HAYES MARTIN MEMORIAL LECTURE
Non Desperandum Harvey W. Baker, MD, Portland,
Oregon
7’,$e Hayw Martin Lwtuw this year is bcting given b.,: Dr. Harw>, Haktlr. Horn cm (jctobcr 5, 291X tn N~~rt’\.ork (‘ity, [jr. Baker received his HA degree from Cornell University in I939 andgraduatc,d from thcaC’ollq~geof I’h~~siciansattd Sur,gtwn.s, C”g)lumbiaIlniversity in 1943. After a year’s internship at King’s (‘aunt)’ Hospital in Brooklyn, ho complt~tc~dtlcw years of military srrvicr as a major in thP Medical Corps. HP s~lroed as Surgical Rr~sidcnt at Kings (‘outlty Hospital for th(z twxt four yt’ars and at Memorial Hospital from 1950 to 1.9was wrtified by th(’ AmcJrican Hoard of Surgery. Ten yrJars aft rlr graduation. from medical .schoo& Dr. Haktprdepart pd for f’ort (and, Orq,wn, rchc,rt~hc sortn cjstablished himsrlf us an authority in thcj treatment of cancer, attainin, 15national as well as rfxgirjttalpr~mlittc~nw. Dr. Baker’s membership in professional organizations and his commit trc>appointments ur(’ numf’rous. Aside>from his membership in state and county ,societies, he was a Ft~llowof thr, American Co&p Of h?Lr#vJn.S and a mPtttbf,r of its Hoard of 6’overnors from 1961 to 1972 and has been a mclmber of its (4)mmission on (‘ancer sinct’ 1966 und (‘hairman since 197.5. He has held membership and offices in the North Pacific Surgical Aswcia&m, tfrv I’acific (‘otrsf Surgical A:xwiation, the Portland Surgical Society, the Western Surgical Association, and the f’ortland A~~ndr~my of Mc~dic~ittf~. H+ was also a membw of IhP Robert A. Wise Surgical Club and thr Amnt. Harl>cJ,v is a mctnhr>rof ttw ~amw &*ing Society (now known as the .%cicty of Surgical hCCJ/O@‘). He u:as its Viw-f’rrsidcrtt it? I!% and I’rt&dadand Nwk Sur,qwn.s inLlolclc>d four yc’ars as a most ctfficic,nt S~,crr~tar~ fo’lou,c>d hv the ptwid~Jnc.y in 1970. The list of Dr. Haker’.s publicatiotzs is almo,st as lcln,qthTas [Jr. ,klar/irls’s, placing him among tht>uppw /wr,/sof forctnost authors in the>fic,ld of cancer thc,rap?,. William S. Mad’omh, MD
To be selected
to present the Hayes Martin Lecture is an honor which I never expected. Clearly recognizing that many among you are more deserving than I am, I nevertheless want to express my deep appreciation to you and will attempt to uphold the traditian established by previous distinguished lecturers. One of the giants of our time, Dr. Hayes Martin, died last December 25 at the age of eighty-five years. Those of us who knew him have lasting vivid memories of him; to others he has become a legend. No one has contributed as much to our knowledge of head and neck cancer and its treatment and I doubt anyone ever will. He was a pioneer in radiation therapy for tumors of the head and neck, in major
From the Department of Surgery, University of Oregon Health Sciences Center, Portland, Oregon. Reprint requests should be addressed to Harvey W. Baker, MD, 2222 NW Lovejoy Street, Portland, Oregon 97210. Presented at the Joint Meeting of the American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons, Toronto, Ontario, Calada, May 29-31. 1978.
