Head and neck cancer: what symptoms matter?

The Royal Marsden

Head and neck cancer: what symptoms matter?

Professor Vinidh Paleri

Consultant Head and Neck Surgeon

87

Outline

2 week wait referral pathway

– Evidence base

– 2015 guidance

– “Tease” out relevant symptoms

– Clinical scenarios

– Neck exam and lumps

– Oral exam and lumps

Head and Neck Cancer referral from Primary Care

88 Head and Neck Cancer referral from Primary Care

Results 89

2012N=1809 Cancer diagnoses 6.3% to 14.6%Pooled detection rate: 11.1%


2016N=4028Cancer diagnoses 2.2% to 14.6%Pooled detection rate: 8.8%Subgroup of later studies 6.6%

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NICE HN cancer 2015 guidance

– June 2015: updated NICE HNC referral guidance

– Categorised by organ sites

– Positive predictive value (PPV) used to determine the high-risk symptoms for HNC.

– Used data from studies within a primary care setting

– The Guideline Development Group (GDG) included all symptoms with a PPV threshold of 3% or higher



Head and Neck Cancer referral from Primary Care92

Total dataset: n = 5,082 via the 2WW systemMissing data = 367 Prediction model = 4,715 M:F = 2,058: 2,657 Mean age: 59 years Patients with HNC = 397 (8.4%)

Multivariate binary logistic regressionIdentify of 2 and 3 way interactions Assess the performance of the current and previous NICE referral guidance


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http://www.orlhealth.com/risk-calculator.html


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Referral symptoms and pick up rates

Symptom Frequency (%) PPV (%)

Persistent otalgia, normal otoscopy 0.9 18.2

Unexplained lump in neck >3 weeks 22.5 17

Dysphagia >3 weeks 4.7 13

Ulceration of oral mucosa >3 weeks 8.7 12.4

Hoarseness >3weeks 20.2 7.76

Persistent sore or painful throat 5.8 5.9

Red and white patches of oral mucosa 3.2 4

Sensation of lump in throat 7.1 1.5

Intermittent hoarseness 7.7 0.8

A different model

Persisting hoarseness > 3 weeks

Unexplained oral ulceration or mass > 3 weeks

Unexplained persistent swelling in the salivary gland >3 weeks

Unexplained neck mass >3 weeks or recently appeared neck mass

Dysphagia > 3 weeks

Odynophagia >3 weeks

Unexplained otalgia with normal otoscopy

Sensation of lump in throat AND presence of blood in mouth

Sensation of lump in throat AND unexplained otalgia and normal

otoscopy

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http://www.orlhealth.com/risk-calculator.html

Head and neck cancer: what symptoms matter?

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Symptom-based telephone triage for suspected head and neck cancer referrals in the UK: 6-month outcomes from a prospective national service evaluation during the initial peak of the COVID-19 pandemic.

- Supported by ENT UK, BAHNO and INTEGRATE

- 16 week period, between 23rd March and 13th July 2020

- Risk stratification with HaNC-RC-v2 http://orlhealth.com/

John Hardman

http://orlhealth.com/

Table 2: Cancers by time of diagnosis, alongside triage outcome, results of risk stratification and clinician advice for assessment

