Head And Neck Cancers
The term “Head and Neck cancer” encompasses a wide range of cancers that occur in several areas of the head and neck region, including the nasal passages, sinuses, mouth, throat, larynx, swallowing passages, salivary glands, and the thyroid gland. Skin cancers that develop on the scalp, face, or neck may also be considered Head and Neck cancers. Head and neck cancer can develop in anyone, but people who use tobacco in any form (including cigarettes, cigars, pipes, bidis, chewed as quid, with betel nut and smokeless tobacco) or drink alcohol excessively are much more likely than others to develop the disease. Most of these cancers are preventable with moderation in alcohol and by refraining from tobacco use.
Below are some of the symptoms and warning signs of head and neck cancer. Many of these symptoms can be caused by other, non-cancerous conditions as well. See your doctor if you notice any of these problems.
• A sore in the mouth that won’t heal (the most common symptom) or that bleeds easily
• A red or white patch in the mouth that doesn’t go away
• Frequent nosebleeds, ongoing nasal congestion, or chronic sinus infections that do not respond to treatment
• Persistent sore throat
• Persistent hoarseness or a change in the voice
• Pain in the neck, throat, or ears that won’t go away
• Blood in the sputum
• Difficulty chewing, swallowing, or moving jaws or tongue
• Numbness in the tongue or other areas
• Loosening of teeth
• Dentures that no longer fit
• A lump or swelling in the neck
• Changes in a mole or discoloration, or a sore on the skin that is crusting, ulcerated, or fails to heal (these are also signs of skin cancer)
TYPES OF CANCERS
There are many different types of head and neck cancer. Several of them are described below. Most head and neck cancers are squamous cell carcinomas, i.e cancers arising from the mucosal lining .
Oral cancer is cancer that arises in the mouth, or oral cavity. The oral cavity includes the lips, the gums and the area behind the wisdom teeth, the inside of the lips and cheeks, the floor and roof (hard palate) of the mouth, and the front two-thirds of the tongue.
Laryngeal (Voice Box) cancer begins in the larynx, an organ also known as the voice box. The larynx sits at the top of the trachea, the respiratory tube that leads to the lungs. Air passes through the larynx on the way to the lungs. The vocal cords, two bands of muscle, are found within the larynx and are used for speech. The larynx also prevents food from entering the lungs.
Nasal cavity and paranasal sinus cancers are found in the tissues that line these hollow structures. The paranasal sinuses are hollow areas in the bones of the face near the nose that produce mucus. The nasal cavity is found just behind the nose and is used to condition the inhaled air before passing it throat.
Nasopharyngeal cancer is found in the nasopharynx, the uppermost portion of the throat (pharynx). It begins just behind the nose and extends to the oropharynx, the portion of the throat found just behind the mouth. It also includes two openings that lead to the ears. (The entire throat is called the pharynx, and is made up of the nasopharynx, the oropharynx just below that, and the hypopharynx, the lower region that meets the esophagus.)
Oropharyngeal cancer is found in the section of the throat (oropharynx) located just beyond the mouth. The region also includes the base of the tongue, the soft palate (the soft area just beyond the roof of the mouth), and the area around the tonsils.
Hypopharyngeal cancer is found in the hypopharynx, the uppermost portion of the esophagus (the tube through which food travels to the stomach). The hypopharynx surrounds the larynx.
Salivary gland cancer – It is found in the salivary glands, the structures that produce saliva to keep the mouth from drying out and aid in the digestion of food. Salivary glands may be found in front of the ears (parotid), under the jaw (submandibular), underneath the tongue (sublingual), and in other areas of the upper aerodigestive passages including the nose, sinus, mouth, and throat.
Thyroid cancer – It develops in the thyroid gland, a small H-shaped structure that wraps around the front of windpipe in the lower part of the neck. The thyroid gland is the source of important hormones that help regulate metabolism, blood pressure, heart rate, temperature and other functions. Thyroid gland cancers are hereditary, or related to a lot of dietery and environmental factore like Iodine deficiency and radiation exposure. It also is more common in females.
Because most head and neck cancers arise after prolonged exposures to known risk factors, these cancers are often considered preventable. Risk factors for head and neck cancers include tobacco and alcohol use, a history of pre-cancerous lesions, and exposure to cancer-causing agents in the environment. People who use tobacco in any form or drink alcohol excessively are at much greater risk for the disease. For example, smoking raises the risk of cancer of the larynx (voice box) or hypopharynx to 5 to 35 times the risk of nonsmokers. Heavy use of alcohol raises the risk of those cancers 2 to 5 times. Those who smoke and also drink heavily might be raising their risk to 100 times that of non-users.
INVESTIGATIONS AND DIAGNOSIS
Doctors perform any of several types of tests that can help to make a definitive diagnosis of a head and neck cancer and to determine the stage of the cancer, or how far it has progressed. Treatment is decided depending on the stage of the cancer at diagnosis.
Physical Examination & History
First, the doctor takes a complete medical history, noting all symptoms and risk factors. Then comes a thorough examination of the head and neck area, during which the doctor will feel for abnormalities and looking at the inside of your mouth and throat, and on the neck for lumps.
The doctor may use mirrors and lights to examine hard-to-see areas and may also use a flexible, lighted tube (fibre optic or a Hopkins’scope) to examine areas that are less accessible. The tube may be inserted through the nose or mouth; an anesthetic spray may be used to make the examination more comfortable. This examination is called a nasopharyngoscopy, pharyngoscopy, or laryngoscopy, depending on which area is examined. Occasionally, this type of examination will be done while the patient is under general anesthesia so a very thorough inspection can be done; this is called a panendoscopy.
