1. Physical Examination & Biopsy
BiopsyA biopsy is used to diagnose all head and neck cancers. During a biopsy, a small amount of tissue is removed from the affected area under local or general anaesthetic. The sample is sent to a lab where a pathologist examines the tissue under a microscope. This test enables the pathologist to see whether cancer cells are present, and determine what type of cancer it is. Biopsy results are usually available in about a week. After initial tests, your general practitioner (GP) will refer you to a specialist for further tests. Depending on your symptoms, tests will include examinations, tissue sampling (biopsy) and imaging tests. You will probably also have blood tests.
Physical examinationYour doctor will examine your mouth, tonsils and soft palate (oropharynx), neck, ears and eyes. A spatula may be used to see inside the mouth more clearly. The doctor may also insert a gloved finger into your mouth to feel areas that are difficult to see, and check your lymph nodes (lymph glands) by gently feeling the sides of your neck. Some head and neck cavities are difficult to see, so for other locations, such as the nasopharynx, tongue base and pharynx, the doctor may use viewing equipment (see below). A tissue sample (biopsy) may also be taken at this time.
Making treatment decisionsSometimes it is difficult to decide on the type of treatment to have. You may feel that everything is happening too fast. Check with your doctor how soon your treatment should start, and take as much time as you can before making a decision.
Understanding the disease, the available treatments and possible side effects can help you weigh up the pros and cons of different treatments and make a well-informed decision that’s based on your personal values. You may also want to discuss the options with your doctor, friends and family.
You have the right to accept or refuse any treatment offered. Some people with more advanced cancer choose treatment even if it only offers a small benefit for a short period of time. Others want to make sure the benefits outweigh the side effects so that they have the best possible quality of life.
Talking with doctors
When your doctor first tells you that you have cancer, you may not remember the details about what you are told. Taking notes or recording the discussion may help. Many people like to have a family member or friend go with them to take part in the discussion, take notes or simply listen.
If you have several questions, you may want to talk to a nurse or ask the office manager if it is possible to book a longer appointment.
A second opinion
You may want to get a second opinion from another specialist to confirm or clarify your doctor’s recommendations or reassure you that you have explored all of your options. Specialists are used to people doing this.
Your doctor can refer you to another specialist and send your initial results to that person. You can get a second opinion even if you have started treatment or still want to be treated by your first doctor. You might decide you would prefer to be treated by the doctor who provided the second opinion.
After initial tests, your general practitioner (GP) will refer you to a specialist for further tests. Depending on your symptoms, tests will include examinations, tissue sampling (biopsy) and imaging tests. You will probably also have blood tests.
If you have a biopsy on a lump in your neck or on a tumour that is difficult to access, it will probably be done with a needle that is guided using an ultrasound or a CT scan.
If you notice a sore, swelling or change of colour in your mouth, make an appointment to see your dentist. Any unexplained changes that are present for more than two weeks may need to be biopsied.
2. Hospital early Stages, Scans & x rays
A CT (computerised tomography) scan is used to assess the extent of many head and neck cancers. A CT scan uses x-ray beams to take pictures of the inside of your body. Before the scan, you may have iodine contrast injected into a vein in your arm to show the blood vessels and make the pictures clearer.
The dye may make you feel flushed or hot for a few minutes. You will lie still on a table that moves slowly through the CT scanner. The scanner is large and round like a doughnut. The CT scan itself takes a few minutes and is painless, but the preparation takes 10–30 minutes. You can go home when the scan is complete.
An MRI (magnetic resonance imaging) scan is used to assess the extent of many head and neck cancers. An MRI uses magnetism and radio waves to build up detailed cross-section pictures of the body. As with a CT scan, a dye may be injected into your veins before the scan to make the pictures clearer. The pictures are taken while you lie on a table that slides into a narrow metal cylinder – a large magnet – that is open at both ends.
An MRI takes about an hour and you will be able to go home when it is over. The test is painless, but the noise of the machine can be a source of distress. In addition, some people feel anxious or claustrophobic lying in such a confined space. If you think this will be a problem, let the doctor or nurse know beforehand, as they can give you medication to help you relax.
A PET (positron emission tomography) scan is nearly always recommended to help diagnose oral, pharyngeal or laryngeal cancer, or to see if the cancer has spread. A PET scan is a specialised imaging test that is available at most major hospitals. Before the scan, you will be injected with a glucose solution that contains some radioactive material. You will be asked to wait for 30–90 minutes as the solution spreads through your body.
