head and neck cancer_2002

GALE ENCYCLOPEDIA OF NURSING AND ALLIED HEALTH1100

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KEY TERMS

Endoscope—A thin, lighted tube with a tiny cam-era attached to the end. It allows the doctor to seethe lining of the esophagus, stomach, and duo-denum.

Endoscopy—A procedure that uses an endoscope.

Gastroenterology—The study of the digestive sys-tem and diseases and disorders affecting it.

Invasive procedure—A medical procedure thatrequires entrance of a foreign object into thehuman body.

Non-invasive procedure—A medical procedurethat does not require entrance of a foreign objectinto the human body.

Serology—Blood tests.

Urea—A waste product of the breakdown of pro-teins.

comfort associated with the procedure, the patient ismildly sedated and a topical anesthetic is sprayed in thethroat. Vital signs and history are important to insure thatthe patient does not have a condition that contraindicatesthe procedure. An intravenous line is used to instill fluidsand the sedative.

For the breath test, a dose of radiolabeled urea isgiven orally to the patient. For serological tests,venipuncture is performed using standard precautions forprevention of exposure to bloodborne pathogens.

Aftercare

Following endoscopy, patients should be observedwhile recovering from sedating medications for any signsof GI bleeding or pain and treated accordingly. Thepatient should remain under medical supervision untilfully alert. After venipuncture, hemostasis should beaccomplished by applying direct pressure to the puncturesite.

Complications

Endoscopy may be associated with GI bleeding,allergic reaction to medications, and throat or abdominalpain. Rare complications also include perforation of anupper GI organ, aspiration of gastric fluid, and phlebitis.Breath and serological tests are not associated with sig-nificant complications.

Health care team roles

Endoscopy is performed by a gastroenterologist withthe assistance of registered nurses. Breath testing can beadministered by a physician or nurse. Venipuncture isperformed by a physician, nurse or phlebotomist.Serological testing is performed by a clinical laboratoryscientist, CLS(NCA)/medical technologist, MT(ASCP)or clinical laboratory technician, CLT(NCA)/medicallaboratory technician, MLT(ASCP).

Resources

PERIODICALSFallone Carlo A., Sander J.O. Veldhuyzen van Zanten, Naoki

Chiba. “The Urea Breath Test for Helicobacter pyloriInfection: Taking the Wind Out of the Sails ofEndoscopy.” Canadian Medical Association Journal(February 8, 2000): 371-2.

Sutton, Fred M. “Diagnosis of H. pylori Infection.” InfectiousMedicine 15 no. 5 (1998): 331-336.

Veldhuyzen van Zanten, Sander J. O. “Treating Non-Ulcerdyspepsia and H. pylori: It Is Economically andClinically Sensible But It Won’t Make Most PatientsBetter.” British Medical Journal (September 16, 2000).

ORGANIZATIONSNational Digestive Diseases Information Clearinghouse. 2

Information Way, Bethesda, MD 20892-3570.<http//www.niddk.nih.gov>.

Peggy Elaine Browning

Hand and arm splints see Upper limborthoses

Haptoglobin test see Plasma protein tests

HCT see Hematocrit

Head and neck cancerDefinition

The term head and neck cancers refers to a group ofcancers found in the head and neck region. This includestumors found in:

• The oral cavity (mouth): the lips, the tongue, the teeth,the gums, the lining inside the lips and cheeks, the floorof the mouth (under the tongue), the roof of the mouth,and the small area behind the wisdom teeth are allincluded in the oral cavity.

• The oropharynx: includes the back one-third of thetongue, the back of the throat, and the tonsils.

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• Nasopharynx: includes the area behind the nose.

• Hypopharynx: the lower part of the throat.

• The larynx (voice box, located in front of the neck inthe region of the Adam’s apple): in the larynx, the can-cer can occur in any of the three regions—the glottis(where the vocal cords are); the supraglottis (the areaabove the glottis), and the subglottis (the area that con-nects the glottis to the windpipe).

