Editorials

Management of head and neck cancer in Britain

Surgical and radiation oncologists will readily disagree over many aspects of cancer management but one point is widely accepted: patients with head and neck cancer probably present the greatest challenge of all. Apart from the obvious difficulty of assessing a range of treatment strategies for an unusually wide number of primary sites (larynx, pharynx, oral cavity, paranasal sinuses, etc) and the consequent difficulty in comparing outcomes, so many patients have to face devastating treatment consequences as the price of cure. What is more, although the incidence of head and neck cancer is rising,¹ the relatively small number of patients—fewer than 5000 new cases a year in Britain—has slowed cooperative efforts in building worthwhile databases or, better still, mounting prospective clinical studies large enough to provide meaningful results.

The brief report by Edwards and colleagues in this week's issue provides a disturbing overview of current provision for the treatment of head and neck cancer in Britain (p 1589).² To discover, for example, that almost a half of consultants had no access to a joint clinic forum (or, worse, chose not to use such an opportunity) is astonishing. How else to decide on a management plan in a patient who might better be treated by non-surgical than surgical means? Or might be suitable for a clinical trial? Or might be best managed by a combination of surgery with planned postoperative radiotherapy? In my own practice I have certainly been aware of patients arriving for a second opinion on the options for management of a locally advanced lymph node positive cancer of doubtful operability. These patients had previously been assessed only in a surgical clinic and been recommended to undergo a radical, mutilating, and demanding operation with virtually no hope of cure by surgery alone.

How much better calmly to assess such a patient within a joint clinic with proper attention paid to the contributions of the surgeon, radiation oncologist, specialist nurses, dental hygienist, speech therapist, dietitian, and other essential members of the group.³ Many would contend that only by working within such a setting, and seeing a large throughput of patients, can one have any hope of developing enough expertise to provide the best possible advice to these especially unfortunate patients. Yet, as Edwards et al report, the average number of patients encountered by surgical specialists is fewer than 10 per consultant a year, even allowing for joint management. Fewer than half of the consultants returning their questionnaire treated more than 10 cases a year at any anatomical site. The competence of the more experienced consultants was clearly illustrated by the observation that those who treated more cases at any one site were also more likely to record tumour stage⁴ —an essential feature of patient documentation crucial to any attempt at treatment comparisons.

Discovering that fewer than half the consultants had access to either nurse specialists (40%) or counselling services (35%) lowered my spirits still further. Few, if any, patients have greater need for the skills of these professionals.^{5 6} Which breast or colorectal cancer clinic could manage without either, yet still retain credibility as a top-class teaching facility or service provider? Who oils the wheels in the complex business of rehabilitation after, say, a complex operation such as laryngopharyngectomy with partial glossectomy and radical neck dissection? Operations for head and neck cancer must be among the most demanding undertaken, even for the most well adjusted and well supported of patients. Yet typically patients with head and neck malignancy are often socially disadvantaged, with little or no domestic support, a history of heavy reliance on alcohol, and exceptionally poor general health. Ironically, this type of surgery may often result both in an unusually lengthy hospital admission and a challenging period of home based non-oral nutrition, typically nowadays by percutaneous endoscopic gastrostomy feeding. Recovery in the community will consequently be all the more difficult.

The findings of Edwards et al make for gloomy reading. The clear message is that we need to do far more than pay lip service to the concept of the team approach recommended for so long⁶ and that treatment decisions should be far more thoroughly discussed before implementation than is currently the case. We also need much better access to support and rehabilitation services and an insistence that more care be taken in documenting all relevant tumour details, using a standard system such as the recently revised TNM. Better still, as many patients as possible should be treated within a well designed prospective clinical trial such as UKHAN 1, one of a portfolio run by the United Kingdom Coordinating Council for Cancer Research.⁷ How can we realistically expect any progress unless we make these simple and professionally rewarding changes?

J S Tobias, President, British Association of Head and Neck Oncologists, and consultant in radiotherapy and oncology ^a

^a Meyerstein Institute of Oncology, Middlesex Hospital, London W1N 8AA

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