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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at Nebraska Medicine. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE
Spring | Summer 2009

Saving Face

John Allbery thought the swollen glands in his throat meant he was coming down with a cold. His family physician suspected an infection and prescribed antibiotics.

Several weeks later with no sign of improvement, Allbery underwent a biopsy at The Nebraska Medical Center.

He and his wife, Leslie, met with William Lydiatt, MD, to learn the results.

William Lydiatt, MD

Lydiatt, a head and neck surgical oncologist at The Nebraska Medical Center, shared a diagnosis that was grim and frightening: squamous cell carcinoma of the throat.

Squamous cell carcinoma forms in the skin and mucus membranes and represents more than 90 percent of all head and neck cancers. According to the American Cancer Society, an estimated 50,000 new cases of head and neck cancers are diagnosed in the United States every year. The incidence of tonsil cancer, for example, is rising by about 3 percent per year, largely due to an association with human papillomavirus (HPV), as well as the known association with alcohol and tobacco.

Allbery didn’t want to believe the diagnosis. “So I went up to the Mayo Clinic to get a second opinion,” he says.

The doctors in Rochester, Minn., agreed with the initial diagnosis and recommendation for treatment.

“They could treat it, but they suggested I go home,” Allbery recalls. “They said that way I could be close to my family, and that we had two of the best doctors in the whole country right here in Omaha.”

They were referring to Dr. Lydiatt and radiation oncologist Weining “Ken” Zhen, MD.

Allbery knew no matter where he sought treatment, he had the fight of his life ahead of him. The American Cancer Society reports that for patients with early stage oropharyngeal (mid-throat) cancer, the survival rate at five years is 57 percent, but it drops to 30 percent for advanced stages. Allbery’s carcinoma was stage 4 – the most advanced stage.

“At the time, my daughters were 10 and 7,” he says. “Dying was not an option.”

Treating squamous cell carcinoma is one facet of the extraordinary work done by the team of head and neck surgeons at The Nebraska Medical Center. They also conduct research and take part in clinical studies that affect the care and treatment of head and neck cancer patients here and worldwide.

Dr. Lydiatt, who also serves as professor and division chief in the Department of Otolaryngology-Head and Neck Surgery at the University of Nebraska Medical Center (UNMC), says the head and neck surgical team is proud of its clinical care and its success in growing a very large practice here.

“Our department is one of the busiest in the country for head and neck cancer, and we are in the process of obtaining a fellowship for head and neck surgeons,” he says. “If accepted, we could potentially begin our fellowship in July of 2010.”

Treatment of cancers of the head and neck commonly involve a combination of surgery, radiation and chemotherapy. The impact of the cancers, as well as the drastic nature of the treatments, can result in disfigurement, pain, a drastic loss of weight when eating becomes impossible for weeks or months and significant depression.

“Our department is one of the busiest in the country for head and neck cancer, and we are in the process of obtaining a fellowship for head and neck surgeons.”
William Lydiatt, MD

Dr. Lydiatt is co-investigator with UNMC professor of psychiatry Bill Burke, MD, in a research project funded by a $1.6 million grant from the National Institute of Mental Health to study the prevention of depression in head and neck cancer patients.

“We have found that the incidence of major depression in head and neck cancer patients is up to 50 percent in the first few months post diagnosis, compared with about 15 percent for patients with other forms of cancer,” he says. “There’s also a higher risk of suicide that is much higher for head and neck cancer patients than any other cancer.”

In one study, patients with tongue and larynx cancer, for example, compose only 2 percent of all cancer cases but account for about 20 percent of suicides committed by cancer patients.

“Head and neck cancers profoundly affect the patients and the lives of those around them,” Dr. Lydiatt says. “For the patients, it may change their facial appearance as well as the ability to speak and eat. For their families, those painful and lasting transformations can be incredibly difficult to stand by and witness.”

Dr. Burke says depression is the number one predictor of whether cancer patients will complete their treatment. “The goal of our study is to see if we can prevent the occurrence of depression in head and neck cancer patients and help ensure they complete their treatment,” he says.

In the study, the team will examine whether prescribing the antidepressant Escitalopram to head and neck cancer patients while they undergo treatment prevents depression.

Those who take part in the study, which is conducted jointly at UNMC and Methodist Hospital, are monitored regularly. If patients receiving the placebo become depressed, they are removed from the study and treated for their depression, Dr. Lydiatt says.

“We are the only center in the country, if not the world, conducting this study in head and neck cancer patients,” he says.

“Head and neck cancers profoundly affect the patients and the lives of those around them. For the patients, it may change their facial appearance as well as the ability to speak and eat.”
William Lydiatt, MD

The current anti-depression project comes on the heels of a pilot study at UNMC that began about 1999. In that study, 15 percent of the head and neck cancer patients who were given antidepressants experienced depression, compared to 50 percent of those given a placebo.

