Head and neck cancer is the leading cancer group in Indian men, driven mainly by tobacco, areca nut and gutkha exposure, with lip and oral cavity tumours alone accounting for an estimated 143,759 new cases and 79,979 deaths in India in 2022 per GLOBOCAN. Inside Delhi NCR, tongue, mouth and tonsil cancers consistently sit inside the top ten cancers for men, and most patients still reach a tertiary centre at stage III or stage IVA. This page explains how head and neck oncologists in Delhi, Gurgaon and Noida actually stage these cancers using AJCC TNM 8, why HPV-positive oropharynx and nasopharynx are staged separately, and what families can expect at each stage in an NCR tertiary centre such as a tertiary cancer centre, Dr BRA-IRCH, leading cancer centres.
What Head and Neck Cancer Staging Actually Means
Head and neck cancer staging is the formal process of deciding how far a squamous cell carcinoma of the upper aerodigestive tract has spread from its starting point in the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, sinonasal tract or salivary glands. The stage is built from three pieces of information: the size and local invasion of the primary tumour (T), whether regional lymph nodes in levels I to V of the neck or the retropharyngeal chain are involved (N), and whether the cancer has seeded the lungs, bone, liver or distant nodes (M). Every NCCN-aligned NCR hospital reports stage in the same AJCC/UICC TNM 8 language, which is why a Delhi patient who moves between a tertiary cancer centre, Dr BRA-IRCH, a tertiary cancer centre and a leading cancer centre does not have to be re-staged. (See the NCI PDQ on head and neck cancers.)
Why Head and Neck Cancers Are Staged With AJCC TNM 8
The 8th edition of the AJCC/UICC TNM made major changes for head and neck cancer that did not exist in TNM 7. Oral cavity T category now includes depth of invasion of the primary tumour, because Indian and international data showed that depth above 5 mm and above 10 mm independently predicts nodal spread and survival, regardless of surface size. HPV-positive oropharyngeal carcinoma was given a completely separate staging system because the prognosis is far better than for HPV-negative tumours of the same size. Extranodal extension on a positive neck node became a major upstaging factor in HPV-negative disease. Nasopharyngeal carcinoma kept its own TNM rules because of its EBV-driven biology. These TNM 8 changes are now embedded in every Indian tumour board including a tertiary cancer centre, a tertiary cancer centre Delhi, leading cancer centres and are reflected in the ESMO head and neck guidelines.
The Eight Anatomic Sites Inside Head and Neck Cancer
Head and neck cancer is an umbrella term, not a single disease. The group covers cancers of the oral cavity (lip, tongue, floor of mouth, buccal mucosa, gingiva, hard palate, retromolar trigone), oropharynx (tonsil, base of tongue, soft palate, posterior pharyngeal wall), hypopharynx, larynx (supraglottis, glottis, subglottis), nasopharynx, nasal cavity and paranasal sinuses, and major and minor salivary glands. Each subsite has its own typical histology, lymphatic drainage, treatment template and prognosis, which is why the AJCC TNM 8 has subsite-specific T tables for oral cavity, oropharynx, larynx, hypopharynx, nasopharynx, sinonasal and salivary tumours. Thyroid, brain, eye and skin cancers of the head are tracked as separate disease groups and are not included in this hub.
Squamous Cell Carcinoma and Its WHO 5 Variants in Head and Neck
The dominant histology across every site except the salivary glands is squamous cell carcinoma, which arises from the squamous mucosa and accounts for roughly 90 percent of head and neck cancers in Indian series. Squamous cell carcinoma is graded as well, moderately or poorly differentiated, and the WHO 5th edition recognises conventional, basaloid, papillary, spindle cell (sarcomatoid), adenosquamous, acantholytic, verrucous, lymphoepithelial and carcinoma cuniculatum variants. Verrucous carcinoma, common in long-term gutkha users in NCR, is a slow-growing locally destructive variant with a better outlook when fully excised. The WHO 5e classification of head and neck tumours is the reference text used by every NCR pathology lab including leading cancer centres, Oncquest and accredited diagnostic laboratories. (See WHO Classification of Tumours, Head and Neck.)
