Overview
Cancers that arise in the mouth and tongue, the pharynx, larynx and sinuses together account for approximately 5% of all cancers. Each year across Europe this amounts to about 120,000 cases. Although there are a number of different head and neck cancers, the treatment is similar for many of them - with radiotherapy being an important treatment modality.
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Key Figures
According to Cancer Research UK, for men over 80 the incidence of oral cancer has halved since 1975. For men in their late 60s and 70s, incidence rates have remained relatively stable.
However, there have been large increases in the incidence of oral cancer diagnosed in men in their 40s and 50s. These rates have doubled from 3.6 to 8.8 per 100,000 for men aged 40-49 and from 11.5 to 24.9 for men aged 50-59.
Rising trends of oral cancer in young and middle-aged men (particularly of cancer of the tongue) have been reported in other European countries and the USA.
In Sri Lanka, India, Pakistan and Bangladesh, oral cancer is the most common cancer in men and may account for up to 30% of all new cases of cancer compared to 3% in the UK and 6% in France.
Within the EU, the highest oral cancer incidence rates for males are found in France and Hungary and the lowest rates in Greece and Cyprus.
Female oral cancer incidence rates are lower, with the highest rates in Hungary, Luxembourg and Germany.
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Cancer of the Oral Cavity
Oral cancer includes cancers of the lips, the buccal mucosa, gums, the front two-thirds of the tongue and the floor and the hard palate.
There are several types of cells found in the mouth which give rise to different types of cancer. However, most are squamous cell cancers.
There are two associated oral conditions - leukoplakia and erythroplakia - which are not cancer but can give rise to cancer. If present they require further investigation (a biopsy). Leukoplakia is a white patch on the mucosa and erythroplakia is a raised red area that bleeds easily if scraped.
25% of leukoplakia cases develop into cancer. However, treatment at this early stage is simple and effective at preventing oral cancer. Erythroplakia is usually more serious with up to 70% of cases giving rise to cancer.
Squamous Cell Carcinomas
Over 90% of mouth cancers are squamous cell cancers and develop from a single abnormal cell. In the early stages, the cancer cells are present only in the top layer of cells called the epithelium (carcinoma in situ). Left untreated, the cancer cells spread into deeper layers of the oral cavity making the treatment required more extensive.
Verrucous carcinoma is another, much less common, type of squamous cell carcinoma. It rarely spreads to other parts of the body but does invade surrounding tissue. The best treatment for this sort of cancer is surgical removal.
Salivary gland cancers can develop in small glands that are found throughout the lining of the mouth and throat and on the tongue. These are adenocarcinomas and are very rare tumours.
Lymphomas can develop in the tonsils which are found at the back of the mouth and the base of the tongue which both contain lymphoid tissue. More information on lymphomas is available in the lymphoma section of this website.
As with most cancers, the earlier the diagnosis is made the better the prognosis.
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Oral Cancer Risk Factors
Oral cancer mainly affects people over the age of 50.
The main risk factors for developing oral cancer are:
- Smoking, especially combined with heavy alcohol consumption
- sun exposure to the lips
- infection of the mouth with the Human Papilloma Virus (HPV)
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Symptoms of Oral Cancer
Often there are no symptoms and cancers are detected by dentists and other health professionals during routine examinations.
Symptoms can include:
- a painless ulcer that fails to heal
- pain numbness or soreness in the mouth
- a red or white patch in the mouth - leukoplakia and erythroplakia respectively
- a lump or thickening in the mouth
- unexplained bleeding
- loose teeth
- a lump in the neck
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Oral Cancer Diagnostic Tests
A biopsy of any abnormal area or lump is required to make a definite diagnosis of oral cancer.
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Cancer of the Pharynx
The pharynx is the cavity inside the neck, starting behind the nose and ending at the top of the larynx and oesophagus. It is sometimes divided into the nasopharynx (the upper part of the throat behind the nose), the oropharynx (the middle part of the pharynx), and the hypopharynx (the lowest part of the pharynx).
Several types of cancers can develop in the pharynx, including:
All these cancers arise from squamous cells and the treatment for them is usually the same.
Lymphomas can also develop in the pharynx. More information on lymphomas is available in the lymphoma section of this website.
Adenocarcinomas can also develop from salivary gland tissue including the numerous small salivary glands found throughout the lining of the mouth and throat and on the tongue. However, these are comparatively rare tumours.
