Head And Neck Cancer_2002


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Head And Neck Cancer_2002

  1. 1. Head and neck cancer Health care team roles KEY TERMS Endoscopy is performed by a gastroenterologist with the assistance of registered nurses. Breath testing can be Endoscope—A thin, lighted tube with a tiny cam- administered by a physician or nurse. Venipuncture is era attached to the end. It allows the doctor to see performed by a physician, nurse or phlebotomist. the lining of the esophagus, stomach, and duo- Serological testing is performed by a clinical laboratory denum. scientist, CLS(NCA)/medical technologist, MT(ASCP) Endoscopy—A procedure that uses an endoscope. or clinical laboratory technician, CLT(NCA)/medical laboratory technician, MLT(ASCP). Gastroenterology—The study of the digestive sys- tem and diseases and disorders affecting it. Resources Invasive procedure—A medical procedure that PERIODICALS requires entrance of a foreign object into the Fallone Carlo A., Sander J.O. Veldhuyzen van Zanten, Naoki human body. Chiba. “The Urea Breath Test for Helicobacter pylori Non-invasive procedure—A medical procedure Infection: Taking the Wind Out of the Sails of that does not require entrance of a foreign object Endoscopy.” Canadian Medical Association Journal into the human body. (February 8, 2000): 371-2. Sutton, Fred M. “Diagnosis of H. pylori Infection.” Infectious Serology—Blood tests. Medicine 15 no. 5 (1998): 331-336. Urea—A waste product of the breakdown of pro- Veldhuyzen van Zanten, Sander J. O. “Treating Non-Ulcer teins. dyspepsia and H. pylori: It Is Economically and Clinically Sensible But It Won’t Make Most Patients Better.” British Medical Journal (September 16, 2000). comfort associated with the procedure, the patient is ORGANIZATIONS mildly sedated and a topical anesthetic is sprayed in the National Digestive Diseases Information Clearinghouse. 2 throat. Vital signs and history are important to insure that Information Way, Bethesda, MD 20892-3570. <http//www.niddk.nih.gov>. the patient does not have a condition that contraindicates the procedure. An intravenous line is used to instill fluids Peggy Elaine Browning and the sedative. For the breath test, a dose of radiolabeled urea is Hand and arm splints see Upper limb given orally to the patient. For serological tests, orthoses venipuncture is performed using standard precautions for Haptoglobin test see Plasma protein tests prevention of exposure to bloodborne pathogens. HCT see Hematocrit Aftercare Following endoscopy, patients should be observed while recovering from sedating medications for any signs of GI bleeding or pain and treated accordingly. The Head and neck cancer patient should remain under medical supervision until fully alert. After venipuncture, hemostasis should be Definition accomplished by applying direct pressure to the puncture The term head and neck cancers refers to a group of site. cancers found in the head and neck region. This includes tumors found in: Complications • The oral cavity (mouth): the lips, the tongue, the teeth, the gums, the lining inside the lips and cheeks, the floor Endoscopy may be associated with GI bleeding, of the mouth (under the tongue), the roof of the mouth, allergic reaction to medications, and throat or abdominal and the small area behind the wisdom teeth are all pain. Rare complications also include perforation of an included in the oral cavity. upper GI organ, aspiration of gastric fluid, and phlebitis. Breath and serological tests are not associated with sig- • The oropharynx: includes the back one-third of the nificant complications. tongue, the back of the throat, and the tonsils. G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H 1100
  2. 2. • Nasopharynx: includes the area behind the nose. included as a risk factor. A combination of tobacco and Head and neck cancer alcohol use increases the risk for oral cancer by six to 15 • Hypopharynx: the lower part of the throat. times more than for users of either substance alone. In • The larynx (voice box, located in front of the neck in rare cases, irritation to the lining of the mouth, due to the region of the Adam’s apple): in the larynx, the can- jagged teeth or ill-fitting dentures, has been known to cer can occur in any of the three regions—the glottis cause oral cancer. Exposure to asbestos also appears to (where the vocal cords are); the supraglottis (the area increase the risk of developing laryngeal cancer. above the glottis), and the subglottis (the area