A Swing of the Pendulum?

Despite these risks inherent in treatment selection, there are no criteria to predict favorable outcomes, oncologically or functionally. Yet with little knowledge of the underlying biology of the HNSCC and virtually no understanding about which patients respond to this cRT approach, we forge on with this nonsurgical paradigm.

Striking a Balance

Are we starting to see a swing of the pendulum? Are we beginning to move away from a reflexive radical nonsurgical approach, perhaps not back to surgery only as the predominant treatment modality, but to a healthy and mature happy medium?

Many have questioned whether the goal for therapy should be striking a balance between the expectation of oncological control and function preservation, rather than simply preserving the organ. In all three disciplines-medical oncology, radiation oncology, and head and neck surgery-risk-based stratification is an important emerging concept in treatment selection.

With intensity-modulated radiation therapy (IMRT), the toxicity of external-beam therapy may be limited to the target tissues, sparing salivary function and collateral damage. But is in-field morbidity higher? How much does IMRT reduce xerostomia? In medical oncology, with the publication of the Bonner trial, cetuximab has emerged an alternative to platin-based chemotherapy. But is this approach on par with concurrent platin-based therapy?

At the same time, conservation surgery of the head and neck has enjoyed a quiet renaissance. Transoral laser microsurgery and supracricoid partial laryngectomies (SCPLs) have been established as viable approaches to treat laryngeal carcinoma. Both European and American schools have developed in the practice of transoral laser microsurgery. Radical or mutilating ablative procedures are no longer the only surgical options. Function-preserving surgery is now a real option for our patients. But are there enough surgeons properly trained to do it? The fiberoptic carbon dioxide laser4 and transoral robotic surgery (TORS)5 are important new tools in the hands of a new generation of head and neck surgeons. However, despite numerous single-institution studies, no Phase III RCT multi-institutional studies have been published examining the efficacy of these new open and endoscopic approaches. Surgical technique and expertise vary from center to center. Can surgeons even perform a randomized trial? The ACOSOG trial in SLN mapping (Z0360) suggests that prospective clinical trials can be done in otolaryngology-head and neck surgery.

How to Reach the Center

Regardless of the discipline, new techniques and technologies are available for patients with head and neck cancer. And so the pendulum is swinging back.

But to where? Hopefully to a balanced center, where treatment decisions are made using evidence-based data and scientific inquiry, focusing foremost on oncologic efficacy but also considering functional outcome.