Head and Neck Cancer Diagnosis & Treatment in Singapore
What are Head & Neck Cancer treatments in Singapore?
Presenting treatments for Nasopharyngeal Cancer, Oropharyngeal Cancer, Hypopharyngeal Cancer, Lip and Oral Cavity Cancer and Salivary Gland Cancer in adults.
When found early, many cancers of the head and neck can be cured. Although eliminating the cancer is the primary goal of treatment, preserving the function of the nearby nerves, organs, and tissues is also very important. When planning treatment, doctors consider how treatment might affect a patient’s quality of life, such as how a patient feels, looks, talks, eats, and breathes.
Overall, the main treatment options are surgery, radiation therapy, chemotherapy, targeted therapy, and immunotherapy. Surgery or radiation therapy by themselves or a combination of these treatments may also be part of the treatment plan.
Treatment options and recommendations depend on several factors, including the type and stage of head and neck cancer, possible side effects, and the patient’s preferences and overall health. More treatment details can be found under each specific cancer type below.
Nasopharyngeal Cancer (NPC, nosecancer)
The nasopharynx is the air passageway at the upper part of the throat behind the nose.
The standard of care for early NPC is radiotherapy alone. For locally advanced NPC, the treatment of choice would be combination of chemotherapy and radiotherapy. Surgery is an uncommon treatment option unless in the salvage/recurrence setting. This is because NPC is highly sensitive to radiotherapy and chemotherapy.
Head and Neck Cancer
Surgery of the head and neck cancer is the removal of the tumour and some surrounding healthy tissue, known as a margin during an operation. An important goal of the surgery is the complete removal of the tumour with “negative margins.” Negative margins means that there is no trace of cancer in the margin’s healthy tissue.
Someof the common surgical procedures for the removal of head and neckcancer include:
- Primary Tumour Surgery:The tumour and a margin of healthy tissue around it are removed to decrease the chance of any cancerous cells left behind. The tumour may be removed through the mouth or through an incision in the neck. A mandibulotomy, in which the jawbone is split to allow the surgeon to reach the tumour, may also be required.
- Glossectomy: This is the partial or total removal of the tongue.
- Mandibulectomy: If the tumour has entered the jawbone but not spread into the bone, then a piece of the jawbone or the whole jawbone will be removed. The entire bone may need to be removed if there is evidence of destruction of the jawbone on an x-ray.
- Maxillectomy: This surgery is the removing of part or all the hard palate (the bony roof of the mouth). Prostheses (an artificial replacement), or the use of flaps of soft tissue with and without bone can be placed to fill gaps created during this procedure.
- Neck Dissection: Cancer of the oropharynx often spreads to lymph nodes in the neck. Preventing the cancer from spreading to the lymph nodes is an important goal of treatment. It may be necessary to remove some or all these lymph nodes using a surgical procedure called a neck dissection. Sometimes, for oropharyngeal cancer, a neck dissection will be recommended after radiation therapy or chemoradiation.
- Laryngectomy: A laryngectomy is the complete or partial removal of the larynx or commonly known as voice box. Although the larynx is important for producing sounds, the larynx is also critical to swallowing because it protects the airway from food and liquid entering the trachea or windpipe and reaching the lungs, which can cause pneumonia. A laryngectomy is rarely needed to treat oropharyngeal cancer. However, when there is a large tumour of the tongue or oropharynx, the doctor may need to remove the larynx to protect the airway during swallowing.
- Transoral Robotic Surgery/Transoral Laser Microsurgery:Transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) are minimally invasive surgical procedures. This means that they do not require large cuts to get to and remove a tumour. In TORS, an endoscope is used to see a tumour in the throat, the base of the tongue, and the tonsils. Two (2) small robotic instruments aid the surgeon to remove the tumour. In TLM, an endoscope connected to a laser is inserted through the mouth. The laser of high-intensity light is used to remove the tumour.
Laryngeal Cancer (throat cancer)
There is specific consideration for laryngeal cancer as traditional surgery of laryngeal cancer with laryngectomy would remove the vocal cords. There is a lot of emphasis to preserve the voice of patients and thus the standard of care would be to use concurrent chemo-radiation. Surgery is usually a last resort option for patients with poor vocal function that is not reversible, recurrent aspiration or recurrent of laryngeal tumor.
For surgery in hypopharyngeal cancer, a surgical oncologist removes the cancerous tumour and some healthy tissue around it, also known as margin.
The most common surgical procedures used to treat hypopharyngeal cancer include:
- Partiallaryngectomy: This is the removal of part of the larynx, which helps preserve the patient’s natural voice. The following are some of the different types of partial laryngectomies:
- Supraglottic Laryngectomy: The removal of the area above the vocal folds.
- Cordectomy: The removal of a vocal fold.
- Vertical Hemilaryngectomy: The removal of one (1) side of the larynx.
- Supracricoid partial laryngectomy: The removal of the vocal folds and the area surrounding them.
- Total Laryngectomy: This procedure removes the entire larynx. During this operation, a hole called a stoma is made in the front of the neck through the windpipe, so the patient can breathe. This is called a tracheostomy. Because the vocal folds have been removed, patients can no longer speak using their vocal folds after a total laryngectomy.
- Laryngopharyngectomy:A laryngopharyngectomy is the removal of the entire larynx, including the vocal folds and part or all of the pharynx.
- Neck dissection: If the cancer has spread to the lymph nodes in the neck, some of these lymph nodes may need to be surgically removed, also known as a neck dissection. There are several types of neck dissections, such as a partial neck dissection, modified neck dissection, or selective neck dissection. Depending on the stage and location of the cancer, some or all the lymph nodes in the neck may have to be removed.
Lip and Oral Cavity Cancer
Surgery is a common treatment for all stages of lip and oral cavity cancer.
Similar as oropharyngeal cancer, the most common surgical procedures used to treat lip and oral cavity cancer include:
- Wide Local Excision: This is the removal of the cancer and some of the healthy tissue around it. If the cancer has spread into the bone, surgery may include the removal of the cancerous bone tissue.
- Neck Dissection: Cancer of the lip and oral cavity often spreads to lymph nodes in the neck. Preventing the cancer from spreading to the lymph nodes is an important goal of treatment. It may be necessary to remove some or all these lymph nodes using a surgical procedure called a neck dissection. Sometimes, for oropharyngeal cancer, a neck dissection will be recommended after radiation therapy or chemoradiation.
- Primary Tumour Surgery:The tumour and a margin of healthy tissue around it are removed to decrease the chance of any cancerous cells left behind. The tumour may be removed through the mouth or through an incision in the neck. A mandibulotomy, in which the jawbone is split to allow the surgeon to reach the tumour, may also be required.
- Glossectomy: This is the partial or total removal of the tongue.
