Introduction:
Globally, India holds almost 30% of all head and neck cancer cases annually. According to the Globocan 2022 India fact sheet, the incidence of head and neck cancer is among the highest for males, whereas for females, it ranks in 4th place. The high rate of occurrence results in the second-highest global cancer mortality rate.
Oncologists report risk factors such as continued tobacco use, alcohol abuse, or infection with Human Papillomavirus for developing oropharyngeal cancer, and Epstein-Barr virus for developing nasopharyngeal cancer. The leading cause of high incidence rates of the disease in India is the prevalence of tobacco chewing or smoking.
Due to a lack of awareness, insufficient screening and prevention programs, late diagnosis, delays in diagnosis due to social or economic factors, and limited or inappropriate use of standardized treatment guidelines, the incidence and mortality rates of the disease among patients are high. Almost 60 to 80% of head and neck cancer cases in India present at advanced stages. The most frequent type of head and neck cancer in India is head and neck squamous cell carcinoma (HNSCC). In this blog, Dr. Dhruv Mehta, a senior head and neck cancer specialist for the entire South Gujarat region, will discuss early diagnosis and treatment.
Clinical Presentation:
In early stages, HNSCCs are asymptomatic, but as they spread and advance in their stages, the patient starts to notice some symptoms. The most common head and neck cancer symptoms you need to look out for are:
- Persistent ear pain, not responding to painkillers
- Neck mass or swelling
- Congestion of the nose or bleeding from the nose
- Difficulty in swallowing or painful swallowing
- Hoarseness of voice
- Headache with swelling on face, arms, or neck
- Blood in saliva
- Non-healing ulcers in the mouth
- Tonsil enlargement on only one side
- Fatigue or excess tiredness
- Bone pain that is worse at night and caused by cancer spreading to the bones
- Weight loss
1. From decreased oral intake due to ulcerations and swallowing difficulty
2. Or decreased oral intake due to reduced mouth opening from prolonged chewing tobacco use.
Depending on the location of the malignancy, there are several associated symptoms peculiar to a particular area. Thus, with oral cancer, patients often experience mouth pain, non-healing mouth ulcers, loosening of the teeth, improper fitting of dentures, difficulty swallowing, loss of weight, mouth bleeding, as well as ear pain. Nasopharyngeal cancer provokes hearing loss, tinnitus, nasal congestion, and pain behind the nose. Whereas throat cancer is characterized by difficulty swallowing, snoring, bleeding, pain behind the nasal cavity, or an appearance of a tumor behind the neck.
Diagnosis:
When the oncologist notices the presence of HNSCC through the initial physical examination and family history, he may suggest undergoing certain screening tests. The most common screening tests suggested are CECT (contrast-enhanced CT), MRI, as well as PET-CT scans. These allow the oncologist to see the size and spread of a tumor.
Biopsy may also be recommended for the confirmation of the presence of cancerous cells. It is done from the neck nodes or from within the cancer site itself. Tissue is removed from the cancerous site and is examined by an experienced oncopathologist in order to confirm the presence of cancer cells. Thus, it is possible to know the presence of cancer and its subtype, be it squamous cell carcinoma or rare tumors, such as melanoma, nasopharyngeal carcinoma, sarcoma, adenocarcinoma, adenoid cystic carcinoma, or mucoepidermoid carcinomas, for molecular characterization and HPV testing.
Keeping early detection and identification of head and neck cancer the priority, Dr. Dhruv Mehta, a senior head and neck cancer specialist at SGHOC, actively conducts various screening camps in the entire South Gujarat region at various time intervals. Awareness talks, community education programs, and training of family doctors about various signs and symptoms of HNSCC are conducted routinely.
A person is at high risk if they consume tobacco and alcohol; have non-healing mouth ulcers, a hoarse voice, unexplained weight loss, difficulty swallowing, or persistent ear pain, as well as lumps in the neck. People who notice these symptoms should immediately consult a head and neck cancer specialist for further evaluation.
Treatment:
The management of HNSCC depends on the stage and location of the cancer. Therapy options include:
1) Surgery – Oncologists suggest surgery for early-stage cancers that are localized in a region. The treatment involves removal of the lymph nodes and the mass.
2) Radiation Therapy – It uses various types of high-energy radiation like X-rays or protons to eliminate cancer cells. It can be post-surgery, for pain relief in stage 4 cancers with painful bone metastasis, or for hemostatic purposes for bleeding cancers. Highly conformal RT techniques, such as intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT), are the standard of care now, as they have demonstrated reduced morbidity.
3) Chemotherapy – Chemotherapy uses medicinal drugs to eliminate cancerous cells in the body. It can be performed before surgery to shrink the cancer and make it easier to remove. Chemotherapy can also be performed after surgery, depending on the stage of cancer, together with radiation, and it can also be used to prevent the development and spread of cancer cells, and in addition, chemotherapy can be used in the treatment of stage 4 cancer, when surgical removal and radiation are not suggested.
4) Targeted Therapy – As the name suggests, targeted medicines attack only specific types of cancer cells, like cetuximab and nimotuzumab.
5) Immunotherapy – aids the immune system in recognizing and attacking cancer cells.
6) Adoptive Cell Therapies – Various experimental cell-based therapies where tumor-infiltrating lymphocytes (TIL) are extracted from a mass, multiplied ex vivo, sensitized to cell-based antigens, and reinfused. These ACTs usually require only a single injection, have long-lasting effects with minimal side effects, and can be considered when all the above lines of therapy are exhausted.
Choosing the right therapy is crucial for improving the response rates and overall survival of the patient. However, there is no one therapy that fits all cases. HNSCC requires a combined-modality approach for disease control in the long term. It is the oncologist who determines the treatment by choosing the appropriate therapies in terms of the combination and the sequence. The selection of the treatments is based on the patient’s stage, location of cancerous growth, comorbidities like diabetes, hypertension, heart problems, and others, as well as the type of head and neck cancer.
Conclusion:
Currently, any patient with HNSCC above stage 3 should first consult a medical oncologist for an immuno-chemotherapy combination for long-term event-free survival and to reduce the risk of relapses. Those patients who are unwilling or unfit for surgery and are not ready for the long-term morbidity associated with surgery should also meet a head and neck cancer specialist first for consideration of immunotherapy and chemotherapy.
With newer advancements in supportive care, antiemetics, GCSF, and nanoparticle technology, side effects of chemo have significantly reduced and are now well tolerated by patients who are above 65 years of age. Timely consultation with a medical oncologist is extremely vital for the best outcomes in head and neck cancers.
