Treatment for head & neck cancers

Monday 1 May, 2017

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On this page: Preparing for treatment | Surgery | Radiotherapy | Chemotherapy | Palliative treatment | Targeted treatment | Immunotherapy | Key points


The main treatments for head and neck cancers are surgery, radiotherapy and chemotherapy. You may have one of these treatments, or a combination. The treatment will depend on:

  • the type, size and location of the tumour
  • your age, medical history and general health
  • whether, and how far, the cancer has spread
  • the types of symptoms and side effects you experience.

Preparing for treatment

Treatment for head and neck cancers, particularly radiotherapy, can affect your mouth, gums and teeth. Before treatment starts:

See a dentist or oral medicine specialist

Have a thorough check-up and ask for an oral health care plan. The plan outlines any dental work you need before treatment starts, and also provides guidance on appropriate care before, during and after treatment. The dentist may recommend taking out any unhealthy teeth that might be affected by radiotherapy. These teeth may be removed during cancer surgery or before radiotherapy.

Start an exercise program

This will help build up the strength needed for recovery. Talk to your doctor about this.

Stop smoking before you have surgery

If you continue to smoke, you may not respond to treatment as well as people who don't smoke. Also, smoking may make side effects worse and increase the chance of a second primary cancer. See your doctor or call the Quitline on 13 7848 for support to quit.

Treatment options by type of head and neck cancer

Mouth (oral) cancer

Commonly treated with surgery. May be followed by radiotherapy alone or combined with chemotherapy (chemoradiotherapy).

Pharyngeal cancer

  • Treatment will depend on the type of pharyngeal cancer you have: nasopharyngeal, oropharyngeal or hypopharyngeal.
  • The options may include surgery, radiotherapy, chemotherapy, or a combination.

Laryngeal cancer

  • Early laryngeal cancer is treated with surgery or radiotherapy.
  • Advanced laryngeal cancer is sometimes treated with surgery first. Radiotherapy (with or without chemotherapy) is usually given after surgery to reduce the chance of the cancer coming back.
  • Surgery may be offered to people who have had radiotherapy if the cancer comes back or is not all destroyed by radiotherapy.

Salivary gland cancer

  • Surgery is the main treatment. This may include removing some lymph nodes.
  • Surgery may be followed by radiotherapy alone or in combination with chemotherapy (chemoradiotherapy).

Nasal or paranasal sinus cancer

  • Commonly treated with surgery, including removal of some lymph nodes.
  • Surgery may be followed with radiotherapy.

Surgery

The aim of surgery is to remove cancerous tissue and preserve the functions of the head and neck, such as breathing, swallowing and talking, as much as possible.

The types of surgical procedures used for the different head and neck cancers are described below. If surgery is minor, recovery is usually fast and there are often few long-term side effects. For more advanced cancer, surgery will be more extensive, lasting 12 hours or more, and often cause longer-lasting or permanent side effects. See the managing side effects section.

See Understanding Surgery or call Cancer Council 13 11 20 for more information.

Removing lymph nodes

If a head and neck cancer has spread to the lymph nodes in your neck, or if there is a chance the cancer will spread, your surgeon will probably remove some lymph nodes. This operation is called a neck dissection or lymphadenectomy.

Most often lymph nodes are removed from one side of the neck, but sometimes they need to be removed from both sides. A neck dissection may be the only surgery needed when the primary cancer will be treated with radiotherapy, or a neck dissection may be part of a longer head and neck operation. Removing the lymph nodes may affect the movement and appearance of your neck or shoulder (see lymphoedema).

How the surgery is done

If you have surgery for a head and neck cancer, different surgical methods may be used to remove the cancer. Each method has advantages in particular situations – your doctor will advise which method is most suitable for you. The options may include:

  • endoscopic surgery – uses telescopes and microscopes through the nose and mouth to remove cancers
  • trans-oral robotic surgery (TORS) – uses robotic arms to access areas through the mouth using standard surgical tools, or specialised tools incorporating laser or robotic technology
  • open surgery – involves making cuts in the neck or the lines of the face to access and remove cancers. Used for larger cancers and those in difficult positions. Bones of the upper and lower jaw or skull may need to be partially removed.

