Treating Oropharyngeal Cancer: Transoral Robotic Surgery and Multidisciplinary Care

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology. 

April is Head and Neck Cancer Awareness Month. So it's only fitting. I'm joined today by Jamie Ku, a head and neck cancer surgeon and director of our robotic surgery program in our head and neck department.

Dr. Ku, welcome back to Head and Neck Innovations.

Jamie Ku: Thank you, Dr. Bryson. Thank you, Paul, for having me here again.

Paul Bryson: Well, it's our pleasure. It's been a little while since your first appearance, so if you wouldn't mind give us some background on yourself for our listeners who might not have heard the other episode from 2023. Where you're from, where you trained, how you came to Cleveland Clinic, and just maybe some of your interests in practice evolution since you were last on the podcast.

Jamie Ku: Perfect, thank you. Yeah. I'm Jamie Ku. I'm one of the head and neck surgical oncologists as well as a reconstructive surgeon here. I'm from Texas. I trained all over the country including residency in Otolaryngology-Head and Neck Surgery at Johns Hopkins University. Then I did my fellowship at MD Anderson Cancer Center and I've been here since 2017 and honestly, I can't imagine a better place to practice and treat patients and collaborate. I mean, it's been phenomenal and I've loved every moment of it and that's why I'm still here. So it's been a great journey so far.

Paul Bryson: And I wanted to highlight your leadership role in our robotic surgery program. Can you tell us a little bit more about that? I know there's different surgical robots that one might encounter, but how has that technology impacted your practice?

Jamie Ku: Yeah. And some of this stuff we'll be talking about today, but essentially as I introduced in the previous podcast, we do provide minimally invasive surgical approach specifically for areas that are hard to reach that require pretty radical open surgery. Such as the throat cancer or even near the voice box, we can use a surgical technique going through the mouth, which is called transoral surgery. And there's been different reiterations of the robotic system, the most recent one being the single port system. And then actually there's another robotics system that we are starting to utilize and think about ways to innovate in our field, it's called Symani Robotic System. Which is using the robot to do micro and super microsurgery. So these are all very exciting areas in robotic surgery and head and neck.

Paul Bryson: Well, thanks for sharing that. And you recently were the senior author on a publication in ASCO titled, Transoral Robotic Surgery in the Multidisciplinary Care of Patients with Oropharyngeal Squamous Cell Carcinoma. Just continuing on with what you were just speaking about, can you tell us a little bit more about this publication?

Jamie Ku: Yeah, just to give a background, ASCO is the American Society of Clinical Oncology. So it's a large organization and obviously they do a wonderful job putting together a panel of experts to put out guidelines to provide best recommendations in a specific topic. And obviously this particular one is on trans robotic surgery in patients with oropharyngeal cancer. And so I was asked to co-chair this guideline along with Dr. Chris Holsinger from Stanford University, and it's a journey we started actually in 2023 and finally got published in Journal of Clinical Oncology in February.

Essentially, this is very important and unique because it actually has focuses on the surgical aspect of the treatment, specifically the trans robotic surgery. Since the last podcast, there have been lots of additional evidence and publications, including the ECOG-3311 clinical trial that seems to indicate that HPV-related oropharyngeal or pharyngeal or throat cancers, the treatment can actually be de-escalated or de-intensified if you start with surgery. And so this guideline tries to provide the best recommendations for standardizing workup and specifically patient selection, which is the most important. Who are the ideal surgical candidates? Who are not well suited for trans robotic surgery?

The guideline also focuses on obviously the multidisciplinary care, even in the pre-treatment phase involving our speech language pathologists and other rehabilitation therapists, and then how to tailor the additional treatment or adjuvant treatment given after surgery based on the information from the surgical pathology. So it was two years of hard work, but it was well worth it and we hope that it'll start a lot of good discussions around the country.

Paul Bryson: Yeah, well congratulations on that. I know it's a high-impact journal and it's an opportunity to really get the message disseminated across a bunch of different specialties, not just otolaryngology.

Jamie Ku: Yes.

Paul Bryson: So yeah, congrats on that.

Jamie Ku: Thank you.

Paul Bryson: And congratulations also in order because you just received two VeloSano Pilot Grants. Congrats. And for listeners who might not be aware of VeloSano, can you share a little bit more about the organization? And I think it's really important and powerful to share what the grants allow you and the team to accomplish. It's a really significant part of the mission and really can impact cancer care.

Jamie Ku: Yeah, VeloSano is actually unique to Cleveland Clinic because it's a Cleveland Clinic year-round philanthropic fundraising effort, and the goal is really simply to beat and cure cancer, and it's through supporting research and innovation in cancer care.

So I believe VeloSano started in 2014 and since have raised over $80 million. And the unique thing is every dollar raised goes directly to cancer research. And actually one really fun way to raise money is participating on this annual Bike to Cure event, which I've done in the last two years and plan on participating this year as well. It's a really fun, well organized, well participated event. I will be riding the 25 miles around downtown and Cleveland Clinic Campus, so anyone can join.

But essentially one of the ways of trying to cure cancer is supporting what they call VeloSano Pilot Grant, which are essentially competitive application and peer review selection process where projects are awarded that have a high likelihood to leading to other extramural grant funding and cancer research. So yeah, I was able to get two, which is very exciting.

Paul Bryson: And it's really, it's real funding. I think they're competitive and it's a really meaningful amount of money to really help you get preliminary data or even data beyond just preliminary data, to strengthen that application for hopefully maybe other funds and grants. Can you share a little bit about the projects?