The most frequently occurring cancers of the headand neck area are oral cancers and laryngeal cancers.Almost half of all the head and neck cancers occur in theoral cavity, and a third are found in the larynx. By defi-nition, the term “head and neck cancers” usuallyexcludes tumors that occur in the brain.

Description

Head and neck cancers involve the respiratory tractand the digestive tract, and they interfere with the func-tions of eating and breathing. Laryngeal cancers affectspeech. Loss of any of these functions is significant.Hence, early detection and appropriate treatment of headand neck cancers is of utmost importance.

Roughly 10% of all cancers are related to the headand the neck. For cancer of the pharynx and oral cavity,there was an estimated 30,200 new cases in 2000.Incidence rates are highest in women and men over age40, and more than twice as high in men as in women. Therates of oral cancers and deaths due to this cancer havebeen declining.

Among the major cancers, the survival rate for headand neck cancers is one of the poorest. Less than 50% ofthe patients survive five years or more after initial diag-nosis. This is because the early signs of head and neckcancers are frequently ignored. Hence, when they arefirst diagnosed, these types of cancers are often in anadvanced stage and not very amenable to treatment.

The risk for both oral cancer and laryngeal cancerseems to increase with age. Most of the cases occur inindividuals over 40 years of age, the average age at diag-nosis being 60. While oral cancer strikes men twice asoften as it does women, laryngeal cancer is four timesmore common in men than in women. Both diseases aremore common in African Americans than amongCaucasians.

Causes and symptoms

Although the exact cause for these cancers isunknown, tobacco is regarded as the single greatest riskfactor: 75–80% of the oral and laryngeal cancer casesoccur among smokers. Heavy alcohol use has also been

included as a risk factor. A combination of tobacco andalcohol use increases the risk for oral cancer by six to 15times more than for users of either substance alone. Inrare cases, irritation to the lining of the mouth, due tojagged teeth or ill-fitting dentures, has been known tocause oral cancer. Exposure to asbestos also appears toincrease the risk of developing laryngeal cancer.

In the case of lip cancer, just like skin cancer, expo-sure to sun over a prolonged period has been shown toincrease the risk. In the Southeast Asian countries (Indiaand Sri Lanka), chewing of betel nut has been associatedwith cancer of the lining of the cheek. An increased inci-dence of nasal cavity cancer has been observed amongfurniture workers, probably due to the inhalation of wooddust. A virus (Epstein-Barr) has also been shown to causenasopharyngeal cancer.

Head and neck cancers are one of the easiest todetect. The early signs can be both seen and felt. Thesigns and symptoms depend on the location of the cancer:

• Mouth and oral cavity: a sore that does not heal withintwo weeks, unusual bleeding from the teeth or gums, awhite or red patch in the mouth, or a lump or thicken-ing in the mouth, throat, or tongue.

• Larynx: persistent hoarseness or sore throat, difficultybreathing, or pain.

• Hypopharynx and oropharynx: difficulty in swallowingor chewing food or ear pain.

• Nose, sinuses, and nasopharyngeal cavity: pain, bloodydischarges from the nose, blocked nose, and frequentsinus infections that do not respond to standard antibi-otics.

When detected early and treated appropriately, headand neck cancers have an excellent chance of being curedcompletely.

Diagnosis

Specific diagnostic tests used depend on the locationof the cancer. The standard tests are:

Physical examination

The first step in diagnosis is a complete and thor-ough examination of the oral and nasal cavity, using mir-rors and other visual aids. The tongue and the back of thethroat are examined as well. Any suspicious lookinglumps or lesions are examined with fingers (palpation).In order to look inside the larynx, the doctor may some-times perform a procedure known as laryngoscopy. Inindirect laryngoscopy, the doctor looks down the throatwith a small, long handled mirror. Sometimes the doctorinserts a lighted tube (laryngoscope or a fiberoptic scope)

Head and neck cancer

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through the patient’s nose or mouth. As the tube goesdown the throat, the doctor can observe areas that cannotbe seen by a simple mirror. This procedure is called adirect laryngoscopy. Sometimes patients may be given amild sedative to help them relax, and a local anesthetic toease any discomfort.

