The necessity of adding chemotherapy to radiotherapy itself is debatable. The MACH -NC reported 4% improvement in overall survival at 2 and 5 yrs with CT. So to prevent death of 400 patients at 5 years, 10,000 patients would have to undergo CT. In O'Sullivan' questionnaire based study, apart from extent of disease the other significant variables that influenced treatment recommendation were physicians specialty and their geographical area of practice. Most LP protocols are often accompanied by increased toxicity and are generally achieved in good performance status patients unlike majority of head and neck cancer patients. In VA trial, 77% patients had Karnofsky performance score (KPS) more than 80 and in RTOG 91-11 trial, 2/3 patients had KPS 90 or more. In RTOG trial, the mucosal toxicity in concurrent CT+RT arm was twice as much as the mucosal toxicity in other two arms. High grade toxic effects occurred more when CT was added to RT but there was no significant difference in rate of toxic effects between concurrent arm and ICT arm. Incidence of treatment modification, treatment interruption and hospitalizations are higher (compared to RT alone) when CT is administered concomitantly or during altered fractionation due to complications such as mucositis, dysphagia, pain, desquamation etc. The indirect costs attributable to non-surgical approaches e.g frequent expensive imagings, duration of treatment , duration of recuperation, cost of chemotherapy drugs, enhanced need for supportive care, stringent follow up and salvage surgery (in one third to half of the patients) may be more than the costs for radical surgery. Careful monitoring of the conservatively treated patient is mandatory to allow for early salvage of failures (in VA trial, induction CT arm had more local recurrences and only 2% patients were lost to follow-up). Given the infirmity and poor compliance of head and neck cancer patients such a stringent follow-up appears difficult (in VA trial patients were followed up every month for 1st year).