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Exploring Options for Head & Neck Cancer

Online Health Chat with Dr. Mumtaz Khan

May 16, 2011


Introduction

Cleveland_Clinic_Host: According to the American Cancer Society, head and neck cancers account for the fifth most common malignancy in the world. These cancer types include cancers of the mouth, nose, sinuses, salivary glands, throat, and lymph nodes in the neck. Treatment of these tumors can have a devastating effect on the lives of patients by affecting their outward appearance; the four senses of sight, smell, taste, and hearing; and the vital functions of breathing, swallowing, and talking. The complexity requires a wide variety of medical and allied specialties to destroy disease and restore function.

Mumtaz Khan, MD, is a head and neck oncologic surgeon in Cleveland Clinic’s Head & Neck Institute. He recently served as associate dean for postgraduate medical education, associate professor and head of the division of Otolaryngology Head & Neck Surgery at Aga Khan University in Karachi, Pakistan. He is the former director of head and neck oncologic surgery at Henry Ford Health System in Detroit. Dr. Khan sees patients at Cleveland Clinic’s main campus. The ENT program at Cleveland Clinic has been ranked in the top 10 by U.S. News & World Report.

To make an appointment in the Head & Neck Institute, please call 216.444.6691 or call toll-free 800.223.2273, ext. 46691. To download a treatment guide for Head and Neck Cancer, please visit www.clevelandclinic.org/headneckcancer.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Mumtaz Khan. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Risk

jazzyj: I smoked for about 25 years, but I quit eight years ago. Does that decrease my chances of getting oral or throat cancer? How often should I get screened?

Dr__Mumtaz_Khan: Even after eight years, you are still at a higher risk than a non-smoker. If there are no specific signs or symptoms of head and neck cancer, then an annual screening would be sufficient. Some of the more common such signs and symptoms may include a lump in the neck, a sore in the mouth, change in voice, difficulty or pain on swallowing, bleeding from the mouth or pain in ears.

pitterpatter: I get chronic sinus infections and have had polyps removed. Am I at a higher risk for cancer in this area?

Dr__Mumtaz_Khan: No. Sinus infections by themselves are not a risk factor for head and neck cancer. However, if you smoke and/or use alcohol heavily, you should be examined by your ENT surgeon.

note_worthy: What is the link between HPV and oral cancer?

Dr__Mumtaz_Khan: In recent years, HPV has been shown to be associated with oropharyngeal cancers typically involving the tonsils and the base of the tongue. These are usually found in younger patients who do not give a significant history of smoking or alcohol abuse.

Fortunately, HPV related head and neck tumors show a better outcome than those cancers that are related to smoking and alcohol. The treatment however, is still the same, either in isolation or in a combination of surgery, radiation and chemotherapy. We now routinely test for HPV status when we biopsy a suspicious lesion.


Signs & Symptoms

gemma: I constantly feel like there is a "frog in my throat." Could it be cancer or am I overreacting?

Dr__Mumtaz_Khan: If this has been a persistent feeling of a lump in the throat, then you should have it examined by an ENT specialist. It may just be related to acid reflux disease or chronic sore throat or dryness, but it should be evaluated. Generally, any symptom that lasts for more than four weeks and does not show signs of improvement, must be assessed clinically.

sight_unseen: I had cancer in the nasal/pharynx area about five years ago (B cell, Stage IV). I was treated with radiation and chemotherapy. I have been having severe headaches lately, along with some other minor annoying symptoms. What would be an indicator that my cancer has returned?

Dr__Mumtaz_Khan: If the headaches are recent in onset, then you must see your medical or radiation oncologist for a clinical assessment and perhaps a scan. Any localized and new symptoms of headaches, nosebleeds, nasal congestion, loss of sense of smell or taste, changes in vision or development of a neck mass needs attention.

help: What are the symptoms of oral cancer, particular in the gums surrounding the teeth?

Dr__Mumtaz_Khan: The signs of oral cancer would include a white or red patch or an ulcer in the mouth that does not show signs of healing. Loose teeth or persistent gum disease should be evaluated.

If a person wears dentures then a recent change in the fitting of the dentures should also be checked by a dentist or a head and neck surgeon.


Diagnosis

plain_speaking: I know it depends on the type of cancer that you have, but how aggressive are head and neck cancers? Are they just as likely or more or even less likely to metastasize and spread?

Dr__Mumtaz_Khan: Head and neck cancers are in general aggressive tumors that grow fairly rapidly. That is why the importance of early detection is stressed. These tumors are staged according to their size, presence of enlarged lymph nodes and evidence of spread to other parts of the body. There are four stages, with stage I being the early staged disease that has much higher success rates than stage III or IV, late staged disease in which the tumor shows signs of spread away from the primary site. They typically metastasize or spread to the neck lymph nodes, and can also metastasize to the lungs, liver, or bones.

The metastasis to the lymph nodes is one of the most important indicators of the aggressiveness of the disease and reduces the prognosis or success rate by almost 50 percent.

king_of_the_hill: I have been diagnosed with cancer in my nasal cavity and would like to get a second opinion. What information do I need to bring?

