A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study—Part 1 (Head and Neck Surgery)

Abstract

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

Lymph node yield in treatment naïve cases of head and neck squamous cell carcinoma: en bloc lymphadenectomy versus level-by-level dissection

“…Despite surgeons and pathologists taking the utmost care to organise the sample and mark the levels separately, the lymph nodes could get mixed up, even after tagging or mounting on a frame. 22,24,25 Handling by trainees and technicians in the operating theatre or the gross room could further compromise the reliability. 21,22,24 Separating the lymph nodes level-by-level during the neck dissection itself and sending them as separate specimens would be the most reliable way to overcome these technical issues.…”

“…[19][20][21][22][23] Apart from the expertise and dedication of the surgeon and the pathologist, a few other determinants could also affect these outcomes of neck dissection. 21,22,[24][25][26][27] One such factor is the variability in lymph node sampling method employed during the neck dissection. While some surgeons prefer to sample cervical lymph nodes separately level-by-level, many others excise multiple levels of lymph nodes together as en bloc.…”

“…25,26 Despite the American Head and Neck Society recommending the former approach, strict adherence by surgeons is not yet a reality. [24][25][26] Although the intra-operative convenience associated with the en bloc technique, such as the surgical ease and time involved, could be one of the reasons for its preference, the lack of compelling evidence on the level-by-level method's effectiveness also seems to make a major contribution to the non-compliance. In other words, the lack of convincing evidence is not just hampering the standardisation of the neck dissection sampling technique, but is also affecting universal adherence.…”

Overview of glottic laryngeal cancer treatment recommendation changes in the NCCN guidelines from 2011 to 2022

“…10,11 Head and neck cancer treatment protocol recommendations may differ according to country-specific conditions, but the overall standardization of recommendations underpinned by high-level scientific evidence and improvements in clinical outcomes is needed to reduce discrepancies in patients' clinical responses. 12 Clinical scenarios for decision making about glottic cancer treatment, including patient preferences and institutional conditions, often reveal challenges. The possibility of the occurrence of morbidities associated with essential functions, such as the loss of the natural voice, breathing, and airway protection during swallowing, should be evaluated carefully.…”

“…Recommendations in these guidelines are updated frequently following the critical review of newly published high‐level evidence and the establishment of consensus by multidisciplinary panels of experts, thereby providing appropriate orientation for decision making about oncological care 10,11 . Head and neck cancer treatment protocol recommendations may differ according to country‐specific conditions, but the overall standardization of recommendations underpinned by high‐level scientific evidence and improvements in clinical outcomes is needed to reduce discrepancies in patients' clinical responses 12 …”