Head and neck cancer (patient information)

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Editor-in-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor-In-Chief: Alexandra M. Palmer

Overview
Head and neck cancer includes cancers of the mouth, nose, sinuses, salivary glands, throat and lymph nodes in the neck. Most begin in the moist tissues that line the mouth, nose and throat.

Head and neck cancers account for approximately 3 to 5 percent of all cancers in the United States. These cancers are more common in men and in people over age 50.

What are the symptoms of Head and neck cancer?
Symptoms include:
 * A lump or sore that does not heal
 * A sore throat that does not go away
 * Trouble swallowing
 * A change or hoarseness in the voice

Other symptoms may include the following:
 * Oral cavity. A white or red patch on the gums, tongue, or lining of the mouth; a swelling of the jaw that causes dentures to fit poorly or become uncomfortable; and unusual bleeding or pain in the mouth.
 * Nasal cavity and sinuses. Sinuses that are blocked and do not clear, chronic sinus infections that do not respond to treatment with antibiotics, bleeding through the nose, frequent headaches, swelling or other trouble with the eyes, pain in the upper teeth, or problems with dentures.
 * Salivary glands. Swelling under the chin or around the jawbone; numbness or paralysis of the muscles in the face; or pain that does not go away in the face, chin, or neck.
 * Oropharynx and hypopharynx. Ear pain.
 * Nasopharynx. Trouble breathing or speaking, frequent headaches, pain or ringing in the ears, or trouble hearing.
 * Larynx. Pain when swallowing, or ear pain.
 * Metastatic squamous neck cancer. Pain in the neck or throat that does not go away.

These symptoms may be caused by cancer or by other, less serious conditions. It is important to check with a doctor or dentist about any of these symptoms.

Who is at highest risk?
Tobacco (including smokeless tobacco, sometimes called “chewing tobacco” or “snuff”) and alcohol use are the most important risk factors for head and neck cancers, particularly those of the oral cavity, oropharynx, hypopharynx, and larynx. Eighty-five percent of head and neck cancers are linked to tobacco use. People who use both tobacco and alcohol are at greater risk for developing these cancers than people who use either tobacco or alcohol alone.

Other risk factors for cancers of the head and neck include the following:
 * Oral cavity. Sun exposure (lip); possibly human papillomavirus (HPV) infection.
 * Salivary glands. Radiation to the head and neck. This exposure can come from diagnostic x-rays or from radiation therapy for noncancerous conditions or cancer.
 * Paranasal sinuses and nasal cavity. Certain industrial exposures, such as wood or nickel dust inhalation. Tobacco and alcohol use may play less of a role in this type of cancer.
 * Nasopharynx. Asian, particularly Chinese, ancestry; Epstein-Barr virus infection; occupational exposure to wood dust; and consumption of certain preservatives or salted foods.
 * Oropharynx. Poor oral hygiene; HPV infection and the use of mouthwash that has a high alcohol content are possible, but not proven, risk factors.
 * Hypopharynx. Plummer-Vinson (also called Paterson-Kelly) syndrome, a rare disorder that results from iron and other nutritional deficiencies. This syndrome is characterized by severe anemia and leads to difficulty swallowing due to webs of tissue that grow across the upper part of the esophagus.
 * Larynx. Exposure to airborne particles of asbestos, especially in the workplace.

Immigrants from Southeast Asia who use paan (betel quid) in the mouth should be aware that this habit has been strongly associated with an increased risk for oral cancer. Also, consumption of mate, a tea-like beverage habitually consumed by South Americans, has been associated with an increased risk of cancers of the mouth, throat, esophagus, and larynx.

People who are at risk for head and neck cancers should talk with their doctor about ways they can reduce their risk. They should also discuss how often to have checkups.

Diagnosis
To find the cause of symptoms, a doctor evaluates a person's medical history, performs a physical examination, and orders diagnostic tests. The exams and tests conducted may vary depending on the symptoms. Examination of a sample of tissue under the microscope is always necessary to confirm a diagnosis of cancer.

