Understanding Head and Neck CancersDownload this book (au/, 25.62 kb)
Head and neck cancers: treatment
Head and neck cancers are treated differently depending on their location and size. Surgery, radiotherapy or chemotherapy, or a combination of these treatments are used to treat the cancer.
Before recommending treatment, doctors determine how easy it is to access a tumour using surgery; the likely success of an operation; and whether surgery will cause major side effects. They weigh up the benefits and impacts of all the treatments, and also consider a person's general health.
- An advantage of surgery is that after the tissue is removed, it can be examined under a microscope to make sure all the tumour has been taken out and is surrounded by normal tissue (clear margins). This is done by a pathologist.
- The tissue can also give information about the stage of the cancer which helps doctors decide on further treatment.
- Surgery is generally the fastest treatment and can be repeated if the cancer comes back.
- Recovery usually depends on how large the cancer is when diagnosed.
Radiotherapy and chemotherapy
- Radiotherapy may be given on its own or after surgery with/without chemotherapy, if the cancer is more likely to recur without these treatments.
- Usually, a course of radiotherapy can only be given once, and it takes about six weeks to recover.
- See the Understanding Radiotherapy and Understanding Chemotherapy pages for more information.
- Your medical team will help you decide what treatment to have.
How different cancers are treated
- Oral cancer -- Cancers of the oral cavity are commonly treated with surgery, then radiotherapy if required. Chemotherapy is sometimes used in combination with these treatments.
- Salivary gland cancer -- Surgery is done in most cases. This is usually followed by radiotherapy. Chemotherapy is not usually given unless the cancer has spread, and it may be offered as palliative treatment.
- Pharyngeal cancer -- This is usually treated with surgery or radiotherapy. If radiotherapy does not destroy all the cancer cells or if the cancer comes back, surgery may be performed. If surgery is done first, radiotherapy may be used afterwards to destroy any remaining cancer cells. Chemotherapy may also be offered, usually with radiotherapy.
- Laryngeal cancer -- Where possible, early laryngeal cancer is treated with either laser surgery or radiotherapy. For larger cancers, radiotherapy is usually combined with chemotherapy (chemoradiation). For advanced cancer, surgery is only used if the cancer comes back or it's not all killed by radiotherapy. Chemotherapy may be given first to ease the pressure on a person's airway while chemoradiation is being planned. Radiotherapy (with or without chemotherapy) will be given after surgery to reduce the chance of the cancer coming back.
- Nasal or paranasal sinus cancer -- These are commonly treated with surgery, followed by radiotherapy and/or chemotherapy.
Before treatment starts
Head and neck cancer treatment, particularly radiotherapy, can cause dental problems, but these can often be prevented.
Before starting cancer treatment you must see a dentist or oral medicine specialist for a thorough oral examination and to get an oral health care plan. The plan outlines if any dentistry work is needed to reduce the chance of future dental problems. A plan also helps you learn good oral health care before, during and after treatment.
The dentist will probably recommend that decayed or damaged teeth, and healthy teeth that will be affected by radiotherapy, are taken out. These teeth may be removed during cancer surgery or before radiotherapy.
Radiotherapy permanently affects tissue healing in the treatment area. In rare cases, it can cause scarring of the jaw, leading to the bone being exposed in the mouth (osteoradionecrosis or ORN). ORN can cause problems if you later need a tooth extraction or surgery to the mouth or jaw.
- Check if you are eligible to receive free or low cost public dental services provided by state and territory governments to Pensioner Concession Card and Health Care card holders.
- Have regular six-monthly dental appointments after your cancer treatment.
The aim of surgery is to remove cancerous tissue and preserve the functions of the head and neck, such as breathing, swallowing and speech, as much as possible. There are different ways surgeons can operate.
- The surgeons may only need to cut out a small area, which will include an area of healthy tissue around the tumour called a margin. If the operation is small, the healing is usually fast, with few long-term side effects.
