Head and Neck Cancer in New Zealand: Observations of a Fellow
Sameer Malick (left with his mentor, Nick McIvor) completed a one year Fellowship at Auckland City Hospital in June 2023 and has now returned to the UK where he will take up a consultancy role.
Sameer conducted some of my surgery and has shown an interest in the patient experience. Here he is sharing his observations based on the patients coming through Auckland City Hospital. This hospital’s catchment area for HNC treatment extends from Northland to South Auckland and includes patients from Hawkes Bay. I asked him about trends and warning signs.
Here is a glossary of medical terms used:
Aetiological = to do with cause, causative
Synergistic = creating a combined effect
Otalgia = pain in the ear
Dysphagia = difficulty swallowing
Resective = removing the cancer
Please bear in mind that my experiences are anecdotal and that I only worked in New Zealand for a year. I will also provide some comparisons to the situation in the UK, of which I obviously have a far greater experience. The UK experience I think is important, especially as many patients in New Zealand have strong links to the UK, and epidemiological observations in the UK will no doubt have an impact on those interested in understanding head and neck cancer in New Zealand.
Metastatic Skin Cancer
I think the most striking difference for me when coming to New Zealand was the volume of advanced skin cancer that we had to deal with. In the UK, we don’t tend to see advanced presentations with such frequency, primarily as we don’t have the same level of UV exposure that you all have down under. Metastatic skin cancer is going to be an ongoing issue, and with issues pertaining to climate change, I suspect it will only get worse. The public health messaging around this seems to be very good, and my children who attended school in New Zealand were constantly reminded by their teachers about taking precautions, such as wearing sun hats and using a good sun cream. Patients need to be made aware about the need to get moles and warts checked, particularly if they bleed on contact, have irregular borders, or have unusual pigmentation.
Oral Cavity Cancers
There was a high volume of oral cavity cancers as well, which was to be expected and numbers weren’t too dissimilar to what I was accustomed to in the UK. The synergistic impact of smoking and alcohol is the number one aetiological factor here, and I must say, one difference I did find is that heavy drinking doesn’t seem to be as much of a social taboo in New Zealand as it is now in the UK. I think the public health messaging around heavy drinking could be better emphasised. The WHO advises no more than 14 units a week for both males and females.
I saw an increasing number of young women with no risk factors presenting with quite nasty, advanced tongue cancers who were of Maori/Pacifica origin. Ilia and I did wonder if there was a genetic factor underlying these presentations that is yet to be studied.
(Note: the group Young Tongues in the UK and US was formed because of this trend in young women of all ethnicities contracting tongue cancer.)
The Betel Nut Factor
I worked in Leicester in the UK where we had a huge Indian population who consume Betel nut in a leaf known as ‘Paan’, which again is an aetiological factor for head and neck cancer. Most of these patients present with Buccal SCC, and most of the patients I saw in New Zealand with Buccal SCC were also South Asian. Certainly, in the UK, Paan shops largely go unregulated, and there certainly is work to be done here. With increasing numbers of South Asian migrants making a living in New Zealand, this is something that needs to be anticipated.
Interestingly, I didn’t see the volumes of laryngeal cancer in New Zealand that we see in the UK. This may reflect the fact that public health measures in New Zealand around smoking are pretty good. Also, in the UK, the high volumes of laryngeal cancer seem to be concentrated in ex-mining communities in the North of England which were decimated during the Thatcher era, resulting in socioeconomic deprivation which they never really recovered from. And that’s the point here, advanced laryngeal cancer tends to go hand in hand with socioeconomic deprivation.
HPV oropharyngeal SCC:
I would estimate that about 10-15% of patients presenting to the Auckland MDM had an HPV positive Oropharyngeal SCC. Incidence will continue to rise. We see much more of it in the UK, and I think that’s simply because we have a larger population in the UK. Vaccine uptake must be encouraged. We are still learning about how best to treat these patients. There most certainly is a role for minimally invasive robotic surgery, and I think it is deeply unfortunate that this isn’t available in the public health system. This is a massive gap in New Zealand, and I believe it needs to be addressed. It simply cannot be fair that minimally invasive surgery for this type of cancer is only available to those who have means.
Warning Signs Observed
- persistent dysphagia
- persistent unilateral sore throat (associated with otalgia),
- hoarseness (particularly in the context of a smoker),
- sensitivity to sharp/spicy foods,
- contact bleeding,
- unexplained weight loss
A non-healing ulcer in the mouth, or a pigmented lesion in the skin must always be investigated. Even in expert hands, a lesion can be missed. If in doubt, get it checked out, keep asking.
The longest surgery I was involved in lasted about 14 hours. But I think patients in Auckland are very fortunate that they have the likes of Nick McIvor, John Chaplin and Ilia Ianovski who are phenomenal surgeons and usually finish most resective/recon surgeries in 6-7 hours from the initial cut to the final stitch.
A big thanks to Sameer for sharing his observations with us.