Head and Neck Cancer

Treatment of cancers involving the head and neck offers challenges to the doctor and patient like no other tumor. Treatment of tumors of the head and neck can have effects on appearance clearly evident at first glance. Important functions such as speaking and swallowing can also be significantly affected.

Tobacco use is the single most preventable cause of cancer in general. It is particularly associated with cancers of the lung, and head and neck areas. Smoking cessation programs are available, and are an important first step for any person interested in improving their health. Excessive use of alcohol is also associated with tumors of the head and neck, and addiction to this substance should be treated as well.

Tumors can be diagnosed when they are small in which case they are referred to as "early", or large, and often referred to as "advanced". The approaches to treatment are very different under these differing circumstances. When tumors are small, often one single type of treatment, either surgery or radiation therapy is sufficient to control them. The choice of treatment depends on a comparison of the expected side effects and potential benefits of either treatment. Advanced tumors often require both surgery and radiation therapy, and sometimes even chemotherapy to provide the best chance for local control. Radiation therapy can be given after or before surgery. If surgery is not possible, radiation is often combined with chemotherapy to increase the chance of control, especially when the treatment has a chance of allowing the patient to avoid disfiguring surgery such as a laryngectomy (removal of the voice box, or larynx).

Quality of life is the subjective feeling of well-being as perceived by the person affected. The primary goal of cancer treatment is complete and permanent eradication of the tumor for the remainder of the patient's life. The cost of the treatment is often determined by measuring the change in quality of life as a result of treatment. Treatment can affect quality of life in three major ways. Besides the possibility of disfigurement, often from surgery, there can be effects on speaking, eating and swallowing. Speech is very important as it affects our ability to communicate. The extent of laryngeal surgery has a direct effect on "understandability" as measured objectively. Of the 4 surgery subtypes in one study, patients with a total laryngectomy scored the lowest in speaking ability. Patients who had had flap reconstruction and those with a partial laryngectomy scored better, and those with wide local excision scored essentially normally. Speech limitations are not acceptable to many patients and there has been an effort to investigate alternatives to radical surgeries.

A multidisciplinary approach to treatment requires close cooperation between all physicians involved. The physicians of Valley Radiotherapy Associates Medical Group (VRA) participate in multidisciplinary Head and Neck Tumor Boards where surgeons, radiation oncologists, medical and dental oncologists as well as pathologists and radiologists review an individual's clinical case in its entirety and formulate treatment recommendations. VRA physicians understand the complexities of quality of life and tumor control issues, and are committed to helping patients through a very difficult decision-making process.

Definitive radiation therapy (i.e., radiation therapy alone) offers several advantages to radical surgery in several situations. One of those situations is when surgery can be avoided by using radiation therapy as the primary treatment. Radiation therapy can eradicate tumors with small daily doses while leaving normal tissues, such as the skin and larynx intact. Patients with cancers of the larynx or skin of the eyelid, for example, often choose this treatment.

This concept of organ preservation is extended to more advanced tumors. Chemoradiation (i.e., the administration of chemotherapy and radiation therapy) has been investigated in patients with advanced laryngeal cancers. A randomized study of laryngeal conservation in patients with stage III and IV resectable laryngeal cancer showed that patients treated with induction (or "upfront" ) chemotherapy followed by definitive radiation had a 62% laryngeal preservation rate with comparable 3 year survivals when compared to patients who had undergone conventional treatment with laryngectomy and radiotherapy. Chemotherapy has also been found to enhance the control of cancers of the nasopharynx.

As with any major treatment intervention including surgery, there are always side effects and there is always a risk of complications. The "therapeutic ratio" of a treatment can be defined as: percentage of patients cured divided by the cost of the treatment in terms of side effects. The fewer the side effects without compromising the chance of cure, the better the therapeutic ratio. The techniques of radiation therapy delivery and other treatment factors are paramount when attempting to reduce the risk of complications, mitigate those that do occur, and increase the chance of cure.

