- Email: [email protected]
Changing concepts in head and neck surgical oncology
HAYES MARTIN MEMORIAL LECTURE
Changing Concepts in Head and Neck Surgical Oncology
Condict Moore, MD, Louisville,
Kentucky
To my great surprise, you have chosen to honor me as the ninth Hayes Martin Lecturer. Thank you sincerely; I can only pretend to deserve it. Hayes Martin was a true giant, bigger than life, and a genuine hero in the history of medicine. As much as any one physician could, he single-handedly developed a field of cancer treatment. Other fine surgeons contributed simultaneously, but Dr. Martin dominated the field. He saw the big picture and at the same time paid the utmost attention to mundane organizational and procedural details. He was an innovator of instruments, a master of office organization, a keen judge of people, an architect of record-keeping systems, and a creator of curative head and neck operative techniques. A diplomate of both the Boards of Surgery and Radiology, he led a life committed to solving the problem of head and neck cancer. One tangible measure of his stature was the calibre of the physicians and others whom he attracted to work with him. Dr. Martin’s staff was composed of men of such ability that they could choose to work with the best, and they chose to work with Hayes Martin. He indeed had a staff of stars. They saw the pioneering challenges as Dr. Martin did and all felt fortunate to work under him. I was privileged to train under him for a full year. His was a developing cancer field with perhaps more promise of success than afforded by any other cancer site. Colleagues in other fields regarded him with awe, so able was he, so single-minded, so meticulously honest. The shadow of this genius of a doctor and surgeon grows larger every year. One of his qualities was always to question dogma but at the same time require rigorous proof for contemplated change. From the Cancer Center, Unwerslty of LowwIle, and the Department of Surgery. University of LouisvilleSchool of Medicine, Health Sciences Center, Louisville, Kentucky Requests for reprints should be addressed to Condict Moore, MD, Cancer Center, Universftyof LouwIle School of Med~cina,Health Sciences Center, Lowville, Kentucky 40292. Presented at the 26th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 14-17, 1980
Fundamental changes are constantly taking place in attitudes and approaches to the treatment and understanding of disease. Changes that affect the treatment of head and neck cancer are no exception. As we point to some changes it may be that Dr. Martin is watching somehow and probably snorting his disagreement, so skeptical was he when upstarts presumed to address weighty problems. History of Head and Neck Cancer A quick review of the history of head and neck cancer treatment over the last 50 years might run something like this: In the 1930s orthovoltage radiation therapy dominated treatment, following Coutard’s fractionation method, curing perhaps one fourth of oral, pharyngeal and laryngeal cancers across the board. In the 194Os, not satisfied with the results, Dr. Martin developed radical surgery, combining wide resection of the primary lesion in continuity with neck dissection for regional metastases. This combined procedure was made possible by transfusions, blood banks, antibiotics and progress in anesthesia. It was a cancer pioneering era where a “one operation fits all” philosophy prevailed. More cures resulted. But the combined procedure was applied indiscriminately, and complications were severe and frequent. In the 1950s radiation therapy equipment took a leap forward, led by MacComb and Fletcher [I]; a combination of radiotherapy and surgery began to receive attention and trial. Intensive training of radiotherapists began. Treatment results again improved. In the 1960s specialties other than general surgery began to contribute. The desirability for immediate repair of large defects of the head and neck became evident and regional skin flap repairs were developed. Conservation laryngeal surgery emerged as a demonstrated advance. Reconstruction made marked progress with the formal recognition and training of maxillofacial prosthetics specialists. The need for cancer education of dental students was recognized. In the 1970s adjuvant chemotherapy The American Journal of Surgery
Head and Neck Surgical Oncology
became established. The staging of disease was standardized and validated, modifications of radical surgery became popular and clinical trials were developed. In the 1980s we can look forward to more triple modality protocol studies for advanced disease, the development of centers for head and neck excellence and finally, a matter I will speak about later, a lowered incidence of squamous cancer beginning in this decade. Several of these trends deserve attention in some detail because they are exerting major effects on the future of the practice of surgical oncology of the head and neck. Trend Toward Conservation First, surgical procedures for head and neck cancer are becoming more varied, more custom-designed for individual patients and particular stages of disease, and generally more conservative; increasing emphasis falls on conservation of function and cosmetic appearance. This trend does not imply devaluation of wide resections for patients whose bulky localized cancer justifies it. The trend does, however, recognize that wider and wider resectional surgery does not necessarily result in more cures. In surgery for differentiated cancer of the thyroid gland, for instance, total thyroidectomies are performed less often, according to recent reports. Cady et al [2] report on almost 800 differentiated thyroid cancers over a 40 year period, noting the lack of improved results when surgery was at its most radical in the 1940s and 1950s. He also noted that there have been fewer regional metastases in recent years and that the incidence of undifferentiated or incurable types is lower. Total throidectomy occupies an increasingly limited role because the incidence of complications is far higher in total than in subtotal thyroidectomy, as reported by Foster [3]. Neck dissections that conserve function are becoming the rule, generally only for patients with proved metastases [4]. These developments toward conservation surgery result from careful reporting and reviews of thousands of operated cases, careful long-term follow-up and an increased understanding of the pathophysiology of differentiated thyroid cancer [5]. Of course, papillary and follicular thyroid cancer is a special, unique tumor. But when Dr. Martin was pioneering radical surgery for head and neck squamous cancer, surgeons and the medical profession at large had great faith in the principle that there was one ideal operation for every condition. Enterprising surgeons could do no better than to find that operation. In those days all cancers of the breast were treated religiously with radical mastectomy. Today’s head and neck surgeon abandons as simplistic the Volume 140, October 1980
