Cancer, in short is an abnormality of the genetics of a cell that causes uncontrolled multiplication of cells that have lost their purpose. This damages surrounding cells and cancer cells can enter the blood and lymph systems to spread to other parts of the body.
When we talk about head and neck cancer we are referring to cancer that started in some part of the head and neck. The most common head and neck cancer sites are the skin of the face or scalp, the mouth including the tongue, the voice box (larynx) and thyroid gland. Other sites include the throat (pharynx) which has three parts, the nose and sinuses, the ear, and the salivary glands.
Most cancers in the head and neck start on the surface cells exposed to our environment. Exceptions to this are thyroid and salivary gland cancers. Cancer develops due to an interaction between genetically predisposed cells and carcinogens (cancer forming substances) over time. Our genetic risk is like a loaded gun, but it is our lifestyle that pulls the trigger.
For example, sun exposure in fair skin has a higher probability of causing skin cancer than someone who is dark skinned or uses sunscreen. A person who smokes or drinks alcohol and has a parent who died from tongue cancer has a higher risk than someone who doesn’t smoke and drink without a family member who has had cancer.
It is difficult to predict how much of these most common carcinogens (sun exposure, smoking, excess alcohol consumption and certain viruses) there has to be before getting cancer, but in general, the longer/more the exposure the greater the risk. We are all on a spectrum of susceptibility.
Stopping the carcinogen exposure before cancer develops reduces the risk of getting a future cancer. It is also important that if head and neck cancer is diagnosed then the relevant carcinogen is stopped, because this affects the chances of whether cancer can be beaten or not.
Any time someone has a swelling, an ulcer somewhere, pain, difficulty swallowing or bleeding in the head and neck area that doesn’t get better within a month, should seek help. For any head and neck complaint an ENT doctor (Ear Nose and Throat surgeon) is the best person to see because of their ability to examine the nooks and crannies of the head and neck.
Any doctor who suspects or has confirmed cancer should refer the patient to a head and neck surgeon who is usually an ENT, general surgeon or maxillofacial surgeon with special interest and training in head and neck cancer.
The best cancer results are seen when the head and neck surgeon is part of a multidisciplinary team who meet regularly and where there is shared decision making.
The primary goals we often ask our patients to align with are: 1. get rid of the cancer, 2. prevent it from ever coming back and 3. maintain a good quality of life. If these are not the primary goals for the patient and their family, we will adjust accordingly.
There are generally three stages of the cancer fight. The first stage is the investigation and planning stage. The second stage is treatment and the last stage is surveillance. The head and neck surgeon must be thought of as the captain of the ship where if there is any confusion or concern at any stage, there is one person to come to for clarity.
After thorough questioning and a thorough examination, if the head and neck surgeon suspects cancer, a biopsy of some kind will need to be taken to confirm cancer. This can be a needle biopsy of a neck lump or a biopsy of an ulcer under local anaesthetic, sometimes general anaesthetic in hospital.
Certain other tests, usually radiological imaging of some kind will also be requested. This helps the surgeon to stage the cancer correctly which gives the patient and doctor an idea of just how difficult the fight is expected to be. Staging the cancer accurately also guides the team to know what treatment to recommend.
Once the head and neck surgeon has all the necessary information, a multidisciplinary team meeting is held, where all options are considered to reach our primary goals. Members of the team include head and neck surgeons, radiation oncologists, medical oncologists, reconstructive and plastic surgeons, maxillofacial surgeons, maxillofacial prosthodontists and oral hygienists, radiologists, pathologists, nuclear physicians, ICU physicians, anaesthesiologists, dieticians, speech and swallow therapists, palliative care physicians and psychologists.
A plan will be proposed and presented to the patient and their family and determined if their goals can be achieved with that plan. If not, adjustments are made. Some of the team members such as the reconstructive surgeon, the dental team, the dietician, or the swallow team may need to be seen by the patient prior to the start of either surgery or radiation, which can be time consuming but is very important in order to reach everybody’s goals and avoid future problems.
The dietician is so important because even when we don’t have cancer, we all have a degree of nutritional deficiency. This is especially worse when we have cancer. The dietician will guide cancer patients to give our body what we need to fight the cancer fight well. This is often advice about what real food to eat or may involve supplements or artificial feeding via tubes if patients are not able to swallow on their own.
The dental team is focused around keeping mouth functioning optimally during and after cancer treatment. Surgery and radiation affect mouth function differently and the value of dental care to quality of life cannot be overstated.
Cancer of the head and neck can also affect speech and swallow function, therefore awareness about what to do to optimise these critical aspects of daily living, is provided by speech and swallow therapists. Once again managing patients in this regard before, during and after cancer treatment provides the best outcomes long term.
