HPV, Head & Neck Cancer and More w/ Dr. Patrick Ha

– For synchronizing audio, you surgeons wouldn’t understand what I do, it’s.

– Very technical.

– Oh they’re here. What’s up Z-Pac, it’s your boy ZDoggMD and I am here today with someone you will recognize if you’re a fan of the show, this is Dr. Patrick Ha, he is the chief of head and neck surgical oncology at UCFS Medical Center, up the road in San Francisco. We’re here on our Bay Area radical sabbatical interviewing folks and luminaries, thanks for coming back on the show.

– Yeah, absolutely, it’s a pleasure.

– So Patrick’s a friend and we got the families together, and anytime we do that I like twist his arm to come on the show because he’s a font of knowledge about stuff that all of us should care about, i.e. cancer, particularly in the head and neck, and a bunch of other issues. And related to that was what we talked about last year on the show which I recently reposted and I’m gonna post a link to again, which is HPV virus, human papiloma virus and its effect on cancer. Not just cervical cancer in women which is what is classically talked about, but head and neck cancers and anal cancers, penile cancers, vulva cancers, all of those kind of things can happen from HPV virus which is why the vaccine is considered to be so important. And this is one of the vaccines that like everybody freaks out about, like oh you heard this story about this girl who became paralyzed or this or that happened. Turns out none of that is true. That’s all anecdotal stories of correlation versus, hey girl, that’s how we do academic medicine in this house.

– What you’re not here, is that what you’re saying? You sure look here to me. So all joking aside, she just walked by, she is getting vaccinated as soon as she’s at the correct age to do that because if we can prevent these cases of cancer, we can do huge good. And the metaanalyses on the vaccine, which has been out for well over a decade now, show that there are really no appreciable major side effects and the benefits seem to be accruing, so.

– Yeah, absolutely. So well, no, I totally agree and I think for us in the head and neck world, you know as we talked about last time, what we’re really focused on are tonsil and base of tongue cancers. So it’s a very unique subset of the cancers that we normally treat in this head, neck region. But for some reason the vaccine, or I’m sorry, the virus likes to live in those areas. And while we don’t have necessarily the best data to support that it’s going to affect tonsil and tongue base cancers, it’s the exact same strain. So we really anticipate that the number of these cancers is going to start to decrease. Another thing we highlighted last time is that this is the one subset of cancer, in the US at least, in the head and neck that’s actually rising in incidence. We call it sort of a slight epidemic in our field, meaning that smoking is going down so larynx cancers, tongue cancers, those are all going down. But oropharynx cancer, so tonsil, tongue base, are on the rise. So we actually exceeded the number of cervical cancers in the US.

– Wow, so this type of cancer, which is HPV related, and it’s the same strain that causes cervical cancer? That is three strains, right, that are typically oncogenic, meaning they cause cancer, is that correct?

– Yeah, so within the head, neck, it’s, we’ll start talking about this I guess then.

– Yeah, ’cause sorry, I forgot to say, we’re gonna take some of your questions from last year that accrued that we didn’t get to answer and Patrick was like hey, there’s some good questions here, let’s talk about them. And I’m like let’s, all right, let’s do this. So are gonna readdress them.

– Yeah, so within the head and neck there are these nuanced differences between head and neck cancer and cervical cancer caused by HPV and notably the strain, so, for us it’s really predominantly HPV 16.

– Mmmmhmm.

– So, that’s probably 90% of the time, that’s the strain that we can identify.

– Hmmm.

– A smaller percentage of the time, it’s 18, and then sometimes we can’t really pinpoint it, cause we’re not necessarily looking that hard exactly.

– To find the virus.

– Yeah.

– But certainly those are all the strains covered by any HPV vaccine, that you look at.

– Got it, got it, got it, so, and will people ask, and this will come up, and we’ll answer it, about ya know, well, if it doesn’t cover all the strains, how’s it gonna prevent cancer, or, ya know, ya know, why shouldn’t we vaccinate someone who’s 45.

– Right.

– Ya know, and short answer for that last part is well, because most people get exposed to HPV very young through any kind of sexual contact, kissing, all the way through to intercourse, oral sex, et cetera, and, so, the cat’s kind of out of the bag for most people, when they’re in their 40’s, some maybe not.

– You know who we’re talking about.

– We know who we’re talking about, but for most, and so, the idea that you really gotta get this vaccine, when they’re, before they’re sexually active, and this is where I think there’s a lot of this, moral police come in, and they go, well, first of all, my child will never be sexually active, okay, yeah, good luck with that, ace, as a dad, who is ready to buy a shotgun, to fend off any suitors from my girls, I know, that I cannot laminate my children with a laminating machine, I cannot keep them safe, they will do what they’re gonna do, and so, we have to keep them, as safe as we can medically, and this is a way to do it, so, you do it early, and that’s part of the reason we do that, now, now, again, if we can prevent cancer, and you mention that maybe the data isn’t robust enough yet, to show the prevention in these tonsillar, and, and base of tongue cancers, that are associated with HPV 16 and 18, but do you think there’s enough, sort of early evidence, or do you think, there’s just a plausible physiological reason, why we’re gonna permit.

– There is a little bit of evidence that’s coming out, that, you can actually reduce the incidence of oral swab HPV presence, in people who have been vaccinated.

