Head and Neck Cancer – Treatment Options
Head and neck cancer specialists usually form a multidisciplinary team to care for each patient, and an evaluation should be done by each doctor before any treatment begins. This team often includes these specialists:
- Medical oncologist: A doctor who treats cancer using medications, such as chemotherapy, immunotherapy, and targeted therapy.
- Radiation oncologist: A doctor who specializes in treating cancer using radiation therapy.
- Surgical oncologist: A doctor who treats cancer using an operation.
- Reconstructive/plastic surgeon: A doctor who specializes in reconstructive surgery, which is done to help repair damage caused by cancer treatment.
- Maxillofacial prosthodontist: A specialist who performs restorative surgery in the head and neck areas.
- Otolaryngologist: A doctor who specializes in the ear, nose, and throat.
- Oncologic dentist or oral oncologist: Dentists experienced in caring for people with head and neck cancer.
- Oncology nurse: A nurse who specializes in caring for people with cancer.
- Physical therapist: A health care professional who helps patients improve their physical strength and ability to move.
- Speech-language pathologist (SLP): This health care professional specializes in communication and swallowing disorders. An SLP helps patients regain their speaking, swallowing, and oral motor skills after cancer treatment that affects the head, mouth, and neck.
- Audiologist: A medical professional who treats and manages hearing problems.
- Psychologist/psychiatrist: These mental health professionals address the emotional, psychological, and behavioral needs of the person with cancer and the patient’s family.
- Social worker: This health care professional provides counseling for patients, family members, and support groups. A social worker may also arrange family meetings, help with practical issues like transportation, and connect patients with local resources.
- Registered dietitian nutritionist: A nutrition professional who helps people understand the best ways to eat and what to eat for their specific conditions and recovery, to ensure they get the proper nutrition.
Cancer care teams include a variety of other health care professionals, such as physician assistants, pharmacists, counselors, and others. It is extremely important for this team to create a comprehensive treatment plan before treatment begins. People may need to be seen by several specialists before a treatment plan is fully developed.
Many cancers of the head and neck can be cured, especially if they are found early. Although eliminating the cancer is the primary goal of treatment, preserving the function of the nearby nerves, organs, and tissues is also very important. When planning treatment, doctors consider how treatment might affect a person’s quality of life, such as how a person feels, looks, talks, eats, and breathes.
Descriptions of the common types of treatments used for head and neck cancer are listed below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Overall, the main treatment options are surgery, radiation therapy, chemotherapy, and targeted therapy. Surgery or radiation therapy by themselves or a combination of these treatments may be part of the treatment plan.
Treatment options and recommendations depend on several factors, including the type and stage of head and neck cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for head and neck cancer because there are different treatment options.
During surgery, the goal is to remove the cancerous tumor and some surrounding healthy tissue during an operation. Types of surgery for head and neck cancer include:
Laser technology. This may be used to treat an early-stage tumor, especially if it was found in the larynx.
Excision. This is an operation to remove the cancerous tumor and some surrounding healthy tissue, known as a margin.
Lymph node dissection or neck dissection. If the doctor suspects the cancer has spread, the doctor may remove lymph nodes in the neck. This may be done at the same time as an excision.
Reconstructive (plastic) surgery. If cancer surgery requires major tissue removal, such as removing the jaw, skin, pharynx, or tongue, reconstructive or plastic surgery may be done to replace the missing tissue. This type of operation helps restore a person’s appearance and the function of the affected area. For example, a prosthodontist may be able to make an artificial dental or facial part to help restore the ability to swallow and speak. A speech pathologist may then be needed to help the patient relearn how to swallow and communicate using new techniques or special equipment.
Depending on the location, stage, and type of the cancer, some people may need more than 1 operation. Sometimes, it is not possible to completely remove the cancer, and additional treatments may be necessary. For example, surgery may be followed by radiation therapy, chemotherapy, or both to destroy cancer cells that cannot be removed during surgery.
Side effects of surgery
Side effects of surgery depend on the type and location of the surgery. Every patient is encouraged to talk with their doctor about the side effects expected from a specific surgery and how long the side effects are likely to last. Common side effects from head and neck surgery include temporary or permanent loss of normal voice, impaired speech, and hearing loss. People often have difficulty chewing or swallowing after cancer surgery, which may require a tube inserted in the stomach for feeding purposes. If lymph nodes were removed, there may be stiffness in the shoulders afterward. In addition, lymphedema can occur. After a total laryngectomy, which is the removal of the larynx, people may have decreased thyroid gland function that will need to be managed, such as by taking thyroid hormone medication.
