FAQs

In collaboration with HNCSA and the HPV Project, we have developed this fact sheet on sexual intimacy and HPV-related throat cancer.

In all of the departments throughout New Zealand, we have multidisciplinary meetings (MDMs). They run slightly differently from one hospital to the other, but as a general rule, we try to discuss every new patient with a head and neck cancer diagnosis in these meetings. This is regardless of whether a patient is initially seen in the private or public sector.

The MDM team includes surgeons, oncologists (specialist cancer doctors), pathologists (who can talk about what the features of the tumour are) and radiologists (who can talk about the scans that have been done). We have dentists and dietitians, because head and neck patients often have dental and dietary needs prior to or during their treatment. We often have a supportive team there as well, including speech therapists (kind of like a physio for the throat). Sometimes we'll have a palliative care representative too.

This means that we can have a discussion about what's the most appropriate treatment approach for a patient, and the patient can be confident that they're getting a consensus from all of the key people.

The two big factors that influence our decision about treatment are: firstly, which is going to give us the best chance of controlling the cancer. Secondly, we look at the functional outcomes - things like swallowing and speech. So, we take into account what treatment approach gives us the best tumour outcome, and the best functional outcome.

Yes. As with a lot of cancers of the head and neck area, it depends how early someone presents with these cancers. If you present with an early tumour, which is small and hasn't spread to the lymph glands in the neck, often surgery is all that you need. For the more advanced tumours - where the tumour in the tongue is a little bit larger, or the tumour has spread to the glands in the neck - you often need to have both surgery and radiotherapy. If you’re more high-risk, you may need chemotherapy and radiotherapy.

We always tend to favour surgery as the first treatment option. Occasionally, people present with a really advanced tumour where we think surgery is not the best thing because functional issues might be a problem. In this case, we treat those with radiotherapy and chemotherapy as their main treatment.

It all really depends on the stage of the tumour. The early ones do well. With the more advanced tumours, there is a risk that they can have a recurrence, so they're monitored very carefully.

We sometimes look at clinical photos during the multi-disciplinary meeting, especially if the patient's not there. That could be a clinical photo of a skin lesion, for example. Generally, patients are examined with the fibre optic laryngoscope - it’s kind of like a little telescope which can pass through your nose, have a look at the back of your nose, throat, and down to your larynx. That's recorded on video, so that we can see the tumour and use this record later on. This can be really helpful in providing information which is complementary to what you see on the scans.

When we're trying to define exactly where the tumour is, we take into account what we can see when we examine the patient, including that video, as well as the scans, in order to get a complete picture. A photo or a video is certainly very important.

The current role of immunotherapy such as ‘KEYTRUDA’ in head and neck cancer is mainly in patients who have disease that has spread (this is what we call metastatic disease). It's also sometimes used if the disease has recurred.

In that context, it can be really effective. It does vary a bit, depending on what type of tumour you have. Some tumours, such as melanoma or some of the skin cancers have quite a high response rate to immunotherapy. With some of the more common head and neck tumours of the mouth or the throat, the response isn't as high - but if you do respond, it can be really effective. It's probably a bit less than a 50/50 chance that it will work in that setting.

The other benefit of immunotherapy is that it tends to be very well tolerated. With some patient groups, there may only be a 20% chance that they'll benefit, but it's still worth having to go.

Although it’s currently mainly used in advanced settings, there's a lot of interest in trying to bring immunotherapy earlier into the management. At the moment, the upfront treatment is still surgery, radiotherapy and chemotherapy, with immunotherapy further down the track.

It’s not readily available in the public sector at present, though that may change in time. There are some patients with oropharyngeal tumours who can still have more conventional surgery in the public setting - if they have a small tumour and the surgeon can get good access. The advantage of robotic surgery is when the surgeon can’t get good access to the tumour.

When we're planning radiotherapy, we’re always very mindful of making sure we spare the surrounding normal tissues as much as we can. Part of that is done by how we plan the treatment. We get a CT scan, and work out exactly where we want to treat. Then, we define a lot of normal tissue structures, including the mandible, the jawbone, the spinal cord, the eye and the ear. We then try to reduce the dose to those normal tissues.

As part of that, we sometimes put a tongue depressor inside the mouth to move the tongue away from the area that's going to receive the dose of radiotherapy. For example, if we're treating the roof of the mouth, it can be good to push the tongue down out of the way. Or if we're treating the side of the mouth, sometimes we use the tongue depressor to push the tongue to the opposite side.

There are very standardised approaches regarding what type of surgery can be done at local hospitals, and what needs to go to a bigger hospital. Some of the smaller tumours can be managed at the local hospitals, whereas the more advanced surgery tends to be done in a big hospital. This is particularly where they're putting in a 'flap', i.e. removing tissue, then taking tissue from elsewhere to reconstruct that area.

With some types of surgery, we need to protect the airway because of the swelling that can occur after the surgery, so the patient has a temporary tracheostomy. These sorts of operations tend to be done in major hospitals.

It does vary a little based on the scenario. For instance, if you've had surgery as your main treatment, the surveillance is different from if you've had radiotherapy as your first treatment.

When you have radiotherapy as your main treatment, we tend to do a PET scan three months after you've finished radiotherapy. The reason we wait three months is because the tumours can continue to shrink down once the radiotherapy is finished, and because the throat is inflamed from the treatment.

Hopefully, after that scan, you'll then go on to a more regular follow up. It's quite common to have a PET scan and it shows that it's responded, but it's not quite back to normal. This might mean we do another scan three months after that. It all just depends on the situation. Eventually, you'll get to the point where you're having a scan once a year.

Because you can visualise the area so well with head and neck cancer, the follow-up clinical exam (which is generally done by the surgeons) is really important as well.