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Head and Neck Cancers

This was originally posted by the National Cancer Institute here.

What are cancers of the head and neck?

Cancers that are known collectively as head and neck cancers usually begin in the squamous cells that line the moist, mucosal surfaces inside the head and neck (for example, inside the mouth, the nose, and the throat). These squamous cell cancers are often referred to as squamous cell carcinomas of the head and neck. Head and neck cancers can also begin in the salivary glands, but salivary gland cancers are relatively uncommon. Salivary glands contain many different types of cells that can become cancerous, so there are many different types of salivary gland cancer.

Cancers of the head and neck are further categorized by the area of the head or neck in which they begin. These areas are described below and labeled in the image of head and neck cancer regions.

Oral cavity: Includes the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, the floor (bottom) of the mouth under the tongue, the hard palate (bony top of the mouth), and the small area of the gum behind the wisdom teeth.

Pharynx: The pharynx (throat) is a hollow tube about 5 inches long that starts behind the nose and leads to the esophagus. It has three parts: the nasopharynx (the upper part of the pharynx, behind the nose); the oropharynx (the middle part of the pharynx, including the soft palate [the back of the mouth], the base of the tongue, and the tonsils); the hypopharynx (the lower part of the pharynx).

Larynx: The larynx, also called the voicebox, is a short passageway formed by cartilage just below the pharynx in the neck. The larynx contains the vocal cords. It also has a small piece of tissue, called the epiglottis, which moves to cover the larynx to prevent food from entering the air passages.

Paranasal sinuses and nasal cavity: The paranasal sinuses are small hollow spaces in the bones of the head surrounding the nose. The nasal cavity is the hollow space inside the nose.

Salivary glands: The major salivary glands are in the floor of the mouth and near the jawbone. The salivary glands produce saliva.

Head and neck cancer regions. Illustrates location of paranasal sinuses, nasal cavity, oral cavity, tongue, salivary glands, larynx, and pharynx (including the nasopharynx, oropharynx, and hypopharynx).

Credit: Terese Winslow

Cancers of the brain, the eye, the esophagus, and the thyroid gland, as well as those of the scalp, skin, muscles, and bones of the head and neck, are not usually classified as head and neck cancers.

Sometimes, cancerous squamous cells can be found in the lymph nodes of the upper neck when there is no evidence of cancer in other parts of the head and neck (1). When this happens, the cancer is called metastatic squamous neck cancer with unknown (occult) primary. More information about this cancer type can be found in Metastatic Squamous Neck Cancer with Occult Primary (PDQ®).

What causes cancers of the head and neck?

Alcohol and tobacco use (including smokeless tobacco, sometimes called “chewing tobacco” or “snuff”) are the two most important risk factors for head and neck cancers, especially cancers of the oral cavity, oropharynx, hypopharynx, and larynx (25). At least 75% of head and neck cancers are caused by tobacco and alcohol use (6). People who use both tobacco and alcohol are at greater risk of developing these cancers than people who use either tobacco or alcohol alone (68). Tobacco and alcohol use are not risk factors for salivary gland cancers.

Infection with cancer-causing types of human papillomavirus (HPV), especially HPV type 16, is a risk factor for some types of head and neck cancers, particularly oropharyngeal cancers that involve the tonsils or the base of the tongue (911). In the United States, the incidence of oropharyngeal cancers caused by HPV infection is increasing, while the incidence of oropharyngeal cancers related to other causes is falling (9). More information is available at the HPV and Cancer page.

Other risk factors for cancers of the head and neck include the following:

Paan (betel quid). Immigrants from Southeast Asia who use paan (betel quid) in the mouth should be aware that this habit has been strongly associated with an increased risk of oral cancer (1213).

Preserved or salted foods. Consumption of certain preserved or salted foods during childhood is a risk factor for nasopharyngeal cancer (1415).

Oral health. Poor oral hygiene and missing teeth may be weak risk factors for cancers of the oral cavity (1617). Use of mouthwash that has a high alcohol content is a possible, but not proven, risk factor for cancers of the oral cavity (1617).

Occupational exposure. Occupational exposure to wood dust is a risk factor for nasopharyngeal cancer (1415). Certain industrial exposures, including exposures to asbestos and synthetic fibers, have been associated with cancer of the larynx, but the increase in risk remains controversial (18). People working in certain jobs in the construction, metal, textile, ceramic, logging, and food industries may have an increased risk of cancer of the larynx (19). Industrial exposure to wood or nickel dust or formaldehyde is a risk factor for cancers of the paranasal sinuses and nasal cavity (2022).

Radiation exposure. Radiation to the head and neck, for noncancerous conditions or cancer, is a risk factor for cancer of the salivary glands (162324).

Epstein-Barr virus infection. Infection with the Epstein-Barr virus is a risk factor for nasopharyngeal cancer (25) and cancer of the salivary glands (2627).

Ancestry. Asian ancestry, particularly Chinese ancestry, is a risk factor for nasopharyngeal cancer (1415).

What are the symptoms of head and neck cancers?

The symptoms of head and neck cancers may include a lump or a sore that does not heal, a sore throat that does not go away, difficulty in swallowing, and a change or hoarseness in the voice. These symptoms may also be caused by other, less serious conditions. It is important to check with a doctor or dentist about any of these symptoms. Symptoms that may affect specific areas of the head and neck include the following:

Oral cavity. A white or red patch on the gums, the tongue, or the lining of the mouth; a swelling of the jaw that causes dentures to fit poorly or become uncomfortable; and unusual bleeding or pain in the mouth.

Pharynx. Trouble breathing or speaking; pain when swallowing; pain in the neck or the throat that does not go away; frequent headaches, pain, or ringing in the ears; or trouble hearing.

Larynx. Pain when swallowing or ear pain.

Paranasal sinuses and nasal cavity. Sinuses that are blocked and do not clear; chronic sinus infections that do not respond to treatment with antibiotics; bleeding through the nose; frequent headaches, swelling or other trouble with the eyes; pain in the upper teeth; or problems with dentures.

Salivary glands. Swelling under the chin or around the jawbone, numbness or paralysis of the muscles in the face, or pain in the face, the chin, or the neck that does not go away.

How common are head and neck cancers?

Head and neck cancers account for approximately 4% of all cancers in the United States (28). These cancers are more than twice as common among men as they are among women (29). Head and neck cancers are also diagnosed more often among people over age 50 than they are among younger people.

Researchers estimated that more than 65,000 men and women in this country would be diagnosed with head and neck cancers in 2017 (29).

How can I reduce my risk of developing head and neck cancers?

People who are at risk of head and neck cancers―particularly those who use tobacco―should talk with their doctor about ways that they may be able to reduce their risk. They should also discuss with their doctor how often to have checkups. In addition, ongoing clinical trials are testing the effectiveness of various medications in preventing head and neck cancers in people who have a high risk of developing these diseases. Descriptions of these clinical trials can be accessed by searching NCI’s list of cancer clinical trials. NCI’s list of cancer clinical trials includes all NCI-supported clinical trials that are taking place across the United States and Canada, including the NIH Clinical Center in Bethesda, MD.  For information about other ways to search the list, see Help Finding NCI-Supported Clinical Trials.

Information specialists from NCI’s Cancer Information Service (CIS) can also help people find clinical trials for the prevention of head and neck cancers. The CIS can be reached at 1–800–4–CANCER (1–800–422–6237) or by chatting with a cancer information specialist online through LiveHelp.

Avoiding oral HPV infection may reduce the risk of HPV-associated head and neck cancers. However, it is not yet known whether the Food and Drug Administration-approved HPV vaccines Gardasil®, Gardasil 9®, and Cervarix® prevent HPV infection of the oral cavity, and none of these vaccines has yet been approved for the prevention of oropharyngeal cancer. More information about these vaccines is in the NCI fact sheet Human Papillomavirus (HPV) Vaccines.