- Mandibulectomy: If the tumour has entered the jawbone but not spread into the bone, then a piece of the jawbone or the whole jawbone will be removed. The entire bone may need to be removed if there is evidence of destruction of the jawbone on an x-ray.
- Maxillectomy: This surgery is the removing of part or all the hard palate (the bony roof of the mouth). Prostheses (an artificial replacement), or the use of flaps of soft tissue with and without bone can be placed to fill gaps created during this procedure.
- Transoral Robotic Surgery/Transoral Laser Microsurgery:Transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) are minimally invasive surgical procedures. This means that they do not require large cuts to get to and remove a tumour. In TORS, an endoscope is used to see a tumour in the throat, the base of the tongue, and the tonsils. Two (2) small robotic instruments aid the surgeon to remove the tumour. In TLM, an endoscope connected to a laser is inserted through the mouth. The laser of high-intensity light is used to remove the tumour.
Salivary Gland Cancer
Surgery is recommended for majority patients diagnosed with salivary gland cancer and is usually the first treatment. During surgery, a doctor performs an operation to remove the cancerous tumour and some surrounding healthy tissue.
The types of surgery used to treat salivary gland cancer include:
- Parotidectomy: In this procedure, part or all the parotid glands may be removed. Parotid glands are located on each side of the mouth (cheek) and in front of the ear. These are the largest salivary glands in the human body. This surgery often involves dissecting the facial nerve. If cancer has spread to the facial nerve, often a nerve graft or other reconstructive procedures are necessary for the patient to regain use of some facial muscles.
- Submandibular or Sublingual Gland Surgery: Depending on the size and location of the tumours (submandibular or sublingual gland), the surgeon will make a cut in the patient’s skin to remove the entire gland and the surrounding tissue and bone.
- Minor Salivary Gland Surgery: In this procedure, depending on the size and location of the tumour, the surgeon may remove the surrounding tissue along with the tumour. Minor salivary gland cancers usually occur in a patient’s lips, tongue, palate (roof of the mouth), mouth, throat, voice box (larynx), nose, and sinuses.
- Endoscopic Surgery: Endoscopic surgery is used particularly when a salivary gland tumour begins in the paranasal area (around the nose) or in the larynx.
- Neck Dissection: Cancers of the salivary gland often spread to the lymph nodes in the neck. A neck dissection may be done if the lymph nodes in the neck are enlarged (often seen in a CT or MRI scan) or if the cancer is of high grade and has a high risk of spreading.
- Sentinel Lymph Node Biopsy: Sentinel lymph node mapping and biopsy have become a common way to find out whether a cancer has spread to the lymph nodes. This procedure may be used in certain types of salivary gland cancer and can help keep a patient from going through a neck dissection. This procedure can also find the lymph nodes that drain lymph fluid from the salivary gland where the cancer started. The surgery involves taking out these lymph nodes and checking them for cancer during the surgery. If no cancer cells are found, the other lymph nodes can be left alone. If these nodes do have cancer cells in them, neck dissection is usually needed.
Radiation therapy is the use of high-energy rays to destroy cancer cells. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
Head and neck cancers including, Nasopharyngeal ,oropharyngeal, hypopharyngeal, lip and oral cancers, salivary glands cancers
There are different types of radiation therapy that a doctor may recommend for nasopharyngeal cancer. Radiation therapy may also be combined with chemotherapy during treatment. When this is done, it is called chemoradiotherapy or concurrent chemotherapy (see chemotherapy below).
- External Beam Radiation Therapy: This is the most common type of radiation therapy to treat nasopharyngeal cancer. A method of external-beam radiation therapy, known as intensity-modulated radiation therapy (IMRT), allows more effective doses of radiation therapy to be delivered, while reducing damage to healthy cells and causing fewer side effects.
- Proton Therapy: Proton therapy is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Proton therapy may be used as part of the treatment for some tumours at the base of the skull to lower the radiation dose to nearby structures, such as the optic nerves in the eye and the brainstem. Proton therapy may also be an option for nasopharyngeal cancer that is located close to parts of the central nervous system, which includes the brain and spinal cord.
- Stereotactic Radiosurgery: Stereotactic radiosurgery delivers radiation therapy precisely to the tumour. This can be used to treat a tumour that has grown into the base of the skull or a tumour that has recurred at the base of the brain or skull.
Chemotherapy is the use of drugs or medication to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells – also commonly known as systemic therapy. This type of medication is given through the bloodstream to reach cancer cells throughout the patient’s body.
A patient may receive one (1) type of systemic therapy at a time, or a combination of systemic therapies given at the same time. It can also be given as part of a treatment plan that includes surgery and/or radiation therapy.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time.
The common ways to give chemotherapy include:
- An intravenous (IV) tube placed into a vein using a needle
- In a pill or capsule that is swallowed (orally)
- A shot (injection) into a muscle, under the skin
Chemotherapy may be given after radiation therapy to kill any cancer cells that are left. Chemotherapy can be given before, during or after radiation therapy, to kill cancer cells and to lower the risk that the cancer will come back,
- For stage II tumour that has spread to the lymph nodes, chemoradiotherapy may be recommended. Chemoradiotherapy is when chemotherapy and radiation therapy are given during the same period.
For stage III to stage IVA nasopharyngeal cancer, either induction chemotherapy plus chemoradiotherapy or chemoradiotherapy and adjuvant chemotherapy are recommended. Cisplatin is the common chemotherapy drug used for nasopharyngeal cancer. Other drugs used in treating nasopharyngeal cancer include:
- Carboplatin (Paraplatin)
- Paclitaxel (Taxol)
- Docetaxel (Taxotere)
- Gemcitabine (Gemzar)
For head and neck cancers such as oropharynx, hypopharynx, laryngeal, lip/oral Cancer (throat cancer)
Tthe use of chemotherapy in combination with radiation therapy, called chemoradiation, is often recommended. The combination of these two (2) treatments can sometimes control tumour growth, and it often is more effective than giving either of these treatments alone. This combined treatment, using cisplatin (chemotherapy drug), may be an option for oropharyngeal cancer that may have spread to the lymph nodes.
Chemotherapy may be used as the initial treatment before surgery, radiation therapy, or both, which is called a neoadjuvant chemotherapy. It may also be given after surgery, radiation therapy, or both, which is called adjuvant chemotherapy.
The chemotherapy drugs used most often for oropharyngeal cancer that can be given with or without radiation therapy include:
- Cisplatin
- Carboplatin
- 5-fluorouracil (5-FU)
- Paclitaxel (Taxol)
- Docetaxel (Taxotere)
Salivary Gland Cancer
For salivary gland cancer, chemotherapy or systemic therapy is most often used to treat later-stage cancer that has metastasized (spread) or to relieve symptoms. Chemotherapy may help to shrink the tumours, however, it is not likely to cure the cancer.
