Introduction
Cancers can arise from the mouth and tongue (oral cavity), the back of the throat (pharynx), the voice box (larynx), and the sinuses. Each one of these cancers is uncommon, but together they make up approximately 7% of all cancers diagnosed each year. Across Europe, this amounts to about 120,000 cases. The treatments for all these cancers are similar, with radiotherapy being a very important part of many treatments.
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Cancer of the Mouth or Oral Cavity
Oral cancer starts in the mouth, which is often also called the oral cavity. This includes the lips, the lining of the inside of the mouth (the buccal mucosa), the gums, the front two-thirds of the tongue, and the floor and bony roof of the mouth (the hard palate).
There are several types of different cells found in the mouth, which give rise to different types of cancer, but the vast majority of cancers arise from skin-like cells and are called squamous cell cancers.
There are two associated oral conditions which are not cancer, but can give rise to cancer. They are leukoplakia and erythroplakia and if present, require further investigation. Leukoplakia is a white patch in place of the normal pink lining of the mouth. Erythroplakia is a raised, red area that bleeds easily if scraped.
If
leukoplakia or
erythroplakia are present, further analysis by an expert will be required. This may involve taking a small sample for testing in the laboratory.
Only one in four cases of leukoplakia develop into cancer, but treatment at this early stage is simple and effective at preventing oral cancer. Therefore, it is worth taking leukoplakia seriously and treating it accordingly. Erythroplakia is usually more serious, as up to 70% of cases will be an early form of cancer. There are several types of cancer that can start in the mouth or throat.
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Types of Oral Cancer
Squamous Cell Carcinomas
Over 90% of mouth cancers develop from cells very similar to skin cells. These are squamous cell cancers and they 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. This stage is often referred to as carcinoma in situ. Left untreated, the cancer cells spread into deeper layers of the oral cavity making the treatment required more extensive.
Verrucous Carcinoma
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 surgery to remove all the cancer cells.
Salivary Gland Cancers
These can develop in small glands that are found throughout the lining of the mouth and throat. These cancers come from gland cells and are called adenocarcinomas. These are very rare tumours.
Lymphomas
Lymphomas can develop in the tonsils which are found at the back of the mouth and the base of the tongue which both contain immune system (lymphoid) tissue. More information on lymphomas is available in the lymphoma section of this website.
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Causes of Oral Cancer
Most people diagnosed with oral cancer are over the age of 50. A number of factors can increase the risk of developing it:
- Smoking, especially when combined with drinking alcohol heavily
- Sun exposure to the lips
- Infection of the mouth with the human papilloma virus (HPV) may also be a risk factor for oral cancer
However many people develop oral cancer without having any of these risk factors.
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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 white or red patch in the mouth (leukoplakia and erythroplakia respectively)
- a lump or thickening of the mouth
- unexplained bleeding
- loose teeth
- a lump in the neck
These symptoms may be due to a number of different diseases, but anyone experiencing them should see their doctor quickly.
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Diagnosing Oral Cancer
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 back of the throat. Several types of cancers can develop in the pharynx, including:
All these cancers arise from the same type of cell, which is very similar to skin cells, and the treatment 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 develop from salivary gland tissue.
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Causes of Pharyngeal Cancer
The exact cause of pharyngeal cancer is not known. Diet may play some part - the cooking of salt-cured fish and meat, which is common in some parts of Asia, is thought to increase the likelihood of developing this form of cancer.
The Epstein-Barr virus may also be linked to an increased risk of pharyngeal cancer.
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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 in swallowing
- Changes in voice, such as hoarseness
These symptoms may be due to a number of different diseases, but anyone experiencing them should see their doctor quickly.
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Cancer of the Larynx
The larynx or voice box has a cartilage framework (the Adam’s apple) which supports the vocal cords. The larynx is covered in moist skin-like cells, and it is these cells that can become cancerous. Cancer of the larynx, or laryngeal cancer, most commonly develops on the vocal cords.
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Symptoms of Laryngeal Cancer
As most laryngeal cancers develop on the vocal cords, a common symptom is a change in voice, such as hoarseness.
In addition, there may be other symptoms such as:
- difficulty in swallowing
- bad breath
- a feeling that there is a lump in your throat
- shortness of breath
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Causes of Laryngeal Cancer
A number of factors may increase the risk of laryngeal cancer. These include:
- smoking (particularly in association with heavy alcohol consumption)
- a poor diet
- a weakened immune system
- exposure to chemicals, sawdust or soot
- acid reflux
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Cancer of the Sinuses
There are a number of sinuses in the skull, above the eyes, behind the nose and in the bones of the cheeks. They are lined with cells that produce mucus to moisten the air we breathe in and they 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 the age of 40 and affects men more often than women.
Causes of Sinus Cancer
The exact cause of sinus cancer is unknown but smokers and people who are exposed to dust are more likely to develop sinus cancer.
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Syptoms of Sinus Cancer
The symptoms of sinus cancer are similar to those of sinusitis and include:
- 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
In some cases, there may be numbness in parts of the face. The patient may experience nosebleeds, headaches and, more rarely, double vision.
