Head and Neck Cancer – Dr Richard Gallagher

About

“Head and neck cancer” does not refer to one type of cancer but to a complex and varied range of cancers. These cancers all start in the head and neck and can include the mouth, tongue, palate, jaw, salivary glands, tonsils, throat (pharynx), voice box (larynx), nose, and sinuses. I treat all types of head and neck cancer. The densely complex anatomy of this part of the body creates a unique range of challenges for treatment. Successful treatment of head and neck cancers requires a multidisciplinary team working in a high volume centre. Your treatment team should not only be focussing on treating the cancer but also on protecting the numerous functions of the head and neck and your long term quality of life.

Causes

Alcohol and tobacco use are still the two most common risk factors for head and neck cancers. But cancers associated with these risk factors are declining in number. By contrast we are seeing an increase in the types of head and neck cancers caused by a virus, specifically the human papillomavirus (HPV). These cancers can present many years, even decades, after a patient has contracted HPV. Often these patients have no history of smoking or drinking and their only symptom is a neck lump. More information is available on the HPV blog page.

Other causes of head and neck cancer include infection with Epstein Barr virus (EBV) which causes nasopharyngeal carcinoma. Betel nut chewing which is a common habit in Southeast Asia resulting in mouth (oral) cancer. Hardwood dust exposure related to carpentry and saw milling can cause ethmoid sinus cancers (sinonasal).

Diagnosis and Treatment

There are plenty of websites which provide detailed information about the different types of head and neck cancers. I particularly recommend the Cancer Council NSW website. What I want to focus on here are the factors patients should consider at the start of their cancer journey.

1. Importance of choosing a high volume head and neck cancer specialist

Choosing the right cancer specialist can be difficult at the best of times, but it can be particularly difficult for patients diagnosed with head and neck cancer. This is due to a range of reasons. To begin with these cancers occur in small numbers. This makes it hard even for general practitioners to find appropriate medical specialists. Secondly, the area affected by the cancer and cancer treatment involves a large number of organs and functions, raising many questions which apply to both immediate treatment and longer term outcomes. Thirdly, successful treatment of these cancers requires a team of experts, not just one clinician, especially as nearly all head and neck cancer patients will need a combination of treatments which may or may not include surgery, radiotherapy, chemotherapy, and now immunotherapy. The low number of these cancers mean that there is only a small number of specialists in Australia consistently treating these patients. The aggressive nature of these cancers and the complex anatomy mean that it is preferable to find a medical practitioner who treats head and neck cancer in a high volume centre on a weekly, if not daily, basis.

2. Relevance of high volume centres

Not all specialists and hospitals treat high volumes of head and neck cancers. Which is a problem because we know that cancer patients treated in high volume centres get the best outcomes. The NSW Cancer Institute recommends ‘that hospitals treating people with complex cancers should perform these surgeries regularly (i.e. perform a certain number of surgeries each year). This is known as a minimum suggested annual caseload.

Nothing frustrates me more than a hospital unit or medical professional who “dabbles” in head and neck cancer. Internationally a high volume unit treats 70 or greater cases of complex head and neck cancer per year. In New South Wales committee that I chaired at the Cancer Institute New South Wales in 2018 agreed to set this level at 25 cases per year. These are complex, aggressive cancers which require sophisticated, immediate treatment. According to the latest NSW Cancer Institute data, St Vincent’s Hospital, Darlinghurst, is the highest volume public surgical head and neck cancer unit in NSW. This volume doubles when we include St Vincent’s Private Hospital. On average 190 complex head and neck cancers are treated on the St Vincent’s campus per year (2012-2017).

Average annual caseload of resections I know of a number of head and neck units in NSW which include surgeons and radiation oncologists who only perform head and neck procedures a handful of times a year. When you are considering the treatment offered by a cancer specialist it is appropriate to ask how often they treat head and neck cancer patients and also when they most recently treated a patient with the same diagnosis as you.

I also want to acknowledge that high volume centres tend to be in metropolitan areas. This makes it harder for regional, rural and remote patients to receive treatment. But I want to emphasise that high volume centres get the best outcomes which is especially important for these aggressive cancers which occur in relatively small numbers. At St Vincent’s we care for many head and neck cancer patients from regional NSW and understand the extra strain and additional services required to support carers and patients far from home.

3. Tests required for correct diagnosis

If you are referred to see me with a suspected cancer then either your referring doctor or my staff will arrange a number of diagnostic tests and investigations before you and I meet face to face. Diagnosing a tumour as cancer is only the first step. We also need to know a lot of other information. This may include medical imaging such as positron emission tomography (PET), computed tomography (CT) and magnetic resonance imaging (MRI) scans, and fine needle aspirant biopsies (FNAB). We need to stage the tumour correctly. This means understanding the extent of the tumour, whether it has spread to other areas of the head and neck and finally whether it has spread to any other part of the body.

