Dr Johann Kluge explains the shift of clinical presentation of throat cancer.
Throat cancer (oropharyngeal carcinoma) refers to cancers developing in a specific subset in the head and neck region (base of tongue (BOT) and tonsils). The most common type of cancer in this region is squamous cell carcinoma, although lymphoma is also encountered.
Pre-1990 era vs. 2000-era
During the past decades, the clinical presentation changed dramatically, with the ‘pre-1990 era’ being tobacco-related oropharyngeal cancers and the ‘2000-era’ and onwards regarded as human papillomavirus (HPV)-related.
In the past two decades, HPV was identified as a direct cause of cancer with management protocols being revisited. The reason for this, is the fact that studies have shown that cancers developing in the tonsillar region and BOT don’t necessarily have a correlation with smoking.
HPV was identified specifically in the younger patient, leading to the collapse of the dogmatic thought process that throat cancer is caused by tobacco use only.
What are the causes of throat cancer?
- Poor nutrition
HPV are small viruses that are widely distributed. More than 150 different strains of HPV exist, with HPV 16 being the most common, leading to cancer. Transmission takes place by sexual contact, making the HPV infection the most commonly sexually transmitted disease.
Significant increase has been associated with: a number of sexual partners; history of oral sex; earlier age at sexual debut; and history of same sex sexual contact.
Eighty percent of human beings are exposed to HPV during their lifetime, with 80% being cleared spontaneously. The timing between exposure to HPV and the development of cancer probably exceeds more than 10 years.
Clinical features and presentation (HPV-related vs Non-HPV)
|HPV-related||Non-HPV (tobacco/alcohol etc.)|
|Age||Younger (bimodal age presentation around 30 and 55 years).||Older patients (mean age of 61 years).|
|Gender||More common in males than females.||More common in males than females.|
|Alcohol history||Usually non-drinkers.||Usually background of alcohol use.|
|Symptoms||Throat pain, difficulty swallowing, weight loss, ear ache, voice change, blood-tinged saliva, persistent mass of the neck.||Throat pain, difficulty swallowing, weight loss, ear ache, voice change, blood-tinged saliva, persistent mass of the neck.|
|Anatomic region||More common in the tonsillar region or base of tongue (BOT).||Any subset/division in the oropharynx.|
|Staging i.e. extent of cancer spread||More common to present as early disease.||Usually presents as late stage disease (i.e. more advanced).|
|Prognosis||Better than non-HPV related.||Worse than HPV-related.|
|Risk of a second malignancy (cancer)||Less likely to develop a second cancer in the head and neck region.||More likely to develop a second cancer in the head and neck region.|