Applied Evidence

Head & neck cancers: What you’ll see, how to proceed

J Fam Pract. 2019 November;68(9):E1-E7

Author(s):

What physical findings should raise your suspicion? How are tumors treated and what follow-up care can you provide? Here’s what you need to know.

PDF Download

PRACTICE RECOMMENDATIONS

› Do not treat a neck mass with antibiotics unless it has features consistent with infection. C

› Order laryngoscopy for all patients with hoarseness that does not resolve after 3 months—or sooner, if malignancy is suspected. C

› Order ultrasonography-guided fine-needle aspiration for diagnostic evaluation of salivary gland masses. B

› Manage a thyroid nodule based on its sonographic features, including size, consistency, and the presence of concerning features. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67:7-30.

2. Smallridge RC, Ain KB, Asa SL, et al; American Thyroid Association Anaplastic Thyroid Cancer Guidelines Taskforce. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012;22:1104-1139.

3. Marur S, Forastiere AA. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008;83:489-501.

4. Seoane J, Alvarez-Novoa P, Gomez I, et al. Early oral cancer diagnosis: The Aarhus statement perspective. A systematic review and meta-analysis. Head Neck. 2016;38(suppl 1):E2182-E2189.

5. Franco J, Elghouche AN, Harris MS, et al Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement. Am J Med Qual. 2017;32:330-335.

6. Pynnonen MA, Gillespie MB, Roman B, et al. Clinical practice guideline: evaluation of the neck mass in adults. Otolaryngol Head Neck Surg. 2017;157(suppl 2):S1-S30.

7. Bosetti C, Gallus S, Franceschi S, et al. Cancer of the larynx in non-smoking alcohol drinkers and in non-drinking tobacco smokers. Br J Cancer. 2002;87:516-518.

8. Hoffman HT, Porter K, Karnell LH, et al. Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope. 2006;116(9 pt 2 suppl 111):1-13.

9. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3 suppl 2):S1-S31.

10. Steuer CE, El-Deiry M, Parks JR, et al. An update on larynx cancer. CA Cancer J Clin. 2017;67:31-50.

11. Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003;349:2091-2098.

12. Mendenhall WM, Werning JW, Hinerman RW, et al. Management of T1-T2 glottic carcinomas. Cancer. 2004;100:1786-1792.

13. Surveillance, Epidemiology, and End Results Unit. National Cancer Institute. Cancer stat facts: oral cavity and pharynx. https://seer.cancer.gov/statfacts/html/oralcav.html. Accessed October 18, 2019.

14. Pytynia KB, Dahlstrom KR, Sturgis EM. Epidemiology of HPV-associated oropharyngeal cancer. Oral Oncol. 2014;50:380-386.

15. Tarakji B, Gazal G, Al-Maweri SA, et al. Guideline for the diagnosis and treatment of recurrent aphthous stomatitis for dental practitioners. J Int Oral Health. 2015;7:74-80.

16. Siu A, Landon K, Ramos DM. Differential diagnosis and management of oral ulcers. Semin Cutan Med Surg. 2015;34:171-177.

17. US Preventive Services Task Force. Final recommendation statement: oral cancer: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/oral-cancer-screening1. Updated November 2013. Accessed October 18, 2019.

18. Villa A, Woo SB. Leukoplakia—a diagnostic and management algorithm. J Oral Maxillofac Surg. 2017;75:723-734.

19. Yang S, Wu S, Zhou J, et al. Screening for nasopharyngeal cancer. Cochrane Database Syst Rev. 2015;(11):CD008423.

20. Turner JH, Reh DD. Incidence and survival in patients with sinonasal cancer: a historical analysis of population-based data. Head Neck. 2012;34:877-885.

21. Ou SH, Zell JA, Ziogas A, et al. Epidemiology of nasopharyngeal carcinoma in the United States: improved survival of Chinese patients within the keratinizing squamous cell carcinoma histology. Ann Oncol. 2007;18:29-35.

22. Chang ET, Adami H-O. The enigmatic epidemiology of nasopharyngeal carcinoma. Cancer Epidemiol Biomarkers Prev. 2006;15:1765-1777.

23. Chua MLK, Wee JTS, Hui EP, et al. Nasopharyngeal carcinoma. Lancet. 2016;387:1012-1024.

24. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg. 1986;8:177-184.

25. Lewis JS. Sinonasal squamous cell carcinoma: a review with emphasis on emerging histologic subtypes and the role of human papillomavirus. Head Neck Pathol. 2016;10:60-67.

26. Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology. 1997;8:414-419.

27. Colella G, Cannavale R, Flamminio F, et al. Fine-needle aspiration cytology of salivary gland lesions: a systematic review. J Oral Maxillofac Surg. 2010;68:2146-2153.

28. Berrino F, De Angelis R, Sant M, et al; EUROCARE Working Group. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995-99: results of the EUROCARE-4 study. Lancet Oncol. 2007;8:773-783.