Endoscopic and trans-oral robotic surgery usually mean less scarring, a shorter hospital stay and faster recovery. However, open surgery may be a better option in many situations.

After open surgery, reconstructive surgery may be needed to restore functions such as eating, talking and breathing, and improve cosmetic appearance. Some people have reconstructive surgery at the same time as the surgery, others at a later date.

Reconstructive surgery may involve using skin, bone or tissue from another part of the body to rebuild the area. This is called a free flap. Occasionally synthetic materials such as silicone and titanium are used to re-create bony or structural areas. This is called a prosthetic reconstruction.

Surgery for oral cancer

The type of surgery will depend on the size of the cancer and where it is. Localised cancers can be treated by removing part of the tongue or mouth. There are often few side effects. If the cancer is larger, surgery may be more extensive and require reconstructive surgery to help you chew, swallow or speak.

Different types of oral surgery include:

  • glossectomy – removes part or all of the tongue
  • mandibulectomy – removes part or all of the lower jaw
  • maxillectomy – removes part or all of the upper jaw (maxilla)
  • mandibulotomy – cuts through the lower jaw to access a cancer in the throat or back of the tongue
  • trans-oral primary tumour resection – removes the tumour through the mouth.

Tony's story

"My dentist suspected I had a tumour in my oral cavity during a check-up for a painful wisdom tooth in my lower left jaw. A biopsy confirmed a squamous cell carcinoma. An x-ray, CT scan, ultrasound and PET scan showed the cancer had spread to my lower left jaw bone and the lymph nodes in my upper left neck.

"I had surgery to remove the tumour, the affected jaw bone and lymph nodes. Later my jaw was reconstructed with bone from my leg. I also had radiotherapy to my lower jaw and neck for six weeks.

"I recovered well. My only ongoing side effect is a dry mouth."

Tell your cancer story.

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 healthy tissue, which is checked by a pathologist to make sure all the cancer cells have been removed.

If the cancer is large or advanced, the surgery is often followed with radiotherapy and possibly chemotherapy. The surgery is more likely to be extensive and may require reconstruction.

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
  • aryngopharyngectomy – removes part or all of the larynx and pharynx.

Surgery for laryngeal cancer

Operations for laryngeal cancer may include removing the cancer through the mouth (endoscopic surgery), open surgery to remove the larynx (laryngectomy) and a neck dissection.

If the cancer is at an early stage, it may be removed through the mouth using trans-oral surgery with standard surgical equipment or laser or robotic surgery. It may take up to six months for your voice to recover. In some cases, there may be long-term or permanent changes to the pitch, loudness or quality of your voice.

If the cancer has advanced, you may need open laryngeal surgery. This will involve removing all of the larynx (total laryngectomy) or part of the larynx (partial laryngectomy).

Total laryngectomy

This operation removes the whole larynx and separates the windpipe (trachea) from the oesophagus. Without your vocal cords, you won't be able to speak naturally, but you will work with a speech pathologist to learn new ways to communicate.

If you have a total laryngectomy, your thyroid gland may be removed during surgery (thyroidectomy). Once the thyroid is removed, you will no longer produce thyroxine (T4), the hormone that maintains your metabolism, energy levels and weight. You will be prescribed an oral hormone tablet, which you will need to take daily for the rest of your life. Ask your doctor for more details.

Partial laryngectomy

This type of operation is used for small laryngeal cancers. A cut is made on your neck and the part of the larynx with the cancer is removed. This surgery is now rare as surgery through the mouth (endoscopic surgery) has become more common for small cancers.

After a partial laryngectomy you will keep parts of your voice box and usually be able to speak and swallow afterwards. However, your voice may be hoarse after surgery and you may have a tracheostomy tube inserted for a short time after the operation. See more details about breathing changes. Talk to a speech pathologist about ways to improve your ability to swallow and speak after surgery.