Volume 136, October 1976
excisional surgery, and in plastic reconstruction as well. He has left behind a group of publications covering all aspects of the behavior of head and neck neoplasms which are as valid today as the day they were printed. His text on head and neck surgery summarizes a lifetime of experience and will be ot lasting value. His foresight in founding the Society of Head and Neck Surgeons as a forum for sharing experience and advancing knowledge has been amply justified by our meetings over thehe past t.wenty-four years. Perhaps the greatest legacy for which he will be remembered is the group of associates he assembled at Memorial Hospital and the group of young surgeons he trained who will carry on the t,radition of excellence he demanded. Serving as a resident on Dr. Martin’s service in the late 1940s and 1950s was an exciting experience for me and others of my age. We had completed military service and training in general surgery, Ijut except for some prior exposure to thyroid operations, we e11countered an entirely new surgical disciplintk. We had to learn the natural history of 21new group ot’ diseases
415
Baker
and to master new methods of examination, new surgical technics, and new problems in postoperative care. We were stimulated by the knowledge, skill, and dedication of Dr. Martin and his unusually gifted group of associates. Other lecturers have mentioned many of Dr. Martin’s attributes: his vision, originality, determination, encyclopedic knowledge, and skill as a surgeon and as an actor. I was particularly impressed by his executive ability and sense of organization which made his service function so efficiently in caring for a huge number of patients. There was a carefully organized routine for all aspects of patient care from first reception and examination to hospital admission, surgical treatment, postoperative management, and follow-up appointments. Such details as anatomic rubber stamps for clinical records, lists of instruments (many devised by Dr. Martin) for each type of operation, well equipped stations for dressing changes on each floor of the hospital, as well as superbly trained nurses and aids and the immediate availability of dental assistance made it possible for all members of the service to carry out their tasks efficiently without bottlenecks or administrative delays. One of the high points of the week for most of us was the head and neck conference at which Dr. Martin and his entire staff discussed details of patient care. At one such conference I had to present one of Dr. Martin’s patients, a man familiar to many of you, who at that time was admitted for his fortyfirst operation for a cancer which had originated on the gum. I recall vividly on this occasion after the patient’s course had been summarized Dr. Martin did not say a word; he merely walked to the blackboard and wrote out the phrase, non desperandum, do not despair. To me this epitomized his philosophy, and I have chosen it as the topic for this address. Dr. William MacComb in writing to me about Hayes Martin stated that from the first time he knew him in 1931, and later on his service from 1935 to 1952, he heard the following dictum repeatedly stated: “When you accept a patient for treatment he becomes your responsibility as long as he or you shall live.” I would like to emphasize this concept of the continuity of care of patients with head and neck cancer which Dr. Martin considered so important. When the definitive treatment for head and neck cancer has been completed, be it surgery, radiation, or both, our task is only just beginning. It is the physician’s duty to do all he can to help the patient return to his usual activity, rejoin his family, and if possible, return to his job. It is no therapeutic triumph to control a cancer and have the patient become a permanent resident of a nursing facility or
416
a recluse in his home. These patients as we well know present multiple problems, and efforts at rehabilitation must be commenced even before treatment. They have nutritional deficiencies which are often severe and frequently associated with alcoholism. Most have chronic pulmonary disease and many have liver disease, peptic ulcer, or cardiovascular disease as well. Many of these problems are aggravated by our therapy, and we frequently add to the patient’s disability by altering his appearance and creating difficulties with speech, mastication, deglutition, sense of taste and smell, and shoulder motion, as well as chronic pain. Although no one of us can begin to cope with all of these problems, the relationship of the patient to his surgeon is the foundation for successful adaptation, He looks to him not only for reassurance regarding his cancer but also for security and stability in his readjustment to society. We must secure the help of appropriate professionals who will devote their attention to specific problems in their field of rehabilitation. These include the speech therapist, the prosthodontist, the physiatrist, the dietitian, the occupational therapist, the social worker, and occasionally, the clinical psychologist or psychiatrist. Cessation of heavy smoking and drinking is important for these patients. Studies by Dr. Condict Moore have indicated that the incidence of second primary tumors of the upper aerodigestive tract is higher in those who continue to smoke compared with those who quit, and I am certain a similar relationship can be demonstrated with alcohol consumption. There is good experimental and clinical evidence that chronic tobacco or alcohol use leads to profound