HEAD AND NECK (HN) CANCER

Cancers that are known collectively as head and neck cancers usually begin in the squamous cells that line the moist, mucosal surfaces inside the head and neck (for example, inside the mouth, the nose, and the throat). These squamous cell cancers are often referred to as squamous cell carcinomas of the head and neck.

Cancers of the head and neck are further categorized by the area of the head or neck in which they begin.

• Oral cavity
• Pharynx
• Larynx
• Paranasal sinuses and nasal cavity
• Salivary glands

Overall, head and neck cancer accounts for more than 550,000 cases annually worldwide. Males are affected significantly more than females. Mouth and tongue cancers are more common in the Indian subcontinent; nasopharyngeal cancer is more common in Hong Kong; and pharyngealand/or laryngeal cancers are more common in other populations; these factors contribute disproportionately to the overall cancer burden in these Asian countries.

In Pakistan, HN cancers are more prevalent in men as compared to women. The HN cancer in Pakistan is mainly attributed to discrete demographic profile, risk elements, eating patterns and family history. The foremost factors of risk are linked with cigarette smoking, alcoholic drinks and tobacco chewing like paan, gutka, etc. The actual burden of HN cancer in Pakistan is 18.74% of all new cancer cases recorded during 2004 -2014. The data is collected from HN cancer patients who are diagnosed from September 2011 till May 2012 in the Institute of Nuclear medicine and Oncology, Lahore Pakistan.

The 2 substances that greatly increase the risk of developing a head and neck cancer are:

• Tobacco: Tobacco use includes smoking cigarettes, cigars, or pipes; chewing tobacco; and using snuff. It is the single largest risk factor for head and neck cancer. Eighty-five percent (85%) of head and neck cancers are linked to tobacco use, and the amount of tobacco use may affect prognosis, which is the chance of recovery. In addition, second-hand smoke may increase a person’s risk of developing head and neck cancer.
• Alcohol: Frequent and heavy alcohol consumption raises the risk of developing cancer in the mouth, pharynx, larynx, and esophagus. Using alcohol and tobacco together increases this risk even more.

Other factors that can raise a person’s risk of developing head and neck cancer include:

• Prolonged sun exposure: This is especially linked to cancer in the lip area, as well as skin cancer of the head and neck.
• Human papillomavirus (HPV): Research shows that infection with HPV is a risk factor for head and neck cancer. Sexual activity with a person who has HPV is the most common way someone gets HPV. There are different types of HPV, called strains. Research links some HPV strains more strongly with certain types of cancers.
• Epstein-Barr virus (EBV): Exposure to EBV, which is more commonly known as the virus that causes mononucleosis or «mono,» plays a role in the development of nasopharyngeal cancer.
• Gender: Men are 2 to 3 times more likely than women to develop head and neck cancer. However, the rate of head and neck cancer in women has been rising for several decades.
• Age: People over the age of 40 are at higher risk for head and neck cancer.
• Poor oral and dental hygiene: Poor care of the mouth and teeth has been suggested as a factor that may increase the risk of head and neck cancer.
• Environmental or occupational inhalants: Inhaling asbestos, wood dust, paint fumes, and certain chemicals may increase a person’s risk of head and neck cancer.
• Marijuana use: Research suggests that people who have used marijuana may be at higher risk for head and neck cancer.
• Poor nutrition: A diet low in vitamins A and B can raise a person’s risk of head and neck cancer.
• Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD): Reflux of stomach acid into the upper airway and throat has been suggested as a factor associated with the development of head and neck cancer.
• Weakened immune system: A weakened immune system can raise a person’s risk of head and neck cancer.

People with head and neck cancer often experience the following symptoms or signs. Sometimes, people with head and neck cancer do not have any of these changes. Or, the cause of a symptom may be a different medical condition that is not cancer.

