Treatment for head and neck cancers

It is important to look after your health before treatment begins. This will help you cope with side effects and can improve treatment outcomes.

Stop smoking – If you smoke, aim to quit before starting treatment. If you keep smoking, you may not respond as well to treatment, side effects may be worse and you will have a higher risk of a new cancer. See your doctor or call the Quitline on 13 7848.

Begin or continue an exercise program – Exercise will help build up your strength for recovery. Talk to your doctor or physiotherapist about the right type of exercise for you.

Improve diet and nutrition – A dietitian can suggest ways to maintain your weight during treatment by changing your diet or taking special drinks (liquid supplements). This will help improve your strength and may mean the treatment works better.

Avoid alcohol – Alcohol can irritate mouth sores caused by the cancer or treatment.

See a dentist – Treatments for head and neck cancer can affect your mouth, gums and teeth. Your specialist may refer you to a special needs dentist who understands the treatments you will be having. You will need a full check-up and an oral health care plan covering any dental work you need and how to care for your mouth.

The aim of surgery is to completely remove the cancer and preserve the functions of the head and neck area, such as breathing, swallowing and talking. If you have surgery, the surgeon will cut out the cancer and a margin of healthy tissue, which is checked by a pathologist to make sure all the cancer cells have been removed. Often some lymph nodes will also be removed.

The types of surgery used for the different head and neck cancers are described below. Thinking about having surgery to your head and neck can be frightening. Talking to your treatment team can help you understand what will happen. You can also ask to see a social worker or psychologist for emotional support before or after the surgery.

Removing lymph nodes

If the cancer has spread to the lymph nodes in your neck, or it is highly likely to spread, your surgeon will probably remove some lymph nodes. This operation is called a neck dissection or lymphadenectomy. Your surgeon will let you know if this is recommended and explain how the procedure is done.

Most often lymph nodes are removed from one side of the neck, but sometimes they need to be removed from both sides. A neck dissection may be the only surgery needed, or it may be part of a longer head and neck operation. The surgeon will make a cut under your jaw and sometimes down the side of your neck. You will often have a small tube (drain) in your neck to remove fluids from the wound for a few days after the surgery. A neck dissection may affect how your shoulder moves and your neck looks after surgery. A physiotherapist can help improve movement and function.

How the surgery is done

If you have surgery for a head and neck cancer, different surgical methods may be used to remove the cancer. Each method has advantages in particular situations – your doctor will advise which method is most suitable for you. The options may include:

• endoscopic surgery – a rigid instrument with a light and camera is inserted through the nose or mouth so the surgeon can see and remove some cancers, particularly from the nose and sinuses
• transoral laser microsurgery (TLM) – a microscope usually with a laser attached is used through the mouth to remove cancers, particularly of the larynx and lower throat
• transoral robotic surgery (TORS) – the surgeon uses a 3D telescope and instruments attached to robotic arms to reach the cancer through the mouth; often used for oropharyngeal cancers
• open surgery – the surgeon makes cuts in the skin of the head and neck to reach and remove cancers; used for larger cancers and those in difficult positions. Part of the upper and lower jaw or skull may need to be removed and then replaced or reconstructed.

Minimally invasive surgery such as endoscopic, TLM and TORS usually means less scarring, a shorter hospital stay and faster recovery. However, these types of surgery are not possible in all cases, and open surgery is often the best option in many situations.

Reconstructive surgery

After open surgery, you may need reconstructive surgery to help with your swallowing and to improve how the area looks. It is usually part of the same operation but is sometimes done later.

Reconstructive surgery uses a combination of skin, muscle and occasionally bone to rebuild the area. This can be taken from another part of the body and is called either a free flap or a regional flap. Occasionally synthetic materials such as silicone and titanium are used to re-create bony areas or other structures in the head and neck, such as the palate. This is called a prosthetic.

Surgery for oral cancer

The type of surgery depends on the cancer’s size and location. Localised cancers can be treated by removing part of the tongue, mouth or lip. For larger cancers, the surgery will affect a bigger area and you may need reconstructive surgery so you can continue to chew, swallow or speak.

Some tumours can be removed through the mouth, but you may need open surgery for larger tumours. Different types of oral surgery include:

• glossectomy – removes part or all of the tongue
• mandibulectomy – removes part or all of the lower jaw (mandible)
• maxillectomy – removes part or all of the upper jaw (maxilla).

Surgery for pharyngeal cancer

Pharyngeal cancers are treated differently depending on which part of the pharynx is affected. Surgery is used for many oropharyngeal and
hypopharyngeal cancers. Nasopharyngeal cancers are usually treated with radiation therapy and rarely treated with surgery.

