Head and Neck Cancer Treatment

Head and neck cancer overview

Head and neck cancer actually includes many different malignancies. The way a particular head and neck cancer behaves depends on the site in which it arises (the primary site). For example, cancers that begin on the vocal cords behave very differently than do those that arise in the back of tongue, just an inch or less from the vocal cords.

The most common type of cancer in the head and neck is squamous cell carcinoma, which arises in the cells that line the inside of the nose, mouth and throat. Other less common types of head and neck cancers include salivary gland tumors, lymphomas and sarcomas.

Cancers spread in three main ways. The first is direct extension from the primary site to adjacent areas. The second is spread through the lymphatic channels to lymph nodes. The third is spread through the blood vessels to distant sites in the body. In head and neck cancer, a spread to the lymph nodes in the neck is relatively common.

The lymph nodes most commonly involved are located along major blood vessels underneath the sternocleidomastoid muscle on each side of the neck, particularly the internal jugular vein node at the angle of the jaw. The risk of spread to other parts of the body through the bloodstream is closely related to whether the cancer has spread to the lymph nodes in the neck, how many nodes are involved, and their location in the neck. The risk is higher if cancer is in lymph nodes in the lower part of the neck rather than only in those located in the upper neck.

What are my treatment options?

Click to play

The three main types of treatment for managing head and neck cancer are radiation therapy, surgery and chemotherapy. The primary treatments are radiation therapy or surgery, or both combined; chemotherapy is often used as an additional, or adjuvant, treatment. The optimal combination of the three treatment modalities for a patient with a particular head and neck cancer depends on the site of the cancer and the stage (extent) of the disease.

In general, patients with early-stage head and neck cancers (particularly those limited to the site of origin) are treated with one modality—either radiation therapy or surgery. Patients who have more extensive cancers are often treated with concurrent chemotherapy and radiation therapy. Sometimes, depending on the clinical scenario, patients are treated with surgery followed by postoperative radiation therapy chemotherapy.

If the plan of treatment is radiation therapy alone for the primary cancer, the neck is also treated with radiation therapy. In addition, a neck dissection to remove involved lymph nodes in the neck may be necessary if the amount of disease in the neck nodes is relatively extensive or if the cancer in the neck nodes has not been eliminated completely by the end of the radiation therapy course.

Another treatment that might be necessary before or after radiation therapy is surgery. In general, if the surgical removal of the primary tumor is indicated, radiation is given afterward if necessary. Sometimes, however, the cancer is extensive or it is not feasible to completely remove the cancer initially. Radiotherapy is then given first to try to shrink the tumor, and surgery will follow radiotherapy.

Recent studies indicate that chemotherapy given at the same time as radiation therapy is more effective than if it is given before a course of radiation therapy. Therefore, radiation treatment schedules sometimes include chemotherapy if the stage of the cancer is advanced (advanced stage III or stage IV). Drugs most commonly given in conjunction with radiation therapy are cisplatin (Platinol) and Cetuximab (Erbitux). Occasionally, other drugs may include fluorouracil (5-FU, Adrucil), carboplatin (Paraplatin), and paclitaxel (Taxol). This is only a partial list of chemotherapy agents; your physicians may choose to use others. The chemotherapy may be given in a variety of ways, including a low daily dose, a moderately low weekly dose, or a relatively higher dose every three to four weeks.

Typically, one of the following radiation therapy procedures may be used to treat Head and Neck Cancer:

• External beam therapy (EBT): a method for delivering a beam of high-energy x-rays to the location of the tumor. The beam is generated outside the patient (usually by a linear accelerator) and is targeted at the tumor site. These x-rays can destroy the cancer cells and careful treatment planning allows the surrounding normal tissues to be spared. No radioactive sources are placed inside the patient's body. See the External Beam Therapy page (www.RadiologyInfo.org/en/info.cfm?pg=ebt) for more information.
• Intensity-modulated radiation therapy (IMRT): an advanced mode of high-precision radiotherapy that utilizes computer-controlled x-ray accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. The radiation dose is designed to conform to the three-dimensional (3-D) shape of the tumor by modulating—or controlling—the intensity of the radiation beam to focus a higher radiation dose to the tumor while minimizing radiation exposure to healthy cells. See the IMRT page (www.RadiologyInfo.org/en/info.cfm?pg=imrt) for more information.

For more information about radiation therapy equipment, visit the following pages:

• Linear Accelerator (www.RadiologyInfo.org/en/info.cfm?pg=linac)
• Gamma Knife (www.RadiologyInfo.org/en/info.cfm?pg=gamma_knife)

What happens during radiation therapy?

The initial visit to the radiation oncologist is for a consultation, when the radiation oncologist will listen to the history of your problem and perform a physical examination. Consultations with other members of the head and neck team, such as the head and neck surgeon, pathologist, radiologist and dentist, usually take place at this time or shortly after. It is important to have the input of various members of the team who will be taking care of you before a treatment plan is decided and treatment begins.

After the recommended treatment and possible options are explained to you and you decide on a course of treatment in conjunction with your doctors, a date will be selected for treatment planning for radiation therapy (if irradiation has been selected as the first or next step in your treatment). You then have what is called a "simulation" using either conventional radiographs (x-rays) or a computed tomography (CT) scan. These radiographic studies are used to plan the type and direction of radiation beams used to treat the cancer. Customized lead alloy blocks or a special collimator (multileaf collimator) in the treatment machine will shape the radiation beams to block areas that do not need to be treated. Treatment fields then will be aligned, and the treatment course will start one to two days after the initial treatment-planning session.

