General Principals

After a histologic diagnosis has been established and tumor extent determined, the selection of appropriate treatment for a specific cancer depends on a complex array of variables, including tumor site, relative morbidity of various treatment options, patient performance and nutritional status, concomitant health problems, social and logistic factors, therapy anticipated for potential recurrences or second primaries, and patient preference. These variables are each considered with respect to the established effectiveness of various treatment regimens available (

Table 90-3).

Several generalizations are useful in therapeutic decision making, but variations on these themes are numerous. Surgical resection and radiation therapy are the mainstays of treatment for most head and neck cancers and remain the standard of care in most cases. For small primary cancers without regional metastases (stage I or II), wide surgical excision alone or curative radiation therapy alone is used. For more extensive primary tumors or for those with regional metastases (stage III or IV), planned combinations of pre- or postoperative radiation and complete surgical excision are generally used. More recently, as historical survival and control rates are recognized as less than satisfactory, there has been an emphasis on the use of various induction or concomitant chemotherapy regimens.

The use of chemotherapy, however, should remain on a protocol basis until efficacy is proven. For selected patients with advanced cancers of specific sites, such as the larynx, treatment approaches with radiation alone, with surgery held in reserve for salvage of recurrences, have been used in attempts to preserve structure and function. Although these organ-preserving techniques have been successful in many patients, they were generally associated with lower overall survival rates.

The overall management goals in treating patients with head and neck cancer are to achieve the highest cure rates at the lowest cost in terms of functional and cosmetic morbidity. These goals include early diagnosis, effective rehabilitation, and appropriate palliation when indicated. The achievement of these goals requires the close cooperation of a multidisciplinary team of practitioners representing surgery, radiation, chemotherapy, prosthodontics, dentistry, social services, dietetics, physical medicine, pathology, nursing, and sometimes psychiatry.

Effective rehabilitation is an important part of the overall treatment of head and neck cancers. Modern advances in surgical reconstruction, microvascular free-tissue transfer, and prosthodontics have significantly improved functional per-formance. Rehabilitation concerns must be addressed at initial treatment planning and carefully integrated with the various treatment modalities used. Pretreatment dental evaluations and speech and swallowing assessments are routine. Needed dental care and/or extractions should be planned prior to chemotherapy or radiation to reduce dental-associated sepsis, mucositis, and osteoradionecrosis. The overall impact of treatment and rehabilitation decisions on a patient’s quality of life is an important issue that may require specialized social or psychiatric support systems for the patient and family. Furthermore, attention must be paid to nutritional support. Contemporary combined approaches of chemotherapy and radiotherapy place a long-term burden on the patient that must be compensated. Indeed, it is this close attention to nutrition and supplementation that makes possible these aggressive regimens. Finally, the prolonged nature of treatment for advanced disease, which may extend over many months, requires consideration of the social and financial impact of treatment decisions on the patient, the family, and the patient’s career.

Biopsies of primary tumors need not be excisional unless the biopsy procedure is sufficient for definitive treatment, and the surgeon performing the excision is responsible for providing curative treatment. Oncologic principles of surgical resection must not be compromised by ill-conceived reconstructive efforts or attempts at modifying the necessary resection in order to minimize functional or cosmetic morbidity. Head and neck cancers are serious threats to life. Temporary preservation of function at the cost of a high risk of recurrence, high morbidity, or death is a poor bargain. Gross residual cancer or positive surgical margins after tumor resection portend inevitable treatment failure. Appropriate management must also include the use of precise modern techniques of conservative surgical resection (eg, partial laryngectomy and functional neck dissection) that, in selected patients, have cure rates similar to those of more radical techniques.