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Head and neck cancer is the sixth most common malignancy in the world. It occurs in the throat, mouth and nasal cavity and accounts for 6% of all cancer cases worldwide. In Canada, more than 4,300 people are diagnosed with this cancer every year.
What is head and neck cancer?
What is head and neck cancer?
Head and neck cancers occur in the throat, mouth, tongue and nasal cavity. About 90% of head and neck cancers (HNC) originate in the squamous cells lining the mucosal surfaces of the mouth, nose and throat, including the larynx. Less common types of HNC occur in the thyroid, salivary glands or nasopharynx, the top of the throat near the nasal cavity. Commonly diagnosed in people 50 and above, head and neck cancers are twice as frequent in men than in women.
Risk factors for HNC
Risk factors for HNC
Risk factors include:
Radiation exposure: Excessive radiation to the head and neck area is a risk factor, particularly for salivary gland cancer.
Epstein-Barr virus: Epstein-Barr virus, also known as human herpes virus 4, is a risk factor for cancers of the nasopharynx and salivary glands.
Genetics: Asian ancestry, particularly Chinese, is a risk factor for nasopharyngeal cancer.
Dental hygiene: Poor oral hygiene, missing teeth and prolonged use of high-alcohol mouthwash may be risk factors.
Environmental or occupational inhalants: Prolonged exposure to various particles, such as wood or metallic dusts, or chemicals such as formaldehyde, is risky.
Diet: Poor nutrition and/or excessive consumption of preserved or salted foods during childhood are risk factors.
Human papilloma virus (HPV): More than 75% of HNC are caused by HPV. They typically involve the tonsils or the tongue. For more information on HPV, visit: hpv global action. Alcohol and tobacco: Smoking – including secondhand smoke – chewing tobacco and alcohol use also cause HNC.
Prevention
Prevention
Prevention is the most effective way to avoid HNC: Get vaccinated against the human papillomavirus (HPV). Vaccinations are available in Canada to males and females aged 9 to 45. These vaccinations also prevent other cancers, such as cervical cancer in women. For more information on HPV vaccination, visit: .
Stop using tobacco of any kind, but particularly smokeless tobacco used in the mouth or nose.Avoid alcohol or at least consume in moderation.Maintain good oral hygiene practices. Reduce dietary and nutrition risks.Use appropriate protective equipment at work when exposed to chemicals mentioned in the section on Risk factors.
Signs and symptoms
Signs and symptoms
List
A sore, swelling or ulcer in the mouth that doesn’t go away
A lump in the neck that lasts more than two weeks
A white or red patch in the mouth
Persistent earache or sore throat or nasal congestion
Pain in the mouth, jaw or ear without obvious cause
Voice changes or hoarseness lasting longer than two weeks
Difficulties with swallowing
Blood appearing in the saliva or phlegm for more than a few days
While many of these are also symptoms of non-cancerous conditions, you should have them examined by a physician if any of them persist.
Early detection
Early detection
You can take the following measures to ensure early detection and diagnosis. Early detection increases the chances of a successful treatment and better health outcomes.
Perform monthly self-exams of your face, neck, lips, nose and inside your mouth to find any lumps, sores or abnormalities that may be early signs of head or neck cancer. Ask your dentist and/or physician to perform an oral, head and neck exam to seek or check on abnormalities.
Diagnosis and staging
Diagnosis and staging
If your general practitioner (GP) suspects a possible cancer, you will be referred to a specialist for further tests. The specialist will likely perform a thorough head and neck exam, including feeling in affected areas for abnormal lumps and using special tools or equipment to allow them to see inaccessible areas. These exams can include passing tools down the throat or into the nose. Depending on the type of problem, x-rays or other imaging scans may be used.
Part of that analysis could be testing for biomarkers, which are tests to find genes, proteins and other substances in the cancer tumour to identify its exact type and help determine what treatment is likely to work best.
Some targeted treatments and immunotherapies only work when specific targets are present. This process can also be called tumour testing, genetic testing or molecular testing.
Biopsies as well as the other tests performed will help determine the stage of the cancer. These findings, including the results of any biomarker test that is done, will dictate the kind and duration of treatment. Head and Neck Cancer (HNC) can be characterized by size or spread from Stage 1 to 4. The two are different. Size is obvious. Spread is the more important. The more widely spread the HNC, the more lethal it can be. In general, early-stage disease spread is referred to as Stage I or II and advanced-stage disease as Stage III or IV. The earlier the cancer is diagnosed, the more likely that treatment will be successful.It is important to remember, however, that even with an advanced cancer diagnosis, treatment options are available.
