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

1. Head and neck cancers Recognising the early signs and symptoms of cancer Mr C. Chan, Consultant H&N Surgeon (OMFS), L&D Dr K. Goodchild, Consultant Clinical Oncologist & NSSG Lead, MVCC Mr P. Kothari, Consultant H&N Surgeon (ENT), L&D

2. Incidence rates for 20 commonest cancers in UK:2010

3. 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)

4. Topics to be covered Incidence Risk factors Prevention and screening Mortality

5. Oral Cancers Lip, tongue, mouth, oropharynx, hypopharynx CRUK How common? • 15th most common cancer UK (2009) – 2% all new cases • 6236 new cases in 2009: >17 people per day • Higher incidence in Scotland and North of England

6. 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?vlnk=8843. 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.

7. Oral Cancers Trends over time • Incidence rates in UK  by > ¼ in last decade CRUK

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

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

10. Oral Cancers Distribution of cases

11. 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

12. 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?vlnk=8843. 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.

13. Laryngeal cancer European Age-Standardised Incidence Rates per 100,000 Population, by Sex, Great Britain Trends over time

14. Laryngeal cancer Profile of Head and Neck Cancers in England: Incidence, Mortality and Survival . OCIU January 2010

15. 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

16. 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 > 2x past 40 years • 5 per 100,000 women

17. 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?vlnk=8843. 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.

18. Thyroid cancer European Age-Standardised Incidence Rates per 100,000 Population, by Sex, Great Britain

19. Thyroid cancer Profile of Head and Neck Cancers in England: Incidence, Mortality and Survival . OCIU January 2010

20. 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

21. Risk factors for HNC

22. 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

23. 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

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

25. Risk factors – oral cancer • Human papillomavirus (HPV-16) Strong association with oropharyngeal cancer • Immunosuppression HIV/ AIDS organ transplants

26. Risk factors – oral cancer • Diet and nutrition some evidence of risk reduction • Sun exposure lip cancers

27. Risk factors – oral cancer • Oral mucosal lesions erythroplakia leukoplakia submucous fibrosis lichen planus syphilitic glossitis • Previous cancer diagnosis

28. 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

29. 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

30. Risk factors – thyroid cancer Women > 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

31. Prevention & Screening in HNC

32. 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

33. Prevention & screening – laryngeal cancer Avoid/ eliminate risk factors No effective population screening tool

34. Prevention & screening – thyroid cancers Avoid/ eliminate risk factors Genetic testing – family history of medullary carcinoma

35. Signs & Symptoms

36. Symptoms & Signs – oral cancer • Non-healing/ persistant ulcer over 3 weeks solitary +/- pain no obvious cause/ trauma • Lump/ swelling in mouth > 3 weeks soft tissues – mucosal/ submucosal exclude dental cause

38. Symptoms & Signs – oral cancer Red or red and white patches of the oral mucosa Dysphagia, including odynophagia, >3 weeks  Unilateral nasal obstruction Unexplained tooth mobility, not periodontal disease Cranial neuropathies – V and VII (Orbital masses)

39. Symptoms & Signs – oral cancer Hoarseness for more than 6 weeks (larynx) Persistent neck lump >3 weeks Unilateral persistent sore throat Unilateral otalgia with normal otoscopy

40. Signs & Symptoms – laryngeal cancer Hoarse voice > 3 weeks, Difficulty in swallowing Weight loss, often with other symptoms Persistent cough/ SOB Neck lump Pain/ otalgia

41. Laryngeal cancer

42. Signs & symptoms – thyroid cancer Solitary thyroid nodule Lymph node enlargement in neck Rapidly growing goitre Pain Stridor/ dysphagia Hoarseness

43. Anaplastic carcinoma of thyroid

44. Mortality & Survival

45. The 20 Most Common Causes of Cancer Death UK: 2010

46. Mortality – oral cancer

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

48. Mortality - oropharynx

49. 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

50. Mortality – laryngeal cancer