Head and Neck Cancers Require Specialized Approach

Although some 40,000 Americans each year are newly diagnosed with head and neck cancers, these cancers are rarely discussed, despite being the 8th-most common form of cancer and causing 20,000 deaths each year.

The primary cause of these cancers is a very familiar one: tobacco, in both cigarette form and "smokeless" or chewing tobacco. Tobacco is linked to about 85% of head and neck cancers.

Stuart J. Wong, MD, Medical College of Wisconsin Assistant Professor of Medicine in the Division of Neoplastic Diseases and Related Disorders, sees the terrible cancers that result chiefly from tobacco use, but is remarkably positive about the potential for treatment, now and in the future.

"The upside is that we have a lot of patients that we can cure," says Dr. Wong. I've just had one of those good days where I could see the really great steps forward in science and oncology that we have taken."

Dr. Wong practices at both the Zablocki VA Medical Center and the Froedtert & The Medical College of Wisconsin Neoplastic Diseases and Related Disorders Clinic.

He stresses that depth of knowledge and experience with head and neck cancers are important factors that patients need to consider when seeking the right doctor. "Head and neck cancers are relatively rare and fairly complicated, so they are best treated by specialists who are familiar with the various types," says Dr. Wong. "Because we see hundreds of cases in the College's Division of Neoplastic Disease, we're equipped to respond with very specific programs and regimens."

Complex Cancers, Individual Treatment
The treatment of head and neck cancers requires a particularly sophisticated approach. "These cancers are much more complicated than, say, colon cancer. The anatomy is very complex, and you need to design a treatment suited to the specific cancer, whether it be in the mouth, the pharynx including the tonsils and upper part of the throat, the larynx including the voicebox, or a nasal-pharynx type of cancer."

"The typical patient is someone in their 50's or 60's, with a history of smoking, when diagnosed, says Dr. Wong. "The combination of smoking and drinking seems to develop genetic abnormalities which take a while to transform into cancer. A common scenario is that we wind up seeing people who started smoking in their late teens, and then it catches up with them in their 50's and 60's."

"But we also encounter some people in their 30's and 40's with no risk factors like smoking," Dr. Wong notes. "These tend to be people whose parents smoked or who work in high-risk environments like bars and restaurants where there is a lot of smoke in the air."

"We find that some of these patients may have been exposed in their households as they were growing up, and people may be more susceptible earlier in life. So we wind up seeing people with no other risk factors except for that. By the time they are in their 30's or 40's, there's been a couple decades for the genetic abnormalities to come to fruition as cancer."

Chewing Tobacco and Disfigurement
One of the worst risk factors is smokeless or chewing tobacco, which is fortunately less popular in Wisconsin than in the South and Southwest. "There's direct exposure of the mucosa (mucous areas of the mouth) to tobacco. The result very often is oral cavity cancer."

Despite the devastatingly disfiguring effects of cancer resulting from chewing tobacco, "Education activities are far more advanced about smoking," says Dr. Wong. "And because chewing tobacco doesn't bother other people with smoke, there is less awareness of the harm it causes."

Warning Signs
Generally, most patients don't become alerted to the possibility of head or neck cancers until their primary doctor or dentist notices something unusual. One problem is that some of the symptoms are relatively minor and do not seem particularly alarming until they become acute.

For example, warning signs might include unusual bleeding, a sore that doesn't heal, difficulty chewing or swallowing, swelling of the neck, or a change in voice. "Quite often, swelling, for example, is assumed to be the result of a head cold or abscess, and it isn't until after the second or third round of antibiotics fails that the doctor or dentist starts to get suspicious that something more major is involved," says Dr. Wong.

"So part of my job is to educate doctors and dentists, to consider smoking and drinking in diagnosing their patients," he explains.

Treatment and Hope
Each case of cancer demands a highly individualized course of treatment, Dr. Wong stresses. "In some cases, the cancers are large and can be surgically removed. But in others, sometimes the cancers are too large to be removed without causing disfigurement, problems with swallowing, or insertion of a trachea tube," he says.

In cases like those, a combination of radiation and chemotherapy can produce remarkably positive results unimagined in previous times, with less painful side effects. Unfortunately, treatment is often very costly, he admits.

"We find that radiation therapy to the mouth results in a lot of sores and excoriations, but a new drug is very helpful in restoring the cells," Dr. Wong says.

Radiation can work well in tandem with chemotherapy in destroying cancerous cells. "Chemotherapy makes the radiation more effective and also neutralizes cells that could potentially break off and spread throughout the body," he states.

Continuing advances are being made in treating head and neck cancers through careful research and experimentation. Dr. Wong is currently involved in a study covering patients across the US and Canada that looks at treating the recurrence of cancer. "We find that when cancer comes back, it returns in a form that can't be surgically removed. So we are now trying a second course of radiation along with chemotherapy."

The study hopes to determine the relative effectiveness of re-irradiation combined with chemotherapy compared with chemotherapy alone. Dr. Wong is optimistic that the study will produce some findings that will make a critical difference in patients' ability to survive and the quality of their lives. "I think we'll come away with a reasonable chance of controlling these cancers," he says hopefully.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.