Key Facts

Head and neck cancer requires multidisciplinary management involving surgeons, oncologists, speech therapists, dietitians, and specialist nurses.

Epidemiology

• Approximately 12,400 new cases/year in the UK
• Male:female ratio 2:1 (narrowing)
• HPV-related oropharyngeal cancer incidence is rising rapidly in younger patients
• Tobacco and alcohol-related cancers declining

Aetiology

• Smoking: most important risk factor; dose-response relationship
• Alcohol: independent risk factor; synergistic with smoking
• HPV-16: responsible for 70-80% of oropharyngeal cancers in the UK (tonsil, base of tongue)
• Betel nut chewing: oral cavity cancer (South Asian populations)
• Poor oral hygiene: oral cavity cancer
• EBV: nasopharyngeal carcinoma

Pathophysiology

• 90% are squamous cell carcinoma

• HPV-positive: p16 overexpression (surrogate marker); better prognosis, younger patients, often non-smokers
• HPV-negative: TP53 mutations, associated with smoking/alcohol; worse prognosis
• Spread: local invasion, lymphatic (cervical nodes — 40% have nodal disease at presentation), distant metastases rare at diagnosis (lung, bone, liver)

By Site

• Oral cavity: non-healing ulcer (>3 weeks), white/red patch (leukoplakia/erythroplakia), loose teeth, difficulty chewing
• Oropharynx: sore throat, dysphagia, referred otalgia, neck lump (cystic — HPV+)
• Larynx: hoarseness (>3 weeks), stridor, dysphagia
• Hypopharynx: dysphagia, referred otalgia, weight loss, neck lump
• Nasopharynx: unilateral nasal obstruction, epistaxis, serous otitis media, cranial nerve palsies

Red Flags (NICE NG12)

• Unexplained neck lump persisting >3 weeks
• Hoarseness >3 weeks
• Oral ulcer not healing >3 weeks
• Persistent sore throat >3 weeks (especially with otalgia)
• Unexplained dysphagia
• Unilateral serous otitis media in an adult

Bedside

• Full ENT examination including flexible nasendoscopy
• Oral examination (inspection, palpation of tongue and floor of mouth)
• Neck palpation (cervical lymph nodes)

Bloods

• FBC, U&Es, LFTs, TFTs (baseline before treatment)
• EBV serology (if nasopharyngeal carcinoma suspected)

Imaging

• CT neck with contrast: initial staging (tumour extent, nodal disease)
• MRI: superior soft tissue detail (oral cavity, oropharynx, parapharyngeal space)
• PET-CT: staging for advanced disease; detection of unknown primary; post-treatment response assessment
• CT chest: exclude lung metastases or synchronous primary
• OPG (orthopantomogram): dental assessment before radiotherapy

Special Tests

• Biopsy: incisional biopsy, punch biopsy, or EUA with biopsy under GA
• Fine needle aspiration (FNA): for neck lumps (cytology)
• p16 IHC: surrogate marker for HPV in oropharyngeal carcinoma
• HPV DNA testing: confirmatory if p16 positive
• Panendoscopy (EUA): assessment of tumour extent, biopsy, exclude synchronous primary
• Speech and swallowing assessment: baseline before treatment

Non-pharmacological

• MDT discussion mandatory (surgeon, oncologist, SALT, dietitian, CNS, dental)
• Smoking and alcohol cessation
• Nutritional optimisation (PEG/RIG feeding may be needed during treatment)
• Dental assessment and extractions before radiotherapy (to prevent osteoradionecrosis)
• Speech and language therapy
• Psychological support

Pharmacological

• Concurrent chemoradiotherapy (locally advanced): cisplatin 100mg/m² on days 1, 22, 43 with 70Gy RT over 7 weeks
  • Alternative: weekly cisplatin 40mg/m²
  • If cisplatin contraindicated: cetuximab 400mg/m² loading then 250mg/m² weekly with RT (Bonner trial)
• Recurrent/metastatic: pembrolizumab + platinum + 5-FU (KEYNOTE-048) or cetuximab + platinum + 5-FU (EXTREME trial)
• Induction chemotherapy (TPF: docetaxel, cisplatin, 5-FU): in selected cases to reduce tumour volume before definitive treatment

Surgical/Interventional

• Primary surgery: for oral cavity cancers (preferred over RT for most oral cavity subsites) and selected early-stage laryngeal/oropharyngeal cancers
• Transoral robotic surgery (TORS) or transoral laser microsurgery (TLM): minimally invasive for oropharyngeal and laryngeal tumours
• Neck dissection: selective or radical for nodal disease (with primary surgery or after chemoRT if residual disease)
• Reconstruction: free tissue transfer (radial forearm flap, fibula, ALT flap) for defect reconstruction
• Total laryngectomy: for advanced laryngeal cancer or recurrence after RT; permanent tracheostomy

Referral Criteria

• Suspected head and neck cancer: 2-week wait referral (NICE NG12)
• All confirmed cancers: head and neck cancer MDT
• Unknown primary with neck lump: urgent ENT/MDT assessment

• Early-stage (I-II): 5-year survival 70-90% (site-dependent)
• Locally advanced (III-IVA): 5-year survival 40-60% with chemoRT
• Metastatic/recurrent: median survival 10-15 months (improving with immunotherapy)
• HPV-positive oropharyngeal: 5-year survival ~80% (significantly better than HPV-negative ~40%)
• Laryngeal cancer (early): 5-year survival >90% with voice preservation
• Overall 5-year survival: approximately 60%
• Late effects of treatment: xerostomia, dysphagia, osteoradionecrosis, hypothyroidism, carotid stenosis, second primary cancers

HPV-Positive vs HPV-Negative Oropharyngeal Cancer

Key Trials