Some of the chemo drugs used to treat salivary gland cancers include:
- Cisplatin
- Carboplatin
- 5-fluorouracil (5-FU)
- Paclitaxel (Taxol)
- Docetaxel (Taxotere)
- Vinorelbine (Navelbine)
- Methotrexate
These drugs may be used alone but are often given in combinations of two (2) or more drugs.
Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
Nasopharyngeal Cancer (upper throat cancer)
Pembrolizumab (Keytruda) and Nivolumab (Opdivo) are drugs that targets PD-1, a checkpoint protein on immune system cells called T cells, that normally helps keep these cells from attacking normal cells in the body. By blocking PD-1, this drug boosts the immune response against nasopharyngeal cancer cells. It has shown promising results in shrinking or slowing down the growth of nasopharyngeal cancer tumours.
These drugs are given as an intravenous (IV) infusion every two (2), three (3) or four (4) weeks. Both pembrolizumab and nivolumab is an option for treatment in selected patients.
Head and Neck cancers (squamous cell carcinoma (of any sites)
In advanced or recurrent stage, immunotherapy is the stadard of care (with or without chemotherapy)
Pembrolizumab (Keytruda) and Nivolumab (Opdivo) are drugs that targets PD-1, a checkpoint protein on immune system cells called T cells, that normally helps keep these cells from attacking normal cells in the body. By blocking PD-1, this drug boosts the immune response against head and neck cancer cells.
These drugs may be used as monotherapy or in combination with chemotherapyand in various lines of treatment (be it first line or later lines. It has been shown to improve overall survival compared to conventional treatment.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the surrounding tissue that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.
Not all tumours have the same targets. To find the most effective treatment, the doctor may run tests to identify the genes, proteins, and other factors in a patient’s tumour. This helps doctors better match each patient with the most effective treatment. Additionally, research studies continue to find out more about specific molecular targets and new treatments directed at them.
Head and Neck cancers
Cetuximab is a targeted therapy drug made from the monoclonal antibody (a man-made version of an immune system protein) that targets the epidermal growth factor receptor (EGFR). EGFR is a protein found on the surface of cells. It normally receives signals telling the cells to grow and divide. Head and Neck cancer cells sometimes have more than normal amounts of EGFR, which can help them grow faster. Therefore, by blocking EGFR, cetuximab may slow or stop this growth.
In treatment for head and neck cancer, cetuximab can be combined with radiation therapy for some locally advanced stage cancers. For more advanced cancers, it may be combined with standard chemotherapy drugs such as cisplatin and 5FU
Cetuximab is given by infusion into a vein (IV).
Are there any side effects of Head and Neck Cancer treatment?
The most common side effects of a neck dissection are numbness of the ear, weakness when raising the arm above the head Surgery can lead to nerve damage and may cause these side effects. After a selective neck dissection, the weakness of the shoulder usually goes away after a few months. However, if either of the nerves that supply these areas is removed as part of a radical neck dissection or because of involvement with tumour, the weakness will be permanent.
A patient may require to go for physical therapy to improve neck and shoulder strength and movement if more extensive neck dissection is done.
Surgery for oropharyngeal cancers that are large or hard to reach may be very complicated. The side effects may include infection, wound breakdown, problems with eating, breathing, and speaking. The surgery also can be disfiguring, especially if bones in the face or jaw need to be removed.
- Impact of glossectomy:Most patients can still speak if only part of the tongue is removed, however their speech may not be as clear as it once was. As the tongue is important in swallowing, speech may also be affected, however, speech therapy can often help with the problem.
When the entire tongue is removed, patients lose the ability to speak and swallow. With reconstructive surgery and a good rehabilitation program including speech therapy, some patients may regain the ability to swallow and speak well enough to be understood.
- Impact of laryngectomy:This surgery leaves a person without the normal means of speech as it removes the larynx (voice box). After a laryngectomy, the patient will breathe through a stoma (tracheostomy) placed in the front of the lower neck. Having a stoma means that the air the patient breathes in and out will no longer pass through the nose or mouth, which would normally help moisten, warm, and filter the air (removing dust and other particles). As the air reaching the lungs will be dryer and cooler, this can irritate the lining of the breathing tubes and cause thick or crusty mucus to build up.
- Impact of facial bone removal:Some cancers of the head and neck are treated with operations that remove part of the facial bone structure. This may have a major effect on how patients view themselves as the changes are visible. This can also affect a patient’s speech and swallowing.
Patients who have a laryngectomy or larynpharyngectomy typically loses the ability to speak normally. Surgeries that involve the throat or voice box can lead to a gradual narrowing (stenosis) of the throat or larynx. This can sometimes make it hard for the patient to breathe and may need a tracheostomy.
Throat or larynx surgeries might also sometimes make it hard to swallow well. This can affect how a patient eats and may be severe enough to require a permanent feeding tube.
Laryngectomy and larynpharyngectomy may also lead to the development of a fistula (which is an abnormal opening between two areas that are not normally connected). Additional surgery may be needed to fix it.
Another very rare but serious complication of neck dissection is rupture of a carotid artery (the large artery on either side of the neck).
Surgery for lip and oral cavity cancer often causes swelling, making it difficult to breathe. It may cause permanent loss of voice or impaired speech; difficulty chewing, swallowing, or talking; numbness of the ear; weakness raising the arms above the head; lack of movement in the lower lip; and changes to the patient’s facial appearance. Surgery may affect the function of the thyroid gland, especially after a total laryngectomy.
For salivary gland cancer surgery, the surgeon may need to cut through the patient’s skin or cut inside the mouth.
If the facial nerve is damaged during surgery, the patient loses control of their facial muscles on the side where the surgery was done. That side of the face may droop. If the injury to the facial nerve is related to retraction (pulling) of the nerve during surgery and/or swelling from the operation, the damage might heal over time.
Sometimes, nerves cut during surgery grow back abnormally and become connected to the sweat glands of the face. This condition, called Frey syndrome or gustatory sweating, results in flushing or sweating over areas of the face when a patient chews. Frey syndrome can be treated with medication or with additional surgery.
Damage to other nerves in the face or mouth may cause problems with tongue movement, speech, or swallowing.
Depending on the extent of the operation, the patient’s appearance may be changed because of surgery. This can range from a simple scar on the side of the face or neck to more extensive changes if nerves, parts of bones, or other structures needs to be removed.
Presenting radiation therapy side effects for Nasopharyngeal Cancer, Oropharyngeal Cancer, Hypopharyngeal Cancer, Lip and Oral Cavity Cancer and Salivary Gland Cancer in adults.
The possible side effects of radiation therapy depend on where the radiation is targeted. The common side effects include:
- Skin irritation (in areas of radiation, ranging from redness, blisters, and peeling)
- Hair loss
- Fatigue
- Nausea
- Diarrhoea
- Lower blood cell counts
- Increase risks of infections
- Mouth and gum sores/difficulty swallowing/dry mouth
- A type of swelling called lymphedema
Presenting chemotherapy side effects for Nasopharyngeal Cancer, Oropharyngeal Cancer, Hypopharyngeal Cancer, Lip and Oral Cavity Cancer and Salivary Gland Cancer in adults.