that con- In the case of lip cancer, just like skin cancer, expo- nects the glottis to the windpipe). sure to sun over a prolonged period has been shown to The most frequently occurring cancers of the head increase the risk. In the Southeast Asian countries (India and neck area are oral cancers and laryngeal cancers. and Sri Lanka), chewing of betel nut has been associated Almost half of all the head and neck cancers occur in the with cancer of the lining of the cheek. An increased inci- oral cavity, and a third are found in the larynx. By defi- dence of nasal cavity cancer has been observed among nition, the term “head and neck cancers” usually furniture workers, probably due to the inhalation of wood excludes tumors that occur in the brain. dust. A virus (Epstein-Barr) has also been shown to cause nasopharyngeal cancer. Description Head and neck cancers are one of the easiest to detect. The early signs can be both seen and felt. The Head and neck cancers involve the respiratory tract signs and symptoms depend on the location of the cancer: and the digestive tract, and they interfere with the func- tions of eating and breathing. Laryngeal cancers affect • Mouth and oral cavity: a sore that does not heal within speech. Loss of any of these functions is significant. two weeks, unusual bleeding from the teeth or gums, a Hence, early detection and appropriate treatment of head white or red patch in the mouth, or a lump or thicken- and neck cancers is of utmost importance. ing in the mouth, throat, or tongue. Roughly 10% of all cancers are related to the head • Larynx: persistent hoarseness or sore throat, difficulty and the neck. For cancer of the pharynx and oral cavity, breathing, or pain. there was an estimated 30,200 new cases in 2000. • Hypopharynx and oropharynx: difficulty in swallowing Incidence rates are highest in women and men over age or chewing food or ear pain. 40, and more than twice as high in men as in women. The • Nose, sinuses, and nasopharyngeal cavity: pain, bloody rates of oral cancers and deaths due to this cancer have discharges from the nose, blocked nose, and frequent been declining. sinus infections that do not respond to standard antibi- Among the major cancers, the survival rate for head otics. and neck cancers is one of the poorest. Less than 50% of When detected early and treated appropriately, head the patients survive five years or more after initial diag- and neck cancers have an excellent chance of being cured nosis. This is because the early signs of head and neck completely. cancers are frequently ignored. Hence, when they are first diagnosed, these types of cancers are often in an Diagnosis advanced stage and not very amenable to treatment. The risk for both oral cancer and laryngeal cancer Specific diagnostic tests used depend on the location seems to increase with age. Most of the cases occur in of the cancer. The standard tests are: individuals over 40 years of age, the average age at diag- nosis being 60. While oral cancer strikes men twice as Physical examination often as it does women, laryngeal cancer is four times The first step in diagnosis is a complete and thor- more common in men than in women. Both diseases are ough examination of the oral and nasal cavity, using mir- more common in African Americans than among rors and other visual aids. The tongue and the back of the Caucasians. throat are examined as well. Any suspicious looking lumps or lesions are examined with fingers (palpation). Causes and symptoms In order to look inside the larynx, the doctor may some- times perform a procedure known as laryngoscopy. In Although the exact cause for these cancers is unknown, tobacco is regarded as the single greatest risk indirect laryngoscopy, the doctor looks down the throat factor: 75–80% of the oral and laryngeal cancer cases with a small, long handled mirror. Sometimes the doctor occur among smokers. Heavy alcohol use has also been inserts a lighted tube (laryngoscope or a fiberoptic scope) 1101 G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H