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Causes of Pharyngeal Cancer
The cause of pharyngeal cancer is not known, however, these are thought to be related:
- diet - the cooking of salt-cured fish and meat, and a diet lacking in fruits and vegetables, which is common in some parts of Asia and is thought to increase the risk
- the Epstein-Barr virus may also be linked to an increased risk of pharyngeal cancer
- tobacco use, both smoking and chewing tobacco
- excessive alcohol
- poor dental hygiene
- human papilloma virus (HPV)
- exposure to asbestos
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Types of Pharyngeal Cancer
Several types of cancers develop in squamous cells in the pharynx:
Other tumour types are:
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Symptoms of Pharyngeal Cancer
Symptoms of pharyngeal cancer can include:
- A lump in the neck that does not go away after several weeks
- Hearing loss, just on one side
- A blocked nose, particularly if just on one side
- Blood stained discharge from the nose
- Headache
- Numbness of the lower part of the face
- Difficulty with swallowing
- Changes in voice, such as hoarseness
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Pharyngeal Cancer Diagnostic Tests
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Cancer of the Larynx
The larynx has a cartilage framework which supports the vocal cords. The larynx is covered in moist squamous cells which can become malignant. Laryngeal cancer most commonly develops on the vocal cords.
Cancer of the larynx most commonly develops from skin-like cells on the vocal cords and is a squamous cell carcinoma.
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Causes of Laryngeal Cancer
- Age: cancer of the larynx is more common in older people - very few cases are in people under 50 years of age
- Drinking alcohol and smoking are the main risk factors for cancer of the larynx
- poor diet
- a weakened immune system
- exposure to chemicals, sawdust and soot
- acid reflux
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Symptoms of Laryngeal Cancer
Symptoms of laryngeal cancer include:
- hoarseness or other voice changes
- difficulty in swallowing
- sensation of a lump in the throat
- Less commonly, bad breath and shortness of breath can occur
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Laryngeal Cancer Diagnostic Tests
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Cancer of the Sinuses
There are a number of sinuses in the skull, above the eyes (frontal sinuses), behind the nose (ethmoid sinuses) and in the bones of the cheeks (maxilliary sinuses).
The sinuses are lined with cells that produce mucus to moisten the air we breathe in. They also give tone to our voices. Sinus cancer is generally rare in Western countries, but is more common in parts of Asia and Africa. It is very rare in people under 40 and affects men more often than women.
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Causes of Sinus Cancer
The exact causes of sinus cancer are not known.
Risk factors include:
- using snuff for many years
- exposure to sawdust or soot
- smoking
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Symptoms of Sinus Cancer
The symptoms of sinus cancer are:
- a feeling of being “blocked up” which does not clear
- pain behind the nose, above the eyes or in the upper teeth
- swelling around the eyes
Less common symptoms include:
- numbness in parts of the face
- nosebleeds
- headaches
- double vision
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Sinus Cancer Diagnostic Tests
Sinus cancer is diagnosed using a number of special tests including:
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Prevention of Head and Neck Cancers
Stopping smoking and avoiding heavy alcohol consumption are the two most important steps anyone can take to reduce the risk of developing these cancers. Carpenters and other people exposed to wood and other forms of dust should take steps to reduce the amount of dust in the air and wear masks to prevent inhalation of potentially harmful dusts.
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Treatment of Head and Neck Cancers
Before deciding on the best treatment for a patient, the clinical team need to know exactly what sort of cancer they are dealing with, its size and whether it has spread from its original site.
The staging of head and neck cancers is complicated because there are a large number of different cancers and for each there are different criteria for assessing how developed it is.
In general:
- Stage I and II cancers are small, have not spread from where they started and are usually curable
- Stage III cancers have spread to nearby tissues and/or to local lymph nodes
- Stage IV cancers have spread to other areas of the body. For this reason, surgery may not be the best treatment option.
Treatment for head and neck cancers usually involves a multidisciplinary team including one or more surgeons, a radiation oncologist, a medical oncologist and other health professionals specialising in helping patients with speech, swallowing and other related difficulties.
The principle underlying all treatments is to cure the patient and where possible to preserve the affected areas (for example the larynx or tongue). This usually involves more than one form of treatment. Where surgery is used to remove a tumour, radiotherapy and chemotherapy will be used to prevent it coming back. Where surgery is not possible, as too much tissue would be removed and it would no longer be possible for the patient to carry out important functions, a combination of radiotherapy and chemotherapy is likely to be the best treatment option.
Surgery
Surgery is used where possible, depending on the position of the cancer and whether or not it has spread into the surrounding area of lymph nodes. Surgery can sometimes be quite extensive and in some cases skin grafts or flaps and other forms of plastic surgery are needed.
