As we ponder which of the approaches to advocate for our patients, it is important to have clear in our mind what ultimately determines success. Survival has always been the gold standard by which a particular therapy has been judged. However, in these advanced cancers there is no clear-cut evidence that any one approach offers a better chance at survival. In fact, as stated by Weymuller in 1994,18 "using the therapeutic end points of survival and loco-regional control, it is true that no multi-institutional study that has utilized surgery as a form of treatment has demonstrated a significant separation between the control and distant arms." Yet it remains the impression of most surgical oncologists that this is incorrect and that in most situations those who undergo radical surgery have a better chance at survival and better palliation but without real scientific data to support this.
If survival cannot be used as an endpoint, the morbidity associated with these approaches needs to be compared. Radical surgery is certainly associated with significant functional deficits, as is radical radiation with or without chemotherapy. Comparing the deficits after the different approaches would be useful, but this can be quite difficult given the myriad of surgical and reconstructive procedures available and the different organ preservation approaches used.
The increased sophistication of the reconstructive techniques employed following radical ablative surgery has certainly leveled the playing field in comparing the radical and organ preservation approaches resulting in improvement of not only cosmesis but function as well (e.g., pharynx, esophagus, mandible, and skin defects of the head and neck).19 Some structures (e.g., tongue and larynx) defy meaningful reconstruction, and it is cancer of these structures that creates the greatest therapeutic dilemma. Using function and form after radical ablation with reconstruction and organ preservation approaches may be impossible as often the organ saved may be dysfunctional.
In the final analysis, it appears that the ultimate goal sought after treating these patients with advanced cancer is a meaningful QOL for their remaining days. What exactly constitutes this quality and whether we best achieve it by radical surgery, organ preservation approaches, or merely palliating the symptoms remain elusive issues; however, real efforts are now being made to clarify this.
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