S2E3: Head and Neck Cancer with Prof Ruta Gupta

In our third episode, RCPA President Dr Lawrie Bott and Prof Ruta Gupta discuss head and neck cancers. Traditionally the most frequent cause of head and neck cancer has been smoking and alcohol. However, with smoking on the decline in Australia, what else can cause these cancers?

Transcript

00:00:00:23 - 00:00:15:18

[Voiceover]

Welcome to the Pathologist Cut podcast. This RCPA podcast explores the broad medical specialty of pathology and the critical role pathologies play in medicine and health care.

00:00:17:13 - 00:00:47:09

[Dr Lawrie Bott]

I'm delighted to be talking today with Professor Ruta Gupta. Prof Gupta is the senior anatomical pathologist at Royal Prince Alfred Hospital, Sydney. She is the lead pathologist with the head and neck oncology and thyroid multidisciplinary team at the Chris O'Brien Lifehouse Cancer Centre. Professor Gupta holds an appointment at the Sydney Medical School, University of Sydney. She is also a member of the Sydney Head and Neck Cancer Institute.

00:00:48:09 - 00:01:00:11

[Dr Lawrie Bott]

Professor Gupta's research interests focus on improving diagnostic methods, genomics and survival outcomes for head and neck cancer. Professor Gupta, thank you for joining us for this podcast.

00:01:01:03 - 00:01:02:03

[Prof Ruta Gupta]

Thank you for having me.

00:01:02:19 - 00:01:06:06

[Dr Lawrie Bott]

Perhaps you could start off by explaining what head and neck cancer refers to?

00:01:07:14 - 00:01:55:16

[Prof Ruta Gupta]

So head and neck cancers are actually many different types of cancers which are grouped together only because of their location, as in they occur on the head and the neck.

Now, because of the area of the body that they affect, they can have very significant effects or impact on the way a person can speak or eat if they have done cancer on the way that they can swallow, if they have cancer of the food pipe on the way that they can hear, if it is skin cancers, which is affecting the ears or on the way, they can see if it is again skin cancers occurring near the eyes.

00:01:56:00 - 00:02:09:15

[Prof Ruta Gupta]

So in that sense, it is a diverse range of cancers caused by a variety of things and risk factors which are all grouped together because of the location on the body.

00:02:10:20 - 00:02:13:08

[Dr Lawrie Bott]

What are the causes of it in that cancer?

00:02:14:00 - 00:02:49:14

[Prof Ruta Gupta]

Traditionally the most frequent cause of head and neck cancer has been smoking and alcohol. However, in Australia the rate of smoking is going down and we are seeing a real decline in smoking associated head and neck cancer. Another cause of head and neck cancer are viruses Epstein-Barr virus,  which causes these different genes cancer, human papilloma virus, which causes cancers of the oropharynx which is present right at the back of the throat.

00:02:49:23 - 00:03:07:02

[Prof Ruta Gupta]

So the incidence of cancers which is caused by viruses such as human papilloma virus, is actually increasing while that of the traditional head and neck cancer which is caused by smoking and alcohol is going down.

00:03:07:17 - 00:03:10:20

[Dr Lawrie Bott]

So what age does hidden cancer typically present?

00:03:11:13 - 00:03:48:12

[Prof Ruta Gupta]

Again, it depends upon the type of cancer and thus we have a wide age range. The traditional head and neck cancer which is associated with smoking or alcohol, is generally seen in older people, much more common in men who've had a lifetime habit of smoking tobacco or having alcohol. On the other hand, the cancers which are associated with the white assists like human papillomavirus, they tend to occur in much younger people.

00:03:48:12 - 00:04:15:13

[Prof Ruta Gupta]

The patients tend to be in their early forties to mid-fifties. They generally do not have lifetime habits of smoking or alcohol. And then there is a third group that is coming up and which we are seeing more recently, and that is of mouth cancers in young women, the reason for which we don't really know currently.

00:04:16:13 - 00:04:19:10

[Dr Lawrie Bott]

So what are the typical symptoms of head and neck cancer?

00:04:20:11 - 00:05:00:24

[Prof Ruta Gupta]

Again, the symptoms of head and neck cancer depend upon the cause so in the older cohort with cancers associated with smoking or alcohol, it tends to be and ulcer on the surface of the tongue or the cheek or on the issue around the teeth and the ulcer bleeds or does not heal over a period of time. However, with today, human papillomavirus caused cancers it is generally a sore throat or a lump in the neck or ear pain.

00:05:00:24 - 00:05:38:16

[Prof Ruta Gupta]

So the symptoms can be quite different to think of it more simply, older population, lifestyle risk factors like alcohol and smoking, they tend to present with ulcers in the mouth, whereas younger patients know the risk factors like alcohol are smoking generally driven by human papilloma virus, then to present with a neck lump or a sore throat that refuses to go away after two weeks or your pain that refuses to subside after two weeks.

00:05:39:23 - 00:05:48:09

[Dr Lawrie Bott]

Course is clearly changing, as you outlined, and you mentioned HPV. What is HPV and has it spread?

