Is surgery necessary in stage III and stage IV cancer of the head and neck that responds to induction chemotherapy?

Objective: To study the influence of surgery in patients who achieve a response to induction chemotherapy. Design: Nonrandomized retrospective study. Setting: Comprehensive cancer center. Patients: The records of all patients with stage III and stage IV squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx were reviewed at the Queensland Radium Institute, South Brisbane, Australia, in the years 1970 through 1990. Interventions: There were 314 patients where induction chemotherapy was used as part of a curative treatment. Complete response occurred in 20 patients, partial response in 110 patients, nonresponse in 162 patients, and unknown response in 22 patients. To assess the impact of surgery, the responders were divided into two treatment groups: one group (n=57) received chemotherapy, surgery, and radiotherapy (C/S/XRT), and a second group (n=73) received chemotherapy and radiotherapy (C/XRT). Main Outcome Measures: Five-year survival, local failure, nodal failure, and distant failure. Results: The 5-year actuarial survival for the chemotherapy responders and nonresponders was 58% and 43%, respectively (P<.05). When analyzed by treatment group, those receiving C/S/XRT had a 65% 5-year survival (95% confidence intervals [CIs], 53 to 78) and those receiving C/XRT had a 56% 5-year survival (95% CI, 44 to 70). However, when the complete responders were assessed, those receiving C/S/XRT had a 90% 5-year survival (95% CI, 72 to 99) vs a 51% survival (95% CI, 18 to 89) for those treated with C/XRT. For the partial responders, the survival for the groups C/S/XRT and C/XRT were 59% (95% CI, 45 to 79) and 53% (95% CI, 41 to 67), respectively. Chemotherapy responders were less likely to fail locally if they were treated with C/S/XRT than with C/XRT (21% vs 43%, P<.01). Conclusion: The results suggest that surgery still has a role to play in patients who achieve a response with chemotherapy, even when the response is complete.