Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team.

Treatment for head and neck cancer depends on:

• the type of cancer
• the stage of the disease
• the location of the cancer
• the severity of symptoms
• your general health and personal preferences.

Treatment may involve the following.

Surgery

Surgery is a common treatment for all stages of head and neck cancer. The type of surgery you have depends on where the cancer is, how big the cancer is, whether the cancer has spread, your age, medical history and general health.

While removing the cancer, the surgeon will also remove surrounding healthy tissue to make sure no cancer cells are left behind. Some lymph nodes in your neck may also be removed, called a neck dissection or lymphadenectomy. This may cause some nerve damage, usually temporary, that makes your neck feel tight and numb, and you may feel pain and stiffness in your shoulder. It may also cause swelling in your neck, face and throat, called lymphoedema, which can be temporary or permanent.

The different types of surgery you can have for head and neck cancers include:

• open surgery, where cuts are made in the skin of the head and neck to remove cancers – part of the upper and lower jaw or skull may need to be removed, then reattached or reconstructed (through reconstructive or plastic surgery).
• endoscopic surgery, where an instrument with a light and camera on the end is inserted through the nose or mouth to see and remove cancers – this is usually used for cancers in the nose and sinuses
• transoral laser microsurgery (TLM), where a microscope with a laser attached is used through the mouth to remove cancers – this is usually used for cancers in the voice box and lower throat
• transoral robotic surgery (TRS), where robotic arms with a 3D telescope and instruments attached are used to reach cancers through the mouth – this is usually used for cancers in the oropharynx.

Reconstructive or plastic surgery may be needed to rebuild bones or tissues after surgery. Another possibility is use of a prosthetic device to restore the function and appearance of the part of the face or mouth that was affected.

If you have trouble breathing after surgery because your mouth or throat are swollen, you may have a tube inserted into your windpipe through a small cut in your lower neck. This is called a tracheostomy. The tube is usually removed within 1 week of surgery.

Mouth cancer surgery

Depending on where the cancer is, small cancers can be treated by removing part of the tongue, mouth or lip. Removal of larger cancers may need reconstructive surgery so that you can still chew, swallow or speak.

Different types of oral (mouth) surgery include:

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

Throat cancer surgery

Many oropharyngeal and hypopharyngeal cancers are treated with surgery. Small cancers can be treated with minimally invasive surgery, sometimes followed by radiation therapy with or without chemotherapy. Large or advanced cancers are usually treated with open surgery through a cut in the neck, often followed with radiation therapy and sometimes chemotherapy.

Different types of pharyngeal (throat) surgery include:

• oropharyngectomy, which removes part of the oropharynx (the part of the throat behind the mouth)
• hypopharyngectomy, which removes part of the hypopharynx (the lower part of the throat)
• laryngopharyngectomy, which removes all of the larynx (voice box) and most of the pharynx (throat).

Nasopharyngeal cancers are hard to operate on because of their location, so they are usually not treated with surgery.

Voice box cancer surgery

The type of surgery you have for cancers of the larynx (voice box) depends on the stage of the cancer:

• For cancers that are only found on the surface of the vocal cords, the cancer and top layers of tissue on the vocal cords may be stripped away, called vocal cord stripping – most people can speak normally after this operation
• For early-stage cancers, you may have part of the larynx (voice box) removed, called a partial laryngectomy – your voice may be affected for several months, or it may be permanently changed
• For advanced cancers, you may need to have open surgery to remove all of the larynx, called a total laryngectomy – you will need to breathe through an opening in the windpipe (called a laryngectomy stoma) and your voice will be permanently changed. You will need speech therapy to teach you to speak in a different way.

During a total laryngectomy, you may also need part or all of your thyroid gland removed (called a thyroidectomy). If this happens, you may need to take thyroid hormone replacement tablets every day for the rest of your life.

Nose or paranasal sinus cancer surgery

The type of surgery you have for nasal (nose) or paranasal sinus cancer depends on where the tumour is and which sinuses are affected. Different types of surgery for nasal and sinus cancer include:

• maxillectomy, which removes part or all the upper jaw (maxilla) and may also include the upper teeth, part of the eye socket and/or the nasal cavity
• skull base surgery (or craniofacial resection), which removes part of the nasal cavity and sinuses
• orbital exenteration, which removes the eyes and may also include some of the tissue around the eye socket
• rhinectomy, which removes part or all the nose.

You will often need reconstructive surgery following these surgeries. You may also lose your sense of smell, and your sense of taste may be affected.

Salivary gland cancer surgery

Salivary gland cancer is mostly found in the parotid glands (the glands in front of the ears). Parotid gland cancer may be treated by removing part or all the parotid gland, called a parotidectomy.