– Hmm.

– So, there’s a bunch of questions about how can you test for it, and certainly, you can take a swab in the mouth, and you can send it for HPV, and you can say, look do I have this, at the time, but really what that is, it’s a spot check of incidence, it doesn’t mean that just because you have that, means you’re gonna get tonsil cancer.

– Right.

– And so, that association is a little bit harder to get.

– Right.

– So, what we really need is survival data or incidence data, that ya know, will show that this exists, so, one of the differences, that we don’t have a pre-cancerous phase, the way that cervical cancer goes through very discrete phases, before it becomes cancer, so, you can identify those population, if that HPV, they’re gonna get this, and you can swab, or you can screen, or you can scrape some cells, and look for that, and then ya know it extratify the risk.

– Hmm.

– For us, it really is a, a situation where, they either have cancer, that’s HPV related, or they don’t have it.

– Hmm.

– And they may have an oral infection, they might have had exposure to HPV, or ya know, to, to some environmental ya know, cause for that, but then that doesn’t mean they actually have cancer.

– Mmmm.

– So, that is a very different setup in the mouth, in the back of the throat, than it is for the cervix.

– Yeah, so again, there’s not a, excuse me, there’s a not, a perfect, model to compare the two.

– Correct.

– But there’s plenty of sort of physiological reasons to think that vaccination prevention might be helpful. In the old days, it was about smoking.

– That’s right.

– And we’re starting to see that change now.

– Well, so, in this subset yes, so, it used to be that, if you develop a head, neck cancer, of any kind, squam cell cancer, it was predominantly in people who smoked, and if you drink, that also contributed, if you did both to a high amount then it multiplied ya know, so, that you were ya know, 15 or 20 fold risk of developing head, neck cancer.

– Mmm.

– For tonsil and tongue based cancer nowadays, the tables are kind of flipped where certainly, there are people who come in with, a history of smoking, or maybe they did it, ya know, 20 years ago, and some people are currently smoking, but most of the people that came in have HPV early disease, so, probably, ya know, in some apparences up to 80%, of people with tonsil cancer, tongue based cancer, they now have HPV related disease, they might have had a distant history of smoking and drinking.

– Mmm.

– But really, if you think what, what caused that cancer it’s probably the HPV virus.

– Yeah, and ya know again, this is relatively new.

– Yeah.

– As you said, it’s a kind of an epidemic in your space, again, we say this, because we wanna understand what’s causing cancer. Even the idea that virus’s could cause cancer, it was a 20th century sort of discovery the Onco, Oncoviruses, that these cancers.

– Right.

– Insinuate themselves in a way, and the genetic makeup, and we can lead to whether it’s tumor suppression failure, or, or whatever, and I forget, now, I’m getting to, do you know any of this?

– I do, but.

– Oh, nerd, I was like I hope he says, well, we don’t need to know this, but he, of course, he knows it, actually ya know, what, just for my identification.

– Yep.

– How is it that HPV might cause cancer?

– Well, so, there’s two basic mechanisms, that they think of, and so there’s these viral proteins, they’re called Oncoproteins, so, basically, when they integrate into the genome, or into the DNA of the host cell or your cell, they basically, these viruses, can oftentimes sit episomally, which means they sit kind of a the periphery of the DNA, then make a whole bunch of more virus, then they spill out, and that’s how they become infectious.

– Mmm.

– But then there are times, when it can actually integrate, and actually jump, and become part of the DNA.

– Part of the DNA.

– So, it’s kind of hidden.

– Body snatcher sort of deal.

– Yeah, exactly, and so, there’s two particular proteins called E6, and E7, and they affect known pathways, known cancer pathways, so, there’s this p53 gene, and something called an RB gene, or retinoblastoma, so, those are known genes that are, are prevalent in many different types of cancers, and these pathways get disrupted, and so, these, it’s thought that these viral proteins really just disrupt those specifically.

– Mmmm.

– So, this is one of the reasons maybe that, in our world for the head, neck cancers, people with HPV related cancers tend to do better, than someone who’s smoked and drink their whole lives, where they’ve accumulated a whole bunch of different mutations.

– Mmm.

– That maybe harder to treat, in this case, there’s gonna be one of two different pathways altered, so, it’s kind of a simpler cancer to treat.

– That’s, see that’s fascinating because cancer, like you said, if it’s not something where you can pinpoint, okay, this was a viral influence in the way that you describe, well, then, ya know, radiation, certain chemotherapy, sort of approach, might be enough, because there isn’t an accumulation of error, a complexity, and an evolution of this tumor, that makes it difficult.

– Right.

– Yeah.

– So, even in the cases, where people have disease that has spread, so, it’s gone from their tonsil and their lungs, normally we would’ve considered that a really, ya know, bad prognosis, and ya know, ya got a year to live, some of these patients can live three, four, five years, even with metastasis, they’re being treated.

– Right.

– But because of the fact it was predominantly HPV derived, there’s something about it, that makes it behave better even in the situation where it has spread.

– Yeah, so, that, that’s fascinating, and again, speaks to the complex nature of cancer, cancer’s not one animal.

– That’s right.

– And a particular type of cancer even within that type, it’s not one animal.

– Yeah.