HPV-Positive vs HPV-Negative Oropharyngeal Cancer
Oropharyngeal squamous cell carcinoma is now split into two clinically distinct diseases by HPV status. HPV-positive (p16-positive) oropharyngeal cancer, usually driven by HPV type 16, has a substantially better prognosis stage for stage and is staged separately under AJCC 8 TNM. HPV-negative oropharyngeal cancer follows the older tobacco-driven biology and is staged with the rest of the head and neck squamous cancers. p16 immunohistochemistry on the biopsy is now standard practice at a tertiary cancer centre Mumbai, a tertiary cancer centre Delhi and most NCR tertiary labs, with reflex HPV DNA or RNA in situ hybridisation when p16 is equivocal. Despite the better outlook, full-intensity concurrent cisplatin and radiation remains the standard of care for HPV-positive disease outside clinical trials, because de-escalation arms in RTOG 1016 and De-ESCALATE HPV3 were inferior to standard chemoradiation. (See the NCI PDQ on oropharyngeal cancer.)
Nasopharyngeal Carcinoma: A Biologically Distinct Disease
Nasopharyngeal carcinoma is biologically distinct from the rest of the head and neck cancer group. The WHO classifies it into keratinising squamous, non-keratinising (differentiated and undifferentiated) and basaloid squamous types, and the non-keratinising undifferentiated form is strongly associated with Epstein-Barr virus rather than tobacco. It typically presents with a unilateral neck node high in the upper cervical chain, blocked or bleeding nose, unilateral hearing loss from eustachian tube blockage, and headaches with diplopia in advanced cases. Incidence is higher in north-east India and in pockets of NCR with migrant populations from the region. It is treated almost entirely with chemotherapy and radiation rather than surgery. Plasma EBV DNA at baseline and during follow-up is used as a biomarker at a tertiary cancer centre and a tertiary cancer centre reference labs. (See the NCI PDQ on nasopharyngeal cancer.)
Salivary Gland Tumours and Sinonasal Rare Histologies
Salivary gland cancers are a separate family with their own histologies and behaviour. The common malignant types are mucoepidermoid carcinoma (low, intermediate or high grade), adenoid cystic carcinoma (with cribriform, tubular and solid patterns and a notable tendency for perineural spread along the facial and trigeminal nerves), acinic cell carcinoma, salivary duct carcinoma (often HER2 or androgen receptor positive and aggressive), polymorphous adenocarcinoma and carcinoma ex pleomorphic adenoma. Sinonasal cancers add further rare entities such as sinonasal undifferentiated carcinoma (SNUC), olfactory neuroblastoma (esthesioneuroblastoma) and NUT carcinoma. Salivary tumours follow the general head and neck T and N tables but histologic grade is a strong prognostic modifier and changes treatment, which is why every NCR tumour board reviews salivary cases as a separate slot. (See the NCI PDQ on salivary gland cancer treatment.)
The T Descriptor for Oral Cavity: Depth of Invasion Matters
Oral cavity T category in AJCC 8 incorporates depth of invasion (DOI) of the primary tumour, which was a major change from TNM 7. T1 is now a tumour up to 2 cm with depth up to 5 mm, T2 covers tumours up to 4 cm or DOI between 5 and 10 mm, T3 is above 4 cm or DOI above 10 mm, and T4a tumours invade through cortical bone of the mandible or maxilla, into deep tongue muscles or facial skin. T4b indicates involvement of masticator space, pterygoid plates, skull base or the internal carotid artery and is usually unresectable. The reason DOI was added is that depth predicts occult nodal metastasis better than surface diameter, which is why elective neck dissection is now recommended in any oral cancer with DOI above 3 to 4 mm, regardless of clinical node status. (See the NCI PDQ on lip and oral cavity cancer.)
The N Descriptor and Extranodal Extension Upstaging in Head and Neck Cancer
Nodal staging in head and neck cancer is anchored on the levels of the neck (I to V plus retropharyngeal), the size and laterality of involved nodes, and the presence of extranodal extension. For HPV-negative tumours, N1 is a single ipsilateral node up to 3 cm without extranodal extension, N2a is a single ipsilateral node 3 to 6 cm or any node with extranodal extension, N2b is multiple ipsilateral nodes, N2c is bilateral or contralateral nodes, and N3 is a node above 6 cm or any clinically overt extranodal extension. Any pathological extranodal extension upstages the patient to at least pN2a in HPV-negative disease and triggers post-operative concurrent chemoradiation per the Bernier-Cooper analysis of EORTC 22931 and RTOG 9501. p16-positive oropharynx and nasopharyngeal carcinoma each have their own simpler N tables.