  3. 3. Head and neck cancer through the patient’s nose or mouth. As the tube goes the cancer is completely removed. The amount of normal tissue removed is minimized using this method. down the throat, the doctor can observe areas that cannot be seen by a simple mirror. This procedure is called a Cancers of the nasal cavity are often diagnosed late direct laryngoscopy. Sometimes patients may be given a because they have no specific symptoms in their early mild sedative to help them relax, and a local anesthetic to stages, or the symptoms may just resemble chronic ease any discomfort. sinusitis. Hence, treatment is often complex, involving a combination of radiotherapy and surgery. Surgery is Blood tests generally recommended for small tumors. If the cancer cannot be removed by surgery, then radiotherapy is used The doctor may order blood or other immunological alone. tests. These tests are aimed at detecting antibodies to the Epstein-Barr virus. Treatment of oropharynx cancers (cancers that are either in the back of the tongue, the throat, or the tonsils) Imaging tests generally involves radiation therapy and/or surgery. After aggressive surgery and radiation, rehabilitation is often X rays of the mouth, the sinuses, the skull, and the necessary and is an essential part of the treatment. The chest region may be required. A computed tomography patient may experience difficulties with swallowing, scan (CT scan), a procedure in which a computer takes a chewing, and speech and may require a team of health series of x ray pictures of areas inside the body, may be care workers, including speech therapists, prosthodon- done. Ultrasonograms (images generated using sound tists, occupational therapists, etc. waves) or an MRI (magnetic resonance imaging) a procedure in which a picture is created using magnets Cancers of the nasopharynx are different from the linked to a computer), are alternate procedures which a other head and neck cancers in that there does not appear doctor may have done to get detailed pictures of the areas to be any association between alcohol and tobacco use inside the body. and the development of the cancer. In addition, the inci- dence is seen primarily in two age groups: young adults Biopsy and 50–70 year-olds. The Epstein-Barr virus has been implicated as the causative agent in most patients. While When a sore does not heal or a suspicious patch or 80–90% of small tumors are curable by radiation therapy, lump is seen in the mouth, larynx, nasopharynx, or throat, advanced tumors that have spread to the bone and cranial a biopsy may be performed to rule out the possibility of nerves are difficult to control. Surgery is not very helpful cancer. The biopsy is the most definitive diagnostic tool and, hence, is rarely attempted. Radiation remains the for detecting the cancer. If cancerous cells are detected in only treatment of choice to treat the cancer that has the biopsied sample, the doctor may perform more exten- metastasized (traveled) to the lymph nodes in the neck. sive tests in order to find whether, and to where, the can- In the case of cancer of the larynx, radiotherapy is cer may have spread. the first choice to treat small lesions. This is done in an attempt to preserve the voice. If the cancer recurs later, Treatment surgery may be attempted. If the cancer is limited to one The cancers can be treated successfully if diagnosed of the two vocal cords, laser excision surgery is used. In early. The choice of treatment depends on the size of the order to treat advanced cancers, a combination of surgery tumor, its location, and whether it has spread to other and radiation therapy is often used. Because the chances parts of the body. of a cure in the case of advanced laryngeal cancers are rather low with current therapies, the patient may be In the case of lip and mouth cancers, sometimes sur- advised to participate in clinical trials so they may get gery is performed to remove the cancer. Radiation thera- access to new experimental drugs and procedures, such py, which destroys the cancerous cells, is also one of the as chemotherapy, that are being evaluated. primary modes of treatment, and may be used alone or in combination with surgery. If lip surgery is drastic, reha- When only part of the larynx is removed, a relative- bilitation cosmetic or reconstructive surgery may have to ly slight change in the voice may occur—the patient may be considered. Some cancers of the lip may be removed sound slightly hoarse. However, in a total laryngectomy, by Mohs’ surgery, also known micrographic surgery. the entire voice box is removed. The patients then have Using this method, the surgeon removes the tumor in thin to re-learn to speak using different approaches, such as slices, examining them immediately under the micro- esophageal speech, tracheo-esophageal (TE) speech, or scope to look for cancer cells. More slices are taken until by means of an artificial larynx. G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H 1102
