Hi Harsha, You do raise some discussion points here.
IMRT, we know, is very good to achieve conformal dose distributions. But this is restricted to the conformality of the prescribed dose. At both extremes of doses, brachytherapy far supersedes in terms of ability to allow conformality thereby restricting lower doses in periphery while giving extremely high doses in the centre. Though this case would be good for brachytherapy, treating with IMRT alone and splashing the low doses all over the place may not necessarily be a good idea. So treatment options have always been brachytherapy alone Vs W/E alone for node negative oral cavity cancers.
In absence of brachytherapy as an option, it would be preferable to proceed with primary surgical approach for two main reasons: short treatment and possibility of not requiring Post-operative adjuvant radiotherapy especially in superficial cancers. The speech quality with limited glossectomy is reasonably good under expert surgical hands. Even in a case where there was just one LN positive but a good neck dissection and pathological sampling we can talk about possibility of close surveillance and avoid radiotherapy.
In scenarios where post-operative adjuvant radiotherapy is necessary, lower total doses would make it more tolerable as against offering definitive radiotherapy to higher doses. But yes, if for a given case the extent of glossectomy required may be more extensive, then we should have the discussion of primary RT +- CT approach with surgery for salvage Vs Sx + PORT +-CT approach with the idea of minimizing the modalities used for treatment. But even in these scenarios, I think primary surgical approach is preferred for better loco-regional control rates [I can't quote any evidence to suppoprt this statement.. may be Rohit and Santam can provide some insights]. Also surgeons as always, prefer operating in primary settings than for salvage.
About whether we need to look at patients with and without tobacco/ alcohol history, I guess there is no evidence to suggest one does better than other. Personally, I think patients with long standing dysplastic changes of unknown aetiology that transform into malignancy don't do as well as tobacco related cancers… I have no basis though of saying this.. just level G evidence.
