Hospital Early Stages - The Swallows

1. Physical Examination & Biopsy

Biopsy

A 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 examination

Your 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 decisions

Sometimes 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.

Tumour Difficulty

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.

Unexplained Changes

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

Scan Types

CT scan

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.

MRI scan

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.

PET scan

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.

Ultrasound

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.

X-rays

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.

Diabetes procedures

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 cancer

Staging 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.

TNM System

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).

Prognosis

Prognosis 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.