Another potential side effect is swelling of the mouth and throat area, making it difficult to breathe. If this side effect develops, patients may receive a temporary tracheostomy, which creates a hole in the windpipe to make breathing easier.
Some people experience facial disfigurement from surgery. Reconstructive surgery (see above) may be recommended to help appearance or maintain important functions, such as chewing, swallowing, and breathing. Patients should meet with different members of the health care team to help them make decisions about their treatment and understand the recovery process. Programs that help patients adjust to changes in body image may be useful both before and after the surgery. Talking with your doctor about what to expect and how recovery will be handled can help you cope.
Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have.
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. It can be the main treatment for head and neck cancer, or it can be used after surgery to destroy small areas of cancer that cannot be removed surgically.
The most common type of radiation therapy is called external-beam radiation therapy, which is radiation given from a machine outside the body. A specific type of external-beam radiation therapy is called intensity-modulated radiation therapy (IMRT). IMRT uses advanced technology to accurately direct the beams of radiation at the tumor. This helps reduce damage to nearby healthy cells, potentially causing fewer side effects.
Proton therapy is another type of external-beam radiation therapy that uses protons rather than x-rays. At this time, proton therapy is not a standard treatment option for most types of head and neck cancer.
When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy.
Before beginning radiation therapy for any type of head and neck cancer, patients should be examined by an oncologic dentist or oral oncologist. Because radiation therapy can cause tooth decay, damaged teeth may need to be removed. Often, tooth decay can be prevented with proper treatment from a dentist before beginning treatment. People should also receive an evaluation from a speech-language pathologist who has experience treating people with head and neck cancer.
Patients may experience short- and long-term pain or difficulty swallowing, changes in voice because of swelling and scarring, and loss of appetite due to a change in their sense of taste. It is important that patients begin speech and swallowing therapy early, before radiation therapy begins to help prevent long-term problems with speaking or eating.
In addition, radiation therapy to the head and neck may cause redness or skin irritation in the treated area, swelling, dry mouth or thickened saliva from damage to salivary glands, bone pain, nausea, fatigue, mouth sores, and sore throat. Many of these side effects go away soon after treatment has finished. Other side effects may include hearing loss due to a buildup of fluid in the middle ear, a buildup of earwax that dries out because of the radiation therapy’s effect on the ear canal, and scarring (fibrosis). If the treatment damaged lymph nodes, there may be a risk for lymphedema.
Radiation therapy also may cause a condition called hypothyroidism in which the thyroid gland (located in the neck) slows down and causes the patient to feel tired and sluggish. This may be treated with thyroid hormone replacement medication. Every patient who receives radiation therapy to the neck area should have their thyroid function checked regularly. Patients are encouraged to talk with their health care team about what side effects of radiation therapy to expect before treatment begins, including how these side effects can be prevented or managed.
Therapies using medication
Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for head and neck cancer include:
- Targeted therapy
Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications.
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time.
The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.
EGFR inhibitors. For head and neck cancers, treatments that target a tumor protein called epidermal growth factor receptor (EGFR) may be recommended. Researchers have found that drugs that block EGFR help stop or slow the growth of certain types of head and neck cancer.
Tumor-agnostic therapy. Larotrectinib (Vitrakvi) is a type of targeted therapy that is not specific to a certain type of cancer but focuses on a specific genetic change in NTRK genes. This type of genetic change is uncommon but does occur in a range of cancers, including head and neck cancer. Larotrectinib is approved as a treatment for head and neck cancer that is metastatic or cannot be removed with surgery and has worsened with other treatments.
Talk with your doctor about possible side effects for a specific medication and how they can be prevented or managed.
Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
Pembrolizumab (Keytruda) and nivolumab (Opdivo) are 2 immunotherapy drugs approved by the U.S. Food and Drug Administration (FDA) for the treatment of people with recurrent or metastatic head and neck squamous cell carcinoma. Pembrolizumab can be used by itself if the tumor expresses a certain amount of the PD-L1 protein. Or it can be used in combination with chemotherapy regardless of the level of PD-L1 expressed by the tumor. Nivolumab can be used if the cancer continued to grow or spread during treatment with platinum-based chemotherapy.
Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you.
Physical, emotional, and social effects of cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
Metastatic head and neck cancer
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option.
Your treatment plan may include a combination of surgery, radiation therapy, chemotherapy, targeted therapy, or immunotherapy. Palliative care will also be important to help relieve symptoms and side effects.
For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery, chemotherapy, targeted therapy, radiation therapy, or immunotherapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope.
If treatment does not work
Recovery from head and neck cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for most people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families.
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