What is Head and Neck Cancer

Head and Neck cancer refers to many types of cancer in different areas located above the shoulders, excluding the brain and spinal cord. Cancer can occur in the oral cavity, nasal sinuses, nasopharynx (area behind the nose), oropharynx (in the throat area) and in the hypopharynx (lower throat and voice box area). Most of these cancers are in the squamous cells that line the moist lining of the mouth, nose and throat. Cancers in the saliva glands are less common and involve other types of cells.

Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. [CC BY 3.0 https://creativecommons.org/licenses/by/3.0)]

Risk Factors

A risk factor is anything that increases the person’s chance of developing a disease. For Head and Neck Cancers, risk factors can include environmental exposure or lifestyle habits such as use of tobacco, alcohol and the HPV type 16 virus that have been related to development of this type of cancer. As well, other risk factors include genetic or personal characteristics such as inherited genes or traits such as a person’s age, gender and family medical history.

Symptoms of Head and Neck Cancer

Common symptoms of Head and Neck Cancers can vary depending on the area affected. They may include a lump or sore that does not heal, a persistent sore throat, difficulty swallowing and changes in the voice. Other symptoms can include ear pain or ringing in the ears, blocked sinuses, white or red patches in the oral cavity, non-healing mouth ulcers, bleeding or pain in the mouth, changes in the fitting of a denture, swelling in the jaw region, and pain, numbness or weakness in the face area. It is important to see your doctor as these symptoms may be caused by other conditions besides cancer.

How is Head and Neck Cancer Diagnosed?

Manual and Visual Examinations

A manual examination is an important step in diagnosing head and neck cancer, with the doctor, dentist or other health professional checking for any of the symptoms noted above such as swelling, ulcers, lumps, visible changes in appearance and signs of weakness or pain. A visual examination of the head and mouth regions, and manually probing the head and neck structures are typically included in this examination.

Family History and Lifestyle Habits

Taking a family history about any cancers that run in a family can be important information for doctors/dentists. Also, understanding any lifestyle patterns or environmental exposure that can be linked to head and neck cancer risk can be important information for the treating doctors

Endoscopy

An endoscope is a fibre optic camera that send images to a computer screen. The endoscopic tube is inserted in the nose or mouth and is used to take pictures of the areas of the nasopharynx and oropharynx that cannot be seen during a standard mouth examination.

Biopsy

A biopsy is a sample of tissue that is taken to examine any changes more closely. Doctors can use various methods including surgery or a needle to obtain cells. These cells are then tested in a laboratory to determine the cause of these changes, including the possible presence of cancer.

Ultrasound

An ultrasound scan uses high-frequency sound waves to create images of the inside of the body. This allows a doctor to see problems with organs, vessels and other tissues without an operation

X-rays

X-rays are a type of radiation that creates pictures of the inside of your body, for example to check the bones, as well as other body areas such as the lungs.

Barium Swallow

This is a specialized type of x-ray. During a barium swallow, the person will drink a milkshake-type liquid containing a substance that shows up on an x-ray. By watching a screen projection of this swallowing process, the specialist can assess the functioning of the throat structures. Common things assessed include the ability to safely swallow and avoidance of aspiration of foods or liquids into the lungs which can be very serious.

MRI (Magnetic Resonance Imaging)

An MRI is a highly technical machine that uses strong magnetic fields to take pictures of the head and neck region. This can be used to assess the location/size of any cancer changes in the sinuses, pharynx or oral areas.

PET Scan (Positron Emission Tomography)

A PET Scan tests the body’s use of glucose (sugar) in the cells. Abnormal cells use glucose differently than normal cells. This test can be used to identify cancer or other unrelated conditions such as an infection.

CT Scan (Computed Tomography)

A CT Scan is a type of x-ray that combines a series of x-ray images from around the body that are then combined into cross sectional slices or images of the body area. These are used to identify any abnormalities, and can include any abnormal masses or growths.

Blood Tests

Blood tests help doctors check for certain diseases and conditions. Testing can also help the doctors understand how organs in the body are functioning. Testing can help in the diagnosis of some cancers.

Grading/Staging of Head and Neck Cancer

Cancer specialists use a standardized system to rate the extent of the tumour, its location in the body and its spread. Determining the long-term outlook (prognosis) and treatment choices of a cancer can depend a great deal on this rating. Various medical tests are used in determining this rating.

Different staging systems are used for different types of cancer. The most common staging system used in Canada is the TNM system. TNM stands for tumour, node (lymph node) and metastasis. It is used to stage most solid tumour cancers.

T stands for tumour. It describes the size of the main (primary) tumour. It also describes if the tumour has grown into other parts of the organ with cancer or tissues around the organ. T is usually given as a number from 1 to 4. A higher number means that the tumour is larger. It may also mean that the tumour has grown deeper into the organ or into nearby tissues.

N stands for lymph nodes. It describes whether cancer has spread to lymph nodes around the organ. N0 means the cancer hasn’t spread to any nearby lymph nodes. N1, N2 or N3 mean cancer has spread to lymph nodes. N1 to N3 can also describe the number of lymph nodes that contain cancer as well as their size and location.

