A Debate for Oral Cancer Treatment: Radiate or Not?
WHY YOU SHOULD CARE
Because overtreatment of cancer patients is all too common.
Arjun Joshi knows what he’s up against. Innovation can be slow and methods entrenched when it comes to the fight against cancer. The 40-year-old threatens to disrupt a $5 billion industry by steering patients away from radiation, long considered an essential element in the anti-cancer arsenal, alongside chemotherapy. The notion “makes a lot of radiation oncologists very nervous, because they don’t get to radiate,” Joshi says, his lithe surgeon’s hands grasping a buttered bagel outside a Washington, D.C., market. “And whether they like it or not, medicine is big business in this country.”
There was never much question about Joshi joining that business, although he did consider becoming a writer in college. That’s great, his mother told him; you can give it a try after med school. “When you grow up in a real traditional Indian household in the ’80s and ’90s, there’s not much more that they want you to do,” he says.
He’s kind of what you want in a surgeon — a little bit of a fighter pilot.
Steve Hendrix, patient of Dr. Arjun Joshi
Joshi was born in India, but his parents, an engineer and a scientist, brought Arjun and his brother to the U.S. in elementary school. They started in Queens, New York, and then moved to Long Island. Joshi did end up at med school, at Syracuse, but it was not a forced march: He realized he had a natural aptitude for science, and the fan of old-school slasher movies wasn’t squeamish around blood and guts. He drifted toward the study of cancer — not for the disease, but for the patients. “Cancer does something to you,” he says. “It strips all of the fluff away. When you know you have cancer, you don’t give a crap about all of the money in the world that you’ve earned, all the jewels that you have and the accolades you’ve attained. The conversations get very real.”
As Joshi developed a surgical specialty in head and neck cancers — he now practices and is a faculty member at George Washington University School of Medicine and Health Sciences — those conversations often turned to the brutal side effects of cancer treatment. Radiation can destroy salivary glands, limit range of motion in the neck and wreak havoc with taste buds. Joshi also thought a different kind of tumor could use a new approach: The sexually transmitted infection HPV has surged as a cause of head and neck cancers, rather than the usual smoking and drinking.
So for select patients with HPV-related tumors, Joshi adopted a strategy of starting with three rounds of chemo and then operating — rather than risk the side effects involved with the more conventional radiation-chemo combo. He’s careful to point out that he is not ditching radiation altogether: If patients don’t respond to the first round of treatment, he will advise radiation therapy. The American Cancer Society estimates that more than 37,000 men will be diagnosed with oral cancer this year — making it the eighth most common form of the disease for men.
At this point, Joshi’s way of attacking this form of the disease only has a few dozen documented cases in the medical literature versus thousands for radiation. In a clinical trial published in 2017, Joshi and five co-authors studied 19 patients diagnosed with a type of throat cancer. They were treated first with chemotherapy, followed by robot-assisted surgery once the tumors had shrunk by 80 percent or more. Of the 14 patients available for follow-up analysis, one died, and three more whose cancer recurred were treated with radiation. The results, the authors declared, were “promising” but require further study. “It appears effective while avoiding adverse effects of” radiation therapy, they concluded.
Dr. Daniel Ma, a radiation oncologist who treats head and neck cancers at the Mayo Clinic, is less impressed. While he commended the “innovative trial,” he says seeing cancer recur in 21 percent of patients is not great — and when you add in the patients unavailable for follow-up, the misses rise to 42 percent. “Based upon this failure rate, it is difficult for us to be enthusiastic about this approach,” Ma says.
Joshi points to a more recent follow-up study at George Washington in which 17 of 20 patients (85 percent) were successfully treated without radiation, while two died and one more survived after being treated with what’s known as “salvage” radiation. “The fact that we can follow this induction chemotherapy protocol and surgery with radiation therapy [when necessary for these aggressive tumors] with still excellent outcomes underscores the flexibility and safety of such a treatment plan,” Joshi says.
In some ways, it’s a turf war. Radiation oncologists want to defend their profession, but as a surgeon, it’s reasonable to believe you hold the solution in your hands.
Steve Hendrix did his homework after Joshi diagnosed him with Stage 4 squamous cell carcinoma in 2015. He grilled Joshi as well as doctors who recommended radiation at Johns Hopkins University in Baltimore, in a manner that came naturally to the Washington Post reporter. “I got to a point where there was almost a level of trash talk that I had them engaged in,” Hendrix recalls.
Joshi’s confidence won Hendrix over, and today he is cancer-free after a successful surgery and chemotherapy. Post-treatment, there have been only two major life changes: Hendrix now prefers bourbon to scotch, and his killer Kermit the Frog impression is no more. “He’s kind of what you want in a surgeon — a little bit of a fighter pilot,” Hendrix says of Joshi. “He had absolute faith in his ability to do what he promised to do.”
Joshi relishes challenging brand-name hospitals like Hopkins and Mayo, and he says his view will gain support with more trials. “This will absolutely change the way we treat head and neck cancer — without question,” he says, with a practiced calm that belies the life-and-death stakes.