When asked why he chose to specialize in head and neck surgery, Stanford Cancer Institute member Chris Holsinger, MD, FACS, professor of otolaryngology - head and neck surgery, offered a simple yet profound answer.
“I was drawn to the complexity, intricacy, and beauty of the head and neck. So many structures work seamlessly together to deliver so much about what makes us human—how we breathe, speak, and express ourselves. How can you not want to devote your life to preserving this incredible system?”
With over two decades of experience, Holsinger reflects, “What is now known as head and neck cancer is a completely different disease than what we saw even 25 years ago.”
The new face of head and neck cancer
Thanks to successful public health campaigns that raised awareness and shifted the landscape of societal norms around smoking, tobacco-related cancers of the head and neck have dramatically declined. However, the American Cancer Society (ACS) reports a troubling new trend. Head and neck cancers are on the rise after years of decline due to the human papillomavirus (HPV).
“HPV explains the precipitous rise in the number of head and neck cancers independent of smoking or heavy drinking, as it has been associated in years past. HPV-driven oropharynx cancer is the new face of head and neck cancer. It's one of the few cancers that are actually still increasing in incidence,” reports Holsinger.
According to the ACS, deaths from HPV-associated cancers of the tongue, tonsil, and oropharynx are increasing by about 2% annually.
HPV vaccine and cancer prevention
In 2018, the FDA added oral and pharyngeal cancer prevention as an indication for the HPV vaccine, which was initially introduced for cervical cancer prevention in 2006. Vaccination is recommended for all adolescents before age 13, yet vaccination rates remain troublingly low, with only 61% up to date on their HPV vaccinations.
A lack of public awareness about the link between HPV and throat cancer is one of the most significant barriers to improving vaccine rates. Holsinger, along with former Stanford fellow Matt Lechner, MD, PhD, conducted a survey evaluating American adults' awareness of HPV and its connection to oropharyngeal (throat) cancer.
“We were shocked to find very little public awareness,” says Holsinger.
Only around 1/3 of respondents knew HPV is a major cancer risk factor, and less than 2/3 were aware of the preventive HPV vaccine. These findings are alarming because of the increasing financial burden caused by the rise in HPV-related throat cancers and the significant lack of public awareness. Public health campaigns, like the highly successful anti-smoking initiatives, are needed to address this educational gap.
HPV-related throat cancers typically emerge when people are in their 50s. Since the vaccine wasn’t approved until 2006, those in this age group missed their chance to be vaccinated as adolescents. As a result, the rate of these cancers is expected to keep rising until those who were vaccinated reach the age when the disease typically occurs. The incidence of HPV-related oropharyngeal cancer is expected to increase substantially in the US population, especially among non-Hispanic white men aged 55-69 years. Within the next few decades, it is projected to become the third most common cancer in this group.
“We have to come up with better ways for prevention, refine the way we treat, and then enhance surveillance after treatment for this unfortunately growing population,” says Holsinger. “The good news is that this is a highly curable cancer. That opens up a lot of different treatment avenues that we didn't have a couple of decades ago. Patients are facing a mortality risk that's two or three times lower than HPV-negative smoking-driven cancers.”
Transoral robotic surgery
One promising development amidst the HPV-related cancer epidemic is the emergence of new treatment options—most notably, transoral robotic surgery (TORS). The randomized ECOG3311 trial demonstrated that frontline TORS could maintain excellent oncologic outcomes while reducing treatment-related toxicity. Holsinger led the national effort to credential surgeons for this study and others, helping to establish a new standard of care.
In 2009, the Food and Drug Administration (FDA) approved the Da Vinci surgical robotics system for minimally invasive transoral robotic surgery (TORS) in head and neck cancers. Rather than making large, disfiguring incisions, surgeons can now perform procedures with remarkable precision, using robotic arms controlled by a 3D, high-definition camera. This allows for more accurate tumor removal while minimizing damage to the surrounding healthy tissue.
Looking back, Holsinger notes, “This has been game-changing. When I was a resident/fellow, no one believed that surgery could cure this disease.”
Holsinger was the lead author of the American Society of Clinical Oncology’s (ASCO) new guideline on transoral robotic surgery for patients with oropharyngeal squamous cell carcinoma. Years in the making, the guideline was published this February. Holsinger chaired a panel of experts, including medical oncologists, radiation oncologists, head and neck surgeons, speech-language pathologists, rehabilitative specialists, and dentists, to develop recommendations for patient selection, preoperative assessments, and postoperative adjuvant therapy. The guidelines highlight careful patient selection, stating TORS is most effective for patients with tumors that are easier to remove and have limited spread to lymph nodes. They also recommend a multidisciplinary approach to treatment planning and recommend that adjuvant therapy be customized based on the extent of the cancer and surgical outcomes.
"It was a lot of fun to work with such a remarkable group of experts. I believe the guidelines will help standardize treatment and improve patient outcomes," says Holsinger.
The road ahead
Holsinger envisions a future where the field adopts a dual-track approach that integrates patients' medical needs along with personal values. With the support of grateful patients, Holsinger launched the BEAT-HPV-OPC (Better Education and Treatment of Oropharynx Cancer) Program in 2022. The program collects patients' treatment preferences, and during multidisciplinary tumor board meetings, the team employs a shared decision-making model to help guide patients toward the best treatment options.
“This framework of patient engagement has been around for a long time. What's novel about the BEAT-HPV-OPC program is it maps patient preferences with real-world biological predictors of response,” explains Holsinger.
As Holsinger begins to approach the end of his surgical career, he finds himself reimagining his own path forward as well. Despite an already impressive array of degrees and accomplishments, Holsinger is back in school. Two quarters into Stanford’s Master of Liberal Arts program, he is honing his writing and critical thinking skills. Holsinger plans to share the very stories that have shaped him over the last 25 years.
“I’ve had the privilege, honor, and pleasure of working with hundreds of patients throughout my career. Their stories have inspired me, and I want to share some of them. I also want to reflect on how robotic surgery has transformed the landscape of surgical oncology and discuss the evolving roles of physicians in today’s highly corporatized healthcare system.”
By Sarah Pelta
April 2025