inviolability of the concept of incontinuity resection and node dissection. More and more often he designs custom-made procedures for each patient and his cancer. Many surgeons say they seldom perform exactly the same operation twice. Furthermore, partial neck dissections, more conservative neck dissections and far fewer prophylactic neck dissections are becoming the rule for N-l neck disease in squamous cancer as well as thyroid cancer [6-81. Part of this is explained by the increased use of combined radiation and surgery regimens and prophylactic radiation to neck nodes, [9] strategies pioneered by Jesse and Fletcher [IO] and others. Conservation surgery for the larynx was developed in the 1960s largely by our otolaryngologic colleagues [11--131. Partial laryngectomy and other functionsparing procedures constitute a landmark contribution to our craft and to the cancer patient. Thus the modern head and neck surgeon needs skill, training and a whole arsenal of procedures to provide the patient with the best end result. The conservative trend results from careful studies showing that conservation surgery works under strictly defined conditions. At least 1 in 10 patients with laryngeal cancer referred to large cancer centers can safely undergo voice-sparing operations [14]. A review of reports on head and neck surgery in 10 leading national journals in the last 3 years confirms that conservation is the conceptual background that dominates the thought and study of leaders in our field. However, two caveats about conservation surgery need emphasis. The studies that lead us into more conservative resections in selective instances should not be extrapolated to support so-called debulking surgery or cytoreductive surgery. This quasipalliative surgery is another matter. It remains in a controversial and anecdotal stage at present and does not fit into any permanent trend. A second &ning bears repetition: conservation cancer surgery in the head and neck requires twice as much experience and skill as so-called radical surgery. Head and Neck Cancer Centers This swing toward conservation surgery is of primary importance. A second important development in the decade of the 1970s has been the formation of more medical centers in the United States, centers that can deliver the best complicated treatment of major disease, especially cancer centers. Of course, centers have become so popular that every small and medium-sized community hospital is changing its name to “center.” The word has become a status symbol, and the public is now looking to centers for the ultimate in medical care. Regardless of the difficulty in defining a “center” and regardless of mis481
Moore
applications of the term, large medical centers have a growing role in this country’s medical organization. These tertiary care facilities handle certain illnesses that cannot be ideally managed in smaller, simpler settings. In the cancer field, pediatric oncology constitutes a good example of the reasons for the center trend. The overwhelming majority of informed opinion now favors treating all childhood cancer in centers. The startling advances in the cure of childhood cancer depend on several types of highly trained superspecialists acting together as a treatment team. Childhood cancer centers bring together under one roof knowledgeable radiotherapists, chemotherapists, oncologic nurses and ancillary personnel as well as experienced pediatric surgeons. This is only possible when there is sufficient volume to support this team of experts, who can then concentrate on the narrow field of pediatric oncology. Head and neck cancer is also now emerging as a complex problem requiring combined modality treatment planning, albeit with the head and neck oncologic surgeon often the leader. It seems to need the same pattern of care as pediatric cancer. Although increased cures from complex treatment planning have not equalled pediatric cancer results, progress has been made. From our training, experience and observation of the development of oncologic science, we believe strongly that all stage II, III and IV head and neck cancers should be seen in centers of head and neck oncologic excellence before treatment is started. Patients need not always be treated at such centers because a complex of surgery, radiation and complicated rehabilitation may not be part of the initial treatment plan, but such patients need to be first seen at a center to receive ideal advice at the very outset when the chance for cure is greatest. Is it really necessary for all stage II and higher patients to travel distances, to undergo repeated scrutiny, second opinions, delay, inconvenience and expense? The answer is yes. One physician can no longer decide at initial diagnosis, before treatment is instituted, whether or not various methods of treatment and oncologic specialists will be beneficial. And certainly it is a disservice to the patient to assume that if simple local treatment will not cure, nothing will. No one physician can keep abreast of recent advances in all aspects of cancer treatment. The treatment team can only be of real help to a patient when asked to see the patient at the initial planning stages. Their combined report becomes a consultation and goes to the referring physician, who then decides whether or not to follow the consultants’ advice. Unfortunately, the way the medical profes482
sion in America often uses oncologic head and neck specialists is as medical priests to administer last rites the day before death. Some physicians still feel that cancer only becomes complicated enough for expert opinion when it is hopeless; this is an insult to our training and our common sense. Head and neck cancer is usually highly complicated to manage, ideally demanding six or seven superspecialists to work as a team for a given patient, and only centers of oncologic excellence have the volume of patients to support these many skills and services. They consist of a head and neck oncologic surgeon, the tumor pathologist who is also skilled in frozen-section analysis and works with the surgeon, the radiotherapist with his assorted machines and techniques, a medical oncologist trained in the use of increasingly more effective drugs, nutrition experts, dentists, maxillofacial prosthetics, speech therapists, social workers, counselors and so on. Some unique advances and teams have been developed in centers; one example is the free flap reconstruction work by Acland and Flynn at the University of Louisville. Edgerton and Bull [15] well described the predicament of head and neck cancer management in the decade of the 19709, a predicament of uneven and inadequate care in a variety of settings where happenstance may have had more to do with outcome than professional judgment. The American College of Surgeons Commission on Cancer developed guidelines for cancer care in the early 1970s; there followed several combined society meetings on head and neck cancer. The conclusions reached at these meetings were that the major national fault was conflicting and overlapping training requirements in different specialties and in different institutions concerned with head and neck cancer. This society then made a concerted effort to remedy the problem by having repeated joint meetings with colleagues in other specialties and by jointly developing training guidelines (161. The response to reorganization through these training guidelines has been spotty; progress may be slow in the future. Only 13 institutions have applied for review: 11 were reviewed, 8 of which were approved and 3 deferred (personal communication: Lore JM Jr.). Most of the highly qualified institutions with a large volume of head and neck cancer cases simply failed to request review. Some joint pilot programs have been started that are bound to be beneficial. However, these efforts rely on the force of persuasion of national societies and their policy-making elder statesmen. Such persuasion is not quickly or widely effective. We need a new approach to remedy the unevenness and inadequacy of head and neck cancer care. The American Journal ol Surgaty
Head and Neck Surgical Oncology
Frequency-Sensitive
Operations
A recent study from Stanford and the University of California, San Francisco [17] indicates that certain surgical procedures carry a lower mortality when performed in larger institutions with a high volume of such surgery than in smaller institutions with a lower volume. Certain operations such as coronary bypass, open heart procedures and transuretheral resection of the prostate are “frequency-sensitive” procedures, most safely done in centers that perform 200 or more a year. Other operations such as cholecystectomy are not sensitive to the volume of such surgery and can be as safely done in a small as in a large institution. The authors estimate that 20 to 30 percent of deaths from frequency-sensitive operations in small, low volume institutions would be prevented if done in large centers. Morbidity variations in large and small institutions would no doubt follow suit. We suggest the initiation of a study of head and neck cancer surgery following the general pattern of the California study. This Society could make a real contribution, in addition to its training guidelines, by studying the mortality, morbidity and cures of major head and neck operations in large and small institutions, to establish the degree of “frequencysensitivity” of these operations. It could also develop and promulgate suggested