  4. 4. In esophageal speech, the patients are taught how to Photodynamic therapy (also called PDT, photoradia- Head and neck cancer tion therapy, phototherapy, or photochemotherapy) is a create a new type of voice by forcing air through the esophagus (food pipe) into the mouth. This method has a treatment for some types of cancer including larynx and high success rate of approximately 65% and patients are oral cavity. even able to go back to jobs that require a high level of Important research is being conducted investigating verbal communication, such as telephone operators and new treatments for several head and neck cancers. There salespersons. are many new promising treatments and improvements to In the second approach, TE speech, a small opening current therapies such as: called a fistula, is created surgically between the trachea • Tumor growth factors. These hormone-like substances (breathing tube to the lungs) and the esophagus (tube into that are naturally occurring in the body typically pro- the stomach) to carry air into the throat. A small tube, mote cell growth. Some tumors may grow quickly known as the “voice prosthesis,” is placed in the opening because of excessive growth factors. New drugs like C- of the fistula to keep it open and to prevent food and liq- 225 may help inhibit tumor growth. C-225 targets a uid from going down into the trachea. In order to talk, the specific area on the cancer cells’ surface; it may even- stoma (or the opening made at the base of the neck) must tually be used to treat other cancers such as colon, be covered with one’s thumb during exhalation. As the prostate, bladder, ovarian, and non-small cell lung air is forced out from the trachea into the esophagus, it cancer. vibrates the walls of the esophagus. This produces a sound that is then modified by the lips and tongue to pro- • New chemotherapy techniques. Intraarterial chemother- duce normal sounding speech. apy, where drugs are injected into arteries feeding the cancer, is being tested in combination with radiation In the third approach, an artificial larynx, a battery therapy in an attempt to improve their effectiveness. driven vibrator, is placed on the outside of the throat. Another new approach uses intralesional chemotherapy Sound is created as air passes through the stoma (open- (injecting the drug directly into the tumor). Preliminary ing made at the base of the neck) and the mouth forms results have been promising with these new chemother- words. apies. Recent developments have been made with the use of lasers for treating many types of cancer. Laser therapy • New radiotherapy methods. Studies have been under- destroys cancer cells by the use of high-intensity light. It way testing the efficacy of new radiation regimens is often used to relieve symptoms of cancer such as delivering twice-a-day irradiation. Higher cure rates bleeding or obstruction, particularly when other treat- have been demonstrated. ments are ineffective. Laser surgery can also treat cancer • Vaccines may be effective by helping the immune sys- by shrinking or destroying tumors. Laser surgery is a tem to recognize and attack the cancer cells. standard treatment for certain stages of glottis. Although there are several different kinds of lasers, only the Prognosis Carbon dioxide (CO2) laser, Neodymium:yttrium–alu- minum–garnet (Nd:YAG) laser, and argon laser are wide- Comorbidities (other illnesses) that may be present ly used in medicine. The CO2 and Nd:YAG lasers are are an important determinant of overall survival in peo- used to shrink or destroy tumors. Laser surgery is also ple with head and neck cancer. used to help relieve symptoms caused by cancer (pallia- tive care) in addition to its use in destroying cancer cells. Oral cavity Since cancer cannot grow or spread without forming With early detection and immediate treatment, sur- new blood vessels, research is being conducted to find vival rates can be dramatically improved. For lip and oral ways to stop angiogenesis. Scientists are exploring the cancer, if detected at its early stages, almost 80% of the use of natural and synthetic angiogenesis inhibitors, also patients survive five years or more. However, when diag- called anti-angiogenesis agents, in anticipation that these nosed at the advanced stages, the five year survival rate chemicals will prevent tumor spread by inhibiting new drops to a mere 18%. blood vessel formation. Taxanes are a group of cancer drugs that includes Nose and sinuses paclitaxel (Taxol) and docetaxel (Taxotere). Taxanes inhibit cancer cell growth by arresting cell division. Cancers of the nasal cavity often go undetected until they reach an advanced stage. If diagnosed at the early They are also known as antimitotic or antimicrotubule agents or mitotic inhibitors. stages, the five-year survival rates are 60–70%. However, 1103 G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H
