Head and Neck Cancer

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Head and Neck Cancer

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Prevention, Causes, and Risk Factors for Head and Neck Cancer

Head And Neck Cancer

The incidence of head and neck cancer is highest in India. These head and neck cancers can affect the lips, tongue, mouth, larynx (voice box), pharynx, salivary glands, sinuses, and thyroid gland. Skin cancer or melanoma of the face and scalp also constitutes head and neck cancers. At our center, we have a dedicated organ-site focused multidisciplinary head and neck cancer team that provides services in areas of diagnosis, treatment, and post-treatment services for all kinds of head and neck cancers, such as Oral Cancer (Mouth Cancer), Throat Cancer, Thyroid Cancer, Tongue Cancer, as per their classification and staging. The team has extensive experience and state-of-the-art technology available to provide advanced/very advanced/recurrent/salvage head and neck cancer surgeries, reconstruction/micro-vascular surgery, dental and maxillofacial prosthetics, and implant surgeries.

The head and neck cancer treatment plan is customised for each patient, depending on the stage of cancer and other medical requirements for mouth cancer and other malignancies developed around. The multidisciplinary team, hence, plays a crucial role in the diagnosis as well as the oral cancer treatment plan for every patient.

The goal of treating head and neck cancer is not just the removal of the tumour, but also to help patients cope with emotional and physical morbidity related to the disease and to provide rehabilitation services to patients. The aim of mouth or oral cancer treatment is to facilitate restoration of confidence and to improve their quality of life. Hence, the comprehensive head and neck treatment plan at our centre also includes complete rehabilitation for each patient, in addition to treatment alone.

RISK FACTORS

There are a number of different factors that can increase your risk of head and neck cancer. Not everyone who is diagnosed with head and neck cancer has a known risk factor. Sometimes there is no clear reason why the disease develops. Risk factors for head and neck cancer vary based on the location and type of cancer, and include:

  • Tobacco use

Smoking cigarettes, cigars, or pipes or using smokeless tobacco puts people at greater risk for head and neck cancer. While cigarette smoking is the most hazardous and prevalent form of tobacco use in the west, consideration also needs to be given to other forms such as bidi smoking in India, reverse smoking by several rural populations and use of snuff and chewing tobacco(gutka).

  • Alcohol consumption

Heavy use of alcohol raises a person’s risk of developing head and neck cancer. Using alcohol and tobacco together increases the risk even more.

  • Betel quid and areca nut

Chewing betel quid or areca nut is common in India. Betel quid, or paan, is areca nut (the seed from the fruit of the oriental palm) and lime with or without tobacco wrapped in a betel leaf. Some people chew areca nut by itself. People who chew betel quid or areca nut have a higher risk of developing oral cancer, especially in the inner lining of the cheeks and lips.

  • Poor-fitting dentures and sharp teeth

A few studies found that having dentures that don’t fit properly can increase the risk for oral cancer. This may because the dentures rub on the gums and cause sores that may develop into a cancerous tumour.

  • Poor nutrition

A diet low in vitamins A and B can raise the risk of head and neck cancer.

  • Prolonged sun exposure

This factor puts a person at greater risk for skin cancer of the head and neck.

  • Human papillomavirus (HPV)

HPV is becoming an increasingly common risk factor for some types of head and neck cancer.

  • Poor oral hygiene

Those who don’t take care of their teeth and gums are at an increased risk of head and neck cancer.

  • Epstein-Barr virus

The virus that causes mononucleosis plays a role in the development of some types of head and neck cancer.

  • Precancerous conditions

Precancerous conditions of the mouth include leukoplakia and erythroplakia. They aren’t cancer, but they can sometimes become oral cancer if they aren’t treated. Some of the risk factors for oral cancer may also cause these precancerous conditions.

  • Environmental factors

It was found that the environmental factors can be seen as one of the main causes of paranasal sinus and nasal cavity cancer.Exposure to textile dust, wood dust, nickel and leather might also cause the paranasal sinus and nasal cavity tumor.Meanwhile, it is also risky to exposure to the radium fumes, formaldehyde fumes and other fumes products used for producing furnitures and shoes. People who exposure to the air pollution is also the high risk group of getting the cancer.

  • Risk Factors of Thyroid Cancers

There is no exact cause of thyroid cancer. There are a few factors, which might be the reason or cause this cancer. These factors include:

  1. Changes in the DNA of cells.
  2. Exposed to more radiation.
  3. Exposure of a neck for X-rays and CT scans.
  4. Low iodine diet.

What Are the Symptoms of Head and Neck Cancers?