How are head and neck cancers diagnosed?

To find the cause of the signs or symptoms of a problem in the head and neck area, a doctor evaluates a person’s medical history, performs a physical examination, and orders diagnostic tests. The exams and tests may vary depending on the symptoms. Examination of a sample of tissue under a microscope is always necessary to confirm a diagnosis of cancer.

If the diagnosis is cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in an operating room), x-rays and other imaging procedures, and laboratory tests. Knowing the stage of the disease helps the doctor plan treatment.

How are head and neck cancers treated?

The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person’s age and general health. Treatment for head and neck cancer can include surgery, radiation therapy, chemotherapy, targeted therapy, or a combination of treatments.

People who are diagnosed with HPV-positive oropharyngeal cancer may be treated differently than people with oropharyngeal cancers that are HPV-negative. Recent research has shown that patients with HPV-positive oropharyngeal tumors have a better prognosis and may do just as well on less intense treatment. An ongoing clinical trial is investigating this question.

More information about treatment for specific types of head and neck cancers is in the following PDQ® cancer treatment summaries, which are available in patient and health professional versions, as well as in Spanish (the links below go to the patient versions in English):

The patient and the doctor should consider treatment options carefully. They should discuss each type of treatment and how it might change the way the patient looks, talks, eats, or breathes.

What are the side effects of treatment?

Surgery for head and neck cancers often changes the patient’s ability to chew, swallow, or talk. The patient may look different after surgery, and the face and neck may be swollen. The swelling usually goes away within a few weeks. However, if lymph nodes are removed, the flow of lymph in the area where they were removed may be slower and lymph could collect in the tissues, causing additional swelling; this swelling may last for a long time.

After a laryngectomy (surgery to remove the larynx) or other surgery in the neck, parts of the neck and throat may feel numb because nerves have been cut. If lymph nodes in the neck were removed, the shoulder and neck may become weak and stiff.

Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth; a dry mouth or thickened saliva; difficulty in swallowing; changes in taste; or nausea. Other problems that may occur during treatment are loss of taste, which may decrease appetite and affect nutrition, and earaches (caused by the hardening of ear wax). Patients may also notice some swelling or drooping of the skin under the chin and changes in the texture of the skin. The jaw may feel stiff, and patients may not be able to open their mouth as wide as before treatment.

Patients should report any side effects to their doctor or nurse, and discuss how to deal with them.

Where can I find more information about clinical trials for patients with head and neck cancers?

Clinical trials are research studies conducted with people who volunteer to take part. Participation in clinical trials is an option for many patients with head and neck cancer. Ongoing clinical trials are testing the effectiveness of treatments for head and neck cancers. Descriptions of these clinical trials can be accessed by searching NCI’s list of cancer clinical trials, which includes all NCI-supported clinical trials that are taking place across the United States and Canada, including the NIH Clinical Center in Bethesda, MD. For information about other ways to search the list, see Help Finding NCI-Supported Clinical Trials.Alternatively, call NCI’s Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) for information about clinical trials for individuals with head and neck cancer, or chat with a cancer information specialist online through LiveHelp.

People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available in the NCI publication Taking Part in Cancer Treatment Research Studies. This resource describes how research studies are carried out and explains their possible benefits and risks.

What rehabilitation or support options are available for patients with head and neck cancers?

The goal of treatment for head and neck cancers is to control the disease, but doctors are also concerned about preserving the function of the affected areas as much as they can and helping the patient return to normal activities as soon as possible after treatment. Rehabilitation is a very important part of this process. The goals of rehabilitation depend on the extent of the disease and the treatment that a patient has received.

Depending on the location of the cancer and the type of treatment, rehabilitation may include physical therapy, dietary counseling, speech therapy, and/or learning how to care for a stoma. A stoma is an opening into the windpipe through which a patient breathes after a laryngectomy, which is surgery to remove the larynx. The National Library of Medicine has more information about laryngectomy in MedlinePlus.

Sometimes, especially with cancer of the oral cavity, a patient may need reconstructive and plastic surgery to rebuild bones or tissues. However, reconstructive surgery may not always be possible because of damage to the remaining tissue from the original surgery or from radiation therapy. If reconstructive surgery is not possible, a prosthodontist may be able to make a prosthesis (an artificial dental and/or facial part) to restore satisfactory swallowing, speech, and appearance. Patients will receive special training on how to use the device.

Patients who have trouble speaking after treatment may need speech therapy. Often, a speech-language pathologist will visit the patient in the hospital to plan therapy and teach speech exercises or alternative methods of speaking. Speech therapy usually continues after the patient returns home.

Eating may be difficult after treatment for head and neck cancer. Some patients receive nutrients directly into a vein after surgery or need a feeding tube until they can eat on their own. A feeding tube is a flexible plastic tube that is passed into the stomach through the nose or an incision in the abdomen. A nurse or speech-language pathologist can help patients learn how to swallow again after surgery. The NCI booklet Eating Hints: Before, During, and After Cancer Treatment contains many useful suggestions and recipes.

Is follow-up care necessary? What does it involve?

Regular follow-up care is very important after treatment for head and neck cancer to make sure that the cancer has not returned, or that a second primary (new) cancer has not developed. Depending on the type of cancer, medical checkups could include exams of the stoma, if one has been created, and of the mouth, neck, and throat. Regular dental exams may also be necessary.

From time to time, the doctor may perform a complete physical exam, blood tests, x-rays, and computed tomography (CT), positron emission tomography (PET), or magnetic resonance imaging (MRI) scans. The doctor may monitor thyroid and pituitary gland function, especially if the head or neck was treated with radiation. Also, the doctor is likely to counsel patients to stop smoking. Research has shown that continued smoking by a patient with head and neck cancer may reduce the effectiveness of treatment and increase the chance of a second primary cancer.

Additional information can be found at NCI’s Follow-Up Medical Care page.

How can people who have had head and neck cancers reduce their risk of developing a second primary (new) cancer?

People who have been treated for head and neck cancers have an increased chance of developing a new cancer, usually in the head, neck, esophagus, or lungs (30–32). The chance of a second primary cancer varies depending on the site of the original cancer, but it is higher for people who use tobacco and drink alcohol (30).

Especially because patients who smoke have a higher risk of a second primary cancer, doctors encourage patients who use tobacco to quit. Information about tobacco cessation is available from NCI’s Cancer Information Service at 1–800–4–CANCER (1–800–422–6237) and in the NCI fact sheet Where To Get Help When You Decide To Quit Smoking. The federal government’s main resource to help people quit using tobacco is BeTobaccoFree.gov.The government also sponsors Smokefree Women, a website to help women quit using tobacco, and Smokefree Teen, which is designed to help teens understand the decisions they make and how those decisions fit into their lives. The toll-free number 1–800–QUIT–NOW (1–800–784–8669) also serves as a single point of access to state-based telephone quitlines.

Selected References

  1. Mendenhall WM, Mancuso AA, Amdur RJ, et al. Squamous cell carcinoma metastatic to the neck from an unknown head and neck primary site. American Journal of Otolaryngology 2001; 22(4):281–287.

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  2. Gandini S, Botteri E, Iodice S, et al. Tobacco smoking and cancer: a meta-analysis. International Journal of Cancer 2008; 122(1):155–164.

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  3. Hashibe M, Boffetta P, Zaridze D, et al. Evidence for an important role of alcohol- and aldehyde-metabolizing genes in cancers of the upper aerodigestive tract. Cancer Epidemiology, Biomarkers and Prevention 2006; 15(4):696–703.

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  4. Hashibe M, Brennan P, Benhamou S, et al. Alcohol drinking in never users of tobacco, cigarette smoking in never drinkers, and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Journal of the National Cancer Institute 2007; 99(10):777–789.

