Mr Priyamal Silva and Dr Nicola Harker Offer Guidance on Identifying and Managing Patients with Head and Neck Cancer
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Head and neck cancer is the eighth most common cancer in the UK, and accounts for approximately 3% of all new cases of cancer. There are approximately 12,000 new cases annually. There is a gender difference: in men, it is the fourth most common cancer in the UK, while in women it is the thirteenth most common cancer in the UK.1
Head and neck cancer comprises a heterogeneous group of tumours that include various anatomical subsites including the oral cavity, pharynx, paranasal sinuses, nasal cavity, larynx, and salivary glands. More than 90% of these cancers are squamous cell in origin.2 Approximately 40% of head and neck cancers occur in the oral cavity, 15% in the pharynx, 25% in the larynx, and the rest in the remaining sites.3
While it is uncommon, the effects of head and neck cancer are significant and carry serious implications. Functionally, the head and neck region performs a myriad of essential roles in terms of respiratory function, swallowing and mastication, as well as in communication through voice production. Psychologically, the effect of head and neck cancer on facial appearance is significant and patients may be distressed about any obvious disfigurement. Head and neck cancer can, therefore, have a devastating effect on the lives of patients in terms of morbidity as well as mortality.
Major depressive disorders can develop in up to 50% of patients undergoing treatment for head and neck cancer—this tends to be more common in women and in younger people with head and neck cancer.4 There is a disproportionately high incidence of depression, suicide, continued substance dependence/abuse, and distress related to relationship conflict, social isolation, disfigurement, and damage to self-image in patients with head and neck cancer.5
Diagnosis poses a challenge; while a proportion of patients may present with a neck lump, other symptoms may be less obvious and may be vague. These may include a persistent sore throat, change in the voice, or swallowing difficulties.
Most GPs may encounter one or two new diagnoses of head and neck cancer in their career. This is reflective of the incidence, which can make the diagnosis of such cases a challenge. Additionally, by virtue of their location, cancers of the oropharynx may reach a significant size before those affected present with symptoms. The first presentation may be a neck lump, representing metastasis from the primary.
Investigations carried out by the GP such as blood tests or ultrasound scans may be of limited benefit and may even serve to delay the diagnosis. Two exceptions may be in the young, low-risk patient presenting with a small likely reactive lymph node with no other red flag signs, or in those with a hoarse voice, where a chest X-ray may be considered to look for any lung lesions, while waiting for a 2-week wait appointment.
If there is uncertainty it may be sensible for the GP to call the patient back for a review. It is often possible to speak to one of the on-call ear, nose, and throat doctors who may be able to advise. In most cases, in the presence of red flag symptoms, following a careful history and examination, expedient referral on a 2-week wait pathway is often the best process for the patient.
The 2-week wait system allows for a patient with a suspected cancer to be referred by their GP to an appropriate specialist and be seen within 2 weeks. Following the 2015 NICE guidelines for suspected cancer,6 the 2-week wait proforma has been updated to highlight the symptoms that are considered to be of concern and warrant a 2-week wait referral.
Red flags include the presence of a persistent unexplained sore throat or unexplained otalgia, along with risk factors including being an ex-smoker (Box 1). While the conversion rate to a diagnosis of a cancer is around 3.5–4.2%,7 nevertheless, it is important to have a high suspicion of head and neck cancer.
|Box 1: Red Flag Signs of Head and Neck Cancer6,8|
While smoking and alcohol are still recognised as risk factors for head and neck cancer, as behaviours have changed, there has been a decline in smoking-related head and neck cancers. Instead there has been an emergence of human papillomavirus (HPV)-related head and neck cancers. This is related to orogenital contact and is linked to number of sexual partners and oral sexual practices. In the long term, the HPV vaccine should help to reduce this rising trend of HPV-related cancers.9
The role of HPV has resulted in a change in the type of patient who may present with a head and neck cancer. Increasingly, we are seeing patients who are non-smokers and non-drinkers presenting with head and neck cancers, and patients may present at a younger age, often in their 40s and 50s.10
These patients occasionally present with cystic neck lumps, which may be mistaken for a branchial cyst. The prognosis for HPV-related head and neck cancers is better than for non-HPV related ones, with 5-year overall survival rates of 70–85% compared with 40–60% for non-HPV related tumours.11
Treatment for head and neck cancers is most successful for patients who are diagnosed and treated early.7 Management is varied and depends on several factors, including the site, the stage at diagnosis, any associated co-morbidities, and patient preferences. Decision making takes place with the patient and the head and neck multidisciplinary team. Early-stage tumours may be treated with single modality treatment such as surgery or radiotherapy. Locally advanced tumours may be treated with chemoradiotherapy or surgery and radiotherapy.
Surgery can range from removal of a small lump on the front of the tongue, to removal of the entire larynx and oesophagus, along with reconstruction of the area. Surgery may also involve removing multiple lymph nodes from the neck (neck dissection). Patients may need plastic or reconstructive surgery for damaged areas, or specialised dentistry after the tumour has been treated. Where tumours interface into other areas such as the skullbase, they may require a combined neurosurgical/ear, nose, and throat procedure.
Effects of Treatment
Treatment for head and neck cancer can impact significantly on function. Patients may have difficulty with eating, drinking, and talking, and some will also need to cope with facial disfigurement.4 Surgery involving the neck may result in painful shoulder movements as a result of nerve involvement. The exact impact will depend on the type of surgery carried out. Treatment for some types of head and neck cancer may involve removing the larynx; if this is the case, the patient will have to breathe through an opening in the neck (stoma) and may need to learn to communicate in new ways. There will also be a significant impact on the patient’s psychology and quality of life. Problems with swallowing and speech are normally well supported by the speech and language team and dietitians, who are an integral part of the head and neck team. The head and neck specialist nurse will usually address psychological problems in the first instance. Problems with shoulder movement are addressed with physiotherapy, which can be organised by the GP or the head and neck team.