In the mouth, cancer can cause—

  • A white or red sore that does not heal on the gums, tongue, or lining of the mouth.
  • Swelling in the jaw.
  • Unusual bleeding or pain in the mouth.
  • A lump or thickening.
  • Problems with dentures.

At the back of the mouth (pharynx), cancer can cause—

  • Trouble breathing or speaking.
  • A lump or thickening.
  • Trouble chewing or swallowing food.
  • A feeling that something is caught in the throat.
  • Pain in the throat that won’t go away.
  • Pain or ringing in the ears or trouble hearing.

In the voice box (larynx), cancer can cause—

  • Pain when swallowing.
  • Ear pain.
  • Change of voice.
  • Breathing difficulty.

In the sinuses and nasal cavity, cancer can cause—

  • Blocked sinuses that don’t clear.
  • Sinus infections that do not respond to treatment with antibiotics.
  • Bleeding through the nose.
  • Headaches.
  • Pain and swelling around the eyes.
  • Pain in the upper teeth.
  • Problems with dentures.

Thyroid cancer symptoms-

  • A lump (nodule) that can be felt through the skin on your neck
  • Changes to your voice, including increasing hoarseness
  • Difficulty swallowing
  • Pain in your neck and throat
  • Swollen lymph nodes in your neck

What is cancer of unknown primary?

Many cancers can manifest solely as neck swelling(lymphadenopathy),the primary lesions not identifiable. Cancer of Unknown Primary in the head and neck region occurs when the origin of the cancer is unknown, but is found to have spread to the lymph nodes in the neck.

Ways to Prevent Head and Neck Cancer

Here are the top ways to reduce your head and neck cancer risk:

  1. If you smoke or use other tobacco products, reach out to a tobacco cessation program, to get help quitting. The Government has also developed and deployed a mobile-based strategy called m-Cessation (011-22901701) to encourage and support those who are desirous of quitting. In this strategy, those desirous of quitting give a missed call to a toll freenumber or login to https://www.nhp.gov.in/quit-tobacco for further details.
  2. If you drink alcohol, do so in moderation.
  3. Protect yourself against HPV infection by practicing safe sex and getting the HPV vaccine.
  4. Do not use tanning beds and avoid extended periods of time in the sun.
  5. Not all nasal cavity and paranasal sinus cancers can be prevented, but the risk of developing these cancers can be greatly reduced by avoiding certain risk factors, such as workplace exposures to certain substances and increased workplace safety measures.Wear a protective face mask if you are exposed to toxic fumes and dust. Companies can install air-filtration systems to minimize employees’ exposure to harmful fumes and dust.
  6. Radiation exposure, especially in childhood, is a known thyroid cancer risk factor. Because of this, doctors no longer use radiation to treat less serious diseases. Imaging tests such as x-rays and CT scans also expose people to radiation, but at much lower doses, so it’s not clear how much they might raise the risk of thyroid cancer (or other cancers).
  7. Genetic testscan be done to look for the gene mutations found in familial medullary thyroid cancer (MTC). Because of this, most of the familial cases of MTC can be prevented or treated early by removing the thyroid gland. Once the disease is discovered in a family, the rest of the family members can be tested for the mutated gene.
  8. It’s also important to schedule regular checkups with your dentist. This is particularly important if you use tobacco or drink heavily. Many oral cancers are found during routine dental appointments.

CANCER SCREENING

Screening refers to tests and exams used to detect a disease, such as cancer, in people who don’t have any symptoms. The purpose is to find cancer at its earliest, most treatable stages.At present, no screening method has been proven to improve survival for people with head and neck cancer. However,  doctors advise a yearly physical exam of the head and neck by your primary care doctor.

The following tests and procedures may be used to diagnose head and neck cancer:

Physical Exam for Head and Neck Cancer

Your doctor will thoroughly examine the head and neck area, feeling for abnormalities, looking inside the mouth and throat, and using mirrors and lights to examine hard-to-see areas.

Endoscopy

In some cases, your doctor may use an endoscope (a thin lighted tube with a camera at its tip). This tool is helpful in examining areas of the head and neck that are more difficult to reach.

  • Nasoscopy: A procedure to look inside the nose for abnormal areas. A nasoscopeis inserted into the nose. A nasoscope is a thin, tube-like instrument with a light and a lens for viewing. A special tool on the nasoscope may be used to remove samples of tissue. The tissues samples are viewed under a microscope by a pathologist to check for signs of cancer.
  • Laryngoscopy: A procedure in which the doctor checks the larynx(voice box) with a mirror or a laryngoscope to check for abnormal areas. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing the inside of the throat and voice box. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
  • Panendoscopy: endoscopic examination, usually with the patient under general anesthesia, of the pharynx, larynx, upper trachea, and esophagus with rigid and flexible endoscopes.

