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Learning About Your Diagnosis

16970620If you have recently been diagnosed with head and neck cancer, then your health care professional probably obtained the results from your biopsy. Other pieces of information that your doctor also collected (or will soon gather) include the grade, histology subtype and stage. Let’s first briefly review what these tests and evaluations are and what they will tell you.

Biopsy, grade, histological subtype and stage

  • Biopsy: A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of any lesion your doctor suspects may be cancer. The biopsy report is extremely important for determining your diagnosis and treatment plan.1 Shah JP, Lydiatt W. Treatment of cancer of the head and neck. CA Cancer J Clin. 1995;45:352-368.
  • Grade: The pathologist will also grade the cells, or categorize them by how well defined the cells appear (in other words, how closely they resemble normal cells). The pathologist will assign a grade to the cells, which typically will range from 1 to 4. If the cells appear normal, then they are categorized as well differentiated and are assigned a score of 1. Conversely, if the cells appear very abnormal, then they are assigned a score of 4.2Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611.
  • Histological subtype: The pathologist will also classify the cell types; over 90 percent of patients diagnosed with head and neck cancer have squamous cell carcinoma.3 Marur S, Forastiere AA. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008 Apr;83(4):489-501.
  • Stage: Cancer is staged by the size of the tumor and how extensive it is within the body.2Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611. The staging system used in the United States is based on tumor size (T) and how extensive the tumor is within the body; for example, whether the malignancy has entered regional lymph nodes (N), or whether the cancer has moved (metastasized) to distant sites within the body (M), such as the lungs.
  • Evaluating how extensive the tumor is within the body involves the use of imaging devices, such as computed tomography (CT), magnetic resonance imaging (MRI) or positron emission tomography (PET).3 Marur S, Forastiere AA. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008 Apr;83(4):489-501.

The types of stages are typically from an early stage (I), with the smallest tumor size that has not yet extended to lymph nodes or distant sites in the body, to stage (IV), which is either the largest tumor size or it has moved to distant sites in the body.2Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611. Specifics are defined in each tumor subsite section of the Head and Neck Cancer Guide.

Why is the name of the specific type of head and neck cancer, along with the assigned grade and stage, important to you? Let’s look at what this information means in the next two sections.

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What your diagnosis means: prognosis

Your health care provider should have provided you with the name of the type of cancer and its grade and stage. This information can be used to provide a prognosis or an estimate of the probable outcome of your cancer, which includes the likelihood of survival.3 Marur S, Forastiere AA. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008 Apr;83(4):489-501.

The Surveillance Epidemiology and End Results (SEER) database collects information on cancer from various regions within the United States; this information can then be used to determine the average outcomes of similar patients.4 Surveillance Epidemiology and End Results (SEER) Website. Accessed at seer.cancer.gov on February 17, 2013.

People who are diagnosed with an early stage of head and neck cancer will have a better prognosis than patients with late stage disease. For example, after five years, most patients (82.4 percent) diagnosed with stage I or II head and neck cancer will be alive, but those in later stages at the time of diagnosis have a reduced chance of achieving a cancer-free state.5 Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). National Cancer Institute. Bethesda, MD.Accessed at http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012.

Table. Five Year Relative Survival for Head and Neck Cancer in the US, by Stage
Stage at Diagnosis Stage Distribution (%)
Localized, Stage I-II 82.4%
Regional, Stage III 57.3%
Distant, Stage IV 34.9%
From Howlander, SEER, 2012

The grade is also related to prognosis; if a patient has cells that appear very abnormal (grade 4), he or she usually has a worse prognosis than a patient with very normal-appearing cells (grade 1).2Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611.

What your diagnosis means: likely treatment course

Numerous clinical studies, which included patients with head and neck cancer, have been conducted. A panel of specialists has evaluated the findings from these clinical studies and recommended which treatments are likely to be most beneficial for particular subsets of patients.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

Your health care professional will likely use the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for Head and Neck Cancers, in addition to your specific diagnosis and stage, to provide a recommendation for the best treatment course for your cancer.1, Shah JP, Lydiatt W. Treatment of cancer of the head and neck. CA Cancer J Clin. 1995;45:352-368.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. In some cases, either the grade and/or the histological subtype (e.g., squamous cell or another type) will also be used to make a treatment recommendation.

It should be cautioned that although the diagnosis and stage are used to provide a recommendation for a treatment course, it does not mean that this is your only treatment option. Often times, there are several possible treatment options.2Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611. In addition, you have the right to evaluate the available information and decide whether it is the best treatment course for you. For example, sometimes patients refuse to have surgery and are instead treated with chemotherapy, radiation therapy or both.

Re-evaluation: should you get a second opinion?

The NCCN Guidelines® for Head and Neck Cancers recommend that patients be treated by a multidisciplinary team; the team members should have an expertise in head and neck cancer.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. Moreover, a study demonstrated that specialists versus non-specialists performed more accurate diagnoses.7 Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol. 2000 Jun;18(11):2327-40. The NCCN Guidelines recommend treatment choices based on the initial diagnosis;6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. therefore, an accurate diagnosis is essential to select the best treatment option.

Head and neck cancers represent about 3 percent of all cancers, so it is fairly uncommon.3 Marur S, Forastiere AA. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008 Apr;83(4):489-501. A hospital in a rural area, for example, may not have health care professionals with a high volume of head and neck cancer patients, which could potentially result in an inaccurate diagnosis and could in turn result in the selection of a less optimal treatment management plan.

You may want to consider identifying medical facilities that have specialists with an expertise in head and neck cancer to receive a second opinion.

I actually felt quite relieved when I was diagnosed with cancer because there was some plan that was laid out for what the doctor was going to do to address the issue.Gordon O. (laryngeal cancer survivor)

References

1 Shah JP, Lydiatt W. Treatment of cancer of the head and neck. CA Cancer J Clin. 1995;45:352-368.

2 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611.

3 Marur S, Forastiere AA. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008 Apr;83(4):489-501.

4 Surveillance Epidemiology and End Results (SEER) Website. Accessed at seer.cancer.gov on February 17, 2013.

5 Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). National Cancer Institute. Bethesda, MD.Accessed at http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

7 Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol. 2000 Jun;18(11):2327-40.