Head and neck cancers Recognising the early signs and symptoms

1. Head and neck cancersRecognising 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

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 CRUK How common? 15th most common cancer UK (2009) – 2% all new cases 6236 new cases in 2009: >17 people per day Higher incidence in Scotland and North of England

5. Oral Cancers Trends over time Incidence rates in UK  by > 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 European Age-Standardised Incidence Rates per 100,000 Population, by Sex, Great Britain Trends over time

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 > 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 > 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 > 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

33. Symptoms & Signs – oral cancer Non-healing/ persistant ulcer over 3 weeks solitary +/- pain no obvious cause/ trauma Lump/ swelling in mouth > 3 weeks soft tissues – mucosal/ submucosal exclude dental cause

34. Oral cancer Features of malignancy Constant soreness Symptoms > 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 > 3 weeks

46. Dysphagia > 3 weeks

47. Any patient with unexplained persistent sore or painful throat Unexplained unilateral pain in the head and neck area for > 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