standards for an institution to carry out these procedures, as suggested by the thoughtful editorial by Longmire and Millenkoff [18] in the New England Journal of Medicine, in which they comment on the frequency-sensitivity study. The California study did not include head and neck procedures. The American Medical Association and the American College of Surgeons probably will not devote further attention to our relatively small field by developing new standards for it. None of us wants the government to do it. Most professional and community leaders expect a national society such as ours to perform this function. Once the facts are in, the chips must then fall where they may. Each region will have to make its own compromises with the ideal, but a study is needed to define the ideal and make it common knowledge. If head and neck cancer has a complexity of management that causes it to emerge as a “fredisease, this quency-sensitive, ” “center-sensitive” knowledge may, more than any other measure, bring peer pressure to bear and lead to a sensible reordering of treatment planning patterns. Public pressure might also result, causing the medical profession as a whole and institutions, large and small, to take a new, hard look at their management practices. To the contrary, if head and neck surgery and full treatment volume 140, October 1980
management emerge as not frequency-sensitive and center-sensitive, then we should stop worrying about this problem and get on to other things. But in the meantime, we can only plan, teach, organize, operate and lead newcomers to our field to work in centers where a critical mass of skills and interests exists, thereby giving patients what we now believe to be the best that modern medicine can offer. Head and Neck Oncology The foregoing discussion touches on the future policies and plans and missions of this Society. We cannot help but mention another somewhat unsuspected trend in head and neck surgery that implies a new view of our contributions. We are no longer preeminent in surgical technique. Other specialties and other societies have caught up with us, and some have passed us in technical excellence. Particularly otolaryngologists and plastic surgeons, despite some overlap with our membership, have their own societies, their own emphases and special interests. Some of you may think our Society is mainly characterized by knowledge and skill in surgical technique: not quite. Skill is only a part of our reason for being. What does uniquely distinguish us is our knowledge of oncology. No other group, specialty or society can rival us there. Oncology is our major interest; it is not the major interest of any other surgical subspecialty except gynecologic oncology. Our preoccupation and fascination with cancer biology of the head and neck gives our organization relevance, essentiality, a highly contributive position and a real distinction and purpose. Our identity as technicians may gradually disappear into the melting pot with other societies and specialties who seek technical proficiency in surgery of the head and neck. We will survive, however, with ever-increasing distinction if we remember that it is our oncologic knowledge that gives us authentic value; we will surely grow in stature if we keep our superiority in head and neck oncology. What guideposts can lead us to chart a more certain course for head and neck cancer surgery during the next 20 years? There exists one guide that is surprising. While searching through some recently compiled data regarding the etiology of head and neck squamous cancer, seeking correlations that may be of value to this group, I came across a predictive indicator for the future that will affect us all. The major cause of the four main head and neck squamous and epidermoid carcinomas, namely those of the oral cavity, the pharynx, the larynx and the esophagus, has now been firmly established: it is tobacco [19]. Alcohol may promote and trauma may increase risk, but after 20 years of research reviews 483
-4
-3
-2
-w
1900
1910
1920
1930
1940 YEAR
1950
Iwo
1970
1979
F/gure 1. Consumption of cigarettes compared with the incidence of iung cancer. The siopes coincide.
by governmental agencies and by individual epidemiologists, reviews of research reports throughout the world, tobacco has emerged as the culprit in these four sites. The causative link between cancer and tobacco was first established for lung cancer. The meteoric rise in the incidence of lung cancer in the last 30 years exactly follows the rise in cigarette consumption (Figure 1). Department of Agriculture data on tobacco [20], (personal communication: Miller RH) and incidence figures from three national cancer surveys (21,221 show parallel curves. Remember to allow 20 years’ lag time between consumption and the development of clinical cancer. There was essentially no commercial cigarette production before 1920 and no reliable incidence figures on lung cancer before 1938. Cigarette consumption and lung cancer are
1900
19~)
wm
1930
w40 VEAR
wso
1960
1970
Importance of Total Tobacco Consumption A look at tobacco consumption from another angle-total tobacco consumption regardless of type-reveals the answer (Figure 4). While cigarette use has increased, total tobacco consumption has not really increased significantly at all. Data covering the last 80 years from the National Economics Division of the U.S. Department of Agriculture (personal communication: Miller RH) show that tobacco consumption was relatively low in 1900, and it did not change from 1910 to 1940, only the form of use changed. Consumption rose in the 1940s during the Second World War, but since 1960 has been declining. Total tobacco consumption in general is a straight line, and the incidence of head and neck squamous cancer is also a relatively straight line; these slopes coincide. Thus when we look at the causative agent for squamous head and neck cancer, we must look at total tobacco consumption, regardless of the type of tobacco. Any type of tobacco including cigarettes reaches the head and neck squa-
1
Figure 2. Consumption of cigarettes compared with the incbnce of head and neck squamous cancer. 77te skyes do not coincide.
484
intimately linked; the slopes of the curves coincide. However, when we look at the incidence of head and neck squamous cancer for the same period, it is astonishing not to find a similar meteoric increase in incidence (Figure 2). If tobacco causes mouth, pharynx, larynx and esophageal cancer as well as lung cancer, and all authorities now accept that it does, why doesn’t it cause those cancers to increase the same as lung cancer? The tobacco tar that causes lung cancer also bathes the head and neck tissues on the way to being trapped in the lungs, and then bathes the same tissues again as it passes out during exhalation (Figure 3). An increase in contact with the causative agent, tobacco tar, must cause an increase in cancers of all tissues reached. But we find no such increase in head and neck cancer, either in incidence [21,22] or mortality [17]. Why not?
Figure 3. Areas through which cigarette tar passes during inhalation and exhalation.
The American Journal ol Surgery
Head and Neck Surgical Oncology
Figure 5. Areas contacted by tobacco tar from consumption of cigars, pipes and chewing tobacco. l900
1910
1920
l930
1940 YEAA
1950
1960
1970
1980
Figure 4. Total consun~W~ of tobacco compared wfth the incklence of squamous cancer of the head and neck. 7he slopes coincide.
mous cancer tissues, the oral cavity, the pharynx, the larynx and the esophagus (Figure 5). Only cigarettes cause lung cancer; all forms of tobacco cause head and neck squamous cancer. If you switch from one form to another but keep total amount about the same, as occurred between 1920 and 1960, there is no variation in the incidence of head and neck squamous cancer. Analysis of the four prominent cancers in the head and neck area (Figure 6) shows that the four lines mimic the composite line; there has been a more or less constant incidence of head and neck squamous cancer for the last 30 or so years. This is true for cancer of the tongue, mouth, pharynx, larynx and esophagus. A further look at total tobacco consumption for the past 20 years shows a rather sharp and steady decline.
