Head and neck cancers Recognising the early signs and symptoms

1
Head and neck cancersRecognising the early
signs and symptoms

• Mr C.Chan, Consultant HN Surgeon (OMFS),LD
• Dr K.Goodchild, Consultant Clinical Oncologist
  NSSG Lead, MVCC
• Mr P.Kothari, Consultant HN Surgeon (ENT),LD

2
Topics to be covered

• Incidence risk factors
• Symptoms signs
• Referral when how
• Diagnosis, treatment, survival

3
Head Neck Cancers

• Oral cancers oral cavity, oropharynx,
  hypopharynx (ICD-10 C00-06,C09-C10, C12-14)
• Larynx (ICD-10 C32)
• Thyroid (ICD-10 C73)
• Others major salivary glands (C07, C08),
  nasopharynx (C11), accessory sinus (C31), nasal
  cavity middle ear (C30)

4
Oral Cancers Lip, tongue, mouth, oropharynx,
hypopharynx

• How common?
• 15th most common cancer UK (2009) 2 all new
  cases
• 6236 new cases in 2009 gt17 people per day
• Higher incidence in Scotland and North of England

CRUK
5
Oral Cancers

• Trends over time
• Incidence rates in UK ? by gt ¼ in last decade

CRUK
6
Oral Cancers
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
7
Oral Cancers
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
8
Laryngeal cancer (ICD10 32)

• How common?
• 2300 diagnosed in 2009 (UK) 6 people daily
• 5 times more common in men than women
• Men incidence rates rose until 1990, then
  fallen
• Women stable past 40 years
• Rare under age 40, majority diagnosed 60 or older

9
Laryngeal cancer

• Trends over time

European Age-Standardised Incidence Rates per
100,000 Population, by Sex, Great Britain
10
Laryngeal cancer
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
11
Laryngeal cancer

• The incidence has fallen by 20 in the study
  period, but levelled off in the last five years
• ? smoking habit
• There is a falling trend from North to South East

12
Thyroid cancer (ICD10 C73)

• How common?
• 2350 diagnosed in 2009 (UK) 6 per day
• More common in women than men
• ½ cases diagnosed age under 50
• Incidence rates in women gt 2x past 40 years
• 5 per 100,000 women

13
Thyroid cancer
European Age-Standardised Incidence Rates per
100,000 Population, by Sex, Great Britain
14
Thyroid cancer
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
15
Thyroid cancer

• Incidence of thyroid cancer has nearly doubled
• May in part be due to imaging of goitres and
  subsequent surgery, leading to an increase in the
  number of small papillary carcinomas being
  detected

16
Risk factors oral cancer

• Tobacco
• Dose and duration dependent
• cigarettes, cigars, roll-ups, pipes
• 70 oral and pharyngeal cancers (male) caused
  by tobacco Parkin DM. Cancers attributable to
  consumption of alcohol in the UK in 2010. Br J
  Cancer 2011 105(S2)S14-S18 doi
  10.1038/bjc.2011.476
• Smokeless tobacco
• Betel quid (paan)
• others

17
Risk factors oral cancer

• Alcohol
• major risk factor
• consumption increasing in the UK
• further increase in risk in smokers
• heavy alcohol smoking 35x risk
• total amount more important
• may explain rising mortality in Europe

18
Risk factors oral cancer
Relative risk of oral/pharyngeal cancer in males
by alcohol/tobacco consumption using US measures
19
Risk factors oral cancer

• Human papillomavirus (HPV-16)
• Strong association with oropharyngeal cancer
• Immunosuppression
• HIV/ AIDS
• organ transplants

20
Risk factors oral cancer

• Diet and nutrition
• some evidence of risk reduction
• Sun exposure
• lip cancers

21
HPV Status

• 5 year overall survival 75-80 if HPV positive
  vs 45 if HPV negative
• Independent of age, TNM stage, smoking

22
Risk factors oral cancer

• Oral mucosal lesions
• erythroplakia
• leukoplakia
• submucous fibrosis
• lichen planus
• syphilitic glossitis
• Previous cancer diagnosis

23
Risk factors laryngeal cancer

• 80 caused by smoking 25 linked to alcohol
• Combined effect 89 of cases
• Risk is proportional to duration and intensity of
  smoking
• Environmental tobacco smoke (ETS) limited
  evidence in causing laryngeal cancer
• Diet high in fruit and vegetables ? risk

24
Risk factors laryngeal cancer

• Gastro-oesophageal reflux - ? risk 2 3 times
• Immunosuppression HIV/AIDS organ transplant
• HPV-16
• Previous H N cancers
• First degree relative with H N cancers

25
Risk factors thyroid cancer

• Women gt men
• Exposure to radiation environmental / medical,
  especially in childhood
• Family history/ genetics medullary FMTC,
  MEN2a, MEN2b FAP
• Some benign thyroid conditions thyroiditis,
  adenomas, goitre
• High BMI