- For more advanced cancer, an operation will be more extensive and will cause longer-lasting or permanent side effects.
Your doctors will discuss whether surgery is an option for you, and the best type of operation for you.
Surgery for early cancers may only take about one hour, but procedures for advanced cancers can take 6-12 hours.
Both are usually done under general anaesthetic. The doctors will discuss any short-term or long-term side effects that might occur. This will help you weigh up the advantages and disadvantages.
If a head and neck cancer has spread to the lymph nodes in your neck, or if there is a chance it will spread, your surgeon will probably remove the nodes. This operation is called a neck dissection or lymphadenectomy. In some cases, this may be the only surgery you have, as the primary cancer will be treated with radiotherapy.
Types of surgeries
- This is used for small and easily accessible cancers.
- An intense beam of light is used as a knife to make cuts in the cancerous tissue.
- Usually more precise and causes less bleeding than open surgery.
- Done as a day or overnight procedure. The tumour is examined under a microscope by pathologists to make sure it has all been taken out. If this isn't the case, you may need to have a second operation.
- Cuts are made through skin and tissue to access the tumour. Sometimes bone needs to be removed too.
- Surgery can leave scarring or significant changes to the face, mouth or neck, depending on the location of the tumour.
- If you have surgery for more advanced cancer, you may have reconstructive surgery at the same time as the main operation or at a later date.
- Surgeons use skin or tissue from another part of the body, or synthetic material (prosthesis), to rebuild the area.
- Many head and neck surgeons are experts in reconstructive surgery too, but the operation may be carried out by two teams if the reconstruction is done at the same time.
Endoscopic (keyhole) surgery
- May be an option for certain cancers that can be accessed through the nasal cavity.
- A thin, flexible tube with a camera and light (endoscope) is inserted into the nose or mouth, like in a nasendoscopy.
- An image is projected onto a screen so the surgeon can see more clearly.
- Tiny surgical instruments are used directly through the nostrils, and no external cuts need to be made to access the tumour.
Surgery for oral cancer
Very early cancers can be treated with simple day surgery to remove part of the tongue or mouth. This will heal without side effects in a few weeks. If the cancer is larger, surgery may be more extensive and may require a reconstruction to help you chew, swallow or speak. You may also need a neck dissection to remove lymph nodes if there is a chance of the cancer spreading.
Different types of oral surgery include:
- glossectomy - removes part of the tongue
- mandibulotomy - cuts through the lower jaw
- mandibulectomy - removes part/all of the lower jaw
- maxillectomy - removes part/all of the upper jaw (hard palate)
- transoral primary tumour resection - removes of the tumour through the mouth.
Surgery for salivary gland cancer
Some tumours found in the salivary glands are benign, but surgery is the same as for malignant tumours.
Most salivary gland tumours affect the parotid gland, which has two parts. Surgery to remove this gland is called a parotidectomy. Surgeons can often cut inside or under the jaw to reach the area but sometimes they need to cut through the jaw. Reconstructive surgery will restore any removed tissue.
The facial nerve, which controls movement and muscle tone in the face, runs through the parotid gland. It may be damaged during surgery or part of it may be removed if the cancer has grown around it. If the facial nerve is affected, the surgeons may be able to rejoin it using a nerve from another part of the body, often the leg (a nerve graft). If successful, this will improve movement and appearance on that side of the face.
If the cancer begins under the jaw or tongue, the entire gland will be removed, along with some surrounding tissue. Nerves controlling the tongue and lower part of the face may be damaged, causing some loss of function. If the cancer is in a minor salivary gland, in a paranasal sinus or the larynx, it may be removed with endoscopic surgery.
Surgery for pharyngeal cancer
Early pharyngeal cancers may be treated with either surgery or radiotherapy. If you have surgery, the surgeon will cut out the tumour and a margin of tissue, which is checked by a pathologist to make sure all the tumour has come out.