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  5. Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. The Lancet Oncology 2008; 9(7):667–675.

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  6. Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 1988; 48(11):3282–3287.

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  7. Tuyns AJ, Estève J, Raymond L, et al. Cancer of the larynx/hypopharynx, tobacco and alcohol: IARC international case-control study in Turin and Varese (Italy), Zaragoza and Navarra (Spain), Geneva (Switzerland) and Calvados (France). International Journal of Cancer 1988; 41(4):483–491.

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  8. Hashibe M, Brennan P, Chuang SC, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers and Prevention 2009; 18(2):541–550.

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  9. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. Journal of Clinical Oncology 2011; 29(32):4294–4301.

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  10. Adelstein DJ, Ridge JA, Gillison ML, et al. Head and neck squamous cell cancer and the human papillomavirus: summary of a National Cancer Institute State of the Science Meeting, November 9–10, 2008, Washington, D.C. Head and Neck 2009; 31(11):1393–1422.

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  11. Gillison ML, D’Souza G, Westra W, et al. Distinct risk factors profiles for human papillomavirus type 16-positive and human papillomavirus type-16 negative head and neck cancers. Journal of the National Cancer Institute 2008; 100(6):407–420.

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  12. Ho PS, Ko YC, Yang YH, Shieh TY, Tsai CC. The incidence of oropharyngeal cancer in Taiwan: an endemic betel quid chewing area. Journal of Oral Pathology and Medicine 2002; 31(4):213–219.

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  13. Goldenberg D, Lee J, Koch WM, et al. Habitual risk factors for head and neck cancer. Otolaryngology and Head and Neck Surgery 2004; 131(6):986–993.

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  14. Yu MC, Yuan JM. Nasopharyngeal Cancer. In: Schottenfeld D, Fraumeni JF Jr., editors. Cancer Epidemiology and Prevention. 3rd ed. New York: Oxford University Press, 2006.
  15. Yu MC, Yuan JM. Epidemiology of nasopharyngeal carcinoma. Seminars in Cancer Biology 2002; 12(6):421–429.

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  16. Mayne ST, Morse DE, Winn DM. Cancers of the Oral Cavity and Pharynx. In: Schottenfeld D, Fraumeni JF Jr., editors. Cancer Epidemiology and Prevention. 3rd ed. New York: Oxford University Press, 2006.
  17. Guha N, Boffetta P, Wünsch Filho V, et al. Oral health and risk of squamous cell carcinoma of the head and neck and esophagus: results of two multicentric case-control studies. American Journal of Epidemiology 2007; 166(10):1159–1173.

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  18. Olshan AF. Cancer of the Larynx. In: Schottenfeld D, Fraumeni JF Jr., editors. Cancer Epidemiology and Prevention. 3rd ed. New York: Oxford University Press, 2006.
  19. Boffetta P, Richiardi L, Berrino F, et al. Occupation and larynx and hypopharynx cancer: an international case-control study in France, Italy, Spain, and Switzerland. Cancer Causes and Control 2003; 14(3):203–212.

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  20. Littman AJ, Vaughan TL. Cancers of the Nasal Cavity and Paranasal Sinuses. In: Schottenfeld D, Fraumeni JF Jr., editors. Cancer Epidemiology and Prevention. 3rd ed. New York: Oxford University Press, 2006.
  21. Luce D, Leclerc A, Bégin D, et al. Sinonasal cancer and occupational exposures: a pooled analysis of 12 case-control studies. Cancer Causes and Control 2002; 13(2):147–157.

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  22. Luce D, Gérin M, Leclerc A, et al. Sinonasal cancer and occupational exposure to formaldehyde and other substances. International Journal of Cancer 1993; 53(2):224–231.

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  23. Preston-Martin S, Thomas DC, White SC, Cohen D. Prior exposure to medical and dental x-rays related to tumors of the parotid gland. Journal of the National Cancer Institute 1988; 80(12):943–949.

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  24. Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology 1997; 8(4):414–429.

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  25. Chien YC, Chen JY, Liu MY, et al. Serologic markers of Epstein-Barr virus infection and nasopharyngeal carcinoma in Taiwanese men. New England Journal of Medicine 2001; 345(26):1877–1882.

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  26. Hamilton-Dutoit SJ, Therkildsen MH, Neilsen NH, et al. Undifferentiated carcinoma of the salivary gland in Greenlandic Eskimos: demonstration of Epstein-Barr virus DNA by in situ nucleic acid hybridization. Human Pathology 1991; 22(8):811–815.

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  27. Chan JK, Yip TT, Tsang WY, et al. Specific association of Epstein-Barr virus with lymphoepithelial carcinoma among tumors and tumorlike lesions of the salivary gland. Archives of Pathology and Laboratory Medicine 1994; 118(10):994–997.

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  28. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA: A Cancer Journal for Clinicians 2017; 67(1):7-30.

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  29. American Cancer Society (2017). Cancer Facts and Figures 2017Exit Disclaimer. Atlanta, GA: American Cancer Society. Retrieved March 29, 2017.
  30. Do KA, Johnson MM, Doherty DA, et al. Second primary tumors in patients with upper aerodigestive tract cancers: joint effects of smoking and alcohol (United States). Cancer Causes and Control 2003; 14(2):131–138.

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  31. Argiris A, Brockstein BE, Haraf DJ, et al. Competing causes of death and second primary tumors in patients with locoregionally advanced head and neck cancer treated with chemoradiotherapy. Clinical Cancer Research 2004; 10(6)1956–1962.

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  32. Chuang SC, Scelo G, Tonita JM, et al. Risk of second primary cancer among patients with head and neck cancers: a pooled analysis of 13 cancer registries. International Journal of Cancer 2008; 123(10):2390–2396.

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Tests and Cancer

Tests and Cancer| Podcasts | Cancer Council NSW

Read full transcript Expert interviewed: Dr Lorraine Chantrill, Medical Oncologist The thing about cancer is that you need to have many tests to diagnose cancer, and see how you’re tracking during and after treatment. But there are many questions that may crop up before and after your cancer diagnosis, such as what’s the difference between all these tests?

Transcript of Episode 15: Tests and Cancer
The Thing About Cancer podcast, Cancer Council NSW

[Episode ID] 
You’re listening to Tests and Cancer, an episode of The Thing About Cancer podcast.

[Series intro]
[woman] The very essence of all cancers is a change in the way that cells divide.
[man] I remember sitting in there thinking, you know, it’s not happening, it’s not real, it can’t be real.
[woman 2] It’s something that we don’t talk about.
[woman 3] This feeling of being overwhelmed − it will get better once you have a plan and you know what to expect and what’s going to happen. It’s not going to be like this all the time.
[various voices] The Thing About Cancer: A podcast from Cancer Council NSW. Information and insights for people affected by cancer.


Julie McCrossin: Hello, I’m Julie McCrossin and today, the thing about cancer is that there are so many tests. It’s natural to wonder what the tests are for and if you need to have them all, and then there’s waiting for the results. 

Dr Lorraine Chantrill: So you may get an answer as to whether it’s cancer or not quite quickly but the oncologist might say, “Look, we know it’s cancer but we’re just still running a few more tests to see exactly what sub-type of lung cancer it is, or exactly what sub-type of breast cancer it is.” And I would implore you to be patient while that is done because it really helps us design our treatment better. 

Julie: That’s Dr Lorraine Chantrill, a medical oncologist from the Kinghorn Cancer Centre at St. Vincent’s Hospital in Sydney. To help plan treatment, Lorraine has ordered many tests. In a moment she’s going to talk about what tests you might need, and in the second half of the episode she’ll explain how these tests help guide cancer treatment. 

Just to be clear this podcast contains general information only so we recommend that you talk to appropriate professionals about your individual situation. You can also call Cancer Council 13 11 20 if you have any questions. 