Jamie Ku: Yeah, sure. I'm really excited about both of these projects and really one of the cool things about these projects is the way we can collaborate with our other team members. And so the first grant funded project is pilot study, really looking at the impact of proactive tongue strengthening exercise program on the speech and swallowing outcomes of patients with tongue cancer after they have tongue surgery and reconstruction. And so this is a collaborative effort along with our speech language pathology colleagues, specifically Molly Smeltzer and Michelle York, and our otolaryngology resident Dr. David Okto.

So essentially we'll be looking at how a very standardized exercise program utilizing a tongue strengthening device that provides immediate biofeedback in the postoperative period impacts their speech and swallowing outcome when you compare to those who are just getting default standard of care, which is just range of motion exercises.

Paul Bryson: Yeah, very exciting.

Jamie Ku: Yeah.

Paul Bryson: Is there any special technology that you'll look at intraoral pressures or tongue strength? How does that look like?

Jamie Ku: Yeah, so that is the benefit of utilizing the commercially available device, is that they get immediate biofeedback. They put the device on their tongue and then it links with the smartphone. And so it gives them immediate feedback on how their exercises are going, how effective is it, are they meeting their goals? And they're able to share this progress with the speech language pathologist so we can keep track of how they're doing.

Paul Bryson: Yeah, it's nice to have the remote stuff too, because people travel from pretty far to seek your care, so that's a really nice way to expand access too. What about the second project?

Jamie Ku: Oh, yeah. So the second funded project, which I'm along with Dr. Shauna Campbell, who is one of our stellar head and neck radiation oncologists here at the Cleveland Clinic Taussig Cancer Center. And essentially we're looking at this idea of omitting completion neck dissection in patients with a positive sentinel lymph node in early stage oral cavity cancer. So just to give you a little background, patients who have very small early stage oral cancer who do not have any obvious positive lymph nodes with cancer, essentially one option right now is you can do what we call sentinel lymph node biopsy to biopsy the lymph nodes, one or four lymph nodes that are at the highest risk. And if those lymph nodes are positive for cancer, then we go back and do what we call completion neck dissection.

However, many of these patients have indications for needing radiation after surgery. So this idea that we're proposing is instead of going back and doing completion neck dissection, which we often find that there's no additional lymph nodes that have cancer, they're going to need to get adjuvant radiation anyway to the mouth and the neck. So we are skipping surgery, completion neck surgery, and then just going straight to radiation and then seeing if there is any worsening or similarity in terms of their regional or nodal controlled. And so this is a very exciting way to treat these patients, but decrease the treatment burden and morbidity long-term. Right? Because we're having them not have additional surgery.

So this is an idea that's already done in other cancer care, so in breast cancer and other types of cancer, and so we're trying to apply in our oral cancer patients.

Paul Bryson: Very exciting. I look forward to seeing the outcomes of these studies. And for the listener, just to continue on with what you're saying, so the Bike to Cure fundraiser, it's 100% the participant raise dollars support cancer research this year. It's September 5th through 6th, and you can learn more about the event and other fundraising opportunities at velosano.org. That's velosano.org. And if they wanted to donate to your team, is that just under your name or do you have a special team name for your group this year?

Jamie Ku: Yeah, so I mean, usually I participate through Taussig Cancer Center and they're called the Cyclones, but I will have a funding page, so that would be wonderful.

Paul Bryson: Yeah, yeah. Well, thank you for doing that and for the work you've been doing. As we wind down the podcast, any additional research or trials that you want to highlight or that you're excited about right now?

Jamie Ku: Yeah, I think there's some really, really paradigm-shifting actually, and practice changing treatment options that have been on the horizon for the last few years. And really some of that has to do with novel systemic therapies or combination therapies given prior to surgery that have led to significant improvement in their patient outcomes.

So one main example I can give you right now is immunotherapy, which is medication given through the IV to help the patient's own immune system to help fight cancer cells, and specifically before surgery for skin cancer, so cutaneous squamous cell cancer. And so we do have an international clinical trial that we're going to open here. And essentially what we've seen is if you give immunotherapy before surgery, it significantly shrinks the cancer, or even in some patients, gets rid of all the cancer cells once you do surgery. So actually leads to a much, much smaller surgery, which also leads to a much improved both functional and cosmetic outcomes. So this is very exciting.

And then I think other areas of exciting research in cancer are developments in various blood and bodily fluid biomarkers to either diagnose cancer or look at the treatment response to cancer treatment, as well as innovative surgical techniques. So I'm sure you've had Dr. Michael Fritz and the colleagues out here talking about early intervention to prevent progression of osteoradionecrosis, as well as the new robotic system that I mentioned before to perform micro and super microsurgery, which we started doing here along with our plastic surgery colleagues.

Paul Bryson: Yeah. Well, yeah, I mean a lot to be excited about. And I think for the listeners or if there's patients or family members of patients that are listening, I think it's a really nice example of how research is trying to push the field forward to de-escalate care for patients, but also have just as good if not better outcomes. Very exciting. Thank you very much for being on the podcast. Anything else? Any final take homes for people?

Jamie Ku: I would say for our listeners, especially our patients, I just want to just encourage all patients to get really a multidisciplinary evaluation and treatment recommendation so you can learn about all the options before making your decisions. And then just know that there are many novel therapeutic and treatment strategies being studied. So enrolling and participating in a clinical trial may actually be the best option for you and your cancer care. And just be engaged in these complex conversations and ask questions because the best way to ensure that you're making the best decision for yourself and your loved ones

Paul Bryson: Well, for more information on head and neck cancer treatment at Cleveland Clinic, please visit clevelandclinic.org/headandneckcancer. That's clevelandclinic.org/headandneckcancer. And to speak with a specialist or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr. Ku, thanks for joining Head and Neck Innovations.

Jamie Ku: Thank you, Paul. Always a joy. Thank you.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts.

Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.