Dr. David Cognetti, MD - Thomas Jefferson University

 

Dr. David Cognetti, MD

Professor & Chair, Department of Otolaryngology - Head and Neck Surgery,

Sidney Kimmel Medical College,

Thomas Jefferson University

Dr. Cognetti is an internationally recognized leader in head and neck cancer. He received  his medical degree from the University of Pittsburgh. He trained in Otolaryngology-Head and Neck Surgery at Thomas Jefferson University and did his fellowship in Advanced Head and Neck Oncologic Surgery  at the University of Pittsburgh Medical Center. Dr. Cognetti has numerous contributions in head and neck squamous cell carcinoma and salivary gland pathology. He has authored >120 publications and approximately 2,500 citations. He has served in multiple leadership positions within the American Head and Neck Society, and the American Academy of Otolaryngology-Head & Neck Surgery, among others.

 

Why did you choose to subspecialize in head and neck surgical oncology?

That's a great question. I just did a Head and Neck Cancer Awareness Week webinar yesterday with some patients with head and neck cancer. One of the questions that the moderator asked us - we had our multidisciplinary team present- was this exact question. So, it made me reflect on this. When I went into medical school, I didn't really know what I wanted to do, in terms of specialty. I was relatively naive. When I went through third year, I found myself liking much of everything. I liked variety, I liked new things, technology, etc. And I remember late in that year is when I was exposed to ENT/ Otolaryngology, and I thought it just had everything: exposure to young and old, men and women. But really what was great about it was the collaborative nature in addition to the innovation and everything that went into it. So that drew me to the field. But what really drew me to head neck oncologic surgery, if I had to be really honest, was watching Dr. Eugene Myers as a medical student, being exposed to him, doing clinic with him, and seeing his relationships with his patients. In the end, it was the head and neck cancer patients. Yes, of course, the surgery is fun, and the anatomy is amazing. We all know that. But at the end of the day, the enriching part of it is the relationships that we build with our patients, and the impact that we have on them, and quite frankly, the impact that they have on us.

 

That's a really, really interesting way to see it. Thank you for that. And is there anything that you don't like about the specialty in general or the sub-specialty?

Honestly, no, I don't have anything. Sure, it's difficult at times, both emotionally and physically. We see people through very difficult things. The complications can be hard on us, as surgeons and caregivers. But I wouldn't say there's anything I dislike. It's an incredibly rewarding field.

 

I'm glad to hear that. Now we want to move to some more clinical questions. Over the past 10-20 years. We've seen the studies on laryngeal preservation, the efficacy of chemo-radiation in HPV+ HNSCC and the more recent breakthroughs with targeted therapies, immune checkpoint inhibition etc. Where do you think this is going? Where do you see surgery in the in the future of cancer care? Will surgery retain its position, or are we transitioning to more debulking approaches followed by targeted therapies and systemic treatments? What is your take on that?

Oh, great question! And you're right. It's fun to look back at our history and see how much has changed in a short time. I consider myself a pretty young guy, but even in my relatively short career, there have been lots of new things introduced, like robotic surgery, immunotherapy, etc. All came after my training. There are now new things coming out yearly that are impacting how we approach things. And I think the speed at which the care of head and neck cancer evolves is only going to quicken. So that's exciting. That should excite people going into the field. Just before I joined the field, there was a lull in people going into head and neck surgery in part because of the VA trial that you referenced. Everybody was worried that surgery was going away. So why would you go into head neck surgery? And then there was a big rebound around my time and thereafter.

I would say I don't see surgery going away in my career, in your career, or in the career of current medical students. There will, however, be an evolution in the role of surgery, almost guaranteed! You could take the word surgery out and replace it with anything else radiation, chemotherapy, immunotherapy and whatever the next thing is. There will be an evolution in the role. I don't like the term “will surgery hold its position?”. I think we as a field, across disciplines, work together well and recognize that we all want the best outcome for the patient, both oncologically and functionally. If that's our goal and new advances mean we're doing less surgery, no problem! There will always be something for us to do.

 

I'll have to admit, it was a quite provocative question. I mentioned on purpose the first chemoradiotherapy studies in laryngeal cancer, because like you said, initially there was this enthusiasm about chemo-radiotherapy, and then the paradigm kind of changed again. The next question will also be somewhat provocative: You mentioned robotic surgery. And we saw the ORATOR-2 trial last year reporting surprisingly and probably unexpectedly more deaths than what we saw before in ECOG. What is your take there? What is the future of TORS?

In the ORATOR studies, I applaud the achievement of randomized data. Surgical RCTs are very difficult to do. I am grateful for the investigators, and grateful for the patients quite frankly. A challenge is it's a very small sample size, in terms of surgeon experience, adoption curve and other things that could impact outcomes. As a result, 1 or 2 deaths make a big difference there. The mortality data doesn't necessarily translate to the national and international experience. So, I don't think ORATOR-2 is going to end TORS. It hasn't. I do think there remains a role. In fact, as we look at some of the new treatments, TORS could play a role with neoadjuvant approaches where surgery is confirming pathologic responses that allow us to deescalate the adjuvant care or eliminate radiation therapy, which contributes most to long term toxicities. There is a balance here. There are currently patients who are getting surgery for oropharyngeal cancer that aren't benefiting. But I think, in general, TORS will still play a role for the foreseeable future.

