The team approach in the management of oral cancer. Alexander D Rapidis DDS. Research Associate, Department of Oral Pathology, University of Athens, and ...
Annals of the Royal College of Surgeons of England (I980) vol 62
The team approach in the management of oral cancer Alexander D Rapidis DDS Research Associate, Department of Oral Pathology, University of Athens, and Attending Oral and Maxillofacial Surgeon, St Paul's Hospital, Athens
Angelos P Angelopoulos DDS MS PhD FRCD(C)
Professor and Chairman, Department of Oral Pathology, University of Athens
John D Langdon
MB BS BDS FDSRCS
Consultant Oral and Maxillofacial Surgeon, Queen Mary's Hospital, Roehampton, London Key words: MOUTH NEOPLASMS; HEAD AND NECK NEOPLASMS; CANCER MANAGEMENT
of any single specialist. No one individual or Summary The managemenit of cancer of the head and discipline can be expected to anticipate all the neck is so complex that it demands the par- problems arising during or after the treatment ticipation of two teams, one major or cura- of the 'cancer patient'. tive and the other minor or supportive, and also of the patient. The make-up of these Diagnosis and prognosis teams and the functions of their members are When dealing with cancer one faces three discussed. The principles of treatment plan- groups of variables: (i) tumour factors, ning along these lines are outlined and the (2) patient factors, and (3) doctor factors. It is apparent that tumour factors are of importance of close interdisciplinary collabothe utmost importance and a proper underration is emphasised. standing and evaluation of the presenting Introduction lesion will be the cornerstone of any further toward control. The diagnosis therefore steps The head and neck has long been designated of malignant lesion in the head and neck any human the of one of the most complex regions body and no other part is affected by such a will not be made until an accurate and objecwide variety of different tumours, although tive clinical description and quantitative asthe majority are squamous-cell carcinomas sessment of the tumour has been carried out (i). Patients who present with malignant tu- and a biopsy has confirmed and determined mours of the head and neck require accurate the histopathological characteristics of the diagnosis and thorough evaluation of their lesion. Biopsy is the foundation on which the treatpresenting condition, comprehensive treatmnent planning, co-ordination of the appro- ment plan for any malignant neoplasm is priate therapeutic modalities, careful recon- based. The more this principle is violated, the struction, and rehabilitation as well as sup- higher will be the probability of error in manportive psychological and social care to agement and consequently the greater the expedite their return as integrated members of tragedy for the patient. In oral cancer with society (2). Especially when dealing with oral regional lymph-node metastasis found only at cancer we should have as a basic aim the the time of surgery the clinical examination of eradication of the tumour with satisfactory the neck reveals positive nodes in only 70physiological function regarding mastication, 80o of the cases (4,5). The only way to imphonation, facial expression, and an acceptable prove on this figure is to have more clinicians examining the patient so that signs that may cosmetic appearance (3). It is therefore quite clear that the manage- have been overlooked by one clinician will be ment of oral cancer is beyond the capabilities picked up by another. Based oIn a paper delivered at the 66th Annual Worldl Dental Congress of the Federation Dentaire Internationale, Mladrid, September 1978.
The team approach in the managemenit of oral cancer So far as the patient is concerned the clinician's approach should have two parallel aims. The first is toi determine and evaluate the patient's overall condition and to prepare him psychologically and physically for the treatment and its consequences. The other aim is to inform the patient to enable him to participate in his own way in the battle which he must fight with the help of his doctors for his own survival. No universally accepted policy in this matter has been adopted, but all studies have stressed that at some stage, at the discretion of the clinician in charge, the patient should have the right to participate in the decision-making and take, or at least share with the clinician, some of the responsibilities. The most important thing is for the clinician to prove to the patient that he is interested not only in his disease and its progress but also in the patient as an individual in his own right. It has been suggested that such discussion be left to the family doctor, who probably knows the patient and his family better (6). The individuals concerned in the management of a patient with oral cancer may be divided into two groups, one major or curative and the other minor or supportive. The major group will include the surgeon, the radiotherapist, the medical oncologist, and the pathologist. The minor group should include the general (family) physician and dentist, the nursing staff, the maxillofacial prosthetist, the psychiatrist, the speech therapist, the social worker, and any strong supportive members of the patient's own family.
