Should Surgery Be First-Line Treatment for Head and Neck Cancer?

He acknowledged that it is difficult for patients to live with uncertainty, but when the risk is so low, it’s more dangerous to overtreat.

CRT appears to work for stage 3 tumors. It is effective in about two-thirds of patients-about the same percentage as surgery combined with radiation, especially in cancer of the larynx, any treatment for which produces significant side effects. However, surgery carries more mutilating effects than CRT. Therefore, the latter has become the therapy of choice for stage 3 patients.

In stage 4 disease, CRT may not restore function. Therefore, surgical resection plus adjuvant CRT may be more appropriate. Patients with advanced adenopathy usually require CRT, but the jury is still out about surgery adding benefit for them.

That’s it in a nutshell, but of course, the decision to choose a treatment is more complicated than that. Physicians are responsible for understanding the differences among types of treatment for various stages and characteristics of head and neck cancer, and they need to guide and teach patients to weigh the appropriate choices, said Dr. Johnson.

The major determinants of whether surgery is an effective treatment are histology and stage. If the tumor is low-grade and/or early-stage, surgery alone can be curative.

-Christine Gourin, MD

Oral and Oropharyngeal Cancers

For cancers in the oral cavity, surgery alone may be sufficient treatment and may, in fact, offer the best chance of cure. CRT is not effective as first-line therapy, said Dr. Gourin. But, she added, You have to address the lymph nodes and dissect them during surgery. If there is no evidence of lymph node involvement and if you can achieve clear margins, surgery can be the sum of treatment.

But if, as is common, the cancer has spread to the nodes, you already have stage 3 or maybe stage 4 disease, and then you have to give adjuvant radiation or CRT. For oropharyngeal cancers, if you know beforehand that you’re facing stage 3 or 4 disease, then CRT as primary treatment is appropriate because there’s no getting around the need for radiation therapy. Unlike oral cancer, these tumors tend to be particularly radiosensitive.

In general, though, we try to avoid radiation because it can cause terrible, and permanent, side effects-for example, xerostomia, swallowing problems, and sometimes such severe fibrosis that patients can become feeding tube-dependent. And what’s more, chemotherapy tends to make tissue more radiosensitive, thus exacerbating the effect of radiation.