In 1979 total tobacco consumption was at its lowest point in this country in the last 80 years. This contradicts the public impression given by tobacco advertising and the prosperous financial reports of tobacco companies. Not since 1900 has total consumption been below 8 pounds per person over age 18. Therefore if this decline in total consumption continues, we must soon see a decline in the incidence of the head and neck squamous cancers, allowing a 20 year lag for the cancer incubation period. If the decline of tobacco consumption flattens out or goes up again, cancers also should return to their present level. But the decline in total tobacco consumption will very likely continue for several reasons: the tobacco industry is using less tobacco per cigarette and is adding more filter space to the length of cigarettes [20], and antitobacco publicity is having some effect. Although the consumption of cigars, pipe tobacco, and particularly chewing tobacco and snuff is on the rise once again (it declined after 1920 when cigarettes began to be popular), the net effect will probably be
50
lo
c
s
w !o i
0
woo
19Kl
1920
1930
l940 YEAR
1950
l960
1970
1990
Figure 6. Consumption of tobacco compared with the inCMencedthelburpnnnlhentcancersoft~headandneck. The slopes coincide.
l9Gil
GO
19io
1930
1940 YEAR
1950
1960
1970
l9m
Figure 7. Consumption of tobacco compared with the mortalfty rate from head and neck cancer In Jefferson County, Kentucky.
405
Moore
a continued decline in total tobacco consumption. We expect this downward trend to continue throughout this century. Allowing for the lag between the beginning of the tobacco decline and its reflection in the incidence of head and neck squamous cancer, the incidence of cancer should begin to decline by 1982 and probably will continue to decline for the rest of this century. I was also interested in my own region’s data (Figure 7). No incidence data are available yet in Kentucky, but the crude mortality rate from head and neck squamous cancer in Jefferson County, Kentucky, has shown a very faint decline for the last 3 years. A lower mortality may already reflect the start of a lower incidence. This may be a significant event in the history of medicine: we have an indicator of the rate of occurrence of a major disease 20 years hence. It proved itself already when the rates of increase of cigarette use and lung cancer slackened together. This trend may be offset by unforeseen events promoting cancer, and the decline may never occur, but it does appear likely. If a decline occurs, it is not what we expected or had dared to hope for. This Society was founded on the belief that the art and science of surgery would eventually lead to more cures of head and neck cancer, causing the mortality to drop and the disease to come under control because of better treatment. This, we trust, is indeed occurring, but surgery probably affects total outcome to a lesser degree than Dr. Martin planned when he conceived of the Society 25 years ago. Yet, if the major factor in ultimate successful control turns out to be reduced exposure to the carcinogenic agent, it is still a happy prospect; the hope of increasing control of this cancer by whatever means is a cause for rejoicing. Meanwhile, our surgery, backed by oncologic knowledge, remains a keystone in treating established cancer. We are improving our cure rates, stimulating earlier diagnosis, performing more effective and appropriate procedures, and achieving better rehabilitation than ever. When we see the patient early and contribute advice to the treatment plan from the very first diagnosis, not always or necessarily surgery, we succeed in curing half of all patients seen today. This was revealed by a recent review of a personal series of 950 patients with squamous head and neck cancer, excluding skin and lip (personal communication: Moore C, Flynn MB, Mullins FX). When we see the patient later, after a single modality decision and treatment have failed, we cure only one quarter of patients.
486
References 1 MacComb WS, Fletcher GH. Planned combrnation of surgery and radiation in treatment of unknown primary head and neck cancers Am J Roentgen01 Radiat Ther Nucl Med 1957;77: 397-414 2. Cady B, Sedgwick CE, Metssner WA, Bookwalter JR, Romagosa V, Werber J Changing clinical, pathologic, therapeutic and survival patterns in differentiating thyroid carcinoma Ann Surg 1976;184:541-53. 3. Foster RS Jr Morbidity and mortality after thyroidectomy Surg Gynecol Obstet 1978;146:423-9 4 Witt TR, Ming RL, Economou SG. Southwick HW. The approach to the irradrated thyroid. Surg Clin North Am 1979;59:4563. 5 Thompson NW, Nishiyama RH, Harness JK. Thyroid carcinoma: current controversies. Curr Probl Surg 1978;15:1-67. 6. Chu W, Strawitz JG. Results in suprahyoid, modified radical, and standard radical neck dtssections for metastatic squamous cell carcinoma: recurrence and survival. Am J Surg 1978; 136512-g. 7 Goodwin WJ, Chandler JR Indications for radical neck dissection following radiation therapy Arch Otolaryngol 1978;104: 367-70 8. Lingeman RE, Helmus C, Stephens R, Helmus C, Ulm J Neck dissection: radical or conservative. Ann Dtol Rhino1 Laryngol 1977;86:737-44. 9. Jesse RH, Lindberg RD The efficacy of combining radiation therapy with a surgical procedure in patients with cervical metastases from squamous carcinoma of the oropharynx and hypopharynx. Cancer 1975;35: 1163-6. 10. Jesse RH, Fletcher GH. Treatment of the neck in patients with squamous cell carcinoma of the head and neck. Cancer 1977,39:868-72 11. Biller HF, Lucente FE. Conservation surgery of the head and neck Semin Oncol 1977;4:365-73. 12 Burns H, Bryce DP, van Nostrand AWP Conservation surgery in laryngeal cancer and its role following failed radiotherapy. Arch Otolaryngol 1979,105:234-9. 13. Ogura JH Hyoid muscle flap reconstruction in subtotal supraglottic laryngectomy: a more rapid rehabilitation of dsglutition. Laryngoscope 1979;89:1522-4. 14. Russ JE, Sullivan C, Gallager HS, Jesse RH. Conservation surgery of the larynx: a reappraisal based on whole organ study Am J Surg 1979;138:588-96. 15. Edgerton MT Jr, Bull JC Jr. General principles in the surgical treatment of patients with head and neck cancer. In: Converse JM, ed Reconstruction and plastic surgery. 2nd ed Philadelphia: WB Saunders, 1977;5:2509-20. 16. A combined guideline from the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery. Washington DC: Joint Council for Approval of Advanced Trainrng In Head and Neck Oncologic Surgery. 17 Luft HS, Bunker JP, Enthoven AS. Should operations be regionalized? The empirical relations between surgical volume and mortality. N Engl J Med 1980;25:1364-9. 18. Longmire WP, Millenkoff SM Regionalization of operations. N Engl J Med 1980;25.1393-4. 19 Smoking and Health-A Report of the Surgeon General. Publication No. 79-50066. Washincrton DC. U.S. Govt Printlna Office U S. Dept HEW, PHS. ?979:l-16-17, l-27, V-321 45. 20. Miller RH. Tobacco use in cigarettes: trends and potentials. Tobacco Situation 1971:137:36-a. 21. Devesa SS, Silverman DT. Cancer incidence and mortality trends in the United States, 1935-74. J Natl Cancer lnst 1978;60:545-71. 22. U.S. National Center for Health Statistics Vital statistics, 1940-1960. pp. 397-402,407-12,1965,1970, 1975, pp. l-92, l-93, l-110, 1-116, l-98, l-99, l-100, l-101.