Treatments
Treatments
Potential treatments for HNC include chemo therapies, immunotherapies, gene-targeted therapies radiation and surgery. They are often used in combination. The treatment plan for an individual depends on the exact location of the tumor(s), the stage of the cancer, whether it is caused by HPV, and the person’s age and general health.
Surgery
There are several different types of surgery that can be performed to remove head and neck cancers. The type of surgery depends on where the cancer is located, its spread and its size. The surgery can range from minimally invasive laser microsurgery done through the mouth to more invasive operations to remove cancerous tissue. Surgeries can require the insertion of breathing or eating tubes for periods of time during recovery.
Radiation therapy
Radiation therapy involves delivering electromagnetic radiation to kill the cancer cells.
Definitive radiation therapy is a curative treatment for certain localized head and neck cancers. The most common is external beam radiation, delivered from outside the body. This type of radiation therapy can also be combined with chemotherapy and/or surgery.
Adjuvant radiation therapy is the term for radiation treatments given after surgery to kill cancer cells that might not have been removed by the surgery. Sometimes, but rarely, it is given before surgery to shrink tumors. Chemotherapy can also be added during this radiation therapy to help make overall treatment more effective.
Common side effects of radiation are tiredness, a hoarse voice, skin irritation at the treated area, pain or difficulty swallowing, irritation in the throat and dry mouth and throat. Again, a feeding tube may be required during treatment.
Chemotherapy
Chemotherapy refers to drugs used to destroy or damage cancer cells. Most often, these drugs for head and neck cancer are given by a fluid into a vein through a needle (intravenous infusion).
Chemotherapy is often used to supplement surgery or radiation therapy. It makes them more effective by killing cancer cells that survive surgery or radiation. Chemotherapy is also sometimes used before surgery or radiation to reduce large cancers and make the surgery easier.
Common side effects of chemotherapy include nausea, loss of feeling in the fingers and toes, hearing loss and ringing in the ears, rashes, a higher risk of infections, as well as greater side effects from radiation if chemotherapy is given at the same time as radiation.
Targeted therapy
Targeted therapy is a treatment that has been specifically designed to act on a cancer tumor with certain characteristics (such as specific genes or proteins). It is normally only used and effective when those characteristics are present in the tumor. The presence of these exact biomarkers (genetic or protein) are found via specific testing on the tumor sample obtained during a biopsy (the removal of a small portion of the cancer tumor to determine its exact type and help determine the best course of treatment).
Targeted therapies can cause side effects like those seen with chemotherapy.
Immunotherapy
Immunotherapy is a relatively new type of cancer treatment that entices the body’s immune system to find and kill cancer cells. Immunotherapy has become the fourth major type of cancer treatment, the others being surgery, radiation and chemotherapy.
Immunotherapy can be used to treat head and neck cancers, either alone or in combination with other types of treatment.
Side effects include flu-like symptoms, and diarrhea, nausea, itching, rash, joint pain and feeling unusually tired or weak.
Sometimes, people are traumatized by the experience and need emotional support. Some patients live in fear that their cancer might return. As well, the emotional changes during a cancer journey can make re-establishing relationships difficult for some.
It is important for patients to be alert to their emotional well-being and discuss their feelings frankly with close family and friends. If necessary, they should seek professional help.
Life after treatment
Life after treatment
HNC can take both an emotional and physical toll on people. Even with successful treatment, dealing with the effects of the disease or treatment is a life-long experience.
For example, head and neck cancer treatment can leave people with scars, changes in appearance, partial paralysis of the face, or problems with speech. Often, speech or other physical therapy are prescribed. Lack of saliva, challenges with swallowing and/or diet restrictions round out common post-treatment adverse effects. Diet and nutrition are especially important after treatment.
Diet and nutrition
Diet and nutrition
Because head and neck cancer can drastically affect the mouth and throat, head and neck cancer and its treatment can make it very difficult for patients to eat, drink and get proper nutrition.
Diet and nutrition
Diet and nutrition
It is important to remain well-nourished and avoid significant unplanned weight loss during treatment. It is sometimes necessary to use a feeding tube, either nasally or directly into the stomach, during treatment or for some time after it. One benefit after surgery or radiation is that the throat and other tissue can heal’ while ensuring proper nutrition and hydration. Having adequate nutrition helps keep energy levels as high as possible and speeds recovery.
HNC and its treatment can also result in changes in or loss of saliva, the ability to taste foods properly or difficulties in swallowing. Anny of these can lessen the desire to eat. These compound the difficulty of keeping a proper diet and quality nutrition. If your cancer care team does not automatically provide you the services of a dietician to help, ask for a referral.