– Just like breast cancer’s not one animal, relating to this, because you mentioned people who are undergoing treatment can live, three, four, five years, even with metastasis, there is recently more data that, they looked at analysis and said, ya know, people who kind of forego the traditional treatments that you might offer, whether it’s surgery, radiation, chemotherapy, immunotherpay, whatever it is, they they do worse, if they just go the alternative medicine or complementary medicine route.

– Yeah, I’m not, ya know, obviously, we’re bias in the people that we see.

– Right.

– And.

– So, you gotta understand our bias.

– And the people who tend to come see us are those who, ya know, they may consider those treatments, and I think that, ya know, we try to be as holistic as we can, given that we don’t have great data to say, ya know, whatever treatment or path that they’re selecting may or may not work, but, but really what I try to emphasize is that, we have data on what we do, we don’t know whether what you treat may be adjunctive we also don’t know whether it might harm it.

– Right.

– It might interfere with treatment actually.

– A lot of herbs and different things like that do affect pathways of drug metabolism.

– Right, so, so it may, so, I think that as long as we have a very clear understanding of what they’re taking, and I think also we, we tend to have sort of a comprisemental zone, where during treatment, don’t do these things.

– Mmm.

– Ya know, afterwards, if you feel there were symptom control or improvement, then by all means, if this is making you feel better, and on the path to recovery, then I would say, ya know, you should do that, and maybe something that we even offer, or suggest to other patients, if we found that that was very beneficial,

– I actually think that’s a good way to deal with it, because people, they do wanna also feel like, they’re in control of their care a little bit, and some of these pathways offer a little bit more control, and whether it works, we don’t, we don’t really know, but we know that there’s a strong placebo effect with many therapies.

– Right.

– And if you can something that isn’t harmful, that’s why I like where he said, don’t do it while we’re in the middle say a chemotherapy, but you can do it after, and talk to us, and make sure it’s not interfering with anything, I think that’s great, but, ya know, the tricky part, and I think a lot of hardcore science based people will say well, it’s a slippery slope, because, we’re sort of advocating what in some instances is almost a magical kind of thinking, so, we don’t have a good basis for this, but there’s energy fields, and this and that, and then kind of encouraging that thinking, kind of leads to an erosion of the the belief that science can actually help improve outcomes now, I’m actually somewhere on the fence about that, because I’m a big believer in harnessing placebo effect, if you can, and also that we don’t know everything, that we have to be humble in medicine, and ya know, the alternative medicine, that’s shown to work, we call it medicine, so, let’s study it, and let’s look at it, whether it’s cannabis or whatever it is, and we’ve done shows on it.

– Yeah, no, absolutely, I think also, ya know, what’s important is that, you’re in a partnership with that patient.

– Mmm.

– So, I think if you alienate them by saying, ya know, you have to do this, or there’s no other acceptable way, when you yourself are not actually sure, then I would say, ya know, you’ve not necessarily treated that patient appropriately.

– Mmmhmm.

– Especially, if they think, okay forget this.

– I’m done with this.

– I’m done, I’m gonna do my thing.

– We see that.

– Yeah.

– Yeah.

– So, I think it’s important to, to be reasonable, and to talk to the patient about it, communicate it well.

– Do you see a lot of patients who are coming to you for a second or a third opinion, as a tertiary care provider.

– Yeah, that happens all the time.

– And what do think are the biggest reasons they do that? Is it because they don’t trust the other doctor? Did the have a bad experience? Was the other doctor actually incapable of treating?

– No, I mean, I think it’s a variety of reasons, and obviously, ya know, we being in an academic center, where we treat this disease, ya know, almost every day essentially, we’re taking care of patients with this, that certainly goes a long way in terms of, ya know, the patient’s faith in our treatment plans, and not to mention or ability to actually create a center, that focuses on this disease.

– Right.

– So, ya know, we’re not, our attention is, is solely focused on this, so, that we don’t have to think about patients with breast cancer, lung cancer, this, ya know, our job is take care of this.

– Right.

– So, we create a system, and a pathway of treatment.

– Yeah.

– That is solely around this, and so, ya know, I would understand that if I, I don’t know, if I went to a car dealership, and I wanted to get my car serviced, I would probably go to the dealership, that sold my car, right, because, ya know, I assume they have expertise, and so, I think most of times, honestly, it’s a question of validating, ya know, they, they met another physician, they had a treatment plant, they just wanna know, does this seem right, cause they don’t know anything about this cancer, right.

– Mmm.

– So, and 99% of the time, you go, yeah, that sounds totally fine.

– Mmmhm.

– You should go for it, ya know, we, we agree with that plan.

– Yeah.

– Do you do a lot of Telehealth visits for people who are far away?

– We’re starting to do more of that.

– Yeah.

– Ya know, there are certain logistical problems, that I see people have to be mildly tech savvy.

– Yeah.

– They have to be able to hear okay, and ya know, that interaction.

– Right.

– But, I think, in particular, a patient that you know, or if they’re looking for a second opinion, you should need to review record, and kind of meet with them, ya know, what you lose out obviously is the physical exam.

– Right.

– Where, ya know, you might have imaging, but you can’t feel something or.

– Mmm.

– Ya know, so, there’s a little nugget that may be missing from your entire picture.

– Right.

– The other thing that we’re starting to do more of is actually for a speech language pathologist is to try to do these Telehealth visits, if someone’s getting treated, ya know, at a distance.

