THE heavy smoking, hard drinking lifestyle prevalent in the West of Scotland has already wreaked havoc with heart and lung disease, and is now being blamed for the rise in instances of oral cancer.

Studies show an increase in oral cancer nationally, but particularly in areas of high industry and low economic circumstance, such as the West of Scotland.

The likes of former mining communities, where heavy smoking is common and drinking and diet attitudes have been passed along the generations, are the most vulnerable.

Smokers are four times more likely to contract oral cancer and, if combined with heavy drinking, the chances increase by a massive fortyfold.

Crosshouse Hospital, one of three served by the North Ayrshire and Arran National Health Service Trust, is fast earning a reputation for head and neck surgery.

The ear, nose, and throat unit was originally set up in Ayrshire in 1968, by the innovative Raj Singh, who had moved from Dundee where he was a recognised specialist in head and neck surgery.

Surgeons John Dempster and Stuart Hislop have been recent and important additions to the team, bringing with them expertise in their own fields.

In the 18 months Mr Hislop has been with the unit, the first six saw two or three oral cancer operations and, in the following year, two a month. This year to May, there have been 18 instances of the disease. In an area the size of Ayrshire - with a population of 400,000 - this is a huge number. Normally about 20 cases a year could be expected.

There is a blurring of the edges between ear, nose, and throat, and maxillofacial surgery in general, and that is why the Crosshouse unit works so well together. The team is unique in that it can carry out, on site, free flap and voice rehabilitation in the same operation if necessary.

The free flap technique was originated by the Chinese and brought from there to the UK by Canniesburn's David Souter. He pioneered the use of a flap to rebuild the mouth after cancer surgery. The Chinese had used it for burns.

If the patient needs a tumour above the larynx removed, the Crosshouse unit would be able, if necessary, to cut away the larynx, put in a valve to allow speech, and also insert flaps. No other hospital can cope as well.

Originally, Mr Singh did everything, but now there is super-specialisation within ear, nose, and throat.

A unit should, ideally, compose of an ENT specialist, a maxillofacial specialist, oncology (cancer) specialist, speech therapist, and physiotherapist. All, apart from the oncologist, are based at Crosshouse, where the oncologist has a specialist clinic.

All surgery, reconstruction and rehabilitation is carried out locally, which is exclusive to the hospital. Crosshouse takes total patient care a step further by getting, for example, a gastrostomy feeding tube inserted during cancer surgery.

General surgeons are happy to supply this service at short notice, and all equipment is on site with the expertise needed, so there is no need to order in.

Budget wise, Crosshouse is the largest non-teaching trust in Scotland and probably the only one which has a full ENT and maxillofacial surgery department and, therefore, can provide total service.

Mr Singh had the foresight to realise that things could not stand still. He has now withdrawn somewhat from head and neck surgery because of his invention of the cochlear (bionic) ear implants, which has spread his name worldwide.

Mr Dempster was taken on as a head and neck surgeon whose main sub-field is the voice box, laryngectomy surgery. He was followed by Mr Hislop, who realised the team was very interested in the multi-discipline approach.

Mr Hislop, whose expertise is in maxillofacial surgery, has brought with him a different dimension to reconstruction work.

It is not just the surgery which is important, but the back up of rehabilitation specialists. Unfortunately, the speech and language therapists unit is, at the moment, under threat because of financial constraints.

According to Mr Dempster, it is just not good enough to obliterate cancer. You must also rehabilitate the patient.

``We must make sure the patient can speak and swallow, which all needs back-up services.

``Unfortunately, the support services, like speech therapists, dieticians, lab technicians, and clerical staff look like being shaved, and this would undoubtedly have a knock on effect on clinical services.

``The North Ayrshire Trust is the most efficient in Scotland and there is not much meat on the bone to make cuts. Management is therefore faced with painful decisions because it is being asked to do 4% more with 3% less funding,'' says Mr Hislop.

``Basically, if you all do your own thing you won't survive because of the rationalisation of cancer services the Government is trying to bring in at the moment. The support of the oncologist is vital and when cancer re-organisation comes around we will need their support to survive,'' Mr Hislop believes.

The unit has enough joint-consultant operating to allow everybody to retain their expertise at a high level. A team approach is needed to get various options of what is possible or not possible on treatment and diagnosis. Otherwise, you don't have functionally and surgically the best results for the patient.

Decisions on treatment are made jointly. Sometimes a small operation is better for the patient, especially the elderly, than six weeks of intensive radiotherapy. Evidence shows that large oral tumours require surgery and radiotherapy for decent survival. Smaller tumours can be treated with either surgery or radiotherapy.

Mr Hislop explained: ``With the functional reconstructions we do now, surgery is the better option for smaller tumours, in certain cases, compared to radiotherapy, but mostly both methods are used. Many criteria decide which way the patient will be treated.''

Crosshouse is a progressive hospital and recently acquired a new MRI scanner, a technique which bends molecules and cells by magnets to highlight the extent of the cancer.

The Health Board, at the moment, has a task force looking at cancer re-organisation, and a final decision will be taken in conjunction with the Royal Colleges and oncologists to come to a mutual plan which is best for the patient.

Mr Hislop's vision for head and neck surgery in the West of Scotland would be for cancer centres in Lanarkshire and Ayrshire, with two centres serving Glasgow.

n Brian Ferguson is the Business Production Editor of The Herald

It's not good enough to

obliterate the disease.

You must also

rehabilitate the patient