M stands for metastasis. It describes whether the cancer has spread to other parts of the body through the blood or lymphatic system. M0 means that cancer has not spread to other parts of the body. M1 means that it has spread to other parts of the body. Doctors use the TNM description to assign an overall stage from 0 to 4 for many types of cancer. Generally, the higher the number, the more the cancer has spread. For most types of cancer, the
stages mean the following:

  •  stage 0 – carcinoma in situ, a precancerous change
  •  stage 1 – the tumour is usually small and hasn’t grown outside of the organ it  started in
  •  stages 2 and 3 – the tumour is larger or has grown outside of the organ it started in to nearby tissue
  •  stage 4 – the cancer has spread through the blood or lymphatic system to a distant site in the body (metastatic spread)

Other factors that are used to determine the stage for some types of cancer include the cell
type or genetic factors. Your doctor is the best source of this more specific type of rating.

Recurrence of Cancer

Once a person is told the stage of their cancer, it doesn’t change. For example, if a stage 2 cancer comes back (recurs) after it is treated, it is still stage 2 cancer that has recurred. And if the cancer has spread to a distant part of the body after it is treated, it is still stage 2 cancer but it is metastatic. If this happens, doctors may revise a treatment plan to deal with these changes in the cancer condition.

Types of Doctors and Medical Treatments

A diverse team of medical and other health professionals collaborate to treat head and neck cancer. The medical team can include:

ENT Specialists are medical doctors who specialize in the diagnosis and treatment of diseases or conditions of the ear, nose and throat. Some specialize in treating head and neck cancer. They may be called Head and Neck surgeons or Otolaryngologists.

Radiation Oncologists are doctors who specialize in the provision of radiation treatments in the treatment of cancer.

Medical Oncologists are specialist doctors who treat cancer using chemotherapy or other medications, such as targeted therapy or immunotherapy.

Oncology nurses are specialized nurses who care for cancer patients. This may involve specialized training in this area of practice.

Determining a medical treatment plan is a highly individual process and sometimes may include different options. These options are discussed with the patient and their support network. Options can include:

Surgery

Surgeons specifically trained in head and neck cancer perform surgery to remove cancer tumors and as necessary, rebuilding structures using various techniques. These can include reconstruction using bony tissue, medical implants and skin grafting, and other surgical methods as determined by the treating physician.

Radiation

Radiation has been used to treat cancer for decades. Specially trained doctors called radiation oncologists design the treatment requirements including the field of radiation, the dosage and the required number of treatments. The area of treatment is precisely identified and the patient is positioned on the radiation machine in the appropriate position. Sometimes, this requires fitting of a mask that permits exact positioning for each treatment. If other treatments are required, radiation is coordinated with the other treating specialists.

Chemotherapy

Medical oncologists prescribe cancer fighting medications that are delivered by intravenous into the blood system. These drugs are often referred to as systemic as they circulate through the body to target cancer cells.

Immunotherapy

Immunotherapy is a newer cancer treatment method that uses the person’s own disease fighting system (immune system) to fight cancer cells

Side Effects

A number of side effects can be experienced and depend on the type of cancer treatment provided. Not every person experiences every side effect and the treating doctors and other cancer professionals can educate a patient on potential side effects they may have. These can include:

Dental Changes

Depending on the cancer treatments provided, a number of side effects can occur in the mouth and jaw area. Reduced saliva flow from the saliva glands can result in symptoms of dry mouth. As saliva is important in dental protection due to its antibacterial characteristics, special attention to dental hygiene is necessary as an increased risk of tooth decay can result. Sometimes reduced healing of the bones and soft tissue in the face and jaw occurs due to radiation therapy, and tooth infection, trauma or any injury such as tooth extraction can lead to a condition referred to as osteoradionecrosis.

Trismus

Another potential side effect is limited mouth opening (referred to as trismus) that can make eating, speaking and dental care challenging.

Sore Mouth/Throat.

This is commonly experienced with radiation treatments, but may be related to other treatments. This may recover but often can linger for individual patients.

Eating and Chewing Difficulties

These side effects can result from pain, reduced saliva flow, loss of teeth, reduced tongue mobility and limited mouth opening. Changes in taste can also be experienced and typically are shorter term in nature, unless otherwise identified by a doctor.

Swallowing Changes

Problems are commonly experienced in swallowing and can be due to loss or stiffness of throat structures. As a result, the patient often needs to relearn how to swallow. This is highly individual depending on the person’s treatment. Treatment can include swallowing testing and treatment by specialized therapists. At times, this could be a long-term issue.

Speaking Difficulties

Speaking difficulties can occur due to loss or damage to mouth and throat structures such as the tongue or the voice box (larynx).

Nutrition Challenges

Due to changes in the ability to eat normally or special requirements due to cancer treatment, a cancer patient may require specialized nutritional support. This may include use of a feeding tube, prescription of a liquid or softer diet and/or prescription of a diet higher in certain types of nutrients.

Hearing Problems

Cancer patients may experience changes in hearing abilities as a result of cancer treatments, including systemic treatments such as chemotherapy.

