Head and Neck Cancer“Head and neck cancer” is the term used to describe different types of malignant tumors that occur in or around the throat, nose, sinuses, larynx and mouth. Approximately 3 percent of all cancers in the United States are head and neck cancers. Every year, more than 60,000 people in the U.S. develop head and neck cancer, with those over the age of 50 being the most affected. Head and neck cancers cause at least 13,000 deaths annually.

Types of head and neck cancers

Most cases of head and neck cancers are squamous cell carcinomas, a type of cancer that starts in the squamous cells making up the thin tissue layer on the surface of the head and neck. Head and neck cancer found only in the squamous cells is called carcinoma in situ, while a cancer that has spread beyond the squamous cell layer into deeper tissues is known as invasive squamous cell carcinoma. In other cases, head and neck cancer may begin in the salivary glands and is called adenocarcinoma, mucoepidermoid carcinoma or adenoid cystic carcinoma.

There are 5 major categories of head and neck cancers:

  • Nasal cavity and paranasal sinus cancer: Cancer that begins in the space behind the nose (nasal cavity) or air-filled areas surrounding the nasal cavity (paranasal sinuses).
  • Laryngeal and hypopharyngeal cancer: Cancer that begins in the voice box (larynx) or in the gullet (hypopharynx).
  • Nasopharyngeal cancer: Cancer of the air passageway found at the upper portion of the throat behind the nose.
  • Salivary gland cancer: Cancer that begins in the gland that produces saliva.
  • Oral and oropharyngeal cancer: Cancer that occurs in the mouth, tongue or in the oropharynx (area running from the tonsils to the tip of the voice box).

There are other cancers such as brain tumors, eye cancer, sarcoma, parathyroid cancer, thyroid cancer and esophageal cancer, which affect the head and neck region. However, their diagnosis and treatment is much different.

Risk factors for head and neck cancers

Tobacco and alcohol use: Tobacco use in the form of cigarettes, pipes, cigars, snuff or chewed tobacco, is the single largest factor for head and neck cancer. Around 85 percent of all head and neck cancers are associated with tobacco use. Alcohol use increases the risk of having cancers of the mouth, larynx, pharynx and esophagus; while using both tobacco and alcohol makes the risk even greater.

  • Poor dental and oral hygiene: Poor care of the mouth and teeth may increase the risk of head and neck cancer.
  • Prolonged sun exposure: Cancer of the lips and of the skin around the neck and head may be linked to prolonged sun exposure.
  • Certain viral infections: Infections with Human Papilloma Virus (HPV) and Epstein-Barr virus (EBV) have been associated with head and neck cancer.
  • Age, gender and race: People 40 years old or older have greater risk of head and neck cancers. Likewise, men have higher risk of the cancers than women, while African-Americans are more likely to have certain types of head and neck cancers than white Americans.
  • Acid reflux: Conditions such as LPRD (laryngopharyngeal reflux disease) and GERD (gastroesophageal reflux disease) increase the risk of head and neck cancers.
  • Weakened immunity: People with HIV/AIDS or using immunity suppressing drugs are at increased risk of head and neck cancer.
  • Occupational (environmental) inhalants: Inhaling wood dust, asbestos or paint fumes increase the risk of head and neck cancer.
  • Poor nutrition and marijuana use: Diets low in vitamins A and B, together with marijuana use, have been associated with head and neck cancer.

Symptoms of head and neck cancer

  • Sore feeling or swelling that does not heal.
  • Lump, mass or bump in the neck or head, with or without pain.
  • White or red patch in the mouth.
  • Double vision, difficulty breathing or frequent (unusual) nosebleeds or nasal discharge.
  • Persistent sore throat or hoarseness of voice.
  • Ear and jaw pain.
  • Loosening of teeth.
  • Persistent nasal congestion or nasal obstruction.
  • Weakness or numbness around the neck and head area.
  • Pain when swallowing, chewing or moving the tongue or jaw.
  • Fatigue.
  • Foul mouth that cannot be explained by hygiene.
  • Blood in phlegm or saliva.
  • Unexplained weight loss.

If you have any of these symptoms, make sure to see your doctor immediately. Remember that early detection of head and neck cancer makes treatment more successful.

Diagnosis of head and neck cancer

Various tests are used to detect and confirm head and neck cancers, and to determine how far a cancer has spread. For most head and neck cancers, biopsy is the surest way a doctor can confirm the cancer. Diagnostic tests for head and neck cancer include:

  • Medical history and physical examination: The doctor takes a complete medical history by noting all risk factors and symptoms, before physically feeling any lumps on the lips, gums, neck and cheeks. The doctor also inspects the mouth, nose, tongue and throat for abnormalities.
  • HPV and EBV testing: Since HPV and EBV are associated with head and neck cancer, the doctor may request tests for these viral infections.
  • Endoscopy: The doctor uses a thin, lighted and flexible tube (endoscope) to see inside the body and check any abnormalities in the larynx (laryngoscopy), pharynx (pharyngoscopy), or nasopharynx (nasopharyngoscopy). Endoscopy procedure combining all these is called panendoscopy.
  • Imaging: The doctor may use barium X-ray, panoramic radiograph, computerized tomography (CT) scan, magnetic resonance imaging (MRI) or positron emission tomography (PET) to detect head and neck cancer.
  • Ultrasound: Sound waves are used to create clear images of internal organs.
  • Biopsy: A small tissue is removed from the area suspected to have cancer. The tissue is examined under a microscope to look for cancer cells.
  • Molecular testing: A tissue sample is tested for specific genes, proteins and factors that may help with treatment, particularly when targeted therapy is to be used.
  • Bone scan: Done to check whether a cancer has spread to the bones.

