Head and neck cancer overview
Head and neck cancer actually includes many different malignancies. The way
a particular head and neck cancer behaves depends on the site in which
it arises (the primary site). For example, cancers that begin on the vocal
cords behave very differently than do those that arise in the hypopharynx,
just an inch or less from the vocal cords.
The most common type of cancer in the head and neck is squamous cell
carcinoma, which arises in the cells that line the inside of the nose,
mouth and throat. Other less common types of head and neck cancers include
salivary gland tumors, lymphomas and sarcomas.
Cancers spread in three main ways. The first is direct extension from
the primary site to adjacent areas. The second is spread through the lymphatic
channels to lymph nodes. The third is spread through the blood vessels
to distant sites in the body. In head and neck cancer, a spread to the
lymph nodes in the neck is relatively common.
The lymph nodes most commonly involved are located along the internal
jugular vein underneath the sternocleidomastoid muscle on each side of
the neck, particularly the internal jugular vein node at the angle of
the jaw. The risk of spread to other parts of the body through the bloodstream
is closely related to whether the cancer has spread to the lymph nodes
in the neck, how many nodes are involved, and their location in the neck.
The risk is higher if cancer is in lymph nodes in the lower part of the
neck rather than only in those located in the upper neck.
What are my treatment options?
The three main types of treatment
for managing head and neck cancer are radiation therapy, surgery and chemotherapy.
The primary treatments are radiation therapy or surgery, or both combined;
chemotherapy is sometimes used as an additional, or adjuvant, treatment.
The optimal combination of the three treatment modalities for a patient
with a particular head and neck cancer depends on the site of the cancer
and the stage (extent) of the disease.
In general, patients with early-stage head and neck cancers (particularly
those limited to the site of origin) are treated with one modality—either
radiation therapy or surgery. Patients who have more extensive cancers
are often treated with a combination of surgery and radiation therapy
or with radiation therapy combined with adjuvant chemotherapy.
If the plan of treatment is radiation therapy alone for the primary cancer,
the neck is also treated with radiation therapy. In addition, a neck dissection
to remove involved lymph nodes in the neck may be necessary if the amount
of disease in the neck nodes is relatively extensive or if the cancer
in the neck nodes has not been eliminated completely by the end of the
radiation therapy course.
Another treatment that might be necessary before or after radiation therapy
is surgery. In general, if the surgical removal of the primary tumor is
indicated, radiation is given afterward if necessary.
Sometimes, however, the cancer is extensive or it is not feasible to completely
remove the cancer initially. Radiotherapy is then given first to try to
shrink the tumor, and surgery will follow radiotherapy.
Recent studies indicate that chemotherapy given at the same time as radiation
therapy is more effective than if it is given before a course of radiation
therapy. Therefore, radiation treatment schedules sometimes include chemotherapy
if the stage of the cancer is advanced (advanced stage III or stage IV).
Drugs commonly given in conjunction with radiation therapy include cisplatin
(Platinol), fluorouracil (5-FU, Adrucil), carboplatin (Paraplatin), and
paclitaxel (Taxol). This is only a partial list of chemotherapy agents;
your physicians may choose to use others. The chemotherapy may be given
in a variety of ways, including a low daily dose, a moderately low weekly
dose, or a relatively higher dose every three to four weeks.
For more information about radiation therapy procedures and equipment,
visit the following pages:
What happens during radiation therapy?
The initial visit to the radiation oncologist is for a consultation,
when the radiation oncologist will listen to the history of your problem
and perform a physical examination. Consultations with other members of
the head and neck team, such as the head and neck surgeon, pathologist,
radiologist and dentist, usually take place at this time or shortly after.
It is important to have the input of various members of the team who will
be taking care of you before a treatment plan is decided and treatment
begins.
After the recommended treatment and possible options are explained to
you and you decide on a course of treatment in conjunction with your doctors,
a date will be selected for treatment planning for radiation therapy (if
irradiation has been selected as the first or next step in your treatment).
You then have what is called a "simulation" using either conventional
radiographs (x-rays) or a computed tomography (CT) scan. These radiographic
studies are used to plan the type and direction of radiation beams used
to treat the cancer. Customized lead alloy blocks or a special collimator
(multileaf collimator) in the treatment machine will shape the radiation
beams to block areas that do not need to be treated. Treatment fields
then will be aligned, and the treatment course will start one to two days
after the initial treatment-planning session.
Typically, treatments are given once or twice a day, five days a week
for five to seven weeks, depending on the treatment schedule selected
by your radiation oncologist. Generally, for the first couple of days
of treatment planning and treatment start, your visit to the radiation
oncology department may take an hour or two. Thereafter, each individual
treatment takes just a few minutes, and you will be in and out of the
radiation department in 30 to 45 minutes for each treatment session. You
will not feel or see anything during a radiation treatment, and any side
effects usually require two or more weeks to become apparent.
What are possible side effects of radiation therapy?
The side effects depend on the site and extent of the head and neck cancer.