We’ll hear more from Lorraine in a moment, but first here’s Phil talking about the tests he had before he was diagnosed with cancer. 

Phil: Went for a check-up because I was tired, I couldn’t walk up hills anymore. The GP put me through all the tests, he said, “Look everything is perfect, you’re really healthy, you’re really, really fit. Let’s just do some blood tests. Within a few days we’ll get the results.” I say, “Sure.” He phoned me the next day and he said, “We have a problem.”

Julie: At the start of this episode, oncologist Lorraine Chantrill spoke about how tests take time and the importance of being patient. And it’s my pleasure to welcome Lorraine now to the podcast. So Lorraine, often the very first thing that happens to you if a doctor suspects you may have cancer is that you have a test. To prepare for these tests are there two or three basic questions to ask first?

Lorraine: Yes, I think so. I think you can ask: Why do I need this test? Is this test really important and urgent? And is there anything special I should know about this test? Is there any preparation that I should have to have to do this? And when will I get the results, and will I be able to talk about the results with you personally? 

Julie: Just before we hear about each of the tests and what’s involved, why are there so many different tests? 

Lorraine: There are a lot of tests. Sometimes more than others. But it’s very important for the treating oncologists to know exactly what the cancer is and where it is. That makes an enormous difference to our treatment plan.

Julie: So each test is giving you different kinds of information and different clues as to what may be happening for the patient?

Lorraine: Yes, that’s right. In some cases different types of tests need to be ordered. So, pancreas cancer is actually quite a good example because often on a regular CT scan we don’t see the tumour very well and sometimes we have to do something like an MRI scan. 

Julie: So for each kind of cancer is there a common sequence of testing that you would do?

Lorraine: More or less yes, but it’s always individualized for the person sitting in front of you. And that might change, for example, if the person who I’m seeing is an elderly person who has kidney failure, then the sort of tests I would order would be very careful because I wouldn’t want to affect their kidneys with the contrast, for example. So yes there’s a kind of a standard list of tests but it is modified for each cancer and then modified for each person. 

Julie: And then again modified depending on what you find?

Lorraine: That’s exactly right. So the findings will dictate the next step. Hopefully in most cases we’re able to do one, two or three tests and get the final answers, but you’re right, there are some situations in which we have to keep doing tests until we find the answer.

Julie: Well, now let’s talk about the most common tests that you’re likely to get, and they seem to be a mixture of blood tests and then the use of various kinds of technology. Can we just run through the most common tests someone with a cancer diagnosis is likely to experience during the journey?

Lorraine: You’re right, Julie, in that blood tests are very commonly done and most of the blood tests are really just a sort of a screening to check what the liver function is, what is the kidney function, are there any abnormalities in the way the bone marrow is producing red cells, white cells and platelets. There are some cancer-specific tests that we do. So those we call “tumour markers” and they’re very specific to certain cancers.

Julie: Could you just explain that term “tumour marker”?

Lorraine: It’s a complicated thing, and the best example I can give you is a tumour marker that is used routinely in the monitoring of bowel cancer. Most bowel cancers but importantly not every one of them, produce a tumour marker which is shortened to CEA. And that stands for carcinoembryonic antigen. That test is used to monitor people after they’ve had curative treatment for bowel cancer, but we also use it in the monitoring of people with advanced or stage 4 bowel cancer to monitor their treatment to see if their treatment is working, but it is not foolproof. We don’t actually have any markers that are foolproof.

Julie: Well we’ve talked about blood tests, just before we come to the scans, there’s also the biopsy. If you get a new diagnosis, there’s often a biopsy. What’s that?

Lorraine: A biopsy is literally obtaining a small piece of the cancer tissue in order for it to be looked at under the microscope. We get a lot of information from biopsies. Now it’s important to know that the biopsy can be of the primary site – that is, where the cancer is originating. Sometimes it’s easier to get a biopsy from a metastatic site, which is where that cancer has spread to. The pathologist looks at those biopsies under a microscope and can give us information about what type of cancer it is. And the other thing the pathologist is able to do now – and more and more so now – is look at molecular markers within that biopsy, which again helps us subdivide the cancers into increasing number of subgroups for each cancer.

Julie: Well look let’s turn now to the most common scans – the CT, the MRI and the PET scan – and get a sense of what each involves for the patient and their purpose. 

Lorraine: The commonest test to have done is probably a CT scan. CT stands for computed tomography. What it means is it’s a very careful scan where you lie on a table. And I say to people it’s a bit like being a loaf of bread and having sort of virtual slices along the loaf of bread and then what we do is turn those bread slices up and we’re able to look at your body in cross-section.

Julie: And when you say it’s virtual slices, these are slices like slices of pictures, aren’t they?

Lorraine: Yes, it’s like taking a 3D photograph of the inside of your body. Usually we do have to administer some intravenous contrast into a vein and sometimes some oral contrast, which you drink. A lot of people do find the contrast a bit unpleasant, and by that I mean the contrast can make people feel a bit hot, a little bit weird, and if that’s all that happens, that’s not dangerous, but there are a very small number of people who do have an allergy to contrast. And if you do have an allergy to contrast it’s very important that you tell your medical staff and the radiology practice.

Julie: And what’s the purpose of the contrast? What does it do?

Lorraine: So the contrast enables the radiologists to differentiate different structures. So the oral contrast is taken by mouth and coats the bowel and the stomach in contrast so that it can easily be separated from the other tissues around it where the contrast isn’t. If you have intravenous contrast, most CT scans will have that, then of course that contrast is in the blood vessels, and so again it allows the blood vessels to be differentiated on the pictures from other structures around them. 

Julie: So that’s the CT scan, let’s turn to an MRI – magnetic resonance imaging. How does that work?

Lorraine: So an MRI is a more complicated test. MRI uses a big magnet so if you’re going to have an MRI scan, the MRI team will ask you a lot of questions about previous treatments you might have had or whether you’ve been involved with any injuries that involved metal. They even may ask about shrapnel injuries, because if you have metal in the place of the body that is going to be in the MRI scanner – because the MRI is a magnet that could present some danger to you. That’s why you get those weird questions about metal implants.

Julie: So, what information does it give you and how do you go about having that test with the magnet?

Lorraine: So it gives you very, very accurate information about soft tissue and can also be done for some bone studies as well. It’s just a very, very accurate way of looking at that tissue. Generally speaking, MRI scanning is not used for the whole body. It would be true to say that the most common part of the body where an MRI is very important is the brain. The other part that’s commonly requires MRI for assessment is the spine. So it really depends on the part of the body as to whether an MRI is required or not.

Julie: And what does it involve for the patient, what does the machine look like, what do you do?

Lorraine: Yeah, so again, it’s quite a big machine. You lie on a metal table and the machine is like a really big doughnut and it spins around you. Now MRI can take a little time and it involves being in quite a small space, so some people with claustrophobia do find an MRI quite challenging. We do have some solutions for that problem. We do sometimes use short-acting sedatives to relax the patient. The staff, however, who do MRIs are very skilled at getting people to relax and they might do exercises like counting to help people relax to have the scan.

Julie: And now let’s talk about PET scans. I understand that PET – P-E-T stands for positron emission tomography. What do these scans involve?

Lorraine: A PET scan is a very special sort of scan and available now in most cancer centres, but not all – sometimes people have to travel for a PET scan. There are a few different types of PET scans but the commonest one is actually a glucose PET scan. So we inject into the person radiolabelled glucose. Cancer cells divide faster than any other cells in your body and so they take up glucose very avidly, and that shows up as being very bright on the pictures that are taken after the PET scan.

Julie: And what are PET scans used for?

