A diagnosis of head and neck cancer can be confusing and overwhelming. Cancer of the head and neck is actually an umbrella term used to describe a variety of malignant tumors that occur in the mouth, throat, nose, sinuses and salivary glands, as well as the lymph nodes in the neck. This type of cancer accounts for about 4% of cancers in the United States.
At Yale Medicine, we offer a combination of surgery, radiation therapy and chemotherapy that is best suited to your specific disease. We use the most up-to-date treatments and technologies with the goal of minimizing damage to surrounding tissues so that you can enjoy the best possible quality of life after treatment.
What are head and neck cancers?
Most head and neck cancers form in squamous cells – thin, flat cells forming the top layer of the mucous lining covering many structures of the head and neck. That's why the majority of cases of head and neck cancer are called squamous cell carcinomas. Cancer of the lip, mouth and larynx are examples of squamous cell carcinomas.
There are rarer forms of head and neck cancer, too, such as adenocarcinomas, which form in glandular cells. Cancers of the salivary glands are often classified as adenocarcinomas.
There are five main types of head and neck cancer, each named for where in the head or neck they form. The most common sites of head and neck cancer are in the mouth, the larynx and the oropharynx (the section of the throat immediately behind the mouth).
- Oral and oropharyngeal: Oral cancer starts in the oral cavity, which includes the lips, gums, the front two-thirds of the tongue and the bottom and top of the mouth (the floor and hard palate). Oropharyngeal cancer occurs in the oropharynx, the area at the back of the mouth and beginning of the throat. Cancers in the oropharynx start in the soft palate, the rear one-third of the tongue, the tonsils and the top of the throat. More than 90% of oral and oropharyngeal cancers are squamous cell carcinomas.
- Nasopharyngeal: This type of head and neck cancer (relatively rare in the United States) begins in the nasopharynx, the upper part of the throat that connects to the nasal cavity at the back of the nose. Most nasopharyngeal cancers are a subtype of squamous cell carcinoma, but they could also be lymphomas or adenocarcinomas.
- Nasal cavity and paranasal sinus: The nasal cavity is the passageway through which air travels from the nostrils to the top of the throat (the nasopharynx). The paranasal sinuses are small hollow pockets within the bones surrounding the nasal cavity. Most cancers of the nasal cavity, or paranasal sinuses, are squamous cell carcinomas, although in rare cases other types of cancer can form there.
- Laryngeal and hypopharyngeal: Laryngeal cancer starts in the larynx (also known as the voice box). Situated at the top of the windpipe leading to the lungs, the larynx contains the vocal cords and is also critical to breathing. Cancer that forms in the hypopharynx is called hypopharyngeal cancer. The hypopharynx is the lower section of the throat, also called the gullet. About 95 percent of laryngeal and hypopharyngeal cancers are squamous cell carcinomas.
- Salivary glands: The salivary glands make saliva and sit under the floor of the mouth, below the jaw and inside the upper cheeks just in front of the ears. Squamous cell carcinomas are rare in the salivary glands. Most cancers of the salivary gland start in other types of glandular cells that aren’t squamous cells. One such type is an adenocarcinoma.
What are risk factors for head and neck cancer?
- Alcohol and tobacco: Drinking alcohol and/or using tobacco (whether smoking or using smokeless forms, such as chewing tobacco and snuff) are the major risk factors, especially for the most common types of head and neck cancer: oral cancer and cancers of the larynx, oropharynx and hypopharynx. According to the National Cancer Institute, about 85 percent of head and neck cancers are linked to alcohol and tobacco use.
- Human papillomavirus (HPV): Infection with certain types of HPV can lead to head and neck cancers. HPV infection is most frequently associated with oropharyngeal cancers starting in the base of the tongue or in the tonsils.
- Epstein-Barr virus: While Epstein-Barr is more commonly associated with mononucleosis, infection with the virus is also linked to development of nasopharyngeal cancer and salivary gland cancer.
- Excessive radiation: This can be from sun exposure or other sources. Prolonged sun exposure, especially without sun protection, is linked most often with lip cancer. Radiation from extensive exposure to X-rays, or from radiation therapy to the head or neck, also increases risk, especially for salivary gland cancer.
- Being male: There are nearly twice as many cases of head and neck cancer in men as in women.
- Age: The majority of head and neck cancers are diagnosed in people ages 50 to 70.
- Diet: Excessive consumption of preserved and salted foods, chewing betel “nut” (a habit among mostly Southeast Asian immigrants) and drinking maté (a South American tea prepared from yerba maté leaves) are all linked to oral cancer. There is also evidence that people whose diets are low in vitamins A and B are at greater risk.
What are the symptoms of head and neck cancer?
Common symptoms of head and neck cancer include:
- A swollen lump or sore that does not go away
- A sore throat that doesn’t get better
- Difficulty swallowing and pain when opening the mouth
- A change in the quality of the voice, including a persistent hoarseness
Additional symptoms that could indicate head and neck cancer include:
- Nasal congestion that won’t go away
- Frequent nosebleeds
- Difficulty breathing
- Unexplained and persistent bad odor in the mouth
- Red or white patches in the mouth
- Double vision
- Ear pain
- Jaw pain
- Numbness or weakness in the head and neck area
- Weight loss
How is head and neck cancer diagnosed?
