Treatment Update: Oral and Head and Neck Cancer

Many types of head and neck cancer can be treated effectively, especially when found early. In many cases, an early diagnosis is made by a dentist who finds a red or white patch in the mouth or throat or a doctor who feels an enlarged lymph node in the neck. (Lymph nodes are small bean-shaped organs located throughout the body that remove waste and fluids and help fight infection.)

As with most cancers, there are three main treatments for head and neck cancer that can be used alone or in combination: surgery, radiation and chemotherapy or targeted treatments. (To destroy cancer cells, targeted treatments focus on specific cell mechanisms thought to be important for the growth and survival of tumor cells. Targeted treatments are designed to spare healthy tissues and tend to cause less severe side effects than chemotherapy.)

Surgery

Newer techniques to remove tumors allow surgeons to make smaller incisions (cuts) with the help of lasers, robotic arms and endoscopes (small tubes that contain a light, camera and surgical instruments). These types of surgery can be done through the mouth, without making incisions on the face or neck. CT and MRI scans guide surgeons to the location of the tumor with three-dimensional images. These scans also help with facial reconstruction, when needed, in advanced cases of head and neck cancer. Surgeons can transplant tissues and nerves from other parts of the body to the head and neck to rebuild the jawbone or tongue, for example. Such reconstruction helps patients speak and swallow and improves the ability to chew and eat. If head and neck surgery alters the way a person looks, these transplants can improve appearance and quality of life.

Radiation

Several technologies have made radiation treatment safer and more effective:

More precisely focused radiation beams help doctors target tumors with less damage to healthy tissues. For example, three-dimensional conformal radiation maps the location of the cancer and shapes the radiation beams to the tumor. The beams are aimed from several directions, which makes this treatment more effective than standard radiation.

Radiosensitizers are drugs taken by mouth or intravenously (through a vein, also called “IV”). These agents sensitize cancer cells so that radiation is more likely to destroy them.

Radioprotectors are drugs designed to protect healthy cells near tumors from the effects of radiation. For example, the drug amifostine (Ethyol and others) protects the salivary glands of the mouth, reducing the dry mouth that is a common side effect of radiation.

Chemotherapy and Targeted Treatments

Most people with head and neck cancer that is locally advanced (spread from where it started to nearby tissue or lymph nodes) or metastatic (spread to other parts of the body) are treated with a combination of radiation plus chemotherapy or a targeted treatment. The medications, which also can be used by themselves in some cases, include:

Cetuximab (Erbitux) is a drug that targets the epidermal growth factor receptor (EGFR), a protein on the surface of certain cancer cells that helps them grow and divide. Head and neck cancer cells often have more-than-normal amounts of EGFR. By blocking EGFR, cetuximab can slow or stop the growth of cancer. This treatment is given with radiation for head and neck cancer that has spread to more distant parts of the body. It also may be given with or without chemotherapy for metastatic head and neck cancer.

Cisplatin is commonly used with radiation to treat head and neck cancer. It is considered a standard of care. Treatment with cisplatin also may be combined with other medications such as fluorouracil plus cetuximab or docetaxel (Taxotere and others) plus paclitaxel (Taxol and others).

Docetaxel and paclitaxel are taxanes, a type of drug that blocks cell growth by stopping cell division. Doctors may use taxanes in combination with other anti-cancer medications such as cisplatin or carboplatin.

Fluorouracil is used to treat some patients with head and neck cancer whose tumor has returned in the same location or spread to other parts of the body. Cisplatin and cetuximab also may be given with this medication.

In the future, finding certain genetic changes in head and neck cancers will help doctors tailor treatments to specific tumors.

Treatments for head and neck cancer can lead to changes in the voice and the ability to swallow. How these changes affect each person depends on where the tumor is, the types of treatments given and the success of surgery to repair the tissues (reconstruction). With the improved surgical techniques described earlier, patients often have shorter hospital stays and faster, more effective recoveries. More focused radiation and targeted treatments can reduce damage to healthy cells.

Ideally, people with head and neck cancer should be evaluated by a speech pathologist before treatment begins to measure their ability to speak and swallow. This will help other members of the health care team choose the most effective treatments that will also reduce side effects. An early evaluation will help your doctor or nurse better manage any symptoms that occur. Research shows that many long-term speech and swallowing challenges can be avoided with a pretreatment evaluation.

New research also has shown that specific swallowing exercises, designed to target the muscle groups affected by head and neck cancer treatment, can be effective in preventing swallowing problems and avoiding the need for a feeding tube.

The best results occur when these exercises are started before treatment begins. Once swallowing difficulties have occurred, it is much more challenging for doctors to help you manage them. Ask your doctor to refer you to a speech pathologist who can evaluate your swallowing ability and teach you the exercises.

After treatment is finished, swallowing difficulties that occur months or years later could be a sign that the head and neck cancer has recurred (come back). So it’s important to stick to a regular schedule of checkups with your doctor and report any change in your ability to swallow.

Patients who maintain their weight throughout treatment tend to tolerate treatments better and have a faster recovery from side effects. To help you meet your nutritional goals, ask your doctor to refer you to a registered dietitian (RD). He or she can advise you on the most healthful way to eat and drink to help you manage treatment side effects.

During treatment, weight loss is common. When people find it difficult to chew and swallow, they tend to eat less. But weight loss can cause delays in treatment and slow the healing process. With the correct diet you can maintain your weight and preserve the lean muscle mass needed for strength. If you lost a lot of weight during treatment but are now at your ideal body weight or above, you do not need to return to your previous weight.

Here are a number of tips for healthful eating:

Try different foods to find the ones you like. If your treatment has caused changes in taste, this may improve over time as you heal. Perhaps foods you didn’t like before treatment may appeal to you now.

Eat small, frequent meals that include protein from eggs, beans, dairy products and meats. Protein helps protect lean muscle mass and aids in healing.

Include fortified food in your diet. Many cereals and liquid diet supplements such as Ensure are fortified with protein and vitamins. Because many people are allergic to soy and whey proteins, ask your RD and doctor to advise you on protein supplements before you use them.

Take a daily multivitamin to help complete your diet. You only need a vitamin that meets 100 percent of your daily needs. The American diet is highly fortified; many foods already have added vitamins.

Eat small amounts of pureed foods. This helps preserve the ability to swallow.

Drink plenty of fluids. To avoid dehydration, drink water, juice or sport drinks. Dehydration can lead to nausea, dry mouth, thick saliva, fatigue and dizziness.

Keep a daily food journal. A record of what you eat can be helpful to your health care team. It will also make you more aware of how often and how much you are eating.

Read food labels. The information provided on labels helps keep track of how much protein you are eating and which foods to avoid because they are too salty, which can make you thirsty.

Even if you have a feeding tube, you should continue to eat whenever possible and swallow, even if it is just your own saliva. Patients who do not take anything by mouth for more than two weeks often have more difficulty swallowing. An RD can help you find foods—and ways to prepare them—that you can tolerate. This type of specialist also can help you decrease the use of your feeding tube and resume a normal diet.