Despite much belief to the contrary, tobacco control has been a major public health success over the last four decades. The number of adult American smokers has dropped from 42% in 1965 to 21% in 2004 and currently 58% of adults have never smoked. As a direct result of these changes, the incidence and mortality rates for head and neck cancer have steadily declined over at least the last 15 years. What impact will this trend have on the field of head and neck oncology? Will the field die out as a discarded cigarette does?
Moreover, most laryngeal and oropharyngeal cancers are curable today with chemoradiotherapy, and targeted therapy has the promise of further improving disease control. Does this improvement in treatment also mean a death knell for head and neck surgery? More and more otolaryngology residents seem to have lost interest in head and neck surgery as well, with more fellowship positions available than we can fill. Is there even going be a need to train head and neck surgeons in the foreseeable future?
The answer is unequivocally YES, but the question remains—how should they be trained?
The Academic Mission
The mission of academic head and neck surgery is clear: to deliver the highest possible quality clinical care for the head and neck cancer patient, to conduct and promote head and neck oncologic research, and to educate future leaders in the field. To this aim, we must provide outstanding surgical care and facilitate the ultimate in multidisciplinary management of our patients.
Furthermore, we must strive to develop and implement innovative approaches to the prevention, detection, treatment, and rehabilitation for malignancies of the head and neck region. Finally we must not lose sight of our obligation to nurture and shape future leaders who will improve the care of head and neck patients and minimize the impact of these diseases on society. This obligation continues for three principal reasons, which also require the traditional paradigm of head and neck surgery training to evolve into something beyond its present scope and breadth.
Ongoing Need for Skilled Head and Neck Surgeons
1) The need to provide quality training and to produce competent head and neck clinicians remains.
Tobacco and alcohol use will never be eliminated; in fact, the absolute number of smokers has remained relatively constant over the last 40 years at approximately 50 million. Additionally, about 45 million Americans are former smokers, and as with our colleagues in thoracic oncology and surgery, we may expect to see more cancers arising in former smokers than current smokers.
In addition to a continued and future need for clinicians to care for these tobacco-associated squamous carcinomas of the head and neck, we are seeing greater numbers of these cancers (particularly oropharyngeal cancers) in never-smokers, presumably caused by a rising population prevalence of oncogenic human papillomavirus.
These trends in the head and neck cancer population, along with the rising incidence of thyroid carcinoma, melanoma, and nonmelanoma skin cancers, will all necessitate a substantial head and neck surgical manpower with a more broad-based skill set.
Given the constant evolution of head and neck cancer care, the coming complexity of highly individualized care, and the pressures for efficient quality and safe care with proven outcomes (in other words cost-effective care), most malignancies of the head and neck will (and should) continue to gravitate toward academic medical centers.
‘More and more otolaryngology residents seem to have lost interest in head and neck surgery as well, with more fellowship positions available than we can fill.’
To reduce the public health burden of squamous carcinoma of the head and neck, we, as academic head and neck surgeons, support efforts at tobacco, alcohol, and human papillomavirus control, but it is principally the survival and mortality rates which we can directly influence. To that end, most in the field advocate that squamous carcinomas of the upper aerodigestive tract should wherever possible be initially treated at academic medical centers and comprehensive cancer centers. To support this goal, we must provide the future well-trained head and neck surgeons capable of providing such tertiary care.
Adapt with a Changing Field
2) The field is changing and the future head and neck surgeon must adapt to this new role.
The makeup of the head and neck practice is evolving from one principally dedicated to the treatment of tobacco and alcohol associated squamous carcinomas of the upper aerodigestive tract to one much more diverse in terms of histologies and etiologies, but also in terms of guiding patients through a complex multimodal treatment plan and rehabilitation.
While it is true that the prevalence of smoking has dramatically dropped and continues to do so, and that the incidence and mortality of oral cavity, hypopharyngeal, and laryngeal cancer has followed, the incidence of oropharyngeal cancer has not changed and the incidence of oropharyngeal (and oral tongue) cancer is actually rising among young adults.
Among women, thyroid cancer (chiefly papillary thyroid carcinoma) is the most rapidly increasing in incidence of all malignancies. In fact, this year it is estimated that 30,000 new cases of thyroid cancer will be diagnosed, numbers equal to the number of new oral cavity and laryngeal cancers combined. Among men, melanoma is the most rapidly increasing in incidence of all malignancies, and this year approximately 15,000 to 20,000 new melanomas of the head and neck region will be diagnosed, a number almost equivalent to the number of new cases of oral cavity cancer.
