Nasopharyngeal Cancer

A painless lump in the neck, persistent ringing, hearing loss in one ear or unexplained nosebleeds may be matters of concern. They can be signs of nose cancer. Dr Ranjit Magherra, Senior Consultant, ENT

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It is one of the more common cancers in Singapore with about 300 new cases diagnosed a year, but nose, or nasopharyngeal cancer (NPC), is often not detected till it's in the late stages.

Common Cancer in Males

The cancer, which occurs in the cells lining the area behind the nose and just above the back of the throat, is one of the most common cancers in males in Singapore, explained Dr Ranjit Magherra, Senior Consultant, ENT, JurongHealth.

“It hits hard because it occurs in people who are in the prime of their working and family lives. It is the second and third most common cancer in men aged between 15 to 34 and 35 to 64, respectively,” he said.

Nasopharyngeal Cancer

However, one of the biggest challenges facing the diagnosis of this type of cancer, he noted, is the difficulty in detecting it.

"Because it grows in a ‘hidden’ area at the back of the nose called the nasopharynx, it is not easy to detect. The symptoms of the disease are also quite non-specific and there may not even be any signs in the early stages," he pointed out.

Nose cancer is not easy to detect because the symptoms, a painless lump in the neck, nosebleeds and hearing changes, can be quite non-specific.

Low Awareness of Nose Cancer

Dr Ranjit noted that a Singapore study indicates that there is a tendency for people to seek medical attention late and for doctors to delay referral to the ENT specialist.

The study revealed that a fifth of nose cancer diagnoses was delayed for an average of seven months due to low awareness of the disease. This resulted in many nose cancers only being detected when they are at stage 3.

This is unfortunate, said Dr Ranjit. "The cure rate after treatment for the stage 3 disease is only 60 percent and it drops to below 50 percent in stage 4."

However, there is a 90 percent cure rate if the disease is treated at an early stage. This highlights the importance of awareness of the signs, symptoms and risk factors.

Signs and Symptoms

Pain

“There is a common misconception that cancer must cause pain, but in many cases, these signs are painless especially if they occur in the early stages,” said Dr Ranjit.

Lumps

One of the most common signs, present in 75 percent of newly diagnosed nose cancer cases, is the appearance of one or more lumps in the nose or on the neck.

Neck lumps typically present in the region on the side of the neck and just behind the ear towards the shoulder.

Headaches, Nosebleeds and Other Symptoms

Other signs and symptoms include frequent headaches or nosebleeds, blood-stained sputum or unexplained weight loss.

Change in Hearing

In some cases, people experience a change in hearing. These hearing changes may present as a sudden loss of hearing, ringing in the ear or a feeling of blockage.

If these symptoms appear and do not heal or go away with time or treatment, you should consider seeking advice from an ENT specialist.

Diagnosis of Nose Cancer

Your doctor will assess if your signs and symptoms point to cancer. If nasopharyngeal cancer is suspected, a battery of tests may be needed.

Nasendoscopy

One way to detect nose cancer is via a nasendoscopy. This involves the use of a long, narrow, flexible tube that is inserted through the nose to look for abnormal growths in the tissues at the back of the nose.

Biopsy

A tissue sample (biopsy) of any suspicious lesions is taken and examined under the microscope to look for cancer cells. If there is a lump in the neck, a tissue sample of the lump may also be removed to be examined for cancer cells. This is done painlessly using local anaesthesia.

Blood Test

A blood test to detect certain antibodies to the Epstein-Barr virus (EBV) is also sometimes used to detect NPC.

If cancer is confirmed, more tests will be done to check if the cancer has spread. Diagnostic tests may take the form of a thorough physical examination, blood tests, chest x-rays and scans of the head and neck region as well as a bone scan and liver scans.

Risk Factors for Nose Cancer

Nose cancer or NPC is associated with an EBV infection of the white blood cells and nasal lining at the back of the nose. EBV is a very common virus that affects 9 in 10 people by the time they reach adulthood. It causes a minor flu-like illness in children and glandular fever in adults.

Once you are exposed, the virus will persist in the blood cells in a dormant state. In some people, the EBV infection subsequently triggers the development of nose cancer, although it is not fully understood how and why.

“One of the predisposing factors is suspected to be diet,” said Dr Ranjit.

The cancer is associated with the high consumption of preserved food such as cured meats, salted fish and fermented soy beans. These foods are high in salt and cancer-causing nitrites.

According to Dr Ranjit, the link was discovered because there was a high incidence of NPC among the boat people of Hong Kong whose staple diet was salted fish.

“It is theorised that the carcinogens released during cooking or eating certain preserved foods ‘primes’ the cells for development of cancer,” Dr Ranjit explained, “Genetics also has a role to play in the risk of getting nose cancer, so if an immediate family member has a history of nose cancer, you may be genetically predisposed to it."

Treating Nose Cancer

Radiotherapy: High-energy X-rays or radiation is sent towards the cancer via a machine.

Chemotherapy: Drugs are injected into the veins to stop the growth of cancer cells and kill them.

Surgery: Physical removal of the cancerous tumour. This is a relatively challenging operation and is often reserved for disease that recurs despite radiation and chemotherapy treatment.

Treatment, said Dr Ranjit, depends on the location of the cancer, extent of the disease, and if the cancer has spread as well as the health status of the patient.

“Recent advancements in radiotherapy equipment and computer planning technology, together with improved shielding techniques to protect healthy tissues, have significantly improved the precision of radiation delivery,” he said.

“This means sensitive nerves, organs and tissues in the face, eyes and brain are spared, improving the outcomes of treatment.”

Preventing Nose Cancer

At the moment, it is not known what the exact causes of nose cancer are but avoiding risk factors may be helpful in lowering the risk of the disease.

For example, it may help to avoid eating excessive amounts of salted fish and other preserved foods.

Other helpful steps are to include lots of fresh fruit, green vegetables and other sources of antioxidants to lower your overall cancer risk.

Avoid inhaling tobacco smoke as well. Both smoking and passive smoking are linked to an increased risk of cancer.

Dr Ranjit pointed out that since the disease has a high rate of cure in its early stages, early detection is therefore the best way to tackle it. “It is important to know if you are in a high risk group,” he said, “Those with a family history (especially first-degree relatives) of the disease should be screened for the disease.

It is also important not to ignore symptoms like hearing loss in one ear, blood stained phlegm and neck lumps especially if these are persistent. Early detection will improve the outcomes for the patient and greatly increase the chance of a cure.”

This article " The "hidden" cancer"  was first published in ONEHealth Magazine, 2015 Issue 6.

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