Early cancers are relatively simple to treat and often have good outcomes. Advanced cancers are more complicated to treat and have poorer outcomes. The tools in our belt to achieve our goals of cancer cure are usually surgery, radiation, chemotherapy, immunotherapy or a combination of any of the above. We sometimes think of the cancer fight as a series of battles in order to win the war.
Surgery is an effective and often the best way to cure head and neck cancer. If the cancer is advanced and the risk of recurrence is high, then radiation after surgery will be recommended, but if the cancer is early and it has been completely surgically removed, no further treatment is often necessary. With early disease, radiation on its own upfront, is frequently an equally successful treatment option, but with a different set of risks. Sometimes, certain advanced cancers can be cured with chemotherapy and radiation given together without surgery. Chemotherapy with radiation makes the radiation work better, but is more toxic. Chemotherapy or immunotherapy is not given on its own if cure is intended. Surgery, radiation, chemotherapy or immunotherapy on their own are options for palliation, where cure is not intended or possible.
Surgery would involve a careful discussion before the operation regarding risk under anaesthesia, and a physician may need to be consulted if the risk is thought to be high. The anaesthesiologist manages the risk intra-operatively and an internal medicine physician or ICU physician will do the same post operatively. Some patients need to be in ICU post-operatively for a few days for monitoring. Depending on the patient’s risk and the nature of the disease, patients can be sent home on average after 1-5 days.
The goal of surgery is to remove all cancer with a margin of safety, without damaging important structures in the head and neck. In general, important structures involve muscles, nerves, arteries and veins. We look for and protect these structures, moving them out of the way unless of course cancer has damaged them which requires us to remove them in order to get the cancer all out. This is another important reason why we like to treat cancer early, because the collateral damage is less. Accidental damage to important structures can result in functional impairment of some kind but in the hands of a skilled and experienced surgeon, the utmost care is given to work around them as far as possible. Often surgery involves getting all the cancer out where it started and also where the cancer has spread to (or will likely spread to) in the neck lymph nodes.
Plastic and reconstructive surgery is sometimes necessary to either improve the chance of healing, improve functional outcomes or maintain cosmetic appearance. These surgeons use different techniques to move tissue from somewhere else in the body, to fill the space the head and neck surgeon creates having removed the cancer. The most common technique they employ are flaps; either regional, close to the operated site, or microvascular free flaps from distant sites of the body such as the leg or arm.
If indicated to try prevent the cancer from coming back, radiation usually starts between three to six weeks after surgery, once most of the surgical healing has occurred.
Radiation works by damaging the DNA of rapidly dividing cancers cells, and once damaged, they cannot recover and therefore die. Radiation also damages other healthy rapidly dividing cells, but these cells recover, though sometimes imperfectly resulting in long term side effects, such as swallowing difficulty or dental problems. The early side effects from which most people completely recover are dry mouth, inflammation of the mouth and throat lining, changes in taste, weight loss and tiredness. It is the total dose of the radiation that is necessary to kill cancer, but this dose needs to be given over a period of time otherwise the side effects cannot be tolerated. The 10-20 minute treatment is given every day from Monday to Friday on a machine at the oncology centre with rest over the weekends for 6-7 weeks.
For reasons we sometimes don’t fully understand, treatment might not work and then surgery is considered as salvage if possible. This type of surgery is not desirable because it is associated with more complications and trouble with healing.
Whether the primary treatment was surgery, radiation, or both, regular follow ups with the head and neck surgeon are necessary to assess the success of treatment.
Usually about 6 -12 weeks after treatment a clinical examination and some sort of imaging is considered. We may use neck ultrasounds, CT scans, MRIs or combinations thereof. The effects of radiation can last for many months. If radiation was part of the treatment, we consider a PET CT scan at 4-6 months after completion of the treatment.
We use a combination of examination, imaging and team discussions to make the wisest decision regarding the success of treatment. We don’t rely on only one piece of information.
The risk for most head and neck cancers coming back is highest in the first two years and regular follow ups, depending on the patient and the disease are indicated every 2-3 months. After two years, the regularity of visits decreases and after 5 years if the cancer has not returned, we consider that person cured.
Palliative care physicians are important to help patients experience their symptoms as well as possible and include pain management, wound dressings, social and emotional support.
We acknowledge that every person experiences health troubles differently, but know that the cancer fight is unique and affects the whole family. We aim to maintain quality of life and reduce suffering to as little as possible, but also believe another noble goal is to help our patients fight well, independent of the eventual outcome. It is also important who we become in difficult times and how we impact the lives of those we love rather than whether we die from cancer or another cause in the future.
The people who often fight the best fight are those: with a positive mindset having hope in the future; who intentionally think about doing something every day to be healthier; and who are emotionally vulnerable with loved ones, accepting the support they provide. Patients themselves and carers of cancer patients are vulnerable to emotional strain and should not be afraid to ask for help.