 

It’s really great to hear this from you! Obviously, Jefferson is one of the few places with such a big volume of cases- it sounds like the department has a lot of experience with it. And in the past few years, or past few decades, Jefferson has trained some of the new generation leaders. So, I wanted to ask you about about that. What in your opinion makes Jefferson Oto unique? What are the main strengths today? And also, are there any areas that you feel that you can improve?

I appreciate your recognition/acknowledgement of the Department, and what we've done in the past decade to two. It's been tremendous for me to be here and participate in helping to drive that advancement. It's been with fantastic partners. So, I will just emphasize that you can name many people, but if you're looking Divisionally Joseph Curry -who I know you’ve previously interviewed -, Adam Luginbuhl and many others have been just outstanding partners for many years now! In terms of what are our strengths, I think there's a passion here amongst us, that's shared. We have a very strong collaborative spirit, in terms of pushing the field forward and offering the best care of our patients. We're committed to education. Starting our fellowship helped drive us forward because, as you said, working with the next generation of leaders and helping train them, helps us get better.

And finally, we have a passion for innovation. We're really excited about new things. When immunotherapy came on the scene, we started doing window of opportunity trials, and neoadjuvant trials because we want to learn. We want to help drive the evolution of the care that we talked about earlier. Maybe that's a point we can tag back to that previous question when you asked whether surgery will have a role in the future. It is better to ask whether surgeons will have a role in the future. I think surgeons will always have a role if we are participating in defining the future of the field, obviously with the patient's best interests in mind. That's what we try to do here.

 

I didn't mention that before, but it really made an impression on me that you noticed the wording, when I asked about surgery retaining its position, and you corrected me there. You were absolutely right. Surgery is one thing and surgeons are another. The fact that you actually rephrased that, I think it reflects on the collaborative spirit that you just described. Are there any areas that you feel that you're actively working on improving or that you envisioning improving in the next decade or so?

That's a broad question, I have to think about that. I mean, we're doing a lot of work here. As I mentioned, some of the clinical trials we've been working on are looking at the neoadjuvant setting. The other thing that we've been fortunate to participate heavily in is photo-immunotherapy, which I don't know if you're familiar with.  You are probably familiar with traditional photodynamic therapy. In that you infuse the patient with a light sensitizer. Then you target the tumor with light, and it's a nonspecific tumor kill. In photo-immunotherapy, the difference is that the light sensitizer is conjugated to a monoclonal antibody. It allows the light sensitizer to therefore attach directly to and concentrate at the tumor cells. This theoretically increases tumor kill and theoretically decreases systemic effects like light sensitivity, etc. We are really excited with what we've seen in some of these early clinical trials.

My point is that there are things coming down the pike that we haven't even thought of yet that potentially will be in the hands of surgeons, even if it's not traditional surgery. And going back to some of my message before that, we as surgeons and surgeon-scientists should be the ones to drive it.

 

I have to admit that I haven't even heard about photo-immunotherapy. It really sounds exciting and obviously very novel. And if you have a few more minutes, I wanted to ask you a couple of questions about residency as well. If you don't have the time, it's absolutely fine.

I have the time. This is this is some of the most important stuff we do. People did this for me, Jason, and I am happy to pay it forward to the next generation of applicants.

 

I really, really appreciate that. So what in your opinion, makes a competitive residency applicant? What are you looking for personally and what would make someone stand out in your eyes?

I might rephrase your question because as an applicant it's hard. We have a brief window with each applicant and it's a competitive specialty. So you do need good board scores and good grades. Strong letters of recommendation are very important. You want to show interest and engagement in the field. That's really where the research comes in: to show your interest, show your dedication to completing projects, etc. In terms of does that translate into a good resident or how do we pick them, that's a little bit more challenging. But I will tell you what I often say to the people who are interviewing with me who ask me what we are looking for in an applicant. I tell them we don't have a specific model that we're looking for. It's not a cookie cutter. We don't want them all to be the same. There is great benefit to having diversity of residents, and just diversity in general: different skills, different learning styles, different everything, that's good.  That strengthens our residency. The two things that I say are important for people to succeed in residency, and quite frankly, succeed in their careers and even succeed in life, are that you need to care and you need to be honest. You need to care about a job well done. You need to care about the patient. You need to care about your colleagues and partners. Support goes back to collaboration that we talked about before. And you need to be honest. And what I mean by that, especially as a resident, but even as far as you go in your career, you need to be able to admit when you don't know something, you need to be able to ask for help. You need to be able to admit when you're wrong. In your training it is important to build trust, but even in your careers, you need to build trust with your patients as well. So maybe humility is a better word.

 

I was about to ask if there are any red flags, but based on your response, I think one can infer the red flags from there. Probably dishonesty would be one of those I presume.

A huge red flag, yeah! You could be the most talented resident in the world, but if you're not trustworthy..

 

Absolutely. And I understand that you've had IMG colleagues before, but did you have any experience in the past with IMGs in residency? Would you consider one in your program?

We have had an IMG fellow. I don't think we've had an IMG resident in our program in the past. But I certainly would consider one, yes.

 

You have answered all my questions with some very, very interesting and inspirational answers. Thank you so much!

Thank you!