Types of Treatment of Head and Neck Cancer

Executive Summary

Treatment (head and neck cancer) recommendations depend upon the size, grade, and type of tumor, metastasis, possible side effects, and patient’s preferences and overall health. The common treatment for head and neck cancer involves surgery (laser technology, excision, lymph node dissection or neck dissection, reconstructive or plastic surgery), radiation therapy (external-beam radiation therapy, proton radiation therapy, internal radiation therapy or brachytherapy), and various systemic therapies (chemotherapy, targeted therapy- tumor-agnostic therapy, EGFR inhibitors) using medication. Palliative care includes medication, nutritional changes, emotional and spiritual support, and other relaxation therapies.

The Healthcare Team

A multidisciplinary approach helps treat any form of head and neck cancer. Hence, the treatment will include the involvement of different doctors and other healthcare members (called the multidisciplinary team) and will use different treatment strategies. They will care for and evaluate the patient before and throughout the treatment period.

The health care team will include the following specialists:

• Medical oncologist: A doctor who specializes in using medications like chemotherapy, radiation, and targeted therapy to treat cancer. 
• A surgical oncologist is a doctor who specializes in and performs surgery or operation to treat cancer. 
• A radiation oncologist is a doctor who uses radiation therapy to treat and destroy cancerous growth.
• Otolaryngologist: a doctor who specializes in the nose, ear, and throat.
• Maxillofacial prosthodontist: a specialist who performs restorative surgery in the neck and head regions. 
• Reconstructive or Plastic surgeon: a surgeon who specializes in reconstructing facial and body tissues, thereby improving a person’s appearance post-cancer treatment.
• An oral oncologist or Oncologic dentist: are dentists (mouth or oral experts) specializing and experienced in treating and caring for people with neck and head cancer.

• Audiologist: a health professional who specializes in hearing and problems related to balance. 

Further medical Practitioners

• A speech-language pathologist (SLP) is a specialist or health professional who helps patients use the throat and mouth muscles. They specialize in swallowing and communication disorders. A Speech-language pathologist allows patients to regain their oral motor skills and ability to swallow and speak after cancer treatment related to the head, neck, or mouth. 
• Mental health providers: Mental health professionals such as a psychologist or a psychiatrist who diagnose and treat the mental health issues of the patients. They also focus on addressing the physical, emotional, and behavioral needs of cancer-affected patients and their family members.
• Social worker: a social worker is a healthcare professional who provides counseling and cancer-affected assistance to patients, family members, and support groups. Patients can address any issue they face with a certified social worker. A social worker may help with practical problems like transportation, connecting patients to local resources, and connecting different patients. They may also arrange family meetings.
• Registered dietitian or nutritionist: the healthcare team for treating head and neck cancers will have a certified nutritionist or dietician. A dietician is a professional who helps people to understand the best ways to eat during treatment and recovery. Dieticians prepare a diet plan suiting the nutritional requirements of each patient.

Besides these people, cancer care includes a variety of other health care professionals like nurse practitioners, physician assistants, pharmacists, counsellors and many more others. All these people come together to devise a treatment plan as suiting the patient’s cancer condition. The team will design a comprehensive treatment plan by evaluating the patient’s disease condition and overall health. 

Treatment of head and neck cancer

Most cancers affecting the head and neck can is curable, especially if detected early. Head and neck cancer treatment focuses on eliminating cancer growth and preserving the functions of nearby tissues, organs, and nerves. While planning the treatment strategy, the healthcare team will consider how the treatment will affect the patient’s quality and comfort of life. 

The standard treatment techniques used to treat head and neck cancers are surgery, radiation Therapy, and various systemic therapies (chemotherapy, targeted therapy) using medication ^​1​. The treatment plan will also focus on managing and relieving symptoms, signs, and side effects, which form an essential part of cancer treatment.

Treatment options and plans are based on several factors like the type of head and neck cancer, its stage and grade, probable side effects, the patient’s preferences, choices, and overall health condition. Patients should take time to learn about all the available treatment options and be sure to ask questions and clear doubts about things that are unclear and appears complex. Ask your doctor about the aim of each treatment and what outcome you can expect while receiving the treatment. This is “shared decision making”. Shared decision-making helps the patients to take informed choices regarding treatment. This will help the healthcare team choose and plan a treatment strategy that best fits your aims and expectations.

