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Head and Neck Cancer Treatment Information
Head and neck cancer overview
Head and neck cancer actually includes many
different malignancies. The way a particular head and neck
cancer behaves depends on the site in which it arises (the
primary site). For example, cancers that begin on the vocal
cords behave very differently than do those that arise in the
hypopharynx, just an inch or less from the vocal cords.
The most common type of cancer in the head and
neck is squamous cell carcinoma, which arises in the cells
that line the inside of the nose, mouth and throat. Other less
common types of head and neck cancers include salivary gland
tumors, lymphomas and sarcomas.
Cancers spread in three main ways. The first
is direct extension from the primary site to adjacent areas.
The second is spread through the lymphatic channels to lymph
nodes. The third is spread through the blood vessels to
distant sites in the body. In head and neck cancer, a spread
to the lymph nodes in the neck is relatively common.
The lymph nodes most commonly involved are
located along the internal jugular vein underneath the
sternocleidomastoid muscle on each side of the neck,
particularly the internal jugular vein node at the angle of
the jaw. The risk of spread to other parts of the body through
the bloodstream is closely related to whether the cancer has
spread to the lymph nodes in the neck, how many nodes are
involved, and their location in the neck. The risk is higher
if cancer is in lymph nodes in the lower part of the neck
rather than only in those located in the upper
neck.
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What are my treatment options?
The three main types of treatment for managing
head and neck cancer are radiation therapy, surgery and
chemotherapy. The primary treatments are radiation therapy or
surgery, or both combined; chemotherapy is sometimes used as
an additional, or adjuvant, treatment. The optimal combination
of the three treatment modalities for a patient with a
particular head and neck cancer depends on the site of the
cancer and the stage (extent) of the disease.
In general, patients with early-stage head and
neck cancers (particularly those limited to the site of
origin) are treated with one modality—either radiation therapy
or surgery. Patients who have more extensive cancers are often
treated with a combination of surgery and radiation therapy or
with radiation therapy combined with adjuvant
chemotherapy.
If the plan of treatment is radiation therapy
alone for the primary cancer, the neck is also treated with
radiation therapy. In addition, a neck dissection to remove
involved lymph nodes in the neck may be necessary if the
amount of disease in the neck nodes is relatively extensive or
if the cancer in the neck nodes has not been eliminated
completely by the end of the radiation therapy
course.
Another treatment that might be necessary
before or after radiation therapy is surgery. In general, if
the surgical removal of the primary tumor is indicated,
radiation is given afterward if necessary. Sometimes, however,
the cancer is extensive or it is not feasible to completely
remove the cancer initially. Radiotherapy is then given first
to try to shrink the tumor, and surgery will follow
radiotherapy.
Recent studies indicate that chemotherapy
given at the same time as radiation therapy is more effective
than if it is given before a course of radiation therapy.
Therefore, radiation treatment schedules sometimes include
chemotherapy if the stage of the cancer is advanced (advanced
stage III or stage IV). Drugs commonly given in conjunction
with radiation therapy include cisplatin (Platinol),
fluorouracil (5-FU, Adrucil), carboplatin (Paraplatin), and
paclitaxel (Taxol). This is only a partial list of
chemotherapy agents; your physicians may choose to use others.
The chemotherapy may be given in a variety of ways, including
a low daily dose, a moderately low weekly dose, or a
relatively higher dose every three to four weeks.
For more information about radiation therapy
procedures and equipment, visit the following
pages:
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What happens during radiation
therapy?
The initial visit to the radiation oncologist
is for a consultation, when the radiation oncologist will
listen to the history of your problem and perform a physical
examination. Consultations with other members of the head and
neck team, such as the head and neck surgeon, pathologist,
radiologist and dentist, usually take place at this time or
shortly after. It is important to have the input of various
members of the team who will be taking care of you before a
treatment plan is decided and treatment begins.
After the recommended treatment and possible
options are explained to you and you decide on a course of
treatment in conjunction with your doctors, a date will be
selected for treatment planning for radiation therapy (if
irradiation has been selected as the first or next step in
your treatment). You then have what is called a "simulation"
using either conventional radiographs (x-rays) or a computed
tomography (CT) scan. These radiographic studies are used to
plan the type and direction of radiation beams used to treat
the cancer. Customized lead alloy blocks or a special
collimator (multileaf collimator) in the treatment machine
will shape the radiation beams to block areas that do not need
to be treated. Treatment fields then will be aligned, and the
treatment course will start one to two days after the initial
treatment-planning session.
Typically, treatments are given once or twice
a day, five days a week for five to seven weeks, depending on
the treatment schedule selected by your radiation oncologist.
Generally, for the first couple of days of treatment planning
and treatment start, your visit to the radiation oncology
department may take an hour or two. Thereafter, each
individual treatment takes just a few minutes, and you will be
in and out of the radiation department in 30 to 45 minutes for
each treatment session. You will not feel or see anything
during a radiation treatment, and any side effects usually
require two or more weeks to become apparent.
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What are possible side effects of radiation
therapy?
The side effects depend on the site and extent
of the head and neck cancer. In general, irradiation of the
head and neck does not cause nausea, but a few patients do
experience nausea during treatment. Many effective antiemetics
(drugs that alleviate nausea) can relieve this symptom if it
should occur.
Generally, the side effects of radiation
therapy become apparent about two weeks into the treatment
course, when a sore throat, loss of taste sensation, dryness
of the mouth and dry skin reactions may occur. Sore throat is
the main side effect that makes the course of radiation
therapy difficult.
If your sore throat is severe, you may be
unable to take in enough food and liquids by mouth to maintain
your weight or avoid dehydration. Your doctors will then
install a feeding tube temporarily into your stomach (a
gastrostomy tube), which will allow you to maintain adequate
nutrition without having to swallow all of the food that you
need. Gastrostomy placement is an outpatient procedure. It is
important, though, to continue swallowing even with a
gastrostomy tube in place. Otherwise, your swallowing muscles
may atrophy; this would cause permanent swallowing problems
and make it difficult to stop using the gastrostomy tube even
after the radiation treatment course is completed.
A dietitian should be involved in your care
during the course of radiation treatments to help you maintain
adequate caloric intake and hydration. When side effects
occur, it may be tempting to take a break from treatments.
This is not a good idea. The "acutely responding"
normal tissues—such as the skin and the lining of the
throat—that are responsible for the side effects during
radiation therapy tend to respond to radiation as do cancer
cells. If the treatment produces few acute side effects, it is
also not likely to be very effective against the cancer.
Therefore, the treatment of most head and neck cancers
represents a classic "no pain, no gain" situation. Breaks in
the treatment course to lessen the side effects give the
cancer a chance to regrow and will significantly reduce the
likelihood of cure. Medications that are almost always needed
during a course of radiation therapy include narcotic pain
medicines, both a long-acting pain medicine and a short-acting
pain medicine for breakthrough pain and stool softeners,
because a common side effect of narcotics is constipation.
Additional medications that may be necessary are topical
anesthetics—such as "magic mouthwash"—to lessen the sore
throat and possibly antiemetics if nausea is a
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