Some types of oral, head and neck cancers are on the rise
Smoking and alcohol can be factors, as well as the human papillomavirus
It’s important to have regular checkups with your doctor — and your dentist
You may not be as familiar with oral, head or neck cancers as you are with, say, breast or colon cancer, but it’s worth knowing more about them. Head and neck cancers are the sixth most-common in the United States and cases of some types of those cancers are on the rise. Viruses, particularly human papillomavirus (HPV), have been attributed as a major cause for increased throat cancer rates over the last several years. With an estimated 30,000-plus people who will be diagnosed with an oral, head or neck cancer this year alone, here’s what you should know about these diseases.
What are oral, head and neck cancers?
They refer to cancers of the mouth, throat, voice box, salivary glands and the skin of the face and neck region, says R. Bryan Bell, MD, DDS, medical director of the Providence Head and Neck Cancer Program and Clinic in Portland, Oregon.
“About 90 percent of these cancers are squamous cell carcinoma — that is, the cancerous cells are in the lining of the mouth, throat and voice box.”
What are the risk factors?
Traditionally, these cancers were more prevalent in men in their 60s and 70s who were heavy smokers and drinkers. (In other parts of the world, such as India, where tobacco and carcinogenic betel nut is heavily used, oral cancer is the most common type of cancer.)
“Smoking, and smoking combined with alcohol, are synergistically the two biggest risk factors for the development of oral cavity cancer,” says Ashish A. Patel, MD, a head and neck surgeon at the cancer clinic. “Tobacco plays a large role — there’s a seven- to nine-fold increase of developing mouth cancer compared to someone who doesn’t use tobacco. When it ignites, there are many compounds that are carcinogens and many that we don’t even know what they do and are potentially carcinogens. With direct contact with the oral cavity, over time they can mutate and alter the DNA of those cells.”
Dr. Patel adds that tobacco and alcohol use is just one piece of the pie when it comes to causes of head and neck cancers. “Head and neck cancers in general are such complex genetic phenomena and they have thousands of mutations — there are so many other complex interactions with our own cells, internal DNA damage and external carcinogens. Each case of oral cavity cancer can be so vastly different from person to person. Even though tobacco is a major risk factor, it’s not the only one.”
Another one is HPV. Dr. Bell says that during the last 15 years HPV, and other viruses, have affected throat cancer rates.
“HPV is a sexually transmitted disease that is highly prevalent in society — at least 20 million Americans are currently infected with HPV,” Dr. Bell says. “It’s been estimated that up to 75 percent of sexually active men and women will be infected with HPV at some point in their lives. Now, this does not mean they will come down with head and neck or throat cancer, but it does increase their risk.”
HPV is also the virus that can cause cervical cancer, and while there is a screening test for that, the same isn’t true for head and neck cancer. “There are many reasons for this, but the most important is that the viruses themselves settle in deep crypts in the back of the throat, the tonsils and the base of the tongue,” Dr. Bell says. “In the cervix, the viruses and the subsequent cancers arise on the surface of the cervix; in the throat area, a brush or swab that would be used in a Pap smear is not effective because of the deep crypts.”
It’s important to note that there is a long latency period between the time the body is infected with HPV and when a cancer develops. “The virus is readily cleared from the body within a few weeks of infection. But essentially a portion of its DNA becomes encrypted within our own DNA and that’s what causes the cancer decades later,” Dr. Bell says. “The risk for developing throat cancer appears to be greater with increasing numbers of sexual partners. Clearly, not everyone who smokes or has sex gets head or neck cancer, but it does increase the risk over the general population.”
HPV also has changed the patient profile for head and neck cancers. Instead of men of advanced age who were heavy smokers and drinkers, now patients are in their 40s and 50s who have never smoked. “They are in the prime of their lives,” Dr. Bell says.
How do you know if you have head or neck cancer?
Because there is no official screening test, the main tool is a physical examination. Some signs of concern could be white or red spots in the mouth, pain in the mouth, ear pain or anything that seems abnormal that doesn’t go away in two weeks, Dr. Patel says. But generally, the first presenting sign from these cancers is usually a lump in the neck.
