Feel a Neck Lump? See Your Doctor

Terminal cancer patient releases his first public service announcement (PSA) aimed at encouraging faster diagnosis of head and neck cancer.

It was November 25th, 2015, the day before Thanksgiving and I was working from home. After responding to some emails that morning, I got ready and tiptoed gingerly up and down the cold white tiles of our bathroom floor, waiting for the shower water to heat up.

In the mirror’s reflection, I suddenly noticed something different about the right side of my neck. Placing my hand there, I could feel a solid lump just under my jawline that was about 3 centimeters in diameter (see Figure 1). The left side of my neck appeared normal.

The bulge wasn’t there the day before, or I would have felt it while shaving. It was a solid mass and wasn’t sore at all to the touch. It didn’t feel warm and seemed tethered to its location.

Putting my shower on hold, I threw my sweatpants and t-shirt back on and hurried back to my computer to do a quick search on the medical literature website PubMed from the U.S. National Library of Medicine. I quickly came across one medical journal article that contained a startling statistic: More than 75% of lateral (side) neck masses in patients older than 40 years are caused by malignant tumors.

The same article continued with guidance that “in the absence of overt signs of infection, a lateral neck mass is metastatic squamous cell carcinoma or lymphoma until proved otherwise.” The results made me nervous enough to reach for the phone and call our family physician for an appointment that day.

The most common cause for enlargement of the lymph nodes is infection or inflammation. However, such lymph nodes are often swollen, tender, and mobile. They can also exhibit abnormal redness of the surrounding skin and feel warm to the touch. Other than being swollen, my enlarged lymph node didn’t have any of these other symptoms.

My physician prescribed an antibiotic and instructed me to follow up with an Ear, Nose, and Throat (ENT) specialist if the lymph node didn’t decrease in size or got worse after the weekend. Unfortunately, there was no change in the size of my lymph node and subsequent testing confirmed the diagnosis of advanced oropharyngeal squamous cell carcinoma (OPSCC).

I’m thankful that my physician gave me a short course of antibiotic treatment. An article from the American Family Physician suggests a 2-week trial of antibiotics and then referring the patient for a biopsy if no resolution. However, every delay of 1 week in the referral of an OPSCC patient to secondary care correlates with a more advanced cancer stage at presentation and is associated with poorer survival. Specifically, researchers estimate that for every 1 week of delay in referral, the stage of presentation will progress by 0.045 of ‘a stage’.

Call to action: Men and women over the age of 40 who discover a suspicious lump or mass on either side of their neck shouldn’t delay in seeking medical attention. Many patients should also avoid being treated by courses of antibiotics for weeks or months, as this causes a delay in referral to secondary care, generally to an ENT specialist. Don’t delay — get a suspicious neck lump checked out today!

Disclaimer: Michael Becker is not a doctor and does not have formal medical training. His commentary should not be construed as recommendations, endorsements, or medical advice.

Image
Figure 1: Self-portrait showing the neck mass (blue side) is visible


Uneventful Streak Ends

It started with a runny nose and sneezing last weekend. Then came a cough and a mild fever that never went above 99.7 Fahrenheit – that is until the following Wednesday. A brief telephone discussion with the doctor on call late that evening confirmed that a trip to Memorial Sloan-Kettering Cancer Center’s (MSKCCs) urgent care facility was in order.

Following my latest round of chemotherapy, a fever of 100.4 Fahrenheit or higher is disconcerting. It could signal that I’m neutropenic – running dangerously low on a type of white blood cell (neutrophils) that serve as the body’s primary defense against acute bacterial and certain fungal infections. The chemotherapy I’ve been receiving can reduce the number of neutrophils circulating in the blood. Alternatively, a fever could be associated with the flu, which is particularly dangerous this season and breaking records.

Lorie and I started packing for an overnight stay at the MSKCC “bed and breakfast” as we like to call it. Before heading out, I hugged each of our dogs – just in case. Unfortunately, that simple action set into motion a rush of feelings and steady stream of tears down my cheeks. I was a total mess by the time Lorie backed the car out from the garage. Our daughters weren’t home at the time, which in retrospect was probably best.

At first, I failed to appreciate why Lorie attempted to set a new land speed record for shortest travel time between Bucks County, PA and New York City. Then, I remembered how I narrowly missed having a tachycardia event (abnormally fast heart rate) on the New Jersey Turnpike during our last trip to MSKCC’s urgent care facility in August 2017 when I ended up in the ICU.

Upon arrival at urgent care just before midnight, a series of tests were ordered – blood work, urine, chest x-ray, and nasal swab to test for influenza. The blood work came back first and my absolute neutrophil count (ANC) was 800 cells per microliter of blood. With an ANC below 1,000 cells per microliter of blood, the risk of infection increases. Combined with my fever, the medical team informed me that I was going to be admitted to the hospital and given a broad spectrum, intravenous antibiotic Zosyn® (piperacillin and tazobactam).

One by one, the other test results came back normal – that is until the nasal swab revealed I was positive for Influenza B. Influenza A and B are the two main types that routinely spread in humans and cause seasonal flu epidemics. Fortunately, I had received a flu shot this season, as this can help reduce the severity of the virus.

Alas, being hospitalized ended the longest “uneventful” streak of my cancer experience. But for six glorious months, living with cancer was relatively dull and boring. And it was wonderful.

With the source of my fever identified as the flu, I was prescribed Tamiflu® (oseltamivir phosphate) and the general plan was to release me from the hospital as soon as my ANC returned to 1,000 or higher. My prior chemotherapy was given on January 30th, so its adverse effect on my blood counts should be diminishing. Patients often have their lowest number (called a nadir) and highest risk of infection around 7 to 10 days after the start of chemotherapy.

However, my next ANC count was 400. When ANC falls below 500 cells per microliter (severe neutropenia), the risk of infection increases significantly. Accordingly, my stay at the bed and breakfast was extended.

Michael and Lorie Becker at MSKCC

By Friday, my ANC rebounded slightly to 700. Heading in the right direction, but still below the 1,000-level needed for my release home. I felt much better than when I was admitted, which was frustrating. In fact, the fever went away as did a runny nose, sneezing, and coughing.

A repeat blood test was scheduled for very early Saturday morning, with the expectation that my ANC would finally rise above 1,000 and we’d be sent home. Or so I hoped. But the test results showed a slight decrease from the prior day to 600.

I was then given a shot of Neupogen® (filgrastim), which works like a natural protein in your body to promote the growth of new white blood cells. Interestingly, Neupogen was among the very first biotechnology products that I learned about during my introduction to the sector in the late 1990s. It was approved by the Food and Drug Administration (FDA) back in 1991.

My blood counts will continue to be monitored until the ANC improves, but sometimes it can take 24-hours to see the effect of Neupogen. And so, we wait.