Head and Neck Cancers

Written by: Dr. Roof

Oral Head and Neck cancer is the 6th most common form of cancer worldwide. It includes any cancer arising in the nasal cavity, sinuses, lips, mouth, throat, salivary glands or thyroid gland. Tobacco and alcohol use are the leading cause of mouth and throat cancer. However, there has been a recent rise in the incidence of oropharyngeal (base of tongue and tonsil) carcinoma in younger adults related to human papilloma virus (HPV) which is a highly prevalent sexually transmitted viral infection. Over 10,000 oral head and neck cancers per year can be attributed to HPV. The HPV vaccine Gardasil may help reduce the risk of head and neck cancer in the future.

Signs or symptoms of head and neck cancer might include a red or white patch in the mouth or a persistent sore throat or hoarseness. Difficulty swallowing, throat pain or a lump in the neck are other possible symptoms.

The best treatment for patients with head and neck cancer depends on many factors including the type, size, location and stage of the cancer as well as the patient’s overall health including their respiratory status, current swallowing or voice function, cardiac and renal status. Treatment options for head and neck cancer patients may include surgery, radiation, chemotherapy or targeted therapy or any combination of the above. The majority of patients present with locally advanced disease. While extensive surgery may play a role in select patients, many patients with locally advanced disease are treated with radiation with or without systemic therapy.

Surgery is an important component of therapy for appropriately selected patients. Surgery may include just a biopsy for diagnosis or may be an extensive surgical procedure with the intent of surgical cure. The extent of surgery varies based on the diagnosis and stage of the cancer. The surgeon may remove just the tumor or may also remove lymph nodes in either one side or both sides of the neck Some surgeons are now performing transoral robotic surgery (TORS) which may improve the surgeon’s ability to resect certain types of tumors.

Systemic therapy can include either chemotherapy or biologic/targeted therapy. A medical oncologist will help determine which therapy is best suited for you. It may be given in advance of radiation (neoadjuvant chemotherapy), at the same time as radiation or rarely by itself.

Radiation in the head and neck region is often delivered using intensity modulated radiation therapy (IMRT). This advanced radiation treatment technique allows your radiation team to develop a plan that shapes the radiation so that it goes to the areas of concern while avoiding nearby structures that do not require radiation. Use of IMRT often in conjunction with image guidance allows your team to confidently target the areas of concern with a high degree of precision and accuracy.

There are many different ways to deliver IMRT including forward and inverse planned techniques, modulated arcs, and tomotherapy. All of these techniques allow for the safe delivery of radiation to the target volumes while minimizing the exposure of nearby healthy tissues to high doses of radiation.

Despite these advanced techniques, radiation to the head and neck region is often a difficult treatment. Symptoms are often exacerbated with the addition of chemotherapy. Many patients receiving chemotherapy and radiation to the head and neck region may require an evaluation for swallowing dysfunction. Often times patients may require placement of a temporary feeding tube to ensure adequate nutritional and hydration support through the course of treatment and during the immediate post-treatment recovery period (the first few weeks to months after radiation is completed). Your physician may recommend that you be evaluated by a speech and swallowing therapist to assess your ability to swallow, and your potential need for a feeding tube.

Patients undergoing radiation therapy usually need a dental evaluation before proceeding with treatment as radiation may cause patients to have a dry mouth, and this can increase the risk of cavities. Additionally, if the jaw bone receives high doses of radiation it can increase the risk of subsequent dental surgeries. Thus, if there are teeth that need dental attention it is ideal to have these issues addressed before starting radiation when possible.

Physical therapists may play an important role in the management of patients with head and neck cancer. Side effects of therapy that therapists might assist with include: lymphedema or swelling of the neck, trismus (difficulty opening your mouth widely), or problems with the neck and shoulders particularly in the post-operative setting. Nutritionists are also important members of the treatment team and can provide value guidance on dietary recommendations as well as nutritional assessments before during and after your treatment course.

Patients going through treatment for head and neck cancer need significant support physically, emotionally and financially. A cancer navigator (a nurse, social worker or other knowledgeable individual), may be an excellent resource for assisting patients in meeting these needs.

This year, about 62,000 Americans will be diagnosed with cancer of the oral cavity, pharynx, larynx and thyroid.

  • More than 25 percent of oral cancers occur in people who do not smoke or have other risk factors.
  • Rates of head and neck cancer are nearly twice as high in men and are greatest in men over age 50.

Risk Factors for Head and Neck Cancer

The use of tobacco and alcohol greatly increases your chances of developing head and neck cancer. Risk factors include:

  • Alcohol consumption
  • Smoking or use of smokeless tobacco, such as chew or dip
  • Exposure to wood or nickel dust or asbestos
  • Plummer-Vinson syndrome (disorder from nutritional deficiencies)
  • Exposure to viruses, including the human papillomavirus (HPV) and Epstein-Barr

Quitting Smoking

If you quit smoking, the health benefits begin immediately.

  • For patients with head and neck cancer, quitting smoking reduces the risks of infections and developing other cancers.
  • To learn how to quit, ask your doctor or visit www.smokefree.gov.

Symptoms of Head and Neck Cancer

Although there are sometimes no symptoms of head and neck cancer, common complaints include:

  • Lump or sore that does not heal.
  • Sore throat that does not go away.
  • Difficulty or pain with swallowing.
  • Change in your voice or hoarseness.
  • Blood in your saliva or from your nose.
  • Ear pain or loss of hearing.
  • Lump in the neck.
  • Nasal stuffiness that does not resolve.