“The cancers themselves can be very small in the back of the throat and are therefore asymptomatic,” Dr. Bell says. “So, many of these patients are being diagnosed at later stages of the disease, which means after the cancer has spread from the throat to a lymph node in the neck.”
Head and neck cancers at those later stages are still treatable, but as with most cancers, early detection is key, Dr. Patel says. “The earlier we catch these cancers, the better people do. The success rate of treatment is directly related to the stage in which the cancer was identified and treated. A lot of it depends on access to health care.”
That’s why both Drs. Bell and Patel stress the importance of maintaining annual doctor visits as well as twice-yearly dental checkups, which are great opportunities to get a health care professional to do a physical exam for any signs of head and neck cancer.
How is head and neck cancer treated?
Patients with head and neck cancers may undergo surgery, and that’s a procedure that has greatly evolved over the years, Dr. Bell says.
“We’ve come a long way philosophically in how we surgically manage patients with head and neck cancer. Gone are the days of radical operations just to perform a radical operation. There’s a much greater emphasis on the patient’s quality of life as well as quantity of life,” Dr. Bell says. “Our operations are performed to preserve noncancerous structures with a much greater emphasis than in years past. Highly disfiguring procedures that were commonly done 30 to 40 years ago are rarely performed now.
“Traditionally for a patient with throat cancer, in the surgery we would split their lip, split the jaw and move it out of the way, take the tumor out of the throat and reconstruct it with tissue from the chest. Because that operation was so radical and involved, during the 1970s and 1980s there was a push to treat patients with high-dose radiation and chemotherapy. The problem is that many patients were left without the ability to swallow or taste their food, and their quality of life deteriorated.”
But some technological advantages have vastly improved the surgical process for head and neck cancer.
“One is the development of microvascular tissue transfer, where we harvest tissue and bone with its blood supply intact from another site on the body and transfer it to the head and neck and fashion it to look like a jawbone by using sophisticated computer surgical software. This gives us a much more favorable and more predictable method of restoring patients to form and function,” says Dr. Bell, who says his credentials in both dentistry and surgery offer a distinct advantage in reconstruction operations that can help patients return to swallowing, speaking and eating normally.
“The second thing is virtual surgical planning, which we helped pioneer here at Providence," Dr. Bell says. "That is using computer-aided surgical planning, importing CT images and the like into a software system and manipulating those skeletal components into the proper position, and then printing guide stents and cutting guides that allow for very precise and accurate skeletal repositioning. Combine that with guided or navigated dental implant placement, and more than ever before we can give patients back their speech, swallowing and appearance, which is so important.”
Dr. Bell adds that robotics have transformed the surgical process as well. Transoral robotic surgery was approved by the U.S. Food and Drug Administration in 2010 and has revolutionized the management of oropharyngeal cancers driven by HPV.
“With transoral robotic surgery, we can treat these patients with a minimally invasive procedure that’s done through the mouth — no jaw or lip splitting,” Dr. Bell says. “We can also eliminate or minimize the dose of radiation therapy afterwards and often eliminate chemotherapy. This is in keeping with our emphasis on not only curing the cancer if we can, but also on preserving the patient’s quality of life.”
Finally, Dr. Bell points to immunotherapy as a more recent exciting development in the treatment of head and neck cancers. In 2016, two different immunotherapies, Opdivo and Keytruda, were approved for patients with head and neck cancer and they are a key part of the cancer clinic’s research emphasis to help improve patients’ overall survival rates.
Dr. Patel urges people to get checked for head and neck cancers. “We can’t necessarily prevent the development of cancer, but catching them early is the best method we have in treating them so people can go on with their lives without the after-effects of head and neck cancer. Early detection is the most important tool in our toolbox.”
If you want to be checked for head and neck cancers, schedule an appointment with your physician or dentist, or come to a free screening from 9 a.m. to 5 p.m. April 18 in the library at the Robert W. Franz Cancer Center at Providence Portland Medical Center. For more information or to register online, click here.
Free Oral, Head and Neck Cancer Screenings – Oregon Region
OR: Providence Cancer Institute, Portland and surrounding communities
MT: Montana Cancer Center at Providence St. Patrick Hospital and Providence St. Joseph Medical Center
This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.