In general, irradiation of the head and neck does not cause nausea, but
a few patients do experience nausea during treatment. Many effective antiemetics
(drugs that alleviate nausea) can relieve this symptom if it should occur.
Generally, the side effects of radiation therapy become apparent about
two weeks into the treatment course, when a sore throat, loss of taste
sensation, dryness of the mouth and dry skin reactions may occur. Sore
throat is the main side effect that makes the course of radiation therapy
difficult.
If your sore throat is severe, you may be unable to take in enough
food and liquids by mouth to maintain your weight or avoid dehydration.
Your doctors will then install a feeding tube temporarily into your
stomach (a gastrostomy tube), which will allow you to maintain adequate
nutrition without having to swallow all of the food that you need.
Gastrostomy placement is an outpatient procedure. It is important,
though, to continue swallowing even with a gastrostomy tube in place.
Otherwise, your swallowing muscles may atrophy; this would cause permanent
swallowing problems and make it difficult to stop using the gastrostomy
tube even after the radiation treatment course is completed.
A dietitian should be involved in your care during the course of radiation
treatments to help you maintain adequate caloric intake and hydration.
When side effects occur, it may be tempting to take a break from treatments.
This is not a good idea. The "acutely responding" normal
tissues—such as the skin and the lining of the throat—that are responsible
for the side effects during radiation therapy tend to respond to radiation
as do cancer cells. If the treatment produces few acute side effects,
it is also not likely to be very effective against the cancer. Therefore,
the treatment of most head and neck cancers represents a classic "no
pain, no gain" situation. Breaks in the treatment course to lessen
the side effects give the cancer a chance to regrow and will significantly
reduce the likelihood of cure. Medications that are almost always needed
during a course of radiation therapy include narcotic pain medicines,
both a long-acting pain medicine and a short-acting pain medicine for
breakthrough pain and stool softeners, because a common side effect of
narcotics is constipation. Additional medications that may be necessary
are topical anesthetics—such as "magic mouthwash"—to lessen
the sore throat and possibly antiemetics if nausea is a problem.
What are some of the possible risks or complications?
A clear goal of treatment must be determined for each patient before
therapy starts. The first question is often whether the goal of treatment
is cure or, instead, the lessening (palliation) of symptoms associated
with an incurable cancer. If cure is unlikely, then potential risks associated
with treatment ought to be less than those associated with a potentially
curative course of radiation therapy.
Palliative courses of treatment generally entail giving a moderate dose
of radiation over a short time. This provides a relatively high chance
of shrinking the tumor and lessening symptoms while exposing the patient
to less risk of side effects and complications, and requiring a relatively
brief time to complete the therapy. A typical course of palliative radiation
treatments would be divided into 10 treatments given over two weeks.
On the other hand, if there is a reasonable chance of cure (the definition
of reasonable can vary, depending on the situation, but generally at least
5 percent to 10 percent), then a longer and more arduous course of treatment
is generally planned. The risks associated with treatment depend on the
location and extent of the tumor and the normal structures that are nearby.
In general, for any type of treatment, the treating physician tries to
estimate the potential risk of a major complication; if this risk is similar
to or exceeds the anticipated likelihood of cure, then the treatment plan
is modified. However, if the likelihood of cure is significantly greater
than the risk of a major complication, then treatment is initiated.
What kind of treatment follow-up should I expect?
There are several reasons for follow-up examinations:
- To detect recurrent cancer and possibly try
further treatment, such as an operation, if the radiation therapy is
unsuccessful
- To treat the acute side effects of the radiation therapy
- To detect and treat late side effects or complications
from the radiation therapy, should they occur
- To detect and treat additional, unrelated head and
neck cancers that may arise
If the initial treatment for the cancer is successful and you are cured,
there is still a relatively low risk (2 percent to 3 percent per year)
of developing a new, completely unrelated head and neck cancer. Follow-up
examinations usually take place:
- Every four to six weeks for the first year
- Every two months for the second year
- Every three months for the third year
- Every six months for the fourth and fifth years
- Annually thereafter
A chest radiograph (x-ray) is obtained once a year, and thyroid functions
are often checked annually to detect any occurrence of hypothyroidism
(decreased thyroid function), which is easily treatable.
Sometimes additional tests are indicated, such as a CT scan or a fluorodeoxyglucose (FDG) positron emission tomography (PET)
scan, to assist in difficult situations where it may not be clear whether
the cancer persists after treatment.
Are there any new developments in treating my disease?
Some new treatments are available, as are new ways of combining old treatments.
A good example of the latter is the use in recent years of a combination
of radiation therapy and chemotherapy for advanced head and neck cancer.
Some new agents include antiangiogenic drugs, which attack the blood vessels
that nourish the tumor, and drugs such as erythropoietin that provide
oxygen to the tumor, making it more sensitive to radiation and increasing
the chance of cure. For updated information on new cancer treatments that
are available, you should discuss these issues with your doctor and consider
obtaining a second opinion before beginning treatment.
Clinical Trials
To learn about current clinical trials being conducted, see the Clinical
Trials page of the National Cancer Institute's Web site.
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