High volume centres are paramount

Choosing Specialists

Choosing the right cancer specialist can be difficult at the best of times, but it can be particularly difficult for patients diagnosed with head and neck cancer. This is due to a range of reasons. To begin with these cancers occur in small numbers making it difficult even for general practitioners to find appropriate medical specialists. Secondly, the area affected by the cancer and cancer treatment involves a large number of organs and functions, raising many questions which apply to both treatment and long term outcomes. Thirdly, successful treatment of these cancers requires a team of experts, not just one clinician, especially as nearly all head and neck cancer patients will need a combination of treatments which may or may not include surgery, radiotherapy, chemotherapy, and immunotherapy.

High Volume Centres

Head and Neck cancers do not qualify as rare cancers but neither are they considered common cancers. There were 3,896 head and neck cancers diagnosed in Australia in 2009, accounting for 3.4% of all cancer diagnoses (114,137). Consequently there are many general practitioners in Australia who have only seen one or two head and neck cancer patients during their entire professional experience. This also means, far more crucially, that not all specialists and hospitals treat high volumes of head and neck cancers. Which is a problem because we know that cancer patients treated in high volume centres get the best outcomes. The NSW Cancer Institute recommends ‘that hospitals treating people with complex cancers should perform these surgeries regularly (i.e. perform a certain number of surgeries each year). This is known as a minimum suggested annual caseload’.

Nothing frustrates me more than a unit or medical professional who “dabbles” in head and neck cancer ie treating 25 or fewer patients a year. These are complex, aggressive cancers which require sophisticated, immediate treatment. According to the latest NSW Cancer Institute data, St Vincent’s Hospital, Darlinghurst, is the highest volume surgical head and neck cancer unit in NSW. Our excellent outcomes are discussion for another blog post, but the demonstrated link between volume and outcomes for all cancer treatment also applies here.

Complex Anatomy

The head and neck are extremely complex parts of the body. They include numerous organs involved in multiple functions. The first and most important functions are breathing, talking and swallowing. You then might think of facial expressions such as smiling and laughing, key but often overlooked components of communication. Let’s go a bit further. Stop for a minute and think about taste, your sense of smell, the workings of your eyes and ears, how saliva is produced, the thyroid gland which produces hormones influencing metabolism, mood, bone, heart and digestive function. Then let’s go deeper again and think about blood and nerve supplies to the head and the brain, including the carotid artery, and other structures such as the lymphatic system which are part of the immune system. All of these organs and functions need to be considered when evaluating a head and neck cancer patient for treatment, especially when we consider the quality of life after cancer, not just immediate cure. This is one of the reasons that so many different medical and allied health clinicians are involved in head and neck cancer care and why Multidisciplinary Teams (MDTs) are of particular importance.

Multidisciplinary Teams (MDTs)

Most head and neck cancer patients require a combination of therapies during their cancer treatment. These may include one or a combination of surgery, radiotherapy, chemotherapy, and immunotherapy. Which is why all major head and neck cancer treatment centres have Head and Neck Multidisciplinary Teams (MDT) which meet on a regular basis. The St Vincent’s Sydney Head and Neck Cancer MDT includes head and neck surgeons, plastic and reconstructive surgeons, radiation oncologists, medical oncologists (they’re the doctors who specialise in chemotherapy), pathologists, dentists, dieticians, speech pathologists, psychologists, social workers, cancer care coordinators and cancer researchers. There is a lot of research that demonstrates that patients who are reviewed by an MDT have better outcomes. In the NSW Cancer’s Institute’s most recent Reporting for Better Cancer Outcomes, the Institute recommends that ‘all people diagnosed with cancer in NSW should have their care overseen by a multidisciplinary cancer care team (MDT). This is considered best practice as it improves cancer outcomes.’ How this is achieved is explored in this recent article from the team at MD Anderson. MD Anderson hold a 75 to 90 minute Head and Neck MDT, known as a Tumor Board Meeting in the US, every Thursday. At St Vincent’s we hold a 120 minute meeting every Tuesday. All our head and neck patients attend, whether they are being treated privately or publicly. As my colleague radiation oncologist Dion Forstner says, debate can become “rather robust” as we discuss the most appropriate treatment course for our patients. Insider tip: If you want an independent assessment of alternative treatment pathways for head and neck cancer I recommend talking to an experienced speech pathologist. These clinicians spend a huge amount of time teaching patients how to speak and swallow again after treatment and have excellent insight into what treatment options are best to avoid long term complications.

Every patient is different and every cancer is different. Even though I am trained as a surgeon not all of my patients have surgery included in their cancer treatment. This is a complex cancer and I am grateful for the expertise and experience of a range of specialists who work together to achieve the best possible results for our patients.