Blood tests

The doctor may order blood or other immunologicaltests. These tests are aimed at detecting antibodies to theEpstein-Barr virus.

Imaging tests

X rays of the mouth, the sinuses, the skull, and thechest region may be required. A computed tomographyscan (CT scan), a procedure in which a computer takes aseries of x ray pictures of areas inside the body, may bedone. Ultrasonograms (images generated using soundwaves) or an MRI (magnetic resonance imaging) aprocedure in which a picture is created using magnetslinked to a computer), are alternate procedures which adoctor may have done to get detailed pictures of the areasinside the body.

Biopsy

When a sore does not heal or a suspicious patch orlump is seen in the mouth, larynx, nasopharynx, or throat,a biopsy may be performed to rule out the possibility ofcancer. The biopsy is the most definitive diagnostic toolfor detecting the cancer. If cancerous cells are detected inthe biopsied sample, the doctor may perform more exten-sive tests in order to find whether, and to where, the can-cer may have spread.

Treatment

The cancers can be treated successfully if diagnosedearly. The choice of treatment depends on the size of thetumor, its location, and whether it has spread to otherparts of the body.

In the case of lip and mouth cancers, sometimes sur-gery is performed to remove the cancer. Radiation thera-py, which destroys the cancerous cells, is also one of theprimary modes of treatment, and may be used alone or incombination with surgery. If lip surgery is drastic, reha-bilitation cosmetic or reconstructive surgery may have tobe considered. Some cancers of the lip may be removedby Mohs’ surgery, also known micrographic surgery.Using this method, the surgeon removes the tumor in thinslices, examining them immediately under the micro-scope to look for cancer cells. More slices are taken until

the cancer is completely removed. The amount of normaltissue removed is minimized using this method.

Cancers of the nasal cavity are often diagnosed latebecause they have no specific symptoms in their earlystages, or the symptoms may just resemble chronicsinusitis. Hence, treatment is often complex, involving acombination of radiotherapy and surgery. Surgery isgenerally recommended for small tumors. If the cancercannot be removed by surgery, then radiotherapy is usedalone.

Treatment of oropharynx cancers (cancers that areeither in the back of the tongue, the throat, or the tonsils)generally involves radiation therapy and/or surgery. Afteraggressive surgery and radiation, rehabilitation is oftennecessary and is an essential part of the treatment. Thepatient may experience difficulties with swallowing,chewing, and speech and may require a team of healthcare workers, including speech therapists, prosthodon-tists, occupational therapists, etc.

Cancers of the nasopharynx are different from theother head and neck cancers in that there does not appearto be any association between alcohol and tobacco useand the development of the cancer. In addition, the inci-dence is seen primarily in two age groups: young adultsand 50–70 year-olds. The Epstein-Barr virus has beenimplicated as the causative agent in most patients. While80–90% of small tumors are curable by radiation therapy,advanced tumors that have spread to the bone and cranialnerves are difficult to control. Surgery is not very helpfuland, hence, is rarely attempted. Radiation remains theonly treatment of choice to treat the cancer that hasmetastasized (traveled) to the lymph nodes in the neck.

In the case of cancer of the larynx, radiotherapy isthe first choice to treat small lesions. This is done in anattempt to preserve the voice. If the cancer recurs later,surgery may be attempted. If the cancer is limited to oneof the two vocal cords, laser excision surgery is used. Inorder to treat advanced cancers, a combination of surgeryand radiation therapy is often used. Because the chancesof a cure in the case of advanced laryngeal cancers arerather low with current therapies, the patient may beadvised to participate in clinical trials so they may getaccess to new experimental drugs and procedures, suchas chemotherapy, that are being evaluated.

When only part of the larynx is removed, a relative-ly slight change in the voice may occur—the patient maysound slightly hoarse. However, in a total laryngectomy,the entire voice box is removed. The patients then haveto re-learn to speak using different approaches, such asesophageal speech, tracheo-esophageal (TE) speech, orby means of an artificial larynx.