Small oropharyngeal and hypopharyngeal cancers can often be treated with minimally invasive surgery, sometimes followed by radiation therapy with or without chemotherapy. If the cancer is large or advanced and surgery is an option, it is more likely to be open surgery through a cut in the neck. If part of the jaw is removed, the jaw will be reconstructed. Surgery is often followed with radiation therapy and possibly chemotherapy.

Different types of pharyngeal surgery include:

• oropharyngectomy – removes some of the oropharynx (the part of the throat behind the mouth)
• hypopharyngectomy – removes part of the hypopharynx (the lower throat)
• laryngopharyngectomy – removes all of the larynx and most of the pharynx. This surgery is less common and is similar to a total laryngectomy

Surgery for laryngeal cancer

If laryngeal cancer is at an early stage, you may have surgery to remove part of the larynx (partial laryngectomy). The surgery may be  minimally invasive or open. It often takes up to six months for the voice to recover. In some cases, the changes to the voice may be permanent.

If the cancer has advanced, you may need open surgery to remove the larynx (total laryngectomy). This operation removes the whole larynx and separates the windpipe (trachea) from the food pipe (oesophagus). After this surgery, you will breathe through a hole in the front of your neck called a laryngectomy stoma. This is a permanent change and you will no longer be able to breathe through your nose and mouth. Because this surgery removes the voice box, you won’t be able to speak in the same way. These changes can be hard at first. A speech pathologist will teach you new ways to talk and communicate.

If you have a total laryngectomy, part or all of your thyroid gland may be removed (thyroidectomy). The thyroid produces thyroxine (T4), the hormone that controls your metabolism, energy levels and weight, so you may need to take thyroid hormone replacement tablets every day for the rest of your life. Talk to your doctor for more details.

Surgery for nasal or paranasal sinus cancer

Your doctor may advise you to have surgery if the tumour isn’t too close to your brain or major blood vessels. The type of surgery will depend on where the tumour is and, if you have paranasal sinus cancer, which sinuses are affected. You will often need to have reconstructive surgery as well.

Nasal and sinus cancers are often close to the eye socket, brain, cheek bones and nose. Your surgeon will talk to you about the most suitable approach and whether any other structures need to be removed to get the best outcome.

Different types of surgery for nasal and sinus cancer include:

• maxillectomy – removes part or all of the upper jaw (maxilla); may include the upper teeth, part of the eye socket and/or the nasal cavity
• skull base surgery – also known as a craniofacial resection, this surgery removes part of the nasal cavity or sinuses; often done endoscopically through the nose, but a cut along the side of the nose may be needed; sometimes a neurosurgeon assists with this surgery
• orbital exenteration – removes the eye and may also remove tissue around the eye socket
• rhinectomy – removes part or all of the nose.

The surgeon will consider how the operation will affect how you look, and your ability to breathe, speak, chew and swallow. If your nose, or a part of it, is removed, you may get an artificial nose (prosthesis) or the nose may be reconstructed using tissue from other parts of your body. The process for completing the prosthetic or reconstructed nose may take several months. Your surgeon will give you more information about the different steps and the overall timing.

Surgery for salivary gland cancer

Most salivary gland tumours affect one of the parotid glands, which sit in front of the ears. Surgery to remove part or all of a parotid gland  is called a parotidectomy.

The facial nerve runs through the parotid gland. This nerve controls facial expressions and movement of the eyelid and lip. If it is damaged during surgery, you may be unable to smile, frown or close your eyes. This is known as facial palsy, and it will usually improve over several months. In some cases, the facial nerve needs to be cut so the cancer can be removed. This will affect how your face looks and moves. There are various procedures that can help improve this, such as using a nerve from another part of the body (nerve graft).

If the cancer affects a gland under the lower jaw (submandibular gland) or under the tongue (sublingual gland), the gland will be removed, along with some surrounding tissue. Nerves controlling the tongue and lower part of the face may be damaged, causing some loss of function.

How long will I stay in hospital?

How long you stay in hospital depends on the type of surgery you have, the area affected, and how well you recover. Surgery to remove some small cancers can often be done as a day procedure. Recovery is usually fast and there are often few long-term side effects.

Surgery for more advanced cancers often affects a larger area, can involve reconstructive surgery and may last all day. You may need care in the intensive care unit before being transferred to the ward, and side effects may be long term or permanent. Once you return home, you may be able to have nurses visit to provide follow-up care.

Will I have any side effects?

Most surgeries for head and neck cancer will have some short-term side effects, such as discomfort and a sore throat. Recovery after larger surgeries may be more challenging, especially at first.

Depending on the type of surgery you had, after a period of recovery, you may not have any ongoing issues. However, some people do need to adjust to lasting changes after head and neck surgery. Long-term side effects can include changes to energy levels, eating, speaking, breathing, appearance, sexuality, vision and hearing, as well as ongoing pain and lymphoedema (swelling caused by a build-up of lymph fluid).