changes in both cellular and humoral immunity. Although the need for alterations in the patient’s habits is obvious, I must admit I have not been too successful in their accomplishment. The effort must be made, however, and we all welcome the appearance of professionals and voluntary groups to aid in this field. It seems hardly necessary to remind a group such as this of the extreme importance of prolonged SYStematic follow-up of these patients. After treating cancer in some sites, the surgeon in good conscience may return the patient to his primary physician for follow-up care. In this field, however, follow-up must be carried out by an expert who is skilled in examination of the head and neck, preferably the patient’s surgeon and preferably the same individual on each visit. Detection of local recurrence or persistence of a tumor at the earliest possible time requires both skill and experience. We are all familiar with the difficult problem of deciding whether induration in
The American Journal of Surgery
Hayes Martin Memorial Lecture: Non Desperandum
a surgical field represents scar or tumor, or deciding whether edema in an irradiated site represents radiation reaction or submucosal cancer. We are aware of the difficulties in examining the laryngopharynx, the maxillary region, and the nasopharynx after surgery or radiation, and we know that biopsy does not always solve the problem, especially through intact mucosa. It may even make a confusing situaticn worse. Repeated examinations by the same examiner to detect subtle changes in the area under suspicion are of prime importance. A problem I have noted in some of our residency training programs is th.& the patient may not be seen by the same examiner on each follow-up visit. Suspicious or worrisome findings on one visit may be carefully noted in the record, but the decision as to whether there is a change from one visit to the next often requires the sane examiner. Follow-up is of course also essential to detect new primary tumors in this group of patients. We are aware of abnormal mucosal changes at a distance from the tumor in many patients, aptly termed “field cancerization” by Harry Southwick and the late Danely Slaughter, and of the fact that perhaps in one of five of our patients whose original tumor is controlled, a new tumor of the upper air and food passages will develop. Timely and thorough reexamination will allow detection and eradication of premalignant mucosal lesions as well as early discovery of new cancers. Various schedules and routines of examination have been suggested for the follow-up of patients with head and neck cancer. These I believe are most useful for hospital departments with large numbers of patients and changing staffs. In my own practice, I tend to be more elastic, varying time intervals acco-ding to the extent of disease of individual patients. We know that the period of greatest risk for recurrence is the first eighteen months after treatment, so the patient must be seen frequently, perhaps monthly, for the first year and less often in subsequent years. Because of the ever present risk of new primary tumors, the patient must be examined indefinitely, preferably once or twice each year for life. The essential parts of a follow-up visit should be questioning to elicit new symptoms of disease and complete examination of the head and neck. I have found it helpful to record the patient’s weight. Except for a yearly chest x-ray film I have not found it useful to carry out a battery of routine laboratory studies. However, I must admit being tardy in recognizing hypothyroidism appearing long periods after radiation or even surgery in the neck. ‘One axiom of cancer therapy is if the first treat-
Volume 136, October 1976
ment fails, there is an ever diminishing chance for success with subsequent measures. In many cancer sites the first recurrence heralds an inexorable course, and the physician’s only concern is for palliation. In no field is there better opportunity for salvage by retreatment than in cancer of the head and neck. Failure of not only one but of several previous treatment attempts may often be successfully overcome by aggressive efforts. This is perhaps best demonstrated in the surgical management of recurrent cancer after radiation therapy. For example, surgical treatment of cancer of the larynx persisting after radiation has a high chance for success, in my experience almost as good as if the primary treatment had been surgical. Surgery is effective in many other irradiated sites in the oral cavity, the pharynx, and the neck as well. We now seldom see the patients Dr. Martin struggled with, those with badly damaged scarred tissues resulting from extremely high doses of radiation delivered by orthovoltage equipment. Here operation was accompanied by a high risk of wound breakdown, fistula formation, and hemorrhage. Competent radiation therapists are now as aware as we are of the opportunity for successful surgical management if they fail, and by limiting their dose to the usual cancerocidal therapeutic range and by using megavoltage equipment, they have made our task much easier. The reverse of this situation is seldom true. Although we may be very successful in operating for recurrent cancer after radiation, I know of extremely few instances in which irradiation has controlled gross recurrent cancer after surgery. Radiation is not without value in this situation, however. It may result in good palliation with decrease in tumor volume and relief of symptoms for long periods of time. Although it cannot eradicate