Head and Neck Cancers: Treatment Options

How is it treated?

As with any other cancer, treatment of Head and Neck Cancers is best undertaken at the earliest stage. This maximizes chances of successful treatment. Smaller areas may be treated by radiation or surgery while larger areas will often necessitate combined therapy. Radiation therapy and/or Surgery are the most common types of treatment for Head and Neck Cancers. Treatment options are different for each individual case, but there are several common procedures listed below. In some cases, the patient is referred to a team of specialists, including a surgeon, ENT specialist, radiation oncologist, medical oncologist, speech pathologist, nurse, and dietitian. A dentist may also be an important member of the team, especially for patients who will receive radiation therapy. The information presented is intended to provide patients with treatment information that they can use in discussing treatment options with their physician.

Surgical Treatments

When a patient needs surgery, the type of operation depends mainly on the size and exact location of the tumor. Surgery or surgery combined with radiation therapy and/or chemotherapy is commonly used for Head and Neck Cancers. A surgical treatment plan that combines radiation therapy and/or chemotherapy has a definite advantage. Radiation and chemotherapy reduce the amount of tissue that needs to be surgically removed. This allows for a greater amount of organ preservation. In other words, a larger portion of the affected structure (the larynx, tongue, jaw, etc.) can be saved and will remain functional. Speech, breathing, eating, and appearance are often less affected when radiation and chemotherapy are added to a surgical treatment.

Oral Cancer

• Primary Tumor Resection: The entire tumor along with some normal surrounding tissue is removed to assure the adequate margins. Smaller tumors can be removed through the mouth without cutting the jawbone. Larger tumors may require splitting the jawbone with a saw (mandibulotomy) to get access to the tumor.
  
  
• Mandible Resection or Maxillectomy: If the tumor invades the jawbones (mandible: lower jaw bone; maxilla: upper jawbone), a full or partial resection of jawbone may be required dependent upon the extension of the tumor.
  
  
• Mohs' Micrographic Surgery: Skin cancer involving the lip can be removed by Mohs' chemosurgery. This method removes the tumor in thin slices, which will be examined under microscope immediately. The surgeon continues to remove more slices until no more cancer cells can be seen under the microscope.
  
  
• Neck dissection: The surgeon removes the lymph nodes from the neck. It is performed to remove cancerous lymph nodes from the neck and possibly cancerous lymph nodes from the body.
  
  
• Some cancers of the tongue, tonsils, or other parts of the mouth can be cured by radiation alone or with chemotherapy.
  

Laryngeal Cancer

• Total Laryngectomy: The whole voice box is removed. With the removal of the voice box, the windpipe is then brought up to the skin of the neck as a stoma (or hole) through which the patient will breathe. This is called a tracheostomy. In total laryngectomy, the stoma is permanent.
  
  
• Partial Laryngectomy: The surgeon removes only part of the voice box with preservation of the voice. Smaller cancers of the larynx can often be removed without taking out the entire voice box. If a stoma is performed during a partial laryngectomy, it is normally only temporary. After a brief recovery period, the tracheostomy tube is removed, and the stoma closes up.
  
  
• Laser surgery: When the tumor on the vocal cord is very small, the surgeon may use a laser to remove cancer.
  
  
• Neck dissection: The surgeon removes the lymph nodes from the neck. It is performed to remove cancerous lymph nodes from the neck and possibly cancerous lymph nodes from the body.
  
  
• Some laryngeal cancers can be cured by radiation alone without loss of the voice box.
  

When the entire voice box is removed, patients must learn to speak in a new way. There are various ways of talking after a total laryngectomy. Some patients can swallow air into the esophagus and create a belching type of speech (esophageal speech). The patients may also use electrical devices to produce a mechanical voice (electrolarynx). One of the most significant advances in restoring speech has been the development of the tracheoesophageal puncture (TEP). The surgeon creates a small opening between the trachea and the esophagus. A plastic or silicone valve is inserted into this opening through the stoma. The valve keeps food out of the trachea. After this operation, patients can cover their stoma with a finger to force air out of their mouths, producing sustained speech.