Surgery for salivary gland cancer

Most salivary gland tumours affect the parotid gland. Surgery to remove part or all of the parotid gland is called a parotidectomy. Some people with salivary cancer will also need a neck dissection.

The facial nerve, which controls expressions of the face and movement of the eyelid and lip, runs through the parotid gland. If this nerve is damaged during surgery, you may be unable to smile, frown or close your eyes. This is known as facial palsy, and it can take months to a year for movement to improve. In some cases, it may need to be repaired using a nerve from another part of the body, often from the leg (nerve graft). If the facial nerve is removed (facial nerve sacrifice), several procedures will help improve movement and appearance of the face.

If the cancer affects the submandibular gland or the sublingual gland, the 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, it may be removed with endoscopic surgery.

Some tumours found in the salivary glands are benign, but these are removed using the same surgical techniques.

"I was diagnosed with cancer after I felt recurring pain in my front left jaw. I had intrusive surgery, which meant my facial nerve was cut, causing paralysis in my face, but I am currently free of the cancer." – Geoff (salivary gland cancer)

Surgery for nasal or paranasal sinus cancer

Your doctor may advise you to have surgery if the tumour isn't too close to your brain or major blood vessels. The aim of surgery is to remove all of the tumour and a small area of normal tissue to obtain clear margins.

The type of surgery depends on the location of the tumour and, if you have paranasal sinus cancer, the affected sinuses.

Different types of surgery for nasal cancer include:

  • maxillectomy – removes part or all of the upper jaw (maxilla), possibly including the 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 – requires 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 – removes part of the nasal cavity or sinuses through the nostrils, using an endoscope
  • midface degloving – accesses your nasal cavity or sinuses by cutting under the upper lip, which avoids scarring of the face.

The surgeons will consider how the operation will affect your appearance, and your ability to breathe, speak, chew and swallow. If your nose, or a part of it, is removed, you may get an artificial nose (prosthesis). This will be synthetic or made of tissue from other parts of your body.

What to expect after surgery

The length of your hospital stay will depend on the type of surgery you have and how well you recover. The side effects listed below are often temporary. For more information about ongoing effects, see the managing side effects section.

Pain

At first, you will need some pain relief. You will have patient-controlled analgesia (PCA), which delivers a measured dose of pain relief when you press a button.

Drips and drains

You may have tubes at the surgery site to drain excess fluid.

Sore throat

This usually lasts for less than 24 hours, but may take longer if you were treated for pharyngeal or laryngeal cancer.

Breathing difficulties

If your mouth or tongue is swollen and breathing is difficult, the surgeon will place a breathing tube in your lower neck (tracheostomy). The tracheostomy is usually temporary.

Speech changes

Your ability to speak may be affected. Often this is temporary, but see changes to speech if this side effect is ongoing.

Dietary changes

You will usually start with fluids, move on to pureed food, and then soft foods. A temporary feeding tube may be inserted through your nasal passageway for a few days or weeks. Alternatively, a gastrostomy tube, known as a PEG feeding tube, may be inserted.

Julie's story

"My cancer was caused by the HPV virus. I hadn't drunk alcohol or smoked for over 30 years.

"The treatment from my multidisciplinary team sent the stage 4 cancer in my tonsils, throat and tongue into remission.

"For a month I had chemotherapy once a week and radiation every day. I had to wear a special mask to keep me totally still while the radiation treatment took place. It is called an "immobilisation mask". The mask keeps you safe by ensuring the radiation is delivered to the precise locations necessary.

"I found this aspect of the treatment challenging. I had never seen a mask like this and I had never heard about their purpose. A combination of listening to music, light sedation and support from a psychologist helped a great deal.

"I have to be honest, the side effects of treatment were tough. My capacity to swallow was limited to liquid food for some time, so I lost 20 kg in 6–8 weeks. I lost the capacity to talk for quite a few weeks, and used an iPad to communicate.

