A Few Questions About Head & Neck Cancer Surgery

[capnamerica]

1. What are the referral patterns like? Do the majority of referrals come from physicians or dentists? How dependent are these patterns on location, especially comparing a major city like NYC or Toronto to a smaller one?

2. Given the changing rates of tobacco consumption and HPV prevalence, do you foresee a glut or shortage of Head & Neck Cancer surgeons a decade or two from now?

3. What's the turnover like in the academic end of the field? Are most surgeons relatively young, with the (relatively) more elderly ones leaving for private practice?

Thanks!

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[Pir8DeacDoc]

Never had a referral from a dentist.
There will always be people
With head and neck cancer. Healthcare gets more specialized day by day. Combine that with trends towards primary treatment being chemo and radiation and the need for someone in a big hospital with the desire to do salvage surgery and there will always be a place for the head and neck cancer surgeon.


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[DrBodacious]

Cap'n - are you a medical student? Resident? See general responses below.

1. As a general ENT, referrals can come from anywhere - dentists, PCP, ER/urgent care, other specialists (could get a referral from ob/gyn), self referred. In my practice, head and neck cancer is fairly uncommon. Referral patterns are the same for a head and neck sub-specialist, but they also get referrals from other ENT, including gen ENT, and other sub-specialists.

Being a sub-specialist is going to work better in larger areas. I can't say if there is a magic number for the population served per each H&N surgeon, I don't know.

2. I have heard there is a glut in large metro areas, now vs a decade ago. I suspect that the SES of a typical H&N cancer patient is very different now compared to the 80s or even the 90s. This is given that it used to be common place for successful people to smoke. (My medical school had ashtrays in the lecture halls at one time.) Now, people who smoke tend to be people who struggle more with decisions of all kinds, and who are negligent with taking care of themselves. The relative /absolute increases in HPV related cancers mean more primary XRT and chemo/XRT. Those cancers, as you may know tend to be more oropharyngeal, which tend to be treated non-surgically, anyway, with HPV having a good response rate to XRT based treatment, also. These are things that you will look at during residency as you determine your motives for wanting to sub-specialize in H&N, and put that together with where you want to live.

3. I know older academic H&N surgeons. I feel like I saw some article on this in the past, you could check pubmed.

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[VisionaryTics]

1. As above. Most referrals in a busy head and neck ablative and reconstructive practice come from other ENTs/endocrinologists/neurosurgeons. If you're earlier in your career and more of your referrals come primary care, you'll probably get more globus, dysphagia, and benign intraoral lesions (papillomas and such).

2. As above, they'll always be a need for the skillset. Field is shifting more towards salvage surgery after radiation rather than upfront surgery, but I think one of the big trends in H&N surgery will be applying "organ preservation" philosophy to surgical approaches, i.e. robotic approaches to oropharyngeal tumors that would've required a mandible split or pharyngotomy, transoral laser microsurgery that goes after laryngeal Ca and keeps radiation as an option in a patient population with a high rate of recurrences and second primaries, etc.

3. At my program, H&N attendings range from 37 to 67. We had one pass away last year in the middle of a busy ablative practice at 75. The overall trend is that younger guys tend to be free flap surgeons, and many who used to do flaps transition to ablative-only practice once they get a little more senior.