“I was 22. I'd just graduated from college. I was involved with two internships, babysitting, dating a great guy, and enjoying the summer after four years of hard work,” Alyssa Fischer says, recalling the months between the time she received her undergraduate degree from American University in Washington, DC, and before she was to begin a master's degree program in public communication at the same university in September of 2003. But the road to her future took a sudden, grim turn.
Fatigue that Ms. Fischer attributed to lack of sleep and a busy schedule was followed by other symptoms — none of which she took seriously. At first. “I dropped quite a bit of weight without trying,” she says. “I'd wake up every morning with a migraine. My eyes burned. I had an extremely bad sore throat and constant earaches. And then a sore developed on the back of the right side of my tongue. I thought maybe I'd bitten it during the night.” However, the sore grew and the discomfort became nearly unbearable. “Eating citrus foods or salads became so painful I had to eliminate them from my diet,” says Ms. Fischer.
Finally, she went to her dentist, who thought she might have an infection and prescribed an antibiotic. But when the sore did not go away, Ms. Fischer sought a consultation with an otolaryngologist at Georgetown University Hospital. “The moment he looked in my mouth, I could tell by his eyes it was something serious,” she says. A biopsy revealed that Ms. Fischer had a large cancer on her tongue. When she received the news, she recalls, “I broke down. I'd been thinking 'This is going to be fine. I can handle this myself. I don't want to bother anyone.'” Ms. Fischer hadn't told her parents. “The doctor sat me down and said, 'Alyssa, you're not leaving here until you tell them.' The three hardest calls I've ever had to make were to my parents and to my sister, Ashley.”
Ms. Fischer and her family turned immediately to the Internet to research the type of cancer she had and to locate the best institution at which to be treated. “I found Memorial Sloan-Kettering Cancer Center's Web site, read Dr. Shah's Web page, and I knew he was going to save my life,” she says, her face lighting up.
“It was all about me and my cancer and what he was going to do to help .”
Dr. Shah is surgeon Jatin P. Shah, Chief of Memorial Sloan-Kettering's Head and Neck Service. He and Ms. Fischer met for the first time in October 2003. “I remember how very patient he was,” she says. “Dr. Shah walked into the room, introduced himself, and closed the door. It was all about me and my cancer and what he was going to do to help. Nothing else mattered. In those moments it was just us.”
“This was an advanced cancer,” says Dr. Shah. “The treatment recommendation was to remove the tumor — which would entail removal of a good part of Alyssa's tongue — removal of the lymph nodes from the right side of her neck, reconstruction of the tongue, and postoperative radiation and chemotherapy. This was a lot for a 22-year-old woman to cope with.”
A fourteen-and-a-half hour surgery took place on November 12. At other institutions at which such a complex procedure might be undertaken, surgeons would have removed Ms. Fischer's jawbone simply to gain access to the cancer. However, at Memorial Sloan-Kettering “we have developed a procedure in which we split the jawbone, spread it open like a book, remove the cancer, reconstruct the tongue, and then put the jawbone back together,” Dr. Shah says. While removal of the cancer remains the focus, equally important in the treatment of all Memorial Sloan-Kettering head and neck cancer patients is preservation, or restoration, of both form and function. “This means devising surgical approaches where the aesthetic and functional impact is minimal,” observes Dr. Shah. “Otherwise, a patient says 'I survived, but I can't go back to work, I can't speak, I can barely swallow.' Our goal is a patient who says 'I am living — and living a full life.'” So, when Dr. Shah had completed his part of the operation, Peter G. Cordeiro, Chief of the Plastic and Reconstructive Surgical Service, stepped in to reconstruct Ms. Fischer's tongue.
“Microsurgery has really revolutionized reconstruction.”
“Clearly, she was going to be missing more than half her tongue,” Dr. Cordeiro says, “a potentially huge deficit. My main objective was to preserve and reconstruct what was left and to allow it to function as well as it could.” Dr. Cordeiro performed what is called a “free tissue transfer,” meaning that living tissue is taken from one place on a patient's body and transplanted to the site where tissue is missing. “To reconstruct the tongue, we use the skin of the forearm and the soft tissues underneath it because they're thin and pliable and give us very healthy tissue,” explains Dr. Cordeiro. “But the other thing we have to do is to make it live, and that's where microsurgery has really revolutionized reconstruction, particularly in the head and neck. We're proud that at Memorial Sloan-Kettering we have a 98 to 99 percent success rate in microsurgical procedures.”
