Head and Neck Cancer

Normally, cells grow and multiply only when they are needed. Cancer occurs when cells grow unchecked and are able to invade other parts of the body.

Cancer can develop in the head and neck, just as it can form elsewhere in the body. However, head and neck cancers are relatively rare. They make up only about 6 percent of all cancers, according to the American Cancer Society.

Several cancers of the head and neck exist. They include:

• Hypopharyngeal cancer: This cancer affects the bottom part of the pharynx (throat).
• Laryngeal cancer: This cancer affects the voice box (larynx), which contains the vocal cords.
• Oral cancer: This type of cancer can involve the lips, gums, lining of the cheeks, and roof of the mouth.
• Nasopharyngeal cancer: This cancer develops in the back of the nose, toward the base of the skull.
• Oropharyngeal cancer: This cancer forms in the middle of the throat (pharynx) behind the mouth. The area affected may include the soft palate, side and back walls of the throat, and tonsils.
• Salivary gland cancer: This is a rare cancer that forms in the glands that release saliva.
• Thyroid cancer: This cancer occurs in the thyroid gland in the neck.

Cancers can also occur in the brain, eye, and skin (melanoma). They will not be discussed in detail here.

Causes
Using tobacco and drinking alcohol excessively can cause damage to cells that may trigger them to become cancerous. Some people may inherit genetic differences that make them more likely to develop cancers of the head and neck.

Risk Factors
The following risks increase the likelihood that you will develop cancer of the head or neck:

• A diet low in fruits and vegetables
• Excess alcohol use
• Smoking
• Use of chewing tobacco
• Exposure to certain industrial chemicals
• Exposure to radiation in the head and neck
• Infection with the Epstein-Barr virus (risk for nasopharyngeal cancer)
• Infection with human papillomavirus (HPV)
• Male gender
• Older age (over age 65)
• Prolonged exposure to sunlight (risk for lip and skin cancer)

Symptoms
The symptoms will vary based on where in the head or neck the cancer is located.

Symptoms of laryngeal and hypopharyngeal cancers:

• Change in the voice or hoarseness that doesn’t go away
• Sore throat that does not go away
• Difficulty swallowing or pain when swallowing
• Ear pain
• Lump in the neck
• Coughing

Symptoms of oral cancer:

• A lump on the lips or in the mouth
• A sore on the lips or in the mouth that does not heal
• A red or white patch on the gums, tongue, tonsils, or lining of the mouth
• Bleeding or pain in the lips or mouth
• Difficulty chewing or swallowing
• Loose teeth
• Sore throat
• Swelling in the jaw

Symptoms of oropharyngeal cancer:

• A lump in the back of the mouth, throat, or neck
• A sore throat that does not go away
• Cough
• Difficulty swallowing
• Pain behind the breastbone
• Pain in the ear
• Unintended weight loss
• Voice changes

Symptoms of salivary cancer:
Salivary cancer often does not have symptoms. It may be discovered during a routine dental check-up or physical exam.

Symptoms, if they occur, may include:

• A lump in the cheek, ear, jaw, lip, or inside of the mouth
• Difficulty opening the mouth fully
• Difficulty swallowing
• Fluid draining from the ear
• Numbness or weakness in the face
• Pain in the face that does not go away

Symptoms of thyroid cancer:

• A lump in the side of the neck
• Difficulty swallowing
• Hoarseness or other voice change

Diagnosis
The doctor will ask about your medical history and perform a physical exam of the mouth, neck, and/or throat, depending on where the cancer is suspected. In addition to the history, physical exam, and blood tests, several tests may be done to diagnose head and neck cancer.

Imaging tests allow the doctor to determine the size, shape and location of the tumor, its relation to other tissues in the head or neck and whether it has spread to other organs in your body.

• Computed tomography (CT) scan—a series of detailed x-ray pictures, often using a dye to more clearly show the area
• Magnetic resonance imaging (MRI) scan—a magnet, radio waves, and a computer are used to create a series of detailed images of the inside of the body
• Positron emission tomography (PET) scan—a small amount of radioactive glucose (sugar) is injected into a vein and a scanner identifies areas where the glucose is taken up (cancerous cells take up more glucose than normal cells)

The doctor will also need to get some cells from the tumor to examine them under a microscope. The technique will be determined by the location of the tumor

• Biopsy-removing cells to check them for cancer. This may be done in the office or in the operating room, depending on the location of the tumor and the amount of tissue necessary to make a diagnosis.
• Fine needle aspiration (FNA) biopsy-a small sample of tissue or fluid is removed using a thin needle, and is examined under a microscope to check for cancer cells
• Laryngoscopy-a mirror or thin, lighted tube used to examine the larynx and take a biopsy.
• Endoscopy-a long, thin scope inserted through a small incision to view the area and take a biopsy
• Exfoliative cytology-cells are removed from the mouth using a piece of cotton or small brush, and then a lab technician then looks at the cells under a microscope to determine whether they are abnormal.

Treatment
How the cancer is treated depends on the size of the tumor and whether the cancer has spread.

Treatments for head and neck cancer include:

• Chemotherapy is medication given through a vein or by mouth that kills cancer cells throughout the body. Because it also destroys healthy cells, chemotherapy can have side effects such as increased risk of infection, hair loss, and anemia.
• Radiation uses high-dose x-rays to kill cancer cells. Radiation can either be delivered from outside the body (external radiation) or from inside the body (internal radiation) using radioactive needles, seeds, or catheters. Because radiation will also damage the tissues surrounding the tumor, side effects can include redness or irritation, dry mouth, hair loss, nausea, and changes in taste.
• Surgery to remove the tumor and affected tissues. Depending on the location of the cancer, surgery may remove the vocal cords, larynx (voice box), thyroid gland, lymph nodes, and tissue in the lips or mouth. Surgery can be performed with a scalpel or laser beam. It also can be done robotically for greater precision. Side effects with surgery include swelling and a change in your ability to chew, swallow, or talk.

Sometimes treatments are combined. For example, radiation may be given to shrink the tumor before surgery. Chemotherapy may be given after surgery to destroy any cancer cells that remain.

New treatments are being developed to combat head and neck cancers. They include:

• Cetumixab. This therapy is called a monoclonal antibody. It attaches to and blocks a protein called epidermal growth factor receptor (EGFR), which may cause cancer cells to grow more aggressively. When given with radiation therapy, cetumixab may prolong survival.
• Hyperthermia therapy. This treatment uses heat to kill cancer cells or to make the cells more responsive to radiation and chemotherapy.
• Isotretenoin. This drug belongs to a class of medications called retinoids. Although it is typically used to treat acne, researchers are studying whether it might also help prevent head and neck cancer from returning.
• Radiosensitizers. These drugs make tumor cells more sensitive to the effects of radiation, and may be used along with radiation therapy to improve its effectiveness.

Prognosis
The prognosis for head and neck cancers depends on the size of the tumor and whether/how far the cancer has spread. This will be determined using a staging system specific for the type of cancer. Cancers that are discovered and treated early as well as localized cancers typically have a better prognosis than those that have spread.

Sources:
American Cancer Society. Overview: Laryngeal and Hypopharyngeal Cancer.
http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?rnav=criov&dt=23.
Bonner JA, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med. 2006;354:567-578.
National Cancer Institute. A Snapshot of Head and Neck Cancers.
http://planning.cancer.gov/disease/Head_and_Neck-Snapshot.pdf .
National Cancer Institute. Head and Neck Cancer.
http://www.cancer.gov/cancertopics/types/head-and-neck/.