  5. 5. Head and neck cancer KEY TERMS Angiogenesis—The formation of blood vessels mouth or nose to examine the larynx and other around a tumor. areas deep inside the neck. Biopsy—The surgical removal and microscopic Magnetic resonance imaging (MRI)—A medical examination of living tissue for diagnostic purposes. procedure used for diagnostic purposes where pic- tures of areas inside the body can be created using Chemotherapy—Treatment of cancer with synthet- a magnet linked to a computer. ic drugs that destroy the tumor either by inhibiting the growth of the cancerous cells or by killing the p53 gene—A tumor suppressor gene that typically cancer cells. inhibits the tumor growth. This gene is often altered in many types of cancer. Clinical trials—Highly regulated and carefully con- trolled patient studies, where either new drugs to Radiation therapy—Treatment using high energy treat cancer or novel methods of treatment are radiation from x-ray machines, cobalt, radium, or investigated. other sources. Computerized tomography scan (CT scan)—A Stoma—When the entire larynx must be surgically medical procedure where a series of x rays are removed, an opening is surgically created in the taken and put together by a computer in order to neck so that the windpipe can be brought out to the form detailed pictures of areas inside the body. neck. This opening is called the stoma Growth factors—Growth factors or human growth Taxanes—Anticancer drugs that inhibit cancer cell factors are compounds made by the body that func- growth by arresting cell division. Also known as tion to regulate cell division and cell survival. Some antimitotic or antimicrotubule agents or mitotic growth factors are also produced in the laboratory inhibitors. by genetic engineering and are used in biological Ultrasonogram—A procedure where high-frequen- therapy. Growth factors are significant because cy sound waves that cannot be heard by human they can induce angiogenesis, the formation of ears are bounced off internal organs and tissues. blood vessels around a tumor. These growth factors These sound waves produce a pattern of echoes also encourage cell proliferation, differentiation, which are then used by the computer to create and migration on the surfaces of the endothelial sonograms, or pictures of areas inside the body. cells. X rays—High energy radiation used in high doses, Laryngoscopy—A medical procedure that uses flex- either to diagnose or treat disease. ible, lighted, narrow tubes inserted through the drugs, the five year survival rate has improved and if cancers are more advanced, only 10–30% of the 5–40% of the patients survive five years or longer. patients survive five years or more. Larynx Oropharynx Small cancers of the larynx have an excellent five- In cancer of the oropharynx, 60–80% of the patients year survival rate of 75–95%. However, as with most of survive five years or more if the cancer is detected in the the head and neck cancers, the survival rates drop dra- early stages. As the cancer advances, the survival rate matically as the cancer advances. Only 15–25% of the drops to 15–30%. patients survive five years or more after being initially diagnosed with advanced laryngeal cancer. Nasopharynx Advances in detecting head and neck cancer at an Patients who are diagnosed with early stage cancers early stage are being made. Patients’ prognoses will that have originated in the nasopharynx have an excellent improve as technological advances are made. Some of chance of a complete cure (almost 95%). Unfortunately, the research that is being conducted includes DNA muta- most of the time the patients are in an advanced stage at tions (changes) that occur in genes. Damage to certain the time of initial diagnosis. With the new chemotherapy DNA can lead to increased growth of abnormal cells and G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H 1104
