Head & Neck Cancer
Cancer is a disease that begins in cells, the body’s basic unit of
life. Normally, cells grow and divide to form new cells in an orderly
way. They perform their
functions for a while, and then they die. Sometimes, however, cells do
not die. Instead, they continue to divide and create new cells that
the
body does not need. The extra cells form a mass of tissue, called a growth
or tumor. Tumors can be benign (not cancer) or malignant (cancer). Cancer
can spread to other parts of the body through a process called metastasis.
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Most head and neck cancers begin in the squamous cells that line the
structures found in the head and neck. Because of this, head and neck
cancers are often referred
to as squamous cell carcinomas. Some head and neck cancers
begin in other types of cells. For example, cancers that begin in
glandular cells are called adenocarcinomas.
Cancers of the head and neck are further identified by the area in
which they begin:
Oral cavity—The oral cavity includes the lips, the
front two-thirds of the tongue, the gums (gingiva), the lining inside
the cheeks and lips (buccal mucosa), the bottom (floor) of the mouth
under the tongue, the bony top of the mouth (hard palate), and the small area behind the wisdom teeth.
Salivary glands—The salivary glands are in several places:
under the tongue, in front of the ears, and under the jawbone, as well
as in other parts of
the upper digestive tract.
Paranasal sinuses and nasal cavity—The paranasal sinuses are small
hollow spaces in the bones of the head surrounding the nose. The nasal
cavity is the hollow space inside the nose.
Pharynx—The pharynx is a hollow tube about 5
inches long that starts behind the nose and leads to the esophagus (the
tube that goes to the stomach) and the trachea (the tube that goes to
the lungs). The pharynx has three parts:
Nasopharynx—The nasopharynx, the upper part of
the pharynx, is behind the nose.
Oropharynx—The oropharynx is the middle part of
the pharynx. The oropharynx includes the soft palate (the back of the
mouth), the base of the tongue, and the tonsils.
Hypopharynx—The hypopharynx is the lower part of
the pharynx.
Larynx—The larynx, also called the voicebox, is a
short passageway formed by cartilage just below the pharynx in the neck. The
larynx contains the vocal cords. It also has a small piece of tissue,
called the epiglottis, which moves to cover the larynx to prevent
food from entering the air passages.
Lymph nodes in the upper part of the
neck—Sometimes, squamous cancer cells are found in the lymph nodes of the upper neck when there is no
evidence of cancer in other parts of the head and neck. When this
happens, the cancer is called metastatic squamous neck cancer with unseen (occult)
primary.
Cancers of the brain, eye, and thyroid usually are not included in the category of
head and neck cancers. Cancers of the scalp, skin, muscles, and bones of
the head and neck are also usually not considered cancers of the head
and neck.
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Head and neck cancers account for 3 percent of all cancers in the
United States. These cancers are more common in men and in people over
age 50. It is estimated that almost 38,000 men and women in this country
will develop head and neck cancers in 2002.
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Tobacco (including smokeless tobacco) 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); 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, mechanical irritation such as
from poorly fitting dentures, and use of mouthwash that has a high
alcohol content.
Hypopharynx—Plummer-Vinson (also called Paterson-Kelly) syndrome,
a rare disorder that results from 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.
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.
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Symptoms that are common to several head and neck cancer sites
include a lump or sore that does not heal, a sore throat that does not
go away, difficulty swallowing, and 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.
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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. 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.
- Biopsy is the removal of tissue for examination
under a microscope. A pathologist studies the tissue 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 surgery, x-rays and other imaging procedures, and laboratory tests. Knowing the
stage of the disease helps the doctor plan treatment.
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Patients with head and neck cancers are usually treated by a team
of specialists. The specialists vary, depending on the location and
extent
of the cancer. The medical team may include oral surgeons; ear, nose,
and throat surgeons (also called otolaryngologists); pathologists; medical oncologists; radiation oncologists; prosthodontists;
dentists; plastic surgeons; dietitians; social workers; nurses; physical therapists; and speech-language pathologists
(sometimes called speech therapists).
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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.
