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For generations, head and neck cancer was largely a disease of smokers, especially smokers who also consumed alcoholic beverages. But the human papillomavirus (HPV) has expanded that disease landscape. Today, head and neck cancers are often HPV-related and found in younger patients who may not even smoke or drink.
Cancers of the head and neck can affect the lips, mouth, salivary glands, throat, nose, sinuses, voice box, trachea, and thyroid. Each of these areas is vital to everyday living—eating, speaking, breathing—and each can have unique diagnostic and treatment challenges. So cancers of this type can most certainly be life-altering.
The good news is that many of these cancers can be prevented.
Head and Neck Cancer Risk Factors
The major risks for head and neck cancer include:
- Tobacco, alcohol, and HPV exposure, including “smokeless” tobacco products, chewed or held in the mouth.
- Being male. We’re not sure why men have twice the risk of women, although it may be due to a greater tendency to smoke and drink.
- Poor oral hygiene. Long-term inflammation of the tissues in the mouth can create damage at a cellular level that could evolve into cancer. Dentists are often the first to spot suspicious abnormalities in a patient.
- Increasing age. As with any cancer, risk increases with age. Head and neck cancers are quite rare in children—most patients diagnosed are over the age of 50. Our cells continually replicate and replace themselves and, over the course of a lifetime, those cells may become exposed to and injured by carcinogens and move a step closer to becoming cancerous. The longer you live, the more likely that your DNA may sustain damage.
- Vaping, or e-cigarettes. This potential new risk is not well regulated, and the possible effect of this vapor is an area of ongoing study.
- Other risks include occupational hazards (such as chemicals), the consumption of smoked and preserved foods, and exposure to Epstein-Barr, the virus that causes mononucleosis.
At this point, with the exception of thyroid cancer, there’s no indication that family history predisposes a patient to contract a head or neck cancer; so far, we’ve seen none of the genetic predictors of risk that we often see with other cancers.
With the exception of salivary gland cancers, no fewer than 75 percent of head and neck cancers result directly from tobacco and alcohol use. While tobacco use alone can be considered a smoldering fire, alcohol can act as the gasoline that feeds it—research clearly shows that the two substances become significantly more lethal when used together.
Rock musician Eddie Van Halen presented a classic case: a smoker and drinker from age 12, he eventually lost part of his tongue to cancer, and later developed throat cancer that helped contribute to his illness and death in 2020. A generation earlier, similar circumstances took the life of entertainer Sammy Davis, Jr., at age 64.
Most cancers of the head and neck are preventable! Stay healthy by knowing the risks, particularly if you combine smoking and drinking, says Dr. Jonathan Giurintano. https://bit.ly/3a5LvFC via @MedStarWHC
The Concern about HPV
In recent years, HPV, a sexually transmitted virus with hundreds of strains, has entered the picture as a major cause of head and neck cancers. Although most strains of HPV—for example, those that cause warts—are fairly innocuous, some create the potential for cells to mutate and become cancerous. Medical science has recognized the cancer link for decades, initially in cervical cancer where men were thought to be asymptomatic carriers of the disease.
In recent years, we have begun to see HPV-related cancers affecting patients a decade younger than previously typical, many of them with no significant history of smoking or drinking. Younger people—both men and women—are developing cancers (very similar to HPV-related cervical cancer) in the throat and at the back of the tongue.
With the great prevalence of HPV, it is felt that most people will become exposed to a strain of this virus at some point in their sexual history. This is why vaccination against HPV is so important, and best administered at an age before sexual activity begins. When HPV vaccines were first developed, they were targeted to protect young girls against cervical and other pelvic cancers; however, now we vaccinate both girls and boys to provide protection against all aspects of HPV for them and their future sexual partners.
Current guidelines recommend that the HPV vaccine be administered to male and female patients ages 9 to 26—one of the most important ways to protect a young person’s health. This effort, as well as more aggressive screening, has resulted in a recent decrease in instances of cervical cancer. And, as HPV vaccines become more widely administered, we hope to see tongue and throat cancer rates drop as well.
Head and Neck Cancer Symptoms
What are the warning signs of head and neck cancers?
Symptoms may include a sore or abnormal spot that doesn’t improve. Patients describe it as feeling like they bit their tongue or burned the roof of the mouth, but the sensation persists for weeks or months.