obvious gross recurrence, I do not mean to imply that radiation cannot control persistent cancer at the primary site or in the neck after surgery. Its role I believe is to manage persistent cancer when it is occult and microscopic, and it is indicated in situations in which the risk of recurrence is high. Studies particularly at the M.D. Anderson Hospital have amply demonstrated this and suggest that radiation given after surgery may be as effective as when given before. Reoperation for cancer recurring after initial surgical management is very frequently successful. Although we are all familiar with this aspect, of head and neck surgery, it has not been given the attention it deserves at our meetings or in the literature, perhaps because few of the procedures are standard or orthodox. They vary from simple reexcisions to extensive procedures that tax the ingenuity of the most
417
Baker
experienced surgeon. Some, such as carotid artery excision or temporal bone resection, include significant risk, and many involve major problems in reconstruction. Although the majority of these procedures are carried out with the hope of long-term control, some may be justified for palliation alone. The gross removal of bulky ulcerated, bleeding, or painful lesions may be of considerable value even if excision is incomplete or if distant metastases are present. I doubt if any of us can match Dr. Martin’s record, whose patient ultimately had more than fifty operations and lived comfortably for years, I know, however, that each of us can recall numbers of patients in whom repeated surgical procedures were carried out with eventual control of the tumor or long-term survival. Dr. Martin was one of the first to recognize that head and neck cancer was not limited to areas above the clavicles, but that metastases to distant sites, particularly the lungs and skeletal system, could occur as well. As we have become more successful in controlling cancer at its primary site or in the neck, we have become far more aware of the problem of distant dissemination. These metastases have not been solitary although they may initially appear to be so, and in my experience attempts at surgical resection have seldom been rewarding. At times it is most difficult clinically and even pathologically to differentiate a metastatic pulmonary mass from a bronchogenic cancer, and I suspect that the few instances in my practice in which pulmonary resection has been successful in controlling disease were actually examples of new primary lung cancers. Worthwhile palliation of metastases by irradiation may often be obtained if the primary tumor in the head and neck remains under control. Since the early days of chemotherapy, head and neck surgeons have joined in the search for drugs that would be useful in. treating their patients with advancing cancer. At our meetings over the years we have. heard numerous reports on the use of these agents administered systemically, by local injection or intraarterial infusion. I have frequently returned home after our meetings filled with renewed enthusiasm only to become ultimately disappointed and discouraged. It is true that some agents, notably methotrexate, bleomycin, and more recently, cisplatinum, do have an effect on the squamous cancers
418
with which we deal, and occasionally the effect is dramatic. However, the effect is usually of quite brief duration, and if one’s main interest is caring for patients rather than evaluating drugs, one cannot help but be aware of the rather poor cost-benefit ratio. On the Head and Neck Service at the Portland Veterans Hospital we have been carrying out a three armed study of adjuvant chemotherapy and immunotherapy given after conventional therapy for selected squamous cancers of the head and neck. After three years of this study we have learned the following: (1) Cellular and humoral immune deficiencies demonstrated by most commonly used tests can be restored by transfer factor therapy. (2) Toxicity from methotrexate has been unexpectedly severe in this group of elderly patients with many coexisting diseases. (3) Neither chemotherapy, immunotherapy, nor both have had any noticeable effect on the incidence of local recurrences or distant metastases. In fact, perhaps fortuitously with our randomization process and the impossibility of finding cases that are entirely similar, our group of control patients receiving conventional therapy alone has done better than the other two groups. This type of effort must continue, and I believe it significant that members of both of our societies have commenced cooperative trials with cis-platinum and bleomycin given both before and after conventional treatment methods. These trials have been very carefully planned, and I hope they will prove worthwhile. I believe the ultimate role of both chemotherapy and immunotherapy will be controlling microscopic foci of both local and distant disease when the host’s tumor burden is minimal. The surgical management of head and neck cancer is a task which requires skill, experience, dedication, and constant observation of the patient. It is rewarding in terms of personal satisfaction and grateful patients and their families. It can be frustrating as well with tragedies, disappointments, and unexpected failures. We can look back on the career of Hayes Martin, whose dictum, non desperandum, indicates a philosophy all of us can follow, and we can look ahead to a future when a new generation of surgeons, very likely influenced by Dr. Martin’s achievements, will solve many of the problems we currently face.
