Head and Neck robot-assisted surgery

This document outlines the current AXA Health policy for Head and Neck robot-assisted surgery and is based on NICE guidance, review of the literature and interviews carried out with a number of chairs/committee leads from BAHNO, BAOMS, and ENT UK.  

It is clear from this work that transoral robotic surgery (TORS) uptake is variable across Head and Neck networks but that there has been increasing linkage of MDTs so that patients can move centres to access TORS as required.  

Overview of Operations and Evidence  

Mucosectomy / Unknown Primary Surgery  

The evidence is strong that TORS is an optimal approach for cancers of unknown primary. The alternative to this is blind random biopsies and bilateral tonsillectomies which will often not find the primary, resulting in the need for wide radiotherapy fields which carry a significant morbidity. The mucosectomy allows the complete or targeted removal of the mucous membrane at the back of the tongue, confirming the diagnosis and removing the primary cancer. This is reflected in NICE guidelines which support this as an option (https://www.nice.org.uk/guidance/ng36/chapter/recommendations).  

• AXA Health policiesⁱ will fully fund these procedures which are widely accepted as safe and lower morbidity for the patient than alternatives.

Primary cancer resection 

There is more variation in primary cancer resection, with some surgeons still proposing open resection and flap reconstructions, and others more convinced by the role of TORS.  There is early evidence in trials that transoral surgery can reduce the subsequent radiation dose required (https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6500) but greater evidence will come from the PATHOS trial which is halfway through recruiting and should report in next few years.  

• AXA Health policiesⁱ will fund TORS resection of primary cancer but not at an additional cost over the standard tariff whilst there is no clear evidence of improved outcomes.  

Recurrent cancer resections  

Recurrent cancers often require more substantial dissection and are technically far more challenging. These procedures are also more likely to leave exposed vessels which may require flap coverage. Whilst some centres are taking on selected recurrent cancers with a TORS approach, this is still in the experimental stages and should be restricted to very experienced surgeons, in tertiary / supra regional centres with careful auditing of outcomes. 

• AXA Health policiesⁱ will not routinely fund TORS resection of recurrent cancers. 

Supraglottic cancers

TORS allows partial supraglottic laryngectomies to be performed, reducing the requirement for major resections or radiotherapy and therefore improving patient outcomes. This is supported by NICE guidelines (https://www.nice.org.uk/guidance/ng36/).  

• AXA Health policiesⁱ will fully fund these procedures which are widely accepted as safe and lower morbidity for the patient than alternatives.  

Benign surgery  

There has been a move towards the limited utilisation of robotic approaches for benign conditions. However, there is currently limited or no evidence of improved outcomes. The one exception is a limited number of benign conditions at the base of the tongue that are very inaccessible by traditional techniques; for example, base of tongue varicoceles leading to recurrent bleeding.  

• AXA Health policiesⁱ will fund TORS for benign conditions but not at an additional cost over the standard tariff whilst there is no clear evidence of improved outcomes. For base of tongue procedures this will be considered case by case.  

Credentialing of surgeons  

It is important for patients to be confident that their surgeons have been appropriately trained in TORS techniques. For more information regarding AXA Health robot-assisted surgeon credentialling contact Sarah Taylor (Head of Specialist & Practitioner Relations): see sidebar for details. 

Summary  

Funding decisions in the private sector can be complex and inevitably there will be surgeons and patients who feel that the bar has been set at the wrong height for a given operation or approach.

This review has attempted to provide clarity in the Head and Neck field, based on evidence and the opinions of three professional societies. We want this process to begin a dialogue with the surgical community and, therefore, please reach out to us if you have any comments or if you feel the evidence has changed.  

Contact us: medevsupport@axahealth.co.uk 

Dr. John Burke (Director of Medical Policy) 

Footnotes
i. Subject to policy terms