Head Neck Cancer
Head cancer is site-specific, which includes oral cavity, pharynx, larynx, paranasal sinuses and nasal cavity, and salivary glands.
About Head Neck Cancer
Head Neck Cancer comprises of Oral (Mouth) Cancer, Oropharangeal (Throat) cancer, Laryngeal (Voice Box), Maxilla and Para Nasal Sinus Tumors, Skull Base lesions, Orbital Cancers, Thyroid and Salivary gland tumors along tumors in the neck in form of lymph nodal metastases and other neck tumors in form of paragangliomas, congenital neck cysts, lymphomas etc.
The most common form of Head Neck Cancer is the one occurring at the mucosal lining of Oral Cavity (Mouth), Posterior tongue and Tonsil (Oropharynx), Laryngeal apparatus (Voice Box) and Upper part of esophagus (food pipe) in the form of Squamous Cell Carcinoma. Tobacco abuse is the most common reason for its development. In our part of world, where the habit of tobacco chewing is very prevalent has led to India having the world’s largest population of Oral Cancer patients. If Alcohol is added to the tobacco the risk or the chances of cancer development are further increased.
The survival statistics in Head Neck Cancer depend on the stage of tumor, treatment modality and its adequacy. The survival, which is more than 80% in stage I, falls to 50% in stage III. Performing a timely biopsy and imaging (CT scan, PET CT etc.) are the essentials of timely diagnosis of HNC.
In early stages the cancer is localized to the primary site without involvement of adjacent tissues and no spread to regional neck nodes. In advanced stages the disease involves adjacent tissues, e.g. a cancer in the cheek will have involved the lower or upper jawbone or the outside skin; and/or the disease spreads to neck lymph nodes. In metastatic stage, the disease spreads to the lungs, liver and/or bones, etc. distant tissues if the body
A. In early stages disease can be controlled with only surgery as single modality of treatment.
The methodology of surgery can vary according to the site.
1. Oral cavity: open approach may be splitting the lip, angle of mouth or intraoral
2. Oropahraynx(Posterior part of tongue, Tonsil, Lateral Pharangeal wall) : Trans oral Robotic or endoscopic approach / Radiation
3. Larynx (Vocal Cord): Laser in form of Microlarangeal surgery / Radiation
B. In advanced stages the treatment becomes multimodality:
1.Oral Cavity: Surgery followed by Radiation (RT) or Chemoradiation (CCRT),
2. Oropharynx, Some sites of Larynx like (supraglottis), Hypopharynx
a. If history of smoking or tobacco abuse present: Induction (Neoadjuvant) chemotherapy followed by reassessment after 2/3 cycles
b. If No history of smoking & with suspected signs and/or symptoms of HPV virus exposure: CCRT (chemoradiation)
3. Larynx: Radiation or Chemoradiation followed by salvage surgery if needed
In the stage when the disease has metastasized to other sites the treatment is mainly palliative in form of low dose chemotherapy known as metronomic therapy; immunotherapy and/or targeted therapy.
About Thyroid Cancer
Thyroid is a butterfly shaped gland present in lower part of the neck below the Adam’s apple in front of the trachea (wind pipe). It has two lobes a right and a left connected together by isthmus in between. A normal thyroid is not palpable.
In Differentiated Thyroid cancers i.e. those thyroid cancers, which concentrate iodine in them the basic guidelines for treatment, are:
1. Early stage: Surgery
2. Advanced Stage: Surgery followed by Radio Iodine Therapy +/- Radiation
3. Metastases: Surgery followed by Radio Iodine Therapy
For differentiated thyroid cancers, the radioiodine reaches the metastatic sites only if thyroid gland in the neck has been removed, otherwise all the radioiodine gets concentrated in the thyroid gland itself
Breast cancer occurs when some breast cells begin to grow abnormally.lifestyle and environmental factors that may increase your risk of breast cancer.
About Breast Cancer
Breast Cancer is the most common cancer among women in India. Every year around 1.5 to 2 lakh new women are being diagnosed with Breast Cancer.