The American Journal of Surgery
Changing Concepts in Head and Neck Surgical Oncology
Condict Moore, MD, Louisville,
Kentucky
To my great surprise, you have chosen to honor me as the ninth Hayes Martin Lecturer. Thank you sincerely; I can only pretend to deserve it. Hayes Martin was a true giant, bigger than life, and a genuine hero in the history of medicine. As much as any one physician could, he single-handedly developed a field of cancer treatment. Other fine surgeons contributed simultaneously, but Dr. Martin dominated the field. He saw the big picture and at the same time paid the utmost attention to mundane organizational and procedural details. He was an innovator of instruments, a master of office organization, a keen judge of people, an architect of record-keeping systems, and a creator of curative head and neck operative techniques. A diplomate of both the Boards of Surgery and Radiology, he led a life committed to solving the problem of head and neck cancer. One tangible measure of his stature was the calibre of the physicians and others whom he attracted to work with him. Dr. Martin’s staff was composed of men of such ability that they could choose to work with the best, and they chose to work with Hayes Martin. He indeed had a staff of stars. They saw the pioneering challenges as Dr. Martin did and all felt fortunate to work under him. I was privileged to train under him for a full year. His was a developing cancer field with perhaps more promise of success than afforded by any other cancer site. Colleagues in other fields regarded him with awe, so able was he, so single-minded, so meticulously honest. The shadow of this genius of a doctor and surgeon grows larger every year. One of his qualities was always to question dogma but at the same time require rigorous proof for contemplated change. From the Cancer Center, Unwerslty of LowwIle, and the Department of Surgery. University of LouisvilleSchool of Medicine, Health Sciences Center, Louisville, Kentucky Requests for reprints should be addressed to Condict Moore, MD, Cancer Center, Universftyof LouwIle School of Med~cina,Health Sciences Center, Lowville, Kentucky 40292. Presented at the 26th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 14-17, 1980
Fundamental changes are constantly taking place in attitudes and approaches to the treatment and understanding of disease. Changes that affect the treatment of head and neck cancer are no exception. As we point to some changes it may be that Dr. Martin is watching somehow and probably snorting his disagreement, so skeptical was he when upstarts presumed to address weighty problems. History of Head and Neck Cancer A quick review of the history of head and neck cancer treatment over the last 50 years might run something like this: In the 1930s orthovoltage radiation therapy dominated treatment, following Coutard’s fractionation method, curing perhaps one fourth of oral, pharyngeal and laryngeal cancers across the board. In the 194Os, not satisfied with the results, Dr. Martin developed radical surgery, combining wide resection of the primary lesion in continuity with neck dissection for regional metastases. This combined procedure was made possible by transfusions, blood banks, antibiotics and progress in anesthesia. It was a cancer pioneering era where a “one operation fits all” philosophy prevailed. More cures resulted. But the combined procedure was applied indiscriminately, and complications were severe and frequent. In the 1950s radiation therapy equipment took a leap forward, led by MacComb and Fletcher [I]; a combination of radiotherapy and surgery began to receive attention and trial. Intensive training of radiotherapists began. Treatment results again improved. In the 1960s specialties other than general surgery began to contribute. The desirability for immediate repair of large defects of the head and neck became evident and regional skin flap repairs were developed. Conservation laryngeal surgery emerged as a demonstrated advance. Reconstruction made marked progress with the formal recognition and training of maxillofacial prosthetics specialists. The need for cancer education of dental students was recognized. In the 1970s adjuvant chemotherapy The American Journal of Surgery
Head and Neck Surgical Oncology
became established. The staging of disease was standardized and validated, modifications of radical surgery became popular and clinical trials were developed. In the 1980s we can look forward to more triple modality protocol studies for advanced disease, the development of centers for head and neck excellence and finally, a matter I will speak about later, a lowered incidence of squamous cancer beginning in this decade. Several of these trends deserve attention in some detail because they are exerting major effects on the future of the practice of surgical oncology of the head and neck. Trend Toward Conservation First, surgical procedures for head and neck cancer are becoming more varied, more custom-designed for individual patients and particular stages of disease, and generally more conservative; increasing emphasis falls on conservation of function and cosmetic appearance. This trend does not imply devaluation of wide resections for patients whose bulky localized cancer justifies it. The trend does, however, recognize that wider and wider resectional surgery does not necessarily result in more cures. In surgery for differentiated cancer of the thyroid gland, for instance, total thyroidectomies are performed less often, according to recent reports. Cady et al [2] report on almost 800 differentiated thyroid cancers over a 40 year period, noting the lack of improved results when surgery was at its most radical in the 1940s and 1950s. He also noted that there have been fewer regional metastases in recent years and that the incidence of undifferentiated or incurable types is lower. Total throidectomy occupies an increasingly limited role because the incidence of complications is far higher in total than in subtotal thyroidectomy, as reported by Foster [3]. Neck dissections that conserve function are becoming the rule, generally only for patients with proved metastases [4]. These developments toward conservation surgery result from careful reporting and reviews of thousands of operated cases, careful long-term follow-up and an increased understanding of the pathophysiology of differentiated thyroid cancer [5]. Of course, papillary and follicular thyroid cancer is a special, unique tumor. But when Dr. Martin was pioneering radical surgery for head and neck squamous cancer, surgeons and the medical profession at large had great faith in the principle that there was one ideal operation for every condition. Enterprising surgeons could do no better than to find that operation. In those days all cancers of the breast were treated religiously with radical mastectomy. Today’s head and neck surgeon abandons as simplistic the Volume 140, October 1980
inviolability of the concept of incontinuity resection and node dissection. More and more often he designs custom-made procedures for each patient and his cancer. Many surgeons say they seldom perform exactly the same operation twice. Furthermore, partial neck dissections, more conservative neck dissections and far fewer prophylactic neck dissections are becoming the rule for N-l neck disease in squamous cancer as well as thyroid cancer [6-81. Part of this is explained by the increased use of combined radiation and surgery regimens and prophylactic radiation to neck nodes, [9] strategies pioneered by Jesse and Fletcher [IO] and others. Conservation surgery for the larynx was developed in the 1960s largely by our otolaryngologic colleagues [11--131. Partial laryngectomy and other functionsparing procedures constitute a landmark contribution to our craft and to the cancer patient. Thus the modern head and neck surgeon needs skill, training and a whole arsenal of procedures to provide the patient with the best end result. The conservative trend results from careful studies showing that conservation surgery works under strictly defined conditions. At least 1 in 10 patients with laryngeal cancer referred to large cancer centers can safely undergo voice-sparing operations [14]. A