Typically, treatments are given once or twice a day, five days a week for five to seven weeks, depending on the treatment schedule selected by your radiation oncologist. Generally, for the first couple of days of treatment planning and treatment start, your visit to the radiation oncology department may take an hour or two. Thereafter, each individual treatment takes just a few minutes, and you will be in and out of the radiation department in 30 to 45 minutes for each treatment session. You will not feel or see anything during a radiation treatment, and any side effects usually require two or more weeks to become apparent.

What are possible side effects of radiation therapy?

The side effects depend on the site and extent of the head and neck cancer. In general, irradiation of the head and neck does not cause nausea, but a few patients do experience nausea during treatment. Many effective antiemetics (drugs that alleviate nausea) can relieve this symptom if it should occur.

Generally, the side effects of radiation therapy become apparent about two weeks into the treatment course, when a sore throat, loss of taste sensation, dryness of the mouth and dry skin reactions may occur. Sore throat is the main side effect that makes the course of radiation therapy difficult.

If your sore throat is severe, you may be unable to take in enough food and liquids by mouth to maintain your weight or avoid dehydration. Your doctors will then insert a feeding tube temporarily into your stomach (a gastrostomy tube), which will allow you to maintain adequate nutrition without having to swallow all of the food that you need. Gastrostomy placement is an outpatient procedure. It is important, though, to continue swallowing even with a gastrostomy tube in place. Otherwise, your swallowing muscles may atrophy; this would cause permanent swallowing problems and make it difficult to stop using the gastrostomy tube even after the radiation treatment course is completed.

A dietitian should be involved in your care during the course of radiation treatments to help you maintain adequate caloric intake and hydration. When side effects occur, it may be tempting to take a break from treatments. This is not a good idea. The "acutely responding" normal tissues—such as the skin and the lining of the throat—that are responsible for the side effects during radiation therapy tend to respond to radiation as do cancer cells. If the treatment produces few acute side effects, it is also not likely to be very effective against the cancer. Therefore, the treatment of most head and neck cancers represents a classic "no pain, no gain" situation. Breaks in the treatment course to lessen the side effects give the cancer a chance to regrow and will significantly reduce the likelihood of cure. Medications that are almost always needed during a course of radiation therapy include narcotic pain medicines, both a long-acting pain medicine and a short-acting pain medicine for breakthrough pain and stool softeners, because a common side effect of narcotics is constipation. Additional medications that may be necessary are topical anesthetics—such as "magic mouthwash"—to lessen the sore throat and possibly antiemetics if nausea is a problem.

What are some of the possible risks or complications?

A clear goal of treatment must be determined for each patient before therapy starts. The first question is often whether the goal of treatment is cure or, instead, the lessening (palliation) of symptoms associated with an incurable cancer. If cure is unlikely, then potential risks associated with treatment ought to be less than those associated with a potentially curative course of radiation therapy.

Palliative courses of treatment generally entail giving a moderate dose of radiation over a short time. This provides a relatively high chance of shrinking the tumor and lessening symptoms while exposing the patient to less risk of side effects and complications, and requiring a relatively brief time to complete the therapy. A typical course of palliative radiation treatments would be divided into 10 treatments given over two weeks.

On the other hand, if there is a reasonable chance of cure (the definition of reasonable can vary, depending on the situation, but generally at least 5 percent to 10 percent), then a longer and more arduous course of treatment is generally planned. The risks associated with treatment depend on the location and extent of the tumor and the normal structures that are nearby.

In general, for any type of treatment, the treating physician tries to estimate the potential risk of a major complication; if this risk is similar to or exceeds the anticipated likelihood of cure, then the treatment plan is modified. However, if the likelihood of cure is significantly greater than the risk of a major complication, then treatment is initiated.

What kind of treatment follow-up should I expect?

There are several reasons for follow-up examinations:

• To detect recurrent cancer and possibly try further treatment, such as an operation, if the radiation therapy is unsuccessful
• To treat the acute side effects of the radiation therapy
• To detect and treat late side effects or complications from the radiation therapy, should they occur
• To detect and treat additional, unrelated head and neck cancers that may arise

If the initial treatment for the cancer is successful and you are cured, there is still a relatively low risk (2 percent to 3 percent per year) of developing a new, completely unrelated head and neck cancer. Follow-up examinations usually take place:

• Every four to six weeks for the first year
• Every two months for the second year
• Every three months for the third year
• Every six months for the fourth and fifth years
• Annually thereafter

A chest radiograph (x-ray) is obtained once a year, and thyroid functions are often checked annually to detect any occurrence of hypothyroidism (decreased thyroid function), which is easily treatable.

Sometimes additional tests are indicated, such as a CT scan, fluorodeoxyglucose (FDG) positron emission tomography (PET) scan or MRI, to assist in difficult situations where it may not be clear whether the cancer persists after treatment.

Are there any new developments in treating my disease?

Some new treatments are available, as are new ways of combining old treatments. A good example of the latter is the use in recent years of a combination of radiation therapy and chemotherapy or immunotherapy for advanced head and neck cancer. Some new agents include antiangiogenic drugs, which attack the blood vessels that nourish the tumor, and drugs such as erythropoietin that provide oxygen to the tumor, making it more sensitive to radiation and increasing the chance of cure. For updated information on new cancer treatments that are available, you should discuss these issues with your doctor and consider obtaining a second opinion before beginning treatment.

Clinical Trials

For information and resources about clinical trials and to learn about current clinical trials being conducted, see:

• Clinical Trials - from RadiologyInfo's News section
  www.RadiologyInfo.org/en/news/newdetarget.cfm?id=16
• Clinical Trials - from the National Cancer Institute's Web site
  www.cancer.gov/clinicaltrials/