John Allbery was one of the patients in the initial pilot study.

“I’m a very positive person by nature,” he says. “When Dr. Lydiatt explained his thesis, I thought I’d do my part.”

Allbery underwent 35 radiation treatments under the care of Dr. Zhen, followed by nine weeks of chemotherapy. When eating became impossible, Allbery was fed through a tube.

“I didn’t eat real food for seven months,” he recalls. “I lost 80 pounds, all the way down to 140.”

The treatments pushed this “very positive person” to his very limits.

“I knew in this depression study that a bunch of people got placebos and the others got the real stuff,” says Allbery.

“My wife and I both thought I got placebos, because I got very depressed – to the point of almost giving up.”

Four years later, Allbery, who learned that he had received the real antidepressant all along, says, “I thought to myself, ‘Thank God. If it was that bad even though I was on the drug, I can’t imagine what it would have been like without it.’”

Dr. Lydiatt calls the results of that pilot study “incredibly hopeful and powerful. Through our current efforts, we are confident we can make a difference in the lives of our patients.”

Dan Lydiatt, MD (Dr. Dan) with
William Lydiatt, MD (Dr. Bill)

Making a difference is a goal for all members of the surgical team led by Dr. Lydiatt, whose brother, Daniel Lydiatt, MD, also specializes in head and neck surgery at The Nebraska Medical Center and UNMC.

“They call me ‘Dr. Bill’ and him ‘Dr. Dan,’” he says.

A native of Chappell, Neb., William Lydiatt had never been to Omaha before his medical school interview. After earning his bachelor’s degree from Stanford University, he received his medical degree from the University of Nebraska School of Medicine. He completed both his general surgery internship and residency in otolaryngology – the medical specialty that focuses on disorders in the ear, nose, and throat – at UNMC, and his fellowship in head and neck surgery at Memorial Sloan-Kettering Cancer Center in New York City.

He returned to Nebraska to join his brother, Dan, in the practice of head and neck oncologic surgery and to conduct ground-breaking, multidisciplinary research.

“Two of the things I like best about Omaha and the medical center are the willingness of people to collaborate and the limited barriers to collaboration that exist here,” he says. “Whether it’s with Dr. (Virginia) Aita in the College of Public Health, or with the Department of Psychiatry in depression research, it’s very easy to work across disciplines here.

“In New York, I didn’t find the same collegiality, the willingness to collaborate – or the willingness to take risks.”

Dr. Dan Lydiatt earned his medical degree from UNMC and his doctor of dental science degree from the University of Nebraska College of Dentistry. In addition to his work at UNMC, he serves as medical director of the Methodist Cancer Center.

The other head and neck surgeons are Alan T. Richards, MD; Oleg Militsakh, MD; and Russell B. Smith, MD.

Dr. Richards is a graduate of the University of the Witwatersrand Medical School in Johannesburg, South Africa. He served his internship at the University of the Witwatersrand Medical School Johannesburg and Baragwanath Hospitals, and his residency at the University of the Witwatersrand & Johannesburg Group of Teaching Hospitals.

Dr. Militsakh graduated with high distinction from the University of Kentucky College of Medicine in Lexington. He completed his general surgery internship at the University of Missouri-Kansas City, his otolaryngology residency at the University of Kansas Medical Center, and his fellowship in oncologic head and neck and microvascular reconstruction surgery at the Medical University of South Carolina in Charleston.

Following the radiation and chemotherapy, Allbery underwent a neck dissection where Dr. William Lydiatt surgically removed any remaining traces of the cancer in January 2003.

Six years later, he is still cancer-free.

Dr. Smith received his medical degree summa cum laude from the University of Missouri-Columbia. He completed his general surgery internship and his otolaryngology residency at the University of Missouri Hospitals and Clinics in Columbia, and his fellowship in head and neck surgical oncology/head and neck reconstruction at the University of Iowa Hospitals and Clinics in Iowa City.

“Each of these surgeons is totally top notch,” Dr. Lydiatt says. “Four are fellowship-trained and the fifth has been a head and neck surgeon for 30 years. Those are good indications of the breadth and depth of our team.”

Dr. William Lydiatt speaks from the unique perspective of being a member of the team – and a former patient. En route to an annual family reunion in the Black Hills of South Dakota in 2002, he felt a lump in the thyroid gland in his throat. Upon returning to Omaha, his brother performed two biopsies and, along with Dr. Richards, a lobectomy to remove half the thyroid. The surgery was successful and he remains cancer-free.

John with his family, wife Leslie and daughters
Alexandra and Whitney.