Lorraine: It’s very, very useful in a number of situations and very sensitive at detecting cancer that’s spread outside of the primary site – that’s the main reason we use it. Mainly it’s before a big surgical procedure we want to do a PET scan – to make sure that before we do a big surgical procedure, for example, like removing a lung for lung cancer, we’ll want to make absolutely certain that there’s no cancer outside of that space, because if there is, then doing that really big surgery may not be the right thing to do

Julie: And are there risks involved when you’re having scans or x-rays? 

Lorraine: So in the case of PET scans, the stuff that’s injected is radioactive. But in the case of CT scans the contrast is not radioactive, where you’re receiving a radiation dose is from the x-rays that make the pictures. So yes, there is a theoretical danger to having too many x-rays but the number of x-rays you require to have a dangerous level is enormous and most cancer patients throughout the course of their treatment do not reach those dangerous levels. And the tests are getting better all the time and they’re quicker and the dose of radiation to a person received during a test is actually getting smaller.

Julie: And from the patient perspective, I’m a cancer survivor myself and I’ve had a few PET scans, I’ve noticed the person injecting the contrast is behind a lead screen. And I just think that’s worth mentioning because that is a slightly confronting thing – that the person administering it needs to be protected from the substance that’s going into your body. So can you explain why that’s necessary?

Lorraine: Yes, absolutely. So the glucose that is injected into you is radiolabelled, which means it’s radioactivity. And it’s this radioactivity which is taken up by those fast-dividing cells and which lights up on the photographic film later when the photos are taken of your body. So it does involve radioactivity, which is precisely why we’re very careful about when we order PET scans. The reason why the person who’s administering the contrast wears a lead apron is that they’re doing many of these every day of the week, and their exposure over many years might be quite high and we want to make sure that we protect staff against any radiation exposure. But for a patient who’s having a single PET scan, the danger to them is almost zero – not completely zero, but almost zero. 

Julie: And what about x-rays? Are they relevant when we’re talking about cancer?

Lorraine: So, x-rays are relevant, but there are a lot more sophisticated imaging techniques that we’ve talked about that give a bit more information. But x-rays are occasionally used, yes, particularly for bones. For example, if someone had a cancer like prostate cancer or breast cancer that might have gone to the bones and we want to check and see what’s happened to that bone and whether there is any possible fracture, then an x-ray would actually be the best test. Chest x-rays can be a good screening test for lung cancers, but generally speaking we prefer what we call a low-dose CT scan to look at lungs.

Julie: And what about ultrasounds, how are they different?

Lorraine: Ultrasound is different altogether, and the big advantage of ultrasound is that it’s non-invasive and it just involves using sound with a probe that’s run over the skin. Ultrasound is very useful at looking at ovaries, which are deep inside the abdomen. We also do use ultrasound to guide us in some of our cancer treatments and therapies. For example, some people with cancer do develop fluid in their abdominal cavity, and we will use an ultrasound to guide were we put a needle to drain that fluid. So there are a number of situations were ultrasound might be your preferred test.

Julie: What are the skills of the people who are doing all these tests for us and what are they called? And then who interprets the scans?

Lorraine: Yeah, so the people who are doing the tests are the radiographers in the radiology facilities. Radiologists are people who are skilled at looking at the scan results and interpreting them for us. 

Julie: There’s a lot of waiting, waiting to have the tests, then waiting for results, all this waiting can make people really anxious. What’s your basic advice to people who are finding this waiting difficult?

Lorraine: I would say, tell us. Call the cancer care coordinator and tell them that you’re really anxious about waiting for the scan and you’d really like some information. It may be possible to bring your appointment forward. It may even be possible for the doctor to call you if you’re happy with that. So just tell someone because we may be able to help you. 


Julie: You’re listening to The Thing About Cancer, a podcast from Cancer Council NSW. I’m Julie McCrossin and I’m talking to medical oncologist Lorraine Chantrill about the different tests you have when doctors are investigating if you have cancer. If you have any questions about this topic, or just want to talk to someone about your concerns, you can Cancer Council 13 11 20.

And for links to any of the resources or services we mention – or to listen to more podcasts – visit cancercouncil.com.au/podcasts and click through to this episode, Tests and Cancer.

We’ll return to Lorraine in a moment, but first we’re going to hear from Matt who talks about how he coped with the anxiety of waiting for test results. 

Matt: The experience of doing some of these tests was another point of fear. There’s a lot of waiting around and I use that to read up fact-based material on the internet. So not so much people’s personal experiences because they’re well-meaning but I’m not sure that their emotional reactions were going to be the same as mine. But certainly the fact-based material on the web I found very useful to just helping manage my fear about what was about to happen. 


Julie: So Lorraine, it often takes quite a long time before the results come through. Why is that, what’s happening? What does it take so long, because it can be a time of, well, considerable distress to the family and patient?

Lorraine: Yes I agree, and in an ideal world it really shouldn’t take that long. So, yes, some tests we should receive results very quickly. So a chest x-ray, for example, would be reported very quickly, and most CT scans are reported fairly quickly. PET scanning may take 24–48 hours to report, but the thing that probably does take time is actually biopsy reporting. So what happens first is that the pathology department takes the piece of tissue and they embed it into paraffin. So they actually fix it in formalin and then embed it in paraffin. This is a way of preserving the tissue. They then take tiny, tiny slices of that paraffin embedded tissue and they examine it under the microscope after staining it.

Julie: And what is staining?

Lorraine: So staining is using antibodies to attach to the surface of the cell and then applying a colour to those antibodies so that we can see whether the protein of interest is present or not. So as you can imagine, if you need to do several of those, it will take time. Now the number of stains that are done, depends on the cancer type and what we’re looking for exactly. And more and more so, we’re also doing some molecular tests on biopsy tissue. 

Julie: And what can those molecular tests tell us?

Lorraine: So probably one of the most common examples now is in lung cancer. So if a person has a diagnosis of adenocarcinoma of the lung, a special type of lung cancer, we will then routinely look for mutations within that tumour tissue. And if a mutation is present in a gene called the EGFR gene, that will determine treatment. And that takes a little time too. So you may get an answer on whether or not it’s cancer quite quickly, but the oncologist might say, “Look, we know it’s cancer but we’re still just running a few more tests to see exactly what sub-type of lung cancer it is, or exactly what sub-type of breast cancer it is.” And I would implore you to be patient while that is done because it really helps us design our treatment better.

Julie: Really, you have to trust that the team is working as quickly as possible to work out the best possible treatment and that they’re keen to get you into treatment as quickly as possible, but some things take time.

Lorraine: That’s right, and usually a few days is not going to make a big difference. There are some exceptions and when there are exceptions we really do hurry people along and go down to the pathology lab and put our head over the shoulder of the pathologist. So there are situations in where we really do rush through results, but most of the time that’s not necessary.

Julie: The reality is though, isn’t it, the system is so busy and you’re dealing with so many different aspects of patient care, sometimes we’re probably waiting for the doctor or clinician to be free to talk it through with us – because a little bit of information without a personalised explanation could just generate more anxiety.

Lorraine: You’re right, but if you communicate your anxiety to your treatment team, they will try and accommodate that as much as they can.

Julie: Let’s come to some practical issues around tests and scans – it goes to consent and money, I suppose. Let’s start with consent. Should you always consent when a doctor suggests a test? 

Lorraine: No, I don’t think you have to. So if you feel uncomfortable about the test that is being suggested or ordered, you need to voice your concerns, because in fact we can’t do anything to you without your consent. So if you really do not want the test, you need to let us know so that we can try to explain why we think the test is necessary, and usually after an explanation most people accept that that’s reasonable. But you may have special reasons why you don’t want to have the test and maybe we can think of other ways of investigating the problem.

Julie: So speak up if you’re concerned, is that what you’re saying?

