Head and Neck Cancers are the most common cancers in developing countries. Also, they are more common in men compared to women. Among all of them, Oral Cancer is the most common Head and Neck Squamous Cell Cancer (HNSCC). HNSCC in the developing world differs in terms of age, site of disease, etiology, molecular biology, poverty, illiteracy, advanced stage at presentation, lack of access to health care, and poor treatment infrastructure pose a major challenge in the management of these cancers.
India’s global contribution of Head and Neck Cancer patients is 57.5%. Over the years, owing to increased use of tobacco, India now contributes to nearly 60% of Head and Neck Cancer patients worldwide. The number is expected to double by 2030. According to the National Cancer Registry’s data, Ahmedabad tops the chart for Oral Cancer. Cancers that are known collectively as Head and Neck Cancers usually begin in the squamous cells that line the mucosal surfaces inside the head and neck (for example, inside the mouth, nose, and throat). These squamous cell cancers are often referred to as squamous cell carcinomas of the head and neck. Head and Neck Cancers can also begin in the salivary glands, thyroid gland, and skin, but these cancers are relatively uncommon.
They are further categorized by the area of the head or neck in which they begin:
Oral cavity: Includes the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips (Buccal mucosa), the floor (bottom) of the mouth under the tongue, the hard palate (bony top of the mouth), and the small area of the gum behind the wisdom teeth.
Pharynx: The Pharynx (or throat) is a hollow tube about 5 inches long that starts behind the nose and leads to the esophagus. It has three parts:
- Nasopharynx – the upper part of the pharynx behind the nose
- Oropharynx – the middle part of the pharynx including the soft palate, base of the tongue, tonsils and Pharyngeal walls
- Hypopharynx – the lower part of the pharynx just above Esophagus
Larynx: The Larynx, also called the voice box, is a short passageway formed by cartilages in front of the Pharynx in the neck. It contains the vocal cords, a small piece of tissue called the Epiglottis, which moves to cover the larynx to prevent food from entering the air passages.
Nose and Paranasal Sinuses: Cancers in the nose and surrounding sinuses are uncommon, but it often presents with advanced stage involving orbital contents (eyeballs and its muscles) or the area lower to the brain (skull base).
Salivary glands: The salivary glands are responsible for producing saliva. The major salivary glands are paired parotid and submandibular glands. The minor glands are in the oral cavity.
Thyroid gland: It is a butterfly-shaped endocrine gland in front of the Larynx and Trachea which is important to produce and maintain thyroid hormones in the body.
Skin cancers: Skin cancers of scalp, face and neck are more common in Australia and coastal areas or in people who are more exposed to sunlight.
Alcohol and tobacco use (including smokeless tobacco, sometimes called “chewing tobacco” or “snuff”) are the two most important risk factors for Head and Neck Cancers, especially cancers of the oral cavity, oropharynx, hypopharynx, and larynx. At least 75% of Head and Neck Cancers are caused by tobacco and alcohol use. People who use both tobacco and alcohol are at greater risk of developing these cancers than people who use either tobacco or alcohol alone. Pan Masala and Areca nut chewing are also associated with oral cancers. It is highly recommended for tobacco users to self-examine the oral cavity regularly in the mirror as it could help in the early diagnosis or prevention of these cancers.
The symptoms of Head and Neck Cancers may include a non-healing ulcer in the mouth, sore throat/pain that does not go away, difficulty in swallowing, and a change or hoarseness in the voice. In advance stage, Head and Neck Cancer metastasize to neck nodes and present with neck lump/mass. These symptoms could also be caused by other, non-cancerous conditions. It is important to check with a doctor about any of these symptoms.
The symptoms that may affect specific areas of the head and neck include:
- Oral cavity. Non-healing ulcers for more than 3 weeks, white or red patches on the gums or tongue or lining of the mouth, poorly fitting dentures, progressive decrease in the mouth opening, unusual bleeding or pain in the mouth.
- Pain while swallowing food, pain in the neck or the throat that does not go away, long-standing earache, difficulty in speaking, a lump in the neck.
- Change in voice, difficulty in breathing, pain while swallowing or ear pain, lump in the neck.
- Nose and PNS: Long-standing unilateral nasal blockage, frequent nasal bleeds, loss of sense of smell, swelling and loss of sensation below eyes, lump in the neck.
- Salivary glands: Lump at the front of the ear or under the chin or around the jaw bone, numbness or paralysis of the muscles in the face, pain in the face or the chin or the neck that does not go away.
The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person’s age and general health. Treatment would be with curative intent or palliative intent in very advanced cases just to control pain and supportive measures to maintain the quality of life. Treatment for Head and Neck Cancers can include surgery, radiation therapy, chemotherapy, targeted therapy, or a combination of treatments. Surgery remains the mainstay treatment option for most Head and Neck Cancers followed by adjuvant treatment either by radiation or chemo-radiation. Recent advances in the form of plastic reconstructive and microvascular surgeries help patients to minimize the disability to chew, swallow, talk, and disfigurement.
Organ preservation treatment in the form of radiation or chemo-radiation is often preferred for Pharyngeal and Laryngeal Cancers. Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth, a dry mouth or thickened saliva, difficulty in swallowing changes in taste, or nausea. It is very essential to rehabilitate the patients for speech and swallowing which affects the quality of life.
Regular follow-up care is very important after treatment for head and neck cancer to make sure that cancer has not returned, or that a second primary (new) cancer has not developed. All patients are called for monthly follow-up for the first year and then the follow-up duration increases for an upcoming couple of years.
The earlier the diagnosis and treatment, the better the outcome and disease-free survival. If cancer is being diagnosed in the first stage, chances of survival are almost around 90-100% for the long term. But the same decreases with an increased or advanced stage of the disease to around less than 40-50%.
The writer, Dr. Shashikant Limbachiya is a Head & Neck Cancer Surgeon at Narayana Multispeciality Hospital, Ahmedabad..