Charleston City Market stalwart returning to activities after bout with oral cancer

When Susan Shelton arrived in Charleston from Chicago in 1983, she couldn’t understand why her mom was selling pressed flower art in the historic Charleston City Market. This was well before Charleston Place Hotel opened in 1986, unleashing the modern tourism industry in Charleston, and before an extensive market renovation in 2011. Shelton was not impressed by the market.

Fast forward 40 years, and where does Shelton spend her time? Sunday through Wednesday, she and her husband, Charlie, are at the market where she’s built her business, Susan’s Pressed Flowers, using flowers from her garden and the pressed flower technique that her mother taught her.

She chuckles at the twists that life takes.

At least, Shelton spent her time at the market until her cancer diagnosis. That’s another twist, and one that’s harder to laugh at. But Shelton chuckles, too, to think how much she didn’t know that she didn’t know when her cancer journey began. Talking it over, she and her mom agreed that if she had known, she might not have shown up for treatment. But she did, and she got through it.

“It’s been an experience,” she said. “But I’m here.”

Oral cancer

Shelton had been dealing with on-again, off-again yeast infections in her mouth for about two years when her ear, nose and throat specialist (ENT) decided to refer her to MUSC Hollings Cancer Center.

Within three days, she was in the office of W. Greer Albergotti, M.D., a head and neck cancer surgeon. He biopsied a lesion under her tongue and diagnosed stage 2 oral cancer, also called mouth cancer.

“Tobacco use, especially in combination with alcohol, is the largest risk factor for oral cavity cancer,” Albergotti explained. “But there's a significant portion of people – somewhere between a third and 50% – who have no risk factors. That's an area of active research interest, and we don't fully understand why those patients are getting cancer.”

In fact, people who don’t smoke might be inclined to ignore symptoms because they assume that only those who smoke are at risk.

Symptoms of oral cancer can include:

• White or red patches.
• Lumps in the mouth.
• Numbness in the mouth or tongue.
• Teeth that become loose.
• A sore that won’t heal.

“Sometimes people let it go, thinking it's just a sore that's not going away but, really, sores should go away within a couple of weeks,” Albergotti said.

Any sore that doesn’t heal within a few weeks should be looked at by a dentist or primary care doctor.

Clinical trial

Once Shelton was diagnosed, a team of doctors and therapists at Hollings swung into action. Shelton was diagnosed around Thanksgiving, and her surgery was scheduled for Jan. 5. There are typically a number of things that need to happen before surgery, Albergotti said, and this gives doctors a chance to enroll patients in a “window of opportunity trial.”

In this case, the window of opportunity of about a month was enough to test whether a cream medication would shrink the tumor, meaning Albergotti would have to remove less tissue during surgery.

Angela Yoon, D.D.S., a Hollings researcher and professor in the James B. Edwards College of Dental Medicine, is running a clinical trial to investigate whether topical imiquimod, a drug approved to treat skin cancer and skin precancer, is effective in shrinking early-stage oral cancer.

“I’m like a dermatologist for your mouth,” Yoon said, noting that most of the medications she prescribes have first been approved for external use. “Because we are such a small field, pharmaceutical companies don't make anything specifically for us."

 

Imiquimod is an immunomodulator. It works on the tumor from the outside, where it directly touches the sore, and also is absorbed into the mouth’s lining, where it trains immune cells to attack the cancer from the opposite side.

In Shelton’s case, her tumor shrank by about half before her surgery, Yoon said.

Because the drug works on the immune cells, the expectation is that those cells will continue to be vigilant if the cancer recurs. Yoon said that cells surrounding the tumor often look normal under the microscope, but because of an effect known as field cancerization, they are prone to turning cancerous later.

Her next project will be to create a personalized vaccine from the immune cells removed during surgery and return them to the patient as an injection.

“Those lymphocytes have already been exposed to that specific person's tumor, so they are tumor-specific. We’ll be giving the vaccine to them after surgery, when there is no tumor, but we're going to make sure there are enough memory T-cells there to prevent future recurrences,” she said. When oral cancer recurs, it almost always happens within the first two years, so an annual vaccine for the first two years after surgery should keep the patient cancer-free.

Surgery and radiation therapy

Shelton’s surgery was Jan. 5. Doctors removed 23 lymph nodes and part of her tongue, which had to be reconstructed.

“They took out a 4 by 8 section of my outer thigh, and doc rebuilt my tongue with that,” Shelton said. Albergotti explained that they used the 4 centimeters by 8 centimeters section as a skin graft following removal of the tumor.

Following surgery, she embarked on two months of radiation therapy. Shelton said she knew nothing of radiation therapy before she started.

“‘What's radiation?’ I said. Now I know,” Shelton explained. “I thought surgery was tough. Oh, boy. Radiation is by far a lot harder.”

Albergotti said the team recommended radiation therapy for two reasons. First, the cancer cells were invading nearby nerves; second, the tumor’s growth pattern indicated it could be trouble later on.

In the type of pattern that Shelton’s tumor had, Albergotti explained, “There's little nests of cells that are spreading out away from the tumor.”

“Some tumors grow in a uniform pathway, and what we see is pretty much what they are. But these send out little nests of cells beyond what we can see, and hers had that pattern, which is a more aggressive pattern.”

Although radiation was necessary, it wasn’t easy. Shelton endured many of the side effects, like radiation burns on her skin caused by the radiation traveling through her skin to reach the site of the cancer.

Her last treatment was March 30.

 

Recovery

Head and neck cancer, in particular, takes a multidisciplinary team. Shelton, for example, has worked with speech language pathologist Julie Blair to exercise her tongue to be able to make the movements necessary for speech.

“I do have problems with my s’s, my t’s and my sh’s – for a Susan Shelton, that kind of stinks,” she said.

She recently consulted with Byung Joo Lee, D.D.S., medical director of maxillofacial prosthodontics and oral oncology, and learned that she’ll have to have three teeth pulled, perhaps followed by reconstructive work.

But she is recovering her strength and venturing out.

She helps Charlie to set up her booth at the market in the morning and break it down each afternoon, but so far, she hasn’t returned to manning the booth. Maybe soon – she certainly isn’t going to take another job, not after working for herself for 40 years.

“I’m the most unemployable person,” she joked. “I could never work for anybody ever again. I really couldn't.”

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