Lorraine: Yes, yes. But for interventions, Julie, but for a biopsy, it’s very important that we get consent because something like a biopsy could have possible adverse effects or side effects, so it’s very important that you know about those before you embark on the biopsy so you’re aware that things can go wrong.

Julie: Let’s just turn to the financial side. Are there financial issues that people need to be aware of, whether they’re a public or private patient, can that influence what tests you’re offered or what tests you may ask for?

Lorraine: Yes, sometimes, not always. So most tests are required for cancer diagnosis and staging are covered by Medicare, and if you’re being treated in a public institution, generally speaking, you won’t pay anything. There are some tests, however, that are not covered by Medicare. Usually there is good reason for that actually, but occasionally if I really want a test that does not happen to be covered by Medicare for that patient, the first thing I’ll do is ask the radiology department, could you possibly do it for this patient if there’s reason that the patient can’t pay? And often they will do it for me compassionately. Sometimes there is a cost for tests that are not approved by Medicare.

Julie: Can you give us an example?

Lorraine: The best example of this is probably some MRI scans where a surgeon is trying to get some very specialised information. If you’re in a public hospital, that will be done and you won’t pay for it, but if you’re an outpatient and you’re seeing a specialised surgeon and they want a test that is more than the standard, you might be asked to pay for it. There are some PET scans that don’t fall under Medicare, and again I often manage to get those compassionately, but there are rare cases were people have to pay for them, and PET scans might be as much as $900 depending on where it’s done. So yes there are sometimes costs but if a test is ordered that you can’t pay for, please talk to the doctor who’s ordering the test, because they may have other ways of doing it.

Julie: It’s very interesting, isn’t it, that that notion of compassionate provision is still within our current system?

Lorraine: I think particularly for people with cancer, whether that’s right or wrong, but ah, I order tests and so, you know, I order hundreds of tests that are completely reimbursed in that situation. The radiologist is very nicely saying we can do one or two compassionately and that’s fine. 

Julie: You’ve already mentioned the possible side effects of tests, but are there any general messages about risks that people should be aware of?

Lorraine: Yes, so I would say in general the government and the guidelines are really encouraging us to do less tests. Partly because of radiation exposure to patients, but also partly because of cost to our community. So that’s the first thing to say, we try not to do them unnecessarily. Secondly, as I mentioned earlier, allergy to contrast is not common but can happen, and it’s very important that if you have an allergy to contrast that that be carefully documented and sometimes people even wear a medi-alert with that on it. Other than that, I think the amount of radiation exposure from each scan is very, very small and is getting smaller as our technology is getting better and scans can be done quicker with less exposure. So the risks are actually getting less, not more, with time.

Julie: And what about pacemakers?

Lorraine: That’s a good question. So the situation where pacemakers are important is in the MRI scanning. So it depends on the material that the pacemaker is made from. So most people who have a pacemaker or indeed any metal object in their body will have some sort of identification of that metal and that needs to be provided to the team if an MRI is ordered. CT scans and x-rays can be done with pacemakers in situ, but they just distort the images a little bit.

Julie: Are there any other conditions that carry risk? I’m thinking of pregnancy, in particular?

Lorraine: Yeah, so, generally speaking, any x-rays or scans should be avoided in pregnancy because of the remote chance of there being some damage to the fetus from the radiation exposure. However, again, that dose is tiny and there are some very special situations where scanning may be required in pregnancy. But, generally speaking, it’s avoided. Ultrasound is safe in pregnancy.

Julie: And diabetes? 

Lorraine: If you’re diabetic then we try to time the scans so that you’re not too much put out with your diabetic medications. So in some scans where fasting is required, we might actually ask the patient not to have their diabetes medicine that morning if they have been fasting. There is an issue with diabetes and PET scanning because PET scanning relies on glucose metabolism. So if you’re a diabetic and you’re having a PET scan, you just need to let the team know, again because you may need to modify or stop your diabetic medications.

Julie: I just want to turn to children. Are there some particular issues for children, both in terms of the nature of the tests, but also in assisting them to cope with the experience?

Lorraine: Absolutely. I think, in principal, the same process is undertaken for diagnosis of children’s cancer but you’re absolutely right, children need special care and assistance when having these tests. Sometimes, depending on the age of the child, sometimes in fact an anaesthetic is required for some of these tests, but the specialist will advise if that’s needed.

Julie: Let’s turn now to staging – the process of working out whether the cancer has spread and, if so, how far. You often hear about TNM. I understand T is for tumour, N is for nodes and M is for metastasis, but what does it all mean?

Lorraine: Staging really applies to all cancers but the staging systems are slightly different depending on the cancer that you have. But very broadly, staging is divided into the tumour stage, the lymph node stage and then the metastatic stage. So the tumour stage is essentially the measurements of the tumour in the primary site and whether it’s kind of gone through the area where it started. Nodal stage is looking at lymph nodes that are nearby the tumour and seeing whether any of those lymph nodes have cancer within them. Most but not all cancers tend to go to lymph nodes first. And then metastatic stage is distance spread. What that means is that the cancer cells have had to go through the blood system usually and landed somewhere distant. So we shorten that staging system to TNM. And we have different numbers for each T, each N and each M. So that’s the staging system and that determines what our treatment should be.

Julie: And there’ll be people listening to this who are frantically riffling through a file to look for their staging right now, and so I guess, I’m someone who’s had a stage 4 cancer, it’s important isn’t it to say you can have numbers that aren’t great and still survive?

Lorraine: Absolutely you can, that’s right. So I don’t think you should hang too much on it, it’s just a way of us labelling things. I think that’s probably the best way of thinking of it.

Julie: And are the tests and scans heading towards that staging?

Lorraine: Exactly, the purpose of the tests and scans and the biopsy is to make that stage for you.

Julie: Often when you have a test, the people hand you something. Sometimes it’s a disc, sometimes it’s a bit of paper – do you always take what you’re given to your next appointment?

Lorraine: You should do, although increasingly now these scans are available electronically to your medical practitioner, so you may not be given anything and that’s okay because presumably your doctor can access those scans on your computer. But if they do give you something like a disk or envelope, a large envelope with films in it, yes, please take them to your doctor.

Julie: I must say, as a cancer patient, what I learned was despite the use of computers and electronically messaging in many other industries, health still has a lot of disconnection and incompatibility or interoperability is not there, is the language I learnt. So I ended up having a list of all my medications with the date, all the relevant medical issues, the sort of things you’ve been describing, whether I have metal in me or other diagnoses and so on. And I took them, multiple copies of them to every appointment I went to, because you were never sure if the person had all your information or if they’d got it yet.

Lorraine: I think that’s very sensible and I would concur with what you did. I think that’s a very good idea because if they don’t need it, no harm done, but if they do need it, you’ve got it right there. And I do meet some very, very organised patients like yourself who have all their information in a folder, and they often find it very helpful to themselves as well as to the practitioners they’re seeing. If you’re having your treatment in one centre, we hope that all the information will be available to the people treating you within that centre. But especially when you go from that centre to another place, I think it’s very important to take the information with you.

Julie: We’ve already mentioned that at various points along the cancer treatment journey, as we often call it, that you may have other tests to check how everything’s going. But tests aren’t always perfect, are they? Can you tell us what we need to face up to as patients, which is that you are diligent professionals doing your best, but you’re on an investigative analysis, aren’t you?

Lorraine: Yeah, tests are not perfect, you’re absolutely right. They’re not perfect for lots of reasons. The best example I can think of, is that in cancer medicine, particularly in cancers of the gastrointestinal tract that I treat, we’re often faced with a situation where cancer has spread to the peritoneal cavity or the abdominal cavity and disease in that cavity is notoriously difficult to see on scans. It can be very hard to see and it’s not until the surgeon actually looks inside the abdominal cavity with a laparoscope or with an operation that the disease becomes visible. So that’s a good example of a test that is not perfect. And as I mentioned earlier, the tumour mark or a blood test, they’re really not perfect at all, they’re not that specific. So yes, we do have to qualify what we say about tests and scans with that knowledge that they’re not 100%.