SURGERY

Surgery is a procedure where the tumor and some surrounding healthy tissues are removed via an operation. It is one of the best treatments for treating and destroying head and neck cancers. There are different types of surgical procedures for treating head and neck cancers. They include:

Laser technology

The procedure helps treat early-stage cancers, especially in the voice box or larynx.

Excision

It is an operation where the cancerous growth or tumor and some surrounding healthy, normal tissue called margin is removed.

Lymph node dissection or neck dissection

If the doctor suspects that the tumor has metastasized to other parts, including lymph nodes, the doctor will remove lymph nodes in the neck. The procedure can be done at the same time as an excision.

Reconstructive or plastic surgery

If the surgical procedure includes a major tissue removal, like removing the skin, jaw, tongue, or pharynx. Then plastic or reconstructive surgery is to replace the missing tissue part. Reconstructive or plastic surgery helps restore the affected area’s appearance and function post-surgical procedure. For instance, a prosthodontist would create an artificial facial or dental part to help restore the patient’s ability to speak and swallow. The speech pathologist will help the patient relearn how to communicate and eat using new equipment(s) and techniques.

Patients may require one or more surgeries based on the disease gravity, stage, location, grade and type of cancer. It becomes impossible to remove the tumour entirely via an operation at times. In such cases, additional treatment procedures like radiation therapy and other medicated therapies might also be necessary to treat cancer. Patients must enquire about the type of surgery necessary to remove the cancer growth and the associated side effects.

Side effects of surgery

Surgery can cause various side effects depending upon the location and type of the surgical procedure. The patients need to talk with their health care team about the probable side effects of a surgical procedure used to treat cancer. They should also enquire about how long these side effects are likely to last post-treatment. The common side effects of head and neck surgery are impaired speech, hearing loss, and permanent loss of normal voice. Patients often find it challenging to swallow or chew after surgery, and some patients may require to insert a tube in their stomach for feeding purposes. 

If the surgical procedure includes the removal of lymph nodes, then the patients are likely to experience stiffness in their shoulders. Additionally, lymphedema can also occur. Swelling the throat and mouth area and eventually experiencing difficulty in breathing is another possible side effect of head and neck surgery. If people experience such side effects, they may receive a temporary tracheostomy, where a hole is created in the windpipe to ease breathing. A total laryngectomy includes complete removal of the larynx. After this procedure, people may experience decreased thyroid gland function and need medical assistance like thyroid hormone medication.

After Care of Surgery

Some people may require reconstructive surgery post-surgical treatment. This is to help the patients who experience facial disfigurement from surgery. Reconstructive surgery helps maintain the appearance and aids in other vital functions like breathing, chewing, and swallowing. Patients would have to meet different specialists to make essential decisions regarding treatment and understand the recovery process. Several programs that aid patients to adjust to body changes before and after the surgical procedure will help in the process of coping. Open talks with the doctor or healthcare team can help patients cope with the situation better. It can be regarding the aim of surgery, what to expect, how will the recovery look like, and the assistance they will receive.

RADIATION THERAPY

Radiation therapy refers to high-energy x-rays or other particles to destroy cancerous growth. A radiation therapy schedule or regimen may consist of a specific number of treatment procedures given over a certain period. Radiation therapy can help to cure the disease or ease and relieve the tumor symptoms and its treatment, or sometimes both. It can be alone or in sequence or in combination with other treatment procedures, like chemotherapy or surgery.

External–beam Radiation Therapy

External-beam radiation therapy is the most common type of radiation therapy. In this, the radiation cast from a machine outside the body. IMRT or intensity-modulated radiation therapy is a specific radiation therapy used to treat cancers. It uses advanced technology to accurately direct the radiation beams at the cancerous growth or tumour. This type of therapy minimizes the damage caused to nearby normal cells, causing significantly fewer side effects.

Proton Radiation Therapy

Proton radiation therapy is also called proton beam therapy. It is a form of external-beam radiation therapy that uses protons instead of x-rays. At high energy, protons can efficiently destroy cancer cells or tumors. The advantage of proton therapy is that it effectively eliminates the targeted tumor by causing very little damage to the nearby normal healthy tissues and cells. However, at present, proton radiation therapy is not a standard treatment procedure for treating head and neck cancers. Ask your doctor about the availability of these treatments and if they are suitable for your disease condition.

Internal Radiation Therapy

Internal radiation therapy or brachytherapy refers to a radiation procedure where the therapy is given using implants.