review of reports on head and neck surgery in 10 leading national journals in the last 3 years confirms that conservation is the conceptual background that dominates the thought and study of leaders in our field. However, two caveats about conservation surgery need emphasis. The studies that lead us into more conservative resections in selective instances should not be extrapolated to support so-called debulking surgery or cytoreductive surgery. This quasipalliative surgery is another matter. It remains in a controversial and anecdotal stage at present and does not fit into any permanent trend. A second &ning bears repetition: conservation cancer surgery in the head and neck requires twice as much experience and skill as so-called radical surgery. Head and Neck Cancer Centers This swing toward conservation surgery is of primary importance. A second important development in the decade of the 1970s has been the formation of more medical centers in the United States, centers that can deliver the best complicated treatment of major disease, especially cancer centers. Of course, centers have become so popular that every small and medium-sized community hospital is changing its name to “center.” The word has become a status symbol, and the public is now looking to centers for the ultimate in medical care. Regardless of the difficulty in defining a “center” and regardless of mis481
Moore
applications of the term, large medical centers have a growing role in this country’s medical organization. These tertiary care facilities handle certain illnesses that cannot be ideally managed in smaller, simpler settings. In the cancer field, pediatric oncology constitutes a good example of the reasons for the center trend. The overwhelming majority of informed opinion now favors treating all childhood cancer in centers. The startling advances in the cure of childhood cancer depend on several types of highly trained superspecialists acting together as a treatment team. Childhood cancer centers bring together under one roof knowledgeable radiotherapists, chemotherapists, oncologic nurses and ancillary personnel as well as experienced pediatric surgeons. This is only possible when there is sufficient volume to support this team of experts, who can then concentrate on the narrow field of pediatric oncology. Head and neck cancer is also now emerging as a complex problem requiring combined modality treatment planning, albeit with the head and neck oncologic surgeon often the leader. It seems to need the same pattern of care as pediatric cancer. Although increased cures from complex treatment planning have not equalled pediatric cancer results, progress has been made. From our training, experience and observation of the development of oncologic science, we believe strongly that all stage II, III and IV head and neck cancers should be seen in centers of head and neck oncologic excellence before treatment is started. Patients need not always be treated at such centers because a complex of surgery, radiation and complicated rehabilitation may not be part of the initial treatment plan, but such patients need to be first seen at a center to receive ideal advice at the very outset when the chance for cure is greatest. Is it really necessary for all stage II and higher patients to travel distances, to undergo repeated scrutiny, second opinions, delay, inconvenience and expense? The answer is yes. One physician can no longer decide at initial diagnosis, before treatment is instituted, whether or not various methods of treatment and oncologic specialists will be beneficial. And certainly it is a disservice to the patient to assume that if simple local treatment will not cure, nothing will. No one physician can keep abreast of recent advances in all aspects of cancer treatment. The treatment team can only be of real help to a patient when asked to see the patient at the initial planning stages. Their combined report becomes a consultation and goes to the referring physician, who then decides whether or not to follow the consultants’ advice. Unfortunately, the way the medical profes482
sion in America often uses oncologic head and neck specialists is as medical priests to administer last rites the day before death. Some physicians still feel that cancer only becomes complicated enough for expert opinion when it is hopeless; this is an insult to our training and our common sense. Head and neck cancer is usually highly complicated to manage, ideally demanding six or seven superspecialists to work as a team for a given patient, and only centers of oncologic excellence have the volume of patients to support these many skills and services. They consist of a head and neck oncologic surgeon, the tumor pathologist who is also skilled in frozen-section analysis and works with the surgeon, the radiotherapist with his assorted machines and techniques, a medical oncologist trained in the use of increasingly more effective drugs, nutrition experts, dentists, maxillofacial prosthetics, speech therapists, social workers, counselors and so on. Some unique advances and teams have been developed in centers; one example is the free flap reconstruction work by Acland and Flynn at the University of Louisville. Edgerton and Bull [15] well described the predicament of head and neck cancer management in the decade of the 19709, a predicament of uneven and inadequate care in a variety of settings where happenstance may have had more to do with outcome than professional judgment. The American College of Surgeons Commission on Cancer developed guidelines for cancer care in the early 1970s; there followed several combined society meetings on head and neck cancer. The conclusions reached at these meetings were that the major national fault was conflicting and overlapping training requirements in different specialties and in different institutions concerned with head and neck cancer. This society then made a concerted effort to remedy the problem by having repeated joint meetings with colleagues in other specialties and by jointly developing training guidelines (161. The response to reorganization through these training guidelines has been spotty; progress may be slow in the future. Only 13 institutions have applied for review: 11 were reviewed, 8 of which were approved and 3 deferred (personal communication: Lore JM Jr.). Most of the highly qualified institutions with a large volume of head and neck cancer cases simply failed to request review. Some joint pilot programs have been started that are bound to be beneficial. However, these efforts rely on the force of persuasion of national societies and their policy-making elder statesmen. Such persuasion is not quickly or widely effective. We need a new approach to remedy the unevenness and inadequacy of head and neck cancer care. The American Journal ol Surgaty
Head and Neck Surgical Oncology
Frequency-Sensitive
Operations
A recent study from Stanford and the University of California, San Francisco [17] indicates that certain surgical procedures carry a lower mortality when performed in larger institutions with a high volume of such surgery than in smaller institutions with a lower volume. Certain operations such as coronary bypass, open heart procedures and transuretheral resection of the prostate are “frequency-sensitive” procedures, most safely done in centers that perform 200 or more a year. Other operations such as cholecystectomy are not sensitive to the volume of such surgery and can be as safely done in a small as in a large institution. The authors estimate that 20 to 30 percent of deaths from frequency-sensitive operations in small, low volume institutions would be prevented if done in large centers. Morbidity variations in large and small institutions would no doubt follow suit. We suggest the initiation of a study of head and neck cancer surgery following the general pattern of the California study. This Society could make a real contribution, in addition to its training guidelines, by studying the mortality, morbidity and cures of major head and neck operations in large and small institutions, to establish the degree of “frequencysensitivity” of these operations. It could also develop and promulgate suggested standards for an institution