Evidence of cancer can also present as swelling in the jaw; pain in the chin, face, or neck; hoarseness; or difficulty swallowing or breathing. As with many cancers, unexplained weight loss may serve as a warning sign as well.
However, in the case of HPV-related cancers, the patient may experience little more than a swollen lymph node in the neck. Because it’s so easy to attribute this symptom to a more benign condition, a regular physical examination with your health care provider is very important.
Diagnosing Head and Neck Cancer
In assessing a patient, I begin with a health history and a thorough examination of the head and neck—looking into the mouth and throat and feeling the neck for enlarged lymph nodes or masses.
I can conduct a non-invasive laryngoscopy on the patient by using a simple local anesthetic spray and passing a small camera into the nose. The flexible fiber-optic laryngoscope gives a good view of the entire back of the throat, down to the voice box.
Sometimes we can also take a small sample of tissue for lab analysis; however, if the area is hard to reach, we’ll schedule a more complete exam and biopsy under general anesthesia. We may also use CT, MRI, or PET imaging to help with a diagnosis.
Fortunately, HPV-related cancers tend to respond well to non-surgical treatment via radiation therapy. Many can be treated with no surgery at all.
Other head and neck cancers, however, can be much more challenging and require extensive and complex surgery, as well as radiation. At MedStar Washington Hospital Center, our aim during surgery is to remove cancerous tissue while preserving the patient’s appearance and functional activities of swallowing, speaking, and breathing.
For complex surgeries, I team with Dr. Matthew Pierce, also a head and neck surgeon. One of us concentrates on removing the cancer, while the other manages any necessary reconstruction. In situations where we must remove significant amounts of tissue, we can often rebuild the area with tissue harvested from another area of the patient’s body, such as the thigh or forearm. We can even rebuild affected bone with tissue from the lower leg.
And while the surgeon essentially serves as the surgical team’s quarterback, the team itself makes all the difference. At the Hospital Center, the head and neck surgeons work closely with radiology and pathology for diagnostics; with nutrition, rehabilitation, and speech therapy in the areas of swallowing and speech; with neurology for pain management; with oncology and radiation oncology for cancer care; with psychologists to help the patient manage their feelings and reactions to the disease; and with skilled nurses who support us every step of the way. Every player contributes to the best possible outcome, with the patient at the center of the effort.
Today’s techniques have brought us a long way from the days when survivors experienced significant disfigurement or had basic functions like swallowing permanently disrupted. Many current research efforts focus on preserving function for the patient and on decreasing the trauma of surgery and follow-up treatment.
In other areas of research, medical scientists are working to develop a testing procedure, similar to a Pap smear, which could identify cellular changes within the tonsil or lingual tonsillar tissue and predict possible future development of an oropharyngeal cancer. New operating room advances include use of radio fluorescence to identify the margins of cancer in areas that are difficult to assess via physical examination and to help ensure more thorough removal of cancerous cells during surgery.
The Best Strategy Is Prevention
It’s an unfortunate reality that the longer that these cancers grow, the more difficult they are to treat. And it’s important to remember that this type of cancer can be aggressive and fast-growing. Once head or neck cancer has spread, the prognosis for the patient can be very poor. Patients with small tumors can have an 80 percent chance of survival. But in patients who neglect treatment for just a few months, the head and neck cancer survival rate may be only 30 or 40 percent over the next five years.
Some of our greatest hope comes in spreading the word about prevention. A few words of preventative advice:
- Visit your healthcare provider for an annual checkup. If you smoke, it’s never too late to quit. Regular users of tobacco and alcohol should have an open and honest discussion with their physician about risks and strategies for early detection of head and neck cancers.
- Drink in moderation, particularly if you are also a smoker.
- Visit the dentist regularly. Unhealthy teeth increase the risk of cancerous conditions, and dentists are trained to recognize problem areas.
- Vaccinate your kids against HPV—or, if you’re a young adult under 26, request the vaccine for yourself.
Don’t Delay Care
The COVID-19 pandemic has had an unfortunate effect—we saw more advanced cases of head and neck cancers than we normally would, as people feared seeking medical treatment during the early stages of the pandemic.
Nearly every week, a patient apologizes for “wasting my time” when I find something benign. Be assured, this is never a “waste of time.” I’m always happy to tell a patient that he or she does not have cancer.
But discovering something more serious is much sadder—especially when it’s too late to make a real difference. The best approach: stay in touch with your doctor and get checked if you see or feel anything suspicious.