Head and neck cancers

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• Head and neck cancers
• Recognising the early signs and symptoms of
  cancer
• 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

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Incidence rates for 20 commonest cancers in
UK2010
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Common 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)

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Topics to be covered

• Incidence
• Risk factors
• Prevention and screening
• Mortality

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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
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Oral Cancers
Oral Cancer (C00-C06,C09-C10,C12-C14) 2007-2009
Average Number of New Cases Per Year and
Age-Specific Incidence Rates per 100,000
Population, UK

• Prepared by Cancer Research UK
• Original data sources
• Office for National Statistics. Cancer
  Statistics Registrations Series MB1.
  http//www.statistics.gov.uk/statbase/Product.asp?
  vlnk8843.
• Welsh Cancer Intelligence and Surveillance Unit.
  http//www.wcisu.wales.nhs.uk.
• Information Services Division Scotland. Cancer
  Information Programme. www.isdscotland.org/cancer.
  
• N. Ireland Cancer Registry. www.qub.ac.uk/nicr.

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Oral Cancers

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

CRUK
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Oral Cancers
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
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Oral Cancers
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
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Oral Cancers

• Distribution of cases

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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

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Laryngeal cancer
Larynx (C32) 2006-2008
Average Number of New Cases Per Year and
Age-Specific Incidence Rates per 100,000
Population, UK

• Prepared by Cancer Research UK
• Original data sources
• Office for National Statistics. Cancer
  Statistics Registrations Series MB1.
  http//www.statistics.gov.uk/statbase/Product.asp?
  vlnk8843.
• Welsh Cancer Intelligence and Surveillance Unit.
  http//www.wcisu.wales.nhs.uk.
• Information Services Division Scotland. Cancer
  Information Programme. www.isdscotland.org/cancer.
  
• N. Ireland Cancer Registry. www.qub.ac.uk/nicr.

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Laryngeal cancer

• Trends over time

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

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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

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Thyroid cancer
Average Number of New Cases Per Year and
Age-Specific Incidence Rates per 100,000
Population, UK

• Prepared by Cancer Research UK
• Original data sources
• Office for National Statistics. Cancer
  Statistics Registrations Series MB1.
  http//www.statistics.gov.uk/statbase/Product.asp?
  vlnk8843.
• Welsh Cancer Intelligence and Surveillance Unit.
  http//www.wcisu.wales.nhs.uk.
• Information Services Division Scotland. Cancer
  Information Programme. www.isdscotland.org/cancer.
  
• N. Ireland Cancer Registry. www.qub.ac.uk/nicr.

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

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Risk factors for HNC
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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

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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

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

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

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Risk factors oral cancer

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

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Risk factors oral cancer

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

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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

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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

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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

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• Prevention Screening in HNC

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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

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Prevention screening laryngeal cancer

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

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Prevention screening thyroid cancers

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

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• Signs Symptoms

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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

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Symptoms Signs oral cancer

• Red or red and white patches of the oral mucosa
• Dysphagia, including odynophagia, gt3 weeks ?
• Unilateral nasal obstruction
• Unexplained tooth mobility, not periodontal
  disease
• Cranial neuropathies V and VII
• (Orbital masses)

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Symptoms Signs oral cancer

• Hoarseness for more than 6 weeks (larynx)
• Persistent neck lump gt3 weeks
• Unilateral persistent sore throat
• Unilateral otalgia with normal otoscopy

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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

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• Laryngeal cancer

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Signs symptoms thyroid cancer

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

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• Anaplastic carcinoma of thyroid

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Mortality Survival
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The 20 Most Common Causes of Cancer Death UK 2010
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Mortality oral cancer
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Mortality oral cancer

• 2000 died of oral cancer in 2010 (UK) around 5
  people per day
• Despite the rising incidence, mortality remains
  essentially static

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Mortality - oropharynx
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Mortality - oropharynx

• A rising trend in mortality
• The increase in mortality is much less than the
  rise in incidence
• ?more effective combined treatment
• ?better prognosis in HPV group
• Stage at presentation detail incomplete

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Mortality laryngeal cancer
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Mortality laryngeal cancer

• Falling trend in mortality 33 reduction study
  period
• Reasons are unclear - Stage and treatment
  information is needed to explore this further
• 760 people died from laryngeal cancer in 2010

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Mortality thyroid cancer
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Mortality thyroid cancer

• Despite the rising incidence, mortality rate has
  remained
• essentially static
• This may in part be due to an increase in the
  number of small papillary carcinomas being
  detected which have high cure rates
• 350 people died of thyroid cancer 2010

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Survival oral cancer
5 year survival rate 56
Profile of Head and Neck Cancers in England
Incidence, Mortality and Survival . OCIU January
2010
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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

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Survival oral cancer
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Survival laryngeal cancer
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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

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Survival thyroid cancer
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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

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Referral pathways

• 2WW proforma
• Indications for referral
• Neck lump clinics

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Referral pathways
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Thyroid Clinics
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HPV Status

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

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Incidence rates for 20 commonest cancers in
UK2010
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Head Neck Cancer

• QA