Other than adding an element of irony, Dr. William Lydiatt says his own bout with cancer is barely worth noting. “What I had is nothing compared to what many of my patients go through,” he says.

Still, it fueled a tremendous empathy for some of the feelings – especially the fears – his patients experience.

“The thing I remember the most is my tremendous desire to survive,” says Dr. William Lydiatt. “I would have guessed I’d have more of a clinical response, weighing the odds and so forth. Instead, I was surprised by my own depth of wanting to survive.”

His three young children dominated his thoughts. “The worst fear I believe for most parents is the possibility of leaving your kids,” he says.

John Allbery experienced that same fear. And he wasn’t about to allow it to become reality.

The radiation he endured affected his saliva glands, making it hard to swallow. “But it’s nothing like it used to be,” says Allbery. “Nothing.”

The scar on his neck is barely noticeable. And though he must eat more slowly than he used to, he has been able to gain back the weight he lost.

“I work out in the gym three times a week,” he says. “I’m more healthy now than I was before the cancer. It actually changed my life for the better.

“Back then, I wasn’t saying that. It was nine months of hell.”

Allbery, 50, is managing director of corporate and institutional services at First National Bank. Active in the fight against cancer, he is a member of the UNMC Eppley Cancer Center board of directors and volunteers to talk with other head and neck cancer patients.

“I work out in the gym three times a week. I’m more healthy now than I was before the cancer.”
John Allbery

At the five-year cancer-free mark, Allbery’s wife threw him a surprise party. Among the 200 attendees were two “special guests” – Drs. William Lydiatt and Zhen. “I consider them to be two of the finest doctors in the world,” he says.

 Dr. William Lydiatt believes the same can be said about any of the head and neck surgeons on the team.

“We have an exceptionally competent and compassionate group,” he says. “It’s not only the five physicians, but it’s also our physician’s assistants, our nurses and our office personnel. They deal with difficult problems on a daily basis, and they are all very dedicated to our patients.”

Patients like John Allbery, who only thought he was coming down with a cold.

A Portrait of Hope

Glenna Oltman, charcoal on
paper, by Mark Gilbert

Glenna Oltman can understand why people stare. Cancer and more than a dozen surgeries have claimed her jaw and part of her tongue. She has no teeth – and no hope of dentures. She doesn’t look or sound like other people.

And the stares from strangers don’t help.

“If only they’d ask me what happened, I’d tell them,” she says. “I had cancer.”

About 14 years ago, the Louisville, Neb., woman was diagnosed with leukoplakia, a condition where thickened, white patches form inside the mouth, sometimes on the tongue. The cause is unknown, and although it usually isn’t dangerous, it can be an early sign of cancer, and many cancers of the mouth occur next to areas of leukoplakia.

Oltman underwent laser surgery to remove the patches from beneath her tongue, but they kept recurring.

At the same time, her husband, Norbert “Sonny” Oltman, was being treated for liver disease that ultimately resulted in a liver transplant at the Lied Transplant Center in Omaha. And although he lived for several months after the transplant, he never fully recovered and died in June 2002.

Less than a week after her husband’s death, Oltman discovered a knot on her jaw. Doctors determined that her jaw was broken and surgically implanted a plate to reconnect it. When they did, they conducted a biopsy.

That’s when they found cancer in her jawbone.

“I hadn’t even had time to grieve for my husband, and here they wanted me to go in for surgery,” she recalls.

She was recommended to William Lydiatt, MD, a head and neck surgical oncologist at The Nebraska Medical Center and the University of Nebraska Medical Center (UNMC).

“Dr. Bill was so honest with me,” Oltman recalls. “I shed a lot of tears, but whenever I spoke with him, I felt much, much better. He told me exactly what they were going to do, and what I might be able to expect.”

Oltman has since undergone so many surgeries that she has to list them in a book to keep track. They’ve removed her jaw bones and replaced them with bones from her legs. They’ve removed pieces of her tongue and patches of skin from her mouth. They’ve stretched muscles from her back and chest to help strengthen and shape her face. She’s endured radiation and chemotherapy, and still the cancer has come back several times – including a bout with breast cancer in 2006.

She’s also had to deal with the debilitating depression that befalls so many head and neck cancer patients – sometimes with the help of her four brothers and sometimes alone.

Last year, she took part in the “Portraits of Care” project, a collaborative research effort involving Scottish artist Mark Gilbert and Drs. Lydiatt and Virginia Aita of the College of Public Health.

Over two years as an artist-in-residence at UNMC, Gilbert engaged in an expansive and subtly radical project uniting art and medicine by painting the portraits of patients and caregivers. The patients, who included children and adults, were dealing with a variety of health and illness situations, from childbirth to medical conditions such as AIDS, head and neck cancer and organ transplantation.

