Development of a transoral robotic surgery program in Canada

Head and neck squamous cell carcinoma (HNSCC) is the fifth most common cancer in Canada, affecting more than 4500 Canadians each year [1]. Despite a national decrease in rates of alcohol and tobacco use, there has been an epidemic rise in the incidence of one subset of HNSCC - cancers arising from the oropharynx [2,3]. Over the last three decades, oropharyngeal cancers have tripled, an increase now known to be due to oral infection with the human papillomavirus (HPV) [3,4]. At many institutions, chemoradiation is the standard of care. However it carries significant short and long term side effects, such as mucositis, fibrosis, dysphagia, xerostomia, and tissue necrosis [5-7]. These results have led the oncology community to reconsider surgical approaches in a minimally invasive context. Since receiving FDA approval in 2009, transoral robotic surgery (TORS) for the treatment of T1-2 oropharyngeal and laryngeal cancers has become rapidly adopted at many institutions in the United States. The initial results of many small studies suggest that this surgical approach provides excellent survival rates and superior speech and swallowing outcomes relative to other organ preservation approaches [8-10]. However, prior to December 2010 a TORS program had not been developed in Canada. Delayed adoption of this promising technology is at least in part due to the disparate healthcare systems. The aim of this article is to describe the development of a TORS program in Canada, highlighting the challenges that needed to be overcome, some of which are unique to a universal healthcare system.Treatment of all head and neck cancer patients at the London Regional Cancer Centre is conducted within the framework of the Cancer Care Ontario guidelines [11]. Treatment recommendations are by consensus of our multidisciplinary team including radiation oncologists, medical oncologists, and head and neck surgeons. To implement any significant changes to the treatment practices of our institution,