Patients about to receive radiation therapy as part of any head and neck cancer treatment are advised to consult an oncologic dentist and conduct a thorough examination. Radiation therapy can cause tooth decay. And so, the damaged teeth should be removed. Patients should consult a dentist and get proper treatment before the radiation therapy begins to avoid tooth decay. Patients seeking treatment for any head and neck cancer are also advised to consult an experienced speech-language pathologist at the earliest. A speech pathologist can teach exercises and begin speech and swallowing therapies to help patients maintain flexibility and strength of the muscles used for swallowing and speech. If the treatment plan is causing side effects that affect a person’s nutrition and health, then consulting a registered dietitian nutritionist (RDN) is also recommended.

Side effects of Radiation

The long-term side effects of radiation therapy include permanent loss of saliva, which can cause mouth dryness (also called xerostomia) and decay and deterioration of teeth. A radiation therapy procedure that causes fewer side effects may be effective in such cases. Fibrosis or scarring, which refers to the thickening of the skin and muscles, may occur in patients several months or years after radiation therapy. This can cause a delay in wound healing, trouble swallowing, and stiffness in the neck region. Rapid narrowing of the carotid arteries, which supply blood to the neck and head region, is another long-term side effect of radiation therapy. Radiation therapy can also cause hypothyroidism or lower thyroid gland functioning, which can be managed with a thyroid hormone replacement medication. 

In addition, radiation procedures for treating head and neck cancers can cause swelling, bone pain, redness or skin irritation in the treated area, fatigue, nausea, sore throat and mouth sores. Other significant side effects include hearing loss due to fluid build-up in the middle ear, scarring or fibrosis, and earwax build-up that dries out because of the impact of radiation therapy on the ear canal. If the radiation procedure has damaged the lymph nodes, there is a chance of lymphedema in the patient.

THERAPIES USING MEDICATION

Treatments that use medications to eliminate cancer cells are systemic therapy. Systemic therapy refers to medication or drugs to eliminate cancer cells. These drugs or medications are administered through the bloodstream to reach tumor growths or cells throughout the body. Medicated therapies can also be administered to the patient’s body locally. In this, the medication or drug is applied directly to the tumor or is kept in a single part of the body.

A medical oncologist usually prescribes such therapies. Systemic therapies have two common ways:

• Using an intravenous (IV) tube to administer medication into the vein using a needle.
• A capsule or pill that is swallowed or administered orally.

The systemic therapies used to treat head and neck cancers are Chemotherapy, Immunotherapy and Targeted Therapy. A patient may receive one of these, or sometimes a combination of both, administered simultaneously. Systemic therapies can also be a part of the overall treatment plan, including surgery or radiation.

Many studies focus on developing efficient medications that can help treat and cure cancer. Learning about the medicines and treatments will help the patients gain more insight into the treatment. Ask them questions regarding the purpose, possible side effects, and their possible interactions with other treatments and medications. One should also let their doctor know about any additional treatment or medicines they are taking well before cancer treatment. This is because certain drugs and herbs can interact with cancer medications and can cause complications.

Chemotherapy

Chemotherapy or chemo procedure refers to drugs or medications to eliminate cancer cells. These drugs operate by preventing the cancer cells from growing, dividing and generating more cells. A chemo regimen generally consists of several cycles given over some time. A patient may receive a single type of drug or a combination of different medications, all given simultaneously.

Chemotherapy can cause side effects, and these depend on the dose of medication used and the individual’s overall health. But common side effects include nausea and vomiting, hair loss, fatigue, loss of appetite, risk of infection, and diarrhoea. These side effects are likely to vanish after the treatment is over.

Targeted therapy

Targeted therapy refers to a systemic treatment that targets specific genes, proteins of the cancer cells and the surrounding tissue that contributes to tumour growth and proliferation. This therapy shuns cancer’s development and metastatic capability by causing very little damage to the surrounding healthy cells. 

The targets of each tumor differ. The doctor will run various tests or scans to identify the tumor’s proteins, genes, and other characteristic features to choose a suitable treatment option. This helps the doctor to implement the most effective treatment. Many types of research are happening in this field, too, to devise better target therapy options.

Tumour-agnostic therapy

A type of targeted therapy called Larotrectinib (Vitrakvi) is not specifically used to treat a certain type of cancer but focuses on a specific genetic mutation in NTRK genes. This type of genetic mutation is uncommon but does occur in a range of cancerous growth, including head and neck cancer. The drug Larotrectinib is approved as a treatment mode for head and neck cancer that is metastatic or cannot be removed with surgery and has worsened with other treatments.