These symptoms may be due to sinusitis, cancer of the sinuses, as well as other conditions. However, anyone with these symptoms should seek medical advice as a priority.
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Diagnosing Sinus Cancer
Sinus cancer is usually diagnosed by a number of special tests which may include:
- X-rays, which may show where the problem is and often that the sinus is blocked
- CT (computerised tomography) scan which provides a 3D picture, used to find the exact site of the cancer or to check for any spread of the cancer
- MRI (magnetic resonance imaging) scan, which also provides more detailed images of parts of the body
- endoscopy which allows your doctor to look inside the nose, at the vocal cords and also to take small samples for examination in the laboratory
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Treating Head and Neck Cancers
Before deciding on the best treatment for your cancer, your doctors need to know exactly what sort of cancer it is, its size and whether it has spread from its original area. This process is known as staging. It involves having a detailed physical examination, followed by the taking of a biopsy, or sample of the cancer, so that its cells can be examined under a microscope, as well as a scan (usually a CT scan or MRI scan), which can show small areas of tumour that cannot be detected by ordinary examination.
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 choice.
Surgery
Surgery may be used, 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.
Radiotherapy
Radiotherapy is frequently used to treat head and neck cancers. Radiotherapy uses high-energy X-ray beams generated from machines to kill cancer cells. Some normal cells will also be affected, but the treatment is planned so that the radiation is focused on the affected areas from a variety of different angles. Normal tissues, therefore, receive a much smaller dose. Additionally, normal cells are better at repairing themselves than cancer cells.
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, and 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 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, but 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.
Radiotherapy treatment
There are a number of ways of delivering radiotherapy. Most use radiation sources outside the body generated by a linear accelerator (Linac).
Radiographers position the patient’s couch so that the target area is under the head of the Linac. The patient then has to lie as still as possible while the machine is switched on.
Treatment plans are drawn up for each patient. Exactly how much radiotherapy is required and the number of sessions it takes to deliver it will depend on a number of factors and will vary from patient to patient.
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 nausea and vomiting, dry eyes and irritation, a sore and dry mouth with difficulty in eating and 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.
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.
Concurrent chemotherapy and radiotherapy
When given at the same time (a concurrent therapy) the combined effect of radiotherapy and chemotherapy together, known as chemoradiation, is more effective in treating lung 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 10 years, a number of monoclonal antibodies have been developed to treat many different types of cancer.
One of the most important receptors for causing this 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.
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Looking after Yourself
Radiotherapy for cancers of the head and neck is highly effective for many patients but does cause a number of side effects, which can be unpleasant. Some patients will not experience any side effects, whilst others may find several troublesome.
Fortunately, many of these side effects disappear soon after the treatment ends and the symptoms can usually be treated, so if you do experience any problems it is important to mention them to your doctor or nurse, so they can give you the treatment you need.
Before treatment begins, you should stop smoking and avoid alcohol.
A dental check-up is advisable. Any tooth decay or infection in the mouth should be treated before treatment to prevent flare-ups after treatment has started. Mouth washes are also useful to keep the mouth clean.
During radiotherapy, loss of appetite and changes to how things taste can result in not eating properly. This is sometimes made worse by soreness in the mouth and difficulty in swallowing. Gargling aspirin can help the soreness, but other painkillers may also be needed. Some foods will be easier to swallow than others, and for some people, liquidised foods and high calorie supplements are the best way to ensure that all necessary nutrients are included in the diet. If swallowing is extremely difficult, a small tube can be temporarily passed into your stomach so you can be fed directly.
Your speech and language therapist and physiotherapist may also be able to help with exercises if you find swallowing difficult.
Dryness in the mouth occurs if the salivary glands are affected by treatment, which is helped by artificial saliva and drinking fluids with meals.
Like the salivary glands, the tear glands of the eyes can be affected by radiotherapy, causing dryness of the eyes. Usually the eyes are shielded and this problem is avoided, but eye drops can be given to keep the front of the eye moist, and so avoid soreness and pain.
Ears can also be painful if in the treatment area. Soreness of the ears usually responds to hydrocortisone drops or cream.
Treatment which involves the trachea can lead to some soreness and difficulty in breathing, which may require admission to hospital. There are a number of ways of treating these symptoms depending on the cause, but the sooner they are treated the better. Chest infections can also occur during treatment so any cough, particularly with sputum or a temperature, should be reported to your doctors straightaway.
Whatever the problem, do not assume that nothing can be done about it – ask your doctor or nurse: do not just grin and bear it.
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Questions for your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your own treatment centre and what they will involve, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you are able to make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits I might get?
- How good are my chances of getting those benefits?
- Could having the treatment make me feel worse? If so, in what way?
- Are there alternative treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
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Conclusion
There is no one solution to the management of head and neck cancer, but for clinical and personal reasons particular treatments will suit some patients better than others. Patients, therefore, need comprehensive information so that they are able to make the right decision for them.
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