The side effects of chemotherapy commonly include the following:
- Nausea and vomiting
- Diarrhoea
- Constipation
- Tiredness
- Pain
- Loss of appetite
- Hair loss
- Skin and nail changes
- Numbness and tingling
- Swelling
- Low white blood counts, low red blood counts and low platelet counts
- Risks of infections
- Risk of infertility
Presenting immunotherapy side effects for Nasopharyngeal Cancer, Oropharyngeal Cancer, Hypopharyngeal Cancer, Lip and Oral Cavity Cancer and Salivary Gland Cancer in adults.
The side effects of immunotherapy may include:
- Nausea and vomiting
- Diarrhea
- Constipation
- Rash and other skin changes
- Rarely: Breathing problems
Presenting targeted therapy side effects for Nasopharyngeal Cancer, Oropharyngeal Cancer, Hypopharyngeal Cancer, Lip and Oral Cavity Cancer and Salivary Gland Cancer in adults.
Depending on the targeted drugs used, the common side effects may include:
- Low or High blood pressure
- Increased blood sugar level or cholesterol
- Fatigue
- Nausea and vomiting
- Diarrhoea
- Poor appetite and weight loss
- Voice changes
- Skin rash/Mouth sores
- Swelling in the arms and legs (fluid build-up)
- Constipation
What do I need to do if I have Head and Neck Cancer?
Head and neck cancer is the term used to describe a number of different malignant tumours that develop in or around the throat, larynx, nose, sinuses, and mouth. A malignant tumour is cancerous, meaning it can grow and spread to other parts of the body.
If you suspect that you or your loved one have head and neck cancer, it is advisable to get the support you need. Early detection and diagnosis of head and neck cancer is key to treating the disease.
Regardless of what stage your head and neck cancer may be, you should schedule an appointment to see an oncologist specialising in head and neck cancer as soon as possible. With the speed of developments in head and neck cancer diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.
Our cancer specialists at OncoCare specialise in treating late stage and advanced stages of head and neck cancer, as well as earlier stages of the disease.
Who are the Head and Neck Cancer Specialists in Singapore?
Senior Consultant, Medical Oncologist
MBBS (Singapore) – M.Med (Singapore) – MRCP (United Kingdom) – FAMS (Medical Oncology)
Dr Leong Swan Swan did her basic Medical studies in the National University of Singapore (NUS) and obtained her Master of Medicine (Internal Medicine), NUS and Membership of the Royal College of Physicians (United Kingdom) in 1995. She started her training in Medical Oncology in 1995, and was awarded HMDP for further training, with special focus on Thoracic Oncology under Dr Mark Green at Holling’s Cancer Centre in 1997. In 2000, she obtained Specialist Accreditation in Medical Oncology as well as European Society of Oncology (ESMO) certification.
Dr Leong has been working in the Department of Medical Oncology, Singapore General Hospital / National Cancer Centre since 1995. She has provided outstanding cancer care for a wide-spectrum of cancers including breast cancer, colorectal and stomach cancers, lung cancer, head & neck cancer, ovarian/uterine/cervical cancers, lymphomas and other solid tumours. Prior to leaving for private practice, Dr Leong was serving as Senior Consultant, managing different tumour types and was involved in the multi-disciplinary care tumour boards, establishing her as a key opinion cancer specialist doctor in lung as well as head and neck cancers. She was also Visiting Consultant at Changi General Hospital. She was Director of the Ambulatory Treatment Unit at National Cancer Centre and was the Chairperson of the Code Blue Team.
Dr Leong was also actively involved in teaching. She was a Clinical Lecturer for medical students, involved in undergraduate teaching as well as teaching for junior staff and nurses. She has also given many public lectures.
She is a member of American Society of Oncology, Singapore Society of Oncology, and she is serving in the Bylaws Committee of International Association of the Study of Lung Cancer (IASLC) and as Auditor of Society of Geriatric Oncology. Her research interest is mainly in the field of lung cancer and head & neck cancer. She was also involved with the setting up and running of the Singapore Lung Cancer Consortium. She has published widely in both local and International journals including Journal of Clinical Oncology, Chest, Cancer and has written book chapters for the staging and treatment of lung cancer. Recognised for her expertise in lung and other cancers, she has been a reviewer for several journals including Journal of Clinical Oncology, Respirology and Singapore Medical Journal.
Dr Leong’s subspecialty interest is in lung cancer, thyroid cancer and head & neck cancer. (Head and neck cancer is a cancer that starts in the lip, oral cavity (mouth), nasal cavity (inside the nose), paranasal sinuses, pharynx, and larynx.) She is fluent in English and Mandarin as well as Cantonese dialect.
MEDICAL PROFILE
- Graduated from the National University of Singapore.
- Obtained Master of Medicine (Internal Medicine) and Membership of the Royal College of Physicians (United Kingdom) in 1995.
- Awarded the Ministry of Health Manpower Development Programme (HMDP) Scholarship HMDP for further training, with special focus on Thoracic Oncology under Dr Mark Green at Holling’s Cancer Centre in 1997. In 2000, she obtained Specialist Accreditation in Medical Oncology as well as European Society of Oncology (ESMO) certification.
- She was the Director of the Ambulatory Treatment Unit at National Cancer Centre and was the Chairperson of the Code Blue Team.
- She has been actively involved in clinical and translational research for many years, in lung cancer and head and neck cancer. These have involved international trials of chemotherapy drugs currently in active use and newer targeted therapy drugs. She was principal investigator for more than 10 clinical trials for cancer drug development.
- Research work by Dr Leong has been published in both local and international reputable journals including Journal of Clinical Oncology, Chest, Cancer and has written book chapters for the staging and treatment of lung cancer. She has been a reviewer for several journals including Journal of Clinical Oncology, Respirology and Singapore Medical Journal.
- With respect to public service, Dr Leong was also actively involved in teaching. She was a Clinical Lecturer for medical students, involved in undergraduate teaching as well as teaching for junior staff and nurses. She has also given many public lectures.
- Accredited for Palliative Medicine.
Senior Consultant, Medical Oncologist
MBBS (Singapore) – ABIM Int. Med (USA) – ABIM Med Onc(USA) – FAMS (Medical Oncology)
MBBS (Singapore) – MRCP (United Kingdom)
Dr Tan Chee Seng is a Senior Medical Oncologist at OncoCare Cancer Centre. Prior to this he was a Consultant with the Haematology-Oncology Department of National University Cancer Institute of Singapore (NCIS), National University Hospital (NUH) and Visiting Consultant at Ng Teng Fong General Hospital (NTFGH).
