Head and Neck Cancer

What are head and neck cancers?

Head and neck cancer is a term used to describe the cancers that start in the tissue or lymph nodes in the head and neck area, which includes the mouth, tongue, palate, gums, salivary glands, tonsils, throat (pharynx), voice box (larynx), nose and sinuses. Most head and neck cancers start in the cells that line the moist surfaces of the mouth, nose or throat (also known as squamous cells). These cancers are therefore referred to as squamous cell carcinomas (SCC).

Locally advanced head and neck cancer is a type of head and neck cancer that has spread from where it started to nearby tissue or lymph nodes, while recurrent head and neck cancer is a type of head and neck cancer that has come back, usually after a period of time during which the cancer could not be detected.

Metastatic head and neck cancer occurs when the cancer cells within the tumour have spread from the original location to other parts of the body. When head and neck cancer spreads (or metastasises), it can spread to the lungs, or other parts of the body.

Types of head and neck cancers

Cancers of the head and neck are usually identified by the area of the head or neck where they begin.
These include:

Mouth ( oral cavity)

Cancer can begin in any part of the mouth. The areas that may be affected include the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, the floor (bottom) of the mouth under the tongue, the hard palate (bony top of the mouth), and the small area behind the wisdom teeth. Cancer which starts in the mouth is called oral cancer.

Nasal cavity and paranasal sinuses

The nasal cavity is a large, hollow space inside the nose which helps to filter, moisten and warm the air we breathe. The bones around the nasal cavity have a group of small, air-filled spaces called the paranasal sinuses.

There are four pairs of paranasal sinuses. These include:

  • ethmoid sinuses located above the nose and between the eyes
  • frontal sinuses located behind the forehead
  • maxillary sinuses located under the eyes and in the cheek area
  • sphenoid sinuses located behind the nose and between the eyes

Cancerous cells can also develop in the tissues of the paranasal sinuses and nasal cavity.

Salivary glands

The salivary glands produce saliva which keeps the mouth moist, helps with swallowing of food and protection of the mouth against infections. The major salivary glands include:

  • parotid glands, which are in front of the ears
  • sublingual glands, which are under the tongue
  • submandibular glands, which are under the jawbone

Most salivary gland cancers affect the parotid glands. In some instances, cancers in the salivary gland may also affect the submandibular and sublingual glands.

Throat (pharynx)

The throat, also called pharynx, is a hollow tube that starts behind the nose and leads to the food pipe (oesophagus), and the windpipe (trachea). The pharynx has 3 parts, which include:

  • Nasopharynx: This is the upper part of the pharynx, behind the nose and above the soft palate. Cancers that develop
    in this area are called nasopharyngeal cancers.
  • Oropharynx: This is the middle part of the pharynx, the area from the soft palate and base of the tongue to the back
    of the mouth, including the tonsils. Cancers that develop in this area are called oropharyngeal cancers.
  • Hypopharynx: This is the lower part of the pharynx, around the voice box (larynx). Cancers that develop in this area
    are called hypopharyngeal cancers.

Larynx

The larynx or voice box is a short passageway formed by cartilage, just below the pharynx in the neck. It connects the lower part of the throat (hypopharynx) with the windpipe (trachea). The larynx contains the vocal cords. It also has a small piece of tissue, the epiglottis, which covers the larynx, preventing food from entering the air passages.

Cancer that affects the larynx is called laryngeal cancer.

SYMPTOMS

Symptoms of head and neck cancers

Symptoms of the different types of head and neck cancers may include the following:

Mouth (oral) cancer

  • pain in the mouth
  • pain when swallowing
  • persistent sore or swelling in the mouth
  • unusual bleeding or numbness in the mouth
  • red or white patches on the gums, tongue or mouth
  • bad breath
  • changes in speech or difficulty pronouncing words
  • difficulty chewing or swallowing food
  • difficulty moving the tongue
  • weight loss
  • a lump in the neck
  • earache, loose teeth, or dentures that no longer fit

Throat (pharyngeal) cancer

  • throat pain or difficulty swallowing
  • persistent sore throat or cough
  • coughing up bloody phlegm
  • bad breath
  • weight loss
  • voice changes or hoarseness
  • a lump in the neck
  • pain in the ear or frequent ear infections
  • numbness of the face
  • compressive symptoms and sternal pain
  • nasal congestion
  • hearing loss
  • headache

Laryngeal cancer

  • swelling or lump in the neck or throat
  • persistent sore throat
  • persisten change in the sound of the voice, including hoarseness
  • difficulty swallowing or pain when swallowing
  • constant coughing
  • difficulty breathing
  • weight loss
  • pain in the ear

Nasal cavity or paranasal sinus cancer

  • decreased sense of smell
  • persistent blocked nose, particularly in one nostril, or a blocked ear
  • frequent nosebleeds
  • excess mucus in the throat or back of nose
  • frequent headaches or sinus pressure
  • difficulty swallowing
  • loose or painful upper teeth
  • a lump on/in the face, nose or mouth
  • numbness of the face, upper lip, or within the mouth or upper teeth
  • pressure or pain in ears
  • a bulging or watery eye
  • double vision
  • complete or partial loss of eyesight