Drs. Aita and Lydiatt are using the project to conduct research into the patients’ health and illness experiences; the caregivers and the personal, non-instrumental aspects of care; and the relationships between those who give and receive care.

Oltman says the portrait sessions helped lessen her depression and bring her back into the world she had tried to escape. “I found myself starting to put on makeup because I was having my portrait done,” she says. “I started looking forward to going to the medical center for something other than treatments or bad news.”

The portraits were exhibited at the Bemis Center for Contemporary Arts. There, Oltman met other patients and their relatives whom she says “had gone through a lot more than I had. That’s when I started thinking, I don’t have it so bad after all.”

The experience has built her confidence to where she goes out with friends, although she still does not eat in public. “My tongue doesn’t work right, and I have no feeling because I have no jaw,” she says. “It’s just numb, so food spills out. I can handle that at home but not in public.”

She also has traveled to visit her brothers in Wyoming and Montana – even boarding a plane last summer despite her admitted hatred of flying. And she was able to share her newfound courage during the return flight – when tornadoes passing through Omaha buffeted the airplane with turbulence.

“When we got close to Lincoln, that plane just shook and shook, moving in every direction,” she recalls. “People were crying and screaming, but I just sat there as calm as could be.

“That’s when the man across the aisle said to me, ‘Aren’t you scared?’ I told him about my cancers and surgeries and said, ‘Now, I know God didn’t bring me through all that and put me up in this plane just to crash it.’

“He looked over at me and said, ‘Thanks. I feel better already.’”

Oltman’s spirit is truly inspiring and touches almost everyone she meets, including Dr. Lydiatt who keeps Oltman’s portrait in his office on the wall beside his desk.

“Glenna has had so many resections and recurrences, yet she keeps this positive attitude that strengthens her and those around her,” he says. “She’s an extraordinary woman.”

That kind of talk makes Oltman laugh.

“He’s a sweet man,” she says, “But there’s things worse than this.”

And although she isn’t fond of how she looks, it doesn’t seem to bother her as much as it does those who don’t know her story.

“You know what?” says Oltman. “Who cares. I’m going to be 70 years old. Why should I care what I look like?

“I’m pretty happy the way I am. After all, I’m still alive.”  

Gorilla Studies

Head and neck surgical oncologist William Lydiatt, MD, never seems to get his mind off his work. Even when he’s reading the newspaper – or visiting the zoo with his children.

That’s how he came up with the concept of conducting thyroid studies of gorillas.

Dr. Lydiatt, a head and neck surgical oncologist at The Nebraska Medical Center and professor and division chief at the University of Nebraska Medical Center, had read how officials at Omaha’s Henry Doorly Zoo and researchers from Creighton University Medical Center’s cardiac unit were collaborating to study heart problems in gorillas. The idea is that the research could eventually benefit gorillas and humans.

Dr. Lydiatt proposed that while the zoo’s gorillas are under anesthesia to perform cardiac echoes to study why they die of heart disease in captivity, they could also be examined for evidence of thyroid cancer.

This information may one day help understand thyroid cancer in humans, where the rate is rising about 7 percent annually.

“There are a number of theories as to why the rate is climbing, including better diagnostic methods and better ultrasounds, but that doesn’t explain it completely,” he says. “I began wondering what the rate is in gorillas. I researched the topic and found nothing about gorilla thyroids.”

So he contacted the zoo and raised interest there. “They were very receptive to the idea of conducting both studies at one time,” he says.
In examinations to date, ultrasound has detected a small nodule in one of the zoo’s gorillas that is being monitored for signs of growth. “The thinking is that if thyroid abnormalities are being found in gorillas, while inconclusive, it does indicate that it’s not just us,” he says.

His work with the zoo veterinarians and staff proved helpful in an emergency situation last October. When a 3-year-old gorilla suffered head injuries and zoo officials wanted to obtain a CAT scan, they called Dr. Lydiatt.

As soon as he was contacted by the zoo, Dr. Lydiatt phoned the head of the radiology department at The Nebraska Medical Center to arrange the CAT scan. The gorilla also was examined by a neurosurgeon, William Thorrell, MD.

“The veterinarians, zoo keepers, emergency room staff and radiology staff handled her very well,” he says. “They were very professional and got her in extremely quickly.”

The gorilla, however, died of her injuries.

“Based on what the CAT scan showed, the neurological assessment, the fact that her heart was extremely irregular and that she had no blood pressure, it was clear that the injuries would prove fatal,” Dr. Lydiatt says.

It was the first time the zoo had sent an animal to a hospital in an emergency. Considering Dr. Lydiatt’s continuing research into gorilla thyroids, and the relationship he is building with zoo staff and researchers, it may not be the last.

Next article in the Spring | Summer 2009 issue of One Thousand And One:
No Small Innovation