Hi everyone, this is Ingrid, Brian's wife typing for him. Brian just came home from a week in the hospital having abdominal surgery and is a little under the weather, hence his absence from the boards, emails, etc. for the last 10 days. While he is dictating this to me he wants you to know that he is under the influence of some drugs that make his thought processes a little choppy so please bear with it all.

As to the question of surgery coming before or after radiation, there are several factors which determine this. One has been mentioned above, and that is the desire for the treatment team to reduce the overall volume of tumor mass to an operable size. This is not to say that a tumor the size of a football could not be surgically removed, as we all have no doubt seen the tabloid stories of these enormous basketball-sized tumors removed from people who thought they were pregnant, fat, or whatever. Oral and head and neck cancers frequently come in close proximity to vital structures such as the primary arteries of the neck, and other significant neuro-vascular bundles, which are delicate to cut around. A smaller object to remove, in theory would make damage to adjacent structures less likely. There is a problem with surgery following radiation however, and that is that the tissues of all types, muscular, fatty, lymphatic, become thick, stringy, and extremely gooey/sticky as surgeons "technically" refer to the radiated tissues. Post radiation surgeries are a pain in the rear to surgeons and most given a choice would prefer to cut normal density tissues. In Brian's case, during his radical neck dissection, this was a particular problem as the surgeon had to spend many hours literally scrapping these gooey tissues from around locations such as his carotid artery. This type of surgery requires supreme skill and the best hands which he was lucky to have working on him. There is also an issue of the tissues ability to heal post radiation as most of you know. Even years after radiation treatments the healing process for those irradiated can be significantly longer for a simple cut or bruise compared to normal people.

All this goes back to the type of center at which you are being treated. At a multidisciplinary facility you will find the debate of what is convenient for the surgeon, less important than what will have the maximum impact on the cancer at the earliest possible time.

Lastly, as to chemotherapies, as a primary treatment for cancer they are normally reserved for use in only those patients which have the worst and most advanced oral cancers. For those with stage two's and early three's chemotherapy is thought of in most circles as a general area/and systemic "wash" to catch errant cancer cells which may have micro-metastasized away from the immediate location of the oral cancer. In the absolute worst scenarios, chemotherapy is sometimes only prescribed as a palliative treatment to extend the life and comfort of someone whose disease is beyond the realm of cure.