He obtained his undergraduate medical degree from School of Medicine, National University of Singapore and his post-graduate qualification from Royal College of Physicians, United Kingdom. He completed his advanced specialist training in Medical Oncology from National University Hospital. He was later awarded with the prestigious Academic Medicine Development Award (AMDA) fellowship to subspecialize in personalization of lung cancer therapies at Addenbrooke’s Hospital, Cambridge University, United Kingdom.
His main clinical interests are in lung/thoracic and head/neck cancers. He was principal investigator or co-investigators for several international multi-center cancer clinical trials including novel chemotherapy agents, targeted therapies, tyrosine kinase inhibitors, antibody-drug conjugates, immunotherapy agents and etc. Dr Tan has also authored or co-authored publications in peer-reviewed international journals including Lancet Oncology, Clinical Cancer Research, Molecular Cancer, Lung Cancer, Oncotarget, Target Oncology, Journal of Cancer Research and Clinical Oncology, Journal of Translational Medicine, Journal of Oncology Practice and etc.
He had been invited to speak or to chair in local and regional oncology meetings. He also routinely held public talks and to local GP to inform them of the latest innovative treatments for cancers. Dr Tan was also the recipient of several grants including National Medical Research Council (NMRC) Clinician Investigator Salary Support Programme and Investigational Medicine Unit (IMU) Bridging Funds.
He is a member of several professional bodies including American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), International Association for the Study of Lung Cancer (IASLC) and was an executive committee member of the Singapore Society of Oncology.
He was actively involved in both undergraduate and post graduate teachings at the Yong Loo Lin School of Medicine (YLLSOM) and National University Hospital (NUH) respectively. He was previously appointed as the Assistant Professor for Faculty of Medicine, YLLSOM and Undergraduate Education Director (Medical Oncology). He was also a core faculty member of Medical Oncology Senior Residency of NUH. He was invited to be examiner for YLLSOM final year MBBS examinations.
Dr Tan is fluent in English, Mandarin and Malay/Bahasa. He is able to speak some Cantonese and Hokkien. He has taken care of patients from many regional and overseas regions including Malaysia, Indonesia, Vietnam, Myanmar, China, Bangladesh, Sri Lanka and India.
MEDICAL PROFILE
- Graduated from the National University of Singapore in 2005.
- Obtained Membership of the Royal College of Physician (United Kingdom) in 2007.
- Awarded ASEAN Scholarship (1998-2000) and KUOK Foundation Scholarship (2000-2005).
- Awarded prestigious AMDA Academic Medicine Development Award (AMDA) (2014-2015) for fellowship training at Addenbrooke’s Hospital Cambridge University, United Kingdom on personalization of treatment for lung cancers.
- Clinical lecturer, Yong Loo Lin School of Medicine, National University of Singapore from 2012-2018.
- Director of Undergraduate (Medical Oncology), Yong Loo Lin School of Medicine, National University of Singapore from 2012-2018.
- Assistant Professor Yong Loo Lin School of Medicine, National University of Singapore from 2016-2018.
- Invited as examiner for Yong Loo Lin School of Medicine final year MBBS examinations.
- Authored or co-authored publications in peer-reviewed international journals including Lancet Oncology, Clinical Cancer Research, Molecular Cancer, Lung Cancer, Oncotarget, Target Oncology, Journal of Cancer Research and Clinical Oncology, Journal of Translational Medicine, Journal of Oncology Practice and etc.
What is Head and Neck Cancer?
Definition of Head and Neck Cancer
Head and neck cancer is the term used to describe several different malignant tumours that develop in or around the throat, larynx, nose, sinuses, and mouth. There are five (5) main types of head and neck cancer, each named according to the part of the body where they develop.
Most head and neck cancers are squamous cell carcinomas. This type of cancer begins in the flat squamous cells that make up the thin layer of tissue on the surface of the structures in the head and neck. Directly beneath this lining, which is called the epithelium, some areas of the head and neck have a layer of moist tissue, called the mucosa. If a cancer is only found in the squamous layer of cells, it is called carcinoma in situ. If the cancer has grown beyond this cell layer and moved into the deeper tissue, then it is called invasive squamous cell carcinoma.
In Singapore, more than 800 patients are diagnosed with head and neck cancer every year. According to the Singapore Cancer Registry, the most common head and neck cancer is nasopharyngeal cancer (NPC), which features as the eighth (8th) most common cancer amongst Singaporeans.
Head and Neck cancer constitutes 12% of all malignancies in the world and is the fifth (5th) most common cancer type and cause of cancer-related deaths worldwide.
What are the Signs and Symptoms of Head and Neck Cancer?
The most common symptoms of Head and Neck Cancer are:
- Swelling or a sore that does not heal; this is the most common symptom
- Red or white patch in the mouth
- Lump, bump, or mass in the head or neck area, with or without pain
- Persistent sore throat
- Foul mouth odour not explained by hygiene
- Hoarseness or change in voice
- Nasal obstruction or persistent nasal congestion
- Frequent nose bleeds and/or unusual nasal discharge
- Difficulty breathing
- Double vision
- Numbness or weakness of a body part in the head and neck region
- Pain or difficulty chewing, swallowing, or moving the jaw or tongue
- Jaw pain
- Blood in the saliva or phlegm, which is mucus discharged into the mouth from respiratory passages
- Loosening of teeth
- Dentures that no longer fit
- Unexplained weight loss
- Fatigue
- Ear pain or infection
Screening for Head and Neck Cancer
For a complete evaluation, a patient may need to be referred to an ear, nose, and throat (ENT) specialist. These doctors are also known as otolaryngologists or as head and neck surgeons.
The specialist will also examine the larynx and hypopharynx (known as laryngoscopy). It can be done in two (2) ways:
- Direct (flexible) laryngoscopy: For this exam, the doctor inserts a fiber-opticlaryngoscope – a thin, flexible, lighted tube – through the mouth or nose to look at the larynx and nearby areas.
- Indirect laryngoscopy: In this exam, the doctor uses special small mirrors to view the larynx and nearby areas.
How Head and Neck Cancer is diagnosed
Tests to diagnose Head and Neck Cancer include:
- Medical history and physical examination: The first step in any medical evaluation is for the doctor to gather information about your symptoms, risk factors, family history, and other medical conditions. A thorough physical exam can help uncover any signs of possible cancer or other diseases. The doctor will pay close attention to your head and neck, looking for abnormal areas in your mouth or throat, as well as enlarged lymph nodes in your neck.
- Panendoscopy: Panendoscopy is a procedure that combines laryngoscopy, esophagoscopy, and (at times) bronchoscopy. This lets the doctor thoroughly examine the entire area around the larynx and hypopharynx, including the esophagus and trachea (windpipe).