Microsurgery is done with the aid of an operating microscope that allows surgeons to connect very tiny blood vessels and nerves. Dr. Cordeiro took the radial artery and cephalic vein, the two main blood vessels in the forearm, and connected these to blood vessels in Ms. Fischer's neck. “They're about two to three millimeters in diameter — that's where the technical difficulty of the procedure comes in,” he notes.
In addition, Dr. Cordeiro performed a relatively new procedure, taking a sensory nerve from Ms. Fischer's forearm and connecting it to the remnant of the nerve that provided sensation to her tongue. “Over the past two or three years that nerve has regrown, and she actually has good sensation in about three-quarters of the reconstructed tongue, which adds to her ability to eat and swallow,” he says.
“ It was all about me and my cancer and what [Dr. Shah] was going to do to help. “
After two weeks in Memorial Hospital, Ms. Fischer returned to Connecticut where her parents, who are divorced, live. She was treated at Greenwich Hospital with concurrent radiation therapy and chemotherapy. It was a grueling course of therapy during which Ms. Fischer suffered numerous complications and setbacks and was hospitalized several times. “My family was wonderful. I depended on them for everything,” she remembers. “I would spend a week with my mom and stepdad and then spend a week with my dad and stepmother.” But a treatment protocol that was supposed to take seven weeks turned into approximately six months.
And that was not the end of her journey. Ms. Fischer still had great difficulty eating and speaking because, although her tongue had been restored, it no longer had the muscles needed to make it function properly. “Under normal circumstances the tongue raises up to the palate to squeeze food back into your throat so you can swallow,” explains Joseph M. Huryn, Chief of Memorial Sloan-Kettering's Dental Service. “And the same thing applies to speech. Certain sounds depend upon the apposition of the tongue toward the palate.” Dr. Huryn, a maxillofacial prosthodontist and dental oncologist, was the third Center specialist to participate in Ms. Fischer's care.
Expert in the prosthetic rehabilitation of patients with defects or deficits of the face, jaw, mouth, and surrounding soft tissues, Dr. Huryn and his staff created a palatal augmentation prosthesis that lowered Ms. Fischer's upper palate. “It's sort of counterintuitive, but it's a tongue prosthesis that's built on the palate,” says Dr. Huryn. “It allows people with difficulty lifting the tongue to positions that allow for normal speech and swallowing to have improved tongue-palate contact.”
“Everything and everyone is interlinked.”
Of her Memorial Sloan-Kettering experience, Ms. Fischer remarks, “It's an amazing community. On every level — from the people who clean the floors, to the nurses who are extraordinarily caring and wholeheartedly devoted to their patients, to the phenomenal doctors — everything and everyone is interlinked.”
Dr. Cordeiro echoes Ms. Fischer's sentiments, from his own perspective. “Our work is entirely collaborative and multidisciplinary. Without our nurses and without the interactions among the surgeons, radiation oncologists, medical oncologists, and maxillofacial prosthodontists we couldn't accomplish all that we do.”
Adds Dr. Shah, “Everyone contributes, and I believe the quality of our results reflects this.”
All her physicians use similar words to describe their patient: “remarkable,” “strong,” “emotionally solid.” Ms. Fischer puts it this way: “I received incredible help from the doctors, the nurses, and medical technology. However I honestly feel that without my sense of hope and optimism I wouldn't have been able to get through the experience to be here today.”
Nine months after her ordeal began Ms. Fischer loaded her car and drove herself back to Washington, where her apartment was waiting. “I walked in the door, turned on music, and sat down on the floor. It was the first time since I'd been diagnosed that I was alone. It was absolutely perfect,” she recalls.
Ms. Fischer reentered graduate school and received her MA in public communications from American University in May 2006. The title of her thesis … The Power of Hope.
[Ms. Fischer now teaches pre-kindergarten in Westport, Connecticut.]