Head and Neck Cancer: Recognition and Management

Introduction

Head and neck cancer is a collective term for malignancies arising in the oral cavity, pharynx (naso-, oro- and hypopharynx), larynx, and related structures, of which the great majority are squamous cell carcinomas. Thyroid cancer and skin cancers of the head and neck are considered separately, despite occurring in the same anatomical region.¹

The condition is important to recognise early because symptoms are often initially non-specific or attributed to more benign causes, and because the prognosis for early-stage disease is very substantially better than for advanced disease - making red-flag recognition and prompt referral the single biggest determinant of outcome that a non-specialist can influence.

Epidemiology and risk factors

Smoking and alcohol remain the dominant risk factors for most head and neck squamous cell carcinomas, and act synergistically - the combined risk in someone who both smokes and drinks heavily is substantially greater than the sum of either risk alone.^1,2

Human papillomavirus (HPV), particularly type 16, causes a rising proportion of oropharyngeal cancers (tonsil and base of tongue), and typically affects a younger patient group with little or no smoking history. This is now recognised as a biologically distinct disease with a significantly better prognosis than HPV-negative, smoking-related oropharyngeal cancer at an equivalent stage.

• Epstein-Barr virus (EBV): strongly associated with nasopharyngeal carcinoma, particularly in patients of Southern Chinese or North African descent
• Betel nut/areca nut chewing: a recognised risk factor for oral cavity cancer, relevant in South Asian populations
• Occupational exposures: hardwood dust (associated with sinonasal adenocarcinoma) and nickel
• Poor oral hygiene and ill-fitting dentures: contribute to oral cavity cancer risk
• Immunosuppression: including HIV, increases risk of several subtypes
• Premalignant oral lesions: leukoplakia (white patch) and, of greater concern, erythroplakia (red patch), which carries a higher rate of malignant transformation

Presentation by subsite

Symptoms depend heavily on the site of origin, and recognising the pattern typical of each subsite is central to prompt diagnosis:^1,3

Red flags and referral criteria

Examination

A thorough examination includes inspection and palpation of the oral cavity and oropharynx, palpation of the neck for lymphadenopathy (described systematically by neck level, I-VI), and cranial nerve assessment, particularly the facial nerve if a parotid mass is present.¹

Flexible nasendoscopy is essential to directly visualise the nasopharynx, larynx and hypopharynx, structures that cannot be adequately assessed by external examination alone, and should be performed by ENT for anyone meeting red-flag criteria.

Investigations

Panendoscopy (examination under general anaesthetic of the oral cavity, pharynx, larynx and oesophagus) with biopsy of any suspicious lesion is the definitive diagnostic step, and also allows assessment for a synchronous second primary tumour, which occurs at an increased rate in this patient group.¹

Fine needle aspiration cytology (FNAC) is used to assess any neck mass. Cross-sectional imaging - CT and/or MRI of the neck - defines local extent and nodal involvement, CT chest screens for pulmonary metastases or a synchronous lung primary (particularly relevant given the shared risk factor of smoking), and PET-CT is used for staging in selected cases and for identifying an occult primary tumour when a patient presents with metastatic neck nodes but no obvious primary lesion.

Every case is discussed at a head and neck multidisciplinary team (MDT) meeting, bringing together ENT/head and neck surgery, oncology, radiology, pathology, speech and language therapy, dietetics, and clinical nurse specialists to agree a staging and treatment plan.

Management

Treatment is tailored to the subsite, stage, and patient factors, and is fundamentally an MDT decision rather than a single-specialty one. Early-stage disease (small, node-negative tumours) is often treated with a single modality - surgery or radiotherapy - achieving excellent local control with less treatment-related morbidity.¹

Locally advanced disease typically requires combined treatment: surgical resection (sometimes with free flap reconstruction for large defects) followed by adjuvant radiotherapy or chemoradiotherapy, or primary chemoradiotherapy where surgery would cause unacceptable functional loss (as is often the case for laryngeal preservation strategies). Metastatic or unresectable disease is managed with systemic therapy and palliative care input, focused on symptom control and quality of life.

Supportive care is integral throughout: speech and language therapy for swallowing and voice rehabilitation, dietetic input given the high risk of malnutrition, and a dental assessment before radiotherapy, since radiotherapy to the jaw significantly increases the risk of osteoradionecrosis and any necessary extractions are best done beforehand to reduce this risk.

Complications

• Airway obstruction, from tumour bulk or treatment-related swelling, sometimes requiring a tracheostomy
• Xerostomia (dry mouth) and dysphagia following radiotherapy, from damage to salivary glands and swallowing structures
• Osteoradionecrosis of the mandible, a serious late complication of radiotherapy, underlining the importance of pre-treatment dental assessment
• Mucositis, particularly during chemoradiotherapy, causing significant pain and difficulty eating
• Carotid blowout syndrome, a rare but catastrophic complication of advanced disease or its treatment, involving rupture of the carotid artery
• Disfigurement and functional loss (speech, swallowing, cosmesis) after major resective surgery, with significant psychological impact
• Cachexia and malnutrition, from a combination of dysphagia, disease burden and treatment effects

Prognosis

Prognosis varies enormously by subsite, stage at diagnosis, and, for oropharyngeal cancer, HPV status. Early glottic laryngeal cancer has one of the best prognoses in head and neck oncology, with high cure rates, largely because hoarseness prompts relatively early presentation.¹

HPV-positive oropharyngeal cancer has a substantially better prognosis stage-for-stage than HPV-negative disease, reflected in separate staging systems for the two groups. Hypopharyngeal cancer, by contrast, tends to present late with more advanced disease and carries a comparatively poorer prognosis. Across all subsites, earlier detection - driven by prompt recognition of the red-flag symptoms above - remains the single most important modifiable factor in outcome.