Thyroid Changes

The thyroid gland is located at the front of the neck and can be affected by radiation treatments, despite efforts to shield this area from radiation. This can result in changes in the gland and this requires long term monitoring to provide timely treatment as necessary.

Emotional Distress

Due to the complexity of treatment for head and neck cancer, it is not uncommon for patients to experience emotional concerns. These may stem from changes in appearance or other physical changes, changing roles in the family such as employment, or loss of function and independence. Similarly, changes in sexual function might be distressing as a result of cancer treatments. Accessing treatment for the patient and his/her support network can be a vital aspect of holistic cancer care.

Fatigue

Fatigue is a common symptom experienced by cancer patients. With head and neck cancer, this can be a result of medical treatments, but also related to dietary or hormonal problems. Patients should discuss these symptoms with their treatment team.

Other Symptoms

Sometimes other symptoms are experienced and can include numbness, temperature sensitivity and pain.

Other Treating Team Members/ Supportive Care

Depending on the individual’s requirements, a diverse team of health professionals can provide care at any point of the patient’s course of treatment. Some forms of treatment can be required indefinitely, due to the complexity of head and neck cancer. This can include services from:

Dentists/Specialist Dentists. Due to changes in head and neck anatomy and oral functions, it is important to have regular monitoring to prevent and treat dental problems before they cause issues. Loss of salivary function may necessitate additional fluoride treatments, use of specialized dry mouth products and specialized dental care. For those with limited mouth opening, more frequent cleaning of teeth may be required. Additionally, consulting with a patient’s cancer care team including specialist dental team members for more involved oral and dental treatment is typically recommended, for procedures such as root canals or extractions. This is due to potential side effects such as jaw osteoporosis (bone weakness). If oral or jaw structures have been removed as part of the cancer treatment, then they will need to be seen by dental specialists called Maxillofacial Prosthodontists who will collaborate with other specialists and be able to provide oral rehabilitation to improve oral function and maintain dignity.

Nutritional Specialists/Dieticians. These professionals specialize in assessing and treating the nutritional needs of head and neck cancer patients and typically work collaboratively with a swallowing therapist and other team members as appropriate. Due to the wide range of individual needs and abilities, treatments may address feeding tube requirements, dietary recommendations appropriate for swallowing abilities and any specialized nutritional needs due to cancer treatments.

Swallowing and Speech Therapists. These rehabilitation professionals have a special interest and/or training in treating the changes in swallowing ability or speaking abilities for individuals with head and neck cancer. These changes can be highly variable depending on the nature of treatment. Therefore, treatments may be very different and can include clinical measuring, swallowing exercises, oral exercises, home exercises and prescription of communication devices. Speech and swallowing therapists work closely with Nutritionists in maintaining and improving diet and nutrition to aid in cancer recovery and long-term health. Options can vary from use of feeding tube to eventual return to a normal diet. Respiratory Therapists. These therapists assess patients and implement respiratory care plans as needed such as the use of oxygen delivery services or other respiratory equipment.

Physical Therapists. These rehabilitation professionals assess and treat any physical changes arising from head and neck cancer treatments. While highly individual, this may include jaw exercises to maintain and improve mouth opening, neck exercises to stretch and strengthen neck tissues, arm exercises, and overall fitness training to aid in overall strength and stamina declines as a result of treatments. Occupational therapists. These rehabilitation professionals focus on improving the physical and mental functioning of head and neck cancer patients in activities of daily living. This can include basic personal care activities, leisure interests and productive activities including household tasks.

Psychologists/Mental Health Therapists. Due to the complexity of care required for head and neck cancer, individuals may experience emotional distress at any point during diagnosis, treatment and recovery. Individual counselling, support groups and other therapies can benefit both patients and their family/support network in this important aspect of recovery.

Social Workers. Social workers can provide valuable information and support regarding financial concerns, government services, community supports and other health related matters.

References

Resources used in compiling the above information are listed below.

Internet references

Canadian Cancer Society:  www.cancer.ca
Head and neck cancers – national cancer institute:  www.cancer.gov
Healthline:  www.healthline.com
Mayo Clinic:  www.mayoclinic.org/test
MedlinePlus:  medlineplus.gov
MyHealth.alberta.ca
BruceBlaus:  creativecommons.org/licenses/by/3.0

Books

100 questions and answers about head and neck cancer (2008) Carper, E. Hu, Kenneth and
Gourin, Christine.Kuzin, E. Jones and Bartlett Publishers. Sudbury, Mass. Isbn-13:978-0-
76374307-9.

Patients Guide to Head and Neck Cancer. John Hopkins Medicine. 2011. Jones and Bartlett
Publishers. Sudbury, Mass. Isbn -13: 978-o-7637-7431-8.

Final Thoughts

There are many educational resources that can help individuals more fully understand their condition. First and foremost, the treating team of cancer specialists can provide information that may be unique to an individual’s personal situation. Other complementary information might be accessed in a resource center at the cancer treatment center or through a medical librarian at a nearby the hospital or educational institution. While the internet might be a ready resource for health information, a cautionary note to ensure that the source is a credible one is recommended. Your treating team or other resources in your cancer facility may be able to provide further guidance in this regard.

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