Dr__Mumtaz_Khan: when you come a for a second opinion you will undergo a clinical assessment again, with a pertinent history and head and neck examination. Whatever tests have been done so far would be helpful, including report of a biopsy, and reports and films of MRI, CT, or PET scans. .If you have had an examination under anesthesia, then the operative report from your physician would also be necessary.

You may be required to undergo scans again depending on how old the existing ones are or how significantly your examination has altered over the course of time. You may also be required to undergo the examination under anesthesia again to re-assess and properly stage the tumor.

jjrps: My wife finished radiation treatments about a month ago. Since then her doctor has done two CT scans that show no new tumor growth. However, I thought that the PET scan was more accurate. I was told that it would not be done until six months after treatment. Why is this?

Dr__Mumtaz_Khan: Typically, after radiation, I would get a scan (be it a CT or MRI or a PET) at around three months. This is because the effects of radiation continue for at least six to eight weeks after the last dose of radiation has been administered.

PET scan is a newer test which helps us detect some abnormal activity in the body, for example, cancer or infection or even inflammation. It does not give us a diagnosis of cancer. It is however, now routinely being used as a part of work up of a cancer or for follow up purposes after treatment. It is more sensitive when it is combined with a CT scan (PET/CT fusion scan) and maybe particularly helpful in indicating possible spread to other parts of the body.

nystrom: What is the importance of head and neck cancer screening?

Dr__Mumtaz_Khan: Great question! Head and neck cancers are generally very aggressive tumors. However, if they are detected at an early stage, then the outcomes are very good; in not only controlling the cancer but also in maintaining a good quality of life with preservation of function. All the new developments in surgical procedures and radiation techniques are geared towards this preservation of normal body functions which are more likely to be preserved when the tumors are small and confined to one area.

Head and neck screening would give you the opportunity to have a comprehensive examination of the upper airway and digestive tract to identify any suspicious lesions. It is particularly important for people who smoke and drink heavily or may have certain specific signs or symptoms, such as a neck mass, persistent sore throat, change in voice, difficulty or pain on swallowing, ear pain, or unintentional weight loss.

newbie: Are there any alternatives to IMRT and chemotherapy for the treatment of throat cancer?

Dr__Mumtaz_Khan: Throat cancers, and in general head and neck cancers are primarily treated with surgery or radiation therapy. Over the last two decades, we have seen the effectiveness of chemotherapy when it is used in combination with radiation therapy for advanced stage disease. The primary treatment methods however, continue to be surgery or radiation. Different combinations of all these methods are utilized, based on the individual patient characteristics, histologic type of the cancer, the site and on the stage of the cancer.


Tumors

mister_dee: Eighteen years I had acinic cell cancer of the parotid. I had s/p surgery and post op XRT. Recently, a chest scan showed metastatic acinic cell carcinoma in the lungs. There are four nodules on each side ranging in size from 4mm to 1.4 cm. I'm scheduled June 2 for a comparative scan to check for growth of the nodules. If there is none, there will be no treatment. If growth is found, the treatment will be Everolimus oral drug. Would you suggest any other treatment or should I follow through with this treatment plan? Thank you. I am a 69-year-old male, in relatively good health, feeling OK without any systemic symptoms.

Dr__Mumtaz_Khan: An acinic cell carcinoma is a rare. Slow growing and not a very aggressive tumor of the salivary glands. Many physicians for a long time considered it to be a benign or non-cancerous form of tumor. When it spreads it typically metastasizes to the lungs which are followed closely for any change. I agree with the treatment being suggested to you right now -- having the scan and comparing it to the previous ones and a close follow-up if there’s no difference.

charley: My husband had adenoid cystic carcinoma. He had his soft palate removed, followed by radiation almost eight years ago. His doctors told him that they expect the cancer to return at some point in the future. Why is this, and is there anything new in the way of treatment or prevention? He gets regular screenings.

Dr__Mumtaz_Khan: Adenoid cystic carcinomas (ACC) are usually very slow growing tumors. If they are completely removed surgically then the risk of recurrence is low. Having said that, they are also known for their unpredictability. I am not sure why you should 'expect' the cancer to return because it may never. Typically, after optimal treatments, the recurrences are late. Therefore, you definitely want to continue with his regular clinical examinations to rule out a possible recurrence. If it comes back, we want it identified as early as possible.

Surgery continues to be the most effective form of treatment for ACC. Radiation, once given cannot be given again. Several new chemotherapeutic drugs have been tried but with limited success. However, there is ongoing research in this field and we hope we can find more options for treatment.

case3: How do you deal with throat and lung cancer that is so aggressive that treatment helps, but that cancer is still growing, even if the tongue is removed?

Dr__Mumtaz_Khan: I hope I understood your question correctly. It sounds like the tumor is growing while getting the treatment and that there is another tumor in the lungs or the throat cancer has spread to the lungs. This typically indicates an advanced stage cancer that is very aggressive being unresponsive to treatments.

