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Mount Vernon Cancer Network Primary Care Cancer Education

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Head and neck cancers
Recognising the early signs and symptoms
Mr C.Chan, Consultant H&N Surgeon (OMFS),L&D
Dr K.Goodchild, Consultant Clinical Oncologist & NSSG Lead, MVCC
Mr P.Kothari, Consultant H&N Surgeon (ENT),L&D
Topics to be covered
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Incidence & risk factors
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Symptoms & signs
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Referral – when & how
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Diagnosis, treatment, survival
Head & Neck Cancers
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Oral cancers: oral cavity, oropharynx,
hypopharynx
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Larynx
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Thyroid
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Others
(ICD-10; C00-06,C09-C10, C12-14)
(ICD-10; C32)
(ICD-10; C73)
– major salivary glands
nasopharynx (C11),
accessory sinus (C31), nasal cavity & middle ear (C30)
(C07, C08),
Oral Cancers Lip, tongue, mouth, oropharynx, hypopharynx
How common?
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15th most common cancer UK (2009) – 2% all new cases
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6236 new cases in 2009: >17 people per day
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Higher incidence in Scotland and North of England
CRUK
Oral Cancers
Trends over time
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Incidence rates in UK пѓЎ by > Вј in last decade
CRUK
Oral Cancers
Profile of Head and Neck Cancers in England: Incidence, Mortality and
Survival . OCIU January 2010
Oral Cancers
Profile of Head and Neck Cancers in England: Incidence, Mortality and
Survival . OCIU January 2010
Laryngeal cancer
(ICD10; 32)
How common?
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2300 diagnosed in 2009 (UK) – 6 people daily
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5 times more common in men than women
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Men – incidence rates rose until 1990, then fallen
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Women – stable past 40 years
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Rare under age 40, majority diagnosed 60 or older
Laryngeal cancer
Trends over time
European Age-Standardised Incidence Rates per 100,000 Population, by Sex, Great Britain
Laryngeal cancer
Profile of Head and Neck Cancers in England: Incidence, Mortality and
Survival . OCIU January 2010
Laryngeal cancer
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The incidence has fallen by 20% in the study period, but
levelled off in the last five years
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↓ smoking habit
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There is a falling trend from North to South East
Thyroid cancer
(ICD10; C73)
How common?
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2350 diagnosed in 2009 (UK) – 6 per day
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More common in women than men
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ВЅ cases diagnosed age under 50
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Incidence rates in women > 2x past 40 years
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5 per 100,000 women
Thyroid cancer
European Age-Standardised Incidence Rates per 100,000 Population, by
Sex, Great Britain
Thyroid cancer
Profile of Head and Neck Cancers in England: Incidence, Mortality and Survival .
OCIU January 2010
Thyroid cancer
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Incidence of thyroid cancer has nearly doubled
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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
Risk factors – oral cancer
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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
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Smokeless tobacco
Betel quid (paan)
others
Risk factors – oral cancer
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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
Risk factors – oral cancer
Relative
risk
of oral/pharyngeal
Figure 4.2: Relative
risk
of oral/pharyngeal
cancercancer
in malesin
bymales by
alcohol/tobacco
consumption
using US measures
alcohol/tobacco
consumption using
US measures
40
Relative risk
30
25
20
1-19/day for 20+ years
30 20-39/day
Ex-smoker
for 20+ years
25 40+/day for 20+ years
Relative risk
35
40 Non-smoker
Non-smoker
35 Ex-smoker
20
15
15
10
10
5
5
0
<1
1-4
0
<1
1-4
5-14
15-29
Drinks/week
5-14
Drinks/week
15-29
30+
30+
Risk factors – oral cancer
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Human papillomavirus (HPV-16)
Strong association with oropharyngeal cancer
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Immunosuppression
HIV/ AIDS
organ transplants
Risk factors – oral cancer
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Diet and nutrition
some evidence of risk reduction
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Sun exposure
lip cancers
HPV Status
5 year overall survival =75-80% if HPV
positive vs 45% if HPV negative
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Risk factors – oral cancer
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Oral mucosal lesions
erythroplakia
leukoplakia
submucous fibrosis
lichen planus
syphilitic glossitis
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Previous cancer diagnosis
Risk factors – laryngeal cancer
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80% caused by smoking; 25% linked to alcohol
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Combined effect – 89% of cases
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Risk is proportional to duration and intensity of smoking
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Environmental tobacco smoke (ETS) – limited evidence
in causing laryngeal cancer
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Diet high in fruit and vegetables: ↓ risk
Risk factors – laryngeal cancer
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Gastro-oesophageal reflux - ↑ risk 2 – 3 times
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Immunosuppression – HIV/AIDS; organ transplant
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HPV-16
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Previous H & N cancers
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First degree relative with H & N cancers
Risk factors – thyroid cancer
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Women > men
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Exposure to radiation – environmental / medical,
especially in childhood
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Family history/ genetics – medullary: FMTC, MEN2a,
MEN2b; FAP
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Some benign thyroid conditions: thyroiditis, adenomas,
goitre
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High BMI
Prevention & Screening in
HNC
Prevention & Screening – oral cancer