BIOPSY

The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. There are three types of biopsy:

Diagnostic Imaging for Head and Neck

  • X-rays of the head and neck: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • MRI(magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dyemay be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Positron emission tomography (PET) scan: For patients who have been diagnosed with head and neck cancer, a PET scan may be used to determine whether cancer has spread to the lymph nodes, to identify the original site of cancer when it is discovered in the lymph nodes, or to check the entire body for the spread of cancer.

HPV Testing for Throat Cancer

Thyroid Nodule Assessment for Thyroid Cancer

Genomic Testing for Advanced Head and Neck Cancer

What Are the Key Statistics About Head and Neck Cancers?

Magnitude of problem in India Overall, 57.5% of global head and neck cancers occur in Asia especially in India.[1]Head and neck cancers (HNCs) are malignant tumors of the upper aerodigestive tract and are the sixth most common cancer worldwide. In India, around 30–40% of all cancers are HNCs.[2]Squamous cell carcinoma (SCC) constitutes for >90% of HNCs. Among all etiologic factors, smoking and chewing of tobacco are considered important for the development of HNCs. In India, there is a significant increase in the incidence of HNCs and there is variability in the management of these patients.
According to GLOBOCAN 2018 report, worldwide HNC statistics indicate that there are 834,860 cases of HNC per year, resulting in approximately 431,131 deaths per year. High incidence rates have been reported from developing countries including India, Pakistan, Bangladesh, Taiwan, and Sri Lanka.[3] HNCs account for approximately 30–40% of all cancer sites, in India.[4],[5] The Cancer Atlas project by the Indian Council for Medical Research (ICMR) reports incidences of different cancers across India. The incidence in Assam, Manipur, Mizoram, Tripura, and Nagaland has been reported to be higher (54%). The world’s highest incidence of cancers in men, which was of the lower pharynx (11.5/100,000 people) and the tongue (7.6/100,000 people), was reported from Mizoram. Pondicherry has also reported the incidence of mouth cancer in males (7.8–8.9/100,000); however, the highest incidence of nasopharyngeal cancer has been reported from Nagaland.[6] The possible reasons for the higher incidence of HNCs in India include extensive use of tobacco, pan masala (which include betel quid, areca nuts, and slaked lime), and gutkha

In India, among patients diagnosed with HNC, 86.5% were reported as tobacco users and 23.2% were reported as alcohol users.[6] Habits of chewing tobacco, areca nuts, slaked lime, gutkha, betel quid, and alcohol consumption add to further adverse prognosis. Tobacco allows long exposure and causes discoloration because of which early changes are masked resulting in an advanced presentation. In oral cancer patients, tobacco users have shown lower survival than nontobacco users (median overall survival [OS] at 5 years: 43% vs. 72%, respectively). Tobacco and alcohol frequently coexist and lead to adverse prognosis. Five-year OS in patients who consumed both alcohol and tobacco was 29%.[7] There is a delayed diagnosis with most commonly reported sites being oropharynx, hypopharynx, oral cavity, and presence of predominantly human papillomavirus (HPV)-negative tumors.[8],[9] Delayed diagnosis leads to poor prognosis with 5-year median OS varying from 100% at stage 1 to 42% at stage 4.[7] 

Treatment options

Surgery

Surgeons are looking at new ways to remove these cancers while doing as little damage as possible to nearby normal tissues. Researchers are also looking for better ways to combine surgery with other cancer treatments to get better outcomes. Selective lymph node dissection  is another research interest. Studies have suggested that even patients who do not appear to have cancer in their lymph nodes have better outcomes when surgery is done to check the nodes close to the cancer compared to patients who have no lymph node treatment or elective neck radiation. More research is needed to know which patients should be offered these options. Studies are looking at the possibility of reconstruction, or rebuilding the effected bony parts of the face, and how to best do it. Bone and tissue grafts, as well as man-made materials are being studied.