Suggestions for helping people with head and neck cancer get adequate nutrition include:
Eat small meals or snacks often rather than just two or three large meals a day
Choose foods that are high in nutrients and calories but low in volume and softer in texture instead of those requiring a lot of chewing
If solid food is an issue, drink high-calorie, high-nutrition milkshakes, smoothies or juice, or nutritional supplement drinks if recommended by a dietician
To protect a sore throat, avoid foods that could irritate it such as citrus, vinegar, high salt or spicy foods and harder foods
Getting involved in your care
Getting involved in your care
It is important to become well informed and take an active role in your care. You should become an active partner with your medical team. Establish a strong rapport with your medical team and inform them about your desired level of involvement.
An important first step is to obtain information about your diagnosis. Your medical team can provide you with this information (see below some questions to make sure you obtain the information you need). Check to see if you can access your reports and tests results about your diagnosis, including any pathology reports, through an online patient portal at your cancer centre. If not, ask for digital access as well as printed copies of reports related to your diagnosis. Study them, bring them to your medical appointments and be prepared to ask a lot of questions.
Ensure that your treatment plan is tailored to meet your needs. Before making decisions about your care, consider what is important to you, including your preferences, values and goals. For instance, you might want to make sure you are well enough throughout the course of treatment to go golfing, practice yoga, go on a vacation, or be there for an important family milestone, like a wedding or a graduation. Balance this against the severity of the disease and what these choices might mean for the effectiveness of the treatment. Think about what you want your medical team to be aware of and share this information with them so they can help you find the optimal course of treatment FOR YOU.
Finally, don’t hesitate to ask for support. Ask a family member, a close friend, or a caregiver to accompany you to medical visits. Be sure that this person can understand what is being discussed, can take accurate notes, ask good questions and thoughtfully evaluate what was said at each visit. Make sure to discuss with them what was said and recommended during these medical visits.
Make sure that you have a good and broad support system. Some people make food, some may drive you to treatments, some make go for walks with you, and so on. It is also important to have people around you who know what you are going through and are helpful to talk with about what you are experiencing and feeling. Your medical team may also be able to help you find emotional support for you and your family (e.g., a psychologist or a support group at the cancer center).
Questions you can ask your medical team:
Questions you can ask your medical team:
What exact type of head and neck cancer do I have and where is it located?
What is the stage of my cancer? In spread and size?
What tests, including biomarker testing, will be performed to analyze my cancer and determine my treatment options?
What are my treatment options, and which one do you recommend for me and why? What is my prognosis with each?
Has my case been discussed at a multidisciplinary team meeting and what were the recommendations?
Is the recommended treatment an infusion or is it taken orally? How long will I be on treatment?
What are the potential side effects of the treatment? How can they be prevented or managed? Sort, medium and long-term.
How will the treatment affect my ability to eat, swallow, or speak? Will I need a feeding tube? Can you refer me to a dietician .
How will the treatment affect my day-to-day life, including work, family activities, and activities I enjoy (e.g., golf, yoga, skiing, etc.)?
Am I eligible for any clinical trials?
Can I get a second opinion? (Ask your doctor to put you in contact with other specialists.
Who should I contact if I have any other questions or if I have any problems during or after treatment?
Insights from a head and neck cancer survivor
Insights from a head and neck cancer survivor
John-Peter Bradford’s head and neck cancer started in his salivary glands. The Ottawa resident was diagnosed in 2009 with the disease already at stage 3, meaning the tumours were large and the cancer had spread from where it had started.
The radiation therapy and surgery that saved his life and eliminated the cancer have left him without functioning salivary glands, so speaking and eating require him to constantly drink water. The left side of his mouth and left shoulder and side of his body don’t function properly.
“But I’m happy as hell!” he says unreservedly. “I live a very full and productive life.”
He wasn’t always so accepting of his fate. “When you’re diagnosed with cancer you suddenly realize there is an expiration date on your birth certificate and you might know what it is,” he says. “It was almost paralysing to think of dying and the pain it would cause my family.”
His successful treatment came from participating in a clinical trial studying the use of very precise positron emission tomography (PET) scans to deliver radiation therapy in a very targeted way, and by varying the doses applied to different areas depending on the size and location of cancer as shown by the scans.
Since then, he co-founded the Life-Saving Therapies Network (LSTN), which works to obtain faster access to better treatments for Canadians with lethal diseases – including head and neck cancer. The aim is to save or extend lives of people who don’t have a lot of time. To do this, LSTN focuses on reform and innovative approaches to regulatory processes, clinical trial protocols, and reimbursement for treatments.
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