Head and Neck Cancer

What counts as head and neck cancer

Head and neck cancer covers several sites, each with its own pattern:

About 90% are squamous cell carcinomas, which start in the flat cells lining these surfaces. Thyroid cancers, brain tumors and skin cancers of the face are usually counted separately. See oral cancer, oropharyngeal cancer and laryngeal cancer for detail on each.

Head and neck cancer symptoms

• a mouth ulcer or sore that does not heal within 3 weeks
• a red (erythroplakia) or white (leukoplakia) patch in the mouth
• a persistent sore throat or feeling of something stuck in the throat
• hoarseness or voice change lasting more than 3 weeks
• pain or difficulty swallowing
• a lump or swelling in the neck, often a lymph node and sometimes the first sign. See neck mass
• ear pain on one side with a normal-looking ear (referred pain)
• a blocked ear or hearing loss on one side
• numbness of the tongue, lip or face
• loose teeth or dentures that no longer fit
• blood in saliva or phlegm
• unexplained weight loss and bad breath

Many of these have harmless causes. Persistence beyond 3 weeks is what matters.

Causes and risk factors

• Tobacco: smoking cigarettes, cigars or pipes, and chewing tobacco or snuff. Smoking is the biggest risk factor for cancers of the larynx, mouth and hypopharynx.
• Alcohol: heavy drinking raises the risk, and combined with smoking the risk is far higher than either alone.
• Human papillomavirus (HPV): HPV type 16 causes most oropharyngeal (tonsil and back-of-tongue) cancers in the US. These often affect younger people who do not smoke. See human papillomavirus.
• Epstein-Barr virus: linked to nasopharyngeal cancer, which is more common in people from southern China and Southeast Asia.
• Betel quid and areca nut chewing: a major cause of mouth cancer in South Asia.
• Sun exposure: lip cancer.
• Occupational exposures: wood dust, nickel and formaldehyde (nose and sinus cancers), asbestos.
• Age and sex: most cases occur over 50, and men are affected two to three times as often as women.
• Weakened immunity: after organ transplant or with HIV.
• Poor oral health and a diet low in fruit and vegetables.

Diagnosis

1. History and examination: of the mouth, throat, neck and cranial nerves.
2. Endoscopy: a thin flexible scope through the nose (nasendoscopy) lets an ENT specialist see the throat and voice box in clinic.
3. Biopsy: a tissue sample from the abnormal area, or a fine-needle aspiration of a neck lump, confirms cancer.
4. HPV (p16) testing: on oropharyngeal cancers, because it changes staging and outlook.
5. Imaging: CT and MRI show the size and spread. A PET-CT scan looks for spread to lymph nodes and distant organs.
6. Examination under anesthesia: to map the tumor and check for a second cancer.

Cancers are staged with the TNM system (tumor size, nodes, metastasis), from stage I to IV.

Treatment

A specialist team plans treatment based on the site, stage and HPV status:

• Surgery: removes the tumor and often lymph nodes in the neck (neck dissection). Transoral robotic or laser surgery can remove some throat cancers through the mouth. Reconstruction may use tissue from elsewhere in the body.
• Radiation therapy: usually daily for about 6 to 7 weeks, alone for early cancers or after surgery.
• Chemotherapy: most often cisplatin given with radiation (chemoradiation) for advanced cancers, sometimes to preserve the voice box.
• Targeted therapy: cetuximab blocks the EGFR receptor.
• Immunotherapy: pembrolizumab or nivolumab for recurrent or metastatic disease.

Side effects and rehabilitation

Treatment can affect eating, speech, saliva, taste and appearance. Common effects include mucositis, long-term dry mouth, swallowing problems, jaw stiffness, dental decay, hypothyroidism after neck radiation, and lymphedema. Speech and swallowing therapists, dietitians and dentists are part of the team, and a dental check is needed before radiation.

Outlook

Survival depends heavily on site and stage. Early cancers of the larynx and mouth are often curable. HPV-positive oropharyngeal cancer responds better to treatment than HPV-negative cancer. People who keep smoking have worse outcomes and a high risk of a second cancer, so stopping smoking is one of the most effective things you can do. Follow-up visits are frequent for the first 2 to 3 years and continue for at least 5 years.

Prevention and early detection

• stop smoking and chewing tobacco, and limit alcohol
• HPV vaccination, recommended at ages 11 to 12 and catch-up through age 26, and available up to age 45 after discussion with a doctor
• use lip balm with sunscreen
• regular dental check-ups, where dentists look for early changes
• see a doctor for any mouth or throat symptom lasting 3 weeks

Frequently asked questions

What are the first symptoms of head and neck cancer?

Early symptoms include a mouth sore or ulcer that does not heal, a red or white patch in the mouth, a sore throat or hoarseness lasting more than 3 weeks, a painless lump in the neck, pain on swallowing and one-sided ear pain. Any of these lasting 3 weeks should be checked.

What causes head and neck cancer?

The main causes are tobacco use, heavy alcohol use and HPV infection. Others include Epstein-Barr virus for nasopharyngeal cancer, betel nut chewing, sun exposure for lip cancer, and workplace exposure to wood dust or certain chemicals.

How is head and neck cancer diagnosed?

An ENT specialist examines the mouth and throat, often with a thin scope, and takes a biopsy of any suspicious area or neck lump. CT, MRI and PET scans then show how far the cancer has spread, which determines the stage and treatment.

Is head and neck cancer curable?

Many are. Early-stage cancers have high cure rates with surgery or radiation alone. Advanced cancers need combined treatment and have lower but still meaningful cure rates. HPV-related throat cancers generally respond particularly well.

Can a neck lump be the only sign of cancer?

Yes. A painless lump from cancer spread to a lymph node is sometimes the first sign, especially with tonsil, tongue base and nasopharyngeal cancers. Most neck lumps are from infections and go away within 2 to 3 weeks. One that stays longer should be checked.