Head and Neck Cancer: What Can Be Done to Mitigate Differences in Diagnosis Between Healthcare Providers?

Rather than being a single disease, head and neck cancer has been described as a collection of rare diseases, said Baran D. Sumer, MD, professor and chief of the division of head and neck oncology in the department of otolaryngology–head and neck surgery at the University of Texas Southwestern Medical Center, and leader of the head and neck cancer disease oriented team at the Harold C. Simmons Comprehensive Cancer Center in Dallas. “This means that pathologic expertise in accurate diagnosis is essential,” he said. “The various types of cancers that can exist in the upper aerodigestive tract, skin, and salivary glands, as well as other types of tissues in this complex region, make diagnosis and management challenging.”

Indeed, because of these challenges, patients diagnosed with head and neck cancer may encounter discrepancies in the pathology of their condition depending on the type of care center where they are diagnosed—a phenomenon documented by a retrospective chart review of 159 adult patients with head and neck squamous cell cancer presenting to a tertiary care center between 2008 and 2014. Of the 159 patients who had documentation of tumor stage that was assigned by a community-based practice, 53% had a tumor staging change made at the tertiary care center, with 43% of these patients upstaged and 10% of patients downstaged; fifty-one percent received a different treatment than had previously been offered at the community practice (Laryngoscope Investig Otolaryngol. 2018;3:290-295).

The researchers noted that the differences in tumor staging may be attributed to overall volume and experience with head and neck cancer, as well as the availability of additional specialists, said Carol R. Bradford, MD, MS, one of the paper’s authors, who is the dean of the College of Medicine and vice president for health sciences at The Ohio State University Wexner Medical Center in Columbus. “For example,” she said, “the diagnosis of salivary gland malignancies and other rare head and neck malignancies is extraordinarily challenging.”

Certainly, there are differences between how a community-based practice and a tertiary care center might approach head and neck cancer diagnosis. But what are they, why do they exist, and what options are there for collaboration?

Differences in Diagnosis and Pathology

For diagnosis of most common otolaryngologic conditions, there’s little difference between a small community hospital and a large academic center. “For more rare diseases such as cancer, however, where complex, coordinated care is required and multidisciplinary evaluation and treatment are essential, diagnosis and management can be challenging if a hospital does not have the full complement of necessary expertise,” said Dr. Sumer.

The main difference between smaller practices and larger centers that affects the approach to cancer diagnosis is volume. “A general otolaryngologist must have broad experience in many different diseases, but may see only one or two cancer cases per year,” said William B. Armstrong, MD, professor and department chair of clinical otolaryngology at the University of California, Irvine, who specializes in head and neck oncology. “As a head and neck specialist, I deal primarily with head and neck and thyroid cancers, but I don’t manage patients with vertigo or patients with ear or sinus diseases.

“I think general practitioners face challenges in terms of assessing the extent of head and neck cancer on clinical examination, or with imaging that may not be quite as specific or high quality,” he continued. “And with pathology, they generally don’t have the luxury of having a subspecialty pathologist who can look for certain nuances, which is more important for unusual pathologies. This has absolutely nothing to do with the competence of community-based doctors, however, many of whom are very skilled and talented, but more with depth of experience.”