29. Baloch ZW, LiVolsi VA, Asa SL, et al. Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008;36:425-437.

30. Haugen BR, Alexander EK, Bible KC, et al; The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133.

31. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for thyroid Cancer: US Preventive Services Task Force recommendation statement. JAMA. 2017;317:1882-1887.

32. Jonklaas J, Cooper DS, Ain KB, et al; National Thyroid Cancer Treatment Cooperative Study Group. Radioiodine therapy in patients with stage I differentiated thyroid cancer. Thyroid. 2010;20:1423-1424.

33. Cooper DS, Specker B, Ho M, et al. Thyrotropin suppression and disease progression in patients with differentiated thyroid cancer: results from the National Thyroid Cancer Treatment Cooperative Registry. Thyroid. 1998;8:737-744.

34. US Food and Drug Administration. Highlight of prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/125431s020lbl.pdf. Updated December 2017. Accessed October 30, 1019.

35. Boomsma MJ, Bijl HP, Langendijk JA. Radiation-induced hypothyroidism in head and neck cancer patients: a systematic review. Radiother Oncol. 2011;99:1-5.

36. The development of quality of care measures for oral cavity cancer. Arch Otolaryngol Head Neck Surg. 2008;134:672.

37. Strojan P, Hutcheson KA, Eisbruch A, et al. Treatment of late sequelae after radiotherapy for head and neck cancer. Cancer Treat Rev. 2017;59:79-92.

38. Chambers MS, Posner M, Jones CU, et al. Cevimeline for the treatment of postirradiation xerostomia in patients with head and neck cancer. Int J Radiat Oncol Biol Phys. 2007;68:1102-1109.

39. Gupta N, Pal M, Rawat S, et al. Radiation-induced dental caries, prevention and treatment - a systematic review. Natl J Maxillofac Surg. 2015;6:160-166.

The statistics reveal a serious problem: This year, an estimated 63,030 Americans will be given a diagnosis of head and neck cancer (which includes laryngeal, oropharyngeal, sinonasal, nasopharyngeal, and salivary gland cancer¹); approximately 13,360 of them will die. Furthermore, thyroid cancer is the most rapidly increasing cancer diagnosis in the United States, with an estimated 56,870 cases in 2017.^1,2 Major risk factors for head and neck cancer are tobacco and alcohol exposure and infection with Epstein-Barr virus and human papillomavirus (HPV).³

In this article, we review the background for each of the principal types of head and neck cancer with which you should be familiar. We also discuss how to evaluate signs and symptoms that raise suspicion of these neoplasms; outline the diagnostic strategy in the face of such suspicion; and summarize accepted therapeutic approaches. Last, we describe the important role that you, the family physician, play in providing posttreatment care for these patients, especially prevention and management of late adverse effects of radiation therapy.

General characterizationsof these cancers

Approximately one-half of patients with head and neck cancer present initially with a nonspecific, persistent neck mass that should be deemed malignant until proven otherwise, because a delay in diagnosis is associated with a worse outcome.⁴ In a series of 100 patients with head and neck cancer, for example, delay in diagnosis occurred in nearly 25%—most often because of time spent providing inappropriate antibiotic treatment.⁵ Guidelines for management of neck masses recommend against the use of antibiotics in patients who do not have evidence of infection.⁶

Patients with a neck mass that has been present for longer than 2 weeks or that is ulcerated, fixed to underlying tissues, of firm consistency, or > 1.5 cm should have a physical examination that includes visualization of the base of tongue, pharynx, and larynx. The mass should be evaluated with fine-needle aspiration (FNA) biopsy, which has a positive predictive value of 96% and negative predictive value of 90% for the diagnosis of a head and neck mass. (Note: Anticoagulation therapy is not an absolute contraindication to FNA, which is not associated with an increased risk of bleeding.⁶)

Laryngeal cancer

What you need to know. More than 90% of laryngeal cancers are squamous cell carcinoma (SCC). Smoking or heavy drinking (> 8 drinks/d), compared to neither behavior, is associated with an increased risk of laryngeal cancer (odds ratio, 9.4 and 2.5, respectively).⁷ The risk of cancer is directly proportional to the degree of tobacco exposure.

One-half of head and neck cancers present with a neck mass that warrants appropriate initial assessment, so as not to delay diagnosis.

Laryngeal cancer occurs in the supraglottic region in one-third of patients; in the glottic region in one-half; and in the subglottic region in a very few.⁸ Glottic cancer presents earlier than supraglottic cancer with hoarseness, whereas supraglottic cancer presents with more advanced disease, causing stridor, dysphagia, and throat pain. (Note: Guidelines recommend against prescribing acid suppressants in patients with hoarseness who do not have symptoms of reflux.⁹)

Stage 1 and Stage 2 laryngeal cancers are localized; Stages 3-4B are locally advanced or involve lymph nodes, or both; Stage 4C is metastatic disease. Overall, 60% of patients have Stage 3 or Stage 4 disease at diagnosis.¹⁰

Continue to: What is the diagnostic strategy?