Outcomes for Head and Neck Cancer and Microvascular Reconstructive Surgery
Understanding the long-term health outcomes of patients is critical to improving care and making choices about therapies. These outcomes include not just survival, but quality of life measures, such as how well a patient is able to swallow food, or if they experience any ongoing pain or discomfort in the long run. Our group has expertise and a focus in outcomes research for head and neck cancer as well as microvascular reconstructive surgery. More specifically, the cancers we focus on for outcomes research include oral cavity, oropharyngeal, and laryngeal/hypopharyngeal, and salivary gland cancers.
Ongoing research endeavours are also centred around functional outcomes for microvascular reconstructive surgery and laryngotracheal/airway surgery. Several ongoing studies collect patient-reported outcomes and quality of life data for skull base surgery, the elderly as well as microvascular reconstructive surgery.
Lastly, our program has expertise with economic analyses for head and neck cancer treatments.
Reconstructive Head and Neck Surgery
The reconstruction of defects and structures altered by the removal of H&N tumors is important to a patient afflicted with H&N tumors as it allows the patient to recover function and live without deformity of the H&N. The Department of Otolaryngology/H&N Surgery has advanced expertise in the use of a variety of reconstructive techniques including microsurgery to allow for the recreation of form and function for our patients. The Departments research program in the Reconstructive Surgery is focused in the development and evaluation of new techniques for reconstruction of the mandible and maxilla. In addition the Department has developed new approaches to laryngeal and airway reconstruction that it continues to develop and evaluate. Working with the Techna Institute and the Guided Therapeutics Program the Department is evaluating and expanding expertise in Virtual Surgical Planning and the use of Surgical Models in the optimization of surgical outcomes.
The Guided Therapeutics (GTx) Program at Techna Institute is dedicated to developing and testing new imaging technologies, including novel contrast agents, and creating software that will merge navigation and surgical tool tracking in real time. Dr. Jonathan Irish leads a collaborative team of engineers, physicists, surgeons, and radiologists who bring their expertise together to use this advanced technology to pinpoint diseased tissue and remove it without harming the surrounding structures. The GTx laboratories at the Princess Margaret Cancer Research Tower in Toronto are engaged in the development of new lipsome- and porphysome-based theranostic nanoparticle contrast agents with contrast enhancement, photoacoustic imaging, photodynamic therapy, and new drug delivery capabilities. This enables us to use new minimally invasive physical therapies such as laser ablation, photodynamic therapy, and high-intensity focused ultrasound (HIFU) as well as robotic and endoscopic ablative surgery.
Our translational clinical research aims to evaluate the safety, efficacy, and accuracy of the systems in first-in-human trials. The GTx Program is engaged in head and neck surgery, lateral and anterior skull base surgery, sarcoma surgery, lung surgery, prostate surgery, GI surgery, and neurosurgery including the spine.
Research in conditions that cause tumor growth (“neoplastic diseases”) in the thyroid and parathyroid glands is a major focus of the Head and Neck Surgery Research Program at UHN. This innovative program in basic, translational, and clinical research involves a multidisciplinary team of endocrine surgeons (otolaryngology – head and neck surgeons, and general surgeons), endocrinologists, radiologists, pathologists as well as radiation and medical oncologists at UHN. Our goal is to provide cutting-edge research that aims to improve the patient’s diagnosis, treatment, disease management, and quality of life through innovation in technology and clinical practice. We have an extensive biobank of thyroid cancer tissues that will soon include needle biopsy specimens and liquid biopsies of select patients.
Active Surveillance in Thyroid Cancer
UHN is the only centre in Canada with a prospective observational study on Active Surveillance of Low-risk Papillary Thyroid Cancer (PTC). This two-phase study is designed to examine whether low-risk PTC patients would choose active surveillance instead of thyroid surgery. This research is funded by the Ontario Ministry of Health and Long-Term Care’s Alternative Funding Plan, and the Canadian Cancer Society.