"But the result made the rigours of treatment absolutely worth the effort. I can talk and swallow, and I am back to work and the joy of daily life.

"I really recommend asking for help from speech pathologists, nutritionists, psychologists and senior nurses, as well as the medical team. Find a dentist who understands the effects of treatment and get advice for the health of your teeth long-term.

"Tell your trusted family members and friends what you need and ask directly for help."

Tell your cancer story.

Long-term side effects of treatment

After surgery or radiotherapy, many people have to adjust to significant changes. You may also see a speech pathologist and/or dietitian before surgery or radiotherapy to discuss these issues. Talk to your doctor about what to expect.

Breathing changes

After some types of throat surgery, the surgeon may need to help you breathe using a temporary tube in your neck. If you have a total laryngectomy, you'll need a permanent hole (stoma).

Taste and smell changes

If you have a craniofacial resection, you may lose the sense of smell, and your sense of taste will be affected. If you have a laryngectomy, air will no longer pass through your nose, which can affect your sense of smell.

Swallowing difficulties

Surgery may affect your ability to swallow. A speech pathologist can suggest modifications to the texture of your food and drink to make them easier to swallow. If you are having difficulty eating or drinking, you may be given a temporary or permanent feeding tube.

Speech changes

Changes to how clearly you speak and/or the quality of your voice depend on the surgery you had. A speech pathologist can provide strategies to help you adjust to these changes.

Appearance changes

Many types of head and neck surgery will cause temporary or permanent changes to appearance. You may feel distressed or embarrassed about these changes. A reconstructive surgeon is often able to make physical changes (such as scars) less visible. If you have lost teeth, they may be able to be replaced/reconstructed surgically.

Lymphoedema

If you have lymph nodes removed, you may experience persistent swelling in the soft tissue of the affected head and neck area.

Vision changes

If the cancer is in your eye socket, the surgeon may have to remove your eye (orbital exenteration). Your changed vision should not prevent you from continuing activities such as driving or playing sport, but it may take time to get used to – and accommodate – the changes.

Pain and physical discomfort

If you have lymph nodes removed, you may have numbness, reduced movement and/or pain in your neck or shoulder on the side of surgery. Sensation may gradually improve over 12 months and rehabilitation with a physiotherapist can help you regain movement.

Further information: See the managing side effects section.

Radiotherapy

Radiotherapy (also known as radiation therapy) uses radiation such as x-rays to kill or harm cancer cells so they cannot multiply. The radiation is targeted at the cancer, and treatment is carefully planned to do as little harm as possible to healthy body tissue near the cancer. Radiotherapy can be given externally or internally, but for head and neck cancers it is usually given externally.

It can be used on its own or in combination with surgery or chemotherapy:

  • before surgery (neoadjuvant), to shrink large tumours so they are easier to remove during surgery
  • after surgery (adjuvant), to reduce the chance of the cancer coming back by eliminating any cancer cells that may not have been taken out during surgery. You will probably start radiotherapy as soon as your wounds have healed and you've recovered your strength, usually within six weeks. Adjuvant radiotherapy is sometimes given together with chemotherapy (called chemoradiotherapy or chemoradiation).

External beam radiotherapy

External beam radiotherapy is common for treating oral, salivary gland, pharyngeal, laryngeal, nasal and paranasal sinus cancers.

The treatment can be delivered in different ways, including intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), and TomoTherapy. These techniques deliver radiation precisely to the affected area, which reduces treatment time and side effects.

Having external beam radiotherapy

Before radiotherapy starts you will be fitted for a plastic mask, called an immobilisation mask. Wearing the mask will help you keep still and ensure the radiation is targeted at the same area during each session. You can see and breathe through the mask, but it may feel strange and claustrophobic at first. During treatment, you will lie on a table under a machine called a linear accelerator. You will wear the mask for 5–15 minutes during treatment (longer during the planning session). Treatment itself is painless and is usually given Monday–Friday as outpatient treatment for 6–7 weeks. You will be monitored by the radiation therapist throughout. Let them know if wearing the mask makes you feel uncomfortable.