Talk to your treatment team about what to expect and try to see a speech pathologist and/or dietitian before treatment starts.

What to expect after surgery

How you will feel after head and neck cancer surgery will vary greatly depending on your age, your general health, how large an area is affected and whether you also have reconstructive surgery. Your surgeon can give you a better idea of what to expect after the operation. The side effects listed below are often temporary.

Pain – You will have some pain and discomfort for several days after surgery, but you will be given pain medicines to manage this. You may take tablets or be given injections, or you may have patient-controlled analgesia (PCA), which delivers a measured dose of pain medicine through a drip when you press a button.

Drains and catheters – For a few days, you may have tubes at the surgery site to drain fluid from the wound into small containers. You may also  have a catheter, a tube from your bladder that drains urine into a bag.

Speech changes – Some surgeries affect the ability to speak clearly, but your team will discuss this with you beforehand. This issue is often temporary, and a speech pathologist will help you improve your speech.

Breathing difficulties – If surgery is likely to cause your mouth, tongue or throat to become swollen, your surgeon will talk to you about having a temporary tracheostomy. This is a breathing tube in your neck that lets you breathe easily.

Sore throat – It is common to have a sore throat after surgery on the mouth or throat, but you will be given medicine to control any pain. You may also have some throat discomfort from the anaesthetic tube for a few days.

Eating and drinking – You will usually wake up from surgery with a drip in your arm to give you fluids. You usually won’t be allowed to eat or drink  for several hours. Depending on the surgery, you may then start with clear liquids, move on to pureed food, and then soft foods.

Swallowing – Surgery will sometimes change the way you swallow and this can often be difficult at first. A speech pathologist will help you regain your ability to swallow.

Feeding tube – If eating and drinking will be difficult while you are recovering, a temporary feeding tube may be inserted through your nose (nasogastric or NG tube). Another option is a gastrostomy or PEG tube inserted into your stomach.

Movement – After some surgeries, you may be in bed for a couple of days. A physiotherapist will teach you breathing exercises to help clear your lungs and reduce the risk of a chest infection. As soon as possible, your team will encourage you to walk around or sit out of bed. This will speed up recovery.

Feeling emotional – Having head and neck surgery can be emotionally challenging. Your treatment team can support you after your surgery  by talking through your feelings. You or your family may like to talk to your nurse, social worker or a psychologist.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, this treatment uses a controlled dose of radiation to kill or damage cancer cells. For head and neck cancer, the radiation is usually in the form of x-ray beams that come from a machine outside the body. This is called external beam radiation therapy (EBRT), and it is often delivered using a technique called intensity modulated radiation therapy (IMRT). This technique targets the radiation precisely to the cancer, which reduces treatment time and causes as little harm as possible to nearby healthy tissue.

Radiation therapy as the main treatment – For some pharyngeal and laryngeal cancers, radiation therapy will be the main treatment, with the aim of destroying the cancer while maintaining normal speech, swallowing and breathing. Sometimes chemotherapy will also be used to make the radiation work better (chemoradiation).

Radiation therapy after surgery – Radiation therapy is often used after surgery for head and neck cancers. This is known as adjuvant treatment. The aim is to destroy any remaining cancer cells and reduce the chance of the cancer coming back. You will probably start radiation therapy as soon as your wounds have healed and you’ve recovered your strength, which should be within six weeks. Adjuvant radiation therapy is sometimes given together with chemotherapy (chemoradiation).

Before radiation therapy begins, you will meet with the radiation oncologist to work out whether radiation therapy is right for you. You will then have a planning session with a CT scan to help show the exact area that needs to receive the radiation. At the planning session, you will also be fitted for a plastic mask called an immobilisation mask. You will wear this at each treatment session.

External beam radiation therapy

Click on image to enlarge

Having radiation therapy

Radiation therapy is carefully planned to make sure enough radiation reaches the cancer, while as little as possible reaches healthy organs and tissues. During treatment sessions, you will lie on a table under a machine called a linear accelerator, which precisely delivers the radiation. The treatment is painless and is usually given Monday to Friday for 6–7 weeks. You usually won’t need to stay in hospital.

Wearing the mask

You will wear the plastic mask for 10–20 minutes at each session. The mask helps you keep still and ensures the radiation is targeted at the same area. You can see and breathe through the mask, but it may feel strange and confined at first. Tell the radiation therapists if the mask makes you feel uncomfortable – you can ask to talk to the social worker or psychologist and may be offered medicine to help you relax.

Side effects of radiation therapy

Radiation therapy side effects vary depending on the area treated, the number of sessions, and whether it is combined with chemotherapy. Side effects often get worse 2–3 weeks after treatment ends and then start to improve. Some side effects may last longer, be ongoing or appear several months or years later. The most common short-term and long-term side effects are listed below.