SurgeryThe 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. Information about rehabilitation can be found
in question 10.
Radiation therapy, also called radiotherapy. This treatment
involves the use of high-energy x-rays to kill cancer cells. Radiation
therapy affects the
cancer cells only in the treated area. 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).
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. Anticancer drugs are used to kill
cancer cells throughout the body. Drugs used to treat head and neck
cancers are usually given by injection into the bloodstream (intravenous,
or IV). Chemotherapy is widely used to treat certain
stages of cancer of the nasopharynx, hypopharynx, and salivary glands.
Its use in treating other head and neck cancers is being tested in
clinical trials (research studies). Chemotherapy may
be combined with radiation therapy to treat cancer of the nasopharynx.
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.
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Clinical trials are research studies conducted with people who
volunteer to take part. Participation in clinical trials is an option
for many patients with head and neck cancers.
Treatment trials are designed to find more effective cancer
treatments and better ways to use current treatments. In some studies,
all patients receive the new treatment. In others, doctors compare
different therapies by giving the new treatment to one group of patients
and standard therapy to another group. Doctors are
studying new types and schedules for delivering radiation therapy, new
anticancer drugs, new drug combinations, and new ways of combining
treatments. They are also studying ways to treat head and neck cancers
using biological therapy (a type of treatment that
stimulates the immune system to fight cancer) by itself or in
combination with anticancer drugs or radiation therapy.
Scientists are also conducting clinical trials to find
better ways to reduce the side effects of chemotherapy and radiation
therapy for head and neck cancers. These clinical trials, called supportive
care trials, explore ways to improve the
comfort and quality of life of cancer patients and cancer
survivors.
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Rehabilitation is a very important part of treatment for patients
with head and neck cancer. The goals of rehabilitation depend on the
extent of the disease and the treatment a patient has received. The
health care team makes every effort to help the patient return to normal
activities as soon as possible.
Depending on the location of the cancer and the type of treatment,
rehabilitation may include physical therapy, dietary counseling, speech
therapy, and/or learning how to care for a stoma after a laryngectomy.
A stoma is an opening into the windpipe through which a patient breathes after a
laryngectomy.
Sometimes, especially with cancer of the oral cavity, a patient may
need reconstructive and plastic surgery to rebuild the bones or tissues of
the mouth. If this is not possible, a prosthodontist may be able to make
an
artificial dental and/or facial part (prosthesis) to restore satisfactory swallowing and
speech. Patients will receive special training to use the device.
Patients who have trouble speaking after treatment, or who have lost
their ability to speak, may need speech therapy. Often, a
speech-language pathologist will visit the patient in the hospital to
plan therapy and teach speech exercises or alternative methods of
speaking. Speech therapy usually continues after the patient returns
home.
Eating may be difficult after treatment for head and neck cancer.
Some patients receive nutrients directly into a vein (IV) after surgery,
or need a feeding tube until they can eat on their own. A feeding
tube is a
flexible plastic tube that is passed into the stomach through the nose
or an incision (cut) in the abdomen. A nurse or speech-language pathologist
can help patients learn how to swallow again after surgery.
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Regular followup care is very important after treatment for head
and neck cancer to make sure the cancer has not returned, or that
a second
primary (new) cancer has not developed. Depending on the type of cancer,
medical checkups could include exams of the stoma, mouth, neck, and
throat. Regular dental exams may also be necessary. From time to
time,
the doctor may perform a complete physical exam, blood tests, x-rays,
and CT or MRI scans. The doctor may continue to monitor thyroid and
pituitary gland function, especially if the head or
neck was treated with radiation. Also, the doctor is likely to counsel
patients to stop smoking. Research has shown that continued smoking may
reduce the effectiveness of treatment and increase the chance of a
second primary cancer (see question 12).
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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.
Patients who do not smoke should never start. Those who smoke should do
their best to quit. Studies have shown that continuing to smoke
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 a second primary
cancer in patients who have been successfully treated for cancers of the
oral cavity, oropharynx, and larynx. However, treatment with
isotretinoin has not been shown to improve survival.
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NCI Online
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