The American Journal of Surgery
Non Desperandum Harvey W. Baker, MD, Portland,
Oregon
7’,$e Hayw Martin Lwtuw this year is bcting given b.,: Dr. Harw>, Haktlr. Horn cm (jctobcr 5, 291X tn N~~rt’\.ork (‘ity, [jr. Baker received his HA degree from Cornell University in I939 andgraduatc,d from thcaC’ollq~geof I’h~~siciansattd Sur,gtwn.s, C”g)lumbiaIlniversity in 1943. After a year’s internship at King’s (‘aunt)’ Hospital in Brooklyn, ho complt~tc~dtlcw years of military srrvicr as a major in thP Medical Corps. HP s~lroed as Surgical Rr~sidcnt at Kings (‘outlty Hospital for th(z twxt four yt’ars and at Memorial Hospital from 1950 to 1.9was wrtified by th(’ AmcJrican Hoard of Surgery. Ten yrJars aft rlr graduation. from medical .schoo& Dr. Haktprdepart pd for f’ort (and, Orq,wn, rchc,rt~hc sortn cjstablished himsrlf us an authority in thcj treatment of cancer, attainin, 15national as well as rfxgirjttalpr~mlittc~nw. Dr. Baker’s membership in professional organizations and his commit trc>appointments ur(’ numf’rous. Aside>from his membership in state and county ,societies, he was a Ft~llowof thr, American Co&p Of h?Lr#vJn.S and a mPtttbf,r of its Hoard of 6’overnors from 1961 to 1972 and has been a mclmber of its (4)mmission on (‘ancer sinct’ 1966 und (‘hairman since 197.5. He has held membership and offices in the North Pacific Surgical Aswcia&m, tfrv I’acific (‘otrsf Surgical A:xwiation, the Portland Surgical Society, the Western Surgical Association, and the f’ortland A~~ndr~my of Mc~dic~ittf~. H+ was also a membw of IhP Robert A. Wise Surgical Club and thr Amnt. Harl>cJ,v is a mctnhr>rof ttw ~amw &*ing Society (now known as the .%cicty of Surgical hCCJ/O@‘). He u:as its Viw-f’rrsidcrtt it? I!% and I’rt&dadand Nwk Sur,qwn.s inLlolclc>d four yc’ars as a most ctfficic,nt S~,crr~tar~ fo’lou,c>d hv the ptwid~Jnc.y in 1970. The list of Dr. Haker’.s publicatiotzs is almo,st as lcln,qthTas [Jr. ,klar/irls’s, placing him among tht>uppw /wr,/sof forctnost authors in the>fic,ld of cancer thc,rap?,. William S. Mad’omh, MD
To be selected
to present the Hayes Martin Lecture is an honor which I never expected. Clearly recognizing that many among you are more deserving than I am, I nevertheless want to express my deep appreciation to you and will attempt to uphold the traditian established by previous distinguished lecturers. One of the giants of our time, Dr. Hayes Martin, died last December 25 at the age of eighty-five years. Those of us who knew him have lasting vivid memories of him; to others he has become a legend. No one has contributed as much to our knowledge of head and neck cancer and its treatment and I doubt anyone ever will. He was a pioneer in radiation therapy for tumors of the head and neck, in major
From the Department of Surgery, University of Oregon Health Sciences Center, Portland, Oregon. Reprint requests should be addressed to Harvey W. Baker, MD, 2222 NW Lovejoy Street, Portland, Oregon 97210. Presented at the Joint Meeting of the American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons, Toronto, Ontario, Calada, May 29-31. 1978.