- Laboratory Tests: Thisexamines samples of blood, urine, or other substances from the body. Other types of tests may be done as part of a workup if a patient has been diagnosed with laryngeal or hypopharyngeal cancer. These tests are not used to diagnose the cancer, but they may be done to see if a person is healthy enough for other treatments, such as surgery or chemotherapy.
- Biomarker testing of the tumour: The doctor may recommend running laboratory tests on a tumour sample to identify specific genes, proteins, and other factors unique to the tumour. This may also be called molecular testing of the tumour.
- Chest X-ray: A chest x-ray may be done to see if laryngeal or hypopharyngeal cancer has spread to the lungs.
- CT (or CAT) Scan: Thisis a series of detailed pictures of areas inside the head and neck created by a computer linked to an x-ray machine.
- Magnetic Resonance Imaging (MRI): This exam uses a powerful magnet linked to a computer to create detailed pictures of areas inside the head and neck. MRI scans use radio waves and strong magnets instead of x-rays.
- PET Scan: This examuses sugar that is modified in a specific way, so it is absorbed by cancer cells and appears as dark areas on the scan.
- Biopsy: This is the removal of tissue. A pathologist studies the tissue under a microscope to make a diagnosis. A biopsy is the only sure way to tell whether a person has cancer. The doctor may order an Endoscopic biopsy or a Fine needle aspiration (FNA) biopsy.
What are the Causes and Risks of Head and Neck Cancer?
There are two (2) substances that greatly increase the risk of developing a head and neck cancer:
- Tobacco: Tobacco use includes smoking cigarettes, cigars, or pipes and chewing tobacco. It is the single largest risk factor for head and neck cancer. Researchers estimate that 70% to 80% of head and neck cancers are linked to tobacco use, and the amount of tobacco use may affect prognosis, which is the chance of recovery. Additionally, second-hand smoke may increase a person’s risk of developing head and neck cancer.
- Alcohol: Frequent and heavy alcoholconsumption raises the risk of developing cancer in the mouth, pharynx, larynx, and esophagus.
Other factors that can raise a person’s risk of developing head and neck cancer include:
- Prolonged sun exposure: This is especially linked to cancer in the lip area, as well as skin cancer of the head and neck.
- Human papillomavirus (HPV): Research shows that infection with HPV is a risk factor for head and neck cancer. Sexual activity with a person who has HPV is the most common way someone gets HPV. There are different types of HPV, called strains. Research links some HPV strains more strongly with certain types of cancers. HPV vaccines can prevent patients from developing certain cancers.
- Epstein-Barr virus (EBV): Exposure to EBV, which is more commonly known as the virus that causes mononucleosis or “mono,” plays a role in the development of nasopharyngeal cancer.
- Gender:Men are two (2) to three (3) times more likely than women to develop head and neck cancer. However, the rate of head and neck cancer in women has been rising for several decades.
- Age: Patients over the age of 40 are at higher risk for head and neck cancer.
- Poor oral and dental hygiene: Poor care of the mouth and teeth may increase the risk of head and neck cancer.
- Environmental or occupational inhalants: Inhaling asbestos, wood dust, paint fumes, and certain chemicals may increase a person’s risk of head and neck cancer.
- Poor nutrition:A diet low in vitamins A and B can raise a person’s risk of head and neck cancer.
- Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD): Reflux of stomach acid into the upper airway and throat may be associated with the development of head and neck cancer.
- Weakened immune system: A weakened immune system can raise a person’s risk of head and neck cancer.
- Exposure to radiation: Exposure to radiation is associated with salivary gland cancer.
- Previous history of head and neck cancer: Patients who have had one (1) head and neck cancer have a higher chance of developing another head and neck cancer in the future.
What are the Types of Head and Neck Cancer?
There are five (5) main types of head and neck cancer, each named according to the part of the body where they develop.
- Laryngeal and Hypopharyngeal cancer:The larynx is commonly called the voice box. This tube-shaped organ in the neck is important for breathing, talking, and swallowing. It is located at the top of the windpipe, or trachea. The hypopharynx is also called the gullet. It is the lower part of the throat that surrounds the larynx.
- Nasopharyngeal Cancer:The nasopharynx is the air passageway at the upper part of the throat behind the nose.
- Lip and Oral Cavity Cancer: The oral cavity includes the mouth and tongue.
- Oropharyngeal Cancer: The oropharynx includes the middle of the throat, from the tonsils to the tip of the voice box.
- Salivary Gland Cancer: The salivary gland produces saliva. Saliva is the fluid that is released into the mouth to keep it moist and that contains enzymes that begin breaking down food.
What are the Stages of Head and Neck Cancer?
Staging is a way of describing where the cancer is located, or if it has spread and whether it is affecting other parts of the body. The tests and scans used to diagnose the patient’s cancer will give some information about:
- the type of cell the cancer started in and where it began
- how abnormal the cells look under the microscope (the grade)
- the size of the cancer and whether it has spread (the stage)
Stage 0 is also known as carcinoma in situ.
Nasopharyngeal Cancer (upper throat cancer)
The cancer is in only the top layer of cells in the tissue that lines the nasopharynx. It has not spread to nearby lymph nodes or organs in other parts of the body.
Oropharyngeal Cancer (middle throat cancer)
The cancer is only in the lining of the oropharynx where it first started. It has not spread to nearby lymph nodes or organs in other parts of the body.
Hypopharyngeal Cancer (lower throat cancer)
The cancer is only where it started, in the top layer of cells lining the hypopharynx. It has not grown into deeper layers of the hypopharynx. It has not spread to nearby lymph nodes or organs in other parts of the body.
Lip and Oral Cavity Cancer
Abnormal cells are found in the lining of the lips and oral cavity. These abnormal cells may become cancer and spread into nearby normal tissue.
Salivary Gland Cancer
The cancer is only in the top layer of the cells lining the salivary duct. It has not spread to nearby lymph nodes or organs in other parts of the body.
Nasopharyngeal Cancer (upper throat cancer)
The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is in the nasopharynx and may or may not have spread into the oropharynx and/or the nasal cavity. Or, no tumour can be seen in the nasopharynx, but cancer is found in lymph nodes in the neck and is Epstein-Barr virus positive (EBV+). In either case, it has spread to one or more lymph nodes on one side of the neck or to lymph nodes behind the throat, and none of the nodes are more than six (6) cm across.
- The tumour has spread to tissues on the left or right sides of the upper throat but not into bone. It may or may not have spread to one (1) or more lymph nodes on one side of the neck or to lymph nodes behind the throat, and none of the nodes are more than six (6) cm across.
Oropharyngeal Cancer (middle throat cancer)
For HPV-positive cancer of the oropharynx:
The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is no bigger than four (4) cm across. It has spread to at least one (1) lymph node on the opposite side of the neck as the tumour, or to lymph nodes on both sides of the neck. None of the lymph nodes are more than six (6) cm across.
