Diagnosis

Head and neck cancers may be discovered in multiple ways. A doctor or dentist may find the first evidence during a routine exam or oral, head and neck screening. For example, a swollen lymph node in the neck or an unexplainable red or white patch in the mouth may be seen. Most often, however, head and neck cancers are discovered only after a patient has sought treatment for symptoms that have become problematic. 

When you see your primary care doctor, you should discuss any past medical history as well as risk factors you have for head and neck cancer such as tobacco or regular alcohol use, and the specific symptoms that you’re experiencing. Your doctor will examine your mouth, head, and neck for lumps, bumps, changes to your mouth or throat, or any problems with the nerves in and around these areas. If he or she feels you need further evaluation, you will likely be referred to an ear, nose and throat specialist (also called an otolaryngologist) or head and neck surgeon.

The ear, nose and throat specialist (ENT) will perform a thorough head and neck exam. Because some parts of your throat are difficult to see, he or she may perform a pharyngoscopy. This procedure can be done in the office and does not require anesthesia. The ENT may use small, long-handled mirrors to see the deeper portions of your throat, the base of your tongue, and portions of the voice box. Alternatively, a tiny, flexible fiber-optic scope may be passed through your nose to examine areas that cannot be seen by eyes or mirrors, including the area behind the nose or the rest of your throat and voice box.

If further investigation is required, your ENT will perform additional tests which may include:

  • Panendoscopy: This procedure is done under general anesthesia. The doctor will use scopes to more thoroughly examine the throat, voice box, esophagus (tube leading to the stomach), trachea (windpipe), and bronchi (airways leading from the trachea into the lungs).
  • Biopsy: In a biopsy, a sample of tissue is removed from the suspected tumor. The tissue is then examined for the presence of cancer or dysplasia (precancerous changes). Biopsies are examined in a lab by a pathologist who is specialized in cancer diagnosis. He or she is trained to distinguish between cancer cells and normal cells, as well as the type of cancer, based on the cells’ appearance. Depending on the specific situation, one or more types of biopsy may be used.
  • Exfoliative cytology – The doctor collects cells from the area of the suspected cancer by scraping it with a small tool. The cells are spread onto a glass slide and examined under a microscope to look for abnormalities.
  • Incisional biopsy – A piece of tissue is cut from the area of the suspected cancer. Depending on where the suspected cancer is located, this procedure may be done in the doctor’s office (the area will be numbed first), or in the operating room while you are asleep.
  • Fine needle aspiration (FNA) – The doctor uses a thin, hollow needle and syringe to remove cells from the suspected tumor. The cells are then examined under a microscope. This type of biopsy is typically used to examine lymph nodes or lumps in the neck.
  • HPV Testing: Tissues from a biopsy that are shown to be squamous cell carcinoma, especially when taken from the tonsil or the base of the tongue, are often tested for a genomic marker called p16, which is a sign that the cancer may be related to an HPV infection. HPV-related (p16+) cancers have been found to be significantly more responsive to treatment than those lacking p16.
  • Imaging Tests: Your doctor may order imaging tests at different times during your diagnosis and treatment to look for a suspect tumor, to see if cancer has spread, to see if treatment is working, or to look for recurrence of cancer after treatment. Many different types of imaging can be used, including:
  • Chest x-rays – These images are used to see if cancer has spread to the lungs.
  • CT Scan – These images provide a detailed view of your organs and soft tissue and allow your doctor to see the location of any tumors, whether a tumor is growing into nearby tissue, or whether the cancer has spread to lymph nodes, lungs or other organs. CT images also provide a detailed assessment of facial bones to see if they are affected by cancer.
  • MRI – These images are useful in examining the neck and brain, as well as the extent that a tumor extends into soft tissue, such as muscle and fat or along nerves.
  • PET Scan – PET scans are useful when cancer has already been diagnosed. They can help doctors see if cancer has spread to lymph nodes or other areas of the body, and it is especially useful if your doctor suspects the cancer may have spread but isn’t sure where. During a PET scan, sugar that contains a low level of radiation will be injected into your blood. Cancer cells will absorb more of this sugar than normal cells, making them more apparent on the images.

Staging

During the process of diagnosing your cancer, the cancer will be staged. Cancer staging is a way of describing the cancer. Diagnosis and staging tell us several things including where in the body the cancer is located, the severity of the cancer (for example, by indicating the size of the primary tumor), and how far the cancer may have spread from its original location. Staging helps your medical team determine your prognosis (the predicted outcome of the disease) and identify the best treatment option for your particular cancer.

