Expertise offers hope to oral and throat cancer patients
LOUISVILLE A common motivational phrase to drive someone to achieve a long-term goal is to “speak it into existence.” As a child growing up in Indianapolis, Melanie Townsend, MD, head and neck surgical oncologist at UofL Health, took that idea a step or two further. Playing the board game LIFE she always wanted her profession to be a doctor – admitting to manipulating the cards to make sure she drew the right card to be a doctor in the game.
Her real-life journey to become a doctor began by completing her undergraduate work at Denison University in Granville, Ohio before attending the Indiana University School of Medicine. She went on to complete a head and neck surgery fellowship at the University of Miami and performed her residency in otolaryngology at Washington University School of Medicine in St. Louis.
“I saw an orthopedic total hip surgery in college and thought it was the coolest thing I had ever seen,” Townsend says, explaining her particular interest in a surgical profession. “In medical school, from the very beginning I was drawn to general surgery. Then I discovered ENT as a really nice specialty option. I specifically liked the head and neck cancer side of things. The anatomy of the neck is very dense with nerves and muscles and blood vessels. Removing tumors while trying to preserve these structures was extremely interesting to me. Our face and our voice is kind of who we are. It’s a delicate place to have a cancer surgery on.”
Townsend spends a couple of days a week in the clinic and attends a weekly cancer conference at the UofL Health – Brown Cancer Center. The conference includes radiation oncologists, medical oncologists, and radiologists.
“We review each new cancer case, and we bring our patients in to meet the entire team,” says Townsend, who is also an assistant professor in the University of Louisville School of Medicine Department of Otolaryngology. “Generally, I’ll have another half day to full day of clinic in a week. The rest of the week I’m usually in surgery. A lot of those cases take all day long.”
Tumors and Trauma
Performing surgery on the head and neck is intricate and often involves not only the removal of the tumor, but also reconstruction as well. She also commonly removes benign tumors on the neck and salivary glands.
“We do overlap with other disciplines,” Townsend says. “For example, we deal with the structure of the upper and lower jaw. Oral maxillofacial surgeons similarly work with jaw structure, oral tumors, and the temporal mandibular joint. Where we overlap is when the tumors need larger removal and reconstruction. We also both manage facial traumas. Where we start to diverge is a lot of the oncology and the reconstruction after the bigger surgery.”
The most common risk factors for oral and throat cancer are tobacco and alcohol use. A large percentage of these patients are adults in their middle to latter ages. Townsend’s patients are often referred by another ENT who has done a biopsy, or by a primary care provider who has a suspicion, but not a diagnosis. Townsend says that they also welcome self-referrals for any concerns about lumps or bumps.
“The anatomy is so dense that time makes a big difference in functionality,” she says. “Throat cancers are generally found at advanced stages. The reason is, people don’t expect that it’s happening. It doesn’t take a large tumor to be considered advanced because the throat anatomy is so compact. One of the earliest signs are the lymph nodes in the neck or changes in voice and swallowing. For oral cancers, generally, the presentation is going to be a new spot in the mouth or a lump in the neck. Any new lump or bump in an adult’s neck is a good reason for a referral to ENT.”
Townsend says screenings play an important role in early detection. Active smokers should be screened every time they see their dentist. “We encourage primary care to refer early for any chronic sore throat or voice changes,” Townsend says. “The incidence is largely based on where it’s located. Even though the throat is all connected, the different areas of the throat are susceptible differently. The voice box, Adam’s apple, and right above it — the larynx and hypopharynx — those two areas are usually tobacco and alcohol use related.”
Another cause of throat cancer is the HPV virus, which Townsend says tends to present in younger people and is often a tonsil or back of the tongue tumor. It is significantly more prevalent in men than women, who are more apt to have cervical cancer from the HPV virus.
Once the patient has been diagnosed with any of these cancers of the throat or mouth, the case is reviewed in the weekly meeting at the Brown Cancer Center to determine the best course of treatment, which often means deciding between radiation and surgery.
“We have good data to show that multidisciplinary care of any cancer is by far the best,” Townsend says. “We put all our heads together at one time and review each case in detail. Cancer is complicated and unpredictable, and to have all our expertise is very helpful. We also bring in our speech pathologist and then we bring the patient in. We present the standard of care to the patient, what the literature and experience shows to be the best pathway for cure. Functional outcome is a huge part of all of our treatment choices. Loss of the voice box or loss of part of the tongue are major functional changes. Our speech therapists and dieticians get involved for that part. The patient is given all the possible choices, and then we make the decision together.”
Minimally Invasive Surgery in Tight Places
If surgery is the choice, Townsend uses minimally invasive techniques to remove tonsil and tongue base cancers in particular. Minimally invasive techniques for thyroid nodules are also gaining traction as a way to avoid surgery in the right cases.
“Chemotherapy agents are in select cases able target tumors better than we could before,” Townsend says of another treatment option. “We have really nice responses from some of our patients where in the past we had no options at all.”
Townsend stresses that screening, early detection, and referral are essential to maximizing the options for the course of treatment.
“We like to see them early because the voice box is one area of the body you can only radiate one time. Most people respond well, but for those that don’t, then we end up having to do a very big surgery. Sometimes we have surgical options for them at the early stages.
“We like to see them early because the voice box is one area of the body you can only radiate one time. Most people respond well, but for those that don’t, then we end up having to do a very big surgery. Sometimes we have surgical options for them at the early stages.”
The primary goal of any course of treatment is, of course, to remove the tumor. But Townsend also understands the importance of limiting the residual damage to the patient.
“I like my patients to have good cosmetic and functional outcomes. I’m very sensitive to that,” she says. “We also have plastic surgeons we work with closely in our department who specialize in scars and rehabilitation and reanimation. How we rebuild people’s tongues and jaws and throats has become increasingly perfected. We can remove sometimes up to half of the tongue and patients can be talking and eating after surgery.”
The passion to care for others that was so prevalent in Townsend as a child still burns bright in her as an adult. She might have “bent the rules” to make sure she became a doctor in the board game, but in the actual game of life, she knows there are no do-overs. The screenings, the science, and the expertise are the tools needed to win the game.
“I value human life. Life is sacred. We each get one, and it’s very important,” Townsend says. “When it comes to cancer, it’s a difficult road, it’s a long journey in this part of the body. I want to do the best surgery so the cancer doesn’t come back. I tell my patients we go by the science that we have and I will be there with them through that journey as long as it takes.”