TABLE 15-1 Treatment Modalities Used in Head and Neck Cancers | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Head and Neck Cancer
Head and Neck Cancer
Nancy D. Tsottles
Anita M. Reedy
I. Definition:
Cancers of the head and neck are characterized by alterations or mutations of the cells of the mucous membranes lining structures in this region. This results in uncontrolled cell growth or cancer.
A. Incidence
1. Ninety percent of these cancers are of the squamous cell type. Head and neck cancers are categorized by location. The regions are the face, the nasal cavity and paranasal sinuses, the oral cavity, the pharynx, the larynx, and the thyroid.
2. Head and neck cancers account for 5% of total cancers or 60,000 new cases per year. Fifty percent of these cancers are located in the oral cavity (25%) and larynx (25%).
B. Epidemiology: The majority of people who contract the disease are over 50 years old, with men being two and one half times more likely to develop it than women. The incidence in women, however, has been increasing due to their increased use of tobacco products and alcohol.
C. Morbidity and Mortality
1. Stage I and II tumors are small and have a 5-year survival rate of 80% or more. Tumors are more difficult to detect at this stage.
2. Stage III and IV tumors may involve surrounding tissue or lymph nodes. The 5-year survival is 40% or less. Detection at later stages is not uncommon, but distant metastases are not usually present.
3. Most relapses occur locally in the head and neck.
4. Distant metastases usually involve the lung, bone, and liver.
5. There is a 20% to 40% chance of developing a second cancer of the head and neck, lung, or esophagus, possibly due to exposure to precipitating carcinogens, such as alcohol and tobacco.
II. Etiology:
The development of head and neck cancers has been linked to several factors.
A. Oral, pharyngeal, and laryngeal cancers have been linked to tobacco, including the smokeless variety, and alcohol use.
B. Nasopharyngeal cancers have been linked to exposure to the Epstein-Barr virus and to being of Chinese ancestry.
C. Exposure to the human papilloma virus, occupational hazards (eg, materials used in the furniture and textile industries), and vitamin deficiencies (vitamins B, C, and riboflavin, among others) may also play a role in the development of head and neck cancers.
D. Genetic predisposition to cancer, such as mutations of the p53 tumor-suppressor gene, may also contribute to the development of head and neck cancers.
III. Patient Management
A. Assessment: Head and neck cancers may be hard to detect because of location.
1. Asymptomatic or silent in the early stages. This is particularly the case in the regions of the nasopharynx, paranasal sinuses and nose, oropharynx, hypopharynx, and cervical or upper esophagus.
2. Leukoplakia (white plaques) or painless erythroplasias (red, smooth areas) are often present in the oral cavity in the early stages of head and neck cancers. These lesions may be precancerous.
3. Sore throats and coldlike symptoms are also considered early signs.
4. Dysphagia, hoarseness, stridor, wheezing, and a lump in the neck are serious, late symptoms caused by tumors of the hypopharynx, larynx, thyroid, and parathyroid glands.
5. Dysphasia and bloody sputum result from tumor growth in the pharynx or esophagus.
6. Persistent earache may be caused by tumors in the nasopharynx and oral cavity.
7. Hearing loss, pain, tinnitus, and nasal obstruction may be caused by tumor growth in the nasopharynx.
8. Metastasis can result if the tumor invades the vascular system. The lungs and bones are the most frequent sites of metastasis.
B. Diagnostic parameters: Usually a combination of some or all of these procedures is used to diagnose head and neck cancers.
1. Physical examination is the best method of detection of tumors in the head and neck region.
a. The mouth needs to be thoroughly examined using a light.
b. The neck needs to be palpated to check for masses and lymph nodes. Although a thyroid nodule is not diagnostic, a rapidly growing mass, especially when associated with pain, does cause a high level of suspicion for a thyroid malignancy.
2. Elevated thyroid function tests and serum calcitonin levels may be a sign of cancer of the thyroid.
3. Imaging tests include computed tomography (CT) scans and magnetic resonance imaging (MRI) for screening as well as diagnosis of head and neck cancers, especially of the sinuses and soft tissue of the neck. MRI has superior capabilities for imaging soft tissue and may reveal small masses. Dental imaging or Panorex studies may be used to evaluate the teeth and to look for bone invasion. Positron emission tomography (PET) scans are also sometimes used to further evaluate the extent of disease and to assist in detecting metastatic disease.
4. Endoscopies can view primary tumors as well as metastasis. Endoscopy can also be used to biopsy places that are difficult to view, such as the nasopharynx, larynx, and esophagus.
5. Biopsy is the only definitive diagnostic procedure and should be performed when cancer is suspected. All sites except the larynx and esophagus are accessible to biopsy using local anesthetics; however, laryngoscopy under anesthesia may be necessary to obtain a thorough examination. The tumor is then staged as to size and the presence of regional or distant metastasis.
C. Treatment: Treatment for head and neck cancers depends on the type of tumor, the staging of the tumor, and the general condition of the patient. There are single and multiple modality treatment approaches. Single modality treatment with surgery or radiation therapy is generally recommended in stage I or II disease. For stage III or IV disease, multiple treatments are utilized (Table 15-1) and may include combinations of chemotherapy, radiation therapy, and surgery. When the disease is advanced, evaluation should include a multidisciplinary team (ie, surgeon, medical oncologist, radiation oncologist, nutritionist, dentist, and rehabilitation specialists in speech and swallowing). Clinical trials are being conducted to evaluate the effectiveness of giving chemotherapy as a first-line treatment to decrease the size of the tumor before surgery or radiation. The goal is to preserve organ function.
1. Chemotherapy may be given in inpatient, outpatient, or home settings. It is usually given in combination with other treatment modalities. Chemotherapy may be used before, during, or after surgery or radiation therapy. Some commonly used agents include cisplatin, carboplatin, paclitaxel, docetaxel, 5-fluorouracil, gemcitabine, and methotrexate. These may be used in combination or as single agents.
a. Patients and families need to be taught what side effects to expect, such as nausea, vomiting, diarrhea, loss of appetite, alopecia, fatigue, peripheral neuropathy, and bone marrow suppression.
b. Patients and families need to be taught how to manage these side effects, including instructions for use of an antiemetic regimen (see Chapters 22, 23, 25, 27, and 28).
c. Patients need to be taught how to take their temperatures to assess for fevers during times when their white blood cell counts are low and to use safety precautions (eg, electric razors for shaving) when their platelet counts are low.
d. Patients and families need to know about troubleshooting problems with infusion pumps and the resources available to them.
e. Home nursing needs to be in place for patients receiving chemotherapy or supportive care at home.
f. Some chemotherapeutic drugs (eg, cisplatin, carboplatin, 5-fluorouracil, and bleomycin) can cause severe nausea and vomiting and are toxic to the kidneys. Patients need to be hydrated with intravenous (IV) fluids and encouraged to take in oral fluids to minimize renal toxicity (see Chapter 6).
g. Teaching should include symptoms and side effects that should be reported immediately (eg, fever, uncontrolled nausea and vomiting).
2. Radiation may be given alone or in combination with other treatment modalities.
a. Patients and families need to know the side effects of radiation therapy, such as fatigue, nausea, vomiting, diarrhea, loss of appetite, loss of taste, mucositis, xerostomia, alopecia, irritation and swelling to the area of treatment, and skin changes.