According to GLOBOCAN 2012,” India is facing challenging situation due to 11.54% increases in incidence and 13.82% increase in mortality due to breast cancer.”
In Urban areas 1 in 22 women are likely to be affected by breast cancer. Upto 50% of these don’t survive within 5 years of the diagnosis, More than half of the cases are detected at advanced stage i.e. Stage III and above i.e. majority of women in India when they are diagnosed with Breast cancer, the cancer has already progressed to arm pit or it has involved the Breast skin or nipple. Out of the two women who are diagnosed with Breast cancer only one survives due to advanced stage of disease presentation. In western population more than 80 % women are being detected when the disease is limited to breast, not spread to armpit or any other site in the body and having a small volume i.e. < 2cm tumor size i.e. Stage I/ II with a survival rate of more than 80%.
Inadequate screening and advanced stage of presentation are the main reasons for the rising death toll, along with limited medical facilities.
In the west majority cases present in Stage I & II, whereas in India 45.7% report in advanced stages(acc to Malviya etal, AP JCO2017). If cancer is detected at early stage the survival can reach upto 90% whereas when detected in advanced stage the survival falls down to less than 50%
Lower age of Incidence (Malviya etal, AP JCO2017)
Another important aspect in Indiais the younger age of presentation of Breast Cancer 45 to 49 is the peak age of incidence of breast cancer across the country. In North East, this age has gone down to 35 years.
It is general thumb rule, younger the cancer, more aggressive it is, also Younger aged patients tends to have the more aggressive variety i.e. be triple negative cancer
Younger age Breast Cancers below 40 are difficult to screen, the increased density of breasts in younger age group makes it difficult to be detected or seen in mammography, making mammography of limited utility.
Breast Cancer in India is rising at a alarming pace, we definitely need to adjust our lifestyle, lead a healthy and stress free life; limit or control our habits. Timely Pregnancy in today’s times shall be 35 yrs or less, it definitely reduces the risk of Breast cancer. If someone feels that there is history of cancer especially Breast and /or ovarian should consults a medical personnel.
Causes Of Breast Cancer
While research is still evolving to ascertain the causes for Breast Cancer, it is generally caused due to the following factors:
1. Lifetsyle Issues: A female’s body is governed by the interplay of estrogen and progesterone hormones. Estrogen promotes cell growth whereas Progesterone causes cell maturation and stabilization. In a woman’s life if estrogen exposure is more, it means more cell growth and cell multiplication, therefore more chances of mutation(changes which cause cancer) to occurleading to Breast cancer. Such situations occur with :
a. Early Puberty
b. Late or no Pregnancy
c. Limited or No Breast Feeding
d. Hormonal exposure in form of Hormonal replacement therapy or Hormones in any form; assisted reproduction methods
e. Even increased stress and alcohol causes estrogen to rise in a woman’s body
f. Obesity and lack of exercise also cause increased levels of estrogen
2. Environmental Factors : Increased exposure to pollutants also contribute to rising Breast cancer in India.
a. The carbon in the air pollution or when a woman smokes bind to the estrogen receptors in the body and breast. Today air pollution is on the rise and lot of women have started to smoke.
b. The Pesticides and chemicals in our food and water also bind to these estrogen receptors and contribute to rise in Breast Cancer.
3. Hereditary factors : There are certain genes like BRCA 1 and BRCA 2 which cause mainly Breast and Ovarian cancers run in the family. It means that if a woman harbour’s BRCA gene there is 80% chance that she will get Breast cancer in her lifetime and 40 % chance that she will get Ovarian cancer. There is a 50 % probability that the gene will be transferred to the next generation and can cause cancer. The exact prevalence of these genes in Indian population is not yet known. In US, around 15% of Breast cancer is Hereditary. A lot more needs to be written about the Hereditary component of Breast Cancer which shall be followed in subsequent articles.
Screening & Early Detection
The only possible solution for the rising problem of Breast Cancer is early detection i.e. catching it at an early stage. At early stage with proper treatment we can expect 80 to 90% survival, 100% Breast preservation and high chances of de-escalation of adjuvant chemotherapy and radiation.