• Swelling or a sore that does not heal; this is the most common symptom
• Red or white patch in the mouth
• Lump, bump, or mass in the head or neck area, with or without pain
• Persistent sore throat
• Foul mouth odor not explained by hygiene
• Hoarseness or change in voice
• Nasal obstruction or persistent nasal congestion
• Frequent nose bleeds and/or unusual nasal discharge
• Difficulty breathing
• Double vision
• Numbness or weakness of a body part in the head and neck region
• Pain or difficulty chewing, swallowing, or moving the jaw or tongue
• Jaw pain
• Blood in the saliva or phlegm, which is mucus discharged into the mouth from respiratory passages
• Loosening of teeth
• Dentures that no longer fit
• Unexplained weight loss
• Fatigue
• Ear pain or infection

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. If this happens, it is called metastasis. For example, imaging tests can show if the cancer has spread. Imaging tests show pictures of the inside of the body. Doctors may also do tests to learn which treatments could work best.

For most types of cancer, a biopsy is the only sure way for the doctor to know whether an area of the body has cancer. In a biopsy, the doctor takes a small sample of tissue for testing in a laboratory. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis.

This list describes options for diagnosing this type of cancer. Not all tests listed below will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

• The type of cancer suspected
• Your signs and symptoms
• Your age and medical condition
• The results of earlier medical tests

If a person has symptoms and signs of head and neck cancer, the doctor will take a complete medical history, noting all symptoms and risk factors. In addition, the following tests may be used to diagnose head and neck cancer:

Physical examination/blood and urine tests: During a physical examination, the doctor feels for any lumps on the neck, lips, gums, and cheeks. The doctor will also inspect the nose, mouth, throat, and tongue for abnormalities, often using a light and a mirror for a clearer view. Blood and urine tests may be done to help diagnose cancer.

Endoscopy: An endoscopy allows the doctor to see inside the body with a thin, lighted, flexible tube called an endoscope. The person may be sedated as the tube is gently inserted through the nose into the throat and down the esophagus to examine inside the head and neck. Sedation is giving a person medication to become more relaxed, calm, or sleepy. The examination has different names depending on the area of the body that is examined, such as laryngoscopy to view the larynx, pharyngoscopy to view the pharynx, or nasopharyngoscopy to view the nasopharynx. When these procedures are combined, they are sometimes referred to as a panendoscopy.

Biopsy: A biopsy is the removal of a small amount of tissue for examination under a microscope. A pathologist then analyzes the sample(s) removed during the biopsy. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A common type of biopsy is called a fine needle aspiration. During this procedure, cells are withdrawn using a thin needle inserted directly into the tumor or lymph node. The cells are examined under a microscope for cancer cells, which is called a cytologic examination.

The biopsy may include testing to see whether the person has HPV. As described in risk Factors, HPV has been linked to a higher risk of some head and neck cancers. In some cases, whether a person has HPV can also be a factor in determining which treatments are likely to be most effective.

Molecular testing of the tumor: Your doctor may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests will help decide whether your treatment options include a type of treatment called targeted therapy.

X-ray/barium swallow: An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A barium swallow may be required to identify abnormalities along the swallowing passage. During a barium swallow, a person swallows a liquid containing barium, and a series of x-rays are taken. Barium coats the lining of the esophagus, stomach, and intestines, so tumors or other abnormalities are easier to see on the x-ray. A special type of barium swallow called a modified barium swallow may be needed to evaluate specific swallowing difficulties. If there are signs of cancer, the doctor may recommend a computed tomography (CT) scan.

Panoramic radiograph: This is a rotating, or panoramic, x-ray of the upper and lower jawbones to detect cancer or evaluate the teeth before radiation therapy or chemotherapy. This is often called a Panorex.

Ultrasound: An ultrasound uses sound waves to create a picture of internal organs.

Computed tomography (CT or CAT) scan: A CT scan creates a 3-dimensional picture of the inside of the body using x-rays taken from different angles. A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a liquid to swallow.

Magnetic resonance imaging (MRI): An MRI uses magnetic fields, not x-rays, to produce detailed images of the body, especially images of soft tissue, such as the tonsils and base of the tongue. MRI can be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a liquid to swallow.

Bone scan: A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark. This test may be done to see if cancer has spread to the bones.

Positron emission tomography (PET) or PET-CT scan: A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Many cancers of the head and neck can be cured, especially if they are found early. When planning treatment, doctors consider how treatment might affect a person’s quality of life, such as how a person feels, looks, talks, eats, and breathes.