Salivary gland cancer

  • swelling or a lump near the ear, jaw or lip, or inside the mouth
  • different appearance on each side of the face or neck
  • difficulty swallowing or widely opening the mouth
  • drooping,
  • numbness or muscle weakness on one side of the face (palsy)

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RISKS

Risk factors for head and neck cancer

Some of the risk factors for head and neck cancers may include:

  • alcohol
  • tobacco (including cigarettes, cigars and pipes)
  • chewing or smoking areca nut, betel nut, pan or gutka
  • infection with the human papillomavirus (HPV), especially HPV 16, or the Epstein-Barr virus (EBV)
  • being overweight or obese
  • individuals aged over 40 years
  • male gender
  • a first-degree relative (parent, child or sibling) with head and neck cancer
  • breathing in asbestos fibres, wood dust, dry-cleaning solvents or certain types of paint or chemicals
  • weak immune system

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DIAGNOSIS

Diagnosis of Head & Neck cancer

Diagnosis

Diagnostic tests are usually conducted to diagnose head and neck cancers because of symptoms experienced by a patient, or during routine visits to the doctor or dentist. The doctor may conduct some general tests and refer the patient to an otolaryngologist (a specialist doctor who focusses on diseases of the ear, nose and throat). The diagnostic tests to be conducted will depend on symptoms experienced by the patient, and these tests may include some examinations, tissue sampling or biopsy, and imaging tests.

Physical examination: The doctor may examine the patient’s mouth, throat, nose, neck, ears and eyes depending on the symptoms experienced. The doctor may examine the mouth by using a thin wooden tongue depressor or by inserting a gloved finger into the mouth to examine difficult to see areas. The neck may also be examined on both sides to ensure the lymph nodes are normal.

Nasendoscopy: This procedure is used by the doctor to examine the nose and throat area with a nasendoscope (a thin flexible tube which has a camera and light at the end). A local anaesthetic is sprayed into the nostril before the procedure to numb the nose and throat. The doctor will gently insert the nasendoscope into one of the patient’s nostrils and down the throat, and examine the nasal cavity, nasopharynx, oropharynx, hypopharynx and larynx, possibly on a screen. The doctor may also take tissue samples, for further examination, during this procedure. It is advisable to not drink any hot beverages for about 30 minutes after the nasendoscopy.

Laryngoscopy: During this procedure, the doctor inserts a laryngoscope (a tube with a camera and light at the end), into a patient’s mouth and throat to examine the throat and voice box on a screen. The doctor may also take a tissue sample, for further examination. A general anaesthetic is usually administered to patients before the procedure, and patients that undergo laryngoscopy may experience a sore throat for a couple of days after the procedure.

A laryngoscope with light on

A doctor examining a laryngoscope

Biopsy: A biopsy is conducted when cell or tissue samples from an affected area are removed by a doctor, either during a nasendoscopy or laryngoscopy, and sent to a pathologist for further examination, to see if these samples contain cancer cells. In instances where samples for biopsy are required from hard-to-reach areas, the samples may be collected using a fine needle. An ultrasound or CT scan is used to guide the needle to the correct place to obtain the sample. If the doctor is unable to diagnose cancer from the cell or tissue sample, the patient may be required to have surgery to remove the mass so it can be checked for any cancerous cells.

Imaging tests: The doctor may perform some imaging tests to provide additional details about the location of the tumour, and to determine if it has spread to other parts of the body. Some of the imaging tests usually conducted are described below:

  • X-rays: These may be used to establish the presence of tumours or to see if there is any damage to the bones. Examples of x-rays include orthopantomogram and chest x-ray. An orthopantomogram is carried out to examine the jaw and teeth of people with mouth cancer. A chest x-ray may be used to determine the general health of patients with mouth, pharyngeal or laryngeal cancer. It may also be used to establish if the cancer cells have spread to the lungs.

  • CT scan: Computerised tomography (CT) scan is a special kind of x-ray which takes detailed pictures to help establish if the cancer has spread to the lymph nodes, lungs, or other organs. Before the procedure, the patient may be injected with a dye (or contrast) into a vein, to ensure the pictures obtained from the CT-scan are clearer. During the scan, the patient lies on a table that moves in and out of the CT scanner.

A lady having a CT scan in hospital

  • MRI scan: An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of a patient’s body. Before the procedure, a dye may be injected into the patient’s veins to make the pictures from the scan clearer. During the scan, the patient lies on a treatment table which slides into a large metal tube which is open at both ends.

A MRI machine

  • PET-CT scan: The positron emission tomography (PET) scan combined with a CT scan is a specialised imaging test usually recommended to diagnose oral, pharyngeal or laryngeal cancer, and to determine if the cancer has spread. The PET scan confirms if there are any cancer cells in the body and the CT scan helps to determine the location of the cancer cells. The patient will be injected with a glucose solution containing some radioactive material before the scan, to ensure that any cancer cells present are clearly seen on the scan. The patient will then be required to sit quietly for about 90 minutes to ensure the glucose solution spreads throughout the body, before the procedure takes place.