Some exams and tests that may be useful are described below:
 * Physical examination may include visual inspection of the oral and nasal cavities, neck, throat, and tongue using a small mirror and/or lights. The doctor may also feel for lumps on the neck, lips, gums, and cheeks.
 * Endoscopy is the use of a thin, lighted tube called an endoscope to examine areas inside the body. The type of endoscope the doctor uses depends on the area being examined. For example, a laryngoscope is inserted through the mouth to view the larynx; an esophagoscope is inserted through the mouth to examine the esophagus; and a nasopharyngoscope is inserted through the nose so the doctor can see the nasal cavity and nasopharynx.
 * Laboratory tests examine samples of blood, urine, or other substances from the body.
 * X-rays create images of areas inside the head and neck on film.
 * CT (or CAT) scan is a series of detailed pictures of areas inside the head and neck created by a computer linked to an x-ray machine.
 * Magnetic resonance imaging (or MRI) uses a powerful magnet linked to a computer to create detailed pictures of areas inside the head and neck.
 * PET scan uses sugar that is modified in a specific way so it is absorbed by cancer cells and appears as dark areas on the scan.
 * Biopsy is the removal of tissue. A pathologist studies the tissue under a microscope to make a diagnosis. A biopsy is the only sure way to tell whether a person has cancer.

If the diagnosis is cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in the operating room), x-rays and other imaging procedures, and laboratory tests. Knowing the stage of the disease helps the doctor plan treatment.

When to seek urgent medical care?
Since cancers are capable of spreading to other parts of the body, it is crucial to see a doctor right away if any of the aforementioned symptoms arise.

Treatment options
If found early, these cancers are often curable. Treatments may include surgery, radiation therapy, chemotherapy or a combination. Treatments can affect eating, speaking or even breathing, so patients may need rehabilitation.

The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person's age and general health. The patient and the doctor should consider treatment options carefully. They should discuss each type of treatment and how it might change the way the patient looks, talks, eats, or breathes.
 * Surgery. The surgeon may remove the cancer and some of the healthy tissue around it. Lymph nodes in the neck may also be removed (lymph node dissection), if the doctor suspects that the cancer has spread. Surgery may be followed by radiation treatment. Head and neck surgery often changes the patient's ability to chew, swallow, or talk. The patient may look different after surgery, and the face and neck may be swollen. The swelling usually goes away within a few weeks. However, lymph node dissection can slow the flow of lymph, which may collect in the tissues; this swelling may last for a long time. After a laryngectomy (surgery to remove the larynx), parts of the neck and throat may feel numb because nerves have been cut. If lymph nodes in the neck were removed, the shoulder and neck may be weak and stiff. Patients should report any side effects to their doctor or nurse, and discuss what approach to take.


 * Radiation therapy, also called radiotherapy. This treatment involves the use of high-energy x-rays to kill cancer cells. Radiation may come from a machine outside the body (external radiation therapy). It can also come from radioactive materials placed directly into or near the area where the cancer cells are found (internal radiation therapy or radiation implant). In addition to its desired effect on cancer cells, radiation therapy often causes unwanted effects. Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth; a dry mouth or thickened saliva; difficulty in swallowing; changes in taste; or nausea. Other problems that may occur during treatment are loss of taste, which may decrease appetite and affect nutrition, and earaches (caused by hardening of the ear wax). Patients may also notice some swelling or drooping of the skin under the chin and changes in the texture of the skin. The jaw may feel stiff and patients may not be able to open their mouth as wide as before treatment. Patients should report any side effects to their doctor or nurse and ask how to manage these effects.


 * Chemotherapy, also called anticancer drugs. This treatment is used to kill cancer cells throughout the body. The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, including blood cells that fight infection, cells that line the mouth and the digestive tract, and cells in hair follicles. As a result, patients may have side effects such as lower resistance to infection, sores in the mouth and on the lips, loss of appetite, nausea, vomiting, diarrhea, and hair loss. They may also feel unusually tired and experience skin rash and itching, joint pain, loss of balance, and swelling of the feet or lower legs. Patients should talk with their doctor or nurse about the side effects they are experiencing, and how to handle them.

Diseases with similar symptoms

 * oral cancer
 * cancer of the larynx
 * thyroid cancer
 * adenoid cystic carcinoma - a type of salivary gland cancer
 * Burkitt's lymphoma - a type of lymphoma that affects the head and neck
 * Dermatofibrosarcoma protuberans - a type of sarcoma that may involve the head and neck
 * Hodgkin's disease - a lymphoma that often involves the lymph nodes in the neck
 * paraganglioma - usually found in the head and neck region
 * skin cancers - may involve the head and neck

Where to find medical care for Head and neck cancer?
Directions to Hospitals Treating Head and neck cancer

Prevention of Head and neck cancer
Avoidance of recognized risk factors (as described above)is the single most effective form of prevention. Regular dental examinations may identify pre-cancerous lesions in the oral cavity.