Stage I and II Head and Neck Cancer
Stage I and II head and neck cancer covers small primary tumours (T1 or T2) with no lymph node spread (N0) and no distant metastasis. For HPV-negative disease, Stage I is T1 N0 and Stage II is T2 N0. For HPV-positive oropharyngeal cancer, Stage I covers T1 to T2 with N0 to N1 nodal disease, reflecting the better biology. Treatment at this stage is single modality, either surgery or radiation, chosen by site. Early oral cavity cancer is removed with wide excision plus elective selective neck dissection of levels I to III. Early glottic larynx tumours are treated with transoral laser microsurgery or definitive radiation. Five-year survival is approximately 75 to 90 percent for stage I and 65 to 80 percent for stage II in HPV-negative head and neck squamous cell carcinoma in Indian and SEER series.
Stage III Head and Neck Cancer
Stage III head and neck cancer (HPV-negative) is defined as a T3 primary with N0 disease, or any T1 to T3 with a single ipsilateral node up to 3 cm (N1). The tumour is large but still confined to its anatomic compartment, and most patients in this group are still candidates for curative treatment with combined modalities. Standard options are radical surgery followed by risk-adapted adjuvant radiation, or organ-preserving concurrent chemoradiation as primary treatment, decided by tumour site, surgical morbidity and patient choice. Five-year survival is approximately 50 to 65 percent and is improved by adherence to a complete chemoradiation course without treatment breaks, supported by good nutrition through a prophylactic PEG tube and rigorous dental care to prevent osteoradionecrosis.
Stage IVA and IVB Locally Advanced Head and Neck Cancer
Stage IVA disease in HPV-negative head and neck cancer is defined as T4a (moderately advanced local disease, such as cortical bone or deep extrinsic tongue muscle invasion) or N2 nodal disease. Stage IVB is T4b (involvement of masticator space, pterygoid plates, skull base or internal carotid) or N3 nodal disease. This is the largest group of patients reaching NCR tertiary centres. Resectable Stage IVA is treated with composite resection, free flap reconstruction and neck dissection, followed by adjuvant cisplatin-based chemoradiation. Unresectable Stage IVB is treated with definitive concurrent chemoradiation, sometimes after induction TPF if the tumour is bulky. Five-year survival is approximately 30 to 50 percent. Aggressive supportive care, speech and swallow rehabilitation and dental clearance are critical to outcome.
Stage IVC Metastatic Head and Neck Cancer
Stage IVC head and neck cancer is defined by distant metastasis (M1), most often to the lungs, then bone and liver. The treatment intent shifts from cure to control of disease, symptom relief and prolongation of life. First-line systemic therapy is based on KEYNOTE-048: pembrolizumab monotherapy for tumours with PD-L1 combined positive score of 1 or higher, and pembrolizumab plus platinum and 5-FU for any CPS, both superior to the older EXTREME regimen of cetuximab plus platinum and 5-FU. Second line is nivolumab based on CheckMate 141. Five-year survival in this group is under 15 percent, but newer immune-based combinations are extending median survival meaningfully and are now available at most NCR tertiary centres.
Nasopharyngeal Carcinoma TNM 8 Staging Rules
Nasopharyngeal carcinoma has its own TNM 8 staging because the disease behaves differently from other head and neck cancers. T category runs from T1 (tumour confined to nasopharynx, oropharynx or nasal cavity without parapharyngeal extension), through T2 (parapharyngeal or adjacent soft tissues), T3 (bony structures of skull base, cervical vertebra, pterygoid structures or paranasal sinuses) and T4 (intracranial extension, cranial nerves, hypopharynx, orbit, parotid or extension beyond the lateral surface of the lateral pterygoid muscle). N1 is unilateral cervical or retropharyngeal nodes up to 6 cm, N2 is bilateral, and N3 is any node above 6 cm or extension below the caudal border of the cricoid cartilage. Stage groupings run I through IVB, with IVA being any M1. Five-year survival is approximately 90 percent for stage I-II and 70 to 80 percent for stage III-IVA in modern Indian series.