Breast Cancer screening in India is at very early stage, also we attribute it to Mammography whereas it forms just one small portion of Breast screening. According to American Cancer Society Guidelines, the standard screening process of mammography should start at the age of 45 followed by yearly intervals till the age of 55 and thereafter 2 yearly interval. In India as we know now, Breast Cancer women is a decade younger in comparison to western women, the disease peaks at 45 – 50 years. The Indian women have inherently higher breast density as compared to west. Both the facts suggest limited application of screening mammography in Indian settings. . For screening process to be effective it should start atleast 10 yrs. before the peak age of incidence. Advising Mammogram at the age of 35 is not at all effective
The manual breast screening methods in form of Self Breast Examination and Clinical Breast Examination are effective but sparingly used also sparingly used. Every woman should do a self Breast Examination. SBE is nothing but to be aware and conscious of the changes happening in one’s breast. If done regularly the woman can definitely detect Breast cancer if unfortunately it has to happen at a much early stage
How does Breast Cancer Present?
The Cancer presents as
• Lump in Breast
• Change in Nipple position in form of retraction or tethering
• Discharge from Nipple especially Bloody discharge
• Depression or scaring of Breast skin
• Redness or changes of Breast skin especially the Peu d orange
form (skin looks and feel like orange peel)
• Fungating mass through the skin
• Mass or swelling in the armpit
Breast Lump Evaluation:
Clinical history and examination, which includes examination of Breast,
axilla and neck to evaluate the primary tumor and nodal metastatic
spread along with suspicion of distant sites. A clinical staging is also put forth.
The cause of the cancer is and need for genetic evaluation is ascertained.
• Routine blood and other standard evaluation
• Ultrasound and Mammogram (SONOMAMMOGRAM)
• According to the results further steps are planned. The report comes in BIRADS category.
• BI-RADS stands for Breast Imaging Reporting and Data System.
The following can be the result post Sonomammogram
◦ 0- incomplete
◦ 2-benign findings
◦ 3-probably benign
◦ 4-suspicious abnormality
◦ 5-highly suspicious of malignancy
◦ 6-known biopsy with proven malignancy
Accordingly the following evaluation and treatment is done.
BIRADS 1 & 2 are evaluated and treated as benign breast lumps
BIRADS 4 and above are evaluated as malignant by doing a core needle biopsy/FNAB to confirm the malignancy
BIRADS 3 the preference is to get a breast MRI
Breast MRI has basically three main uses
1. Further evaluation of BIRADS 3 lesion, which suggests further whether to recommend a histological evaluation or keep the patient in follow up
2. Evaluating Centricity or Focality of Breast Tumor: The MRI is a better investigation to make sure that their is no other focus of malignancy in the same breast both in the same quadrant as well as other quadrants and also in the other breast. This evaluation is very important to select the suitable patient for Breast Conservation surgical procedure
3. Mammogram shows ACR C/D i.e. when the Breasts are dense which make them unsuitable for mammographic evaluation, Breast lumps or other pathologies occurring in these women will be evaluated by MRI
Followed by Clinical and radiological examination:
Histopathological evaluation is needed which is preferentially done by Core needle (Trucut) Biopsy to proof whether the lump is cancerous (Malignant) or not.
Core needle Biopsy is preferable or FNAC due
• Its better accuracy in terms of specificity i.e. false positivity
• It Provides tissue for IHC or Molecular analysis and categorization
Following histological confirmation, further diagnostic tests are prescribed according to clinical staging.
1. If Clinically its an early stage disease i.e. lump size less than 5 cm with no palpable lymph nodes in axilla then tests for systemic evaluation shall be just Ultrasound abdomen and X ray of the chest.
2. If clinically its an advanced stage disease i.e. a large size lump with or without changes in nipple and/or breast skin with palpable Lymph nodes in axilla and/or neck then systemic evaluation in form of CECT scan of chest and abdomen with bone scan with or without MRI Brain OR a whole body PET CT scan is required.
MRI brain is more relevant in triple Negative Breast cancers.