If the cancer is large or advanced, the surgery is often combined with radiotherapy and possibly chemotherapy. The surgery is more likely to be extensive and may require reconstruction. Often, lymph nodes will be removed from your neck to prevent the cancer spreading.
Different types of pharyngeal surgery include:
- pharyngectomy - removes part or all of the pharynx
- mandibulotomy - cuts through the lower jaw
- mandibulectomy - removes part or all of the lower jaw
- maxillectomy - removes part or all of the upper jaw
- laryngopharyngectomy - removes part or all of the voice box (larynx) and pharynx.
Surgery for laryngeal cancer
If the cancer is at an early stage, you may be offered laser surgery. If any of the margins are not clear, you may have more tissue removed in a second procedure. Your voice will recover over six months.
If the cancer has advanced, you may need open surgery. The surgeon will work with a speech pathologist to choose a type of operation that reduces the effect on your voice and ability to swallow.
Different types of laryngeal surgery include:
- Total laryngectomy - This removes the larynx and separates the windpipe (trachea) from the oesophagus. Without your vocal cords, you won't be able to speak naturally after this procedure, but you will work with a speech pathologist to learn ways to communicate.
- Partial laryngectomy - This takes out part of the larynx. It is a rare operation because laser surgery has become more common. You will keep part of your voice box and be able to speak but after surgery your voice may be hoarse.
If the thyroid gland is taken out (thyroidectomy) during surgery on the voice box, you will need to take thyroid medication for the rest of your life.
Surgery for nasal and paranasal sinus cancer
Your doctor may advise you to have surgery if the tumour isn't too close to your brain, eyes or major blood vessels. The aim of surgery is to remove all of the tumour and a small area of normal tissue.
There are various operations for cancers of the nasal cavity and paranasal sinuses - the type you have depends on the location of the tumour. Surgery
for paranasal sinus cancer, in particular, varies, depending on which sinuses are affected.
Different types of surgery for nasal cancer include:
- maxillectomy - removes part or all of the upper jaw, possibly including upper teeth, part of the eye socket and/or the nasal cavity
- craniofacial resection - removes tissue between the eyes, requiring a cut along the side of the nose
- lateral rhinotomy - cuts along the edge of the nose to gain access to the nasal cavity and sinuses
- orbital exenteration - removes the eye
- rhinectomy - removes part or all of the nose
- endoscopic sinus surgery - removal of part of the nasal cavity or sinuses through the nostrils, using an endoscope
- midface degloving - gaining access to your nasal cavity or sinuses by cutting under the upper lip, which means there will be no scar on the face.
Some people also have surgery to remove lymph nodes in the neck (neck dissection or lymphadenectomy).
Your surgeons will plan the operation carefully to avoid damaging healthy tissue. You may have a major operation, with cuts along the edge of the nose, or you may have endoscopic surgery or midface degloving so that no cuts are made to the face.
The surgeons will consider how the operation will affect your appearance, and your ability to breathe, speak, chew and swallow. If they have to remove part or all of your nose, you may get an artificial nose (prosthesis). This will be synthetic or made of tissue from other parts of your body.
Radiotherapy is the use of high-energy x-rays or electrons to kill or damage cancer cells so they can no longer grow and multiply. It can be used alone or with other treatment. Radiotherapy can be given in different ways, either externally or internally.
Before radiotherapy begins, the staff will see you to plan the treatment. You will have scans and you may need to be fitted for a mask to wear so that the same location is treated at each session. You will wear the mask for up to an hour in the planning session, but only for 5-40 minutes during treatment, depending on the location of the cancer. You can see and breathe through the mask.
- External beam radiation - This is the traditional (conventional) way radiotherapy is given. This form of treatment is common for oral, salivary gland, laryngeal, pharyngeal, nasal and paranasal sinus cancers. During treatment you will lie on a table while radiation is directed from a machine into your body. Treatment itself is painless and the medical team will try to make you as comfortable as possible. It is usually given daily as outpatient treatment, Monday to Friday, for 6-7 weeks. Many people are able to return to their usual activities 4-5 weeks after treatment ends.
