Head and Neck Cancer

 

Cancer of the head and neck is cancer developed from the soft tissues, muscles, skin, or blood vessels, thyroid or salivary gland, upper aerodigestive tract, or mucosa of the upper respiratory or digestive system covering the oral and nasal cavity.  The majority of head and neck cancer patients (90%) are diagnosed with the squamous cell carcinomas.  The top three types of such cancer in Taiwan are oral cancer (>5000/yr), nasal-pharyngeal cancer (1000/yr), and larynx cancer (500/yr).  Salivary gland cancer and thyroid cancer require the tight collaboration of multi-disciplinary teamwork because they are associated with the neural functions.  Skin cancers of head and neck and Sarcoma are rare and also require attention from several specialty teams.

 

Our Head & Neck Team

The treatment of head and neck tumors involves functional loss and esthetic issues resulting in the possibility of altered appearance, impaired speech, and swallowing or breathing difficulty.   In order to provide a timely management which can secure the best possible result and quality of life within the means of the patient, our head and neck team meets with other teams on a weekly basis to discuss the development of the patient and related plans.  The head and neck team also assumes the role of contact point in the care of the patients and takes charge of the follow-up scheduling and related healthcare arrangement to eliminate communication gaps. 

According to the treatment results published by the Ministry of Health and Welfare, we have delivered survival rates superior to those of the same disease stages:  the 2002-2006 5-year survival for oral cavity and pharyngeal cancer (male) in Taiwan is 46.7% while it is 62.2% in our hospital; the 2002-2006 5-year survival for nasal-pharyngeal cancer (male) in Taiwan is 59.1% vs. 75.4% in our hospital.

 

Diagnosis︰

Following a thorough physical exam and chest x-ray, the diagnosis of all head and neck cancer requires fine needle aspiration for tissue proof to determine whether the tumor is benign or malignant.  Imaging tests are used to further investigate the extent of tumor invasion and disease stage for treatment planning.

 

Staging：

MRI or CT are used to detect the degree of tumor or lymph node invasion; chest x-ray, abdominal ultrasound and bone scan are for detection of possible distant mets to the lung, liver or bones. 

 

PET/CT scan

PET/CT scan is effective in finding lymph node metastasis and distant mets to other organs or bones. It is also useful in staging of the tumor recurrence.  Higher risks of distant mets with locally more advanced head and neck cancer are the indicators for PET/CT scan in our guideline.  PET/CT scan is also used for treatment planning of tumor relapse. 

We also use imaging modalities to monitor the treatment results to help minimize the anxiety and worry on the patient’s part.  Different follow-up guidelines are developed based on the characteristics of the different sites of the cancer. 

Aside from diagnostic use and treatment planning, imaging tools are also used to check for disease or treatment-related side effects.  For instance, Doppler ultrasound is used for confirmation of narrowing of arteries in the neck or presence of carotid artery invasion.    

 

Surgical excision

Therapeutic options for head and neck cancer consist of surgery, radiotherapy, chemotherapy and concurrent-chemoradiotherapy (CCRT).  Treatment of cancer of the oral cavity relies heavily on surgery; most oropharynx cancer requires radiation therapy in conjunction with radiotherapy, and nasopharynx cancer requires CCRT.  For hypopharynx and larynx cancer, both surgery and radiotherapy are used.  Treatment may result in defects in the structure (such as deformities of the face in the nose, lips, eyelids and cheeks), and sometimes deficits in the function of head and neck organs (like difficulties in eating, swallowing, speaking, and breathing) because the malignant tumors of the head and neck may involve the face, scalp, ears, nose, mouth, tongue, throat, and glands of the face and neck. Reconstruction after cancer surgery aims to preserve or restore both the appearance and function of the involved area. Small tumors can often be closed by sewing the edges of the incision together. Alternatively, adjacent skin can often be shifted into position to fill the defect. Larger and deeper defects may require the transfer of muscle, bone, or skin flaps to close complex wounds of the nasal and oral passages, particularly when the cancer surgery has removed bone from the cheek or jaw. Microsurgery may be used to reconnect tiny blood vessels to provide adequate circulation to insure proper healing.  A simple removal of early stage tumor plus lymphadenectomy usually takes 4 -6 hours while a more complex surgery plus reconstruction for a later stage patient may take 10-15 hours followed by 2-3 weeks of hospitalization.

Decisions regarding appropriate treatment are based on more than just the disease stage, tumor features, or metastatic status.  Many other factors such as the patient’s performance, physician, patient’s age, organ functions, function preservation, and even the patient’s work and psychological state need to be taken into consideration for a comprehensive treatment plan.  There is no cookie cutter formula to follow in predicting the treatment outcome.  A very detailed discussion where the physician explains all information / options / possibilities / risks and answers all  questions is very important. 

