H/N Cancer Introduction, Anatomy & Physiology Review, Staging

What is Cancer?

• Generic term for large groups of diseases

  • Malignant tumors

  • Neoplasms

What is a malignant tumor?

• cancerous/typically aggressive and can be life-threatening

What is a neoplasm?

• Refers to any new growth of tissue, regardless of whether it is benign (non-cancerous) or malignant (cancerous)

What causes cancer?

• caused from a single cell that transforms as a result of interaction between genetic factors, age, & 3 types of external agents:

  • Physical carcinogens

  • Chemical carcinogens

  • Biological carcinogens

Physical carcinogens:

• radiation (x-ray, VFSS)

Chemical carcinogens:

• asbestos, tobacco, alcohol, marijuana, hookahs, food/water contaminants, agent orange (defoliant), etc.

What is the #1 risk factor for any cancer?

• smoking!

Biological carcinogens:

• Virus (Hep B, Hep C, HPV, HIV/AIDS, COVID-19?), bacteria, parasites

(Risk Factors) What are lifestyle risk factors for cancer?

• Tobacco, EtOH (ethyl alcohol), obesity, sexually transmitted viruses

• Tobacco most significant: 20% of all cancers; 70% of lung cancer worldwide

(Risk Factors) What are environmental risk factors for cancer?

• Pollution (air, water, dioxin)

• Indoor smoke & other VOC’s (tobacco, gasoline from garage, hair spray, cleaning agents)

• Sodium nitrates are carcinogenic

(Risk Factors) What are genetic risk factors for cancer?

• breast cancer gene

Cancer… Some global numbers…

• WHO, “World Cancer Report”, February 2024

  • 20 million new cases in 2022

  • 9.7 million deaths in 2022

  • About 1 in 5 will get cancer in their lifetime!

    • 400k children/year

  • 1 in 6 deaths is from cancer

    • ~33% are from 5 behavior risks:

      • High BMI

      • Low fruit/veggie intake

      • No exercise

      • Tobacco use

      • Alcohol use

    • ~77% increase by 2050

      • 35+ million/year by 2050

    • Higher burden in developing countries

      • ~142% increase in cases; & mortality will double its current rate (70%)

    • Cost: ~$1.16 Trillion/year

Cancer…Some USA numbers…

• CDC, “Cancer Statistics at a Glance”, June 2024

  • 1.78 million new cases in 2021

    • 439 per 100,000 people

(Common Cancers) Male:

• Prostate

• Lung

• Colorectal

• Stomach

• Liver

• Esophageal

• H&N

(Common Cancers) Female:

• Breast

• Lung

• Colorectal

• Cervix

• Stomach

Where can H/N Cancer occur?

• Mouth

• Nose

• Throat/Pharynx

• Larynx

• Sinuses

• Salivary Glands

• NOT Esophagus CA, but, esophageal can progress to pharyngeal or laryngeal; &, treatment may involve pharynx or larynx

H/N Numbers in the U.S. (2024 data):

• 7th most common “group” of cancers

• 4% of all cancers in (2016: 3%)

• ~72K new diagnoses/year

  • ~75% male; 25% female (2016: 70% vs. 30%)

• ~16K die annually (2016: ~13%)

  • Men ~2-3x > Women (2016: 2%)

• Average Age at Dx: 60-70 years

• 5-year Survical Rate: ~69% (range 40-84%)

What are the most common risk factors for H/N?

• Tobacco

• Alcohol

• Human Papilloma Virus (HPV)

• Betel Quid & Gutka (chewing)

• Radiation exposure

• Age

There are multiple strings of HPV virus, which are more implicated in H/N and oropharyngeal cancers?

• HPV 16 & HPV 18

What are the other contributors risk factors for H/N?

• Social Isolation (you do not actively do anything about it → leads to having worse cancer at the time you finally do something about it)

• Low SES

• Medical Co-Morbidities

• GERD → Barrett’s Esophagus (cancer in esophagus; If you have Barrett’s, your risk of getting cancer is higher, not all Barrett’s tho!)

• Diet (low fruits/veggies; high in salt-cured meat & fish)

• Particle inhalation

• Sun

• Poor Oral Care including ill-fitting &/or poorly maintained dentures

What is a newly identified risk factor in H/N cancer?

