High-risk patients with a growing mass require proper assessment, including a thorough history, physical examination, and fine-needle aspiration for diagnosis.
A 65-year-old Vietnam veteran with a history of posttraumatic stress disorder (PTSD), transient ischemic attack, alcohol dependence, and a smoking history of 50 pack-years presents with a neck mass that has been growing for 2 months and unintentional weight loss of 25 pounds over 6 months. What is the differential diagnosis? How does a general practitioner evaluate, manage, and efficiently triage this patient?
Such cases, in which a head and neck cancer (HNC) diagnosis is suspected, can be unnerving for both physician and patient. However, knowledgeable general practitioners (GPs) can play a pivotal role in recognizing high-risk patients, initiating workups, and referring to appropriate specialists, resulting in earlier detection and potentially better outcomes.
This article outlines the authors’ recommended best practices for GPs treating patients with presumed HNC. Although the focus here is on the veteran population, in which HNC rates are significantly higher, many of the suggestions presented are applicable to the general population.
Background
Head and neck cancers represent a diverse family of malignancies of the nasopharynx, oropharynx, hypopharynx, larynx, oral cavity, paranasal sinuses, and salivary glands. This article does not cover thyroid, ophthalmologic, neurologic, or skin malignancies. The yearly worldwide incidence of all HNC cases is more than 550,000. 1 In the U.S., 55,000 new HNC cases, representing 3% of all new malignancies, are reported annually. The 5-year survival rate is 60%, but 12,000 Americans die each year of head and neck cancer. 2 Most HNCs occur in males aged ≥ 50 years, and the incidence increases with age. Almost $3.6 billion is spent treating HNC in the U.S. annually. 3
Risk Factors
Alcohol and tobacco consumption strongly predisposes patients to squamous cell carcinoma (SCC), which accounts for 90% of HNCs. Together, alcohol and tobacco act multiplicatively. 4,5 For instance, heavy drinkers (≥ 10 drinks daily) are at 5-fold increased risk for oral and pharyngeal cancers, heavy smokers (≥ 1 pack daily) are at 20-fold increased risk, and people who both drink and smoke heavily are at 50-fold increased risk. 6 Head and neck cancer rates are significantly elevated even for moderate/light drinkers and smokers.
Veterans have disproportionately high rates of alcohol drinking and tobacco smoking, 7,8 in part because these habits are ingrained in military culture. During World Wars I and II, tobacco companies supplied soldiers with daily rations of cigarettes, 9 and advertisers targeted military personnel by linking smoking with patriotism, strength, and toughness. 10 The VHA and the DoD reported that 33% of veterans and active-duty service personnel smoke—compared with 23% of civilians. 11 Vietnam veterans, 47% of whom smoke, are at particular risk for HNC. 12
Cessation of alcohol drinking and tobacco smoking is essential for overall prognosis, especially after HNC has been diagnosed. Continued smoking after HNC treatment increases the recurrence rate 4-fold. 13 There also is mounting evidence that cessation of drinking and smoking can reverse the risk for HNC over time. According to a meta-analysis, quitting smoking for just 1 year begins to lower the risk for HNC. Quitting smoking for 20 years reduces the risk to the level of never smokers, and abstaining from alcohol for 20 years decreases the risk by nearly 40%. 14
