HEAD & NECK CANCER

In Australia, by far the most common cancers of all affect the skin due to exposure to the sun’s UV rays. Cancers arising in the mouth, jaws and neck make up around 2% of all cancers diagnosed annually. Many of these are linked to smoking tobacco however a small proportion are associated with viruses (such as Human Papilloma Virus- HPV) similar to those that cause cervical cancer in women.

Head and neck cancers can involve the tongue, mouth, salivary glands and the various areas of the pharynx (throat). Also, malignant change can occur in the nasal cavity, middle ear, sinuses and larynx. The majority of these tumours arise in the cells that form the lining of the surfaces of the head and mouth (mucosal squamous cell cancers) but some arise from the glandular cells beneath (adenocarcinomas).

Oral and Maxillofacial Surgeons play an essential role in the management of patients with oral and maxillofacial cancer, as well as for patients with head & neck cancers in general.

Patients are best managed within multi-disciplinary head and neck oncology teams, usually based in major hospitals. The team includes representatives of Oral and Maxillofacial Surgery, Otorhinolaryngology Head and Neck, Reconstructive Plastic and General Surgery. Essential Medical Specialties include Radiation Oncology, Medical Oncology, Palliative Medicine as well as Investigative Medicine, Radiology, Pathology and Nuclear Medicine.

Allied Health representatives include Speech Pathology, Nutrition, Radiation Therapy and Clinical Psychology. Nursing provides for care co-ordination, peri-treatment care and theatre care. Special Needs Dentists contribute to the care of patients, particularly when radiotherapy to the jaws and salivary glands is provided, and as part of post-operative rehabilitation.

Oral and Maxillofacial cancer is a serious malignant disease, which will likely prove fatal if not treated. In 2010 Head and Neck Cancers were responsible for 1045 deaths in Australia.

Risk Factors

The causes of head and neck cancer are multifactorial and include smoking tobacco and marijuana, chewing tobacco and or betel nut, as well as frequent alcohol use. Additional factors include sun exposure for lip and skin cancer, Human Papilloma Virus, particularly for oropharyngeal cancer. Chronic infection and dental irritation may also be factors.

There is a significant group of patients who develop oral cancers who are both non-smokers and non-drinkers, and are very often females in either their 4th or 6th decade. The fact that a patient is neither a smoker nor a drinker should not reduce the suspicion that the patient may have a cancer.

Cancers in the oral cavity usually begin as an ulcer or lump affecting the lip, tongue, palate or floor of mouth, they may also appear as a red or white patch on the surface of the lining of the mouth (mucosa). These cancers have a significant potential to spread to the regional lymph nodes in the neck and present as firm swellings in the neck, sometimes with only small lesions to be found in the mouth or oropharynx.

Dentists and general medical practitioners have a role to play in the early diagnosis of head and neck cancers by examining the oral cavity, oropharynx, facial and neck skin as a form of screening when patients present for routine dental and medical care. This is most important for patients who are heavy smokers and drinkers. Some patients may present with pre-malignant lesions, which are likely to progress to established cancers. These so called potentially malignant lesions may be white or red or speckled patches in the mucosa. Their removal may prevent the development of an established cancer.

The outcomes of care for patients who are diagnosed with small, early tumours is much better than for patients diagnosed with large, late tumours. Patients who are suspected of having a malignant or potentially malignant lesion in the head and neck should be immediately referred to an Oral and Maxillofacial Surgeon or head and neck cancer team for assessment, a likely biopsy, diagnosis and staging.

Management

Patients with oral and maxillofacial facial cancer should be referred to a multi-disciplinary head and neck cancer team in a major hospital. Some of these teams have regional affiliated outreach clinics where patients can be assessed and staged, and when appropriate have their treatment regionally. The sequence of care can vary depending on the tumour type and its extent.

Surgery is the mainstay for patients with cancers involving the oral cavity, salivary glands and skin. Patients presenting with advanced disease will most often have initial surgery and follow on (adjuvant) radiotherapy often combined with chemotherapy. After complete removal of the cancer, reconstruction of the defect, often utilizing Microvascular Surgery and free tissue transfer. Bone, muscle and skin can be taken from other parts of the body and used to replace the missing part.

Rehabilitation is the process of assisting the patient to return to as near normal function as possible, with speech, swallowing, chewing and facial form as important goals. Every attempt is made to achieve physical and aesthetic rehabilitation so that patients can reasonably resume their place in society, the workplace and family. Psychosocial factors must be addressed as part of multi-disciplinary care.