 

Esophageal Cancer 

The patients we saw with new esophageal cancer accounted for 3% of all esophageal cancer patients nationwide for the year 2011.  Alcohol drinking, tobacco smoking, and betel nut chewing are strong and independent risk factors for esophageal cancer.   The most important step in treatment is to quit all the above-mentioned bad habits.  PET and CT scans can help determine the treatment plan by identifying the disease stage.  Stage I patients are normally given laparoscopic chest surgery; stage II and III would receive CCRT, and in the event of good response, it would be followed by surgical resection; stage IV patients are given radiation and chemotherapy as the main treatment modalities.   

　　

Our results (esophageal, oral, laryngeal & hypopharyngeal cancer)

Esophageal cancer survival by AJCC staging 1990-2011(%)

Male: 596 (91.7%)    Female: 54  (8.3%)   Median age :  58 years (32 - 93) 
 

Stage	0	I	II	III	IV	Unclear	Total
# of patients	8	48	105	208	189	92	650
% of patients	1.2%	7.4%	16.2%	32.0%	29.1%	14.2%
5-year survival	-	66.2%	41.0%	25.7%	12.9%		26.3%
10-year survival	-	31.6%	27.6%	18.7%	6.1%		16.8%

KFSYSCC Annual Report 2011

 

Comparison of data from National Ministry of Health and Welfare 2006-2010（%）

	KFSYSCC				Island wide
Survival	All patients		Male	Female	Male
	1990-2011	2006-2010	2006-2010	2006-2010	2006-2010
1-year	60.5	67.7	66.7	79.2	43.2
2-year	40.3	49.3	49.3	47.7	24.5
3-year	31.6	35.6	35.3	39.8	17.7
4-year	27.5	32.5	32.1	-	14.5
5-year	26.9	31.2	30.9	-	12.7

Data source: Health Promotion Administration, Ministry of Health and Welfare (2013)

 

　　Data released by the U.S. Surveillance Epidemiology and End Result (SEER) showed a 5-year relative survival rate of 17.6% for men and 17.2% for women (2004-2010) as opposed to our 5-year absolute survival rate of 27.7% for men and 26.6% for women. The fact that esophageal adenocarcinoma is known to be the prevalant type for Americans while the esophageal squamous cell carcinoma for Taiwanese should be taken into account for the gaps between the survival rates.  

Comparison of data with SEER result 2004-2010（%）

	KFSYSCC			SEER#
	All patients	Men	Women	All patients	Men	Women
Survival rates	27.5	27.7	26.6	17.5	17.6	17.2

# SEER Cancer Statistics Review 1975-2011. Relative survival is a net survival measure representing cancer survival in the absence of other causes of death, and, generally speaking, it is higher than the corresponding absolute survival by 1-3%.  The difference is greater in older patient populations.  
KFSYSCC Annual Report 2011

 

Survival rates of oral, layngeal and hypopharyngeal cancers by AJCC staging (1990-2011)

 

	Stage	I	II	III	IVA	IVB	IVC	Unclear	Total
Oral cancer	# of patients	357	211	162	423	45	12	47	1,271
	% of patients	28.4%	16.8%	12.9%	33.7%	3.6%	1.0%	3.7%
	% of patients	86.2%	82.0%	64.1%	54.3%	29.6%	8.3%		67.8%
Laryngeal	# of patients	41	37	66	165	41	8	41	400
	% of patients	10.3%	9.3%	16.5%	41.4%	10.3%	2.0%	10.3%
	5-year survival	73.6%	72.8%	61.1%	55.4%	40.4%	0.0%		58.0%
Hypopharyngeal	# of patients	10	10	27	90	35	14	28	214
	% of patients	4.7%	4.7%	12.6%	42.1%	16.4%	6.5%	13.1%
	5-year survival	52.5%	90.0%	54.1%	41.6%	20.0%	14.3%		37.3%

 

Facing cancer

Facing cancer is facing a threat to one’s very existence.  The blow from cancer hits not just the physical being but often scars the mental and emotional presence of the patient as well as the patient’s family.  The different phases of reactions, from shocking blank to angry denial, are normal and expected. But if not managed well, they could add more pain and damage on top of the cancer itself.   Anxiety, sense of loss, fear of uncertainty, insomnia, guilt, depression, despair, and anger are among the commonly seen symptoms which require professional help as well as social support. 

 

Stress Screening

About 50% of cancer patients worldwide develop psychological symptoms but only 8 – 10 % would voice their concerns and seek help.  In our hospital, a Distress thermometer is offered to every patient upon their first visit to assess their distress level.  When necessary, the social psychotherapy team and the social workers are asked to join the multidisciplinary team to help the patient and the family cope with cancer and to safeguard the quality of life for the patient.   There are also various cancer support groups and religious support organizations that will offer to accompany the patient in their walk with cancer and fight against cancer.

 

A letter to the family

Being there for the patient means the world to the patient.  Support and company from the family and relatives are a critical part in cancer care.   Listening to the patient and respecting the patient’s wishes bring positive energy.    When a member in the family gets cancer, the rest of the family is affected in many aspects: physical, psychological, financial, and emotional, to where the whole family system could collapse.  When providing the much deserved and much needed care to the patient, the family members must remember to also provide an equal amount of care to one another and to oneself.   In the event of exhaustion or burn-out, remember to seek professional help.