earn a living, and the loss of vocal ability would be devastating.

"We have to find the best strategy to cure the cancer while also returning to them that function -- the ability to speak," he says.

The clinic also offers two treatment strategies not available elsewhere in the state: Intraoperative Radiation Therapy (IORT) and re-irradiation therapy. IORT allows oncologists to target a beam of radiation directly on a tumor during surgery, offering precise control that helps preserve surrounding tissue.

IORT can even be used safely on patients who've had previous radiation therapy and is one of the types of re-irradiation treatment offered at the Brown Cancer Center.

"Classically, radiation therapy was thought to be a one-shot deal," Bumpous explains. "But we can, in some instances, give additional therapy using a type of chemotherapy that will sensitize the tumor to the radiation."

The UofL clinic was one of just a handful of centers nationally that helped develop re-irradiation protocols, he adds.

Rehabilitation therapy

The multidisciplinary clinic also is helping develop novel treatments to preserve or maintain patients' ability to eat, drink and swallow, says Melissa Stewart, a speech language pathologist at the James Graham Brown Cancer Center.

Many patients stop trying to eat, drink or swallow during cancer treatments because therapy can cause changes in saliva production or taste and may result in pain while swallowing, Stewart explains. This can cause atrophy of the muscles used for swallowing, creating significant dysfunction. (The location and size of tumors, as well as tissue fibrosis, also can significantly impact patients' ability to eat or drink, she notes.)

Using a new tool, however, Stewart is attempting to preserve patients' ability to swallow throughout the course of their chemotherapy and radiation treatments. The tool, called a VitalStim, stimulates the muscles involved in swallowing, which may reduce or prevent their atrophy.

"The thinking is: Use it and you won't lose it," she says. "We see patients five times a week and stimulate the area most affected by the radiation. That area also is within close proximity to the site of the tumor, which already may be causing some form of swallowing discomfort."

Stewart hopes to begin a prospective randomized study this spring, but anecdotal results so far have been promising.

"We've found that patients either maintain or demonstrate improvement in their swallow function by using VitalStim and other therapy," says Stewart, who also helps patients regain the ability to communicate effectively following cancer treatments.

Another rehabilitation issue -- smoking cessation -- receives a great deal of attention at the clinic, partly because smoking is one of the primary causes of head and neck cancer and partly because it is so difficult to get lifelong smokers to stop.

"Research has shown that one of the key factors in getting people to quit is just having the physician emphasize how important it is that they stop," Bumpous says. "But beyond that, we have to do a lot more.

"Many of our patients have other smokers in their environment, so smoking cessation is not just a patient problem; it tends to be a family and social-contact problem. The other factor at work here is that there's a lot of psychological dependence.

"So we incorporate a broad range of strategies: smoking cessation programs, psychological support, social support and the use of medications like nicotine replacement therapy."

Benefits of the team approach

All of these approaches to cancer care -- the multidisciplinary paradigm -- mean a lot of extra work for health-care workers, Spanos says, but the payoff is worth it.

"We started this project realizing that it was a considerable amount of time expenditure, coordination and logistical work above and beyond what we normally do in our pattern of seeing patients," he says. "But it's been very rewarding. I think all of us would tell you the same thing: We have really benefited in our own personal satisfaction because of the way we can treat patients and provide for them in a special way."

Of course, the patients benefit, too.

"I think we have been able to offer state-of-the-art care for head and neck cancer that's as good as you can get anywhere in the country," Bumpous says. "Not only that, we've begun to lead. I think others are beginning to look to us for innovative forms of treatment for this cancer.

"There's no question that our patients have benefited tremendously."