To resect or not to resect?July 16, 2018
Head & neck cancer surgeons debate the feasibility of `compartment resection’ in oral cancer
Compartment resection in oral cancers, which involves the removal of a whole compartment of the oral cavity to prevent the cancer from recurring, continues to divide the surgeon community, going by discussions this year’s at Cancon, held in Bengaluru on 23-24 June.
While many surgeons, especially younger ones, preferred to resort to the technique to prevent a recurrence of the cancer, many of the traditional practitioners were skeptical.
Resection often results in the patient being unable to speak intelligibly, and in some cases, not even being able to swallow food, forcing the patient to be relied on feeding tubes for the rest of his life.
However, recurrence is a big risk faced by oral cancer patients, and doctors often resort to removing not only the cancerous part, but also any potential site of recurrence.
“Whichever is the site which is tumorous, whichever is the site which may harbour it, it has to be removed,” pointed out Dr. Pankaj Chaturvedi, a head and neck cancer surgeon at Tata Memorial Hospital in Mumbai and one of the most famous cancer specialists in India.
On the other hand, the extensive use of the technique was opposed by those like Dr. Rajendra Toprani, veteran cancer surgeon at HCG Ahmedabad, who argued that a cure that left the patient completely debilitated was no cure at all.
“Whichever is the site which is tumorous, whichever is the site which may harbour it, it has to be removed”
Dr. Pankaj Chaturvedi
Head and Neck cancer surgeon at Tata Memorial Hospital, Mumbai
“We need to be honest with the patient and relatives about the morbidity rates and what quality of life they can expect”
Dr. Rajendra Toprani
Cancer Surgeon, HCG Ahmedabad
He also said there was no ‘head-to-head comparison’ that showed that the technique reduced recurrences, and removing an entire compartment to cure cancer was like ‘destroying the whole forest’ to make a road through it.
“These surgeries are not without a bad morbidity,” Toprani said. “We need to be honest with the patient and relatives about the morbidity rates and what quality of life they can expect.”
Toprani’s stand was opposed by practitioners such as Dr. Moni Kuriakose of Cochin Cancer Research Center — one of India’s top cancer surgeons — who pointed out that if a person’s life can be saved, it should be saved, without worrying about quality of life.
“We must not give up on a patient,” he said, adding that he too was advocating the procedure only for stage 3 and stage 4 cases. “We can only talk about quality of life for a live person. A dead person does not have quality of life.”
Dr. Anil D Cruz, director at Tata Memorial Hospital acknowledged that the industry was divided about the use of the procedure.
He said nobody disputes the need for surgery “in 99% of the cases”.
“There is a big fight about the extent of resection. Youngsters want to push the boundary more and more. People who are more mellow, want to be more circumspect,” he said, adding that sometimes, removing a tumour doesn’t always result in a better outcome for the patient.
For doctors like Krishnakumar Thankappan of Amrita Institute of Medical Sciences at Kochi, the discussions provided valuable insights into the technique.
“It’s a new concept that’s coming in how to clear the disease,” he said.
“The attendees brought an insight into the usefulness of the procedure and how that will improve the outcomes.”
Dr. Moni Kuriakose
Cochin Cancer Research Center., Kochi
India’s HNC burden
Carcinoma of the head and neck constitute nearly one-third of all cancers in India. Whereas, it is only 4–5% in the developed world. Even though the cancer burden is significantly high, there is no specific guidelines to manage head and neck carcinoma (HNC) in India. Currently, the management of HNC is dictated by guidelines from the west since there are only a few seminal publications from India.
The western world could successfully bring down the incidence of HNC by decreasing use of tobacco over the last few decades. The government of India has initiated some attempts to cut tobacco use. It is yet to make the desired impact, considering the magnitude of the problem.
In India, majority of cancers present as locally advanced Stage III/ IV disease. Most efforts usually focus on therapy and outcomes in India. Emphasis is still needed for early detection.
A randomized controlled trial conducted in the southern Indian state of Kerala showed a reduction in mortality from oral cancers in high-risk individuals subjected to screening by trained health workers. Measures such as opportunistic screening among high-risk individuals or mouth self-examination are considered cost-effective alternatives.
Courtesy: South Asian Journal of Cancer