Treatment of patients with stage IV cancer: Do the ends justify the means?

Most experienced head and neck surgeons recommended aggressive treatment - including radical surgery - for patients with resectable Stage IV cancers. Yet, given the poor overall cure rate of 15% and the deformity and disability often associated with treatment, one of the most frequently asked questions at our conference on tumors was: Are we really helping these patients? We found little data in the relevant literature to answer this or other questions. Are there subgroups with a better outlook? What is the evidence for palliation in the 85% of patients who fail treatment and how is it best achieved? How do patients and their families view their treatment in retrospect? To find the answers, we studied the records of 76 consecutive patients (previously untreated) who presented with Stage IV carcinoma of the upper aerodigestive tract in 1981-82. We also interviewed surviving patients or family members and friends by phone. Overall mean survival was 15 months, with a 2-year disease-free survival rate of 16%. More to the point, resectable patients treated with curative intent had a mean survival of 19.4 months, and 12 of 42 patients (29%) were disease-free at 2 years. Patients with laryngeal cancer had the best survival results, and patients with sinus cancers had the worst (25.2 vs. 10.5 months). Those with N(2A) staging lived longer than other groups (24.1 vs. 12.1 months). T4 lesions portend a particularly poor prognosis; mean survival was just 7.5 months and only 1 of 28 patients (3.6%) was alive and disease-free at 2 years. Twenty-five percent of patients returned to normal function, but 75% had significant problems eating or speaking. Thirty-four interviews revealed that 44% of patients enjoyed life after treatment and that 55% (in retrospect) would accept treatment. Quality of life, as determined by our adjustment index, was better in patients who had undergone operation; radiation and/or chemotherapy - when offered for palliation - gave little benefit. We conclude that the results justify aggressive treatment in resectable Stage IV cancer of the head and neck - particularly in patients who do not have T4 primary tumors.