Side effects of radiotherapy

The side effects vary depending on the area treated, the number of treatments, the type of radiotherapy you have and whether it is combined with chemotherapy.

Side effects often peak in the final week of treatment, or shortly afterwards, then start to ease 2–3 weeks after treatment ends. Some side effects may last longer, be ongoing or appear several months or years later. The most common short-term and long-term side effects are listed below.

  • During or immediately after treatment – fatigue, mouth sores, dry mouth and thick saliva, skin redness and burning in the area treated, breathing difficulties, weight loss.
  • Ongoing or permanent – dry mouth, thick saliva, difficulties with swallowing and speech, changes in taste, fatigue, muscle weakness, appetite and weight loss, thrush, hoarseness, dental problems, difficulty opening the mouth, hair loss. Some people find that food and fluid goes into the windpipe. This is called aspiration and it causes obstruction and difficulty breathing. People who develop an underactive thyroid (hypothyroidism) may need to take thyroid medication after radiotherapy, see total laryngectomy.

See information about managing side effects. You can also see Understanding Radiotherapy or call Cancer Council 13 11 20.

Osteoradionecrosis

Radiotherapy to the head and neck can damage blood vessels, causing bone in the lower jaw to die and become infected. This is called osteoradionecrosis (ORN).

Having any necessary dental work done before treatment starts reduces the risk of ORN.

Treatment for ORN may include long-term antibiotic medicines or hyperbaric oxygen treatment. While you sit or lie in a pressurised chamber, concentrated oxygen is delivered to the bone to help it heal. Other treatment options include certain medicines and sometimes surgery.

Chemotherapy

Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells. You will probably receive chemotherapy by injection into a vein (intravenously) at treatment sessions over several weeks.

Chemotherapy may be given for a range of reasons:

  • in combination with radiotherapy (chemoradiotherapy), to increase the effects of radiation
  • before surgery or radiotherapy (neoadjuvant chemotherapy), to shrink a tumour
  • after surgery (adjuvant chemotherapy), along with radiotherapy, to reduce the risk of the cancer returning
  • as palliative treatment to relieve pain and improve quality of life.

Side effects of chemotherapy

Chemotherapy can affect the healthy cells in the body and cause side effects. Everyone reacts differently to chemotherapy, and effects will vary according to the drugs you are given.

Often, combined chemoradiotherapy causes more severe side effects than if you have chemotherapy and radiotherapy separately, but the side effects can be managed.

Common side effects include:

  • tiredness and fatigue
  • nausea and/or vomiting
  • tingling in fingers and/or toes (peripheral neuropathy)
  • changes in appetite and loss of taste
  • diarrhoea hair loss
  • low red blood cell count (anaemia)
  • hearing loss
  • a drop in levels of white blood cells, which may
  • increase the risk of infection
  • mouth sores.

Keep a record of the doses and names of your chemotherapy drugs handy. This will save time if you become ill and need to visit the hospital emergency department.

To find out more see Understanding Chemotherapy or call Cancer Council 13 11 20.

Targeted therapy

New types of drugs known as targeted therapy are designed to attack specific changes within cancer cells.

Targeted therapy drugs work differently from chemotherapy drugs. While chemotherapy affects all rapidly dividing cells and kills cancerous cells (cytotoxic), targeted therapy drugs affect specific molecules within cells to block cell growth (cytostatic).

A number of targeted therapy drugs are being tested for head and neck cancer in clinical trials. One targeted therapy drug called cetuximab is available in Australia for head and neck cancers, when people cannot take the standard chemotherapy drug. Cetuximab is a monoclonal antibody that binds to the surface of cancer cells and stops them growing and dividing. When used to treat head and neck cancer, it is used with radiotherapy.

Immunotherapy

These drugs can stimulate the body's own immune system to attack the cancer. Immunotherapy may be effective in treating some forms of head and neck squamous cell cancer.