- The tumour is more than four (4) cm across, or it’s growing into the base of the tongue (the epiglottis), the voice box (larynx), the tongue muscle, nearby bones, the jaw, or the hard palate. One of these is also true:
- It has not spread to nearby lymph nodes.
- It has spread to at least one (1) lymph node on the same side as the tumour, but none of the nodes are more than six (6) cm across.
For HPV-negative cancer of the oropharynx:
The tumour is between two (2) cm and four (4) cm. It has not spread to nearby tissues, lymph nodes, or organs in other parts of the body.
Hypopharyngeal Cancer (lower throat cancer)
The cancer has not grown into the voice box (larynx), nearby lymph nodes, or organs in other parts of the body, with one of these facts:
- The cancer is in more than one part of the hypopharynx.
- The tumour is between two (2) cm and four (4) cm across.
- The cancer has spread to nearby tissues.
Lip and Oral Cavity Cancer
The tumour is two (2) centimeters or smaller and the deepest point of tumour invasion is greater than 5 mm; or it is larger than two (2) centimeters but not larger than four (4) centimeters and the deepest point of tumour invasion is ten (10) mm or less.
Salivary Gland Cancer
The tumour is between two (2) cm and four (4) cm across. It has not spread into nearby lymph nodes or nearby tissue. It has not spread to organs in other parts of the body.
Nasopharyngeal Cancer (upper throat cancer)
The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is in the nasopharynx. It may or may not have spread into the oropharynx and/or the nasal cavity. Or, no tumour can be seen in the nasopharynx, but cancer is found in lymph nodes in the neck and is Epstein-Barr virus positive (EBV+). In either case, it has spread to lymph nodes on both sides of the neck, and none of the nodes are more than six (6) cm across.
- The tumour has spread to tissues on the left or right sides of the upper throat but not into bone. It has spread to lymph nodes on both sides of the neck, and none of the nodes are more than six (6) cm across.
- The tumour has grown into the sinuses and/or nearby bones. It may or may not have spread to lymph nodes in the neck or to lymph nodes behind the throat, and none of the nodes are more than six (6) cm across.
Oropharyngeal Cancer (middle throat cancer)
For HPV-positive cancer of the oropharynx:
The cancer has not spread to organs in other parts of the body. It has spread to at least one (1) lymph node on the opposite side of the neck as the tumour or to lymph nodes on both sides of the neck, but none are more than six (6) cm across. One of these is also a fact:
- The tumour is more than four (4) cm across.
- The cancer is growing into the base of the tongue (epiglottis).
- The cancer is growing into the voice box (larynx), tongue muscle, nearby bones, the jaw, or the hard palate.
For HPV-negative cancer of the oropharynx:
The cancer has not spread to organs in other parts of the body, and one of these is true:
- The tumour is more than four (4) cm across and may or may not be growing into the base of the tongue (epiglottis).
- The tumour is any size and may or may not have grown into nearby tissues. It has spread to one (1) lymph node on the same side of the neck as the tumour. The node is no more than three (3) cm across, and the cancer has not spread to the outside of it.
Hypopharyngeal Cancer (lower throat cancer)
The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is more than four (4) cm across, or it has grown into the esophagus, or it’s affecting the vocal cords. It has not spread to nearby lymph nodes.
- The tumour is any size. It may or may not have spread into nearby tissues. It may or may not be affecting a vocal cord. It has spread to one (1) lymph node on the same side of the neck as the tumour, and that node is not more than three (3) cm across.
Lip and Oral Cavity Cancer
The tumour is larger than two (2) cm but not larger than four (4) cm and the deepest point of tumour invasion is greater than ten (10) mm; or is larger than four (4) cm and the deepest point of tumour invasion is ten (10) mm or less; or has spread to one lymph node that is three (3) cm or smaller, on the same side of the neck as the primary tumour.
Salivary Gland Cancer
The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is more than four (4) cm across and/or has spread into nearby soft tissues. It has not spread to nearby lymph nodes.
- The tumour is any size and may or may not have spread into nearby soft tissues. It has spread to one (1) lymph node on the same side of the head as the tumour. The node is no more than three (3) cm across, and the cancer has not spread to the outside of it.
Nasopharyngeal Cancer (upper throat cancer)
This stage is divided into two (2) groups:
- Stage IVA: The cancer has not spread to organs in other parts of the body, with one of these facts:
- The cancer has spread to the skull and/or nerves in the head, the hypopharynx (the lower part of the throat), the main salivary gland, or the eye and its nearby structures. It may or may not have spread to lymph nodes in the neck or to lymph nodes behind the throat, and none of the nodes are more than six (6) cm across.
- The cancer has spread to structures outside the nasopharynx and to lymph nodes that are either more than six (6) cm across or are above the collarbone.
- Stage IVB: The cancer may or may not have spread to structures outside the nasopharynx or to nearby lymph nodes. It has spread to distant lymph nodes or organs in other parts of the body, like the bone, liver, or lung.
Oropharyngeal Cancer (middle throat cancer)
For HPV-positive cancer of the oropharynx:
The tumour is any size. It may or may not have grown into nearby tissues or lymph nodes. It has spread to organs in other parts of the body, like the bones or lungs.
For HPV-negative cancer of the oropharynx:
This stage is divided into three (3) groups:
- Stage IVA: The cancer is any size and has spread into nearby tissues, like the voice box (larynx), tongue muscle, nearby bones, the jaw, or the hard palate. It has not spread to organs in other parts of the body, and one of these facts:
- It has not spread to nearby lymph nodes, or it has spread to one (1) lymph node on the same side of the neck as the tumour. The node is no more than three (3) cm across, and the cancer has not spread to the outside of it.
- The cancer has spread to one (1) lymph node on the same side of the neck as the tumour. The node is between three (3) cm to six (6) cm across, and the cancer has not spread to the outside of it.
- It has spread to more than one (1) lymph node on the same side of the neck as the tumour. None of the nodes are more than six (6) cm across, and the cancer has not spread to the outside of any of them.
- The cancer has spread to at least one (1) lymph node on the opposite side of the neck as the tumour or to lymph nodes on both sides of the neck. None of the nodes are more than six (6) cm across.
- Stage IVB: The cancer is any size and may have spread into nearby tissues, like the voice box (larynx), tongue muscle, nearby bones, the jaw, or the hard palate. It has not spread to organs in other parts of the body, and one of these facts:
- There is spread to lymph nodes in one of these ways:
- The cancer has spread to one (1) lymph node that’s more than six (6) cm across, but the cancer has not spread to the outside of it.
- It has spread to one (1) lymph node that’s more than three (3) cm across, and the cancer has clearly spread outside the node.
- It has spread to more than one (1) lymph node on the same side of the neck as the tumour, a node on the opposite side of the neck, or to nodes on both sides of the neck. The cancer has clearly spread outside at least one (1) lymph node.