00:05:49:05 - 00:06:29:04

[Prof Ruta Gupta]

So HPV or human papilloma virus, it is a diverse group of viruses. It the family includes about a hundred different members. The peculiarity of HPV is that it affects the interface between normal skin and wet surfaces. So in that sense, the mouth forms a very good interface between skin and wet surfaces. If we look at the evolutionary history of human papillomavirus, it is more ancient than the human race.

00:06:29:16 - 00:06:58:23

[Prof Ruta Gupta]

If we look at the old texts from the Roman Empire from 2580, they had a classification system for diseases that we know to date to be caused by human papilloma virus. So they had a classification system for what? So they had good warts and bad words. In that sense, HPV has been around through the centuries. HPV does tend to affect about 90% of the population.

00:06:59:01 - 00:07:31:10

[Prof Ruta Gupta]

Nearly all adults get the infection at some point in time, but most people clear the infection. It is a small proportion, about six to 7% of people, both men and women, who will not clear the human papilloma virus from their system. And it is these people who are at higher risk of developing cancers, either cancers of the head and neck or in the case of women, cancers of the cervix.

00:07:32:12 - 00:07:34:13

[Dr Lawrie Bott]

So how do you know if you've got an HPV?

00:07:35:06 - 00:08:15:14

[Prof Ruta Gupta]

So for women, those women who go through regular tests and at this governance they are specifically tested for presence of HPV and they will be aware whether they have had HPV infection and whether they have gone on to clear it or been treated for it. Unfortunately, there is no such system for men in the context of cancers of the head and neck and of that, Don, since most people will never know whether they have got HPV the most common risk factor is oral sex.

00:08:15:23 - 00:08:32:00

[Prof Ruta Gupta]

But having said that, most people will catch and clear HPV only a small percent of people do not clear HPV. And we currently do not have a reliable way of detecting these people, particularly the men.

00:08:32:22 - 00:08:44:03

[Dr Lawrie Bott]

I'm actually going off piece now, but I'm intrigued at how we know that HPV existed before human beings how was that research done?

00:08:45:06 - 00:09:00:18

[Prof Ruta Gupta]

It's very ubiquitous, apparently, like our favourite  coronavirus. It started life in the reptiles and birds and then came to the human beings. And I guess they must have found it in the relics from the reptiles and birds of that era.

00:09:01:13 - 00:09:10:00

[Dr Lawrie Bott]

It's intriguing is how we can establish these things. So how is hidden cancer diagnosed and what's the role of the pathologist?

00:09:10:08 - 00:09:33:10

[Prof Ruta Gupta]

It depends upon the type of cancer. If we are looking at the traditional head and neck cancer in older people with smoking and alcohol, it will generally be picked up by their GP or their dentist that they have an ulcer in their mouth, which is not healing. They will take a biopsy of this ulcer and send it to the pathologists.

00:09:33:23 - 00:10:13:14

[Prof Ruta Gupta]

Pathologists, of course, are the ones who make the diagnosis. They're the ones who diagnose all cancers and that is the main, the role of a pathologist in making the diagnosis of a cancer in these patients. In the context of patients who develop head and neck cancer due to human papillomavirus, it is slightly different. They generally present with a neck lump and they may go to their GP because the neck lump or their sore throat is not resolving, at which point they undergo a procedure called fine needle aspiration.

00:10:13:20 - 00:10:42:20

[Prof Ruta Gupta]

Simply put, what is done is we take a needle and syringe and like an injection except over here we are not injecting material into the patient, but we are taking a few cells out from the lump in the neck. We spread them on the slide. We use different chemicals to make the cells obvious and we look at it under the microscope to make a diagnosis of cancer.

00:10:43:17 - 00:11:09:03

[Prof Ruta Gupta]

If we do diagnose cancer, the patient is then sent to a head and neck surgeon because the cancer that arises from human papilloma virus is generally hidden in the foliage of the tonsils or it occurs right at the back of the tongue where the tongue is attached to the throat. It can be very, very difficult to see it.

00:11:09:16 - 00:11:41:15

[Prof Ruta Gupta]

And the surgeons will use tools they can endoscopic machine to look and take biopsies from the tonsils or the back of the tongue. These biopsies are then sent to the pathologist and again, the pathologist looks at them under the microscope and makes a diagnosis of cancer. Once that diagnosis of cancer is made, the patient then undergoes surgery for head and neck cancers.

00:11:41:22 - 00:12:16:13

[Prof Ruta Gupta]

It is not only the removal of the tissue with cancer, so it is not just taking out the tongue or the jaw or the tonsil, but we also need to take out lymph glands from the patient's neck. So these are big surgical procedures. They are often followed by admissions or stay into the ICU while the patient recovers. So the diagnosis of head and neck cancer is a very, very critical step to start the patient's cancer journey.

00:12:16:24 - 00:12:46:05

[Prof Ruta Gupta]

It is the pathologist who informs every step of the patient's cancer management in the way of making a diagnosis so that a radical surgery can be performed. Examining the tissues from the surgery to determine whether we need additional chemotherapy, additional radiotherapy, now, we also have another thing like immunotherapy, which has come up for patients who recur or metastasize.