- Intensity modulated radiation therapy (IMRT) - IMRT is a type of external radiation. It is more common for cancers of the tongue, larynx and paranasal sinuses. The radiation can be shaped around the tumour, which reduces possible damage to healthy tissue. This means a higher dose can be given than in conventional radiotherapy. You will have treatment for 1-6 weeks.
- Tomotherapy - This is a type of three-dimensional radiotherapy that allows the radiation beams to be shaped around a tumour more precisely. It is currently only available in Brisbane.
- Internal radiation - Also known as brachytherapy, this treatment is only occasionally used for oral cancers. Small tubes are inserted into and around the tumour while you are under a general anaesthetic. Radioactive material is then placed in the tubes. Your doctor will give you more information about this treatment.
Radiotherapy side effects
Many side effects of radiotherapy are temporary, and they will start to ease 2-3 weeks after treatment. However, some side effects may be present for a longer period of time or permanently.
Side effects depend on the location of treatment, how long you have treatment for, and the type of radiotherapy you have. If you have radiotherapy after surgery, it may worsen or intensify the side effects experienced after your operation.
Radiotherapy to the throat area may cause an underactive thyroid. Many people need to take thyroid medication after radiotherapy.
Before radiotherapy it is important to have a dental appointment to check for existing problems with your teeth and to have teeth removed if necessary. This is to reduce the chance of future dental problems.
Side effects may include:
- dry mouth
- dental problems
- thick saliva that feels like mucus
- damage to the jaw bone (osteoradionecrosis)
- difficulty swallowing
- blocked or swollen salivary glands
- difficulty opening te mouth fully (trismus)
- changes in sense of taste
- hair loss in the treated area (particularly facial hair)
- loss of sweat glands in the treatment area
- muscle weakness in the treatment area
- appetite loss
- weight loss
- nausea or gagging due to a build-up of phlegm
- an underactive thyroid gland (hypothyroidism)
- skin soreness, redness, burning or ulceration
- damage to sight or eye function
- inflammation in the mouth or throat (mucositis)
- thrush (white spots) in the mouth due to less saliva
The website www.eviq.org.au also has information for head and neck cancer patients about radiotherapy and its side effects.
Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs and newer "˜targeted' agents. The aim of chemotherapy is to kill cancer cells while doing the least possible damage to healthy cells. It can be given for different reasons:
- It is often used with radiotherapy - this is called chemoradiation, where the drug increases the effects of the radiotherapy.
- It may be given to try to shrink a tumour before surgery or radiotherapy. This is called neoadjuvant chemotherapy.
- Chemotherapy can be given after surgery, along with radiotherapy, to reduce the chances of the cancer coming back.
- It can also be given as a palliative treatment for symptom management. This aims to reduce pain or discomfort by stopping the cancer from growing and pressing on nerves and other tissue. See the next page for more information.
You will probably receive chemotherapy by injection into a vein (intravenously) at treatment sessions over several weeks.
Chemotherapy side effects
There are many possible side effects of chemotherapy, depending on the drugs that you are given. People rarely get all of the potential side effects, many of which are preventable and treatable. Chemoradiation may cause more severe side effects than if you have chemotherapy and radiotherapy separately.
The Cancer Institute's website www.eviq.org.au, also has information for head and neck cancer patients about chemotherapy and its side effects. Side effects may include:
- tiredness and lethargy
- nausea and vomiting
- tingling due to nerve damage
- taste changes
- poor appetite
- hair loss
- hearing loss
- an increased risk of infection
- mouth sores
- memory problems (chemo brain).
Palliative treatment helps to improve people's quality of life by reducing symptoms of cancer without trying to cure the disease. It is not just for end-of-life care and can be used at different stages of cancer. Often treatment is concerned with pain relief and stopping the spread of cancer, but it also involves the management of other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy or other medications.
Call the Helpline 13 11 20 for more information about palliative care, advanced cancer and cancer pain.