You will need to lie still during this time. The glucose solution gathers in the cells, including cancer cells, which are using more energy. These show up as ‘hot spots’ during the scan. Not all PET hot spots indicate cancer. The scan itself takes around 30 minutes.
An ultrasound is sometimes used to assess pharyngeal cancer or to see if another type of cancer has spread. A gel will be spread over your neck, and a paddle-shaped device called a transducer will be moved over the same area. The transducer creates soundwaves that echo when they meet something dense like an organ or a tumour.
The ultrasound images are then projected on to a computer screen. An ultrasound is painless and takes about 15 minutes to perform.
You may need standard x-rays of your head and neck to check for tumours or damage to the bones. X-rays are quick and painless and may include the following:
- Orthopantomogram (OPG) – Used to examine the jaw and teeth of people with mouth cancer.
- Chest x-ray – Sometimes used to check the general health of people with mouth, pharyngeal or laryngeal cancer, or to see whether the cancer has spread to the lungs. However, most people have CT scans and PET scans to look at these areas.
- X-ray of facial bones – Used in the case of nasal or paranasal sinus cancer to check whether the cancer has spread.
Iodine and your kidneys
The dye that is injected into your veins before a CT or MRI scan may contain iodine, and may affect your kidneys. Tell your doctor if you are pregnant, have any allergies or kidney problems before preparing for your CT scan. You may need to have blood tests to check your kidney function.
If you have diabetes, you may need to follow a different procedure for a PET scan. Your blood sugar levels may need to be checked before the scan. Tell your doctor so the test can be adjusted.
Cancer of Unknown Primary (CUP)
CUP, or cancer of unknown primary, is a metastatic cancer (cancer that has spread) with an unknown starting point. If CUP first shows up as a tumour in the head or neck, doctors may call it metastatic neck cancer and treat it like a head and neck cancer.
3. Staging & Prognosis
Staging head and neck cancerStaging determines how large the cancer is and whether the cancer has spread from the original site to nearby structures and other parts of the body. Your doctor will give the cancer a stage from 1-4 to help determine the best treatment. The head and neck staging system is called the TNM system. This system is also used to stage cancers in other parts of the body.
|T (Tumour) 1-4||N (Nodes) 0-3||M (Metastasis) 0-1|
|Refers to the size of the primary tumour. The higher the number, the larger the cancer.||Shows whether the cancer has spread to the regional lymph nodes of the neck. No nodes affected is 0; increasing node involvement is 1, 2 or 3.||Cancer has either spread (metastasised) to other organs (1) or it hasn’t (0).|
PrognosisPrognosis means the expected outcome of a disease. However, it is impossible for any doctor to predict that exact course of the disease. Test results, the type and stage of the cancer, how well you respond to treatment, and factors such as age and medical history are all important in assessing your prognosis. The results of head and neck cancer treatment are best when the cancer is found and treated early.
4. Who will I see
Which health professionals will I see?
Your GP will usually arrange the first tests to assess your symptoms. If you need further tests, you will be referred to a specialist, who will make a diagnosis and advise you about treatment options.
You will be cared for by a team of health professionals who meet regularly to discuss and plan your treatment. This team may include some or all of the health professionals listed on the following pages.
Health Professional Roles
ENT (ear, nose and throat) specialist
Treats disorders of the ear, nose and throat
Head and neck surgeon
ENT or general surgeon specialising in cancer of the head and neck
Oral (maxillofacial) surgeon
Specialises in surgery to the face and jaws
performs surgery that restores, repairs or reconstructs the body’s appearance and function.
Prescribes and coordinates chemotherapy, hormone therapy and targeted drug therapies.
Diagnoses and treats hearing problems.
Supports and educated patients about nutrition, diet and tube feeding
Specialises in disorders of the digestive system, and inserts, a feeding tube if required.
Health Professional Roles
Prescribes and coordinates radiotherapy
Dentist or oral medicine specialist
Evaluates and treats the mouth and teeth
Plans and delivers radiotherapy treatment
Specialises in replacing any missing teeth
Nurses and cancer nurse coordinators
Coordinate your care and support you throughout treatment
Helps with communication and swallowing
Social workder, psychologist and counsellor
Provide emotional support and help manage anxiety and depression
Physiotherapist and occupational therapist
Assist in restoring range of movement after surgery