to carry out these procedures, as suggested by the thoughtful editorial by Longmire and Millenkoff [18] in the New England Journal of Medicine, in which they comment on the frequency-sensitivity study. The California study did not include head and neck procedures. The American Medical Association and the American College of Surgeons probably will not devote further attention to our relatively small field by developing new standards for it. None of us wants the government to do it. Most professional and community leaders expect a national society such as ours to perform this function. Once the facts are in, the chips must then fall where they may. Each region will have to make its own compromises with the ideal, but a study is needed to define the ideal and make it common knowledge. If head and neck cancer has a complexity of management that causes it to emerge as a “fredisease, this quency-sensitive, ” “center-sensitive” knowledge may, more than any other measure, bring peer pressure to bear and lead to a sensible reordering of treatment planning patterns. Public pressure might also result, causing the medical profession as a whole and institutions, large and small, to take a new, hard look at their management practices. To the contrary, if head and neck surgery and full treatment volume 140, October 1980
management emerge as not frequency-sensitive and center-sensitive, then we should stop worrying about this problem and get on to other things. But in the meantime, we can only plan, teach, organize, operate and lead newcomers to our field to work in centers where a critical mass of skills and interests exists, thereby giving patients what we now believe to be the best that modern medicine can offer. Head and Neck Oncology The foregoing discussion touches on the future policies and plans and missions of this Society. We cannot help but mention another somewhat unsuspected trend in head and neck surgery that implies a new view of our contributions. We are no longer preeminent in surgical technique. Other specialties and other societies have caught up with us, and some have passed us in technical excellence. Particularly otolaryngologists and plastic surgeons, despite some overlap with our membership, have their own societies, their own emphases and special interests. Some of you may think our Society is mainly characterized by knowledge and skill in surgical technique: not quite. Skill is only a part of our reason for being. What does uniquely distinguish us is our knowledge of oncology. No other group, specialty or society can rival us there. Oncology is our major interest; it is not the major interest of any other surgical subspecialty except gynecologic oncology. Our preoccupation and fascination with cancer biology of the head and neck gives our organization relevance, essentiality, a highly contributive position and a real distinction and purpose. Our identity as technicians may gradually disappear into the melting pot with other societies and specialties who seek technical proficiency in surgery of the head and neck. We will survive, however, with ever-increasing distinction if we remember that it is our oncologic knowledge that gives us authentic value; we will surely grow in stature if we keep our superiority in head and neck oncology. What guideposts can lead us to chart a more certain course for head and neck cancer surgery during the next 20 years? There exists one guide that is surprising. While searching through some recently compiled data regarding the etiology of head and neck squamous cancer, seeking correlations that may be of value to this group, I came across a predictive indicator for the future that will affect us all. The major cause of the four main head and neck squamous and epidermoid carcinomas, namely those of the oral cavity, the pharynx, the larynx and the esophagus, has now been firmly established: it is tobacco [19]. Alcohol may promote and trauma may increase risk, but after 20 years of research reviews 483
-4
-3
-2
-w
1900
1910
1920
1930
1940 YEAR
1950
Iwo
1970
1979
F/gure 1. Consumption of cigarettes compared with the incidence of iung cancer. The siopes coincide.
by governmental agencies and by individual epidemiologists, reviews of research reports throughout the world, tobacco has emerged as the culprit in these four sites. The causative link between cancer and tobacco was first established for lung cancer. The meteoric rise in the incidence of lung cancer in the last 30 years exactly follows the rise in cigarette consumption (Figure 1). Department of Agriculture data on tobacco [20], (personal communication: Miller RH) and incidence figures from three national cancer surveys (21,221 show parallel curves. Remember to allow 20 years’ lag time between consumption and the development of clinical cancer. There was essentially no commercial cigarette production before 1920 and no reliable incidence figures on lung cancer before 1938. Cigarette consumption and lung cancer are
1900
19~)
wm
1930
w40 VEAR
wso
1960
1970
Importance of Total Tobacco Consumption A look at tobacco consumption from another angle-total tobacco consumption regardless of type-reveals the answer (Figure 4). While cigarette use has increased, total tobacco consumption has not really increased significantly at all. Data covering the last 80 years from the National Economics Division of the U.S. Department of Agriculture (personal communication: Miller RH) show that tobacco consumption was relatively low in 1900, and it did not change from 1910 to 1940, only the form of use changed. Consumption rose in the 1940s during the Second World War, but since 1960 has been declining. Total tobacco consumption in general is a straight line, and the incidence of head and neck squamous cancer is also a relatively straight line; these slopes coincide. Thus when we look at the causative agent for squamous head and neck cancer, we must look at total tobacco consumption, regardless of the type of tobacco. Any type of tobacco including cigarettes reaches the head and neck squa-
1
Figure 2. Consumption of cigarettes compared with the incbnce of head and neck squamous cancer. 77te skyes do not coincide.
484
intimately linked; the slopes of the curves coincide. However, when we look at the incidence of head and neck squamous cancer for the same period, it is astonishing not to find a similar meteoric increase in incidence (Figure 2). If tobacco causes mouth, pharynx, larynx and esophageal cancer as well as lung cancer, and all authorities now accept that it does, why doesn’t it cause those cancers to increase the same as lung cancer? The tobacco tar that causes lung cancer also bathes the head and neck tissues on the way to being trapped in the lungs, and then bathes the same tissues again as it passes out during exhalation (Figure 3). An increase in contact with the causative agent, tobacco tar, must cause an increase in cancers of all tissues reached. But we find no such increase in head and neck cancer, either in incidence [21,22] or mortality [17]. Why not?
Figure 3. Areas through which cigarette tar passes during inhalation and exhalation.
The American Journal ol Surgery
Head and Neck Surgical Oncology
Figure 5. Areas contacted by tobacco tar from consumption of cigars, pipes and chewing tobacco. l900
1910
1920
l930
1940 YEAA
1950
1960
1970
1980
Figure 4. Total consun~W~ of tobacco compared wfth the incklence of squamous cancer of the head and neck. 7he slopes coincide.
mous cancer tissues, the oral cavity, the pharynx, the larynx and the esophagus (Figure 5). Only cigarettes cause lung cancer; all forms of tobacco cause head and neck squamous cancer. If you switch from one form to another but keep total amount about the same, as occurred between 1920 and 1960, there is no variation in the incidence of head and neck squamous cancer. Analysis of the four prominent cancers in the head and neck area (Figure 6) shows that the four lines mimic the composite line; there has been a more or less constant incidence of head and neck squamous cancer for the last 30 or so years. This is true for cancer of the tongue, mouth, pharynx, larynx and esophagus. A further look at total tobacco consumption for the past 20 years shows a rather sharp and steady decline.
