Advanced squamous cell cancer of the head and neck presents an enormous challenge to the oncologist. This devastating disease is associated with pain, disfigurement, loss of essential bodily functions, and a tremendous sense of loss of self-image and self-esteem. These events, occurring in patients who usually already suffer from significant comorbidity by virtue of their longstanding self-abuse from excess alcohol and tobacco usage, result in an enormously fragile human being in desperate need of kind and compassionate care from the health care provider.
How best to treat these patients without further adding to their problems and misery is a great source of anguish to the head and neck oncologist and for which there remains no clear-cut solution. There are essentially three options available for treating these patients:
- An aggressive attempt at cure, understanding clearly the reality that in spite of our best efforts, only a small percentage of these patients can be expected to survive long term—Radical surgery is usually the cornerstone of this approach with adjunct radiation or chemotherapy, or both, usually added. Although most believe that this approach offers the best chance at cure, there is a price to pay, including mutilation and further impairment in quality of life. The question that haunts the surgeon is whether one is doing more harm than good.
- Purely palliative care—This treatment may be limited to protection of the airway, nutritional support, and pain management. However, occasionally it may consist of radiation or palliative resection (debulking), or both, to improve function and decrease pain. This ultraconservative approach would be used in those cases in which it is believed that although heroic radical surgery is possible, the chances of cure are so slight that it is just not worth the effort or in the patient’s best interest to pursue this. Examples may include stomal recurrence after laryngectomy or recurrent nasopharyngeal cancer. Although theoretically this approach can be intellectualized in principle, in practice this philosophy is difficult to implement, as it consists essentially of “giving up” on the patient from the outset and thereby condemning him or her to certain death. This “playing God” is in general an anathema to most contemporary physicians, especially in the absence of any clear-cut indicators that would determine which patients should fall into this category.
- A compromise “organ-sparing” approach consisting of less aggressive therapy geared to preservation of the vital organs affected by the malignancy, minimizing the cosmetic and functional sequelae—This approach usually consists of using nonsurgical modalities (e.g., chemotherapy and radiation in various combinations) but may use innovative surgical techniques that are modifications or extensions of traditional conservation surgery (e.g., partial laryngectomy procedures). The basic premise of this approach is that the cure rates are equal to the more aggressive approach, but function, cosmesis, and a more meaningful quality of life (QOL) can be preserved.1–17 Unfortunately, it remains unclear that this is an accurate assumption. Survival rates may be compromised and the promise of improved QOL may not be realized. This approach remains a work in progress, and it may be many years before the answer to this question is available.
While we await clarification of this debate, the question of what to offer our patients remains. The oncologist clearly wishes to do the right thing, that is, to optimize the chances of cure without causing the patient unnecessary harm. Unfortunately, no body of scientific evidence clearly supports one approach over another, and the “experts” remain divided in their approach. Likewise, no prognostic indicators (biomarkers) are yet available that can accurately predict tumor behavior sufficiently to convincingly dictate one approach over another. The oncologist is therefore compelled to rely on experience and instinct in managing these patients, together with the patient’s physical and emotional state, as well the characteristics of the tumor—hardly the most scientific of approaches in making these life-altering decisions.
Evaluation of Therapy in Advanced Head and Neck Cancer
As we ponder which of the approaches to advocate for our patients, it is important to have clear in our mind what ultimately determines success. Survival has always been the gold standard by which a particular therapy has been judged. However, in these advanced cancers there is no clear-cut evidence that any one approach offers a better chance at survival. In fact, as stated by Weymuller in 1994,18 “using the therapeutic end points of survival and loco-regional control, it is true that no multi-institutional study that has utilized surgery as a form of treatment has demonstrated a significant separation between the control and distant arms.” Yet it remains the impression of most surgical oncologists that this is incorrect and that in most situations those who undergo radical surgery have a better chance at survival and better palliation but without real scientific data to support this.
If survival cannot be used as an endpoint, the morbidity associated with these approaches needs to be compared. Radical surgery is certainly associated with significant functional deficits, as is radical radiation with or without chemotherapy. Comparing the deficits after the different approaches would be useful, but this can be quite difficult given the myriad of surgical and reconstructive procedures available and the different organ preservation approaches used.
The increased sophistication of the reconstructive techniques employed following radical ablative surgery has certainly leveled the playing field in comparing the radical and organ preservation approaches resulting in improvement of not only cosmesis but function as well (e.g., pharynx, esophagus, mandible, and skin defects of the head and neck).19 Some structures (e.g., tongue and larynx) defy meaningful reconstruction, and it is cancer of these structures that creates the greatest therapeutic dilemma. Using function and form after radical ablation with reconstruction and organ preservation approaches may be impossible as often the organ saved may be dysfunctional.
In the final analysis, it appears that the ultimate goal sought after treating these patients with advanced cancer is a meaningful QOL for their remaining days. What exactly constitutes this quality and whether we best achieve it by radical surgery, organ preservation approaches, or merely palliating the symptoms remain elusive issues; however, real efforts are now being made to clarify this.
Quality of Life
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