Head & Neck Cancer
By Dr. Shashikant Limbachiya, Head & Neck Cancer Surgeon at Narayana Multispeciality Hospital, Ahmedabad
Head and neck cancers are the most common cancers in developing countries. Head and neck cancers are more common in males compared to females. Oral cancers are most common amongst all head and neck squamous cell cancers (HNSCC). HNSCC in the developing world differ in terms of age, site of disease, etiology, molecular biology, poverty, illiteracy, advanced stage at presentation, lack of access to health care, and poor treatment infrastructure pose a major challenge in management of these cancers.
India’s global contribution of head and neck cancer patients is 57.5%. Owing to increased use of tobacco, India contributes to nearly 60% of head and neck cancer patients worldwide. The number is expected to double by 2030. According to national cancer registries data, Ahmedabad tops the chart for oral cancers. Cancers that are known collectively as head and neck cancers usually begin in the squamous cells that line the 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. Head and neck cancers can also begin in the salivary glands, Thyroid gland & skin, but these cancers 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 (Buccal mucosa), 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 esophagus. It has three parts:
a) The nasopharynx – The upper part of the pharynx, behind the nose
b) The oropharynx – The middle part of the pharynx, including the soft
palate, base of the tongue, tonsils & Pharyngeal walls.
c) The hypopharynx – The lower part of the pharynx just above esophagus
Larynx: The larynx, also called the voice box, is a short passageway formed by cartilages in front of 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.
Nose & Paranasal sinuses/ Skull Base : Nose and surrounding sinuses cancers are uncommon, but it often present with advance stage involving orbital contents(eyeballs and its muscles) or area lower to the brain (skull base)
Salivary glands: The major salivary glands are paired parotid and submandibular glands. The minor glands are in the oral cavity. The salivary glands produce saliva.
Thyroid gland: It is butterfly shaped endocrine gland in front of larynx and trachea which is important to produce and maintain thyroid hormones in the body.
Skin cancers: skin cancers of scalp, face and neck are more common in Australia and coastal areas or people who are more exposed to sunlight
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. Pan Masala & Areca nut chewing are also associated with oral cancers. It is highly recommended for tobacco users to self-examine oral cavity regularly in mirror and can prevent /early diagnose these cancers.
The symptoms of head and neck cancers may include a non-healing ulcer in mouth, sore throat/pain that does not go away, difficulty in swallowing, and a change or hoarseness in the voice. In advance stage head and neck cancer metastasize to neck nodes and present with neck lump/mass. These symptoms may also be caused by other, non-cancerous conditions. It is important to check with a doctor about any of these symptoms. The symptom that may affect specific areas of the head and neck includes:
- Oral cavity: Non healing ulcers for more than 3 weeks, White or red patches on the gums, tongue, or lining of the mouth , poorly fitting dentures , progressive decreased in mouth opening and unusual bleeding or pain in the mouth.
- Pharynx: Pain while swallowing food, pain in the neck or the throat that does not go away, long standing earache, difficulty in speaking ,neck lump.
- Larynx: Change in voice , difficulty in breathing, Pain while swallowing or ear pain, neck lump.
- Nose & PNS: Long standing unilateral nasal blockage, frequent nasal bleeds, loss of sense of smell, swelling and loss of sensation below eyes, neck lump.
- Salivary glands: Lump infront of ear, under the chin or around the jawbone, Numbness or paralysis of the muscles in the face, Pain in the face, the chin, or the neck that does not go away..
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 would be with curative intent or palliative intent in very advance cases just to control pain and supportive measures to maintain quality of life. Treatment for head and neck cancer can include surgery, radiation therapy, chemotherapy, targeted therapy, or a combination of treatments. Surgery remains the mainstay treatment option for most head and neck cancers followed by adjuvant treatment either by radiation/chemoradiation. Recent advances in form of plastic reconstructive and microvascular surgeries help patients to minimize the disability to chew, swallow, or talk and disfigurement.
Organ preservation treatment in form of radiation or chemoradiation is often preferred for pharyngeal and laryngeal cancers. Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth, a dry mouth or thickened saliva, difficulty in swallowing, changes in taste, or nausea. It is very essential to rehabilitate the patients for speech and swallowing which affects the quality of life.
Regular follow-up care is very important after treatment for head and neck cancer to make sure that the cancer has not returned, or that a second primary (new) cancer has not developed. All patients are being called for monthly follow up for first year and then follow up duration increases for upcoming couple of years.
The earlier the diagnosis and execution of treatment, better are outcomes and disease free survival. If cancer is being diagnosed in first stage, chances of survival are almost around 90-100% for long term. But the same decreases with increasing in stage of the disease to around less than 40- 50% for advance stage.