Written by Max McCormick
Prompted by a statement from the Director of the National Cancer Institution, Washington, “thus we are saving thousands of lives today that weren’t saved 20 years ago”, Philip Stell analysed his own results to see if they supported this hypothesis.
Before presenting the analysis of his figures, Philip Stell gave a broad overview of the improvements that had occurred in the diagnosis and management of head and neck cancer during his working lifetime from 1962 to 1985. These included improvements in:
- a) Diagnosis
TNM staging
Microlaryngoscopy
Computerised tomography
- b) Excisional surgery
Partial laryngectomy
Prophylactic neck dissection
- c) Reparative surgery
Axial flaps
Musculocutaneous flaps
Revascularised flaps
Gastric and colonic transposition for pharyngeal cancer
- d) Radiotherapy
Linear accelerator
Isotopes
- e) Adjuvant treatments
Radiotherapy plus surgery
Chemotherapy plus radiotherapy
Thus, given the advances in technology involved with repair, reconstruction has certainly improved the patients’ lot. However did this mean there was in fact an improvement in the overall survival?
From his personal records of 3,608 patients, the analysis undertaken was as follows:
The following patients were not included in the study:
- Patients who did not have squamous cell carcinoma
- Those without histological confirmation of the disease
- Those with cancer of the lymph or skin
- Those with a secondary deposit in the nose or neck from an undiscovered primary tumour
- Those initially treated elsewhere
- Survival time of at least five years
This left a total of 1,225 patients who had had potentially curative surgery but nonetheless were at risk of recurrence. This group was subjected to multivariant analysis, the dependant variable being survival to five years and amongst the independent variables were the year the patient was first seen, age, sex, general condition and neck nodal status.
The vast majority of deaths from head and neck cancer occurred within two years and survival to five years can almost certainly be regarded as a cure.
The results showed that the regression coefficient for year of initial treatment was completely non-significant.
There were also several other unexpected findings: T stage as defined in the UICC was not a very significant predictor of survival because of confounding by nodal stage. Survival decreased for increasing T stage, mainly because larger tumours are more likely to metastasise to nodes in the neck.
Age and general condition proved to be very important prognostic factors but were not allowed for in the UICC classification of tumours. The histological grade was valueless as an indicator of prognosis.
A disquieting feature is the advanced stage at which patients presented for treatment: 15% of patients seen in the 60s had stage T3 or T4, 27% in the 70s and 28% in the 80s. Thus, Stell pointed out that we were not curing more people because of the distortion produced by late diagnosis.
Stell suggested that earlier diagnosis appeared the most likely path to improved survival figures.