- The cancer has spread to one (1) lymph node on the opposite side of the neck as the tumour. The node is no more than three (3) cm across, and the cancer has clearly spread outside the node.
- The cancer is growing into the base of the skull or other nearby bones, or it’s wrapped around the carotid artery. It may or may not have spread to nearby lymph nodes.
- There is spread to lymph nodes in one of these ways:
- Stage IVC: The cancer is any size and may or may not have spread into nearby tissues. It may or may not have spread to nearby lymph nodes, but it has spread to organs in other parts of the body, such as the lungs or liver.
Hypopharyngeal Cancer (lower throat cancer)
This stage is divided into these three (3) groups:
- Stage IVA: The cancer has not spread to organs in other parts of the body, and one of these facts:
- The cancer is growing into cartilage, bone, the thyroid gland, or nearby fat or muscle. It either has not spread to nearby lymph nodes, or it has spread to one (1) lymph node that’s less than three (3) cm across and on the same side of the neck as the tumour.
- The tumour can be any size. It may or may not have grown into a vocal cord or nearby structures. It has spread to lymph nodes in one of these ways:
- It has spread to one (1) lymph node that’s more than three (3) cm but less than six (6) cm across and on the same side of the neck as the tumour.
- It has spread to more than one (1) lymph node on the same side of the neck as the tumour, and none of the lymph nodes are more than six (6) cm across.
- It has spread to at least one (1) lymph node on the other side of the neck, and none of the lymph nodes are more than six (6) cm across.
- Stage IVB: The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is growing into the space between the lungs, into the area in front of the spine in the neck, or it wraps around a carotid artery. It may or may not have spread to nearby lymph nodes.
- The tumour is any size. It may or may not have spread into a vocal cord or nearby tissues. It has spread to at least one (1) lymph node that’s more than six (6) cm across, or it has spread to and grown outside of the lymph node.
- Stage IVC: The tumour is any size. It may or may not have spread into a vocal cord or nearby tissues. It may or may not have spread to nearby lymph nodes. The cancer has spread to distant lymph nodes or organs in other parts of the body, like the lung, liver, or bone.
Lip and Oral Cavity Cancer
This stage is divided into three (3) groups:
- Stage IVA: The tumour is larger than four (4) cm and the deepest point of tumour invasion is greater than ten (10) mm; or cancerhas spread to the outer surface of the upper or lower jawbone, into the maxillary sinus, or to the skin of the face. The cancer may have spread to one (1) lymph node that is three (3) cm or smaller, on the same side of the neck as the primary tumour.
- Cancer has spread to the outer surface of the upper or lower jawbone, into the maxillary sinus, or to the skin of the face.
- The cancer has spread to one (1) lymph node that is three (3) cm or smaller, on the same side of the neck as the primary tumour, and cancer has spread through the outside covering of the lymph node into nearby connective tissue
- to one (1) lymph node that is larger than three (3) cm but not larger than six (6) cm on the same side of the neck as the primary tumour
- to multiple lymph nodes that are not larger than six (6) cm, on the same side of the neck as the primary tumour
- to multiple lymph nodes that are not larger than six (6) cm on the opposite side of the neck as the primary tumour or on both sides of the neck.
- Stage IVB: the tumour:
- has spread to one (1) lymph node that is larger than six (6) cm
- has spread to one (1) lymph node that is larger than three (3) cm on the same side of the neck as the primary tumour, and cancer has spread through the outside covering of the lymph node into nearby connective tissue
- has spread to one (1) lymph node of any size on the opposite side of the neck as the primary tumour, and cancer has spread through the outside covering of the lymph node into nearby connective tissue
- has spread to multiple lymph nodes anywhere in the neck, and cancer has spread through the outside covering of any lymph node into nearby connective tissue; or
- has spread further into the muscles or bones needed for chewing, or to the part of the sphenoid bonebehind the upper jaw, and/or to the carotid artery near the base of the skull. Cancer may have also spread to one (1) or more lymph nodes of any size, anywhere in the neck.
- Stage IVC: The tumour:
- has spread beyond the lip or oral cavityto other parts of the body, such as the lung, liver, or bone.
Salivary Gland Cancer
This stage is divided into three (3) groups:
- Stage IVA: The cancer has not spread to organs in other parts of the body, and one of these facts:
- The tumour is any size and is growing into nearby tissues, like the jawbone, ear, skin, and/or facial nerve. It may or may not have spread to nearby lymph nodes. If it has, it’s in only one (1) lymph node on the same side of the head or neck as the tumour. The node is no more than three (3) cm across, and the cancer has not spread to the outside of it.
- The cancer is any size and may or may not be growing into nearby tissues. It has spread to lymph nodes in one of these ways:
- It’s in only one (1) lymph node on the same side of the head or neck as the tumour. The node is between three (3) cm and six (6) cm across, and cancer has not spread to the outside of it.
- It’s in more than one (1) lymph node on the same side of the head or neck as the tumour. None of the nodes are more than six (6) cm across, and cancer has not spread to the outside of any of them.
- It’s in more than one (1) lymph node on the opposite side of the head or neck as the tumour, or it’s in nodes on both sides of the head or neck. None of the nodes are more than six (6) cm across, and the cancer has not spread to the outside of any of them.
- Stage IVB: The cancer has not spread to organs in other parts of the body, and one of these is true:
- The tumour is any size and may or may not be growing into nearby tissues. It has spread to lymph nodes in one of these ways:
- It’s in only one (1) lymph node that’s more than six (6) cm across, and the cancer has not spread to the outside of it.
- It has spread to one (1) lymph node that’s more than three (3) cm across, and the cancer has clearly spread outside the node.
- It’s in more than one (1) lymph node in the neck, and the cancer has clearly spread to the outside of them.
- It has spread to one (1) lymph node on the opposite side of the neck as the tumour. The node is no more than three (3) cm across, and the cancer has clearly spread outside the node.
- The tumour is any size and may or may not be growing into nearby tissues. It has spread to lymph nodes in one of these ways:
- The tumour is any size and is growing into nearby tissues, such as the base of the skull or other nearby bones, or it’s wrapped around the carotid artery. It may or may not have spread to nearby lymph nodes.
Stage IVC: The tumour is any size and may or may not have spread to nearby structures and lymph nodes. It has spread to distant lymph nodes or organs in other parts of the body, such as the lungs.
One tool that doctors use to describe the stage is the TNM system. Results from diagnostic tests and scans are used to answer these questions:
- Tumour (T): How large is the primary tumour? Where is it located?
- Node (N): Has the tumour spread into the lymph nodes? If yes, where and how many?
- Metastasis (M): Has the cancer spread to other parts of the body? If yes, where, and how much?
The results are combined to determine the stage of cancer of each patient and to plan the best treatment.