Multidisciplinary care has become the standard of care for most squamous cancers of the head and neck and the place of surgery in that care continues to evolve. While chemoradiotherapy has become the standard central treatment for most pharyngeal and laryngeal cancers, surgery remains the central treatment of oral cavity cancers. In parallel to the rise of non-surgical therapies, there has been more of an understanding and attempt to maximize both quality of life and functional outcomes. So, although targeted and neoadjuvant therapy may reduce the need for surgery, it is likely that in selected cases, surgery—in particular, less invasive approaches—may also have an important role in maximizing functional outcomes.
‘Tobacco and alcohol use will never be eliminated; in fact, the absolute number of smokers has remained relatively constant over the last 40 years at approximately 50 million.’
The head and neck surgeon is best positioned to understand the complex choices available to the head and neck cancer patient, and as such, it is he or she who must lead the multidisciplinary team. It is imperative for the head and neck surgeon to play a leading role in shaping the future of head and neck oncologic care as we will remain central to the evaluation of, treatment selection for, and salvage of squamous carcinoma of the head and neck.
Reducing the Burden of Disease
3) It is our obligation to attempt to shape the future for the better.
How can we shape the future, not simply to protect the field of otolaryngology or the surgeon’s pocketbook? While these are important, the pursuit of a future in the context of public health and multidisciplinary foundations is more likely to be viewed as legitimate by the broader health-care community as well as policy-makers and consequently more likely to actually effect change. To this end, our guiding principles should be to reduce the disease burden on society and to enhance the cost-effectiveness of care, and in shaping the future paradigm of head and neck surgical training we should work from these principles.
Simply put, to reduce the disease burden (i.e., reduce incidence and mortality as well as better manage prevalent cases) we must educate future clinicians to improve prevention, detection, treatment, and rehabilitation. Of course, as principally clinicians we focus on treatment, and better treatment of cancer should be more cost-effective.
Refining Multidisciplinary Education
To improve current and future treatment, multidisciplinary education is necessary. While many current head and neck fellowships have provided outstanding surgical training, the mentoring needed to integrate surgery into and to oversee the complex multimodal therapeutic puzzle is lacking. While the potentials of radiation, chemotherapy, and targeted therapy are required learning, future head and neck surgical trainees must develop openness to these potentials so that they can manage multidisciplinary care and honestly integrate surgery into this paradigm.
Secondly, such education should be based not only on multidisciplinary care but also on evidence-based care. As these are rare diseases, much care for head and neck patients has been anecdotal, but various practice guidelines have been developed and are being modified based on existing and evolving evidence; these should not only be followed but also taught so that current and future care is standardized and likely more effective and efficient.
Thirdly, selected individuals should be targeted for physician-scientist or physician-public health professional training in order to affect more global advances in prevention, detection, and treatment. Previously, we have stressed research training for all. However, I would argue that this is misguided and that very, very few completing such training will continue research efforts in their academic careers. Consequently, we should provide such added training only for those who are genuinely interested and have the potential for such a career.
Finally, we should codify head and neck oncologic training, and the easiest means would be as a certificate of added qualification. As care becomes more complex and individualized as well as centralized to tertiary care centers, this training will need to mirror this change so that we have a well-trained surgical work force, but this training must also be standardized with some degree of quality control.
A Future of Head and Neck Surgery
In summary, I find the demographic and epidemiologic trends with the shift in the histologic and etiologic patient mix re-energizing for the field and the future potential for patient-centered, individualized care exciting. Changes in the treatment paradigm and challenges (financial and otherwise) to tertiary centers will be threatening. However, as head and neck surgeons we must be active participants in such change and work to shape the future of head and neck cancer care for the public good. While being advocates for our patients through the process of multidisciplinary care is critical in the present, it is through the training of future surgeons that we benefit the most patients and the public at large.
Head and Neck Cancer Statistics Resources
- National Cancer Institute’s Surveillance, Epidemiology, and End Results Web site: http://seer.cancer.gov
- Morbidity and Mortality Weekly Reports: www.cdc.gov/mmwr .
- Shiboski CH, et al. Tongue and tonsil cancer: increasing trends in the U.S. population ages 20-44 years.
©2006 The Triological Society