Julie: Which brings me really to one of my closing points, which is one of the key skills as a cancer patient that I felt like I learnt was: we have to learn to live with ambiguity. We have to learn to communicate constantly with our team two-way and we have to learn to live with ambiguity because we’re on this journey of discovery and treatment and hopefully survival and recovery together. 

Lorraine: Yes, as doctors we also need to express sometimes that we just don’t know. And I think it’s very useful for doctors to communicate that to their patients to explain exactly why it is that they don’t know. Sometimes I don’t know the answer but I have a plan for how we’re going to work it out. 

Julie: And that you’ll stay with us. 

Lorraine: Yes, that’s right.

Julie: That’s really important that you know we’re in this together and I will stay with you and sort this out. 

Lorraine: Yes, exactly.


Julie: That’s it for this episode of The Thing About Cancer. Thanks to Lorraine, Phil and Matt for sharing their insights. If you’re looking for more information, you can ring Cancer Council 13 11 20 Information and Support service from anywhere in Australia. Or go to cancercouncil.com.au/podcasts. If you have any feedback on this episode, we’d love to hear from you, so leave us a review on iTunes or on our website. If you’d like to subscribe to the show, you can do it in Apple Podcasts or your favourite podcasting app. 

If you found this episode helpful, you might want to listen to our podcast on making treatment decisions. In that episode, I talk to practising GP and Professor of Primary Healthcare at the University of Sydney Lyndal Trevena about how to decide on the best cancer treatment for you. 

Lyndal Trevena: One of the things often weighs on people’s minds at that time and later on is, did I make the right decision? And I think you can be satisfied that you have if you’ve done your best to get all the information, consult all the right people, weigh it all up, and that’s the best you can do at that time. So do that, do that when you have the opportunity, and then don’t look back.

Julie: You can find that episode Making Treatment Decisions on our website at cancercouncil.com.au/podcasts. 

The stories and experiences contained in this podcast represent the views and opinions of the speakers. They do not necessarily represent the views and opinions of Cancer Council NSW. This podcast contains general information only, and Cancer Council NSW recommends you obtain independent advice specific to your circumstances from appropriate professionals. 

I’m Julie McCrossin and this has been The Thing About Cancer, a podcast from Cancer Council NSW. 

[Music fades out]

Tests for Head and Neck Cancers

This was originally published by the Cancer Council here.

In this section we look at the different tests you may have to see if you have a head and neck cancer.

Learn more about these tests for head and neck cancers:

  • Physical examination
  • Nasendoscopy
  • Laryngoscopy
  • Biopsy
  • Imaging tests

Physical examination

Depending on your symptoms, the doctor will examine your mouth, throat, nose, neck, ears and/or eyes. They may use a thin wooden tongue depressor to see inside the mouth more clearly. The doctor may also insert a gloved finger into your mouth to feel areas that are difficult to see, and gently feel both sides of your neck to check your lymph nodes.

The doctor may use equipment to see some areas of the head and neck, such as the nasopharynx, tongue base and pharynx.


In this procedure, your doctor examines the nose and throat area using a thin flexible tube with a light and camera on the end. This device is called a nasendoscope. Before the nasendoscope is inserted, a local anaesthetic is sprayed into the nostril to numb the nose and throat.

You may find that the spray tastes bitter. The doctor will gently pass the nasendoscope into one of your nostrils and down your throat to look at your nasal cavity, nasopharynx, oropharynx, hypopharynx and larynx. Images from the nasendoscope may be projected onto a screen. This test may feel uncomfortable, but should not hurt.

You will be asked to breathe lightly through your nose and mouth, and to swallow and make sounds. The doctor may also take tissue samples (biopsy). A nasendoscopy usually takes a few minutes. If you need a biopsy, the test may take longer. You will be advised to not have any hot drinks for about 30 minutes after the procedure, but you can go home straightaway.


This procedure allows the doctor to look at your throat and voice box, and take a tissue sample (biopsy). The doctor inserts a tube with a light and camera on the end (laryngoscope) into your mouth and throat. The camera projects images onto a screen. The procedure is done under a general anaesthetic and takes 10–40 minutes. You can go home when you’ve recovered from the anaesthetic. You may have a sore throat for a couple of days.

A bronchoscope is similar to a laryngoscope, but it allows doctors to examine the airways to see if cancer is present in the lungs. The tube (bronchoscope) is inserted into the lungs via the mouth and throat. This may be done under a local or general anaesthetic.

Head & Neck Cancer Screening Guidelines

This resources was original published by Memorial Sloan Kettering Cancer Center here.

The term “head and neck cancer” encompasses a wide range of tumors that occur in several areas of the head and neck region, including the nasal passages, sinuses, mouth, throat, larynx (voice box), swallowing passages, salivary glands, and the thyroid gland. The two major known risk factors for head and neck cancer are exposure to tobacco and heavy use of alcohol. A type of cancer of the head and neck known as head and neck squamous cell carcinoma (HNSCC) is a relatively uncommon disease, with 40,000 new cases and 10,000 deaths estimated in 2008 in the United States. Twenty-five percent of HNSCCs harbor human papillomavirus (HPV), a commonly occurring virus that may play a role in the development of head and neck cancer. Non-squamous cancers of the head and neck — which include tumors of the thyroid, skin adnexa, salivary glands, sarcomas, and lymphomas — are even more uncommon.

Head and Neck Cancer Risk – High-Risk Groups

Heavy exposure to tobacco and heavy use of alcohol are well documented as major risk factors for head and neck cancer. In addition, patients cured of HNSCC have an approximately 10 percent risk of developing second primary cancers of the head and neck at five years after treatment. Individuals with a premalignant lesion in the mouth known as dysplastic oral leukoplakia have an almost 30 percent risk of oral cancer at ten years after treatment. Individuals with the following diseases and syndromes are at increased risk for head and neck cancer: Fanconi anemia, a rare, inherited disease in which the bone marrow fails to function properly; Li-Fraumeni syndrome, a rare, inherited disorder that greatly increases the risk of developing several types of cancer; and Plummer-Vinson syndrome, a disorder characterized by long-term iron deficiency anemia, which causes swallowing difficulty.

Head and Neck Cancer Screening Tests

Currently, there are no screening methods that have been proven to increase survival rates for HNSCC. A screening physical examination of the neck, oropharynx (the middle section of the throat that includes the soft palate, the base of the tongue, and the tonsils), and the mouth has been widely adopted as part of a routine dental examination. However, there is no evidence that this intervention reduces mortality from oral cancer. It is likely that in the coming decades this routine screening will allow earlier identification of oral cancer, when it is in a less advanced form, but this has yet to be proven in clinical studies.

At Memorial Sloan Kettering Cancer Center, we offer yearly free head and neck screenings in the spring to anyone in the community. These screenings provide an opportunity to educate interested patients on awareness of oral cancer and its risk factors.

There are no HNSCC screening guidelines from the American Cancer Society, the National Comprehensive Cancer Network (NCCN), or the National Cancer Institute. And, at present, there are no known tests of blood or saliva proven to be effective for detection of HNSCC.

Our Head and Neck Screening Guidelines

Our doctors advise that all individuals have a yearly physical examination of the head and neck and oropharynx (the middle section of the throat that includes the soft palate, the base of the tongue, and the tonsils) conducted by their primary care physician, as well as a yearly routine dental evaluation to include examination of the neck and inspection of the oropharynx and the mouth.

Our Screening Guidelines for High-Risk Patients

For high-risk patients cured of HNSCC, our doctors use the NCCN’s follow-up guidelines outlined below to look for both recurrence of the initial cancer and second primary cancer formation.