People who have been treated for head and neck cancer have an increased chance of developing a new cancer, usually in the head and neck, esophagus, or lungs. The chance of a second primary cancer varies depending on the original diagnosis, but is higher for people who smoke and drink alcohol. Patients who do not smoke should never start. Those who smoke should do their best to quit. Studies have shown that continuing to smoke or drink (or both) increases the chance of a second primary cancer for up to 20 years after the original diagnosis.

Some research has shown that isotretinoin (13-cis-retinoic acid), a substance related to vitamin A, may reduce the risk of the tumor recurring (coming back) in patients who have been successfully treated for cancers of the oral cavity, oropharynx, and larynx. However, treatment with isotretinoin has not yet been shown to improve survival or to prevent future cancers.

What to expect (Outlook/Prognosis)?
Although early-stage head and neck cancers (especially laryngeal and oral cavity) have high cure rates, up to 50% of head and neck cancer patients present with advanced disease. Cure rates decrease in locally advanced cases, whose probability of cure is inversely related to tumor size and even more so to the extent of regional node involvement.

Consensus panels in America (American Joint Committee on Cancer AJCC and Europe) have established staging systems for head and neck squamous cancers. These staging systems attempt to standardize clinical trial criteria for research studies, and attempt to define prognostic categories of disease. Squamous cell cancers of the head and neck are staged according to the TNM classification system, where T is the size and configuration of the tumor, N is the presence or absence of lymph node metastases, and M is the presence or absence of distant metastases. The T, N, and M characteristics are combined to produce a “stage” of the cancer, from I to IVB.

Residual deficits
Even after successful definitive therapy, head and neck cancer patients face tremendous impacts on quality of life. Despite marked advances in reconstructive surgery and rehabilitation, intensity-modulated radiotherapy (IMRT) and conservation approaches to certain malignancies, some patients continue to have significant functional deficits.

Problem of second primaries
Survival advantages provided by new treatment modalities have been undermined by the significant percentage of patients cured of head and neck squamous cell carcinoma (HNSCC) who subsequently develop second primary tumors. The incidence of second primary tumors ranges in studies from 9.1% to 23% at 20 years. Second primary tumors are the major threat to long-term survival after successful therapy of early-stage HNSCC. Their high incidence results from the same carcinogenic exposure responsible for the initial primary process, called field cancerization.

Throat cancer has numerous negative effects on the body systems.

Digestive system
As it can impair a person’s ability to swallow and eat, throat cancer affects the digestive system. The difficulty in swallowing can lead to a person to choke on their food in the early stages of digestion and interfere with the food’s smooth travels down into the esophagus and beyond.

The treatments for throat cancer can also be harmful to the digestive system as well as other body systems. Radiation therapy can lead to nausea and vomiting, which can deprive a body of vital fluids (although these may be obtained through intravenous fluids if necessary). Frequent vomiting can lead to an electrolyte imbalance which has serious consequences for the proper functioning of the heart. Frequent vomiting can also upset the balance of stomach acids which has a negative impact on the digestive system, especially the lining of the stomach and esophagus.

Respiratory system
In the cases of some throat cancers, the air passages in the mouth and behind the nose may become blocked from lumps or the swelling from the open sores. If the throat cancer is near the bottom of the throat it has a high likelihood of spreading to the lungs and interfering with the person’s ability to breathe; this is even more likely if the patient is a smoker, because they are highly susceptible to lung cancer. If the respiratory system is unable to bring oxygen into the body, the oxygen deprivation will cause the body's cells to wither and die, causing one to become weaker and sicker.

Others
Like any cancer, metastasization affects many areas of the body, as the cancer spreads from cell to cell and organ to organ. For example, if it spreads to the bone marrow, it will prevent the body from producing enough red blood cells and affects the proper functioning of the white blood cells and the body's immune system; spreading to the circulatory system will prevent oxygen from being transported to all the cells of the body; and throat cancer can throw the nervous system into chaos, making it unable to properly regulate and control the body.