Radiotherapy may cause severe dryness of the mouth by affecting the remaining salivary glands, which can impact on swallowing and may occasionally necessitate a stomach feeding tube. As saliva normally helps to protect the teeth, there is also a greater risk of dental-related problems such as tooth decay. The patient will often require regular follow up with their dentist every 3–6 months. The use of high fluoride toothpaste will help to protect and strengthen the teeth.
The effects of a dry mouth can be difficult to manage. Some benefit may be gained by sipping water regularly to try and reduce the dry feeling. The use of artificial saliva preparations can be of some benefit. These come in different preparations including sprays, lozenges, and gels. The extent to which this dryness recovers varies and depends on the extent of any radiotherapy. Nevertheless, recovery may continue for up to 12–18 months after radiotherapy is completed, although this may not be to the pre-morbid state.
All head and neck departments will provide written and verbal information to support the patient. Further patient resources are available online (Box 2). For advice and general enquires, the head and neck specialist nurse is often a useful first point of contact for the GP.
|Box 2: Online Patient Resources|
Macmillan Cancer Support. Information covering various aspects from diagnosis to treatment and living beyond: www.macmillan.org.uk/information-and-support/head-and-neck-cancers
Changing Faces. For patients living with surgery that affects their physical appearance, this can prove a useful resource: www.changingfaces.org.uk
Cancer Laryngectomee Trust. For patients who have undergone surgery to remove their larynx, this website provides support to people who have had a laryngectomy: www.cancerlt.org
Patients are often followed up for 5 years in the hospital setting, with regular input from dietitians, speech therapists, and physiotherapists. The effects of treatment are often longstanding, with many patients requiring lifelong support from a functional point of view following discharge. After radiotherapy to the neck, which may potentially affect the thyroid gland and result in hypothyroidism, it is often the practice to check thyroid function tests on an annual basis. This is usually organised by the head and neck team. Even though a patient may be discharged from active follow up, they should always have access to the head and neck team who should be the first point of contact if there are any concerns. See Box 3 for a patient’s perspective on their experience of having head and neck cancer and how the GP can help.
|Box 3: A Patient’s Experience of Head and Neck Cancer|
‘In late January 2015, I was seen by my GP as I had what I thought was a minor chest infection resulting in a persistent cough and sore throat. A course of antibiotics was prescribed but the symptoms were unchanged following this treatment. My GP felt that I should have a deeper investigation of whatever was going on and referred me to the ENT department, where I was diagnosed with cancer.
‘I underwent treatment for my head and neck cancer. My GP organised the physiotherapy sessions required following my neck dissection surgery, and these continue on a permanent basis.
‘I believe my GP is aware that life was not good during the treatment process but I doubt if there was a deep understanding of the rollercoaster ride that I was going through.
‘There was the shock of discovering that I had cancer in the first place followed by meetings with the support team, tests, PEG placement and then the treatment began. During this short pre-treatment period, I was given a lot of information, which, quite frankly, I really did not absorb properly as my life had, at a stroke, completely changed and I was wondering what the future, if I had one, was going to be like. I must stress that the hospital’s medical support team could not have done more considering the time pressure they work under. I was just not able to take it all in.
‘The strain on the family is immense as they, in all probability, have no idea what is coming or what to do about it when issues arrive. It should be noted that employers, generally, have no idea what the patient’s treatment regimen really entails and, more importantly, how physically and emotionally drained the patient can be at the end of the treatment. It seems they assume the patient “cured”.
‘Should the GP become more involved with the patient while under the care of the hospital? Probably not. The reality is that the patient is really only interested in getting to the end of the particular treadmill of the daily process of attending the hospital for whatever treatment has been prescribed.
‘It’s when the treatment ends that I believe more can be done by the GP. It’s the patient’s day-to-day support group that really needs the advice/discussion with the family doctor. It is hard to describe the cliff edge the patient falls off when at last you are told “the treatment is over and we will see you in 3–4 weeks’ time”.
‘The issue is simple, for the period of treatment the patient is cared for every day. Every issue is quickly resolved and questions are answered promptly. Nothing is too much.
‘Then you are on your own! In many cases, the side-effects of the treatment continue to grow for several weeks. Issues and questions can take much longer to be resolved. The patient and their family can feel abandoned.
‘It is just over 2 years since completion of my head and neck treatment. I am still having swallowing issues, which I accept have become part of my life. Physiotherapy is improving my left arm/shoulder mobility (I can play a reasonable game of golf!). I consider that, given the serious issues that came up in 2015, I have been very lucky.’
Head and neck cancer represents a heterogeneous term, involving multiple areas that cannot often be assessed or visualised easily. Symptoms may be innocuous and therefore it may be difficult to diagnose. Awareness of red flag symptoms is important. This may result in earlier referral and subsequent diagnosis, and improved oncological outcome. Risk factors for head and neck cancer have evolved and now include HPV. The management of head and neck cancer may have devastating effects on a patient’s function, often in more ways than many other cancers. Patients, therefore, often require ongoing lifelong support. An awareness of the problems that these patients face can help the clinician direct and provide appropriate support.
Mr Priyamal Silva
Consultant Otolaryngologist/Head and Neck Surgeon, Oxford University Hospitals NHS Foundation Trust
Dr Nicola Harker
Macmillan GP Adviser