The doctor may also suggest several other tests, including imaging procedures such as a CT or computed tomographic scan (a special type of x-ray), an MRI or magnetic resonance image scan (which uses magnetic waves to produce pictures), or an ultrasound exam (which uses sounds waves to produce images). Doctors also now use PET (positron emission tomography) scans to help diagnose head and neck cancers, but this is not yet a routine practice. Currently, research is investigating whether PET scans will improve the ability to detect the spread of cancer to lymph nodes in the neck and other areas of the body.
Other possible tests include an orthopentogram (a special x-ray of the jaws), a barium swallow, dental x-rays, chest x-rays, and a radionuclide throid scan in case of thyroid cancers.
If a suspicious area is noted, the doctor may do a biopsy: he or she will remove a small piece of tissue with either a scalpel or a needle, and send it to a laboratory for examination under a microscope. Biopsies are often done when the patient is under general anesthesia. Biopsies of easily accessible areas are done under local anesthesia. Before starting any form of treatment, a biopsy is mandatory to prove the diagnosis.
Many cancers of the head and neck can be cured, especially if they are found early. Treatment varies according to the type, severity, and location of the disease. It may include surgery (the primary treatment method), radiation therapy, or chemotherapy. Increasingly, oncologists are combining treatment modalities to maximize chances of curing the cancer.
Although cure of the cancer is the primary goal in treatment, preserving a patient’s appearance and ability to function, and thus the quality of life, also are very important goals and are considered an integral part of treatment. Today, advances in surgical techniques, reconstruction, and non surgical treatment methods combined with a comprehensive team approach, which brings the expertise of numerous specialists to each patient’s care have made it possible to attain those quality of life goals in nearly every patient receiving treatment.
Surgery is the mainstay of treatment for most cancers of the head and neck. Loss of speech was once common after head and neck surgery, because of damage to the larynx (voice box). Continual advances in surgical techniques, however, allow more patients to preserve normal functioning. Surgeons have perfected techniques, for example, that remove only part of the larynx instead of the entire organ. Indeed, larynx-preserving surgery is possible in more than half of the cases that once would have required that organ to be completely removed. Also, now we have gadgets which can be inserted into the throat which will help patient to speak even after his larynx has been removed completely. Other advances now allow doctors to spare the jaw or replace it with some other bone from the patient’s body to maintain a normal face. Also the eye can be spared when a tumor is crowding that area.
When surgery is extensive, immediate reconstruction of the area is often possible. For example, in cases where the jaw bone must be removed, a surgeon can fashion a new jaw using bone from the patient’s own leg. Blood vessels are moved along with the leg bone and are attached to blood vessels in the neck, creating a blood supply for the new jaw. Similarly, skin and muscle from a patient’s back or abdomen can now be used to replace part of the scalp. Dental implants can be used to replace teeth.
Radiation therapy may involve external beam treatment or brachytherapy, a technique in which tiny radioactive seeds are implanted directly in a tumor. In some cases, both approaches are used. Radiation therapy is often given in conjunction with surgical treatment, but studies are showing that in some cases, radiation therapy sometimes combined with chemotherapy is just as effective as surgery. These new approaches can often preserve the ability to speak and swallow normally, even in patients with advanced disease.
The use of chemotherapy in head and neck cancer is also expanding, especially in cases that previously would have been considered untreatable. Chemotherapy is often used to enhance the response of cancer cells to radiation therapy, and often makes it possible to preserve organs, such as the larynx, that once would have been removed. For patients with advanced disease, too, chemotherapy is helping to increase longevity; this is especially true in patients who have cancer of the nasopharynx or other areas that are not easily treated surgically.
APPROACH TO HEAD AND NECK CANCER
Early stage disease
- Surgery alone is often the standard of care for early stage disease.
- Radiation therapy alone is also acceptable for stage I and II malignancies, although squamous cells are only moderately radiosensitive.
Late stage disease
- Surgery is part of a combination approach, either before or after other modalities.
- Radical or modified neck dissection if there is cervical lymph node spread.
- Reconstructive procedures are very important adjunct to tumor resection.
- Radiation therapy plays role in large, unresectable tumors for palliation and preservation of speech and swallowing functions.
- Chemotherapy combination regimens have not yet demonstrated better tumor control or survival when used alone. However, many late stage disease patients are at risk of occult metastases and/or recurrence, thus chemotherapy plays a role.
Focus on Quality of Life
When planning a course of treatment for a patient, doctors place great emphasis on quality-of-life issues, such as the ability to speak or swallow. Surgery is the primary form of treatment for head and neck cancers, and today such surgery is often much less disfiguring than patients may fear. Numerous surgical procedures have been developed that permit removal of tumors from complex areas, such as the base of the skull, that were not possible in the past and, at the other end of the spectrum, preserve organ function and facial appearance to a far greater degree than was possible in the past, while keeping cure of the cancer as the main goal.
Indeed, the standards of care for head and neck surgery have changed substantially in recent decades. Reconstructive surgery has improved dramatically, expanding the range of tumors that can now be removed surgically and yielding previously unattainable cosmetic and functional outcomes. Research data indicates that the results of complicated surgical procedures like these are best when the procedures are done by specialists who perform them on a regular basis.