Head and neck cancer is increasing worldwide. During the past 15 years, oral and neck cancer has increased from 2,000 to 8,000 new cases per year in the United Kingdom. This may be a reflection of better recording of data and awareness. But with the increased incidence of cancers driven by the human papillomavirus, especially among younger patients, the growth likely is real.
So are the consequences. Working in a busy medical unit in London is always challenging, with multidisciplinary specialist discussions about each case and the complex surgical techniques needed in the operating theater. This week, I had a long discussion with a family following the death of a patient.
The surgery was major for a tongue cancer, and given his other issues, it was not risk-free. But following the 12-hour procedure, we were cautiously optimistic. The short stay in intensive care and transfer to the ward was encouraging. His smiles and “thumbs up” made us feel that we were winning.
The sudden call at midnight from the ward 9 days after the surgery was a shock. A catastrophic bleed was the cause. The autopsy concluded it was a gastric bleed, out of the blue, with no previous history or signs. The discussion with the family was much needed by both the clinicians and the relatives.
Questions must be answered, and “what ifs” must be aired openly and honestly. But the man’s memory must not be forgotten as well. Fortunately, this is a rare occurrence. Yet it does bring home the very real risks of cancer surgery.
A Closer Look
The gentleman did not fit the normal profile of most of my patients. Usually, alcohol and smoking play an important role in the lives of most of my cancer patients. Betel quid (also known as paan) and tobacco chewing also are factors. Plus, some vegetarian Asian patients may have a genetic susceptibility to mouth cancer.
This cancer presented as a lump on the tongue. If a lump or abnormal patch or ulcer persists for more than 3 weeks as it did in this case or grows, then it is likely to start to be painful, bleed, or cause difficulty in speaking or swallowing food. Sometimes, pain can radiate to the ear and cause earaches or present with a lump in the neck.
If patients ignore their symptoms for too long, as in this case, then the stage of cancer progresses and the patient’s overall outlook deteriorates. The morbidity (surgical destruction to tissues and organs) also increases with the size and site of the tumor.
Removing part or most of the tongue as we did in this case will cause many future functional issues related to eating, swallowing, and speaking. Some patients may become dependent upon a long-term feeding tube inserted directly through the abdominal wall into their stomach.
The surgical management of advanced tongue cancer is agreed upon after discussions during a multidisciplinary team meeting. Once the treatment plan is ratified, the patient and family are involved in the process, and the subsequent steps are discussed. This involves meeting the oncologists, clinical nurse specialists, speech and language therapists, dieticians, and dental team.
The surgery is planned with 2 consultant lead teams: one ablative (removing the cancer) and the other reconstructive (replacing the lost structures). This complex surgery often takes 10 hours or more in the operating theatre. However, the team approach is the most important factor in the patient’s management.
The vast majority of our patients survive the hospital stay and may need postoperative radiotherapy or chemotherapy as outpatients. Each step has its potential risks and benefits. We continue to work in the hope we are making a difference and caring for our patients.