When the Cure Isn’t Everything…

By Dr Ryan Sommerville, Consultant ENT, Head and Neck, Skull Base Surgeon and Senior Lecturer, University of QLD

InFocus Issue 22, January 2022

Australian-trained Ear, Nose and Throat, Head and Neck Surgeon Dr Ryan Sommerville explains why Quality of Life and Survivorship are essential considerations in every patient’s treatment.

As we navigate our way through treatment plans for our patients’ problems, it is easy to focus on curing them of their infection, cancer, inflammatory disorder, sometimes forgetting one of the most important factors – Quality of Life (QOL). As hard to define as this concept is, it is probably one of the most central points that get discussed in Multi-Disciplinary Team (MDT) meetings. In my sub-specialty areas of interest – Head and Neck Cancer and Skull Base Disorders – there are particular issues that are both specific to those patients, but also applicable to all our patients.

In Head and Neck Cancer, non-smoking status, older age, higher education level, oral vs laryngeal primary site and earlier stage disease are associated with a better functional well-being. Beyond this one of the big factors is something we take for granted – being able to eat. If a patient needs a feeding tube then they feel their quality of life is reduced. This is compounded with a reduction in quality of life in the first few months after treatment if they need radiation – this effect of radiation on QOL does disappear by 2-4yrs after treatment. There are also well described (and not unexpected) reductions in QOL, libido, and self-worth with disfiguring surgery. This concept of the patient having ongoing effects of their cancer and the treatment required is known as ‘Survivorship’ – they are cured, but are they happy? As surgeons we need to ask – just because I can do an operation, should I?

One of the more common Skull Base tumours are Acoustic Neuromas (Vestibular Schwannomas). In vestibular schwannoma patients, the most important QOL factors are the diagnosis, vertigo, temporary or permanent facial weakness and disabling tinnitus. Even the diagnosis itself can be a major QOL factor. In larger tumours, our focus is on the facial nerve with our teams philosophy being total resection, but not at the expense of the facial nerve. Small residual tumours can always undergo focused radiation, but a permanent facial weakness is physically and mentally disabling.

So how do we use this for our day-to-day patients? Those with sinusitis, for example? Well, if they have mild disease and normal scans, then do they need treatment at all? It’s hard to make an asymptomatic patient better. If they do, then could they have medical management and avoid surgery entirely? In most patients, sinusitis is a medical disease and surgery is an adjunct only. Keeping a focus on the patients’ Quality of Life is as important in sinusitis as it is in vestibular schwannoma or laryngeal cancer treatment. Our job is after all to make our patients feel better.