When Eric Moore, MD, a professor of otolaryngology at the Mayo Clinic in Rochester, Minn., gives a lecture on transoral robotic surgery for supraglottic laryngectomy, one of the first slides he shows contains a list of the tenets for a successful surgery that came from Joseph Ogura, MD, a pioneer in laryngeal surgery.
While decades have passed since Dr. Ogura compiled that list, his points are still critical ingredients in a successful surgery, said Dr. Moore while delivering the Joseph H. Ogura Memorial Lecture during the Triological Society’s annual meeting. “The rules that he developed then are as relevant today as they were in his lectures.” This goes to show, Dr. Moore said, the ways in which today’s otolaryngologists learn from the past even as they apply those lessons using new knowledge and technology to improve outcomes for patients. The best medicine, he said, is an approach that is “tempered by the experience of the past and technological developments of the present.”
Dr. Moore traced the recent history of the treatment of oropharyngeal cancer to illustrate the ways that medicine can become slightly cyclical, tending to repeat itself while still moving forward.
Facing Obstacles
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In 2006, Dr. Moore was studying and practicing transoral surgery of the oropharynx. A review of 51 trials had concluded that the preferable treatment for the majority of patients with squamous cell carcinoma of the oropharynx was non-surgical, because “non-operative therapy had equivalent disease control with half the complications of surgical therapy,” he said. The efficacy of the non-surgical approach for the larynx was being extrapolated to the oropharynx, he added, with many centers abandoning mandibulectomies and base-of-tongue resection in favor of chemoradiation. “Gazing at the horizon of head and neck surgery at that time,” in 2006, he said, “the sun appeared to be setting on surgery for oropharyngeal cancer. In fact, surgery for cancer of the oropharynx had encountered some considerable obstacles.”
Eventually, however, the tables started to turn. “As the results of non-operative therapy trials and the patients who participate in them mature, we have come to realize that the fibrotic necks and dysphagia in patients with a heavily radiated pharynx are not so different than” the complications that the move away from surgery was meant to avoid, Dr. Moore said.
In the ECOG 3511 trial, one of the few randomized trials with a surgical arm for head and neck cancer, researchers are examining whether, in the era of HPV-mediated cancer, upfront margin-clearing transoral surgery for these patients can de-intensify their therapy and provide excellent function, a result that would mean increased oncologic control.
Moving Forward
Drawing from a 1977 lecture given by Dr. Ogura that focused on how the future would involve delivery of care at cancer centers by teams of specialists, Dr. Moore said, “I will continually work with my colleagues in other specialties to strengthen bonds that will work as Ogura’s utopian vision of a cancer care team, each of us empowered by sharing our unique knowledge and experience.”
Thomas R. Collins is a freelance medical writer based in Florida.
Lessons From the Past
As Dr. Moore moves forward in his treatment of oropharyngeal cancer, he intends to apply teachings from several previous Ogura lecturers, including the following contributions:
Charles Cummings, MD (“Requisites for Survival of Otolaryngology–Head and Neck Surgery,” 1996)—Dr. Moore said he will look for new ways to improve TORS by adopting and adapting new technology. “I’ll continue to try to improve my transoral procedures and develop better ways to expose and remove tumors and work with engineering and industry to perfect our tools,” he said.
David Eibling, MD (“When More than the Patient Is Ill,” 2014)—Dr. Moore has resolved to fight the temptation to believe he knows more than he does. “I will keep my mind open and fight against the ‘illusion of knowledge’ as we explore less morbid intensification strategies. Continually testing new therapies and studying our results is how we will find the sweet spot of delivering just enough treatment to each and every patient and each and every tumor. We owe it to our patients to break through this illusion of knowledge by systematically testing our results and the effectiveness of our treatments.”
Donald Harrison, MD (“Moral Dilemmas in Head and Neck Cancer,” 1990)—“Although we are getting closer to avoiding a one-size-fits-all treatment recommendation through knowledge gained in prospective trials, our science can never be perfect enough,” Dr. Moore said. Until then, otolaryngologists should heed the reminder in Dr. Harrison’s lecture and “first, do no harm.”