Current Practices in Head & Neck Cancers: Ask an Expert - Mumtaz Khan MD
April 4, 2013
Head and neck cancer refers to several types of cancers that affect the head and neck areas. These cancers account for approximately 3 to 5 percent of all cancers in the United States. Head and neck cancer is more common in men and in people over age 50. Nearly 65,000 patients are diagnosed with cancer of the head and neck in the United States each year.
These cancers can affect:
- nasal passages
- larynx (voice box)
- swallowing passages
- salivary glands
- and thyroid gland
Head and neck cancer can be hard to diagnose, because symptoms are often mild and can mimic less serious conditions such as a cold or sore throat. Fortunately, almost three-quarters of all head and neck cancers can be easily detected during an examination. Other diagnostic tests may include lab tests, endoscopy, head and neck imaging (with X-rays, CAT scans, MRIs or PET scans) and biopsy.
Options for treating cancers of the head and neck may include surgery, radiation therapy, chemotherapy, and targeted therapy. One of these therapies, or a combination of them, may be part of a person’s treatment plan. Head and neck cancers are very treatable if caught early, and are easily preventable. The most common causes of head and neck cancer are tobacco and alcohol use.
About the Speaker
Mumtaz Khan, MD, is a head and neck surgical oncologist in Cleveland Clinic’s Head & Neck Institute. He specializes in the treatment of: head and neck cancer, carotid body tumor, laryngeal cancer, oral cancer, oropharyngeal cancer, paraganglioma, salivary gland cancer, thyroid cancer, thyroid nodule and robotic surgery.
Dr. Khan completed his fellowship in head and neck surgery at Vanderbilt University Hospital, in Nashville, TN, after completing his residency in otolaryngology head and neck surgery at Henry Ford Hospital, in Detroit, MI. Dr. Khan graduated from medical school at Aga Khan University, Faculty of Medicine, Karachi, Pakistan. He is board certified otolaryngology.
Let’s Chat About Current Practices in Head and Neck Cancers: Ask an Expert
Moderator: Welcome to our Online Health Chat with Cleveland Clinic expert Dr. Mumtaz Khan. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.
Head and Neck Cancer Screening
markeyjd2: What do doctors do during a head and neck cancer screening?
Mumtaz_Khan,_MD: Screening involves evaluating the upper airway and digestive tract. This entails examining the mouth and evaluating the tongue, gums, teeth, the voice box and pharynx. The neck is also examined for enlarged lymph nodes.
Base of Tongue Tumor: Diagnosis and Prognosis
tinytear: Is a base of tongue (BOT) mass usually caused by HPV (human papillomavirus)? Is this a slow-growing form of cancer?
Mumtaz_Khan,_MD: HPV is only one of the causes of a malignant mass at the base of the tongue. HPV-related BOT and tonsil tumors are being diagnosed more readily now than they used to be. These are typically not considered to be slow growing, and are clinically taken to be as serious as non-HPV related squamous cell cancers of the base of the tongue.
tinytear: How common is base of tongue (BOT ) mass? What is the cause and what is the growth rate? What is the usual treatment for BOT mass and for lymph nodes of the neck that are involved? What is the survival rate?
Mumtaz_Khan,_MD: BOT cancers are one of the most common sites for head and neck cancer to occur. The most common causes include smoking, alcohol use, and more recent evidence suggests that certain types of human papillomavirus may be responsible. A small percentage of patients may not have exposure to any of these risk factors, and may still develop cancer.
Once the cancer is properly staged, treatments are based on the size of the primary tumor and the presence of lymph node involvement in the neck as well as spread of disease to other parts of the body. These treatments may include surgery, radiation, chemotherapy or a combination of more than one of these modalities.
Squamous cell cancers, which are the most common type of cancer, are aggressive tumors that need to be treated as soon as possible. The survival rate is seen to be better with early stage disease. HPV-related tumors have been shown to have a 20 to 25 percent better 5 year survival (prognosis) than those related to smoking and alcohol.
tinytear: A patient who was diagnosed with BOT (base of tongue) cancer that has spread to the lymph nodes of the neck and a mass on the carotid artery that was diagnosed in August of 2012 is afraid to seek treatment. The patient has a history of panic attacks. What advice and help can you give for this type of patient who is terrified? How long can this patient live without treatment? Will it be a long and painful death or quick?
Mumtaz_Khan,_MD: Unfortunately, it is impossible to predict longevity. I would, however, encourage you to discuss treatment options with your treating physician. We emphasize greatly on the treatment of the cancer as well as the quality of life issues. There has been a significant improvement in not just the surgical techniques but also in the way radiation therapy is administered. Without compromising the cancer treatment, these developments ensure better quality of life and preservation of function. So, please do seek medical advice for your disease. This is still a very curable and treatable disease, but one must not waste time in getting the appropriate treatments.
Oral Cancer Diagnosis and Cervical Human Papillomavirus
calli: If I have tested positive for cervical HPV, does that increase my risk for oral cancers?
Mumtaz_Khan,_MD: There is insufficient information to determine that you would be at risk for oral cancer. There are certain types of HPV virus (HPV 16 and 18) that are related to cervical cancers and oropharyngeal cancers but there is no data to suggest that if someone has cervical cancer, they are more at risk of oropharyngeal cancer also.
porter4: My dentist noticed that my left tonsil was unusually enlarged and that I should get it checked out. It does not hurt and I have no other symptoms. I am very busy with work and children that I have not made an appointment. I just assumed it had gotten irritated and would be fine. However, I mentioned this to a friend who told me that 1 enlarged tonsil can indicate cancer. Is this true? Should I be more concerned than I am?