– Right.

– But they may not have SLP support.

– Right.

– Locally, ya know, in terms of people, who understand head, neck cancer, so, they can see the, ya know, the, the SLP’s, they can go through therapy, they can do a lot of those things actually through that interface, and it keeps ’em going.

– And we have a ton of SLP fans on the show, they’ve been wanting us to talk about speech and language pathology forever.

– Yeah.

– And head and neck it’s such a crucial Piece.

– Yep.

– Of what you guys do, speaking of technology, you mentioned you have to be tech savvy, you’re pretty tech savvy, because you printed out, hella questions from Facebook, let’s pull ’em up, so, we’re gonna read some questions, that came up from the last show we did on HPV, and head and neck cancer with Dr. Patrick Ha, who is the head of head and neck surgical Oncology at UCSF, kind of a big deal, and also a small deal, because he’s my friend, so, we have him on the show, and he’s a great resource, so, let’s go to some of your questions. What do you think here?

– Alright, well, there’s a couple of questions here, that we sort of touched on, but Marlow Feller, and Nicole Dill asked similar questions about are there routine swabs for testing HPV, in the back of the throat, i.e is there something like a pap smear for the throat.

– Hmm.

– And ya know, for example, if you were in family practice, how would you test for this type of cancer, and would a swab or something be helpful.

– And I think this also got to some other people’s questions of how do you screen for head and neck cancer. So, we’re kind of conflating is there a pap smear of the throat, to test for the virus to see if you’re at risk, and then how would you screen?

– Yeah, so, the first question, again, we touched on was is there a swab that you can do to test for HPV, and the answer is yes, the question is, is it helpful, and I think it’s just probably no.

– Right, because so many people are positive, right.

– Yeah, and so a good probably 10, 11, 12% of people, just in the U.S., if you went around and swabbed them are positive.

– Mmm.

– Yet, ya know, the number of people, with this type of cancer per year is probably about somewhere around 15,000 or 16,000.

– Mmmm.

– So, this get’s to the question of screening where if you have such a big population, and just a small percentage, ya know, has this actual disease.

– True positives, yeah.

– Yeah, then your screening test has to be pretty darn close to perfect, otherwise you’re gonna send all these people for imaging, and all these things when.

– Cause trouble, big trouble.

– And drive up the cost actually, when you’re trying to help them.

– Right.

– So, you’re actually hurting the majority to help a minority.

– Right.

– So, yeah, so the bottom line is that we have these swabs, occasionally, we get people referred in from an office, where they do the swab, and it’s positive, and they’re all concerned, and certainly, in that case, we’ll take a look around, and we’ll ya know, maybe pass a little scope down, look at the back of the tongue, and do these things, but our expectation is that it’s going to be negative.

– Yeah.

– Right, so, it’s not very helpful and so, if anything, I think it makes people more anxious.

– Right.

– Like many screening tests that, that again, where the incidence is low, and so your false positives are gonna be higher by definition, and it’s gonna create, Iatrogenesis, which is we’re gonna try poking to find stuff, and we might cause more harm, more anxiety, more stress.

– Right.

– And more false positives.

– So.

– So, unfortunately we don’t have a good, a swab, or a good test.

– But we.

– That actually looks for tonsil cancer.

– But we might have a good prevention, which is vaccine.

– Absolutely.

– Yeah.

– Yeah, so, that’s actually one step before that.

– Right.

– So, one of the questions, I think was related to that was oh, so, a few quick people asked about, and we really should of covered this was ya know, what are the symptoms, and.

– Yeah.

– That’s really a great question.

– Kind of important, how would you know.

– Yes.

– What are symptoms and signs of of head and neck cancer.

– Yeah, and so, I think that, that really is, it’s a tough one, and this is why, a lot of times people present with a neck mass, and what that neck mass implies is that, the cancer’s already had the time, or the, whatever the, picked up the aggressiveness, for it to start in the tonsil, and then go to a lymph node.

– Mmm.

– So, it’s metastasized, not far, but just locally, regionally, and so, that speaks to the fact that either these cancers like to spread pretty quickly, which is probably the case, at least in lymph nodes, but also what it means is that, people don’t feel it on the inside, when they go hey, there’s something going on here, find it, before it actually goes to this lymph node.

– Mmmm.

– But the signs that people will typically present with are dysphagia which just means, it’s hard to swallow, maybe it hurts a little bit, there’s this phrase we use called referred pain, which means, when they actually get pain in their ear, usually when swallowing, or ya know, talking or something, and but basically, the pain fibers, or the cancer’s in the back of the throat, they’re not so pinpoint, and so, when something brushes across ’em, or you, ya know, eat something acidic, the nerve fibers cross, and it sends pain to the ear.

– Mmmm, that’s interesting, I actually didn’t know that.

– Yeah, so, that actually is, we see that in tongue cancer as well, so, not specific for pharynx cancer, so, that would be one.

– If you can have referred pain, can you have referred pleasure as well.

– Only you would know.

– So, so, so, refer, what’s interesting is that we don’t wanna panic people who have these symptoms.

– That’s right.

– Like, oh my god, I have cancer, it’s just one potential sign, and it could be nothing, it could be something different, but again, if you’re at risk, if something’s going on, we wanna pay attention.