  6. 6. formation of cancers. Recent studies suggest that tests to and beans. Reducing one’s intake of high-fat food from Head and neck cancer animal sources is advised. Following the The Dietary detect p53 gene alterations may allow very early detec- Guidelines for Americans published by the United States tion of oral and oropharyngeal tumors. Other substances Department of Agriculture and Health and Human Services under investigation that may help early prognosis of can- can provide a broad overall view of good nutrition. cers are epidermal growth factor receptor, transforming growth factor-alpha, and cyclin D1. These dietary guidelines include these seven basic recommendations: Using targeted chemoradiation, one clinical study revealed that statistical projections for overall and can- • Eat a variety of foods. cer-related five-year survival was 38.8% and 53.6%, • Control your weight. respectively for patients with advanced (stage III-IV) • Eat a low-fat, low-cholesterol diet. carcinoma of the head and neck. • Eat plenty of vegetables, fruits, and grains. Health care team roles • Eat sugar in moderation. Depending on the diagnosis, disease stage, level of • Use salt in moderation. nursing care required, and different psychosocial factors, • If you drink alcohol, do so in moderation; no more than the patient’s health care needs will vary. The care two drinks per day of wine, beer, or spirits. required is unique to each patient and family. For patients The Food Guide Pyramid was created by the United who will be in transitional care, an optimal integration States Department of Agriculture to help Americans between inpatient and outpatient care is needed to ensure choose foods from each food grouping. The food pyra- the best care possible. Outpatient care includes home mid, developed by nutritionists, provides a visual guide care, rehabilitation centers, nursing homes, and hospice to healthy eating. care. Health care teams should make the transition from the different types of inpatient and outpatient care as easy Resources as possible. Effective communication between profes- BOOKS sionals is critical. Harrison, Louis B., et al., eds. Head and Neck Cancer: A A dental team with experience in oral oncology, may Multidisciplinary Approach. Philadelphia: Lippincott reduce the risk of oral complications for patients with Williams & Wilkins Publishers, 1999. oral cancers. Thawley, Stanley E., et al., eds. Comprehensive Management of Head and Neck Tumors. 2nd ed. London: W. B. Saunders Co., 1999. Prevention ORGANIZATIONS Refraining from the use of all tobacco products (cig- American Association of Oral and Maxillofacial Surgeons. arettes, cigars, pipe tobacco, chewing tobacco), consum- 9700 W. Bryn Mawr; Rosemont, IL 60018. (800) 467- ing alcohol in moderation, and practicing good oral 5268. <http://www.aaoms.org>. hygiene are some of the measures that one can take to American Dietetic Association. 216 W. Jackson Blvd. prevent head and neck cancers. Since there is an associa- Chicago, IL 60606-6995. (312) 899-0040. tion between excessive exposure to the sun and lip can- <http://www.eatright.org>. cer, people who spend a lot of time outdoors in the sun International Association of Laryngectomees (IAL). 7440 should protect themselves from the sun’s harmful rays. North Shadeland Avenue, Suite 100, Indianapolis, IN Regular physical examinations, or mouth examination by 46250. <http://www.larynxlink.com/welcome.html>. the patient himself, or by the patient’s doctor or dentist, National Cancer Institute (National Institutes of Health). 9000 Rockville Pike, Bethesda, MD 20892. (800) 422-6237. can help detect oral cancer in its very early stages. <http://cancernet.nci.nih.gov>. Since working with asbestos has been shown to National Oral Health Information ClearingHouse. 1 NOHIC increase one’s risk of getting cancer of the larynx, asbestos Way, Bethesda, MD 20892-3500. (301) 402-7364. workers should follow safety rules to avoid inhaling <http://www.nohic.nih.gov>. asbestos fibers. Also, malnutrition and vitamin deficiencies Oral Health Education Foundation, Inc. 5865 Colonist Drive, have been shown to have some association with an P.O. Box 396, Fairburn, GA 30213. (770) 969-7400. increased incidence of head and neck cancers. The Support for People with Oral and Head and Neck Cancer American Cancer Society recommends eating a healthy (SPOHNC). P.O. BOX 53 Locust Valley, NY 11560- diet, consisting of at least five servings of fruits and veg- 0053. (800) 377-0928. <http://www.spohnc.org>. etables every day, and six servings of food from other plant sources such as cereals, breads, grain products, rice, pasta, Crystal Heather Kaczkowski, MSc. 1105 G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H