Radiation therapy

Doctors are always looking better ways to focus radiation on tumors more precisely to get more radiation to the tumor while limiting damage to nearby areas. This is especially important for head and neck tumors like nasal cavity and paranasal sinus cancers, where there are many important structures (like the eyes and brain), blood vessels, and nerves close to the tumor. Research looking at whether proton therapy (which uses proton beams instead of xrays) could work better than IMRT. (IMRT is the type of radiation most often used today.) Proton therapy could allow doctors to give higher doses of radiation to the cancer with less damage to the tissues the rays pass through. This might also cause fewer side effects, like mouth pain, eating problems, and weight loss. Different radiation schedules are also being studied. For instance, instead of giving one large dose of radiation each day, there may be less damage to the eyeball and optic nerve if radiation is split into 2 smaller doses each day. This is called hyperfractionation and needs to be studied more. Improvements in radiation have also led doctors to test repeating radiation  for cancers that come back after the initial course of treatment.

Chemotherapy

Doctors are looking at how chemotherapy can be used with other treatments to improve outcomes, especially for bigger cancers that may have already spread. Induction chemotherapy ,chemo given before surgery and/or radiation , is of special interest because studies suggest that it may help preserve the eyeball in people with advanced disease. It’s also been linked to longer survival. Intra-arterial chemo (putting drugs right into the blood vessels feeding the tumor) for advanced cancers is another area of interest. Research has suggested that this might help reduce damage to the nearby tissues — especially the eyeball. Still, there are a lot of side effects seen with this treatment, and more research is needed to know if it helps. More research is needed to know when to use chemotherapy and which chemo drug combinations are best for these cancers.

Targeted therapies

Clinical trials are studying several targeted therapies that block the action of the substances (such as growth factors and growth factor receptors) that cause head and neck cancers to grow and spread. Cetuximab is already used in some cases, and pembrolizumab and bevacizumab are also being studied. Many studies are testing combinations of targeted therapies plus chemo or radiation. As has been the case with many other kinds of cancer, targeted therapies may prove to be a great advancement in the treatment of nasal cavity and paranasal sinus cancers. PDT Photodynamic therapy13 or PDT uses drugs and light to treat small cancers that can be reached with lasers. Researchers are looking at how this treatment might be used to treat recurrent esthesioneuroblastoma and other paranasal sinus tumors that come back after treatment. Because nasal cavity and paranasal sinus cancers are rare, nearly all clinical trials include patients with other types of head and neck cancer as well. Although these studies are not specific to nasal cavity and paranasal sinus cancers, doctors will be able to apply the results when choosing treatment for patients with nasal cavity and paranasal sinus cancers.

Treatment for Thyroid Cancer

The thyroid cancer could be treated both with surgery and by radioactive iodine. In certain cases, radiation therapy is also used as a mode of treatment. Before treating a patient with this cancer, it is more important to check the age of a patient, type, and stage of thyroid cancer. Other treatments include:

  • Targeted drug therapy.
  • Alcohol ablation.
  • Chemotherapy.
  • Thyroid hormone therapy.
  • Removal of the thyroid and the infected gland through surgery.

Hyperlinks

Need more information

Dr. Sampath Chandra Prasad Rao
MS, DNB, FEB-ORLHNS, FACS, FEAONO
Consultant ENT – Skull Base Surgeon
Manipal Hospital & Columbia Asia Hospital, Bangalore
Hon Visiting Assoc Professor,
Shanghai Jiao Tong University, China

Dr.Ganga J Kamath
MS,DNB,Diploma in Lateral Skull Base surgery,
Fellow in training ,BSBI,Bangalore.

Dr.Sohini Chakrabarti
MS-ENT
Consultant ENT-Skull Base Surgeon
Manipal Hospital & Columbia Asia Hospital, Bangalore

References:

  1. Kulkarni, Manik. (2013). Head and Neck Cancer Burden in India. International Journal of Head and Neck Surgery. 4. 29-35. 10.5005/jp-journals-10001-1132.
  2. Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck. Indian J Cancer 2020;57, Suppl S1:1-5
  3. Krishna Rao SV, Mejia G, Roberts-Thomson K, Logan R. Epidemiology of oral cancer in Asia in the past decade-An update (2000-2012). Asian Pac J Cancer Prev 2013;14:5567-77.
  4. Bhattacharjee A, Chakraborty A, Purkaystha P. Prevalence of head and neck cancers in the north east-An institutional study. Indian J Otolaryngol Head Neck Surg 2006;58:15-9.
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  7. Lohia N, Bhatnagar S, Singh S, Prashar M, Subramananiam A, Viswanath S, et al. Survival trends in oral cavity cancer patients treated with surgery and adjuvant radiotherapy in a tertiary center of
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  8. Prabhash K, Patil VM, Noronha V, Joshi AP, Bhattacharjee A, Mathrudev V, et al.  Nimotuzumab-cisplatin-radiation versus cisplatin radiation in HPV-negative oropharyngeal cancer.
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