Stages of head and neck cancer

Once head and neck cancer is diagnosed, the doctor will run some tests to determine the extent of spread of the cancer. Knowing the stage of a head and neck cancer helps to decide the right treatment. For head and neck cancers, doctors usually use the TMN staging system.

  • Tumor (T): How large is a primary tumor and where is it located?
  • Node (N): Has the cancer spread to lymph nodes and how many nodes are affected?
  • Metastasis (M): Has the cancer spread to other parts of the body? Where has it spread to and by how much?

If the doctor is dealing with a recurrent head and neck cancer, another round of tests may be used to assess the extent of recurrence.

Treatment options for head and neck cancer

Head and neck cancer treatment is usually completed through a multidisciplinary approach in which a team of highly-skilled specialists work together before, during and after treatment. The treatment team includes:

  • Medical oncologist: A doctor who specializes in cancer treatment with medication (chemotherapy).
  • Radiation oncologist: A doctor who specializes in cancer treatment with radiation (radiotherapy).
  • Surgical oncologist: A doctor who specializes in cancer treatment with surgery.
  • Otolaryngologist: Doctor who specializes in ear, nose and throat disorders.
  • Oral oncologist or oncologic dentist: Dentists specialized in caring for patients with head and neck cancers.
  • Reconstruction (plastic) surgeon or maxillofacial prosthodontist: Specialist in restorative surgery of the head and neck areas.
  • Speech pathologist, audiologist, physical therapist and psychiatrist (psychologist).

Other professionals such as physician assistants, social workers, nurses, counselors, pharmacists and dietitians.
The cancer treatment team creates a comprehensive plan before treatment commences. The team will consider the type, size and stage of the cancer, location of the cancer, overall health of the patient, possible side effects, and patient’s preferences. Most head and neck cancers are treated by combining two or more treatments, with chemotherapy, surgery and radiotherapy being the mainstays.

1. Surgery

During surgery for head and neck cancer, the tumor and some of the surrounding healthy tissue is removed. Depending on the location and type of cancer, treatment may involve laser technology, excision, lymph node dissection (neck dissection) and plastic (reconstructive) surgery. Laser technology is used to treat early-stage cancer, particularly cancer of the pharynx. Excision is used to remove cancerous tumors and some surrounding healthy tissue (margin), while neck dissection (lymph node dissection) is used to treat cancer that has spread to the lymph nodes. To restore the appearance and function of affected areas, plastic (reconstructive) surgery may be used in surgeries that require major tissue removal. If the cancer is not completely curable through surgery, other treatments such as chemotherapy and radiotherapy may be necessary.

2. Radiation therapy

Radiation therapy (radiotherapy) uses high-energy beams such as protons or X-rays to destroy cancer cells. It can be used as the main treatment or combined with other treatments such as surgery and chemotherapy. A radiotherapy treatment schedule (regimen) consists of a set of treatments provided over a period of time, with a series of painless daily sessions of about 30 minutes given for 5 days a week (Monday through Friday) for 5-8 weeks.
Most commonly, radiotherapy for head and neck cancer is delivered through external beam radiation, where radiation is given from a machine located outside the body. Special external beam radiation techniques such as three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) are used to accurately direct high-energy beams at the tumor, killing cancer cells while sparing healthy tissues. In other cases, radiation may be delivered by inserting radioactive implants into or around the tumor, a method called internal radiation therapy (brachytherapy). Brachytherapy for head and neck cancer is often combined with external beam radiotherapy, but also may be used alone.

3. Chemotherapy

Chemotherapy uses specific drugs to destroy cancer cells and prevent tumors from spreading. A chemotherapy schedule (regimen) consists of a specific number of treatment cycles given over a period of time. The patient may receive one drug at a time or a combination of different drugs at the same time. The drugs may be administered intravenously (via injection) or as pills or capsules that are swallowed (orally).

4. Targeted therapy

Treatment can be targeted at specific genes, proteins or the tissue environment contributing to the growth and survival of cancer. Targeted therapy blocks the growth and spread of cancerous cells while sparing healthy cells. Not all head and neck tumors have the same targets, so the doctor will run various molecular tests to determine the appropriate factors to target. For example, treatments for head and neck cancers frequently have targeted the tumor protein called epidermal growth factor receptor (EGFR) which, when blocked, helps to stop or slow the growth of malignant tumors.

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