Patient Guide

Head and Neck Cancer

Introduction

The diagnosis of a new head and neck cancer is typically received with a combination of disbelief and sense of helplessness by both the patient and the immediate family. 

The sense of helplessness stems from little, if any prior knowledge of the condition as well as the available treatment options.
This webpage intends to educate the reader about head and neck cancers in general: How they present, symptoms they may experience, investigations that are required treatment options and side effects, as well as general prognosis. For more specific information, it is best to seek a specialist opinion for a face to face discussion of your condition.

What is a head and neck cancer?

The head and neck region is the part of the body that spans the area between the brain and the chest. Cancers arising in this area range from cancers that arise from the lining of the nose, sinuses, mouth, upper food tube and airway to ear cancers to cancers of the salivary glands or thyroid gland. Occasionally, the cancers may straddle the area between the neck and brain or neck and chest and these require additional input from a neurosurgeon or thoracic specialist respectively.

What causes the head and neck cancer?

The causes are variable depending on the type of cancer. Smoking and alcohol use accounts for a large majority of squamous cell carcinomas of the upper food tube and airway. Nasopharyngeal cancers (nose cancers) are often associated with a family history, frequent consumption of preserved food and also the presence of a virus (Epstein Barr virus). In some situations, oropharyngeal cancers (cancers of the back of the throat) may be related to previous sexual exposure and practices. Thyroid cancers are associated with a family history and previous irradiation to the neck.

What are the typical symptoms of a head and neck cancer?

The symptoms and examination findings depend very much on the type of cancer growth. A tongue cancer usually presents as a painful ulcer on the tongue. Nasopharyngeal carcinoma (cancer arising at the back of the nose) typically presents with lymph node enlargement (neck swellings) and blood stained saliva. Cancer of the voice box (laryngeal carcinoma) presents with hoarsness, difficulty breathing or swallowing. Pharyngeal cancers (cancers of the back of the throat) may present with a sore throat or difficulty swallowing. Many of these cancers have a tendency to spread to lymph nodes (which are natural defence stations in the body) and a patient may also present with enlarged lymph glands in the neck.

How are head and neck cancers staged?

The staging system varies depending on the cancer type. However, in general small tumors (usually less than 4 cm) make this an early stage lesion (stage 1 and 2), whereas larger tumors (> 4cm) or tumors that invade surrounding critical structures (even if less than 4 cm) are considered to be stage 3 and 4 cancers. The presence of spread to a lymph node immediately makes this at least a stage 3 cancer. If the cancer has spread to the rest of the body, this makes it an advanced stage 4 cancer.

What are appropriate investigations?

Investigations are generally divided into 2 broad groups. The first thing to do is to obtain a tissue sample (biopsy) to confirm that the growth indeed is a cancer. The second thing to do is to obtain scans of the tumor, the neck and the rest of the body to determine what stage the cancer is. Scans that may be performed include CT, MRI, US or PET scans. Many of the scans are complimentary and do not be surprised if your doctor asks for more than one scan as each scan compliments the other.

What are the general principles of treatment?

The management of head and neck cancers, especially for advanced cancers can be complex but in general, the following principles apply:

  1. Early stage cancers usually need one mode of treatment (either surgery or radiotherapy)
  2. Advanced stage cancers usually need at least 2 modes of treatment (either surgery with radiotherapy, or radiotherapy with chemotherapy)
  3. The use of chemotherapy with radiotherapy (as opposed to surgery and radiotherapy) has the advantage of enabling preservation of the tissues and organs from which the cancer arises (and hence in theory preservation of functions like swallowing and speech). Equivalent cure rates can be achieved with either option in some instances. However this is not always the case. Depending on the location and size of the cancer, the choice of surgery and radiotherapy may be preferable over chemoradiotherapy to achieve better cure rates. Additionally, some cancers are best treated with surgery and radiotherapy rather than radiotherapy and chemotherapy. Your specialist is best placed to explain this to you.
  4. Whether or not a patient is suitable for surgery and radiotherapy or chemotherapy and radiotherapy also depends on many other factors, such as age of the patient, health in general and current function of the organ from which the cancer arises.
  5. Sometimes, very advanced cancers are best treated with all 3 modalities (surgery, radiotherapy and chemotherapy)

What is the prognosis and cure rate?

This varies greatly depending on the stage of tumor and type of tumor. Clinicians often talk about 5 year survival rates, as it is premature to say a patient is cured till at least 5 years have elapsed. In general, the 5 year overall survival rate is about 70-90% for early stage cancers and 30-50% for advanced stage cancers. However, certain cancers like nasopharyngeal cancers, some oropharyngeal cancers, voice box and most thyroid cancers have a much better prognosis then the general figures.

What are the side effects of treatment?

Many patients are naturally worried about the side effects of surgery, radiotherapy and chemotherapy. They are in particular worried about the effects of treatment on physical functions such as speech and swallowing. These worries are well founded, but this should not stop the patient from undergoing treatment. The reason for this is that if the cancer is left untreated, these very functions will be severely affected nonetheless by the growth of the cancer.

Your specialist will discuss with you the best treatment options available to achieve a cure, yet ensuring optimal bodily functions such as speech and swallowing. When surgery is performed, there are certain “procedures” that can be performed to ensure better speech and swallowing outcomes. For example, a patient with a tongue cancer that requires surgery to remove the tongue cancer may in certain situations, benefit from having his/ her tongue reconstructed by a reconstructive surgeon to optimise speech and swallowing. Another example would be in patients that have to undergo voice box removal for treatment of laryngeal cancer. A small operation (Tracheo-esophageal puncture) will allow the patient to develop natural speech with the help of a speech therapist.

Head and neck Cancer Service at TTSH

Here at TTSH, we believe that your first treatment for head and neck cancer is the most important as salvage cases are more difficult to cure. Hence the type of treatment you receive on initial diagnosis is very important. At the same time, we realise that surviving a head and neck cancer is an entire journey, a journey that we will take with you.

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