Naming the sub-sites of the head and neck region is a favourite rookie question when one is training in oncology. For such a relatively small area much can go wrong. Head and neck cancers are those that begin in the cells of the skin of the head and mucosal lining of the mouth, nasal sinuses, salivary glands, thyroid and voice box
The ‘neck’ component also comes from the fact that between the muscles and skin of the region, lie glands called lymph nodes and these are beloved places for wandering cancer cells to lodge and grow. It is not uncommon that the first symptom a patient may present with is a lump in the neck.
As with many others, there are some risk factors that play a role in the development of these cancers. These can be infectious or non-infectious. Infective agents that are a commonly implicated are Epstein Barr virus (EBV) and Human papilloma virus (HPV). However, we know that Cytomegalovirus and Herpes simplex 1 also have a role in the development of some cancers with a prevalence of about 7.5 – 10 % (Polz-Griszka, 2015).
Epstein Barr virus, also known as human herpes virus 4, commonly causes a disease called mononucleosis or kissing disease. This gives away to the fact that its main mode of transmission is through saliva but it can be transmitted through other bodily fluids like semen and blood. Important knowledge to have is that sharing of items like toothbrushes and even drinking cups or bottles can facilitate transmission. EBV is quite a stubborn virus that can spread no matter how much time has passed since the initial infection.
HPV is well known to you now as a cause of cervix, vulva, penile and anal cancer. The prevalence of HPV related mouth and throat cancer is on the rise as lifestyle choices evolve. The paradox of HPV related head and neck cancers is that they present with big neck nodes but demonstrate early response to treatment.
Excessive alcohol and tobacco consumption are high on the list of risk factors both individually and if consumed together outside infectious factors. In a way poor oral hygiene, poor nutrition and a weakened immune system co-exist to facilitate an environment for cancer to develop. I can’t imagine someone arriving home after a nice binge drinking in the wee hours to brush his or her teeth before tucking into bed!
Something not so relevant to our population here in Zambia is the consumption of a natural neurostimulant called betel quid. In Asia it is a big deal because some people consume it in the same way we would a cup of coffee.
Unfortunately no specific tests have proven benefit to implement standardisation of screening but an annual check up with a physician and a dentist should be adequate. It is also important to seek medical attention in a timely manner should neck lumps persist.
Symptoms of head and neck cancers can be ambiguous so self-motivation and patience in seeking medical help is necessary, as the doctors will treat what is common first and require that you return for follow ups. A persistent sore throat, nasal congestion, ulcer in the mouth or bad breath can be early signs. A lump in the neck, difficulty in breathing, double vision and hoarseness of the voice are indicative of progressive disease.
If a lesion can be seen, diagnosis is not a challenge as the next step would be to biopsy and characterise the tumour under the microscope. However, some head and neck cancers hide well and require cameras to be put through the nostrils to visualise them.
Use of more expensive scans like CT scan and MRI are useful as they show whether the patient has a curable cancer or not. Once the primary site of a cancer is identified, how far it has infiltrated is usually accurate on determining curability.
When the cancer is in its early stages surgery is a good modality to cure it. In recent times reconstruction allows for radical removal of the cancer followed by restoration of the structural frame. During, my training we had patients come for post surgical radiation with ‘hairy tongues’ after reconstructive surgery with flaps from not so obvious donor sites. Three months down the line, the new tongue was as smooth as can be.
Chemoradiation is also an excellent way to treat advanced head and neck cancers with particularly high efficacy in HPV related ones. Unfortunately, the side effects can be life changing. One of the most common side effects is a dry mouth – in scientific language, Xerostomia. Though measures are taken to spare as much salivary gland as possible, the doses required for cure shut down production and the patients require artificial supplementation of this very important fluid that we don’t appreciate enough!
Inflammation of the throat lining that can result in ulceration is another side effect that results in weight loss because swallowing becomes unbearable. Topical analgesia, high calorie diets and support get patients through to the other side.
For cancers around the voice box, the air passage gets obstructed or blocked and can only be relieved by creating an outlet below the blockage. This is called a tracheostomy. Without this intervention a patient could basically suffocate. Tracheostomies are particularly a challenge in my personal practice with many patients preferring to meet their maker than live with one. Though it is not my usual site of practice because of rotations I had a patient with cancer of the larynx who presented early enough to undergo radical treatment. He was admitted to the ear, nose and throat ward and saw how other patients had to live with these artificial orifices. During his time there he concluded that the quality of life was not acceptable to him and signed a do not resuscitate order, declining any further treatment. He couldn’t imagine how one could clean and maintain the tracheostomy.
Support groups play a very important role. In such places people who are many years post treatment encourage the newly diagnosed and they can peer to peer teach how to vocalize through the stomas.
Though fighting head and neck cancer is an unimaginable challenge, the words of William Arthur Ward must push you on’The experienced mount climber is not intimidated by a mountain – he is inspired by it. The persistent winner is not discouraged by a problem – he is challenged by it. Mountains are created to be conquered; adversities are designed to be defeated; problems are sent to be solved. It is better to master one mountain than a thousand foothills.