Some types of immunotherapy drugs work by enabling the immune system to bypass "checkpoints" set up by the cancer that block the immune system. These antibody drugs can block a protein called PD-1 found on immune cells. The drugs release this "brake", allowing the immune system to better attack the cancer. Several checkpoint immunotherapy drugs for head and neck cancers are currently being tested in clinical trials.

Pembrolizumab has been approved for head and neck cancer, but is not yet reimbursed (as of June 2017).

Side effects of immunotherapy

The side effects of immunotherapy drugs are different to chemotherapy, and are caused by an overactive immune system attacking the normal parts of the body. Most commonly this includes fatigue, rash and diarrhoea, but as any part of the body can be attacked by the immune system, other side effects can occur. Early side effects can usually be controlled before they become severe, so let your medical team know as soon as they appear.

Palliative treatment

Palliative treatment helps to improve people's quality of life by alleviating symptoms of cancer without trying to cure the disease and is best thought of as supportive care. Many people think that palliative treatment is for people at the end of their life, however, it may be beneficial for people at any stage of advanced head and neck cancer.

As well as slowing the spread of cancer, palliative treatment can help manage symptoms such as pain and help you live as long as possible in the most satisfying way you can. Treatment may include radiotherapy, chemotherapy or other drug therapies. For more information, see Understanding Palliative Care and Living with Advanced Cancer or call Cancer Council 13 11 20.

Key points

  • Head and neck cancer is commonly treated with surgery, radiotherapy or chemotherapy, either alone or in combination.
  • The type of surgery depends on the part of the head and neck affected.
  • Not everyone with a head and neck cancer will have surgery. Many people with advanced cancer will have radiotherapy.
  • For cancers that are easily accessible, surgery is straightforward. Most people recover quickly and manage any side effects well.
  • For some head and neck cancers, surgery may be more invasive and lead to long-term side effects that require ongoing rehabilitation.
  • Reconstructive surgery, if required, can be carried out at the same time as the main operation or at a later stage.
  • Radiotherapy, used alone or with other treatments, is commonly used for head and neck cancers.
  • Before radiotherapy, you may be advised to see a dentist to reduce the chance of serious future problems with your teeth and jaw.
  • During radiotherapy, you will need to wear a speciallymade mask to keep you still during treatment.
  • Chemotherapy can be used before or after surgery or radiotherapy, or at the same time as radiotherapy (chemoradiotherapy).
  • Palliative treatment is given to alleviate symptoms, such as pain. It may include radiotherapy, chemotherapy or medication.

Reviewed by: A/Prof Ardalan Ebrahimi, Head and Neck Surgeon, Liverpool, Macquarie, St George Private and Sydney Southwest Private Hospitals, NSW; Jenne Farrant, Senior Physiotherapist, Intensive and Critical Care Unit, Flinders Medical Centre, SA; Merran Findlay AdvAPD Executive Research Lead – Cancer Nutrition, and Oncology Specialist Dietitian, Royal Prince Alfred Hospital, NSW; Dr Tsien Fua, Radiation Oncologist, Peter MacCallum Cancer Centre, VIC; Dr Craig Gedye, Medical Oncologist, Calvary Mater Hospital, Newcastle, and Conjoint Senior Lecturer, School of Biomedical Sciences and Pharmacy, The University of Newcastle, NSW; Jenny Holland, Head and Neck Oncology Nurse Consultant, Monash Health at Moorabbin Hospital, VIC; Dr Steven Kao, Medical Oncologist, Chris O’Brien Lifehouse, NSW; Cindy Lyons, Social Worker (Radiology), Gosford Hospital, NSW; Dr Elishka Marvan, Dental Oncologist, Peter MacCallum Cancer Centre, VIC; Dr Julia McLean, Speech Pathologist, St George Swallow Centre, St George Hospital, NSW; Rohan Miguel, Senior Physiotherapist, Community Services, Disability SA; Tracey Nicholls, Nurse Practitioner Ear Nose and Throat, Department of ENT Otolaryngology Head and Neck Surgery, Flinders Medical Centre, SA; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Gail Williams, Consumer.