Head and Neck Cancer

Eric Levi

Welcome to the month of Manuary! A Head and Neck Cancer Awareness Month.

What is a Head & Neck Cancer? Head & Neck Cancer is a diverse group of cancers that can arise from anywhere above the collar bones and outside the brain. They can occur from the skin, glands, soft tissue or the aerodigestive tract of the head & neck. What kind of cancers are included in this group? Many types including, throat cancer, tongue cancer, thyroid cancer, voice box cancer, tonsil cancer, melanoma, parotid cancer, etc. Overall, the morbidity and mortality rates have improved only very slightly.

Based on Canadian data, in males thyroid cancer is the 7th and oral cancer is the 9th most common cancer; whereas in females, thyroid cancer is the fifth most common type of cancer. My days are spent treating these unfortunate patients. Depending on the type, location and stage of tumour, treatment may involve surgery, radiation, chemotherapy or a combination of them. As a Head & Neck Surgeon I often have to perform radical and disfiguring surgeries to remove the cancer. We split the jaw, the cheekbone, or the skull base to get to whatever tumour that needs to be removed. We peel the face, drill the skull, chisel the nose, laser the throat, slice the neck, and gouge the eyes. It’s a cut-throat matter, literally. We take parts of the leg, the thigh or the arm to reconstruct the jaw, the tongue or the voice box. We leave some patients breathing permanently through a hole in the neck. We do 12-18 hour long resection and reconstruction cases with knife, drill, saw, chisel, laser, microscope, and even the robot. You would not believe some of the horrific things that patients have to go through to get their cancer resected. This is sometimes done in combination with, or in addition to, 6 weeks of chemoradiation. It’s a really rough time for our patients who would never be the same after what we do to them.

So why don’t Head and Neck Cancers get more attention? Unfortunately, the typical patient is usually, but not always, the elderly cachectic male who has been a smoker and drinker all his life. They often sound hoarse, cough a lot, and have poor socioeconomic support. Their cancer is a horrible sight to behold. Can you imagine a face with a fungating tumour or a tongue that is swollen with cancer? These are not emotionally inviting images. In my experience, most people’s initial reaction to a Head and Neck Cancer patient is not pity or compassion, but repulsion and disgust. They are so deformed that society looks away from them.

The one specific cancer subgroup that is experiencing an epidemic is Human Papilloma Virus (HPV) induced oropharyngeal carcinoma, a tonsil or tongue base cancer that is triggered by latent viral infection. This cancer strikes the young, non-smoker, non-drinker and is rapidly increasing in incidence. I still have in my mind the image of my first patient diagnosed with this tumour. She’s a 30-year-old gorgeous young chic graphic designer who came in with a sore throat and a lump in her neck. The next thing we knew, she went under the knife and we cut open her beautiful neck and throat. She subsequently had chemotherapy and radiotherapy. She could not stop her tears from smearing her designer mascara and dripping onto her branded clothes. I cried with her when we discussed her treatments.

Think of a patient with tongue cancer and consider if the taste of her food include the taste of her cancer. Think of a patient with parotid cancer with a facial paralysis and consider how that changes all of his facial expression. Think of a patient with nasal cancer that has eaten into the eyeball and consider how difficult it would be to see through a painful cancer-ridden eye. Think of a patient with laryngeal cancer and consider how difficult it would be for them to speak or even take a breath. Can you imagine breathing permanently through a hole in the neck? Can you imagine having a piece of your leg sitting in the mouth to replace your jaw and tongue? Can you imagine having a permanent voice and swallowing difficulty due to the treatment? Can you imagine having a thyroid cancer so big we have to split open your chest? Can you imagine having your eye and ear removed and having half your face covered by a thick piece of muscle?

I want them to do better. I want us to find better ways of treating thyroid cancer and laryngeal cancer. I want us to find better ways of cutting out cancers so they don’t suffer terrible side effects. I want us to find ways of diagnosing these cancers earlier so their survival improves. I want us to improve the care we give to these patients.

Don’t look away from them. I look at them everyday and I know that they desperately need our attention.

I want your support. Financially. Not for me, but for them because that’s the most practical gift that they need.

New Year’s Revolution: Less is Less

Eric Levi FP

Welcome to 2016! How’s your New Year’s Resolution going? It’s good to know that there is some science behind New Year’s Resolution. Apparently you are 10 times more likely to stick to a change made at the New Year (See here). So if you have any new year resolutions, good on you! I hope you’ll stick by them.

