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Head & neck cancer surgery


In contrast to other malignancies, head and neck cancers can impact upon the senses like no other. A greater understanding of these cancers will help raise awareness and ultimately improve patient outcomes


O


ur ability to interact with friends, family and loved ones routinely involves all of the fi ve


senses. Cancers of the head and neck have the ability to impact upon these. T ey comprise a heterogeneous group which includes tumours of the mouth, throat, neck, sinuses and ears. T e traditional risk factors of


smoking and alcohol are still recog- nised,


however as health-related


behaviours have changed and people adopt a healthier lifestyle, there has been a decline in smoking-related head and neck cancers. With human papil- loma-related head and neck cancers on the rise, doctors are encountering an increasing incidence of oropharyn- geal


cancers. HPV-related cancers MR PRIY SILVA MD FRCS


After graduating as a doctor more than 20 years ago, Mr Priy Silva undertook his surgical training in Manchester, working with a number of leaders in the fi eld. He then undertook a two-year period of research into head and neck cancers. These years spent in basic science cancer research helped cement an academic understanding of the area and led to an MD and a number of presentations and publications both nationally and internationally. Mr Silva then spent a further two years of advanced surgical training in head and neck surgery in Oxford and a further year in Brisbane Australia. This surgical experience has allowed the development of a wide experience base in the management of the entire 360 degrees of ENT and head and neck pathologies. Now permanently based in Oxford for over 10 years, Mr Silva is fortunate to work as part of a team in a renowned head and neck centre. Apart from being fully trained in general ENT, his areas of interest also include tumours of the head and neck as well as those of the anterior and lateral skull base.


are related to orogenital contact and number of sexual partners. In the long term, the role of the HPV vaccine may aid in reducing this rising trend of HPV-related cancers. Cancers in the head and neck are


relatively rare, with the average GP encountering just one head and neck cancer patient in the whole of their careers; nevertheless, the impact of delayed diagnosis or presentation is signifi cant.


Patient journey T e pathway of the patient from presenting with a symptom of concern to seeing the appropriate specialist and commencing treatment can be beset on all sides by many challenges. Delays in diagnosis aren’t uncommon. T is may represent a lack of knowl-


edge or experience in the health care practitioner. Increased work in both the primary and secondary care setting has helped to increase awareness and reduce the challenges of this. For the individual who now has


become a patient, fear of the unknown and what may lay ahead can result in a delay in seeking help. Unfortunately, delays may result in later stages at presentation and a potential change in the overall outcome. Once the patient has seen the appropriate specialist, the process of having investigations, biopsies and treatment can be under- taken expediently.


As with all cancers, the diagnosis


can be overwhelming and it’s imper- ative that the patient is appropri- ately supported. A multidisciplinary team (MDT) comprising the cancer specialist nurse, dietician, speech and language therapist and psychologist are typically on hand to provide this, supporting the


treatment provided


by the surgeon and oncologist. While surgery is an important facet of the treatment, it’s important to be cognisant of the wider impact that treatment may have on the individual. T e team is crucial in undertaking this. T e support of the patient doesn’t end with the treatment and continues with regular follow-up and manage- ment of any problems by the MDT team should and when they occur. T e drive for a holistic approach has led to a move away from how such patients were managed historically and resulted in an overall better expe- rience for the patient.


The professional context In contrast to other surgical disci- plines, head and neck


surgery and specifi c is


practiced by a number of diff erent specialities including ENT, maxillofa- cial and plastic surgeons. Anatomical boundaries


expertise


exist, which may help to determine who is involved in your care, but the experience of the treating surgeon may also infl uence that.


T ere has been an increasing drive


in recent years to ensure that exper- tise in an area is practiced by those who defi nitely have this. T e centrali- sation of cancer services and the crea- tion of MDTs have served to reduce the outliers, who may not have practiced within these boundaries in the past. Ultimately, the aim is to create a stand- ardisation of service and a uniform high quality of care. T e creation of interface training programmes, where trainee surgeons spend time in all these three subspecialties, has helped to facilitate this and increase dialogue among the various groups. In Oxford, there is a single head and


neck cancer centre where all the three subspecialties, including oncology, are co-located. T is has allowed for a greater patient experience and better quality of care and the development of a cohesive unit.


The future While the principles of surgery may not have changed signifi cantly, the advent of the robot and the parallel technical advancements have led to a paradigm shift in the way in which certain cancers are managed. T e ability to access areas of the


head and neck without causing signif- icant morbidity has improved the outcome for most patients. Areas in the back of the throat, around the tongue and tonsil, can now be safely accessed, without having to under- take surgery that may have otherwise signifi cantly


impacted on speech,


swallow and appearance. Moving away from 12-hour operations and prolonged hospital stays has led to quicker recovery for the patient and generally better outcomes. T is tech- nology, which was initially driven by and invested in by the military for managing battlefi eld trauma remotely, has progressed rapidly. T e robot has become an increasing part of the armamentarium of the head and neck cancer surgeon. T e advent of microvascular-free reconstructive


fl ap surgery has


Cancers in the head and neck are relatively rare, with the average GP encountering one head and neck cancer patient in the whole of their careers; nevertheless, the impact of delayed diagnosis or presentation is signifi cant


revolutionised head and neck cancer practice. While removal of a tumour is a major part of cancer surgery, the reconstruction of the area is similarly important albeit for entirely diff erent reasons. T e ability to tailor the recon- struction according to the area and avoiding a one-size-fi ts-all approach is often a refl ection of the expertise of the team. In Oxford, Mr Silva is fortunate to work with a highly skilled reconstructive team who are able to off er the full range of reconstruc- tive techniques including both local and free fl ap reconstruction as well as facial nerve reconstruction when facial


function might be aff ected.


Novel as well as well-established tech- niques have been tried and tested. T e oncological team who are


involved in non-surgical treatments, are increasingly able to tailor the treatment modalities available to the patient, which can result in improved outcomes, even when surgery or cura- tive treatment may not be an option. T e role of biological and immuno- logical therapies have altered the way in which some of these patients are managed. T e large number of trials within head and neck have opened up options for patients, which until now didn’t exist.


Final comments T ere’s a lack of recognition and limited awareness of head and neck cancers. As with all cancers, early diagnosis is crucial. T e importance of seeing the appropriate doctor as soon as possible can result in a better outcome both oncologically and func- tionally. While other cancers may be at the forefront of many people’s minds, head and neck cancers have the ability to impact function, form and all fi ve senses like no other.


Genesis Care Oxford/ Nuffi eld Health Oxford oxfordheadandnecksurgeon.co.uk T: 01865 307556 E: natasha.edmonds@ nuffi eldhealth.com


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