Early Symptoms of Head and Neck Cancer in Indian Patients
Early head and neck cancer is often subtle and easy to dismiss. A non-healing ulcer in the mouth that lasts beyond two weeks, a white patch (leukoplakia), a red patch (erythroplakia) on the tongue or buccal mucosa, a small painless neck node, or persistent hoarseness in a smoker are typical first signs. Many patients in Delhi NCR present with restricted mouth opening, a feature of submucous fibrosis driven by areca nut. Pain on swallowing, referred ear pain (otalgia) on one side, a change in voice quality lasting beyond three weeks and unexplained loosening of teeth are red flags that deserve specialist evaluation by an ENT or head and neck surgical oncologist within two weeks. Public awareness of these warning signs in NCR remains poor, which is the main reason most cases still present at stage III or IVA.
Symptoms of Locally Advanced and Metastatic Head and Neck Cancer
In locally advanced stage III and IVA head and neck cancer, symptoms become harder to ignore. Patients describe a fixed neck lump, loose teeth or ill-fitting dentures, blood-tinged saliva, difficulty swallowing solids, weight loss and a change in speech. Trismus, where the patient can no longer open the mouth more than two finger-breadths, points to involvement of the pterygoid muscles. Numbness of the chin or lower lip suggests inferior alveolar nerve involvement. A tongue that deviates on protrusion points to hypoglossal nerve invasion. Hoarseness with stridor in laryngeal cancer signals airway compromise and is a surgical emergency. Stage IVB disease invades the skull base, prevertebral fascia or carotid sheath with cranial nerve palsies, Horner syndrome and uncontrolled bleeding. Stage IVC distant spread shows up as cough, breathlessness, bone pain or jaundice.
Risk Factors for Head and Neck Cancer: Tobacco, Areca Nut, Alcohol, HPV and EBV
Tobacco in every form is the dominant cause of head and neck cancer in India. Smoked tobacco (cigarettes, bidis, hookah, shisha) and smokeless forms (gutkha, khaini, zarda, paan masala with tobacco, mawa, mishri) are all classified by IARC Monograph 100E as Group 1 human carcinogens. Areca nut on its own, even without tobacco, is a Group 1 carcinogen and is the main driver of oral submucous fibrosis. Alcohol is an independent risk factor and acts synergistically with tobacco. HPV 16 is the cause of an increasing share of oropharyngeal cancers in non-smokers, and Epstein-Barr virus is the established cause of non-keratinising nasopharyngeal carcinoma. Other recognised risks include occupational wood dust, nickel, chromium and formaldehyde, prior head and neck radiation, Plummer-Vinson syndrome, Fanconi anaemia and dyskeratosis congenita. (See IARC Monograph 100E.)
Diagnosis of Head and Neck Cancer: ENT Examination, Laryngoscopy and Biopsy
Diagnosis of head and neck cancer starts with a full head and neck examination by an ENT or head and neck surgical oncologist, including mirror and flexible fibre-optic laryngoscopy to view the oropharynx, hypopharynx and larynx. Any suspicious mucosal lesion that has persisted beyond three weeks is biopsied under local or general anaesthesia. Histopathology is the anchor: the biopsy is reviewed for squamous cell carcinoma and its variants per the WHO 2022 classification, with depth of invasion reported for oral cavity tumours. In NCR centres such as leading cancer centres, Dr BRA-IRCH, leading cancer centres Saket, leading cancer centres Memorial, a leading cancer centre Indraprastha and a leading cancer centre Dwarka, the standard workup combines direct visualisation, imaging and tissue confirmation before any treatment decision is taken.
Imaging in Head and Neck Cancer: MRI, CT and PET-CT
Imaging in head and neck cancer is built around contrast-enhanced MRI of the primary site and neck for oral cavity, oropharynx, nasopharynx and sinonasal tumours, because MRI defines soft tissue spread, perineural invasion along cranial nerves V and VII, marrow involvement of the mandible, skull base erosion and intracranial extension with higher accuracy than CT. Contrast CT of the neck and chest is used for laryngeal and hypopharyngeal tumours and to assess nodal levels I through V, retropharyngeal nodes and cartilage invasion. Whole-body 18F-FDG PET-CT is indicated for stage III and IV disease, for unknown primary presentations and for post-treatment response assessment at 12 weeks per the PET-NECK protocol, which validated PET-CT as a way to avoid planned neck dissection in node-positive patients who had a complete response to chemoradiation. Dental orthopantomogram is mandatory before radiation.