In 1979 total tobacco consumption was at its lowest point in this country in the last 80 years. This contradicts the public impression given by tobacco advertising and the prosperous financial reports of tobacco companies. Not since 1900 has total consumption been below 8 pounds per person over age 18. Therefore if this decline in total consumption continues, we must soon see a decline in the incidence of the head and neck squamous cancers, allowing a 20 year lag for the cancer incubation period. If the decline of tobacco consumption flattens out or goes up again, cancers also should return to their present level. But the decline in total tobacco consumption will very likely continue for several reasons: the tobacco industry is using less tobacco per cigarette and is adding more filter space to the length of cigarettes [20], and antitobacco publicity is having some effect. Although the consumption of cigars, pipe tobacco, and particularly chewing tobacco and snuff is on the rise once again (it declined after 1920 when cigarettes began to be popular), the net effect will probably be
50
lo
c
s
w !o i
0
woo
19Kl
1920
1930
l940 YEAR
1950
l960
1970
1990
Figure 6. Consumption of tobacco compared with the inCMencedthelburpnnnlhentcancersoft~headandneck. The slopes coincide.
l9Gil
GO
19io
1930
1940 YEAR
1950
1960
1970
l9m
Figure 7. Consumption of tobacco compared with the mortalfty rate from head and neck cancer In Jefferson County, Kentucky.
405
Moore
a continued decline in total tobacco consumption. We expect this downward trend to continue throughout this century. Allowing for the lag between the beginning of the tobacco decline and its reflection in the incidence of head and neck squamous cancer, the incidence of cancer should begin to decline by 1982 and probably will continue to decline for the rest of this century. I was also interested in my own region’s data (Figure 7). No incidence data are available yet in Kentucky, but the crude mortality rate from head and neck squamous cancer in Jefferson County, Kentucky, has shown a very faint decline for the last 3 years. A lower mortality may already reflect the start of a lower incidence. This may be a significant event in the history of medicine: we have an indicator of the rate of occurrence of a major disease 20 years hence. It proved itself already when the rates of increase of cigarette use and lung cancer slackened together. This trend may be offset by unforeseen events promoting cancer, and the decline may never occur, but it does appear likely. If a decline occurs, it is not what we expected or had dared to hope for. This Society was founded on the belief that the art and science of surgery would eventually lead to more cures of head and neck cancer, causing the mortality to drop and the disease to come under control because of better treatment. This, we trust, is indeed occurring, but surgery probably affects total outcome to a lesser degree than Dr. Martin planned when he conceived of the Society 25 years ago. Yet, if the major factor in ultimate successful control turns out to be reduced exposure to the carcinogenic agent, it is still a happy prospect; the hope of increasing control of this cancer by whatever means is a cause for rejoicing. Meanwhile, our surgery, backed by oncologic knowledge, remains a keystone in treating established cancer. We are improving our cure rates, stimulating earlier diagnosis, performing more effective and appropriate procedures, and achieving better rehabilitation than ever. When we see the patient early and contribute advice to the treatment plan from the very first diagnosis, not always or necessarily surgery, we succeed in curing half of all patients seen today. This was revealed by a recent review of a personal series of 950 patients with squamous head and neck cancer, excluding skin and lip (personal communication: Moore C, Flynn MB, Mullins FX). When we see the patient later, after a single modality decision and treatment have failed, we cure only one quarter of patients.
486
References 1 MacComb WS, Fletcher GH. Planned combrnation of surgery and radiation in treatment of unknown primary head and neck cancers Am J Roentgen01 Radiat Ther Nucl Med 1957;77: 397-414 2. Cady B, Sedgwick CE, Metssner WA, Bookwalter JR, Romagosa V, Werber J Changing clinical, pathologic, therapeutic and survival patterns in differentiating thyroid carcinoma Ann Surg 1976;184:541-53. 3. Foster RS Jr Morbidity and mortality after thyroidectomy Surg Gynecol Obstet 1978;146:423-9 4 Witt TR, Ming RL, Economou SG. Southwick HW. The approach to the irradrated thyroid. Surg Clin North Am 1979;59:4563. 5 Thompson NW, Nishiyama RH, Harness JK. Thyroid carcinoma: current controversies. Curr Probl Surg 1978;15:1-67. 6. Chu W, Strawitz JG. Results in suprahyoid, modified radical, and standard radical neck dtssections for metastatic squamous cell carcinoma: recurrence and survival. Am J Surg 1978; 136512-g. 7 Goodwin WJ, Chandler JR Indications for radical neck dissection following radiation therapy Arch Otolaryngol 1978;104: 367-70 8. Lingeman RE, Helmus C, Stephens R, Helmus C, Ulm J Neck dissection: radical or conservative. Ann Dtol Rhino1 Laryngol 1977;86:737-44. 9. Jesse RH, Lindberg RD The efficacy of combining radiation therapy with a surgical procedure in patients with cervical metastases from squamous carcinoma of the oropharynx and hypopharynx. Cancer 1975;35: 1163-6. 10. Jesse RH, Fletcher GH. Treatment of the neck in patients with squamous cell carcinoma of the head and neck. Cancer 1977,39:868-72 11. Biller HF, Lucente FE. Conservation surgery of the head and neck Semin Oncol 1977;4:365-73. 12 Burns H, Bryce DP, van Nostrand AWP Conservation surgery in laryngeal cancer and its role following failed radiotherapy. Arch Otolaryngol 1979,105:234-9. 13. Ogura JH Hyoid muscle flap reconstruction in subtotal supraglottic laryngectomy: a more rapid rehabilitation of dsglutition. Laryngoscope 1979;89:1522-4. 14. Russ JE, Sullivan C, Gallager HS, Jesse RH. Conservation surgery of the larynx: a reappraisal based on whole organ study Am J Surg 1979;138:588-96. 15. Edgerton MT Jr, Bull JC Jr. General principles in the surgical treatment of patients with head and neck cancer. In: Converse JM, ed Reconstruction and plastic surgery. 2nd ed Philadelphia: WB Saunders, 1977;5:2509-20. 16. A combined guideline from the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery. Washington DC: Joint Council for Approval of Advanced Trainrng In Head and Neck Oncologic Surgery. 17 Luft HS, Bunker JP, Enthoven AS. Should operations be regionalized? The empirical relations between surgical volume and mortality. N Engl J Med 1980;25:1364-9. 18. Longmire WP, Millenkoff SM Regionalization of operations. N Engl J Med 1980;25.1393-4. 19 Smoking and Health-A Report of the Surgeon General. Publication No. 79-50066. Washincrton DC. U.S. Govt Printlna Office U S. Dept HEW, PHS. ?979:l-16-17, l-27, V-321 45. 20. Miller RH. Tobacco use in cigarettes: trends and potentials. Tobacco Situation 1971:137:36-a. 21. Devesa SS, Silverman DT. Cancer incidence and mortality trends in the United States, 1935-74. J Natl Cancer lnst 1978;60:545-71. 22. U.S. National Center for Health Statistics Vital statistics, 1940-1960. pp. 397-402,407-12,1965,1970, 1975, pp. l-92, l-93, l-110, 1-116, l-98, l-99, l-100, l-101.
The American Journal of Surgery