Volume 136, October 1976
excisional surgery, and in plastic reconstruction as well. He has left behind a group of publications covering all aspects of the behavior of head and neck neoplasms which are as valid today as the day they were printed. His text on head and neck surgery summarizes a lifetime of experience and will be ot lasting value. His foresight in founding the Society of Head and Neck Surgeons as a forum for sharing experience and advancing knowledge has been amply justified by our meetings over thehe past t.wenty-four years. Perhaps the greatest legacy for which he will be remembered is the group of associates he assembled at Memorial Hospital and the group of young surgeons he trained who will carry on the t,radition of excellence he demanded. Serving as a resident on Dr. Martin’s service in the late 1940s and 1950s was an exciting experience for me and others of my age. We had completed military service and training in general surgery, Ijut except for some prior exposure to thyroid operations, we e11countered an entirely new surgical disciplintk. We had to learn the natural history of 21new group ot’ diseases
415
Baker
and to master new methods of examination, new surgical technics, and new problems in postoperative care. We were stimulated by the knowledge, skill, and dedication of Dr. Martin and his unusually gifted group of associates. Other lecturers have mentioned many of Dr. Martin’s attributes: his vision, originality, determination, encyclopedic knowledge, and skill as a surgeon and as an actor. I was particularly impressed by his executive ability and sense of organization which made his service function so efficiently in caring for a huge number of patients. There was a carefully organized routine for all aspects of patient care from first reception and examination to hospital admission, surgical treatment, postoperative management, and follow-up appointments. Such details as anatomic rubber stamps for clinical records, lists of instruments (many devised by Dr. Martin) for each type of operation, well equipped stations for dressing changes on each floor of the hospital, as well as superbly trained nurses and aids and the immediate availability of dental assistance made it possible for all members of the service to carry out their tasks efficiently without bottlenecks or administrative delays. One of the high points of the week for most of us was the head and neck conference at which Dr. Martin and his entire staff discussed details of patient care. At one such conference I had to present one of Dr. Martin’s patients, a man familiar to many of you, who at that time was admitted for his fortyfirst operation for a cancer which had originated on the gum. I recall vividly on this occasion after the patient’s course had been summarized Dr. Martin did not say a word; he merely walked to the blackboard and wrote out the phrase, non desperandum, do not despair. To me this epitomized his philosophy, and I have chosen it as the topic for this address. Dr. William MacComb in writing to me about Hayes Martin stated that from the first time he knew him in 1931, and later on his service from 1935 to 1952, he heard the following dictum repeatedly stated: “When you accept a patient for treatment he becomes your responsibility as long as he or you shall live.” I would like to emphasize this concept of the continuity of care of patients with head and neck cancer which Dr. Martin considered so important. When the definitive treatment for head and neck cancer has been completed, be it surgery, radiation, or both, our task is only just beginning. It is the physician’s duty to do all he can to help the patient return to his usual activity, rejoin his family, and if possible, return to his job. It is no therapeutic triumph to control a cancer and have the patient become a permanent resident of a nursing facility or
416
a recluse in his home. These patients as we well know present multiple problems, and efforts at rehabilitation must be commenced even before treatment. They have nutritional deficiencies which are often severe and frequently associated with alcoholism. Most have chronic pulmonary disease and many have liver disease, peptic ulcer, or cardiovascular disease as well. Many of these problems are aggravated by our therapy, and we frequently add to the patient’s disability by altering his appearance and creating difficulties with speech, mastication, deglutition, sense of taste and smell, and shoulder motion, as well as chronic pain. Although no one of us can begin to cope with all of these problems, the relationship of the patient to his surgeon is the foundation for successful adaptation, He looks to him not only for reassurance regarding his cancer but also for security and stability in his readjustment to society. We must secure the help of appropriate professionals who will devote their attention to specific problems in their field of rehabilitation. These include the speech therapist, the prosthodontist, the physiatrist, the dietitian, the occupational therapist, the social worker, and occasionally, the clinical psychologist or psychiatrist. Cessation of heavy smoking and drinking is important for these patients. Studies by Dr. Condict Moore have indicated that the incidence of second primary tumors of the upper aerodigestive tract is higher in those who continue to smoke compared with those who quit, and I am certain a similar relationship can be demonstrated with alcohol consumption. There is good experimental and clinical evidence that chronic tobacco or alcohol use leads to profound changes in