Molecular Testing in Head and Neck Cancer: p16, EBV DNA, PD-L1 and NTRK
Molecular testing has a defined role in head and neck cancer in 2026. p16 immunohistochemistry is done on every oropharyngeal biopsy as a surrogate for HPV status and decides whether the patient is staged under the HPV-positive AJCC 8 system or not. Plasma EBV DNA and EBER in situ hybridisation are used in nasopharyngeal carcinoma at baseline, during treatment and during follow-up to monitor response. PD-L1 combined positive score using the 22C3 antibody is reported on every recurrent or metastatic squamous case to decide first-line pembrolizumab eligibility per KEYNOTE-048. NTRK fusions are tested in salivary gland cancers, particularly secretory carcinoma, to enable larotrectinib or entrectinib. HER2 and androgen receptor are tested in salivary duct carcinoma. NCR centres including leading cancer centres run these panels in-house or through reference labs.
Treatment of Early Oral Cavity Cancer: The D’Cruz Trial
Early oral cavity cancer is the largest single subgroup of head and neck cancer treated in NCR. Standard treatment is transoral wide excision with elective selective neck dissection of levels I to III, even when the neck looks clinically negative. The reason is the landmark Indian randomised trial from a tertiary cancer centre by D’Cruz and colleagues, published in NEJM 2015, which showed that elective neck dissection improved overall and disease-free survival compared with therapeutic neck dissection at relapse in node-negative oral cancer. This trial is the reason elective selective neck dissection is now the default in every NCR oral cavity case at a tertiary cancer centre, Dr BRA-IRCH, leading cancer centres. Reconstruction with a radial forearm or anterolateral thigh free flap is routine for tongue and floor-of-mouth resections to preserve speech and swallow.
Larynx Preservation in Head and Neck Cancer: RTOG 91-11 and the NCR Standard
For locally advanced larynx and hypopharynx cancer, the goal of treatment in fit patients is to cure the cancer while preserving the voice box. The RTOG 91-11 trial, with long-term follow-up published in the Journal of Clinical Oncology in 2013, established concurrent cisplatin plus radiation as superior to induction chemotherapy followed by radiation and as the strategy with the highest chance of larynx preservation. Total laryngectomy is reserved for T4a disease (cartilage invasion, base of tongue invasion, extensive soft tissue spread) or for salvage after failed chemoradiation. Even after total laryngectomy, voice can be restored with a primary tracheoesophageal puncture and Provox prosthesis, which gives fluent speech and is routinely offered at a tertiary cancer centre, Dr BRA-IRCH, leading cancer centres head and neck units.
Concurrent Chemoradiation in Locally Advanced Head and Neck Cancer
Concurrent chemoradiation is the backbone of curative treatment for locally advanced head and neck cancer when surgery is either not feasible or would cause unacceptable morbidity. The reference regimen is cisplatin 100 mg/m2 every three weeks for three cycles given alongside IMRT or VMAT to 66 to 70 Gy over 6 to 7 weeks. Weekly cisplatin 40 mg/m2 is the alternative for patients who cannot tolerate three-weekly dosing, but the ConCERT trial from a tertiary cancer centre Hospital showed that three-weekly cisplatin was superior to weekly cisplatin in locoregional control in an Indian population, so three-weekly is preferred where renal function and performance status allow. Cetuximab plus radiation (Bonner regimen) is reserved for cisplatin-ineligible patients and is no longer recommended for HPV-positive disease after RTOG 1016 and De-ESCALATE HPV3.
Adjuvant Chemoradiation in Head and Neck Cancer: Bernier-Cooper EORTC 22931 / RTOG 9501
After radical surgery for locally advanced head and neck cancer, the indication for adjuvant treatment is set by the Bernier-Cooper pooled analysis of EORTC 22931 and RTOG 9501, which is the standard reference at every NCR tumour board. Positive surgical margins or extranodal extension on a positive neck node are the two high-risk features that mandate concurrent cisplatin chemoradiation, not radiation alone. Other adverse features such as pT3 or pT4, multiple positive nodes, level IV or V nodal involvement, perineural invasion or lymphovascular invasion are treated with adjuvant radiation alone. Adjuvant treatment should start within six weeks of surgery and the total package time (surgery to end of radiation) should not exceed 11 weeks, because longer intervals are associated with worse locoregional control and survival.