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In esophageal speech, the patients are taught how tocreate a new type of voice by forcing air through theesophagus (food pipe) into the mouth. This method has ahigh success rate of approximately 65% and patients areeven able to go back to jobs that require a high level ofverbal communication, such as telephone operators andsalespersons.

In the second approach, TE speech, a small openingcalled a fistula, is created surgically between the trachea(breathing tube to the lungs) and the esophagus (tube intothe stomach) to carry air into the throat. A small tube,known as the “voice prosthesis,” is placed in the openingof the fistula to keep it open and to prevent food and liq-uid from going down into the trachea. In order to talk, thestoma (or the opening made at the base of the neck) mustbe covered with one’s thumb during exhalation. As theair is forced out from the trachea into the esophagus, itvibrates the walls of the esophagus. This produces asound that is then modified by the lips and tongue to pro-duce normal sounding speech.

In the third approach, an artificial larynx, a batterydriven vibrator, is placed on the outside of the throat.Sound is created as air passes through the stoma (open-ing made at the base of the neck) and the mouth formswords.

Recent developments have been made with the useof lasers for treating many types of cancer. Laser therapydestroys cancer cells by the use of high-intensity light. Itis often used to relieve symptoms of cancer such asbleeding or obstruction, particularly when other treat-ments are ineffective. Laser surgery can also treat cancerby shrinking or destroying tumors. Laser surgery is astandard treatment for certain stages of glottis. Althoughthere are several different kinds of lasers, only theCarbon dioxide (CO2) laser, Neodymium:yttrium–alu-minum–garnet (Nd:YAG) laser, and argon laser are wide-ly used in medicine. The CO2 and Nd:YAG lasers areused to shrink or destroy tumors. Laser surgery is alsoused to help relieve symptoms caused by cancer (pallia-tive care) in addition to its use in destroying cancer cells.

Since cancer cannot grow or spread without formingnew blood vessels, research is being conducted to findways to stop angiogenesis. Scientists are exploring theuse of natural and synthetic angiogenesis inhibitors, alsocalled anti-angiogenesis agents, in anticipation that thesechemicals will prevent tumor spread by inhibiting newblood vessel formation.

Taxanes are a group of cancer drugs that includespaclitaxel (Taxol) and docetaxel (Taxotere). Taxanesinhibit cancer cell growth by arresting cell division.They are also known as antimitotic or antimicrotubuleagents or mitotic inhibitors.

Photodynamic therapy (also called PDT, photoradia-tion therapy, phototherapy, or photochemotherapy) is atreatment for some types of cancer including larynx andoral cavity.

Important research is being conducted investigatingnew treatments for several head and neck cancers. Thereare many new promising treatments and improvements tocurrent therapies such as:

• Tumor growth factors. These hormone-like substancesthat are naturally occurring in the body typically pro-mote cell growth. Some tumors may grow quicklybecause of excessive growth factors. New drugs like C-225 may help inhibit tumor growth. C-225 targets aspecific area on the cancer cells’ surface; it may even-tually be used to treat other cancers such as colon,prostate, bladder, ovarian, and non-small cell lung cancer.

• New chemotherapy techniques. Intraarterial chemother-apy, where drugs are injected into arteries feeding thecancer, is being tested in combination with radiationtherapy in an attempt to improve their effectiveness.Another new approach uses intralesional chemotherapy(injecting the drug directly into the tumor). Preliminaryresults have been promising with these new chemother-apies.

• New radiotherapy methods. Studies have been under-way testing the efficacy of new radiation regimensdelivering twice-a-day irradiation. Higher cure rateshave been demonstrated.

• Vaccines may be effective by helping the immune sys-tem to recognize and attack the cancer cells.

Prognosis

Comorbidities (other illnesses) that may be presentare an important determinant of overall survival in peo-ple with head and neck cancer.

Oral cavity

With early detection and immediate treatment, sur-vival rates can be dramatically improved. For lip and oralcancer, if detected at its early stages, almost 80% of thepatients survive five years or more. However, when diag-nosed at the advanced stages, the five year survival ratedrops to a mere 18%.