4. Importance of cancer staging

Cancer staging is the process of determining how much cancer is in the body, the severity of the cancer and how far it is spread. Head and neck staging systems include information about:

Size of the tumour
Depth of the tumour
Pathology
Whether or not the tumour has spread (metastasised) to lymph nodes
Whether or not the cancer has spread (metastasised) to other parts of the body.

Staging is one of the tools used by a team of medical experts to determine an individual head and neck cancer patient’s treatment plan. Surgery, radiotherapy, chemotherapy and immunotherapy are all considered as part of this plan. The staging process also allows a discussion with the patient and their families about their likely outcome from treatment (prognosis).

5. The essential role of Multidisciplinary Teams (MDTs)

Every head and neck cancer patient should be reviewed by a multidisciplinary team (MDT). The St Vincent’s Head and Neck Cancer Multidisciplinary Team meets for two hours every Tuesday to review all private and public head and neck cancer patients who have been referred in the previous week. The St Vincent’s Sydney Head and Neck Cancer MDT includes head and neck surgeons, plastic and reconstructive surgeons, radiation oncologists, medical oncologists (they’re the doctors who specialise in chemotherapy), pathologists, dentists, dieticians, speech pathologists, psychologists, social workers, cancer care coordinators, cancer researchers and specialist nurses. Most head and neck cancer patients require a combination of therapies during their cancer treatment. These may include one or a combination of surgery, radiotherapy, chemotherapy, and immunotherapy. There is a lot of research that demonstrates that patients who are reviewed by an MDT have better outcomes. In the NSW Cancer’s Institute’s most recent Reporting for Better Cancer Outcomes, the Institute recommends that ‘all people diagnosed with cancer in NSW should have their care overseen by a multidisciplinary cancer care team (MDT). This is considered best practice as it improves cancer outcomes.’ How this is achieved is explored in this article from the team at MD Anderson. MD Anderson hold a 75 to 90 minute Head and Neck MDT, known as a Tumor Board Meeting in the US, every Thursday. At St Vincent’s, Sydney, we hold a two hour meeting every Tuesday at The Kinghorn Cancer Centre. There are usually in excess of 20 clinicians in attendance who are involved in the care of head and neck cancer patients. All head and neck cancer patients referred to St Vincent’s specialists, surgical or medical, are reviewed at this meeting regardless of whether they are being treated privately or publicly.

6. Quality of life after treatment

Currently the survival rate of head and neck cancers in Australia beyond five years is 70%. These statistics are a great improvement on previous decades and continue to improve year on year. When I first started my training twenty years ago the focus of head and neck cancer treatment was survival. Now we are far more focused on quality of life in addition to survival. This specifically means doing what we can to preserve patients’ ability to speak and swallow. It is one of the main reasons I trained as a Transoral Robotic Surgeon (TORS) and why I work so closely with speech pathologists both before and after treatment. This also drives my commitment to voice preservation and why I perform partial rather than total laryngectomies whenever possible.

7. Why patients with an HPV oropharyngeal cancer diagnosis should attend an MDT which includes a Transoral Robotic Surgeon (TORS)

Transoral Robotic Surgery (TORS) is only appropriate for certain cancers. But what it does particularly well is allow surgical access to tumours of the oropharynxand throat , minimising permanent damage to patients’ ability to speak and swallow. Transoral Robotic Surgery (TORS) is a relatively new surgical technique and there are currently only a handful of a volume TORS surgeons working in Australia.

The potential benefits to patients are excellent, particularly for patients with an early stage HPV related oropharyngeal cancer. If you are diagnosed with an early stage HPV related oropharyngeal cancer then I strongly suggest you seek an opinion from a Multidisciplinary Team which includes a TORS surgeon, otherwise you are not being offered the full range of treatments available for this cancer.

I am passionate about the benefits of TORS for patients because I see every week the fantastic way TORS preserves the swallowing, speech and salivary production of patients who would previously have spent the rest of their lives managing difficult post treatment complications. I have been performing robotic surgery to treat these cancers since 2011 and am Australia’s highest volume individual da Vinci robot surgeon, having performed this surgery hundreds of times.

8. Accessing clinical trials

Unfortunately I see a number of patients each year with advanced head and neck cancers which are considered unsuitable for treatment. Often the last hope for these patients is participation in clinical trials. High volume head and neck cancer centres such as St Vincent’s Sydney, have close ties to clinical trials, particularly through our award winning clinical trials unit at The Kinghorn Cancer Centre. Part of the treatment we offer patients suitable for clinical trials is connection to trials which may not be taking place at our own hospital. Navigating the Australian New Zealand Clinical Trials Registry can be difficult but we are here to help and do our best to direct patients to appropriate trials whenever possible.