At the outset it should be stated that there exists no ideal treatment for these cancers. The primary aim is, of course, cure. However, a quality of life issue is always paramount in making the appropriate therapeutic decision. If at all possible, mutilation and profound impairment of function should be avoided unless deemed absolutely necessary. A classic example is a patient with carcinoma of the larynx, which might have been treated with a total laryngectomy in years gone by; today every effort is made to preserve function by using radiation therapy or performing a conservation laryngectomy. Because of the difficulty in making these decisions, it is essential that these patients be managed only by the most experienced oncologists, preferably in a multidisciplinary setting.
Primary prevention of these cancers is theoretically an achievable goal by eliminating or significantly limiting tobacco and alcohol consumption. However, this obvious solution continues to elude us, despite increased public awareness. Various attempts at chemoprevention continue to be investigated, using various antioxidants, particularly vitamin A derivatives, but definitive studies have not yet been conclusive as to their efficacy.
The ideal treatment for an individual patient depends on tumor, physician, and patient factors. Tumor factors include site, size, histologic variant, and tumor behavior. Patient factors include the general medical condition, emotional status (i.e., ability to tolerate radical therapy), and the support system available (i.e., home circumstances and family support). Physician factors include the philosophy and experience of the oncologist and the facilities available for treatment. The accepted modalities available include surgery, radiation therapy, and chemotherapy, either on their own or in various combinations. In general, early cancers are treated with surgery or radiation therapy with equal survival rates, with the therapy in any given patient depending on the previously mentioned factors. Exceptions include lymphoepithelioma, which is treated with radiation therapy, irrespective of size and site, with good results, and verrucous carcinoma, which conversely is treated with surgery, irrespective of size. Advanced cancers usually require combination therapy with surgery followed by postoperative radiotherapy being the standard approach.
In general, the basic surgical premise is to remove the cancer with an adequate margin of normal tissue, reconstructing the defect created by primary closure, skin graft, and regional or revascularized distant flaps. Frequently these resections and reconstructions permit the patient almost normal residual function and adequate quality of life. Sometimes these operations may be mutilating (e.g., total laryngectomy or total glossectomy). These situations have stimulated contemporary oncologists to attempt organ preservation approaches using a combination of chemotherapy and radiation therapy. However, it still remains unclear whether this trend ultimately will result in equal or better cure rates or whether the adjunct chemotherapy is in fact superfluous.
The treatment of the cervical lymph nodes is likewise mired in controversy with overt nodal metastases usually treated with a neck dissection - selective, modified radical, or radical removal of the involved nodes. If no palpable nodal metastases are noted, radiation therapy, observation, or neck dissection is employed, depending on the size, site, and type of primary tumor and the philosophy of the oncologist.
Adequate rehabilitation is the key to the management of these patients with emphasis on physical, functional, psychosocial, and occupational rehabilitation. This requires a team approach of dedicated health care professionals including physical therapists, speech and swallowing therapists, psychologists, social workers, nurses, and prosthodontist.
All patients should be followed up for life with frequent visits, particularly in the first 2 years, when the risk of recurrence is greatest. There is always a risk for the development of a second cancer up to 20 years later, particularly if the patient continues to smoke.
Revision date: July 9, 2011
Last revised: by Jorge P. Ribeiro, MD