It takes practice and patience to learn new ways of speech after total laryngectomy. Speech therapists help in this regard. There is a "New Voice" club for people with permanent tracheostomies who share experiences and give each other support.

Nasopharyngeal Cancer

Because the nasopharynx is close to vital nerves and blood vessels and not easy to reach, it is very difficult to remove the entire tumor with an adequate margin. Most patients require radiation therapy with or without chemotherapy. Surgery can be used for patients with recurrent disease who have received a maximal dose of radiation. Neck dissection is sometimes performed in conjunction with radiation therapy for patients with a neck lump or mass.

Other treatments

There are several non-surgical treatment options that may be combined with surgery or used in place of surgery. These treatment options are applicable to all types of Head and Neck Cancers. For Head and Neck Cancer, alternate treatments are important to reduce the need for extensive surgical procedures resulting in loss of function or disfigurement.

• Radiation Therapy - Radiation therapy uses high-energy radiation to kill cancer cells. External beam radiation therapy uses radiation from outside the body to focus on the cancer. Radiation can also come from radioactive materials placed directly into or near the tumor. This is called brachytherapy. Radiation therapy can be given either in daily fractions, five days per week or two treatments per day (altered fractionation). Radiation treatment can be used in conjunction with surgery and/or chemotherapy for selected group of patients. You should discuss these options with your doctor to explore different treatment approaches.
  
  
• Chemotherapy - Drugs are administered by mouth or injection to kill the cancer cells. The drugs enter the blood stream and can, therefore, reach areas of the body where the cancer may have spread. Some recent studies have demonstrated the advantage of combining radiation therapy and chemotherapy for patients with advanced Head and Neck Cancers.
  
  
• Clinical Trials - With the introduction of many new drugs that affect Head and Neck Cancers and combinations with radiotherapy, there are new experimental treatments being tested that have promising results. The effectiveness and side effects of clinical trials are not always known, but they can sometimes offer hope of survival especially for end-stage cancer patients. Consult your physician or the Rhode Island Cancer Council to find out what clinical trials are going on near you and if you are eligible.
  

What are the side effects of the treatments?

Possible side effects from Surgical Treatment

Surgery to remove a small tumor in the mouth usually does not cause any lasting problems. More extensive surgery, such as mandible resection and maxillectomy, is likely to change the patient's ability to swallow, chew, or talk. The patient may also look different. Reconstruction surgery may be needed to repair defects in the mouth, throat, or neck caused by removal of larger tumors.

• Total Laryngectomy - The patient will permanently have a hole in the neck (stoma) from which to breathe for the rest of his/her life. Like any surgeries, wound infection and bleeding may occur.
  
  
• Partial Laryngectomy - The stoma is temporary. As soon as the skin around the stoma heals, the tracheostomy tube is removed. The voice may change after partial laryngectomy.
  
  
• Neck Dissection - There are a number of important structures in the neck (blood vessels, nerves, other structures) that are at risk of injury during a neck dissection. The top of the lungs actually enter the neck and the lining of the lung can be injured during a neck dissection resulting in a collapsed lung requiring a tube in the chest for a short time to reinflate the lung. All of these risks occur in just a small minority of cases but must be understood by the patient before agreeing to undergo a neck dissection.
  

Possible Side Effects from Non-Surgical Treatments

*Most side effects are temporary and can often be relieved with medication.

• Radiation Therapy
  
  • Skin problems, looks like sunburn
    
  • Dry mouth (may persist and even be permanent)
    
  • Sore throat
    
  • Worsening of hoarseness, especially at beginning
    
  • Difficulty swallowing
    
  • Decreased taste
    
  • Fatigue
    
  • Difficulty breathing
    
  
  
• Chemotherapy
  
  • Nausea and vomiting - Loss of appetite
    
  • Loss of hair
    
  • Mouth sores
    
  • Decreased blood count
    
  • Increased susceptibility to infection
    

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