Physical exam

  • Year One: every one to three months
  • Year Two: every two to four months
  • Years Three to Five: every four to six months
  • Year Five and Beyond: every six to 12 months

Chest x-ray annually

If an individual has received radiation treatment of the thyroid, then a TSH thyroid function test should be performed annually.

For high-risk patients with surgically unremovable or recurrent dysplastic oral leukoplakia, our doctors recommend observation on the same schedule as above and biopsies for suspicious changes in the lesions. These patients are also sometimes eligible to be enrolled in prospective clinical trials in head and neck cancer prevention at Memorial Sloan Kettering.

Overview: Head & Neck Cancer

Head and Neck Surgeon, Dr. Namou Kim provides and important overview of what to expect with Head and Neck Cancer

Identifying Biomarkers Gives Doctors Known Targets to Treat Many Cancers

This blog was originally published by Cancer Treatments Centers of America on August 21, 2019, here.

Doctors are increasingly relying on biomarkers, which help determine a patient’s overall health and/or the presence of disease. Learn what biomarkers are and why they are increasingly important in cancer care.

When faced with opposition, it’s beneficial to learn as much as possible about the opponent. A pitcher reads a scouting report before facing a lineup. An army consults intelligence before engaging the enemy in battle.

The same principles apply to the treatment of some cancers. When treating a tumor, it’s important for a doctor to know as much as possible about that cancer—specifically, what is driving the tumor’s growth.

To get the inside information on a tumor, doctors are increasingly relying on biomarkers, short for biological markers, measurable signs or substances in the body that may indicate a patient’s overall health and/or the presence or progression of disease.

The discovery of biomarkers in cancer drastically changed the course of cancer treatment. For decades, many cancers were treated similarly, with surgery, radiation therapy or chemotherapy. Identifying biomarkers in cancer cells has led to the development of new precision medicine drugs, such as targeted therapy and immunotherapy, designed to target specific features in cancer cells, potentially reducing the damage to healthy cells. “The routine use of a variety of biomarkers has substantially changed the way in which cancer medicine is practiced,” says Maurie Markman, MD, President of Medicine & Science at Cancer Treatment Centers of America® (CTCA), “from providing more accurate prognostic information to assisting in the prediction of specific therapeutic strategies that are more likely to result in a favorable outcome for an individual patient.”

What are biomarkers?

A biomarker is any measurable indicator of a person’s health. Blood pressure is a biomarker, as are body temperature, blood sugar and cholesterol measurements. In cancer, biomarkers also include proteins, hormones, gene aberrations, such as mutations or rearranged genes, and other molecules found in or on cancer cells. Cancer biomarkers may be found in routine blood, urine or stool tests. Others may require a biopsy and/or advanced genomic testing to uncover. “Genomics has made it so much easier to find gene mutations,” says Arturo Loaiza-Bonilla, MD, MSEd, FACP, Vice Chair for the CTCA® Department of Medical Oncology. “Now we may be able to target a mutation and potentially get the cancer to stop growing.”

Biomarkers play multiple roles in the treatment of diseases, such as cancer, including:

Diagnostic: Helping confirm the presence of disease, sometimes before symptoms develop

Prognostic: Helping forecast the progression and aggressiveness of the disease and the risk of recurrence

Predictive: Helping doctors identify how patients may respond to certain drugs

Biomarkers may play any or all these roles and more. Some biomarkers may be used to assess a patient’s risk of developing disease, the effectiveness of a treatment or whether a treatment is safe or toxic.

Common cancer biomarkers include:

  • BRCA1 and BRCA2 genes: Mutations in these genes may increase a woman’s risk of breast and ovarian cancer. In men, it may increase the risk of prostate cancer.
  • PSA: Prostate specific antigen may indicate prostate cancer. This biomarker may be used not just to diagnose the disease, but to measure its progression and how the treatment is performing.
  • HER2: Human epidermal growth factor receptor 2 is found in many cancers, especially breast cancer. The targeted therapy drug trastuzumab and other similar monoclonal antibodies may be a treatment option for patients with HER2-positive cancers.
  • BCR-ABL: This gene, known as the Philadelphia chromosome, is found in patients with chronic myelogenous leukemia. Presence of the gene may indicate the patient may respond well to treatment with a tyrosine kinase inhibitor drug such as imatinib.
  • PD-L1: Programmed death ligand 1 is the companion receptor to PD-1. It may indicate a cancer’s ability to evade the immune system. Immunotherapy drugs called checkpoint inhibitors may be an option to treat cancers high in PD-L1.
  • CA-125: High levels of cancer antigen-125 are found in many cancers as well as other diseases. Treatment options for cancers with CA-125 vary depending on where the cancer originated.
  • MSI-H: Microsatellite instability-high is a mutation in the DNA of cells found in many cancers, especially colorectal cancer. Checkpoint inhibitor drugs have been approved for cancers with MSI-H.

Difficult targets

Biomarkers don’t always tell the full story. Discovery of a biomarker that might indicate an increased cancer risk doesn’t mean a patient will get cancer. Not all cancers have identifiable biomarkers. And identifying a driving biomarker in a cancer does not necessarily lead to a treatment option. Some biomarkers for cancer have no corresponding targeted therapy or immunotherapy drug. For example:

  • TP53: Tumor protein 53 is a tumor suppressor gene designed to help stop cancer cells from growing. TP53 mutations are the most common found in cancer cells and may be found in most types of cancer.
  • RAS: About 30 percent of all cancers, including 95 percent of all pancreatic cancers, have known mutations in the RAS family of genes that control cell death and growth.

No targeted therapy drugs have been approved specifically to treat cancers with these mutations. “A number of recognized critical signaling pathways in cancer development, progression and resistance remain very difficult to ‘target’ to influence clinical outcomes,” Dr. Markman says. “The ability to successfully and safely target either or both of these pathways has the potential to be an important advancement in cancer management.”

Many cancers, especially solid tumors, have multiple biomarkers, any one of which may be able to drive a cancer’s growth. Target one biomarker, and another may take over as the driving mutation. And not all the same biomarkers are found in every cancer cell. “As cancer cells grow, they start to develop new abnormalities, mistakes made while the cells are multiplying,” Dr. Bonilla says. These new mutations may make the cancer more resistant to treatment.

Also, doctors need to take steps to prevent the patient from being harmed by the process of targeting a specific biomarker. For instance, patients on a checkpoint inhibitor that targets cancers high in PD-L1 may develop symptoms of autoimmune diseases, such as colitis. “The goal is to find the specific biomarker that every single cell expresses without compromising the normal cells,” Dr. Bonilla says, “because once you tell the immune system to kill a population of cells, it is going to kill all those cells, whether they are good or bad. But if you are able to find the specific biomarker that is the hallmark of this disease and needs to be eliminated, then it’s much easier to find a therapy.”

The discovery of biomarkers has led to game-changing developments in the cancer treatment. Women who learn they have BRCA mutations are now empowered to make potentially life-saving decisions to prevent breast and ovarian cancer. Men with slow-developing prostate cancer can now actively monitor their disease, in part, because their PSA levels can be measured. And research is ongoing to find new biomarkers to help in the treatment of other cancers and diseases, such as diabetes, Parkinson’s disease and heart disease.

“Biomarkers offer an opportunity to apply genomics to population health and see what diseases or conditions people may be predisposed to,” says Pamela Crilley, DO, Chair of the CTCA Department of Medical Oncology. “Am I going to get diabetes? Am I going to get elevated cholesterol? Is there anything I can do about it? Look at hereditary breast and ovarian cancers. The science has led to being able to prevent disease in patients with BRCA1 and BRCA2 mutations. Now we may be able to significantly reduce your risk of disease.”