The curative team Patients with oral cancer are referred to hospital from many sources. The general dental or medical practitioner and the ear, nose and throat and oral surgery outpatient departments in hospitals are usually the first places at which a patient with a lesion in the mouth will seek advice. When a biopsy has confirmed the diagnosis the patient with oral cancer should be seen at a joint meeting of the major group for advice and treatment planning. The surgeon will state the advantages and disadvantages of a surgical approach, the radiotherapist will discuss the technical possibilities of radiotherapy, the medical oncologist will state the way that antimitotic drugs might be of help, and the pathologist will discuiss the
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histological character and likely behaviour of the tumour. A combination of approaches should be considered and a definitive treatment plan agreed by the team. After treatment the patient's progress should then be reviewed at joint meetings of the major team from time to time. There are of course many difficulties and problems when arranging for a clinical team of this sort. The difficulties start when one tries to decide which individuals will be members of the team and what qualifications, training, and experience they should possess. THE SURGEON
For various reasons (educational systems, availability of appropriate training programmes, hospital philosophy, and individual attitudes) many surgical specialties have been dealing with the treatment of patients with oral cancer. Until recently otorhinolaryngologists had the first and major responsibility in this respect. The development of otomicrosurgery and microlaryngeal surgery has diverted the interest of a number of contemporary ENT surgeons away from head and neck oncology. The same diversion has been seen among plastic surgeons with the development and spread of aesthetic and cosmetic surgery. Today their role lies largely in areas of functional reconstruction following ablation of the tumour. A new specialist, the head and neck surgeon, has been introduced lately and has received considerable publicity, mainly in the United States and Canada. The head and neck surgeon has been gaining the prior responsibility for the treatment of maxillofacial tumours in those countries. In Europe the development of maxillofacial surgeons from the medically qualified dentists of the post-war era gave the dental profession access to this field. Recently the Dental Liaison Committee of the countries of the European Economic Community with its new directives, which have now been signed by all member countries, has given the responsibility for dealing with all diseases of the mouth and adjacent structures to the dental profession. Whoever the designated surgeon is, adequate training and surgical ability in the specialised field of maxillofacial oncology are more important than his title. THE RADIOTHERAPIST
Cancer of the head and neck is a disease of
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Alexander D Rapidis, Angelos P Angelopoulos, and John D Langdon
the elderly. It has been reported that the mor- THE SUPPORTIVE GROUP tality of surgery for head and neck cancer is The role of the supportive group is to facilitate 6%/o up to the age of 70 years but increases the prompt application of the selected therato 50% for ages above 8o (7). Many of these peutic regimen and also to help the patient risks can be reduced when surgery is combined overcome the psychological and social probwith or replaced by radiotherapy. Radio- lems that will arise during or after treatment. The family medical and dental practitioners therapy has changed dramatically in the past few years. New techniques have emerged and will help the major team by providing useful better technical devices have been developed. information about the patient's general conTissue reactions have been evaluated and cell dition and about the family environment and kinetics have been studied. Although general will facilitate communication between the guidelines can be drawn, the decision regard- team and the patient. The role of the nurse as a participant in ing the specific type of therapy must be made on an individual basis for each patient after the team is very important. The postoperative course is prolonged under the best of circumcomplete evaluation of his condition. stances. Local tissue reactions following irradiation may cause delay in healing. During THE MEDICAL ONCOLOGIST Chemotherapy in cancer of the head and neck this time the nurse may be helpful in changing has until recently been predominantly palli- dressings and in carrying out treatment deative. The medical oncologist would have been signed to aid the healing of flaps or donor consulted only when both the surgeon and the sites for skin grafts. She is also in a position to radiotherapist had failed either to cure the pa- help the morale of the patient. Other members of the supportive group tient or to control the disease. Today, with as the maxillofacial prosthetist, the speecl such the combined use of various agents and with the psychiatrist, and the social therapist, on of the action of the drugs the exploration the mitotic phase of the cancer cell, chemo- worker can provide great help in selected therapy can help both surgery and radio- cases. The proper understanding of the disease therapy by either decreasing the bulk of the and its consequences by any strong members primary lesion so that a previously inoperable of the patient's own family and friends will tumour becomes accessible or by sensitising help him to readjust within the family environment and help to maintain his morale. the tumour cells to the effects of irradiation. THE PATHOLOGIST
There is clearly a strong association between the histological grade of a malignant tumour of the head and neck and its subsequent behaviour, particularly within the squamouscell carcinoma group. With decreasing degree of differentiation there is an increased likelihood of regional lymph-node involvement at presentation, a reduced time interval between primary treatment and the recurrence of the tumour, and a reduced 5-year survival rate (8). It is quite clear that no treatment should be started on a patient suffering from oral cancer before the tumour's histological behaviour has been evaluated by the pathologist and discussed by the team. The oral pathologist has been assuming an increasingly important role during the past few years, particularly in stimulating the early clinical detection of oral cancer by the practising dentist (9).