In such cases, we may not be able to achieve complete control on the disease. Although we tend to be more aggressive with our treatment strategies in such cases, but we always put the patient first. His/her comfort and quality of life is of extreme importance and we would very carefully choose treatments so as to minimize the adverse effects.


Treatments

1959: I’ve read that robotic surgery is an option for some head and neck cancers. What are the criteria for this type of surgery? Is everyone eligible for it?

Dr__Mumtaz_Khan: Robotic surgery is one of the new methods of minimally invasive surgery. It was recently also approved by the FDA for head and neck cancers. However, it is merely another way of cutting out the tumor.

The criteria are dependent on patient factors and on the location and size of the tumor. Since the instruments have to be passed through the mouth, people with a small mouth opening, large tongue, or full set of teeth may not be the ideal candidates. It also depends on the experience and training of the surgeon. It is primarily used for cancers of the tonsil, base of the tongue, and the larynx (voice box). Robot assisted surgery is also done for thyroid tumors through the armpit

joy_to_the_world: Is it possible to treat throat cancer with only surgery, or would I need radiation or chemotherapy?

Dr__Mumtaz_Khan: The treatment of throat cancer depends on the stage of the disease, and that would dictate if the treatment should be only surgery, only radiation, radiation and chemotherapy, or a combination of these methods. It also depends on the general health status of the individual as some treatments may not be suitable because of other co-existing conditions.

Generally speaking an early-stage cancer is treated with a single modality (method of treatment), such as radiation or surgery, which have similar outcomes. Advanced-staged cancers, stage III and IV, would require multiple methods of treatment, which would include a combination of surgery, radiation, and chemotherapy

playmates: What is the best treatment for larynx cancer?

Dr__Mumtaz_Khan: Larynx cancer treatment methods also depend on the stage of the disease. Please see previous question.

t_time: I’ve been diagnosed with laryngeal cancer, and my doctor has recommended surgery. I’m very concerned about preserving my voice, because I use it for my profession. Are there any types of surgery that will minimize damage to my voice?

Dr__Mumtaz_Khan: voice preservation procedures are possible only when the extent of the tumor allows saving a portion of the voice box without compromising on the cancer operation. There are several surgical methods that preserve the voice, in which one or both or part of a vocal cord can be saved. This of course depends on the stage of the disease and on the patient's general health. These minimally invasive voice preservation procedures are meant to preserve voice without affecting the protective mechanism of the larynx. You may want to ask your surgeon if you are a candidate for such a procedure.

hotntot: My mother was diagnosed with a carcinoma on the back (base) of her tongue. She was told that she should have the tongue removed, followed by chemotherapy/radiation. This is terrifying to my mother. What would her chances be if she did not have the tongue removed, but only accepted the chemotherapy/radiation treatment?

Dr__Mumtaz_Khan: The treatment options are dependent on the stage of the disease, which include the size of the tumor, the presence of lymph nodes in the neck and on the presence or absence of spread to other areas of the body. From the sound of your description, it is perhaps an advanced stage disease, and her physician feels that chemotherapy/radiation therapy as a primary treatment will not be sufficient. In such a case, removing the tumor first, followed by chemotherapy/radiation has better outcomes; and with the newer methods of reconstruction with free tissue transfer, we are now able to reconstruct the base of the tongue with the patients own tissue and restore near normal function.

jollo: My brother was diagnosed with papillary carcinoma and is going to be on radioactive iodine treatment. What can we expect from this and how can we (his family) best help him?

Dr__Mumtaz_Khan: Radioactive iodine therapy is provided by the endocrinologist and not head and neck surgeons. It would be best to get this information from your endocrine physician.


General Question

pp867: I had cisplatin for chemotherapy, and I understand that hearing loss is a side effect. How does that hearing loss manifest itself? Is it sudden or gradual? I’ve had earaches (throbbing pain) and ‘stuffiness’ in my left ear. It makes sounds muffled and hard to hear. There is also some ringing. I have an appointment in a couple of weeks and will discuss this with my doctor then, but I just wanted to know how worried I should be.

Dr__Mumtaz_Khan: Typically it is a gradual loss of hearing related to nerve deafness. You should get a hearing test or an audiogram for assessment, especially if you are going to receive additional cisplatin therapy. You must get a baseline hearing test.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Mumtaz Khan is now over. Thank you again Dr. Khan for taking the time to answer our questions today about head and neck cancer.

Dr__Mumtaz_Khan: Thank you for giving me the opportunity to answer your questions. For further information, please refer to our website to make an appointment or to see a head and neck specialist.


More Information

To make an appointment with Dr. Khan, or any of the specialists at the Head and Neck Institute at Cleveland Clinic, please call 216.444.6691 or call toll-free at 800.223.2273, ext. 6691. You can also visit us online at www.clevelandclinic.org/headneckcancer.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

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This chat occurred on May 16, 2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.