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

Head and neck cancer specialists are increasingly advocating surgery alone-or at least as first-line treatment. Often, patients with small tumors, and even some with larger ones, can avoid the well-known and significantly life-altering toxicity of chemoradiation.

Is this a reasonable clinical idea? It’s a huge question, said Jonas T. Johnson, MD, Chairman of the Department of Otolaryngology at University of Pittsburgh School of Medicine.

Christine Gourin, MD, Associate Professor and Director of the Clinical Research Program in Head and Neck Cancer at Johns Hopkins School of Medicine in Baltimore, agreed. 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, she said.

For small tumors, surgery is very efficient and cost-effective, and it allows patients to get back to their usual lives faster than with chemoradiation. Surgery carries few lingering after-effects, and there are lots of arguments in its favor.

-Bruce T. Haughey, MBChB

Bruce H. Haughey, MBChB, Kimbrough Professor of Otolaryngology-Head and Neck Surgery and Director of the Head and Neck Cancer Center at Washington University School of Medicine in St. Louis, added that this is a serious debate. For small tumors, surgery is very efficient and cost-effective, and it allows patients to get back to their usual lives faster than with chemoradiation. Surgery carries few lingering after-effects, and there are lots of arguments in its favor.

In a Nutshell

We never give chemotherapy or chemoradiation (CRT) for stage 1 or stage 2 disease, simply because it is not required, said Dr. Johnson. The biologic costs are too great, and there are no data to show that chemo provides a benefit in early-stage disease. It’s just too much treatment.

For example, in some patients, endoscopic resection of the larynx, which can be done on an outpatient basis, is more effective and efficient than six weeks of radiation.

Dr. Gourin agreed with him about early laryngeal cancer but warned that all head and neck cancer patients have a high lifelong risk of second such cancers. The ability to hold radiation in reserve for the future is a huge potential benefit of primary surgery for early-stage cancer, she noted.

But what about patients who want chemo and/or radiation after surgery to destroy micrometastases? Dr. Johnson replied, Currently, we have no way to find metastatic disease before it becomes detectable, so there’s no point in giving highly toxic drugs for the very unlikely event of distant metastasis. Thus, only patients with advanced tumors should be offered adjuvant CRT.