26

• Prevention Screening in HNC

27
Prevention Screening oral cancer

• Avoid risk factors primary prevention
• smoking cessation 50 ? risk in 3 5 years
• education delay in presentation
• Screening secondary prevention
• no cost-effective population screening tool/
  test
• opportunistic screening of at risk population

28
Prevention screening laryngeal cancer

• Avoid/ eliminate risk factors
• No effective population screening tool

29
Prevention screening thyroid cancers

• Avoid/ eliminate risk factors
• Genetic testing family history of medullary
  carcinoma

30
Signs Symptoms

• Recognize early stage of disease
• Prompt referral saves lives
• minimize morbidity
• How - history
• examinations look and feel
• identify high risks patients
• Referral guidelines
• 2WW referral proforma
• NICE primary care referral guidelines

31
Primary Care Referral Guidelines

• Oral mucosal ulcer persisting gt 3 weeks
• Oral swelling persisting gt 3 weeks
• Red or white patches of oral mucosa
• Neck lump persistent for 3 weeks or more
• Dysphagia gt 3 weeks
• Hoarseness gt 6 weeks
• Dysphagia gt 3 weeks
• Unexplained tooth mobility (not periodontal
  disease)
• Cranial neuropathies
• Orbital masses

32
(No Transcript)
33
Symptoms Signs oral cancer

• Non-healing/ persistant ulcer over 3 weeks
• solitary
• /- pain
• no obvious cause/ trauma
• Lump/ swelling in mouth gt 3 weeks
• soft tissues mucosal/ submucosal
• exclude dental cause

34
Oral cancer

• Features of malignancy
• Constant soreness
• Symptoms gt 3 weeks
• May affect eating/ speech
• Referred pain otalgia
• /- systemtic symptoms
• Risk factors

35
Oral cancer

• Features of malignancy
• Solitary non-healing ulcer
• Margins poorly defined
• ? vascularity
• Induration
• Rolled edges
• /- neck lump

36
Early (small) cancer
37
Advance cancer
38
Can present as swellings
39
Unexplained tooth mobility/ non-healing
extraction socket
40
Pre-malignant lesions
Speckled leukoplakia
Leukoplakia (white patches)
41
Pre-malignant lesions
Erythroplakia (red patiches)
42
Oral lichen planus
43
Nicorandil induced ulcers
44
Minor aphthous ulcer
Traumatic ulcer (dental)
45
Neck lump gt 3 weeks
46
Dysphagia gt 3 weeks
47

• Any patient with unexplained persistent sore or
  painful throat
• Unexplained unilateral pain in the head and neck
  area for gt 4 wks associated with earache
  (otalgia) BUT normal otoscopy
• Unexplained, persistent swelling- parotid or sub-
  mandibular salivery gland

48
Unilateral nasal obstruction especially
purulent discharge
49
Cranial nerve neuropathies
Orbital mass - rare
50
Laryngeal Cancer
51
Signs Symptoms laryngeal cancer

• Hoarse voice gt 3 weeks,
• Difficulty in swallowing
• Weight loss, often with other symptoms
• Persistent cough/ SOB
• Neck lump
• Pain/ otalgia

52
Thyroid Cancer
53
Signs symptoms thyroid cancer

• Solitary thyroid nodule
• Lymph node enlargement in neck
• Rapidly growing goitre
• Pain
• Stridor/ dysphagia
• Hoarseness

54
Definitive Diagnosis

• Biopsy histological diagnosis
• USS FNAC thyroid and neck lumps
• Investigations prior to referral doubtful value
• avoid delay

55
Management hospital

• Establish diagnosis
• Staging of the cancer
• MDT discussion individualized treatment plan
• Holistic approach towards patient care

56
Treatment options

• No active anti-cancer therapy
• Palliative radiotherapy/ chemotherapy
• Curative intent Surgery alone
• Surgery Radiotherapy /- Chemo.
• Radical RT /- Chemo
• Others PDT, Cyber knife

57
Survival oral cancer

• Trends in 1- and 5-year relative survival -
  significant improvement
• 5-year relative survival rate for the most recent
  period is 56
• In 2010, 2000 people died from oral cancer
• Survival is related to stage at presentation,
  sub-sites, HPV status

58
Survival oral cancer
59
Survival laryngeal cancer

• 5-year relative survival rates have remained
  unchanged
• The absence of any significant new therapies is a
  likely factor
• 5-year relative survival rate is 65
• ? of men survive for 5 years or more
• There is evidence of improved quality of life
  with advances such as surgical voice restoration

60
Survival thyroid cancer

• Trends in one and five year relative survival -
  an increase of11
• Identifying and treating smaller cancers may be a
  factor
• The 5-year relative survival rate for the most
  recently diagnosed cases is 87
• Survival is better for the younger age 95
  under 40 are likely to survive at least 5 years

61
Referral pathways

• 2WW proforma-
• Indications for referral
• How to refer
• Neck lump clinics

62
Referral pathways
63
Thyroid Clinics
64
Key Messages

• Refer early when appropriate
• Early stage disease has good prognosis
• High index of suspicion in patients with risk
  factors
• Use 2WW proforma to streamline referral pathway

65
Questions