Radiotherapy may be as effective as surgery

EDITOR—In her review article on oral cancer,1 Zakrzewska takes a strongly surgical view of its treatment and does not give a balanced view of the benefits and toxicities of surgery and radiotherapy. I take issue with her statements that “treatment for oral cancer is principally surgical,” that “radiotherapy and chemotherapy are often used for adjuvant and adjunctive therapy,” and that “radiotherapy is rarely used as a primary treatment.” It is fairer to say that surgery and radiotherapy are the only curative treatments for oral cancer. Adjuvant chemotherapy with platinum containing regimens may improve local control but at the expense of enhanced toxicity.

Interstitial radiotherapy alone or in combination with external beam is an important component in curative treatment of squamous carcinomas of the floor of the mouth and tongue.2 3 In a series of 166 patients from France treated by iridium-192 implantation alone, the five year local control rate for stage T1-T2 node negative cancers of the anterior two thirds of the tongue was 87%, with cause specific survival of 90% for T1 and 71% for T2 cancers respectively.3

Zakrzewska states that ablative surgery “is used to improve healing and restore function and improve the patient's quality of life.” She does not mention the mutilating effects of surgery for oral cancer but cites oral mucositis and osteoradionecrosis as complications of radiotherapy. Radiotherapy's main advantage over surgery is that it preserves normal anatomy and function, an important determinant of quality of life. A study comparing radiotherapy with surgery at the base of the tongue concluded that radiotherapy resulted in fewer side effects, irrespective of stage, without adversely affecting prognosis.4 Zakrzewska rightly commends the importance of quality of life assessments. However, the real impact of the different but substantial toxicities of surgery and radiotherapy for oral cancer are often most eloquently described in patients' own words.5 Patients need to be briefed in detail of the trade off between local control and toxicity from surgery, radiotherapy, and chemotherapy when coming to an informed decision about treatment for oral cancer.

Biopsy under local anaesthetic is inadequate

EDITOR—Zakrzewska's article on oral cancer1 does not mention the important risk of patients presenting with synchronous primary tumours of the upper aerodigestive tract.2 She states that a biopsy under local anaesthetic is the most important investigation in diagnosing oral cancer. We believe that biopsy under local anaesthetic has little or no role in the investigation of these patients. Superficial biopsy specimens taken under local anaesthetic may indeed confirm the diagnosis, but assessment is incomplete unless deeper specimens are obtained to confirm the degree of invasion. These can be difficult to obtain under local anaesthesia. More importantly, general anaesthesia also allows formal pan-endoscopy to assess the whole of the upper aerodigestive tract and exclude “silent” synchronous tumours.

Finally, the author suggests that all patients with suspected oral cancer should be referred to an oral physician or an oral and maxillofacial surgeon. It is our view, and that of our specialist associations,3 4 that such cases should be referred to multidisciplinary head and neck oncology clinics. Indeed, this philosophy is supported by the recommendations of the Calman-Hine report.