Diagnosing Head and Neck Cancer

To look for cancer, your doctor will examine all the areas of your head and neck.

  • Your doctor will first feel for lumps on the neck, mouth and throat. He or she may also use a flexible endoscope, a thin, lighted tube that is passed through the nose, to obtain a more comprehensive assessment of the head and neck area.
  • X-ray, CT, MR and PET scans are often needed to show the location and extent of the cancer.
  • To confirm if you have cancer, some tissue will be removed and analyzed. This test is called a biopsy.

Types of Head and Neck Cancers

Head and neck cancers arise from the cells that make up the face, mouth and throat. Because cancers in different locations behave differently, treatment depends on the cancer type and extent. Some common locations include:

  • Nasal cavity/paranasal sinuses.
  • Nasopharynx.
  • Oral cavity (lips, gums, floor of mouth, oral tongue, cheek mucosa, hard palate, retromolar trigone).
  • Oropharynx (base of tongue, tonsils, soft palate, oropharyngeal wall).
  • Larynx (vocal cords and supraglottic larynx).
  • Hypopharynx (pyriform sinuses, post-cricoid area, posterior pharyngeal wall).
  • Salivary glands (parotid, submandibular, sublingual and minor salivary glands).
  • Thyroid.

Cancers arising in the brain or eyes are considered different from head and neck cancers. However, your doctor will check the areas to make sure the cancer has not spread.

Treatment for Head and Neck Cancer

Treatment for head and neck cancer depends on several factors, including the type of cancer, the size and stage, its location, and your overall health.

  • Surgery, radiation therapy and chemotherapy are the mainstays of treating head and neck cancer.
  • For many head and neck cancers, combining two or three types of treatments may be most effective. That’s why it is important to talk with several cancer specialists about your care, including a surgeon, a radiation oncologist and a medical oncologist.
  • An important concept in treating head and neck cancer is organ preservation. Rather than relying on major surgery, an organ preservation approach first uses radiation and chemotherapy to shrink the tumor. This allows for a less extensive surgery and may even allow some patients to avoid surgery altogether.

External Beam Radiation Therapy

External beam radiation therapy involves a series of daily outpatient treatments to accurately deliver radiation to the cancer.

  • Painless radiation therapy treatments are delivered in a series of daily sessions. Radiation treatments take only a few minutes, but each session takes about half an hour to get checked in, change clothes, get into position and receive the radiation. For some conditions, radiation is given twice a day, with a four to six hour gap between treatments.
  • Treatments are usually scheduled Monday through Friday, for five to eight weeks. However, your radiation oncologist may schedule your treatments more or less often depending on your cancer.
  • 3-dimensional conformal radiotherapy (3D-CRT) combines multiple radiation treatment fields to deliver precise doses of radiation to the affected area. Tailoring each of the radiation beams to accurately focus on the patient’s tumor allows coverage of the cancer while at the same time keeping radiation away from nearby healthy tissue.
  • Intensity modulated radiation therapy (IMRT) is a form of 3D-CRT that further modifies the radiation by varying the intensity of each radiation beam. This technique allows a precise adjustment of radiation doses to the tissue within the target area. IMRT may allow doctors to direct a higher radiation dose to the affected area and keep more radiation away from nearby healthy tissue.
  • To help you keep still during treatment, your doctor may use a plastic head or shoulder mask. These devices are specially fitted for you and are painless to use.

Internal Radiation Therapy

Also called brachytherapy, internal radiation therapy involves surgically implanting radioactive material into a tumor or surrounding tissue. For head and neck cancers, brachytherapy is often used in conjunction with external beam radiation therapy, but may be used alone.

  • During low-dose-rate brachytherapy, your radiation oncologist implants thin, hollow, plastic tubes in and around a tumor.
  • These tubes are loaded with tiny radioactive seeds that remain in place for one or several days to kill the cancer. The seeds and the tubes are then removed. Sometimes, tiny radioactive seeds are implanted directly into the tumor and remain permanently.
  • For high-dose-rate brachytherapy, your doctor implants hollow tubes in and around the tumor site.
  • After these tubes are implanted, they are then connected to a special brachytherapy machine that houses a high activity radioactive source. According to your doctor’s specifications, the seed is automatically delivered from the machine and into the tubes, delivering localized radiation over several minutes to kill the cancer.

Possible Side Effects

Side effects of radiation therapy are limited to the area that is receiving treatment.

  • Side effects can include redness of the skin, sore throat, dry mouth, alteration of taste, pain on swallowing and possible hair loss in the treated area. Fatigue is also very common.
  • Side effects are different for each patient. Medications and nutritional supplements may be prescribed to make you as comfortable as possible.
  • If at any time during your treatment you feel discomfort, tell your doctor or nurse. They may be able to alter the treatment or prescribe a drug to help you feel better.

Mouth Care

It is important to take care of your mouth, teeth and gums during radiation.

  • Careful brushing of your teeth can help prevent tooth decay, gum disease, mouth sores and jaw infections.
  • Be sure to tell your dentist that you received radiation to the head and neck area.
  • Talk to your doctor or dentist about any problems you are having.