Nose and sinuses

Cancers of the nasal cavity often go undetected untilthey reach an advanced stage. If diagnosed at the earlystages, the five-year survival rates are 60–70%. However,


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if cancers are more advanced, only 10–30% of thepatients survive five years or more.

Oropharynx

In cancer of the oropharynx, 60–80% of the patientssurvive five years or more if the cancer is detected in theearly stages. As the cancer advances, the survival ratedrops to 15–30%.

Nasopharynx

Patients who are diagnosed with early stage cancersthat have originated in the nasopharynx have an excellentchance of a complete cure (almost 95%). Unfortunately,most of the time the patients are in an advanced stage atthe time of initial diagnosis. With the new chemotherapy

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mouth or nose to examine the larynx and otherareas deep inside the neck.

Magnetic resonance imaging (MRI)—A medicalprocedure used for diagnostic purposes where pic-tures of areas inside the body can be created usinga magnet linked to a computer.

p53 gene—A tumor suppressor gene that typicallyinhibits the tumor growth. This gene is often alteredin many types of cancer.

Radiation therapy—Treatment using high energyradiation from x-ray machines, cobalt, radium, orother sources.

Stoma—When the entire larynx must be surgicallyremoved, an opening is surgically created in theneck so that the windpipe can be brought out to theneck. This opening is called the stoma

Taxanes—Anticancer drugs that inhibit cancer cellgrowth by arresting cell division. Also known asantimitotic or antimicrotubule agents or mitoticinhibitors.

Ultrasonogram—A procedure where high-frequen-cy sound waves that cannot be heard by humanears are bounced off internal organs and tissues.These sound waves produce a pattern of echoeswhich are then used by the computer to createsonograms, or pictures of areas inside the body.

X rays—High energy radiation used in high doses,either to diagnose or treat disease.

KEY TERMS

drugs, the five year survival rate has improved and5–40% of the patients survive five years or longer.

Larynx

Small cancers of the larynx have an excellent five-year survival rate of 75–95%. However, as with most ofthe head and neck cancers, the survival rates drop dra-matically as the cancer advances. Only 15–25% of thepatients survive five years or more after being initiallydiagnosed with advanced laryngeal cancer.

Advances in detecting head and neck cancer at anearly stage are being made. Patients’ prognoses willimprove as technological advances are made. Some ofthe research that is being conducted includes DNA muta-tions (changes) that occur in genes. Damage to certainDNA can lead to increased growth of abnormal cells and

Angiogenesis—The formation of blood vesselsaround a tumor.

Biopsy—The surgical removal and microscopicexamination of living tissue for diagnostic purposes.

Chemotherapy—Treatment of cancer with synthet-ic drugs that destroy the tumor either by inhibitingthe growth of the cancerous cells or by killing thecancer cells.

Clinical trials—Highly regulated and carefully con-trolled patient studies, where either new drugs totreat cancer or novel methods of treatment areinvestigated.

Computerized tomography scan (CT scan)—Amedical procedure where a series of x rays aretaken and put together by a computer in order toform detailed pictures of areas inside the body.

Growth factors—Growth factors or human growthfactors are compounds made by the body that func-tion to regulate cell division and cell survival. Somegrowth factors are also produced in the laboratoryby genetic engineering and are used in biologicaltherapy. Growth factors are significant becausethey can induce angiogenesis, the formation ofblood vessels around a tumor. These growth factorsalso encourage cell proliferation, differentiation,and migration on the surfaces of the endothelialcells.

Laryngoscopy—A medical procedure that uses flex-ible, lighted, narrow tubes inserted through the

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formation of cancers. Recent studies suggest that tests todetect p53 gene alterations may allow very early detec-tion of oral and oropharyngeal tumors. Other substancesunder investigation that may help early prognosis of can-cers are epidermal growth factor receptor, transforminggrowth factor-alpha, and cyclin D1.

Using targeted chemoradiation, one clinical studyrevealed that statistical projections for overall and can-cer-related five-year survival was 38.8% and 53.6%,respectively for patients with advanced (stage III-IV)carcinoma of the head and neck.