both cellular and humoral immunity. Although the need for alterations in the patient’s habits is obvious, I must admit I have not been too successful in their accomplishment. The effort must be made, however, and we all welcome the appearance of professionals and voluntary groups to aid in this field. It seems hardly necessary to remind a group such as this of the extreme importance of prolonged SYStematic follow-up of these patients. After treating cancer in some sites, the surgeon in good conscience may return the patient to his primary physician for follow-up care. In this field, however, follow-up must be carried out by an expert who is skilled in examination of the head and neck, preferably the patient’s surgeon and preferably the same individual on each visit. Detection of local recurrence or persistence of a tumor at the earliest possible time requires both skill and experience. We are all familiar with the difficult problem of deciding whether induration in
The American Journal of Surgery
Hayes Martin Memorial Lecture: Non Desperandum
a surgical field represents scar or tumor, or deciding whether edema in an irradiated site represents radiation reaction or submucosal cancer. We are aware of the difficulties in examining the laryngopharynx, the maxillary region, and the nasopharynx after surgery or radiation, and we know that biopsy does not always solve the problem, especially through intact mucosa. It may even make a confusing situaticn worse. Repeated examinations by the same examiner to detect subtle changes in the area under suspicion are of prime importance. A problem I have noted in some of our residency training programs is th.& the patient may not be seen by the same examiner on each follow-up visit. Suspicious or worrisome findings on one visit may be carefully noted in the record, but the decision as to whether there is a change from one visit to the next often requires the sane examiner. Follow-up is of course also essential to detect new primary tumors in this group of patients. We are aware of abnormal mucosal changes at a distance from the tumor in many patients, aptly termed “field cancerization” by Harry Southwick and the late Danely Slaughter, and of the fact that perhaps in one of five of our patients whose original tumor is controlled, a new tumor of the upper air and food passages will develop. Timely and thorough reexamination will allow detection and eradication of premalignant mucosal lesions as well as early discovery of new cancers. Various schedules and routines of examination have been suggested for the follow-up of patients with head and neck cancer. These I believe are most useful for hospital departments with large numbers of patients and changing staffs. In my own practice, I tend to be more elastic, varying time intervals acco-ding to the extent of disease of individual patients. We know that the period of greatest risk for recurrence is the first eighteen months after treatment, so the patient must be seen frequently, perhaps monthly, for the first year and less often in subsequent years. Because of the ever present risk of new primary tumors, the patient must be examined indefinitely, preferably once or twice each year for life. The essential parts of a follow-up visit should be questioning to elicit new symptoms of disease and complete examination of the head and neck. I have found it helpful to record the patient’s weight. Except for a yearly chest x-ray film I have not found it useful to carry out a battery of routine laboratory studies. However, I must admit being tardy in recognizing hypothyroidism appearing long periods after radiation or even surgery in the neck. ‘One axiom of cancer therapy is if the first treat-
Volume 136, October 1976
ment fails, there is an ever diminishing chance for success with subsequent measures. In many cancer sites the first recurrence heralds an inexorable course, and the physician’s only concern is for palliation. In no field is there better opportunity for salvage by retreatment than in cancer of the head and neck. Failure of not only one but of several previous treatment attempts may often be successfully overcome by aggressive efforts. This is perhaps best demonstrated in the surgical management of recurrent cancer after radiation therapy. For example, surgical treatment of cancer of the larynx persisting after radiation has a high chance for success, in my experience almost as good as if the primary treatment had been surgical. Surgery is effective in many other irradiated sites in the oral cavity, the pharynx, and the neck as well. We now seldom see the patients Dr. Martin struggled with, those with badly damaged scarred tissues resulting from extremely high doses of radiation delivered by orthovoltage equipment. Here operation was accompanied by a high risk of wound breakdown, fistula formation, and hemorrhage. Competent radiation therapists are now as aware as we are of the opportunity for successful surgical management if they fail, and by limiting their dose to the usual cancerocidal therapeutic range and by using megavoltage equipment, they have made our task much easier. The reverse of this situation is seldom true. Although we may be very successful in operating for recurrent cancer after radiation, I know of extremely few instances in which irradiation has controlled gross recurrent cancer after surgery. Radiation is not without value in this situation, however. It may result in good palliation with decrease in tumor volume and relief of symptoms for long periods of time. Although it cannot eradicate obvious gross recurrence, I