Treatment of Nasopharyngeal Carcinoma: Zhang Induction and Immunotherapy
Treatment of nasopharyngeal carcinoma is built around concurrent cisplatin plus IMRT to 70 Gy, with induction chemotherapy added for stage III and IVA disease. The current induction standard at a tertiary cancer centre, Dr BRA-IRCH, leading cancer centres is gemcitabine plus cisplatin for three cycles followed by concurrent cisplatin and IMRT, based on the Zhang NEJM 2019 trial which showed improved recurrence-free and overall survival over chemoradiation alone. Adjuvant capecitabine for one year, shown in a 2022 Lancet trial by Chen, further improves failure-free survival in high-risk disease and is being adopted selectively. For recurrent or metastatic nasopharyngeal carcinoma, toripalimab plus gemcitabine and cisplatin (JUPITER-02) and camrelizumab plus gemcitabine and cisplatin (CAPTAIN-1st) are the current first-line standards, with toripalimab now FDA-approved and accessed in India on a named-patient basis.
First-Line Immunotherapy for Recurrent or Metastatic Head and Neck Cancer: KEYNOTE-048
For recurrent or metastatic squamous head and neck cancer, first-line systemic therapy is based on the KEYNOTE-048 trial, which established pembrolizumab monotherapy for tumours with PD-L1 combined positive score (CPS) of 1 or higher, and pembrolizumab plus platinum and 5-FU regardless of CPS. Both pembrolizumab arms were superior to the older EXTREME regimen of cetuximab plus platinum and 5-FU. Nivolumab is the standard second-line option after platinum failure based on CheckMate 141, which showed an overall survival benefit over investigator choice of methotrexate, docetaxel or cetuximab. In NCR, both drugs are available at leading cancer centres in the region Saket, a leading cancer centre Shalimar Bagh, leading cancer centres. Targeted options for rare subsets include larotrectinib for NTRK fusion salivary cancers, trastuzumab for HER2-amplified salivary duct carcinoma and dabrafenib plus trametinib for BRAF V600E disease.
Cost of Head and Neck Cancer Treatment in Delhi, Gurgaon and Noida
Head and neck cancer treatment is one of the most cost-variable cancer journeys in NCR because it combines major surgery, six to seven weeks of daily radiation, concurrent chemotherapy, dental and prosthetic work, free-flap reconstruction, speech and swallow rehabilitation, and immunotherapy or targeted therapy in advanced disease. Diagnostic workup including ENT examination, biopsy, p16 IHC, MRI, contrast CT, FDG PET-CT, FNAC and dental clearance ranges from approximately INR 25,000 at leading cancer centres in the region to INR 75,000 to 1,40,000 at private NCR hospitals. Curative composite resection with free-flap reconstruction is INR 60,000 to 1,20,000 under PMJAY at a tertiary cancer centre and Dr BRA-IRCH, INR 2,80,000 to 5,50,000 at a tertiary cancer centre, and INR 4,50,000 to 9,50,000 at leading cancer centres in the region. IMRT or VMAT for 30 to 35 fractions is INR 75,000 to 1,50,000 at subsidised a tertiary cancer centre and Dr BRA-IRCH and INR 4,50,000 to 7,50,000 at private NCR hospitals. Pembrolizumab Keytruda is approximately INR 2,10,000 to 2,60,000 per dose. Government and trust pathways include PMJAY HBP 2.2, CGHS, DGEHS, ECHS, ESIC, Delhi Arogya Kosh, Delhi Arogya Nidhi, Health Minister’s Cancer Patient Fund, Rashtriya Arogya Nidhi, a tertiary cancer centre Patient Assistance, Cipla Access, Dr Reddy Sparsh, Natco Lifeline, a leading cancer centre India Foundation, Roche Patient Access Solutions, CanSupport, Indian Cancer Society Delhi, CanKids, Ugam and Cuddles. (See PMJAY HBP 2.2 and Health Minister’s Cancer Patient Fund.)