Most New Year’s Resolutions are about becoming better, healthier, more successful. We are always aiming to have a better, bigger year than last. Our society drives us to expect that this year is meant to be more successful than last.

I’m going the other way. I’m going for less.

Here are my 3 simple New Year’s Revolution.

  1. Do less.

How often have we cried “Too busy, too noisy, too much, too many things to do, too many commitments.” It’s the underlying exhausting dance of our society. We are burnt out. Our souls have not had enough time to catch up with our bodies running at breakneck speeds. Even holidays are no longer about resting, it’s about doing. Running from one place to another checking your phone in between. I’m guilty of doing too many things. I need to simplify my life. Before I commit to anything this year, I need to ask myself, “Do I really need to do this?”.

  1. Speak less.

We use words to puff ourselves up everyday. We use hyperbole and superlatives to describe things. We paint a hyperrealistic picture of ourselves and our lives. Words have been cheapened. Words have been used to hurt, harm and belittle others. The meaning, value and sanctity of words have been diluted in today’s age. Let your ‘yes’ be ‘yes’ and your ‘no’ be ‘no’. I’m guilty of the unnecessary use, misuse & abuse of words. I need to simplify my words. Before I speak, I need to ask myself, “Do I really need to say this?”

  1. Own less.

Our possessions are called possessions because they do just that. They possess us. How many times have we heard that money and stuff doesn’t buy you happiness, and yet we disregard that and fill our lives with goods to impress people we don’t even know or like? Look at how many pairs of socks I have! There are so many bestsellers out there now about how to declutter, tidy up and simplify your life. People are realising more and more that decluttering our lives from goods has a powerful effect on our souls. I’m guilty of cluttering my life with wants and not needs. I need to simplify my life. Before I have, own or buy anything, I need to ask myself, “Do I really need to have this?”

With doing less, speaking less, and owning less, wouldn’t I be… less?

Well that’s the crunch. Do I really have to be bigger, better, more successful this year compared to last? Why? What measuring stick am I using for that? At the core of my new year revolution is the simple question: Am I humble enough to be less? Am I humble enough to be a nobody? Am I humble enough to surrender to this process this year of doing less, speaking less and owning less? Am I humble enough to surrender to whatever comes my way and tackle them with less deeds, less words and less things? I need to simplify my life.

The ABCDE of Internship


Does my hip look big with these?

Congratulations to all the new interns starting tomorrow in Australia. You’ve done all the hard work. Got through high school with flying colours, survived undergrad, selected into med school, made it through the med school exams, interviewed for jobs and tomorrow, your patients and the nurses will call you ‘Doctor’. Well done! It’s been hard work till this point. Now the actual hard work begins. Here are a few things to keep in mind during your internship:

A. Ask for help

You’re an intern! On your first day, first week, first month, first rotation, first year. You are not expected to know everything and pretty much everyone in the hospital will have more experience than you. I asked for help from anyone around me including nurses, pharmacists, ward clerks, allied health and even the janitor. Be humble and accept that you will need help. And it’s not you they’re helping. It’s your patient.

B. Be kind to everyone.

Hospitals are high-pressure systems. The doctor you’re handing over to, the registrar you are referring the patient to, the nurses you round with, the admin people who organizes your rotations, are all under pressure. Understand that sometimes things don’t happen as planned or as expected. In all circumstances, be kind. You are a doctor, you are big enough to do the smallest things: clean up the mess, pick up the trays, carry the patients belongings, etc.

C. Consider the patient first and always.

Remember, they’re not rolling out the red carpet for you tomorrow. The whole thing about being part of a healthcare team is that the patient is at the centre. The hospital universe revolves around the patient, not around you.

D. Debrief often.

You will need this. Really. There will be tough days. I’ve cried alone and I’ve cried with patients (yes, we male surgeons are also in touch with our emotions). There will be days when you think you’re not cut out for this. Debrief. Speak to someone. Have coffee. Eat meals together with your team, fellow interns, friends. Talk about what you’re going through. You can’t do medicine alone. It’s a team sport. I used to debrief often with my wine, sorry, no, my wife, who’s a physician. We understand our common experiences. You will find people who share your experiences.

E. Enjoy

Don’t ever forget the wonder of medicine and the privilege of becoming a doctor. You are practicing a modernized ancient art for the benefit of others. No matter how tough your day is, remember that you are doing some crazy stuff that very few people ever get to do. I used to love doing the little things like IV lines, IDC, suturing, writing brief discharge summaries, etc. There will be lots of paperwork you’ll have to deal with as an intern. Might as well start enjoying them now. You’ll get so good at it because, you know, paperwork makes the system work.