00:12:46:05 - 00:13:08:01

[Prof Ruta Gupta]

And we can test whether the patient will respond or not in the pathology lab. So to my mind, a pathologists run in the management of hidden cancer in the patient's journey of head and neck. Cancer is very integral. They are the ones who decide what the battle plan should be.

00:13:08:13 - 00:13:22:22

[Dr Lawrie Bott]

So like other areas of medicine, the signs and symptoms, they're often very nonspecific for the clinical doctor point and it takes the pathology tests to say whether it is cancer and what type of cancer.

00:13:23:19 - 00:13:24:09

[Prof Ruta Gupta]

Exactly.

00:13:24:22 - 00:13:31:11

[Dr Lawrie Bott]

So what's the survival rate for these hidden cancers, in particular the HPV cancer.

00:13:31:23 - 00:14:10:23

[Prof Ruta Gupta]

So the HPV associated cancer has a much better survival than the traditional head and neck cancer associated with smoking and alcohol. The HPV associated cancer responds well to both surgery as well as radiotherapy and chemotherapy. Even the HPV associated cancers can be further stratified by the patient's smoking habits. So the HPV cancers do better in general. However, non-smokers with HPV cancers tend to do much better then smokers with HPV cancer.

00:14:12:07 - 00:14:21:17

[Dr Lawrie Bott]

The HPV vaccination program provides free HPV vaccination to both boys and girls at school. How important is this vaccine?

00:14:22:21 - 00:14:55:15

[Prof Ruta Gupta]

To my mind, it is the single most important step to prevent both head and neck cancer associated with HPV, as well as cervical cancer in women. So if a simple thing like a vaccine or an injection shot can prevent cancer and it's associated treatment that is totally what doing cancer treatments are not something that should be taken lightly, particularly for the head and neck.

00:14:55:15 - 00:15:20:04

[Prof Ruta Gupta]

The surgeries are devastating. People lose that ability to speak, to swallow. The following radiotherapy also has significant side effects and a vaccine that can prevent or protect one from these kind of cancers and their treatment is something that should be done by everyone.

00:15:20:17 - 00:15:31:11

[Dr Lawrie Bott]

Thank you. Okay. To finish, everyone has to answer this question now. What would you say to anyone considering a role in pathology?

00:15:32:07 - 00:16:09:21

[Prof Ruta Gupta]

I would love to answer that question. As an anatomical pathologist and I would very much like to welcome them to the most exciting medical specialty ever. I may be a little biased, but I think that pathologists, because they make the diagnosis are very important for all patient management. They make an impact on a patient every 10 seconds of their working life.

00:16:10:14 - 00:16:36:15

[Prof Ruta Gupta]

To put it in perspective, there are thousands of types of diseases we might think of cancer as one disease, but just going back to head and neck cancer, this is a cancer that affects ten different sites on the head and neck. At each site. We can have 20 different types of cancers, all of which have different treatment. And different outcome.

00:16:37:01 - 00:17:12:09

[Prof Ruta Gupta]

So it is the pathologist who actually recognises which of the 200 type of cancers the patient has and then provides information on which all of their further management is based. It's very exciting detective work, but in solving, looking at a lot of clinical information, looking at the patients tissues, a pathologist actually looks at the issues and provides the answers.

00:17:13:05 - 00:17:44:07

[Prof Ruta Gupta]

In that sense, it is also very fulfilling, not only in terms of the impact we can make on the patient at hand, but also on the future generations because the tissues provide an avenue for translation and research. Thus it is one of the few medical specialties that can drive, practice changing research and help improve patient care in the future.

00:17:45:13 - 00:18:18:03

[Prof Ruta Gupta]

And all of this can be done in a way that is compatible with sane work life balance. So what's not to like? You are a consultants consultant. You're providing advice to all of the surgeons and the medical and the radiation oncologists and transplant physicians. At the same time, you can talk with the research scientists, propel the research and treatment identification further.

00:18:18:07 - 00:18:31:04

[Prof Ruta Gupta]

So I think I think it is one of the most exciting careers to have and most of us have been lucky enough to work with wonderful pathologists. So they would be joining a wonderful community as well.

00:18:32:07 - 00:18:58:13

[Dr Lawrie Bott]

I absolutely agree. It's a wonderful career. It's very collegiate and it's very enjoyable. And you're you end up huge contributors to the health care of this country. So first, we got to thank you so much for talking with us today. It's been an absolute pleasure. You've given us a wonderful outline of head and neck cancer, which is an increasingly frequent cancer in our community.

00:18:58:13 - 00:19:00:22

[Dr Lawrie Bott]

And thank you very much.

00:19:01:05 - 00:19:02:10

[Prof Ruta Gupta]

Thank you. Thanks.

00:19:02:16 - 00:19:17:21

[Voiceover]

You have been listening to the Pathologists Cut Podcast with RCPA president, Dr Lawrie Bott. To learn more about pathology, check us out on Facebook, Instagram and Twitter.