Health care team roles

Depending on the diagnosis, disease stage, level ofnursing care required, and different psychosocial factors,the patient’s health care needs will vary. The carerequired is unique to each patient and family. For patientswho will be in transitional care, an optimal integrationbetween inpatient and outpatient care is needed to ensurethe best care possible. Outpatient care includes homecare, rehabilitation centers, nursing homes, and hospicecare. Health care teams should make the transition fromthe different types of inpatient and outpatient care as easyas possible. Effective communication between profes-sionals is critical.

A dental team with experience in oral oncology, mayreduce the risk of oral complications for patients withoral cancers.

Prevention

Refraining from the use of all tobacco products (cig-arettes, cigars, pipe tobacco, chewing tobacco), consum-ing alcohol in moderation, and practicing good oralhygiene are some of the measures that one can take toprevent head and neck cancers. Since there is an associa-tion between excessive exposure to the sun and lip can-cer, people who spend a lot of time outdoors in the sunshould protect themselves from the sun’s harmful rays.Regular physical examinations, or mouth examination bythe patient himself, or by the patient’s doctor or dentist,can help detect oral cancer in its very early stages.

Since working with asbestos has been shown toincrease one’s risk of getting cancer of the larynx, asbestosworkers should follow safety rules to avoid inhalingasbestos fibers. Also, malnutrition and vitamin deficiencieshave been shown to have some association with anincreased incidence of head and neck cancers. TheAmerican Cancer Society recommends eating a healthydiet, consisting of at least five servings of fruits and veg-etables every day, and six servings of food from other plantsources such as cereals, breads, grain products, rice, pasta,

and beans. Reducing one’s intake of high-fat food fromanimal sources is advised. Following the The DietaryGuidelines for Americans published by the United StatesDepartment of Agriculture and Health and Human Servicescan provide a broad overall view of good nutrition.

These dietary guidelines include these seven basicrecommendations:

• Eat a variety of foods.

• Control your weight.

• Eat a low-fat, low-cholesterol diet.

• Eat plenty of vegetables, fruits, and grains.

• Eat sugar in moderation.

• Use salt in moderation.

• If you drink alcohol, do so in moderation; no more thantwo drinks per day of wine, beer, or spirits.

The Food Guide Pyramid was created by the UnitedStates Department of Agriculture to help Americanschoose foods from each food grouping. The food pyra-mid, developed by nutritionists, provides a visual guideto healthy eating.

Resources

BOOKSHarrison, Louis B., et al., eds. Head and Neck Cancer: A

Multidisciplinary Approach. Philadelphia: LippincottWilliams & Wilkins Publishers, 1999.

Thawley, Stanley E., et al., eds. Comprehensive Managementof Head and Neck Tumors. 2nd ed. London: W. B.Saunders Co., 1999.

ORGANIZATIONSAmerican Association of Oral and Maxillofacial Surgeons.

9700 W. Bryn Mawr; Rosemont, IL 60018. (800) 467-5268. <http://www.aaoms.org>.

American Dietetic Association. 216 W. Jackson Blvd.Chicago, IL 60606-6995. (312) 899-0040.<http://www.eatright.org>.

International Association of Laryngectomees (IAL). 7440North Shadeland Avenue, Suite 100, Indianapolis, IN46250. <http://www.larynxlink.com/welcome.html>.

National Cancer Institute (National Institutes of Health). 9000Rockville Pike, Bethesda, MD 20892. (800) 422-6237.<http://cancernet.nci.nih.gov>.

National Oral Health Information ClearingHouse. 1 NOHICWay, Bethesda, MD 20892-3500. (301) 402-7364.<http://www.nohic.nih.gov>.

Oral Health Education Foundation, Inc. 5865 Colonist Drive,P.O. Box 396, Fairburn, GA 30213. (770) 969-7400.

Support for People with Oral and Head and Neck Cancer(SPOHNC). P.O. BOX 53 Locust Valley, NY 11560-0053. (800) 377-0928. <http://www.spohnc.org>.

Crystal Heather Kaczkowski, MSc.


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head and neck cancer_2002

Health & Medicine