Cancers

2ww Late Any time

% of all cases

% n % n % n

By triage outcome 4332 4112 4330

Urgent 53.2 9.5 218/2304 0.4 8/2086 9.8 226/2304

Investigation first 26.7 9.3 108/1156 0.5 5/1048 9.8 113/1156

Face-to-face review first 26.5 9.6 110/1148 0.3 3/1038 9.8 113/1148

Non-urgent 46.8 0.0 0/2028 0.9 19/2026 0.9 19/2026

Deferred 29.6 0.0 0/1283 0.9 12/1283 0.9 12/1283

Discharged 17.2 0.0 0/745 0.9 7/743 0.9 7/743

By clinician preference 4278 4060 4276

Clinician advised for Rx/Ix 68.3 7.0 205/2920 0.6 16/2715 7.6 221/2920

Clinician NOT advised for Rx/Ix 31.7 0.8 11/1358 0.7 10/1345 1.5 21/1356

By risk stratification 4345 4116 4334

High risk 30.5 12.8 170/1324 0.6 7/1153 13.4 177/1323

Low risk 69.5 1.6 48/3021 0.7 20/2963 2.3 68/3011

OVERALL 100 5.0 218/4345 0.7 27/4116 5.7 245/4334

OUTER:PPV of symptom

INNER:How commonly that symptom is reported

0.0 1.3

2.9

3.5

3.7

3.7

3.7

4.4

5.0

5.9

6.67.8

7.9

8.1

8.3

9.1

9.6

10.1

10.2

10.5

13.9

14.717.1

2.1 12.1

25.3

5.3

11.1

32.6

3.1

5.2

9.7

28.01.7

10.711.116.5

5.8

10.4

1.2

9.8

9.5

6.1

6.0

21.9 0.9

Ho

ars

e

(

pers

., e

xp

lain

ed

)

Th

roat

pain

(

int. b

ilat.

/mid

.)Hoa

rse

(

int.)

Throat p

ain

(

int.

unilat.)

Dysphagia

(int.)

FOSIT

Mouth ulcer

Neck lump

(fluct./reduc.)

Throat pain

(pers. bilat./mid.)

Ex−

smoker

Strid

or

Ota

lgia

Ho

ars

e

(

pers

.)Curr

ent

smoke

r

Mouth

sw

ellin

gOdynophagia

Ex−excess

alcohol

Weight loss

Heavy alcohol

Throat pain

(pers. unilat.)

Dysphag

ia

(pers.)

Neck lu

mp

(pers

.)

Sk

in le

sio

n

OUTER:Straight to Ix

INNER:Straight to discharge

15.015.6

16.6

17.6

21.5

22.8

22.9

23.0

23.6

24.2

24.425.428.5

28.9

29.9

30.1

31.5

35.7

38.5

38.7

40.4

44.858.0

20.724.0

3.5

31.9

8.1

17.3

16.7

16.7

13.5

11.12.4

7.99.71.3

4.9

11.8

11.3

1.1

9.6

6.1

16.7

1.2 2.2

Th

roa

t p

ain

(in

t. b

ila

t./m

id.)

Ho

ars

e

(

int.

)H

oar

se

(

per

s.)

Hoarse

(

pers.,

explain

ed)

Mouth ulcer

FOSIT

Ex−smoker

Heavy alcohol Throat pain

(int. unilat.)

Thro

at p

ain

(pers

. bila

t./mid

.)

Skin

lesio

n

Mo

uth

sw

ellin

g

Ota

lgiaStr

idor

Odyn

ophagia

Dysphagia

(in

t.)

Current

smoker

Throat pain (pers. unilat.)

Ex−excessalcohol

Weight loss

Neck lu

mp

(fluct./red

uc.)

Dysp

hag

ia

(pers

.)

Ne

ck

lum

p

(pe

rs.)

Key points- Reporting outcomes from a prospective multicentre national

study of telephone triage of 4,345 suspected head and neck

cancer referrals in 40 centres with minimum follow-up of 6

months.

- Over a quarter of patients were triaged directly to an

investigation and 1 in 6 were discharged directly from the

telephone consultation.

- The overall cancer rate in this population was 5.7% after 6

months minimum follow-up, similar to non-pandemic rates.

- The rate of late cancer diagnosis leading to harm was 0.2% in

patients seen and/or investigated urgently and 0.4% in those

triaged as non-urgent who were deferred or discharged.

- If performing telephone triage, clinicians should be mindful

that nasal cavity/nasopharygeal, oesophageal and lung cancers

were the highest incidence in the late cancer group.

