Head and Neck Cancer

The incidence of head and neck cancer is rising worldwide as well as in India.
For any kinds of head and neck cancer, the treatment plan is customised for each patient, depending on the site and stage of cancer and patient condition. The multidisciplinary team, hence, plays a crucial role in the diagnosis as well as the treatment plan for every patient.

The goal of treating head and neck cancer is not just the removal of the tumour, but also to help patients cope with emotional and physical morbidity related to the disease. The aim is to facilitate restoration of confidence and to improve their quality of life.

What are cancers of the head and neck?

Cancers that are known collectively as head and neck cancers usually begin in the squamous cells lining the moist, mucosal surfaces inside the head and neck (for example, inside the mouth, nose, and throat). Head and neck cancers can also begin in the salivary glands, but are relatively uncommon. Cancers of the head and neck are further categorized by the area of the head or neck in which they begin.

Oral cavity: Includes 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 of the gum behind the wisdom teeth.
Pharynx: The pharynx (throat) is a hollow tube about 5 inches long that starts behind the nose and leads to the . It has three parts: the nasopharynx (the upper part of the pharynx, behind the nose); the oropharynx (the middle part of the pharynx, including the soft palate [the back of the mouth], the base of the tongue, and the ); the hypopharynx (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.
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.
Salivary glands: The major salivary glands are in the floor of the mouth and near the jawbone. The salivary glands produce saliva.

Sometimes, cancerous squamous cells can be found in the 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 unknown (occult) primary.

What causes cancers of the head and neck?

Alcohol and tobacco use (including smokeless tobacco, sometimes called “chewing tobacco” or “snuff”) are the two most important risk factors for head and neck cancers, especially cancers of the oral cavity, oropharynx, hypopharynx, and larynx .At least 75% of head and neck cancers are caused by tobacco and alcohol use .People who use both tobacco and alcohol are at greater risk of developing these cancers than people who use either tobacco or alcohol alone
Infection with cancer-causing types of (HPV), especially HPV type 16, is a risk factor for some types of head and neck cancers, particularly oropharyngeal cancers that involve the tonsils or the base of the tongue .
Other risk factors for cancers of the head and neck include the following.
Poor Oral health. Poor oral hygiene and missing teeth may be weak risk factors for cancers of the oral cavity Use of mouthwash that has a high alcohol content is a possible, but not proven, risk factor for cancers of the oral cavity
Occupational exposure. Occupational exposure to wood dust is a risk factor for nasopharyngeal cancer.Certain industrial exposures, including exposures to asbestos and synthetic fibers, have been associated with cancer of the larynx, but the increase in risk remains controversial .People working in certain jobs in the construction, metal, textile, ceramic, logging, and food industries may have an increased risk of cancer of the larynx Industrial exposure to wood or nickel dust or is a risk factor for cancers of the paranasal sinuses and nasal cavity
Radiation exposure. Radiation to the head and neck, for noncancerous conditions or cancer, is a risk factor for cancer of the salivary glands.
Epstein-Barr virus infection. Infection with the is a risk factor for nasopharyngeal cancer and cancer of the salivary glands.

What are the symptoms of head and neck cancers?

The symptoms of head and neck cancers may include a lump or a sore that does not heal, a sore throat that does not go away, difficulty in swallowing, and a change or hoarseness in the voice. Symptoms that may affect specific areas of the head and neck include the following:

Oral cavity. A white or red patch on the gums, the tongue, or the 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.
Pharynx. Trouble breathing or speaking; pain when swallowing; pain in the neck or the throat that does not go away; frequent headaches, pain, or ringing in the ears; or trouble hearing.
Larynx. Pain when swallowing or ear pain.
Paranasal sinuses and nasal cavity. 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 in the face, the chin, or the neck that does not go away.

How are head and neck cancers diagnosed?

Details physical examination depending on the site of involvement,
Imaging both to assess local extent of disease and to rule out distant mets(CT scan, MRI, PET – CT )
Biopsy and Histopathology from the primary site or from involved nodes.

How are head and neck cancers treated?

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. Treatment for head and neck cancer can include surgery, radiation therapy, chemotherapy, targeted therapy, or a combination of treatments.

Surgery:
Surgery is a crucial treatment modality in case of head and neck cancers. Even if the tumour is completely removed, Many patients require a multi-modality approach that integrates chemotherapy and/or radiation therapy after surgery
Radiotherapy:
For head and neck cancers except very early cases most of the patients require post operative radiation with or without chemotherapy depending on site and stage of disease.
For early stage cancers of some specific subsites like tongue even single modality of internal radiotherapy known as Brachytherapy gives equivalent results as with Surgery.
Chemotherapy/Targeted therapy:
They are important when given for an huge inoperable tumor to make it amenable for surgery or given along with radiation to enhance its effect. For Metastatic cancers systemic chemotherapy are important.