EGFR inhibitors

Sometimes, treatments targeting a certain tumour protein called epidermal growth factor receptor (EGFR) may be prescribed for head and neck cancers. Studies have found that drugs that block EGFR help limit, stop or slow the growth of certain types of head and neck cancers.

Immunotherapy

Immunotherapy is also called biologic therapy. The medicated treatment focuses on improving the body’s natural defences to fight and destroy cancer growth. This therapy uses materials made either naturally by the body or in a lab to improve, target or restore the functions of the immune system ^​2​.

Nivolumab (Opdivo) and Pembrolizumab (Keytruda) are two immunotherapy drugs approved by the U.S. Food and Drug Administration (FDA) for the treatment of patients with metastatic or recurrent head and neck squamous cell carcinoma. Pembrolizumab can be effective by itself if the cancer growth expresses a certain amount of the PD-L1 protein. Or it can be effective in combination with chemo procedure, regardless of the level of PD-L1protein expressed by the tumor mass. Nivolumabis also applicable if cancer grows or metastasizes during treatment with platinum-based chemotherapy.

Side effects of Immunotherapy

Different types of immunotherapies can cause various side effects. Common side effects of the procedure include flu-like symptoms, skin reactions, weight changes and diarrhoea. Talk with your healthcare team or doctor regarding the possible side effects of the immunotherapy procedure recommended for you. 

Physical, emotional, and social effects of head and neck cancer

Cancer can cause many physical, emotional, and social effects. Cancer care does not end with active treatment. Post-treatment care is as critical as active treatment. Palliative or supportive care focus on managing and relieving symptoms and side effects associated with cancer treatment. It can help in improving the treatment efficiency by slowing the cancer growth or destroying it.

Supportive care focuses on improving a patient’s condition by helping them to manage and relieve symptoms. The care extends support not just to the patients but also to their loved ones. It also focuses on the non-medical needs of cancer patients, like managing finances.

Palliative care

Palliative care is independent of the age, cancer stage, or type of patient. This helps prevent the cancer condition and its symptoms and side effects from aggravating. Palliative focuses on improving the comfort and quality of a patient’s life. Palliative care enhances the effectiveness of active treatment. Sometimes a patient may receive chemotherapy, surgery, or radiation therapy as palliative care. Patients should talk with their health care team about the aim of each treatment option, the probable side effects, and, the available palliative care options before the active treatment begins.

The health care team will enquire about your medical history, symptoms and side effects during treatment. Be sure to communicate whatever you are feeling to the doctor. This helps them treat any symptoms or side effects that you are experiencing with ease. This will eventually help prevent your condition from becoming worse. 

Metastasis of head and neck cancer

Metastatic cancer refers to cancer or tumour that spreads from its origin to different body parts. If you are experiencing any signs or symptoms related to cancer metastasis, communicate it with your doctor. The doctor or the health care team will develop an active treatment plan to cure this condition. One can also go for clinical trial options. 

Metastasis can occur even after active treatment and removal of the cancer growth. Hence it can be stressful for the patient and their loved ones to bear the diagnosis. And so, communicating with loved ones can help them cope better. Patients can also talk with other cancer survivors or join a support group.

Remission and the chance of Cancer Recurrence

Remission refers to a stage where there are no signs or symptoms of cancer in the body. The condition can be called NED or “no evidence of disease” in the body. Remission can be permanent or temporary. Cancer patients in remission are constantly anxious about a probable cancer recurrence. Whatever but patients must continue tests, scans, and physical examinations even after successful treatment to look for recurrence. Talk with your doctor about the chance of the cancer condition recurring back in your body. Local recurrence is when cancer recurs in the same place as before. If it happens nearby the origin point, it is a regional recurrence. And, if it recurs in some distant place in the body, it is a distant recurrence.

Concern and Care

Cancer recovery may not be successful at times. Any stage of cancer can be stressful for people. A diagnosis that states an advanced, aggressive tumor can cause even more stress and make people hopeless and uncertain about their lives. Therefore, patients should have open, honest communications with their doctor or health care team about their concerns, feelings, and preferences. Health care team members can support the patients and their caregivers. So, they will focus on improving the comfort and quality of the patient’s life by providing them physical, mental, and financial support.

People diagnosed with advanced cancer and the expected chance of survival is for less than six months can consider hospice care. Hospice care focuses on providing the best possible quality care for patients whose survival chance is low. So, patients and their families can talk to the health care team about the available hospice options, including a unique hospice centre, hospice care at home or any other health care location. People can also avail nursing care options.

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