Serendipity in Tonsillectomy

Why tonsil removal appears to decreases a person's risk of cancer

"They ought to be disengaged by the finger and removed," the Roman aristocrat Cornelius Celsus wrote of tonsils in the time of Jesus of Nazareth. If the finger proved ineffective, Celsus recommended lassoing the tonsils and pulling them forward before severing them with a scalpel. And he was not the first. A millennium earlier, the procedure was described in Hindu medical literature—with the prudent caveat that "so much blood may be discharged as will destroy the individual."

By the late 1950s, around 1,400,000 tonsillectomies were performed annually in the United States, often as a precautionary measure to prevent infection. Evidence for the practice did not pan out, and that rate has steadily declined in popularity to a few hundred thousand. Having one's tonsils taken out is not yet back in style, but otolaryngologists at Johns Hopkins University announced some interesting findings today that could make a new case: the first study to look at the association between tonsillectomy and oral cancer.

Because of the sexually transmitted human papillomavirus (HPV), rates of cancer of the palatine and lingual tonsils are increasing. Writing today in the journal Cancer Prevention Research, the Hopkins team led by head-and-neck surgeon Carole Fakhry call the increase "rapid" and partly attributable to "the sexual revolution" on a global scale—people starting younger and having more net partners.

"Concurrent with a change in sexual behavior," the researchers write, people are not getting their tonsils taken out. That has created a breeding ground for oral cancer. Indeed, Fakhry and colleagues report that 77 percent of tonsil cancers in Denmark between 2000 and 2010 were related to HPV. In today's study, the team evaluated more than three million Danish patients in a 35-year database and found that palatine tonsil removal was associated with a 60 to 85 percent decrease in tonsillar cancers.

Ultimately it seems obvious that if you get your tonsils taken out, and they are floating in a jar on your shelf, those tonsils cannot turn cancerous. So your risk of cancer will be that much lower. The question raised by the researchers, then, is if rates of oral cancers are increasing as HPV spreads, would this be a worthwhile procedure for everyone to have?

Before jumping into everyone's throats with a hot spoon, Anil Chaturvedi, an investigator at the Division of Cancer Epidemiology at the National Institutes of Health says in an accompanying editorial, as scientists are wont to say, that more studies are needed.

"Although a common surgical procedure, tonsillectomy is not without minor complications," Chaturvedi notes, "such as postoperative bleeding, pain, and nausea, as well as major complications, such as hemorrhage and death." (He cites an analysis of 5,968 adult tonsillectomy cases, in which the mortality rate was 0.03 percent.) They also cost money. The average cost associated of a tonsillectomy is $3,832 in total. And that's if there are no complications. If patients wind up in an emergency department because of undue postoperative bleeding, that averages $6,388. With pain, $4,708, and with dehydration, $5,753.

If people who are at high risk for tonsillar cancer could somehow be identified early on, Fakhry noted in a press statement—likening to situation to BRCA-positive women at risk for breast cancer, of which Angelina Jolie has become the face—then those people could potentially benefit from prophylactic tonsil removal.

Meanwhile, the importance of this study is in underscoring that there is a cost-effective and overall-effective way to dramatically lower everyone's risk of oral cancer without reviving of the dental dam: the HPV vaccine, which is widely available and poses no risk of destroying the individual. An ounce of prevention is worth a clump of tonsillar carcinoma, and yet most young Americans aren't getting vaccinated.