During or immediately after treatment – Short-term side effects can include fatigue, mouth sores, taste changes, loss of appetite, dry mouth and thick saliva, swallowing difficulties, skin redness, burning and pain in the area treated, breathing difficulties and weight loss.

Ongoing or permanent – Longer-term side effects may include dry mouth, thick saliva, difficulties with swallowing and speech, changes in taste, fatigue, muscle stiffness, neck swelling, appetite and weight loss, mouth infection (oral thrush), hoarseness, dental problems such as tooth decay, difficulty opening the mouth, and hair loss.

Aspiration – Some people develop a temporary or ongoing problem where fluid or food enters the windpipe while swallowing. This is called aspiration and it can cause coughing, lung infections such as pneumonia and, sometimes, difficulty breathing.

Thyroid damage – If the treatment damages the thyroid, it can cause an underactive thyroid (hypothyroidism). This can be managed with thyroid hormone replacement tablets.

Osteoradionecrosis of the jaw – Radiation therapy can damage blood vessels, reducing the blood supply to the area treated. Occasionally, the bone starts to die, leading to pain, infection and fractures. This is known as osteoradionecrosis or ORN. About 5–7% of people who have radiation therapy to the head and neck develop ORN of the jaw. It can occur months or years later, most commonly after having dental work such as the removal of teeth, when the bone is unable to heal itself. This is why you will usually see a dentist before your cancer treatment, so any dental issues can be treated before there is a risk of ORN.

It is very important to tell your dentist that you have had radiation therapy before beginning any dental work. Treatment for ORN may include antibiotics, other medicines or surgery. To help the bone heal, you may also have hyperbaric oxygen treatment (breathing in concentrated oxygen in a pressurised chamber).

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells. You will usually receive chemotherapy by injection into a vein (intravenously), although it is occasionally given as tablets. How often you have chemotherapy sessions will depend on the treatment plan.

Chemotherapy may be given for a range of reasons:

• in combination with radiation therapy (chemoradiation), to increase the effects of radiation
• before surgery or radiation therapy (neoadjuvant chemotherapy), to shrink a tumour
• after surgery (adjuvant chemotherapy), along with radiation therapy, to reduce the risk of the cancer returning
• as palliative treatment to relieve symptoms such as pain.

Side effects of chemotherapy

Chemotherapy can affect the healthy cells in the body and cause side effects. Everyone reacts differently to chemotherapy, and effects will vary according to the drugs you are given. Some people may have few side effects, while others have many. Your medical oncologist or nurse will discuss the likely side effects with you, including how these can be prevented or controlled with medicine.

Common side effects include tiredness and fatigue; nausea and/or vomiting; tingling or numbness in fingers and/or toes (peripheral neuropathy); changes in appetite and loss of taste; diarrhoea or constipation; hair loss; low red blood cell count (anaemia); hearing loss; ringing in the ears (tinnitus); lower levels of white blood cells, which may increase the risk of infection; and mouth sores.

Keep a record of the names and doses of your chemotherapy drugs handy. This will save time if you become ill and need to go to the hospital emergency department.

Download our booklet ‘Understanding Chemotherapy’

In certain situations, you may be offered another type of drug therapy for head and neck cancer. The options may include targeted therapy  and immunotherapy, which work in different ways to chemotherapy. They will usually be combined with other treatments such as radiation therapy.

Targeted therapy – Targeted therapy targets specific features of cancer cells to stop the cancer growing and spreading. Each targeted therapy drug works on a particular feature, and the drug will only be given if the cancer cells have that feature. For some head and neck cancers, a targeted therapy drug called cetuximab is occasionally used when people cannot take the standard chemotherapy drug or the cancer is advanced.

Download our fact sheet ‘Understanding Targeted Therapy’

Immunotherapy – Immunotherapy uses the body’s own immune system to fight cancer. The main type of immunotherapy in Australia uses drugs known as checkpoint inhibitors, which help the immune system to recognise and attack cancer cells. Nivolumab is a checkpoint inhibitor used to treat some types of advanced head and neck cancer.

Download our fact sheet ‘Understanding immunotherapy’

Other targeted therapy and immunotherapy drugs are being studied in clinical trials. Talk with your doctor about the latest developments and whether a clinical trial would be an option for you.

In some cases of very advanced head and neck cancer, the medical team may talk to you about palliative treatment. Palliative treatment aims to improve your quality of life by managing the symptoms without trying to cure the disease. When used as palliative treatment, radiation therapy, chemotherapy or other drug therapies can help manage pain and other symptoms, and may also slow the spread of the cancer.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, spiritual and social needs. The team also supports families and carers.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’