Health Tips

Head & Neck Cancer:

What are Head and Neck Cancers?

Ninety percent of diagnosed cases of head and neck cancer are of the squamous cell variety. Squamous cells are the thin flat cells that line the surface of the oral cavity, aerodigestive tract and other organs. When these cells rapidly divide in random order and form a tumor in the oral cavity or aerodigestive tract, the malignant tumor is referred to as a squamous cell carcinoma.

Cancers of the head and neck include those that occur above the clavicle (collar bone) excluding tumors in the eyes and brain, but include the oral cavity and aerodigestive sites listed below:

Cancer of the oral cavity includes the following sites:
* Lips
* Buccal mucosa (the inside lining of the cheeks)
* Tongue
* Hard palate (front area of the roof of the mouth)
* Tonsils
* Floor of the mouth (bottom of mouth)
* Retromolar trigone (the area behind the wisdom teeth).

Aerodigestive sites are:
* Oropharynx
The hollow tube at the back of the throat that extends from the nose to the top of the trachea (windpipe). Included in the oropharynx is the back of the tongue; the soft palate (the back of the roof of the mouth); and the tonsils.

* Hypopharynx
The hypopharynx is the bottom portion of the pharynx. The pharynx is a hollow organ extending to the esophagus. Air and food passes through the pharynx. However, the air travels on to the trachea into the lungs; and, food is transported to the esophagus into the digestive system.

* Larynx
The larynx or voicebox is a two-inch tube shaped organ through which air passes as it is inhaled or exhaled from the lungs. It is the vocal cords within the larynx that contract and vibrate to produce a pitch or sound when we speak.

Risk Factors

There are significant risk factors that contribute to head and neck cancers. A few are genetic, which predisposes one to developing a cancer later in life. Others are environmental or behavioral based, such as the use of tobacco products, second hand smoke and alcohol.

Typically, oral cancer occurs in older individuals between the ages of 65 and 75 and increases with age. It can also occur in younger individuals. However, those persons between the defined ages are thought to have longer exposure to the following risk factors:


Environmental

Exposure to known carcinogens such as industrial toxins (for example, asbestos, benzenes). Causative agents are identified when individuals have a specific type of cancer and are found to have a history of high exposure to particular agents. It is repeated exposure to such agents (i.e. chemicals in tobacco and tobacco smoke) which can cause cellular alterations leading to cancer. Carcinogens are believed to play a part in damaging or destroying genes that control cell proliferation. Unrestrained proliferation of rapidly dividing cells results in a mass of abnormal cells known as a tumor. Carcinogens may selectively enhance the growth of tumor cells.


Behavioral

Socioeconomic factors (particularly with regards to ethnicity) have a defined role in the acquisition of oral cancer. In cases where individuals have an underprivileged lifestyle, nutrition may be deficient and social habits may include frequent and regular indulgence in the use of alcohol and tobacco products. Individuals who use tobacco products such as cigarettes, cigars, pipes and chewing tobacco are at a greater risk of acquiring the disease. The combined use of both alcohol and tobacco increases this risk more than using either substance alone.

Tobacco
Tobacco smoke is the single most lethal carcinogen in the United States. Tobacco contains multiple chemicals; at least 60 are cancer-causing agents and are contributing factors in one-third of all annual cancer deaths. Whether an individual acquires a tobacco related malignancy, or benefits from the preventive effects of smoking cessation, is dependent upon their total lifetime exposure. This includes the frequency, quantity of cigarettes smoked and duration of the habit. The risk is significantly greater for individuals who began smoking at a young age.

Secondhand smoke
Health risks posed by environmental tobacco smoke are not limited to smokers. Secondhand or passive smoking contributes annually to a few thousand cancer diagnoses; and, in some cases deaths from lung cancer can be attributed to secondhand smoke. Frequent inhalation of secondhand smoke has the same effect as breathing environmental pollutants. In the past decade, the Environmental Protection Agency has classified passive cigarette smoke as a Group "A" carcinogen, thereby categorizing it as a known human carcinogen.

Alcohol
Frequent and heavy use of alcohol has an impact on many health disorders and diseases. However, when it is combined with tobacco, the two substances are believed to have a synergistic effect whereby one substance significantly amplifies the hazardous effects of the other.


Genetics

Genetics influence the development of some cancers, as it predisposes one to the possibility of acquiring the disease. Through genetics, it is possible to inherit gene mutations that promote growth of cancer cells. However, genetics are responsible for less than five percent of the development of fatal cancers. Genetic variables are higher within races than between.


Mortality

The cure rates for cancer of the oral cavity varies depending on the stage and site. Early stage cancers are thought to have a cure rate as high as 90 percent. Moderate or advanced cancers may be controlled by combined modality therapies such as surgery or radiation or both. In the case of the latter, the survival rate differs and is dependent upon the site and the extent of spread of the disease.

Diagnosis:

Cancer may be present even in the absence of classic symptoms. It is important to consider that some of the symptoms indicative of head and neck cancer can also be caused by diseases other than cancer. Patients experiencing prolonged abnormalities, or those at high risk (frequent tobacco and alcohol use), should seek the advice of a medical practitioner who specializes in the diagnosis and treatment of oral cancer to obtain a definitive diagnosis. This usually involves a visit to an otolaryngologist who specializes in head and neck surgery; however, a diagnosis may also be made by an oral surgeon (a physician who specializes in surgery of the mouth and jaw), or by a family dentist during routine examinations.