Overall, the main treatment options are surgery, radiation therapy, chemotherapy, and targeted therapy. Surgery or radiation therapy by themselves or a combination of these treatments may be part of a person’s treatment plan.

Treatment options and recommendations depend on several factors, including:

• The type and stage of head and neck cancer
• Possible side effects
• The patient’s preferences and overall health

Surgery: During surgery, the goal is to remove the cancerous tumor and some surrounding healthy tissue during an operation. Types of surgery for head and neck cancer include:

• Laser technology: This may be used to treat an early-stage tumor, especially if it was found in the larynx.
• Excision: This is an operation to remove the cancerous tumor and some surrounding healthy tissue, known as a margin.
• Lymph node dissection or neck dissection: If the doctor suspects the cancer has spread, the doctor may remove lymph nodes in the neck. This may cause stiffness in the shoulders afterward. This may be done at the same time as an excision.
• Reconstructive (plastic) surgery: If cancer surgery requires major tissue removal, such as removing the jaw, skin, pharynx, or tongue, reconstructive or plastic surgery may be done to replace the missing tissue. This type of operation helps restore a person’s appearance and the function of the affected area. For example, a prosthodontist may be able to make an artificial dental or facial part to help restore the ability to swallow and speak. A speech pathologist may then be needed to help the patient relearn how to swallow and communicate using new techniques or special equipment.

Depending on the location, stage, and type of the cancer, some people may need more than 1 operation. Sometimes, it is not possible to completely remove the cancer, and additional treatments may be necessary. For example, surgery may be followed by radiation therapy, chemotherapy, or both to destroy cancer cells that cannot be removed during surgery.

Radiation therapy: Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. It can be the main treatment for head and neck cancer, or it can be used after surgery to destroy small areas of cancer that cannot be removed surgically.

The most common type of radiation therapy is called external-beam radiation therapy, which is radiation given from a machine outside the body. A specific type of external-beam radiation therapy is intensity-modulated radiation therapy (IMRT). IMRT uses advanced technology to accurately direct the beams of radiation at the tumor. This helps reduce damage to nearby healthy cells, potentially causing fewer side effects.

Proton therapy is another type of external-beam radiation therapy that uses protons rather than x-rays. At this time, proton therapy is not a standard treatment option for most types of head and neck cancer.

When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy.

Chemotherapy: Chemotherapy is the use of drugs to destroy cancer cells, usually by ending the cancer cells’ ability to grow and divide.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or combinations of different drugs given at the same time.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished.

Targeted therapy: Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible.

For head and neck cancers, treatments that target a tumor protein called epidermal growth factor receptor (EGFR) may be recommended. Researchers have found that drugs that block EGFR help stop or slow the growth of certain types of head and neck cancer.

Larotrectinib is a type of targeted therapy that is not specific to a certain type of cancer but focuses on a specific genetic change in NTRK genes. This type of genetic change is uncommon but does occur in a range of cancers, including head and neck cancer. Larotrectinib is approved as a treatment for head and neck cancer that is metastatic or cannot be removed with surgery and has worsened with other treatments.

Immunotherapy: Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Pembrolizumab and nivolumab are 2 immunotherapy drugs approved by the U.S. Food and Drug Administration (FDA) for the treatment of people with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) that has not been stopped by platinum-based chemotherapy. Both are immune checkpoint inhibitors that are also approved for the treatment of some people with advanced lung cancer or melanoma.

Following preventions should be followed:

• Avoid oral HPV infection may reduce the risk of HPV-associated head and neck cancers. Reduce risk of HPV infection by giving the HPV vaccine.
• Stop the use of all tobacco products is the most important thing a person can do to reduce their risk, even for people who have been smoking for many years.
• Avoid alcohol
• Avoid marijuana use
• Use sunscreen regularly, including lip balm with an adequate sun protection factor (SPF)
• Limit number of sexual partners, since having many partners increases the risk of HPV infection.
• Use a condom during sex cannot fully protect you from HPV.
• Maintaining proper care of dentures. Poorly fitting dentures can trap tobacco and alcohol’s cancer-causing substances. People who wear dentures should have their dentures evaluated by a dentist at least every 5 years to ensure a good fit. Dentures should be removed every night and cleaned and rinsed thoroughly every day.

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