– Yeah, and I really think that, I tell, and maybe this conversation I have mostly with people who they’ve already had this cancer, we treated them, they’re doing great, but every sore throat they have, every tickle in the back, they start thinking.

– It’s a big deal yeah.

– They’re really, ya know, hypersensitive about it.

– Mmmhmm.

– So, in the same lines what I tell them is, they need to be there for two weeks.

– Mmmm.

– Consistently.

– Yeah.

– Or getting worse, ya know.

– Yeah.

– It’s not like a cold that should pass.

– Right.

– But if you’ve had a sore throat for like two or three weeks, it’s not getting better, you feel well otherwise, you might wanna go see your doctor, and say something, well, why is this occurring, and there are a number of reasons why that could be happening, so, it doesn’t mean that you have cancer, but.

– Reflux, it could be, sinusitis, you’re right.

– Right, so, there’s a number of things, but, in any case, I think that is one of the symptoms, that when people have the cancer, or diagnosed, and they look back and go, yeah, I guess it did tickle a little bit, ya know, I had something, and it just didn’t get better, and they just sort of let it, let is pass, because it wasn’t that bad.

– Mmmhmm.

– It typically wasn’t effecting in their life, or what they were eating.

– Mmmm.

– In the extreme case, then it’s really hard to swallow, you lose weight, ya know, it maybe become hard to breathe, your voice may sound muffled, you may bleed, ya know, cough up blood and stuff like that, but those cases are pretty unusual, because most of the times, once someone shows up with a bump in their neck, they know to, to seek attention.

– Do you see a lot of cases, where people are just in denial about it, and they let things grow, and get out of control.

– It, we don’t see that many, because, maybe it’s because we live in the Bay area, and people are.

– People are hyper vigilant.

– Yeah, ya know, and there’s.

– Oh, my god, Doctor Ha, I have a little thing here, I was wondering.

– Yeah, sometime’s that, and ya know, but we do get a pretty wide range of folks who come visit us, so, I think there are, there’s a subset of people, who typically will, will ignore things.

– Right.

– For some reason I think that this because it typically is a younger population, like in the mid forties and fifties.

– I’m glad that’s young now.

– Yes, he’s talking to me, certainly. But, ya know, that, that group is I don’t know, maybe a little more in tune with healthcare, and they’ve, they’ve when something is off, they will seek attention.

– Right, yeah, that, that’s good.

– And that’s a generalization, but that maybe the reason.

– Yeah, excellent, what we got here, so, let’s see, Lyndon Demming, so, is the vaccine for preventing the strain of HPV, that causes cervical cancer effective in preventing these cancers? So, we kind of touched on that, the idea is that, there’s overlap in the strains, that cause cancer, even though they tend to be predominant in different cancers, in different strains.

– Yeah, yeah.

– But the same vaccine should cover those strains.

– Right, so, that’s why, ya know, again, there’s certain things we do in medicine, because we have studies and randomize studies, that say we tested against this and this, we know for sure, that this is, this is happening, then there’s other studies your like, well, this is just so logical, why would we need a study to do a study, that would seem harmful to people to ya know, not give this, and give this, ya know, when we know that this already works.

– Right.

– Ya know, so, it’s not that this is a study per se, but the fact that it’s exactly the same strain.

– Mmm.

– And we know this based on the DNA sequence, that this is exactly the same thing that’s causing cervical cancers, so, if you can eliminate that, or prevent that, from ya know, causing infection early on, and give that person immunity, then ya know, it should help them, with any other type of cancer that’s caused by that.

– Remembering that the downside is soreness in the arm.

– Yeah.

– It is not, ya know, death, it’s not autism, it’s not the things that people keep talking about, because they’re not true, excellent, ya know, I was, I was gonna say, actually, let’s answer another question, then I wanna get back to the CNN piece about vaccinating men.

– Yeah.

– In Great Britain, cause I think it’s an interesting angle, because a lot of people are what about boys and, the whole thing is boys get this, girls get this, and in addition boys can get, anal, anal, rectal cancer from HPV, as well and penile cancer, which ya don’t want.

– No.

– To my understanding.

– That would be horrible probably than tonsil cancer.

– I would say, ah yeah, exactly, the amputation involved is not pleasant.

– Surgery certainly not.

– Yes, miserable, referred pleasure.

– Christi Rosata, Rossoto, asked, why does it seem as more men have HPV head, neck cancers.

– Hmm.

– I don’t know what Christi does, but that’s very, I don’t know, it’s a very knowledgeable question, but, so, the incidence is definitely higher in men.

– Hmm.

– To the point where it’s like two or three fold to one higher in men than women.

– Mmm.

– And I gotta say we don’t really know why that is.

– Ah, so it’s not an acquisition of virus orally somehow that men get.

– It could be, so, there’s a lot of hypotheses.

– Yeah.

– Ya know of the actual transmission itself, and is there a higher disease burden that happens if a man performs oral sex on a woman.

– Right.

– versus vice versa, or whether it’s some immune system issue, that, that men have, it’s not as strong at fighting off this infection.

– Right, the man flu, case in point.

– Yeah, so, there could be something to that, or.

– Yeah.

– Ya know, but other than that we don’t really know the answer to that.

– It’s interesting, now, are you seeing it more in a population of men who have sex with men.

– Not necessarily, actually, yeah. So, it’s, obviously, it’s a smaller population, so.