Arriving at a diagnosis of head and neck cancer typically involves several steps, including:
- Physical exam/diagnostic tests: A person with the symptoms above usually first has a physical exam by an otolaryngologist (an ear, nose and throat specialist also known as an ENT). The ENT feels for lumps and examines the nose, tongue, gums and throat for irregularities. Blood and urine tests are likely to be ordered. They can reveal markers that may indicate the presence of cancer.
- Imaging tests: Doctors use imaging tests to get a clearer picture of what’s going on inside the head and neck, and to find a suspected tumor. They may use more than one type of test to guide diagnosis and treatment decisions.The major types of imaging tests used are:
- Computerized tomography (CT) scan: Using X-rays, a CT scan creates images that display a cross-section of an area inside the body. CT scans help doctors pinpoint the location and exact size of a tumor. CT scans are most often used to look at the sinuses and the nasal cavity.
- Magnetic resonance imaging (MRI): MRI uses magnetic fields from a powerful magnet and radio waves (not radiation) to produce detailed pictures of bones and tissues inside the head.
- Ultrasound: Ultrasound uses sound waves to create a picture of structures inside the body. This allows doctors to see whether a tumor is present.
- Endoscopy: Endoscopy uses a thin, lighted tube, called an endoscope, that has a camera on the end. The scope is inserted through the nose or the mouth and into the throat to get an up-close look. During the endoscopy you may or may not be sedated.
- Biopsy: A biopsy can unequivocally determine whether a tumor is cancerous or benign. Your doctor will remove a tissue sample from the tumor (either by inserting a needle into a tumor or lymph nodes to withdraw tissue, or, by removing the lump or nodes via surgery). The sample is then tested by a pathologist, whose specialty is analyzing cells to check for disease.
- Staging. Part of the diagnostic process includes the staging of the cancer. Staging refers to how advanced the cancer is. Head and neck cancers are staged from 0 to IV.
How is head and neck cancer treated?
Surgery, radiation therapy and chemotherapy are the typical treatments for head and neck cancer. In many cases, those treatments are combined.
Early-stage head and neck cancers that are small and haven’t spread are usually treated with either radiation or surgery. If surgery is used to remove the tumor, radiation therapy may be used afterwards, to kill any remaining cancer cells in the tumor area. If the cancer is more advanced, chemotherapy is likely to be used in addition to surgery and radiation therapy.
External beam radiation therapy, in particular, is critical to treating head and neck cancers.
“Because the head and neck is such a sensitive area in terms of speech and swallowing function, radiation actually enables us to treat a lot of cancers curatively in ways that don’t require surgical removal of the organ,” says Zain Husain, MD a Yale Medicine radiation oncologist with the Department of Therapeutic Radiology. “For example, for advanced larynx cancers, previously it was thought that you need to do a significant surgery to removes the larynx, called a laryngectomy, which would remove the voice box and the ability to speak naturally. But with advances in radiation therapy, which is given usually in combination with chemotherapy, we’ve found that we can actually save the larynx in a majority of our patients.”
Potential side effects for radiation treatment include mouth sores, pain or difficulty with swallowing, significant weight loss and skin irritation at the treatment site. In terms of treating the side effects, “We try to reassure our patients that we are a high-volume center and have a large team of specialists, including physicians but also nurses, nutritionists, speech therapists and physical therapists who are focused on getting patients through their head and neck cancer treatment," says Dr. Husain.
After treatment, Yale Medicine’s specialists remain highly committed to each patient’s care and well-being. “The main thing we try to stress with our patients is that we’re with them every step of the way,” Dr. Husain says. “So, we can adjust their follow-up schedule depending on how they are at the end of treatment.” For example, doctors may give a patient hydration after treatment to speed recovery, or have them continue to see nutritionists and speech and swallowing rehabilitation therapists for some time post-treatment.
How is Yale Medicine’s approach to treating head and neck cancer unique?
At Yale Medicine, patients are treated by a team of doctors who collaborate to determine the best individualized treatment course. Radiation oncologists, medical oncologists, surgeons and other specialists meet weekly. “Through that experience, and that level of communication, we’re able to take care of patients and really try to tailor the recommended treatment course for a specific patient in the context of their specific disease,” says Dr. Husain. "Collaboration is key, and by all of us meeting together and deciding what approach is best, we hopefully get the best outcome for that patient and also choose the path that’s most in accordance with that patient’s wishes and preferences.”
Yale Medicine’s therapeutic radiology department employs advanced radiation techniques, which often allow doctors to limit the toxicity of the radiation dose to critical areas in the head and neck, such as salivary glands and muscles that aid in swallowing. “Through those techniques, we hope to optimize patients’ long-term speech and swallowing function,” Dr. Husain says. Yale Medicine is currently conducting clinical trials looking at the effects of giving less radiation in order to hopefully limit long-term side effects for patients.
Yale Medicine surgeons also employ state-of-the-art techniques, including, in the last several years, advanced robotic surgery, which has yielded excellent results.