The otolaryngologist will assess your medical history and perform a physical examination of the outside of the face and neck and the inside of the mouth and oral cavity. Pending the result of the examination, suspicious lesions or tumors may be biopsied. A biopsy is the only way to confirm for certain whether cancer is present in tissue.

Biopsies are performed by excising a sample portion of a tumor or suspicious lesion. This sample is sent to a laboratory for microscopic examination by a pathologist (a physician who is skilled at examining cells for the presence of cancer or other abnormalities). Some biopsies can and may be performed under the administration of local anesthetic in the physician's office. Biopsies of tumors in deeper regions of the throat (oropharynx or larynx) are done under general anesthesia in the operating room with the use of an endoscope. An endoscope permits careful evaluation of a tumor's dimension and depth. In addition, the throat, esophagus and lungs may also be examined for further signs of cancer.

To complete a diagnosis, imaging studies such as CAT or MRI scans may be performed. A CAT (computerized axial tomography) scan is a series of computer generated x-rays which form detailed pictures of areas of the body. Magnetic Resonance Imaging (MRI) creates pictures through the use of a magnet which is linked to a computer. Imaging studies, when compared with histological (biopsy) results, assist the practitioner in determining the stage and extent of the cancer (whether it has spread to other areas); and allows the clinician to determine appropriate treatment methods.

Staging:

Staging describes the extent of a cancer, especially whether the disease has spread from the original site to other parts of the body. Staging is important in cancer diagnosis because it assists the physician with determining the progression of a disease in order to choose an appropriate method of treatment and to accurately assess a prognosis.

The most widely used system in the United States for staging cancer is called the TNM System. It describes the extent of the primary tumor (T stage), the absence or presence of spread to nearby lymph nodes (N stage) and the absence or presence of distant spread, or metastasis (M stage).

The TNM System involves using the letters T, N and M to assess tumors by:

* the size of the primary tumor (T);
* the degree to which regional lymph nodes (N) are involved; and
* the absence or presence of distant metastases (M).

Once the T, N and M are determined, a "stage" of I, II, III or IV is assigned:

* Stage I cancers are small, localized and usually curable.
* Stage II and III cancers typically are locally advanced and/or have spread to local lymph nodes.
* Stage IV cancers usually are metastatic (have spread to distant parts of the body) and generally are considered inoperable.
Treatment of Head and Neck Cancers

Treatment of head and neck cancer varies with each individual. Which option you and your physician choose is dependent upon tumor size, location and stage. Treatment may include individual or combined modalities such as surgery (removal of tumors while preserving the integrity of surrounding tissues); radiation therapy (high energy x-rays to kill cancer cells and shrink tumors); or chemotherapy (cancer killing drugs which are administered intravenously).

Current treatments for head, neck and oral cancers involve a multidisciplinary approach. This may include care from one or all of the following practitioners:

* Otolaryngologist, Head and Neck Surgeon: Confirms the diagnosis of oral cancer. Performs the necessary surgery to remove cancerous tumors.
* Medical Oncologist: Physician who diagnoses and treats cancer with chemotherapy and may become the primary health care provider of a cancer patient during treatment, or coordinate treatment with other specialists.
* Radiation Oncologist: Specializes in the use and administration of radiotherapy.
* Collaborative Practice Nurse: A nurse who, with the oncologist, helps coordinate patient testing and treatment, and assists with symptom management.
* Treatment Room Nurse: A nurse who specializes in the delivery and monitoring of chemotherapy and other treatments to patients.
* Clinical Research Nurse Coordinator: A nurse who works with patients and oncologists participating in clinical trials to oversee treatment, monitor patients, and collect information as required by the research.
* Prosthodontist: A dentist who is familiar with changes that cancer therapy can cause, who advises patients on the best methods for maintaining healthy oral hygiene during their treatment to minimize problems. These dentists also make special dental appliances to substitute for normal tissues removed during surgery.
* Social workers: Assists patients with coping with cancer related stresses by providing therapy or references to support groups for patients and their families.
* Dietitians: Provides nutritional advice for patients undergoing cancer treatment.
* Speech therapist: Patients who have difficulty speaking and/or swallowing following surgery are referred to a speech therapist. The therapist teaches the patient exercises which can improve speech during the patient's rehabilitation and can help to improve swallowing.
* Plastic Surgeon: Patients who undergo extensive surgery for cancer may need reconstructive surgery to achieve functional results and minimize the physical and emotional effects of surgery.

Treatment decisions may be complex and many factors influence the method of treatment. Before deciding on a treatment, patients should consider the following issues:

* All treatment choices with regards to their particular cancer and what is most likely to be the best method for them.
* The benefits and risks of all of the treatment options
* What are the side effects of treatment and what can be done to assuage them?
* What clinical trials may be available for participation?

Many patients choose to seek a second opinion to assist them in making treatment choices. Regardless of what type of treatment is recommended, or whether you are in the beginning, middle, or have completed treatment, it is important that you continue to receive regularly scheduled follow-up care.

Treatment Methods

Treatment of head and neck cancer varies with each individual. Which options you and your physician choose is dependent upon your type of cancer. Combined modality therapy is the principal treatment method for patients with locally advanced head and neck cancer. It may include one or more of the following methods:

* Surgery
* Chemotherapy
* Radiation Therapy