– Right.

– Sometimes a little bit harder to.

– To study, quantify.

– Ya know to know for sure. But yeah, as far as I know, there’s not necessarily a difference.

– Mmm. So, then that get’s to this question I think of do we vaccinate boys, in the U.S., it is now recommended, that you vaccinate both boys and girls, it’s a gender neural assignment of the vaccination, that wasn’t always the case, there was just an article on CNN about how the national health service in Great Britain was struggling for a long time with this, because that health service has to weigh costs very carefully, because they’re providing it for their citizens, and basically on a tax dollar, so, they do a very careful cost analysis, and they felt that the initial theory was that by vaccinating women, girls enough, you’d generate enough herd immunity, enough community immunity that boys would be protected by proxy, and it turns out, they never reached enough of a vaccination level to do that, so, they said ya know what, we better just vaccinate the boys, and it made sense, and they get a discount on the vaccine, and so, and so forth, because out of pocket, this vaccine can be expensive.

– Yep.

– It can be ya know, $200 dollars a dose or so, and you have to take three, two to three doses to make it work.

– Yeah.

– Yeah.

– No, and I think that, we talked about this last time, or last show I think, but ya know, it doesn’t necessarily make sense to vaccinate boys to prevent tonsil cancer.

– Mmmm. Mmmhm, cause there’s not enough of it.

– Yes, on the other hand, we in the head and neck community are really happy that that’s happening, cause we’re seeing it more in men, and it’s the same strain, so, we believe that’s gonna help a large majority of our population.

– Right.

– Ya know, 20, 30 years from now.

– This was part of the calculus the Brits did, they said, well, okay, radiv head and neck cancer still relatively low.

– Yeah.

– Compared to total population, but you have penile cancer, you have anal cancer, and there’s a question of, are you generating better herd immunity in general, by also vaccinating boys.

– That’s right.

– Because boys are the ones, ya know, that are gonna be dating my daughters, which will never happen, because daddy’s gonna own a shotgun, and and so, having a bigger, broader immunity, might have a synergistic effect, on the population as a whole.

– Yeah.

– Yeah.

– As it has been shown in ya know, Measles, and Mumps and Rubella, and why that herded immunity collapses, when we have people who don’t vaccinate their children.

– Right.

– So, you need enough of it.

– Yeah.

– And then you need a stable population.

– Yep.

– Ya know, that’s not traveling around, or kind of intermixing with groups.

– Correct, correct, going to the, to merin where no one’s vaccinated.

– Okay. Kelly Woodfin asked a question, simple one, any alternatives to chemo and radiation, so, that’s a very broad question, but one that I don’t think we had a good chance to cover, and one that’s really exciting for us as surgeons, is that you may have heard of this, this we, our acronym is TOR is trans oral robotic surgery.

– Hmm.

– But what that means is that we can use an endoscopic robotorless tool, to help us get back there, and do fairly complex receptions, without making an incision, so, it all is just happening through the mouth.

– Just like, down the, down the craw, and this thing does stuff.

– Well, we’re.

– It’s like a terminator.

– We’re controlling it.

– Oh, okay.

– It’s not, it’s a little bit of.

– So, it’s not like the Jetsons yet.

– It’s not like a self driving car.

– Gotch, with a little thing on it.

– Yes, yes.

– Right yeah.

– So, we’re still there manning it and controlling it.

– Right.

– But it allow us to go around corners, and see in high definition ya know.

– Wow.

– Like we’re staring right at it. So, we can take out a lot of these early stage tumors, and do a neck dissection, and remove these lymph nodes, and potentially try to avoid ever having to receive radiation or chemo radiation.

– Aaah.

– So, this is one of the things I think that being in a tertiary center, and offering this it gives a broader scope of looking at a patient saying okay, what are the features that would make me think we could do this, or not do this successfully, and then sending them down this path.

– Wow.

– Sp, what is also means is that, we have a lot more trials open now, where we can look at this, and study this, and say, okay, are we helping, the other thing we can do is actually, introduce a, an endoscopic surgery, and then say, okay, let’s reduce the dose of radiation, or let’s not give chemo into radiation, as a result of this, so, there’s a lot of excitement about trying to de-intensify therapy, and try to decrease things here and there, to try to reduce the side effect.

– I think that’s happened a bit in breast cancer as well, and maybe in prostate and yeah, so, this is a good thing.

– Yes.

– Because you’re reducing morbidity, you’re reducing side effects, you’re reducing unnecessary radiation, you’re reducing all these compitential complications, that’s wonderful, and ya know what’s interesting is we we’re talking earlier about sleep apnea, which isn’t specifically your field of research, or expertise, but you, you deal with it.

– Yep.

– And the fact that now, they’re getting so good, that they can put in little endoscopic cameras, and see while you’re sleeping, what part of your airway is causing the trouble when you’re snoring, or when you’re having obstructive sleep apnea, and then address just that.

– Yep.

– And that’s tremendous, so, it’s no longer, you just throw a big ole, ya know, silence of the lambs sleep app on your face, do you hear them, Clarice, do you hear the bleating of the lambs, hhhm, you can target the specific piece of tissue.

– So, more and more it’s very individualized and personalized treatment.