Chemotherapy
This is the use of drugs to destroy cancer cells. Although chemotherapy is helpful for many cancers, it is not very effective for sinus cancer and is only used occasionally.
Chemoradiation - Concurrent Chemotherapy and Radiotherapy
When given at the same time, the combined effect of radiotherapy and chemotherapy together is more effective in treating head and neck cancer than when given separately. It is particularly useful for patients for whom surgery is inappropriate or carries high risks.
Monoclonal Antibody Therapy
Monoclonal antibody therapy uses antibodies made in large numbers in a laboratory to identify and block specific receptors of cancer cells. Over the past ten years, a number of monoclonal antibodies have been developed to treat many different types of cancer.
One of the most important receptors in this type of cancer is epidermal growth factor. Cetuximab is a monoclonal antibody used to block this receptor and in combination with radiotherapy is very active in the treatment of head and neck cancers.
Radiotherapy
There are a number of ways of delivering radiotherapy. Most use radiation sources outside the body generated by a linear accelerator (Linac).
From the patient’s perspective, treatment involves lying on a couch underneath a linear accelerator, which looks a bit like a large X-ray machine. The linear accelerator is a source of powerful X-rays. Electrons produced in the machine are accelerated in a straight line, hitting a metal target within the machine. This produces high energy X-rays, which are then focused into a beam that can be used for treatment.
The X-ray beam itself is generated in a linear accelerator, the treatment head rotates around the patient. Scanning machines are used to ensure that the radiation is correctly targeted before each treatment and lasers are used to check that the patient is in the proper position. The linear accelerator can deliver radiotherapy from any angle by rotating the treatment head and moving the treatment bed.
The shape of the radiation beam used to treat the cancer is shaped to the cancer itself, using an attachment called a multi-leaf collimator. A number of metal sheets are used to block the beams from reaching areas where there is no cancer, whilst still allowing the radiation beams to target the area of the cancer. Therefore, a high dose of radiation is given where it is needed whilst at the same time healthy surrounding tissues are protected, thus reducing side effects.
Intensity Modulated RadioTherapy (IMRT) is a more advanced form of treatment. It uses computer-controlled machines to deliver precise doses of radiotherapy to a specific area where there is a cancer. By building a precise 3D image of the tumour, the radiotherapy is made to conform precisely to the shape of the tumour. Controlling the intensity of the radiation beam to focus on the cancer minimises exposure of surrounding normal tissues to radiation.
This allows the use of higher and more effective radiation doses. Currently, IMRT is being used to treat head and neck cancers.
Radiotherapy Side Effects
Radiotherapy treatment does cause some side effects. In the treatment of head and neck cancers, radiotherapy often causes:
- a sore and dry mouth
- difficulty in eating
- sometimes dry eyes and irritation
- headaches
These side effects are common but will not affect everyone. Many of these side effects can be effectively treated and will usually reduce gradually once the treatment has finished.
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Prognosis
Oral Cancer
The prognosis for patients with oral and oropharyngeal cancers varies depending on the stage of the disease and the location of the tumour.
According to the American Cancer Society, 83% of patients who have early-stage cancer of the lip survive five years from the time of diagnosis and 47% of those with late stage disease live for five years or longer.
For mouth cancer found in other places in the oral cavity, the five year survival rate is 68% for early stage cancer and 27% for later stage cancers.
Pharyngeal cancer
For those with pharyngeal cancer, the survival rates are 57% for early stage disease and 30% for later stage cancers.
Laryngeal cancer
The prognosis depends on a number of factors including the stage of the disease, the size and location of the tumour, and the patient’s age and general health.
Patients with early stage cancers are cured in over 75% of cases. Late stage cancers that have metastasised to other areas of the body have a poor prognosis.
Cancer of the Sinuses
The prognosis depends on the stage the cancer has reached at the time of diagnosis. Five year survival rates for patients with sinus cancer range from 11% for people with advanced cancers to almost 100% for people with very small cancers that are diagnosed and treated in the very early stages.
Key Trends and Current Developments
- Human Papilloma Virus (HPV) appears to be associated with more oropharyngeal cancers in women, and the prognosis for this form of cancer seems to be better.
- Treatment with monoclonal antibodies is increasing.
- The importance of quality of life issues in deciding on the most appropriate treatments.
- Refining treatments to improve organ sparing strategies.
- The use of genomics to determine which patients will benefit from specific treatments.
- Improving strategies for local control of cancer and treatment of metastatic disease.
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