Evan Matros, MD, MPH, MMSc, a plastic and reconstructive surgeon, and Rebecca Gao, MD, and Michael Wu, MD, head and neck surgeons with training in reconstructive surgery at Memorial Sloan Kettering Cancer Center (MSK), see patients at the David H. Koch Center for Cancer Care in New York City and at MSK Bergen and MSK Monmouth in New Jersey.
The head and neck service at MSK offers a distinctive collaborative and multidisciplinary approach. Advanced capabilities include dental rehabilitation at the time of surgery using bone-for-bone reconstruction, and virtual Surgical Planning (VSP) using CAD/CAM technology for preoperative modeling to improve reconstructive outcomes.
“One thing that we do particularly well is education. When a patient comes to us, what they often worry about most is how they will look. Your face is what you show the world. It’s how you interact with other people, how you speak, how you eat, and how you share meals with people. We strive to ease some of the psychological burden preoperatively,” said Dr. Matros.
“In a place that sees as much volume as MSK, every single player on the team is at the top of their game,” added Dr. Gao.
“At MSK lot of times you’re being asked to solve the unsolvable problem. Just by nature of our practice pattern, we see some very challenging cases. We take pride in our ability to tackle these situations,” said Dr. Wu.
We sat down with Drs. Matros, Gao, and Wu to learn more about these innovative approaches to reconstructive surgery in the care of head and neck cancer at MSK. Dr. Matros is an attending surgeon and Vice Chair of Health Information Technology in the Department of Surgery, with research interests on patient-reported outcomes and quality of life, and the application of CAD/CAM technology to head and neck reconstructive surgery. Dr. Gao, an assistant attending surgeon, has research interests on interoperative surgical guidance in head and neck cancer resection, and preoperative virtual modeling for both resection and reconstruction. Dr. Wu, also an assistant attending surgeon, has research interests in head and neck cancer survivorship, long-term quality life outcomes, and transoral robotic surgery.
What makes head and neck reconstruction at MSK distinctive?
Dr. Matros: What makes our service unique is that we always have more than one pair of hands. That is super critical. You have not just two surgeons working together, but also two problem solvers. This allows us to do outside-the-box thinking with novel solutions and creativity, all the things that come together in high-functioning teams.
What capabilities, expertise, or approaches allow your team to manage particularly complex cases or achieve outcomes?
Dr. Wu: The ability to do dental rehabilitation at the time of surgery is becoming more common at centers across the country. We continue to lead that and are very proud to be able to offer it at a high level. Research by our team at MSK has shown that virtual surgical planning (VSP) enables surgeons to safely replace like with like to achieve better outcomes for our patients. Long-term outcomes following immediate dental implant placement in free fibula flap (FFF) surgery suggest that patients who received immediate placement may safely achieve dental restoration in less time and at a higher rate, than patients who did not receive immediate placement. FFF was pioneered at MSK by Dr. David Hidalgo in 1989, and uses bone, blood vessels, and soft tissue from the lower leg to rebuild the mandible.
Dr. Matros: What we’re doing is replacing bone with bone, not bone with soft tissue, we are replacing like with like. That is what enables us to have dental restoration. Working together in a collaborative way often enables us to perform two reconstructions at a time. That allows for a very bespoke type of reconstruction that is tailored to the individual’s needs. It allows us to provide a unique offering to the patients here.
Describe the multidisciplinary team involved in head and neck reconstruction at MSK.
Dr. Wu: Head neck is a team sport. The team is more than the plastic surgeons, head and neck surgeons, and reconstructive surgeons. The dental team is highly involved in our entire process from the beginning. The speech and language therapists, and speech and swallow therapists are like the physical therapists of our team. We pride ourselves in being able to talk across the table to these other disciplines that affect the reconstructive outcome. That’s unique here. We have a specialty focus, and that allows us to have a multidisciplinary team.
What research or other topics happening at MSK should clinicians know about?
Dr. Gao: MSK is taking the lead in neoadjuvant therapy given before surgery to optimize oncologic outcomes, but also to potentially shrink the size of the tumor and decrease the size of the resection needed. That can make the reconstruction more complicated. We don’t always know what we’re getting into before the day of surgery because of potentially dramatic effects of neoadjuvant therapy. It takes a much higher level of experience to do these resections and reconstructions. It’s a judgment call to know when less is more, or when you have to do the maximum possible. That only comes with a lot of experience. MSK is a leader in doing neoadjuvant therapy, as well as minimizing surgery and maximizing reconstruction.
Dr. Wu: We have developed a strong measure to assess quality of life outcomes in head neck cancer patients called FACE-Q. It captures aspects of head and neck cancer patients’ quality of life such as appearance, eating/drinking, salivation, smiling, speaking, and swallowing, and distress related to these variables. For example, research from our team using the FACE-Q measure has found that long-term functional recovery after glossectomy is similar across age groups although older patients may have lower satisfaction, and in-situ condyle preservation may result in better patient reported outcomes such as facial appearance and eating function compared to condyle resection. AI and machine learning are probably our next frontier for patient quality of life survey research to reduce survey burden surrounding questionnaires.
What should referring physicians know about the care their patients can expect from your team?
Dr. Matros: We listen to our patients, and care very much about our relationships with referring physicians. We want to be seamless communicators both before and after surgery because we know patients are going back to their local providers.
Dr. Wu: There can be a fear that somebody may sort of disappear when you send them to a big tertiary care center. We want to communicate with people. We want to make access to care easy for head and neck cancer patients, which historically has tended to occur in a somewhat marginalized population. A huge part of that is communicating with referring physicians. We really take pride in doing that.
What do you find most gratifying about your work as part of the head and neck team at MSK?
Dr. Matros: For me, it’s having an impact on the ablative side. Sometimes we can allow for greater tumor margins. Sometimes that might mean we have a positive impact on the way the ablation or tumor removal is performed. It’s fantastic anytime I can influence the whole operation and lead to a better outcome for the patient. It’s putting the patient first and tailoring it to their specific scenario.
Dr. Gao: Patients often see me on the worst day of their lives. Being able to be there for somebody is an incredible honor and privilege. It makes me feel like I’m doing something right to be able to provide some level of hope, to be a guide in the darkness. It is not just about removing the cancer, but about restoring all the things they love about life. My favorite visit is the one-year visit when I see the patient and I say, “Look, you did it. You got through all of that. Remember last time we talked, you were having a hard time. Now look at how much you have gone through and succeeded. I’m so proud of you.”
Dr. Wu: This part of the body is special. It is the part of our body that faces the world. It’s a huge part of social interaction and identity. Reconstruction becomes an integral part of it. We follow these patients over the long-term, sometimes for the rest of their lives. We develop this long-term relationship with patients who sometimes have extremely challenging problems. That’s very gratifying.