– Ahh, and that’s what we want, that’s what health 3.0’s all about, it’s about, first of all, being able to spend time with our patients, so, we know who they are, and then treating them individually, and that can involve molecular genetic testing, it can involve just having a conversation, which you’re quite good at, which I’m very impressed as a surgeon, you seem to actually listen to patients, and talk to them, and care about them, and ya know, you said something way before we started, look at you guys, what’s up, come over here, she’s getting vaccinated. How’s the fire out there?

– Hot.

– Is it hot?

– Yeah.

– Yeah.

– Oh, you are guys are bouncing, okay, go say bye.

– The idea that, as, as just a practice thing, we were talking about like the difference between medicine, and say, not doing medicine, or another field, right, of, of interest, whether it’s business, or, or workings whatever, there’s something about medicine, where there are days when you don’t realize it’s happening, but you are making a difference in people’s lives, you’re helping people, and it’s a kind of a special calling, you may have a bad week, a bad day, a bad hour, where you don’t feel that, but at any point, you can wake up, and it’s there, it’s right there, and you’re saying on your best days, it’s there all the time, and I think that’s what is really wonderful, about what we get to do, you get to do it in surgery, I get to do it, I’m not sure what I do in internal medicine, I’m gonna tell you the truth, I don’t think I do a lick of good, alright, see ya guys, no, is everybody bouncing, see you guys, half the family’s leaving, and we’re gonna, hey, we’re gonna wrap up our show, you wanna sit on my lap? While we do the rest of our show, alright.

– She’s so excited.

– I know, she’s like, okay, I’ll do it, alright, so now, did we have other questions we wanted to answer.

– So, there’s a question, with, by Judith Shaw Beatie.

– Mmm.

– About would you please address the belief that HPV vaccine doesn’t protect against all the strains.

– Mmm.

– Which is actually true.

– Yeah.

– It doesn’t.

– It’s not a belief, it’s a truth.

– Yeah, so, but it doesn’t have to necessarily for a cancer, because what they’re looking at is there are many different strains, there’s over 200 now.

– Mmm.

– I was looking this up, but back when I was in training there was about 60, and then.

– Aaah.

– Ya know, by the end of my training, there was about 100. and, now there’s over 200.

– They keep coming up with more.

– They keep finding more and more, because we’re getting better at detecting it.

– Right.

– And sequencing it, things like that, but only a very small percentage of them, like these ya know, three, four, five strains, actually can cause cancer, or are known to cause cancer.

– Are known, yeah.

– So, the vaccine doesn’t necessarily need to cover 200 different strains, so they’ve really focused on the ones that they feel, either can cause cancer.

– Mmmhmm.

– There’s some in our field that can cause respiratory papillomatosis or warts within the throat.

– Mmmm.

– Which can be actually life threatening, if they get bad enough to occlude the airway,

– Yeah, I’ve seen that, yeah.

– So, there are other strains that they cover, as a result, ya know, trying to get those strains, but they don’t by all means, by any means cover all the strains.

– Right, yeah, and again, so, that’s a great question, and again, it’s not a, it’s not a question that sinks the idea of getting a vaccine, in fact, it’s all the more reason to get the vaccine, that covers the strains that matter.

– Yeah.

– Yeah. Yeah.

– Where’s another question.

– There’s some funny one’s here, do you do local events? I love these. Is HPV vaccine more contention on age or sexual activity, ya know, honestly, it’s so hard to gage sexual activity.

– Yeah.

– You kind of have to make a contingent on age, because, you just never I mean, it doesn’t take much to get infected, and again, at some point, we’ll get an HPV, actually we had my brother in law on the show, he’s an infectious disease doc, and we talked quite a bit about HPV vaccines.

– Yeah.

– I’ll reboot that episode as well.

– Someone asked Liz Mangerie.

– Mangerie, yeah, she’s a big time zpacker.

– She was asking, ya know, have things improved, in terms of the treatments, and like we talked about the robotic surgery, I think they have, and this sort of lends itself also to other, systemic treatments like immunotherapy, which we didn’t really get a chance to talk too much about.

– Mmm.

– So, definitely things have changed in a sense that, ya know, our surgeries are much more modest I guess, ya know, so we don’t necessarily need to do radical neck dissection, removing all the lymph nodes, and the muscle and the nerves, and things like that, so, we can spare a lot of those structures during surgery, and the other things is that the post opular treatment, the radiation is given for example, is now, much more targeted.

– Yeah.

– Ya know, just the techniques that they have, and now with proton therapy coming out, that’s gonna be even more targeted, so, the idea is that you don’t hit normal tissue, so, you have less, less collateral damage.

– Mmm.

– And then with, with immunotherapy, I’m not an immunotherapist, but obviously we, we deal with a lot of patients who are on this, but there’s a landmark study, that came out, about a year ago, looking at immunotherapy in patients who have had head, neck cancer, failure of treatment basically, so, they’ve had surgery, and chemo and radiation, and maybe even other chemotherapy to try to, ya know, take care of the metastasis, and in this group, in this really tough to treat group, they give single agent immunotherapy, and they actually had about a 15 to 20% response rate.

– Wow.

– So, that doesn’t sound awesome, but on the other hand.

– Advanced cancer.

– Yeah.

– Yeah.

– They have nothing else to offer these patients.

– Right.

– And you give one drug.

– Yeah.

– With a really low side effect profile.