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The neck lump

Midlinethyroidlarynx

104

Laterallymph nodes salivary glands

Non- cancer Cancer

Neck lump

Rapid increase in sizeHardSkin invasionNon-inflamedRegional symptomsSystemic symptoms

InflammatoryDevelopmentalBenign neoplasm

Source: National Cancer Information Service

269 papers, 19,000 + patients

Branchial Cyst (A dangerous diagnosis >35 years)

– Presentation

– Management

Current recommendation

Comprehensive ENT

examination±NBI

Fine needle cytology

18FDG-PET/CT

Panendoscopy, bilateral

tonsillectomy and tongue base

mucosectomy

“True” unknown primaries 15%

US guided core biopsy

Beware

Neoplastic neck nodes

Lymphoma

SCC

Thyroid

A lesson learnt

A lesson learnt

Cervical lymphadenopathy

– Infective– Specific

– Non specific

Glandular fever

Toxoplasmosis

TB

Atypical TB

Kawasaki disease

CMV

Etc….

Thyroid Lumps

– History– Toxic symptoms

– Hypofunction

– Examination– Eye signs

– Tremor

– Reflexes

– Swallowing

US guided FNA and/or core biopsy

Thyroglossal cysts

25 year old womanAcute presentation with fever and sore throat

A. Blood testsB. CT scanC. Ultrasound scan

64 year old manWorsening swelling for 4 weeksNo systemic symptomsExamination reveals a brawny swelling, relatively superficial, fluctuant at sitesWeeping wound

A. Parotid MalignancyB. Organised parotid abscessC. Sebaceous cyst

34 year old manWorsening swelling for 6 weeksNo systemic symptomsDental work prior to onset of swellingExamination reveals a fluctuant swelling

A. Submandibular salivary gland malignancy

B. Actinomyces C. Sebaceous cyst

1 year old Lump present for 3 months

A. 1st branchial arch cystB. Parotid abscessC. Atypical TB

What will clinch the diagnosis? A. Clinical examinationB. Ultrasound scanC. CT scan

30 year old manSwelling for 9 monthsNo systemic symptoms

14 year old Lump present for 2 yearsIntermittent infection

14 year old Wetness noticed with intermittent inflammation

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The oral cavity

Oral cavity

Oral cavity exam

../Documents/BMJ review oral ulcer/OralCavityExam-VinidhPaleri/OralCavityExaminationVinidhPaleri.f4v

Features that may reduce suspicionRecurrent ulceration that heals inbetween episodesMultiple synchronous ulcers Clustering of ulcersOccurrence in association with systemic diseasesBlister formationAssociated sore and bleeding gumsIdentifiable local causes (for example, sharp tooth)

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Features that should raise suspicion Non-healing painless ulcer present for >3 weeksInduration and lack of inflammation surrounding ulcerUlcer with rolled thickened edgeSmoking and alcohol useAge (85% of cases at age >50 years)Male sex (2:1)Previously diagnosed premalignant lesion No history of previous ulcerationNo local factors of ulcerationNo systemic factors of ulcerationHistory of oral squamous cell carcinoma

Non-cancer lesions

Lichen planus

Lichenoid reactions

Lupus erythematosus

Graft versus host disease

Lichen sclerosis et atrophicus

Lichenoid & granulomatous stomatitis

Oral Premalignant Lesions

Leukoplakia

Erythroplasia

Lichen planus

Oral submucous fibrosis

Syphilitic leukoplakia

Chronic hyperplastic candidosis

Actinic keratosis

Discoid lupus erythematosus

Sideropenic dysphagia

Immunosuppression

Aphthous ulcers

Common oral infections

Chronic hyperplastic candidosis

Denture stomatitis

Drug induced ulcers

Oral lumps

Submandibular gland

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Conclusions - Adopt a systematic approach to neck and oral cavity

examination

- Examine UADT mucosa for all patients presenting with neck lumps

- Treat all neck lumps in patients >35 as cancer unless proven otherwise

- Unexplained otalgia is a red flag symptom with high PPV

- Flat, non-indurated oral ulcers have a multitude of causes, many self limiting

- Treat all non-bony oral lumps as cancers unless proven otherwise

- A more evidence based approach to HN cancer referral is awaited

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