• Marijuana (Cannabis use disorder; when you develop a physical & psychological dependency)

HPV & Cancer (2024 stats):

• ~37K new cases/year

• Sexually transmitted

• HPV has many different strains, causing different types of cancers:

  • 90% of cervical & anal cancers

  • 70% of vaginal & vulval

  • 60-70% of oropharyngeal (81% = Male; 14% = Female)

• And non-cancers – genital warts, intra-oral/intra-tracheal papilloma

• Prolonged intubation period > 10 years, & can be as long as 30 years

• Individual may not know he/she is infected & then can pass it on

What are the vaccines available for HPV & Cancer?

• 9-valent – targets 16, 18, 6, 11, & 5 more cancer causing types: 31, 33, 45, 52, 58

• Vaccinate girls & boys starting at age 11 & continuing up to 26 (girls) or up to 21 (boys); before 1st sexual contact

Community socioeconomic status & rural/racial disparities:

• Lower community socioeconomic status is associated w/ delayed diagnosis & treatment, & lower survival for H/N Cancer patients

• Rural-Urban disparities in H/N Cancer outcomes are minimal after conditioning on community socioeconomic status

• In low socioeconomic communities, we still observe significant disparities in delayed diagnosis & treatment for non-Hispanic Black adults

(Histology) Squamous Cell Carcinoma (SCC, SCCA, SCCa):

• Mucosal lining

  • Tongue

  • Oral Cavity (FOM, palate)

  • Oral & Hypopharynx (Tonsil, BOT)

  • Larynx

  • Nasopharynx

  • Skin

  • Lymph nodes (metastatic from other SCCA)

(Histology) Adenocarcinoma:

• Glandular

  • Parotid & other salivary glands

(Histology) Thyroid:

• multiple types, treated differently than SCCA

(Histology) Lymphoma:

• Not usually metastatic from SCCA

(Histology) Esthiosoneuroblastoma:

• olfactory bulb/neuron

(Histology) Ameloblastoma:

• dental tissue

(Histology) Sarcoma:

• bone

(SCCA) Oral:

• Tongue

• Lip

• Oral Cavity

  • FOM

  • Anterior tongue

  • Alveolar ridge

  • Buccal mucosa

  • Hard palate

(SCCA) Oropharynx:

• Tonsil

• Tonsillar fossa

• BOT

(SCCA) Hypopharynx:

• Piriform sinuses/fossa

• Postcricoid

(SCCA) Larynx:

• Supraglottis

• Glottis

• Subglottis

Diagnosis:

• Imaging

• Biopsy

What are the types of imaging?

• CT Scan (computerized tomography)

• MRI (magnetic resonance imaging)

• PET (positron emission tomography)

What are the types of biopsy?

• Fine Needle Aspiration (FNA)/US-FNA

  • Ultra sound FNA

• Surgical Specimen

• core biopsy: chunk taken out as opposed to a few cells, taking a core out, somewhere in middle between fine needle & full surgery

(TNM Staging/TNRM Staging) Tumor:

• primary tumor size

• how big is the tumor? (e.g., right-sided tumor & left-sided lymph node/regional tumor

(TNM Staging/TNRM Staging) Nodes:

• are local &/or regional lymph nodes involved?

• if yes, how many, & how big are they?

  • how big is the tumor? (e.g., right-sided tumor & left-sided lymph node/regional tumor)

(TNM Staging/TNRM Staging) Metastases:

• Is there a secondary tumor?

  • Has the cancer spread to other areas than H/N, i.e., lung, brain, leg?

  • typically a brain tumor would not spread to H/N

(TNM Staging/TNRM Staging) Recurrence:

• Yes or no?

  • R1 - first recurrence

Take a screenshot of slide 25 & other staging

What is the SLP’s role in Staging?

• NOTHING!

• But, we need to understand it bc our patients often have questions related to tumor stage & swallowing outcomes

What is the management of H/N Cancer?

• Surgical

  • Open laryngectomy (they open it)

  • Trans Oral Robotic Surgery (TORS)

  • Radiation Therapy (XRT)

  • Radiation + Chemotherapy (CRT)

• Multi-disciplinary care

Who is a part of the multi-disciplinary care team for H/N Cancer?

• MD (ENT, Radiation Oncology, Hematology, Pathology)

• RN

• Dietitian

• Psychosocial (LCSW, Psychologist, Psychiatrist)

• Rehab (SLP, PT, OT)

• Alternative Medicine (homeopathy, acupuncture, massage, dance, art)

• Clergy/Faith Community

• Caregiver (May or may not be family member)