– Yeah.

– 15% to 20% did well, actually had a response, and then there’s this group that had this tail of response, but they’re doing fine, they actually beyond the study limit, where the study cut off.

– Wow.

– After two years, they’re still alive and doing well.

– Wow.

– So, there maybe this group of patients, this is just with a chance, ya know, one drug, and there are many now, where they actually, had durable response, as oppose to chemo, where you give it, and you expect it to fail, the tumor’s gonna eventually outgrow it.

– Right.

– This, you’re actually training your immune system to go fight the cancer.

– Which makes sense.

– Yeah, and so, in that case, you might have a lasting response, as oppose to just, it’s only responding what I’m giving it.

– That is very exciting.

– Yeah.

– Yeah, I think that’s very exciting, ya know, so, I think the bottom line guys is like there’s a lot of cool stuff happening in cancer, particularly in head and neck, that we’re talking about here, this is to some degree preventable don’t smoke, don’t drink too much, don’t smoke and drink too much, and get vaccinated, get your kids vaccinated with HPV vaccine, when you have a complex situation, a tertiary center can help, particularly, if it’s a new technique, like robotics, whether it’s immunotherapy, whether, it’s a more holistic approach of everything, and Doctor Ha and I agree that, there’s a space for patient empowerment that’s important, and it is, you talked about it earlier, it’s really shared decision making.

– Absolutely, yeah.

– Yeah. And, instead of being paternalistic and patronizing and condescending, we’re partners, and you have expertise, that you can share with them, and they can make decisions based on being educated about it, and that’s what we’re trying to do even with the show is try to spread some knowledge, and get people to be empowered to ask the right questions of their doctors, and seek a second opinion, if it’s necessary from a tertiary center, like where you are, any other parting sort of thoughts, in this pantheon of.

– No, I think this is, this has been a lot fun for me.

– Ahh.

– I think it’s great too, that people are so interested in this, and engage in the topic.

– The last time we talked about it, people were just, it strikes something, because a lot of people have a loved one who’ve had this, many people work in this space, and so, to see how it’s changed, even for me since training, ya know, EMT was a barbaric thing, where you just chopped and took everything out, and now, you’re talking about sparing all these structures, and, and the rate of being able to help people with HPV related cancers in particular, and people are just smoking less, do you think vaping is contributing any of this. Ya don’t know.

– I it’s hard to say, because HPV was around in the tonsils and the tongue based even before vaping became a thing.

– Right yeah.

– I think the hard part is that, it’s just an unregulated space.

– That we don’t understand.

– Yeah, and it’s, it’s complicated, ya know.

– Smoking marijuana, do you think it’s as harmful as say smoking tobacco or something in terms of the effects on head and neck.

– So, actually the studies show that it is, probably not as bad as smoking cigarettes.

– Mmhmm.

– But that there is a distinct increase in the risk of head, neck cancer for smoking marijuana.

– Got it.

– So, it’s a little hard to study, because, ya know, it.

– It often comes with come more come morbid smoking.

– Yeah, it may also come with, well, in other words, like saying how much you smoke a day of cigarettes, you can say, well, I smoke half a pack.

– Right, right.

– Or three quarters of pack, but with marijuana it’s kind of hard to.

– To smoke two joints, and then I smoke two joints, and then I smoke two joints.

– Yeah, I shared that one with, yeah.

– Right.

– It’s hard to.

– And bong versus vaporizer versus joint versus edibles versus, there’s so many different routes.

– Yeah.

– So, yeah, it’s very tough.

– I think it’s just any combustible element, that goes in your throat, it has a potential for causing harm, I would say cigarettes are probably the worst thing.

– Cigars.

– Likewise.

– Yeah, yeah.

– But again, not as bad as cigarettes probably.

– Chew.

– Interesting, you would think that would be really bad, but it’s actually, it’s a relatively low rate of true cancer developing, and again, I think it has something to do with the combustibility versus ya know putting something just ya know, in a localized place.

– I’mma get my skull on.

– We don’t recommend that either.

– Yeah no, because it does have, it does increase risk, but it, like you said, and it does other things.

– Yeah, bad dentition.

– Other things, yeah, which are grody to the max.

– Yes.

– But, yeah, well, that’s super helpful man, I had such a, throughout the week outlasted your family they left without you. He’s went out each time, daddy’s talking about cancer again. It’s bad luck, we’re out.

– Boring.

– That’s right boring, we had some great pizza by the way, Pochi’s pizza.

– Well, thank you.

– Not bad, no, thanks for coming.

– Of course.

– Least I can do is feed you pizza, it’s like morning report or something. Here ya go, alright, here’s some stale bagels, and ya know hella carbs bro, man, thank you.

– Yeah, absolutely.

– So, if people wanna ask questions, you can leave ’em in the comments, you can always private message, we can’t answer individual medical advice questions, but we can answer bigger questions, and then the hope is we have Patrick back on the show for a third time, and he’s at UCSF, you can check out their website, and see all the information on, all the specialties there, and we out people what up.

– Alright.

– By the way, what ya doing this weekend man?

– This weekend.

– Yeah.

– I don’t what are you up to.

– I don’t know.

– Yeah, let’s do something, I’m gonna get him on a mountain bike, and we’re gonna hurt ourselves. Alright guys we out.

– Alright.