Treatment planning All who are concerned with the care of patients suffering from oral cancer are well aware of the low cure rates. Oral cancer rarely kills by extension below the clavicles (io). Patients die because of our failure to control the local disease and its spread to adjacent lymphatics (8,1 i). In recent years the survival rate for the surgical treatment of head and neck cancer has assumed a plateau (3). With a better understanding of tumour biology and the patterns of spread most surgeons have realised that their results frequently depend upon biological behaviour rather than the technical refinements of surgery. Surgery and radiotherapy can be integrated in many ways to the advantage of the patient in terms of reduction in morbidity and possibly improved survival rates. Planned curative radical irradiation to the primary lesion and neck, if involved, can be given,
The team approach in the management of oral cancer
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reserving surgery for failed radiotherapy (3). the present interdisciplinary competition which Planned radical preoperative irradiation can sometimes results in personal confrontation be given to the primary lesion and neck if between general surgeons, otorhinolaryngolothere are cervical-node metastases, to be gists, plastic surgeons, oral and maxillofacial followed by elective surgery, where necessary surgeons, and head and neck surgeons as to including neck dissection. Irradiation can be who has or should have the prime responsigiven to the primary site and neck following bility for the treatment of the poor patient surgery as soon as healing is complete-that who 'happens to have cancer' will be a great is, planned postoperative radiotherapy. Finally, advance in the management of head and neck radiation therapy can be reserved for failed cancer for which our patients will thank us. surgery when local recurrence or lymph-node References involvement becomes apparent. i Harrison DFN. The natural history of some cancers affecting the head and neck. J Laryngol Otol There are several aims of adjuvant chemotherapy: initial tumour shrinkage, sensitisation 2 I972;86: I I89-202. Sandler HC. A retrospective study of a head and to radiotherapy, and the elimination of microneck cancer program. Cancer I970;25: I153metastases or residual tumour. It has been 6i. stressed that for better results, apart from the 3 Lindberg RD. Present day role of radiation therapy in the treatment of head and neck canneed for yet more specific antitumour agents, cer. In: Chambers RG et al., eds. Cancer of the further exploration of the combination of head and neck. Amsterdam: Excerpta Medica, chemotherapy with surgery and radiotherapy 1975: 7-I3is indicated. It is apparent that as yet there 4 Cady B, Catlin D. Epidermoid carcinoma of the gum: a 20 year survey. Cancer I969;23:55Ihas not been a clear delineation of the role of 69. chemotherapy in combination with surgery Spiro RH, Frazell EL. Evaluation of radical surand radiotherapy in the management of early 5 gical treatment of advanced cancer of the mouth. head and neck cancer. Recently encouraging Am J Surg I968;II6:57I-7. results have been reported from several cen- 6 Brewin TB. The cancer patient: communication and morale. Br Med J I977;ii:I623-7. tres using multiple drug chemotherapy in com7 Williams RG, Murtagh GP. Mortality in surgery bination with radiotherapy (I2,13). for head and neck cancer. J Laryngol Otol 1973; There have been many studies on the im87:431-40portance of certain clinical or histological 8 Langdon JD, Rapidis AD, Harvey PW, Patel MF. criteria that may affect the prognosis of a paSTNMP-a new classification for oral cancer. Br J Oral Surg 1977;15:49-54. tient with oral cancer and hence alter the life Shafer WG. Role of the oral pathologist in oral expectancy. Although there are some differ- 9 cancer. In: Oral cancer: international symences in the views expressed by various authors posium. Washington DC: Public Health Services it is clear that assessment of the site of the Publication No i86, I966;3I-6. primary tumour, measurement of its exact di- io Westbury G. Management of metastatic cervical mensions, detection of positive lymph nodes, ir nodes. Proc R Soc Med I976;69:865-7. Patel Langdon JD, Harvey PW, Rapidis AD, the presence or absence of distant metastases, MF, Johnson NW, Hopps R. Oral cancer: the and the histopathological grading of the pribehaviour and response to treatment of I94 mary tumour have statistical significance in cases. J Maxillofac Surg 1977;5:221-37. determining the prognosis of the patient (8, I, 12 Clifford P, O'Connor AD, Durden-Smith J, Hollis BA, Edwards WG, Dalley VM. Synchronous I4,I5). multiple drug chemotherapy and radiotherapy Our aim therefore should be in two direcfor advanced (Stage III and IV) squamous cartions: firstly, to learn and understand more cinoma of the head and neck. Antibiot Chemother 1978;24: 60-72. about the disease itself with the ultimate aim LA, Hill BT. A kinetically based logical of its elimination or prevention; and secondly, 13 Price approach to the chemotherapy of head and neck to educate a new generation of doctors in all cancer. Clin Otolaryngol 1977;2:339-45. specialties to work together in close collabo- 14 Rapidis AD, Langdon JD, Patel MF, Harvey PW. Clinical classification and staging in oral ration for its management. Instead of developcancer. J Maxillofac Surg 1976;4: 219-26. ing the super-clinician who deals with oral AD, Langdon JD, Patel MF, Harvey cancer after a long head and neck training it 15 Rapidis PW. STNMP-a new system for the clinicois better to teach young trainees to co-operate pathological classification and identification of and work as a team. The final elimination of intra-oral carcinomata. Cancer 1977;39: 204-9.