  • Ultrasound: An ultrasound may be used to examine the thyroid, salivary glands and lymph glands in the neck for the presence of any tumours. For this procedure, the patient lies down, and a gel is spread over the neck. A small device (a transducer) is then moved over the area. If tumours are present in the area, the transducer sends echo soundwaves and the ultrasound images of the area are projected onto a computer screen.

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TREATMENT

Treatment options for head and neck cancer

The main types of treatment for head and neck cancer are local treatment and systemic treatment.

Surgery and radiotherapy are used to treat only the cancer. They do not affect the rest of the body. This is called local treatment.

Chemotherapy and targeted therapy medicines go through the whole body. They can reach cancer cells anywhere in the body. They are called systemic treatment.

Doctors may use both local and systemic treatments for head and neck cancers. The treatment plan chosen by the doctor may depend on:

  • the location of the cancer
  • the stage of the cancer
  • the likelihood that the treatment option selected will cure or shrink the cancer cells
  • how the treatment will affect the patient’s speech, breathing or ability to eat
  • the patient’s age
  • other health problems the patient may have
  • side effects of the treatment options

Surgery

The aim of surgery is to remove cancerous tissue and to preserve the functions of the head and neck area, such as breathing, swallowing and talking. During surgery, the surgeon cuts out the tumour and a margin of healthy tissue. This is checked by a pathologist to make sure all the cancer cells have been removed. Surgery may also be used to take out lymph nodes in the neck that haven’t improved with other treatments.

Some side effects of surgery may include:

  • changes in the sense of taste and smell
  • breathing difficulties
  • difficulty with swallowing
  • changes in the speech or voice
  • pain and physical discomfort
  • swellings in the head or neck area

Radiotherapy

Radiotherapy involves the use of a controlled dose of radiation to kill or damage cancer cells. The radiation is targeted at the cancer, and treatment is carefully planned to do little harm to healthy body tissue near the cancer. Radiation therapy can be given externally or internally, but for head and neck cancers it is usually given externally.
Radiation therapy can be used on its own as the main treatment for pharyngeal and laryngeal cancers, to preserve important functions such as speech, swallowing and breathing. When radiotherapy is used after surgery, the aim is to eliminate any cancer cells that may not have been removed during surgery and reduce the chance of the cancer coming back.

Some side effects of radiotherapy may include:

  • skin changes where the radiation is given
  • fatigue
  • hoarse voice
  • taste changes
  • mouth and throat sores
  • dry mouth
  • trouble swallowing or eating

Chemotherapy

Chemotherapy is the use of medicines to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells. Chemotherapy is usually given in cycles or rounds, and each round/cycle of treatment is followed by a treatment break.

Chemotherapy may be given:

  • in combination with radiation therapy (chemoradiation), to improve the effects of radiation
  • before surgery or radiation therapy (neoadjuvant chemotherapy), to shrink a tumour
  • after surgery (adjuvant chemotherapy), along with radiation therapy, to reduce the risk of the cancer returning
  • as palliative treatment to relieve pain and improve quality of life

Some side effects of chemotherapy may Include:

  • fatigue
  • nausea
  • vomiting or diarrhoea
  • numbness in the fingers and/or toes
  • loss of taste
  • hair loss or thinning
  • low red blood and white blood count
  • mouth sores
  • ringing in the ears
  • hearing loss

Targeted therapy

Targeted therapy medicines affect specific features of cancer cells, to block their growth. A targeted therapy medicine, used to treat head and neck cancer is a type of monoclonal antibody, which targets specific features of cancer cells. This medicine is called an epidermal growth factor receptor (EGFR).

Some side effects of targeted therapy may include:

  • skin problems (such as redness, swelling, an acne-like rash or dry, flaky skin)
  • mouth sores
  • fatigue
  • diarrhoea

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QUESTIONS

Questions to ask your doctor about head and neck cancer

It is important to have honest, open discussions with the cancer care team. They can answer all questions to enable the patient to make informed treatment and life decisions. Some of the questions that may be included in a question checklist are listed below:

When informed of a head and neck cancer diagnosis

  • What type of head and neck cancer do I have?
  • Has the cancer spread? If so, where has it spread? How fast is it growing?
  • Are the latest tests and treatments for this cancer available in this hospital?
  • Will a multidisciplinary team be involved in my care?

When deciding on a treatment plan

  • What treatment do you recommend? What is the aim of the treatment?
  • Are there other treatment choices for me? If not, why not?
  • If I don’t have the treatment, what should I expect?
  • How long will treatment take? Will I have to stay in hospital?
  • How will we know if the treatment is working?
  • I’m thinking of getting a second opinion. Can you recommend anyone?

During treatment

  • What are the risks and possible side effects of each treatment?
  • Will I have a lot of pain? What will be done about this?
  • Can I work, drive and do my normal activities while having treatment?
  • Will my face or neck have significant scarring, or will I look different?
  • What kind of rehabilitation can I have?

After treatment

  • How often will I need check-ups after treatment?
  • If the cancer returns, how will I know? What treatments could I have?

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