Quality Improvement Studies
The increased incidence of thyroid cancer is attributed to over-diagnosis. Our research team is working on identifying and understanding the factors associated with over-diagnosis in order to try and develop interventions aimed at addressing this issue.
The Endocrine Research Program also has a research interest in investigating cost effectiveness of new technologies and molecular testing as well as alternative therapies such as active surveillance.
Clinical Outcomes and Quality of Life Studies
Assessing treatment outcomes and pathologic variables is a major component and strength of our Research Program, aided by the high volume of patients treated at UHN. We are also engaged in ongoing research projects to study the impact of thyroid cancer treatments on patients’ quality of life.
Minimally Invasive Ear Surgery
The Division of Otology/Neurotology is a leader in lateral skull base microsurgery and stereotactic radiation, in collaboration with the Neurosurgery and Radiation Oncology divisions at UHN. Microsurgery and stereotactic radiation are used for the conservative management (microsurgical removal) and radiation treatment of vestibular schwannomas and other cerebellopontine angle tumours. We also specialize in advanced microsurgical treatment of inner ear vestibular disorders, ranging from canal dehiscent syndromes to intractable positional vertigo, and challenging middle ear disease.
Under the guidance of the late Dr. David Pothier, we developed expertise in minimally invasive, or endoscopic ear surgery (EES). This technique allows us to use endoscopes and advanced micro-instrumentation instead of an operating microscope to perform delicate middle-ear surgery to remove cholesteatoma, repair tympanic membrane perforations, and reconstruct the ossicular chain to improve hearing. Advantages of EES include shorter procedures and less post-operative pain, in many cases allowing surgeons to avoid external incisions. As this new technology continues to evolve, the indications for EES will be further expanded to include more extensive diseases that now can only be treated with open procedures.
Management of dizziness and imbalance represents the core strength of the Division of Neurotology at UHN, and the Hertz Multidisciplinary Neurotology Clinic is Canada’s only fully multidisciplinary centre that can fully investigate, manage, and treat dizziness and imbalance under one roof.
The Centre for Advanced Hearing and Balance Testing at UHN performs a number of tests including advanced/evoked audiometry such as auditory brainstem response (ABR), electrocochleography (ECochG), and cortical electric response audiometry (ERA); electronystagmography (ENG) and videonystagmography (VNG); vestibular evoked myogenic potential (VEMP), and video head impulse testing (vHIT). Our multidisciplinary clinical team includes neurotologists, a neurophthalmologist, vestibular rehabilitation physiotherapists, a vestibular nurse, and a vestibular psychiatrist.
Active clinical research is an integral part of the Hertz Multidisciplinary Neurotology Clinic’s mandate. Our research looks at various disorders and how they affect the vestibular system. Advanced protocols have also been created to monitor and prevent vestibular toxicity from aminoglycoside antibiotic therapy using computerized dynamic visual acuity testing (custom developed posturography). Our large prospective databases have allowed for further studies into the nature of post-traumatic dizziness in the workplace setting, evaluations of trends in the management of chronic ear disease and the evaluation of vestibulotoxicity – both topical and systemic.
We are engaged in a number of exciting projects with respect to rehabilitative medicine. As part of our Translational Program, we measure outcomes because we are concerned about our patients’ physical ability after cancer treatment.
When the patient comes to our clinic, it is likely that they will be asked to participate in research in the form of questionnaires. Those questionnaires help us understand our cancer patients’ perspective and provide better treatment and better support to them. For some patients, we measure financial stress, trying to understand what kind of financial burden they are placed under while undergoing cancer treatment.
In addition, some of our new research initiatives are trialing biofeedback for the rehabilitation of patients who have been treated for oral cancer. We use electrode arrays to train the patient’s tongue to be in the correct position. Some of our patients go home with special computers for tongue rehabilitation and we provide ways for them to communicate with us without having to come in for follow-up visits. We also measure our patients’ speech and swallowing functions a year after their treatment to understand how we can optimize them and improve our reconstructive interventions.