VRA physicians employ only the most advanced treatment methods and philosophies:

1. "An ounce of prevention is worth a pound of cure." No where is this as true as in the field of dental oncology. A dental oncologist is a dentist or oral surgeon who has special training in the effects of cancer surgery or radiation therapy on normal tissues. If a surgery was performed that resulted in a loss of normal tissues, a dental oncologist can fashion a prosthesis that will correct the deficit as much as possible. When indicated, they prescribe mouth care and prevention regimens that are extremely valuable for keeping teeth healthy despite dryness which can occur if the salivary tissues are irradiated. They also make special shields and other devices that aid in reducing the amount of radiation reaching the normal tissues.

   VRA physicians strongly believe that patients who are to receive radiation therapy to an area that will include the jaw should be evaluated by a dental oncologist prior to any therapy, and will make such a referral.

2. Treatment planning is what can determine the difference between adequate and superior radiation therapy. Treatment planning often starts with the fabrication of a mask used to hold the patient's head as still as possible. Normal tissues (e.g., salivary glands, jawbone, skin, tongue if it is not involved with tumor, and spinal cord) are carefully taken into account when designing the treatment fields and choosing the optimal radiation beam energy. Computerized treatment planning is used as needed.

   All the above are critical in order to deliver precision targeted radiotherapy that will control the tumor and minimize the risk of long-term side effects. VRA physicians have extensive experience in treatment planning techniques as developed in major academic institutions across the country.

3. Research has shown that the therapeutic ratio can be increased with the use of innovative dose-fractionation techniques, that is, the method of delivering the curative treatment dose. These include hyperfractionated and accelerated radiotherapy, techniques which VRA physicians are experienced with.

4. Another way of improving the chance of cure while preserving normal structures such as the larynx is to use chemotherapy to increase the effectiveness of the radiation therapy. Referrals to a medical oncologist will be made by one of our physicians if chemotherapy may be indicated.

5. Supportive services such as nutritional counseling and special regimens designed to reduce dry mouth are used in an individualized manner to make the treatment as tolerable as possible. We believe that our patients should be seen and monitored at least weekly by a registered dietitian who is experienced in the effects of head and neck irradiation.

Valley Radiotherapy Associates welcome you and your family to seek a consultation with one of our physicians. We will be happy to answer any questions you may have.

References:

1. Gritz E R, Hoffman A, Behavioral and psychosocial issues in head and neck cancer. In: Beumer, John III, Curtis, Thomas A, Marunick, Mark T, Eds. Maxillofacial Rehabilitation. St. Louis, Missouri, Ishiyaku EuroAmerica, Inc., 1-14, 1996.

2. List M, Ritter-Sterr C, Lansky S: A performance status scale for head and neck cancer patients. Cancer. 66:564-567, 1990.

3. Karp D, Vaughan C, Carter R, et al: Larynx preservation using induction chemotherapy plus radiation therapy as an alternative to laryngectomy in advanced head and neck cancer: A long-term follow-up report. Amer J Clin Oncol 14: 273-279,1991.

4. The Department of Veterans Affairs Laryngeal Cancer Study Group: Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 324: 1685-1690, 1991.

5. Giri PS, LeBlanc M, Al-Sarraf M, Fu K, Cooper J, Vuong T, Forastiere, A, Adams G, Sakr W, Schuller D, Ensley J. Improved survival with chemotherapy and radiation therapy versus radiation therapy alone in advanced nasopharyngeal cancer. Preliminary results of an intergroup randomized trial. RTOG 88-17. Proc Am Soc Ther. Radiol Oncol (ASTRO), Los Angeles, CA Int J Radiat Oncol Biol Phys, 36 (1):162, 1996.

6. Beumer, John III, Curtis, Thomas A, Marunick, Mark T, Eds. Maxillofacial Rehabilitation. St. Louis, Missouri, Ishiyaku EuroAmerica, Inc., 1996.

7. Million, R, Cassisi N. Eds. Management of Head and Neck Cancer, Ed. 2. Hagerstown, J. B. Lippincott Company, 1994.