Head and Neck Cancer

Head and neck cancer is the 8th most common cancer in the UK. Over 90% are Squamous Cell Carcinomas (SCC). Sites include the larynx, oropharynx, oral cavity, hypopharynx, and nasopharynx. Traditionally, these were diseases of elderly smokers and drinkers, but there is a rising incidence of HPV-associated oropharyngeal SCC (specifically HPV-16) in younger, non-smoking populations. HPV-positive tumours generally have a significantly better prognosis than tobacco-related ones. Diagnosis is often delayed as early symptoms mimic benign conditions. NICE (NG12) provides strict '2-week wait' (2WW) referral criteria: persistent hoarseness (>3 weeks), unexplained neck lumps, or unexplained ulcers/lumps in the mouth. Nasopharyngeal carcinoma (associated with EBV) has a different demographic, common in Southern Chinese populations. Management is complex and determined in a Multidisciplinary Team (MDT) meeting, balancing survival with the preservation of speech and swallowing functions.

HNSCC develops via a multistep progression of genetic mutations. Tobacco smoke contains carcinogens like polycyclic aromatic hydrocarbons that cause DNA damage (p53 mutations). Alcohol acts as a solvent, increasing mucosal permeability to these carcinogens. In contrast, HPV-driven cancers occur through the action of viral oncoproteins E6 and E7, which inactivate the p53 and RB tumour suppressor pathways respectively. HPV-positive cancers characteristically show p16 overexpression on immunohistochemistry, which is used as a surrogate marker. Lymphatic spread is common, usually to the deep cervical lymph nodes (Levels I-V). Distant metastasis occurs most frequently to the lungs.

Clinical presentation depends on the site: Laryngeal cancer (hoarseness, stridor, persistent cough); Oral cavity (non-healing ulcer, red/white patches - erythroplakia/leukoplakia); Oropharynx (dysphagia, referred otalgia - ear pain via CN IX/X); Nasopharynx (unilateral glue ear, epistaxis, neck lump). On examination, look for a firm, non-tender, fixed neck lump. All patients require a full ENT examination, including flexible nasendoscopy. Red flags for general practice: Hoarseness >3 weeks; Unexplained neck lump; Unexplained oral ulceration >3 weeks; Persistent unexplained sore throat.

- Bedside: Flexible nasendoscopy (FNE) to visualize the larynx and pharynx.
- Imaging: CT neck/thorax (staging), MRI (better for soft tissue/base of tongue), PET-CT (detecting occult primaries or recurrence).
- Biopsy: Fine Needle Aspiration Cytology (FNAC) or Core Biopsy of neck lumps; formal 'Panendoscopy' (Examination Under Anaesthesia - EUA) to biopsy mucosal lesions and look for second primaries.
- Special tests: p16 staining (for HPV status in oropharyngeal SCC).

Management is decided by MDT. Early-stage (T1-T2): Often single-modality treatment—either surgery (e.g., Transoral Laser Microsurgery) or radiotherapy. Late-stage (T3-T4): Multimodal therapy—surgery (e.g., total laryngectomy, neck dissection) followed by adjuvant radiotherapy or chemoradiotherapy. Chemotherapy (e.g., Cisplatin) is often used as a radiosensitizer. Palliative care: Focuses on airway security (tracheostomy) and nutrition (PEG/NG tubes). Speech and Language Therapy (SALT) and Dietetics are essential for rehabilitation of speech and swallowing post-treatment.