Cancer may be staged at multiple points during the processes of diagnosis and treatment.  Your medical team may use one or more of the following types of staging:

  • Clinical Staging – This method of staging uses physical examinations, imaging (x-rays, CT scans, MRI, etc.), and biopsies to determine the severity and extent of your cancer.
  • Pathologic Staging – This method combines the findings used in clinical staging with findings from surgery (for example, if you have a tumor removed or if your medical team does an exploratory surgery).
  • Post-Therapy Staging – This type of staging describes the severity and extent of the remaining cancer following an initial course of treatment, such as chemotherapy or radiation.
  • Restaging – Restaging occurs if your cancer returns following treatment.

Staging describes four characteristics of the cancer:

  • Location of the primary tumor
  • Size or extent of the tumor
  • Whether or not the cancer has spread to lymph nodes near the tumor
  • Whether or not the cancer has spread to distant parts of the body

To be effective and useful, cancer staging relies on a set of standardized criteria that allow all medical professionals to have the same understanding of a particular cancer. The staging system used most often in the U.S. and around the world is the TNM Staging System developed by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC).

This system describes a patient’s cancer according to 3 categories, each with multiple grades:

  1. T – This category describes the extent of the tumor
    1. TX: Primary tumor cannot be evaluated
    2. T0: No evidence of primary tumor
    3. Tis: Carcinoma in situ (early cancer that has not spread to neighboring tissue)
    4. T1–T4: Size and/or extent of the primary tumor
  2. N – This category describes whether or not nearby lymph nodes are involved
    1. NX: Regional lymph nodes cannot be evaluated
    2. N0: No regional lymph node involvement (no cancer found in the lymph nodes)
    3. N1-N3: Involvement of regional lymph nodes (number and/or extent of spread)
  3. M – This category indicates whether the cancer has spread to distant parts of the body
    1. M0: No distant metastasis (cancer has not spread to other parts of the body)
    2. M1: Distant metastasis (cancer has spread to distant parts of the body)

It is important to note that each type of cancer has its own classification system. Within head and neck cancer, the numbers and letters for one type do not mean the same as those for another type.  For example, in salivary gland cancer a T1 classification means the tumor is smaller than 2cm and does not involve the soft tissues, but in sinus cancers, the same classification means the tumor is confined to one site with no destruction of bone. To better understand your specific cancer stage, ask your doctor to explain it you in terms you and your family understand.

The T, N and M classifications are then combined to determine a stage of 0, I, II, III, or IV. While stage 0 and I cancers are the least advanced and often easiest to treat, it is important to note that higher stage cancers can often be successfully treated as well.

As our understanding of cancer evolves, so does the way oncologists stage cancers.  As of January 1, 2018, a new staging methodology was put into place by the American Joint Committee on Cancer (AJCC), and the way head and neck cancers are now staged has changed significantly. The most dramatic changes have been made to staging for mucosal melanoma, oropharyngeal cancer, cancer with an unknown primary, and oral cancer. For example, prior to the changes instituted in 2018, most oropharyngeal cancers were classified as stage IV. Today, many of those would be considered stage I or II. We also now know that oropharyngeal cancers that are HPV positive (also called p16 positive)--that is, they contain DNA from the human papillomavirus (HPV)—have a better prognosis than those that are HPV negative.  Under the recent changes to the TNM system, there are different staging criteria for HPV positive and HPV negative oropharyngeal cancer. You can learn more about the changes to the staging system here.


References
  • Becze, Elisa. “AJCC Cancer Staging System Will See Changes in 2018.” ONS Voice, 5 June 2020, voice.ons.org/news-and-views/cancer-staging-system-changes.
  • “Can Oral Cavity and Oropharyngeal Cancers Be Found Early?” American Cancer Society, www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/detection-diagnosis-staging/detection.html.
  • “New Staging System on Horizon for Head and Neck Cancers.” ENTtoday, 28 June 2017, www.enttoday.org/article/new-staging-system-horizon-head-neck-cancers/?singlepage=1.
  • “Oral Cavity and Oropharyngeal Cancer Stages.” American Cancer Society, www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/detection-diagnosis-staging/staging.html.
  • “Tests for Oral Cavity and Oropharyngeal Cancers.” American Cancer Society, www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/detection-diagnosis-staging/how-diagnosed.html.

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Take it from me: cancer prevention is always preferable to cancer treatment. As I’ve transitioned from cancer researcher to cancer patient to cancer survivor, I vow to make every effort to keep others from joining my club.Stewart Lyman, Ph.D.
Cancer Researcher and Biotechnology Consultant Survivor of HPV-attributed Tonsil Cancer


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