do not mean to imply that radiation cannot control persistent cancer at the primary site or in the neck after surgery. Its role I believe is to manage persistent cancer when it is occult and microscopic, and it is indicated in situations in which the risk of recurrence is high. Studies particularly at the M.D. Anderson Hospital have amply demonstrated this and suggest that radiation given after surgery may be as effective as when given before. Reoperation for cancer recurring after initial surgical management is very frequently successful. Although we are all familiar with this aspect, of head and neck surgery, it has not been given the attention it deserves at our meetings or in the literature, perhaps because few of the procedures are standard or orthodox. They vary from simple reexcisions to extensive procedures that tax the ingenuity of the most
417
Baker
experienced surgeon. Some, such as carotid artery excision or temporal bone resection, include significant risk, and many involve major problems in reconstruction. Although the majority of these procedures are carried out with the hope of long-term control, some may be justified for palliation alone. The gross removal of bulky ulcerated, bleeding, or painful lesions may be of considerable value even if excision is incomplete or if distant metastases are present. I doubt if any of us can match Dr. Martin’s record, whose patient ultimately had more than fifty operations and lived comfortably for years, I know, however, that each of us can recall numbers of patients in whom repeated surgical procedures were carried out with eventual control of the tumor or long-term survival. Dr. Martin was one of the first to recognize that head and neck cancer was not limited to areas above the clavicles, but that metastases to distant sites, particularly the lungs and skeletal system, could occur as well. As we have become more successful in controlling cancer at its primary site or in the neck, we have become far more aware of the problem of distant dissemination. These metastases have not been solitary although they may initially appear to be so, and in my experience attempts at surgical resection have seldom been rewarding. At times it is most difficult clinically and even pathologically to differentiate a metastatic pulmonary mass from a bronchogenic cancer, and I suspect that the few instances in my practice in which pulmonary resection has been successful in controlling disease were actually examples of new primary lung cancers. Worthwhile palliation of metastases by irradiation may often be obtained if the primary tumor in the head and neck remains under control. Since the early days of chemotherapy, head and neck surgeons have joined in the search for drugs that would be useful in. treating their patients with advancing cancer. At our meetings over the years we have. heard numerous reports on the use of these agents administered systemically, by local injection or intraarterial infusion. I have frequently returned home after our meetings filled with renewed enthusiasm only to become ultimately disappointed and discouraged. It is true that some agents, notably methotrexate, bleomycin, and more recently, cisplatinum, do have an effect on the squamous cancers
418
with which we deal, and occasionally the effect is dramatic. However, the effect is usually of quite brief duration, and if one’s main interest is caring for patients rather than evaluating drugs, one cannot help but be aware of the rather poor cost-benefit ratio. On the Head and Neck Service at the Portland Veterans Hospital we have been carrying out a three armed study of adjuvant chemotherapy and immunotherapy given after conventional therapy for selected squamous cancers of the head and neck. After three years of this study we have learned the following: (1) Cellular and humoral immune deficiencies demonstrated by most commonly used tests can be restored by transfer factor therapy. (2) Toxicity from methotrexate has been unexpectedly severe in this group of elderly patients with many coexisting diseases. (3) Neither chemotherapy, immunotherapy, nor both have had any noticeable effect on the incidence of local recurrences or distant metastases. In fact, perhaps fortuitously with our randomization process and the impossibility of finding cases that are entirely similar, our group of control patients receiving conventional therapy alone has done better than the other two groups. This type of effort must continue, and I believe it significant that members of both of our societies have commenced cooperative trials with cis-platinum and bleomycin given both before and after conventional treatment methods. These trials have been very carefully planned, and I hope they will prove worthwhile. I believe the ultimate role of both chemotherapy and immunotherapy will be controlling microscopic foci of both local and distant disease when the host’s tumor burden is minimal. The surgical management of head and neck cancer is a task which requires skill, experience, dedication, and constant observation of the patient. It is rewarding in terms of personal satisfaction and grateful patients and their families. It can be frustrating as well with tragedies, disappointments, and unexpected failures. We can look back on the career of Hayes Martin, whose dictum, non desperandum, indicates a philosophy all of us can follow, and we can look ahead to a future when a new generation of surgeons, very likely influenced by Dr. Martin’s achievements, will solve many of the problems we currently face.
The American Journal of Surgery