Then there are other practical miscellaneous stuff like:

Always introduce your self, “#Hellomynameis _________, I’m an Intern.”

Don’t wear anything you can’t do CPR in.

Don’t wear anything you don’t want to get blood, urine, or vomit on.

Listen to the nurses and pharmacists.

Your tie bar should never be wider than your tie.

You must wear colourful socks.

Have a muesli bar and rehydrating drink ready at all times (energy drinks cause palpitations and tremor).

Have a change of clothes in the locker.

Have a sleeping bag and small pillow in the car boot.

Listen to the nurses and pharmacists.

Carry a folder of paperwork (blood requests, imaging requests, scripts, etc.). This will save you time!

Have a quicklist of your favourite drugs and emergency drugs (You will need this!).

Write frequently used contact numbers at the back of your name tag.

Form a WhatsApp group with your team.

Listen to the nurses and pharmacists.

Make sure you know the names of your consultants, nurses and other members of the allied health team.

Listen to the nurses and pharmacists.

And etc!

The Dangers of Not Being on Social Media

A few weeks ago, this cartoon strip appeared by @TheBadDr Ian Williams

There’s a certain helplessness in the physician. “There’s nothing much we can do about that.”

Well, actually, there are a few things we CAN do about that. Doctors can actually manage their social media presence effectively through some simple means. Social media is prevalent, inevitable, and is a significant part of mainstream media. Social media is one of the most powerful tools we have in communication and public health engagement.

To illustrate the dangers of NOT being on Social Media, here’s what happened in the last 5 hours in Australia.

The Australian Doctor Tweeted this:

The Royal Australian & New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Victoria and Tasmania branch organized a regional conference which includes a debate which was provocatively titled. It was probably done for controversial effect but had a negative reception all around. Many were outraged at the debate topic. This was picked up by various Twitter personalities and News Agencies around the world. Over a span of 3-5 hours I watched the discussion on this topic explode. How dare a College debate the reproductive freedoms of their trainees! Of note, the organizers consisted of an all-female panel. The RANZCOG has some of the highest proportion of female trainees and specialists, and they have one of the most progressive flexible training programs. The President of the RANZCOG Federal body Prof Michael Permezel was quoted in The Australian as saying that this was in “bad taste”. He was held responsible for this debate topic.

I am not discussing the topic itself here, but I’d like to tease out some social media lessons I’ve learned.

The rapid dissemination of this controversial matter via Twitter and Facebook meant that there were thousands of views and thousands of opinions filling up the online discussion forums, swiftly. Emails were directed to the President of the College. But the RANZCOG was silent, because they had a semi-active non-engaging Facebook page but no Twitter handle.


And guess what happened next:

These two accounts (one for the College and one for the President) were set up while this fiasco was unfolding. Note their Twitter handles.



Here’s what I learned:

They lost their handle on social media (literally and figuratively).

Someone else managed the RANZCOG and the President’s reputation.

This is real. The unprecedented rapidity of social media and how it permeates traditional media has created a problem for the College and its President. To respond to this crisis, they now have to return to traditional media on Monday and perhaps, get their responses publicized on Tuesday. In the mean time, the battle for public education and understanding has been lost. This weekend’s discussion will be around the opinion that RANZCOG is a regressive College, unfortunately. The image of the RANZCOG has been tainted.

Hear me now: I do believe that there are good people on RANZCOG Council. They are specialists in women’s health. Women’s reproductive system is their biggest agenda. I cannot comprehend that they would have double standards when treating their trainees. However, in this instance, what may have started off as a tongue-in-cheek provocative debate topic has turned into a big PR disaster for the College.

Dear Doctors, your patients have moved. The public has moved. They have moved geographically to this place called the internet where social transaction there is an acceptable norm. For the sake of our patients and the future of medicine, we need to move in and speak their language. Your online presence is no longer optional. It is a basic necessity of being a specialist and a professional College in today’s world.

I’m sure this story will evolve in the coming days.



As of Sat January 2nd, 2016, 02.17am Atlantic Canada Time, RANZCOG has officially taken control of the Twitter handle @RANZCOG. I can only imagine what kind of swords and arrows battle that happened behind the scene between the parody account and the official account which resulted in the SAFE DELIVERY of the perfect twitter handle for RANZCOG (pun intended). Welcome and good luck RANZCOG on your Social Media Presence.