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Avoid risk factors – primary prevention
smoking cessation : 50% ↓ risk in 3 – 5 years
education: delay in presentation
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Screening – secondary prevention
no cost-effective population screening tool/ test
opportunistic screening of at risk population
Prevention & screening – laryngeal
cancer
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Avoid/ eliminate risk factors
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No effective population screening tool
Prevention & screening – thyroid
cancers
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Avoid/ eliminate risk factors
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Genetic testing – family history of medullary carcinoma
Signs & Symptoms
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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
Primary Care Referral Guidelines
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Oral mucosal ulcer persisting > 3 weeks
Oral swelling persisting > 3 weeks
Red or white patches of oral mucosa
Neck lump persistent for 3 weeks or more
Dysphagia > 3 weeks
Hoarseness > 6 weeks
Dysphagia > 3 weeks
Unexplained tooth mobility (not periodontal disease)
Cranial neuropathies
Orbital masses
Symptoms & Signs – oral cancer
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Non-healing/ persistant ulcer over 3 weeks
solitary
+/- pain
no obvious cause/ trauma
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Lump/ swelling in mouth > 3 weeks
soft tissues – mucosal/ submucosal
exclude dental cause
Oral cancer
Features of malignancy
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Constant soreness
Symptoms > 3 weeks
May affect eating/ speech
Referred pain – otalgia
+/- systemtic symptoms
Risk factors
Oral cancer
Features of malignancy
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Solitary non-healing ulcer
Margins poorly defined
↑ vascularity
Induration
Rolled edges
+/- neck lump
Early (small) cancer
Advance cancer
Can present as swellings
Unexplained tooth mobility/ nonhealing extraction socket
Pre-malignant lesions
Speckled leukoplakia
Leukoplakia (white
patches)
Pre-malignant lesions
Erythroplakia (red patiches)
Oral lichen planus
Nicorandil induced ulcers
Minor aphthous ulcer
Traumatic ulcer (dental)
Neck lump > 3 weeks
Dysphagia > 3 weeks
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Any patient with unexplained persistent sore or painful
throat
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Unexplained unilateral pain in the head and neck area
for > 4 wks associated with earache (otalgia) BUT
normal otoscopy
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Unexplained, persistent swelling- parotid or submandibular salivery gland
Unilateral nasal obstruction – especially purulent discharge
Cranial nerve neuropathies
Orbital mass - rare
Laryngeal Cancer
Signs & Symptoms – laryngeal cancer
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Hoarse voice > 3 weeks,
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Difficulty in swallowing
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Weight loss, often with other symptoms
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Persistent cough/ SOB
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Neck lump
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Pain/ otalgia
Thyroid Cancer
Signs & symptoms – thyroid cancer
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Solitary thyroid nodule
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Lymph node enlargement in neck
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Rapidly growing goitre
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Pain
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Stridor/ dysphagia
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Hoarseness
Definitive Diagnosis
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Biopsy – histological diagnosis
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USS + FNAC – thyroid and neck lumps
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Investigations prior to referral – doubtful value
avoid delay
Management – hospital
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Establish diagnosis
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Staging of the cancer
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MDT discussion – individualized treatment plan
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Holistic approach towards patient care
Treatment options
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No active anti-cancer therapy
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Palliative – radiotherapy/ chemotherapy
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Curative intent – Surgery alone
Surgery + Radiotherapy +/- Chemo.
Radical RT +/- Chemo
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Others – PDT, Cyber knife
Survival – oral cancer
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Trends in 1- and 5-year relative survival - significant
improvement
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5-year relative survival rate for the most recent period is
56%
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In 2010, 2000 people died from oral cancer
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Survival is related to stage at presentation, sub-sites,
HPV status
Survival – oral cancer
Survival – laryngeal cancer
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5-year relative survival rates have remained unchanged
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The absence of any significant new therapies is a likely
factor
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5-year relative survival rate is 65%
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в…” of men survive for 5 years or more
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There is evidence of improved quality of life with
advances such as surgical voice restoration
Survival – thyroid cancer
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Trends in one and five year relative survival - an
increase of11%
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Identifying and treating smaller cancers may be a factor
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The 5-year relative survival rate for the most recently
diagnosed cases is 87%
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Survival is better for the younger age – 95% under 40
are likely to survive at least 5 years
Referral pathways
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2WW proforma:-
Indications for referral
How to refer
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Neck lump clinics
Referral pathways
Thyroid Clinics
Key Messages
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Refer early when appropriate
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Early stage disease has good prognosis
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High index of suspicion in patients with risk factors
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Use 2WW proforma to streamline referral pathway
Questions
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