Frequently Asked Questions About Head and Neck Cancer Stages
Do I need a PET-CT for early oral tongue cancer? For clinical T1-T2, N0 oral cavity cancer, contrast MRI of the tongue and neck plus a chest X-ray or low-dose CT chest is sufficient at a tertiary cancer centre and a tertiary cancer centre. PET-CT is added for clinical T3-T4, any clinically positive node, suspected second primary in heavy chewers, or oropharyngeal, hypopharyngeal, laryngeal or nasopharyngeal primaries.
How does HPV status change treatment of oropharyngeal cancer? p16 immunohistochemistry decides whether the tumour is staged under the HPV-positive AJCC 8 system. HPV-positive disease has substantially better survival, but full-intensity concurrent cisplatin and radiation is still the standard outside trials such as ECOG 3311, NRG HN002 and PATHOS.
Will I lose my voice if I have laryngeal cancer? Not necessarily. Early glottic larynx tumours are treated with transoral laser microsurgery or radiation alone, both of which preserve the voice. Locally advanced larynx cancer is treated with concurrent cisplatin and radiation per RTOG 91-11. Total laryngectomy is reserved for T4a disease or salvage and even then a Provox prosthesis can restore fluent speech.
Why is dental clearance done before radiation? Radiation damages salivary glands and small blood vessels in the jaw, raising the lifetime risk of osteoradionecrosis if any teeth need extraction afterwards. Pre-radiation dental clearance, scaling, fluoride trays and selective extractions at least two weeks before radiation begins prevent the most dreaded long-term complication of head and neck radiation.
Why a feeding tube before treatment even starts? Concurrent chemoradiation causes severe mucositis, dysphagia and weight loss in almost every patient by week three. A prophylactic PEG placed before treatment lets nutrition continue, prevents weight loss above 10 percent, reduces hospital admissions and lets the radiation course finish without breaks.
Is nasopharyngeal cancer different from other head and neck cancers? Yes. It is EBV-driven, presents with neck nodes and ear symptoms, is treated almost entirely with chemoradiation rather than surgery, and responds very well even at locally advanced stages. Standard NCR treatment is induction gemcitabine plus cisplatin followed by concurrent cisplatin and IMRT to 70 Gy per Zhang NEJM 2019.
Is immunotherapy available for head and neck cancer in NCR? Yes. Pembrolizumab is approved first-line for recurrent or metastatic squamous head and neck cancer per KEYNOTE-048 and nivolumab is approved second-line per CheckMate 141. Both are available at leading cancer centres in the region Shalimar Bagh, leading cancer centres, with patient access programmes through Roche India, a leading cancer centre India Foundation and HMCPF reducing out-of-pocket cost.
What is the chance of cure at each stage? Five-year overall survival in HPV-negative head and neck squamous cancer is approximately 75 to 90 percent for stage I, 65 to 80 percent for stage II, 50 to 65 percent for stage III, 30 to 50 percent for stage IVA-B and under 15 percent for stage IVC. HPV-positive oropharyngeal cancer has survival above 80 percent even at stage III. Nasopharyngeal carcinoma has 90 percent five-year survival at stage I-II and 70 to 80 percent at stage III-IVA.
How often is follow-up after treatment? The standard NCCN and ESMO schedule, also followed at a tertiary cancer centre, Dr BRA-IRCH, leading cancer centres, is every one to three months for the first year, every two to four months for year two, every four to six months for years three to five and annually thereafter. TSH is checked every six to twelve months after neck radiation. Plasma EBV DNA is monitored serially in nasopharyngeal cancer.
What financial help is available? The layered pathway in NCR is PMJAY at empanelled leading cancer centres and Felix, plus CGHS, DGEHS, ECHS or ESIC for eligible employees, Delhi Arogya Kosh and Delhi Arogya Nidhi for low-income Delhi residents, HMCPF and Rashtriya Arogya Nidhi for treatment at a tertiary cancer centre and Dr BRA-IRCH, a tertiary cancer centre Patient Assistance by referral, Roche Patient Access Solutions and a leading cancer centre India Foundation for branded immunotherapy and targeted therapy, and CanSupport, Indian Cancer Society Delhi, CanKids and Ugam for palliative and survivor support.
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