The facial nerve may be damaged or cut during surgery, which will affect your ability to smile, frown or close your eyes (called facial palsy). A damaged nerve usually improves over several months. If your nerve is cut, you may need it to be replaced by a nerve from another part of the body (called a nerve graft).

If cancer is in a gland under the lower jaw (submandibular gland) or under the tongue (sublingual gland), the gland and some surrounding tissue will be removed. This may also damage the nerves controlling the tongue and lower part of the face, as well as sensation and taste.

Metastatic squamous neck cancer with unknown primary surgery

Surgery for metastatic squamous neck cancer with unknown primary may include:

• tonsillectomy, to remove the tonsils – this can also be done to help diagnose the type of cancer.
• neck dissection, to remove the enlarged lymph node and any surrounding lymph nodes – if tissues need to be removed from one or both sides of the neck between the jawbone and collarbone (including nerves and possibly muscles), this is called a radical neck dissection, and physiotherapy may be needed afterwards.

Radiation therapy

Along with surgery, some people may receive radiation therapy.

For pharyngeal and laryngeal cancers, radiation therapy will be the main treatment. Radiation therapy may also be the main treatment for oral and nasal cavity tumours that are small, or for oral cavity, nasal cavity or salivary gland cancers that can’t be treated with surgery. Chemotherapy may be given at the same time to enhance the effect of radiation treatment (called chemoradiation). For metastatic squamous neck cancer with unknown primary, radiation therapy may be used to treat the lymph nodes affected by cancer.

Radiation therapy may also be used before surgery to shrink the tumour, and/or after surgery to kill any remaining cancer cells and reduce the risk of the cancer returning. It can be used to relieve symptoms of advanced cancer.

Chemotherapy

Chemotherapy is most often delivered at the same time as radiation treatment (called chemoradiation). In some instances, it may be given both before and during radiation treatment. In people with cancers of the nasopharynx, chemotherapy may also be given after completing radiation therapy or chemoradiation.

Chemotherapy may be used to shrink the tumour before surgery or radiation therapy. It may also be used after surgery to kill any remaining cancer cells and reduce the risk of the cancer coming back. Chemotherapy can also be used to relieve symptoms of advanced cancer.

Chemotherapy is not often used to treat salivary gland cancers.

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells. They are usually given with other treatments such as radiation therapy.

Cetuximab is a targeted medicine that is sometimes used to treat cancers of the head and neck. It is a monoclonal antibody that binds to a protein on the surface of cancer cells and stops them growing and dividing. Cetuximab is sometimes used when people cannot have chemotherapy, or for advanced cancer.

Immunotherapy is a type of targeted therapy that uses medicines to stimulate the immune system to attack cancer cells. Immune checkpoint inhibitors are a type of immunotherapy. They block the proteins on immune system cells that stop these cells from attacking other cells in the body. This can help boost the immune system’s response against cancer cells.

Nivolumab is a checkpoint inhibitor that is used to treat some advanced head and neck cancers.

Feeding tube after treatment

If you have trouble eating and swallowing after surgery or radiation therapy, you may have a feeding tube inserted so that you can get the nutrition you need while healing.

If you will only need the feeding tube for the first few days or weeks after treatment, it will be put through a nostril, down your throat and into your stomach. This is called a nasogastric (or NG) tube. If you will need the feeding tube for a longer period, it will be inserted through an opening in your abdomen, directly into the stomach. This is called a gastrostomy tube.

Follow-up

After treatment, you will need regular visits with appropriate specialists for follow-up examinations of your head and neck. These may involve some of the tests that were used to diagnose the cancer or to find out the stage of the cancer.

If you were treated with radiation, it might affect how your thyroid gland works. You may need to have your thyroid function checked regularly.

Advanced head and neck cancer

Treatment of advanced head and neck cancer may involve surgery, chemotherapy and/or radiotherapy. Some types of advanced head and neck cancer may not be treatable with surgery. Treatment of these cancers may involve chemotherapy and/or radiotherapy.

For very advanced head and neck cancer, you may have treatment to slow the growth of the cancer and to relieve symptoms. This is called palliative treatment, and can include radiation therapy, chemotherapy, or other drug therapies.

Recurrent cancer

Head and neck cancer can recur (come back) after treatment. The cancer can recur in the head or neck (local), or it can come back somewhere else in the body (distant).

If head and neck cancer comes back, the treatment you have will depend on the type of cancer, where it has spread, the type of treatments you have already had and your general health. Treatment options for recurrent head and neck cancer include surgery, chemotherapy, radiation therapy and targeted therapy.