Mumtaz_Khan,_MD: It is true that an asymmetrically enlarged tonsil (one-sided) may be a sign of an underlying tumor. It may be nothing more than a chronically infected tonsil, but you should get this checked out sooner rather than later. It is recommended for adults to undergo evaluation and sometimes even tonsillectomy to rule out cancer. I would not delay this unnecessarily and would make an effort to have it evaluated.
Necrotic Lymph Node
tinytear: Can you talk about a necrotic lymph node in the neck? Will this need surgical removal?
Mumtaz_Khan,_MD: A necrotic lymph node may be an indication of an infection or tumor spread. The size of the lymph node and the time that it has been present matters. Typically, a lymph node larger than 1.5 centimeter in size and present for more than a month should be evaluated. The most efficient way to evaluate a necrotic lymph node is by performing a fine needle aspiration, which is a relatively simple test that can be performed in the clinic. Surgical removal may not always be necessary.
Irritation Fibroma and Cancer
sisters: What is the likelihood that a benign head and neck lesion like an irritation fibroma caused from chronically biting or sucking the cheek will turn into cancer?
Mumtaz_Khan,_MD: Any persistent ulcer or sore should be evaluated. Chronic irritation from a sharp tooth edge or ill-fitting dentures has been shown to cause cancer. Maintaining proper oral hygiene and dental evaluation is very important.
bbo: What causes a hoarse voice?
Mumtaz_Khan,_MD: Hoarseness most commonly results from voice abuse. It also certainly results from smoking and may cause cancer of the vocal cords. If hoarseness persists beyond two to three weeks, it should be evaluated by an ear, nose and throat (ENT) doctor or head and neck surgeon who can examine the vocal cords in the office and identify any potential problems. Smoking cessation, anti-reflux measures and avoiding extreme voice abuse will help.
Cancer Free Diagnosis
Mr. T.: I got a PET/CT Scan on March 12 and received an ‘all clear’ from tonsil cancer. How long before I can be declared ‘cancer free’?
Mumtaz_Khan,_MD: By definition you will be labeled ‘cancer free’ five years after completion of your treatments. The risk of recurrence is the highest in the first two years. So, the longer you are from your last treatment the higher the chance of being cancer free.
Heredity and Mouth Cancer
tiller3: If my father had mouth cancer, do I have a higher risk of getting this type of cancer too?
Mumtaz_Khan,_MD: There is not sufficient evidence to suggest a hereditary link to mouth cancers. Smoking and alcohol and HPV exposure continue to be the main cause for squamous cell carcinoma.
SDHB Mutation and Paraganglioma
dharmanita: I have mutant SDHB gene, and had a single 2.5 cm carotid body tumor removed four and one half years ago when I was 30 years old. I'm curious to know how likely it is that I will develop either a recurrence or new primary tumor. I ask because of some concern I have about the inherent risks involved with regular and indefinite annual screening. I've scoured the research for years now and I know that the risk of malignancy is relatively high with my mutation. However, I can't find anything that even hints at the chances that my original tumor will end up being the only manifestation of my mutation.
Mumtaz_Khan,_MD: SDHB mutation has been identified in hereditary paraganglioma-pheochromocytoma syndromes. I would encourage you to continue with your regular screenings which is the best way to identify any new masses. There is a reported age-related penetrance of SDHB, meaning the older the individual is, the more likely they would be diagnosed with a paraganglioma. There is also an inherent risk for this mutation to cause malignant transformation and hence the need for continued screening. Needless to say, genetic testing should be considered in all patients.
tinytear: Is a feeding tube always needed for the treatment of cancer of the head and neck? Can a patient refuse a feeding tube?
Mumtaz_Khan,_MD: A feeding tube is not necessary for all patients. It is typically recommended for those who have difficulty swallowing solids and liquids, or are unable to maintain their weight. Treatments such as radiation or chemotherapy may cause people to have difficulty swallowing during the course of the treatments. For those patients a feeding tube is very helpful. Also a feeding tube may be necessary for some surgical procedures to ensure proper healing. The patient always has the right to refuse any treatment. However, they should strongly consider the recommendations given by their physician.
Treatment of Carotid Artery Mass
tinytear: Can radiation and/or chemotherapy alone shrink a mass on the carotid artery of the neck? Is surgery always needed?
Mumtaz_Khan,_MD: It depends on the type of tumor as well as the extent of involvement of the carotid artery. All of the treatments mentioned (surgery, radiation or a combination of chemotherapy and radiation) may be used to treat a mass in the neck. The first choice of treatment essentially depends on the primary site of the tumor.
Sinonasal Undifferentiated Carcinoma Treatment
big sis: My brother was recently diagnosed with T1, sinonasal undifferentiated carcinoma (SNUC) and he is scheduled for surgery. It is hard to find much information on this. Can you talk a little about expected treatments, survival rate, and so on?
Mumtaz_Khan,_MD: SNUC is an uncommon but very aggressive tumor of the sinonasal tract. Proper staging is crucial in selecting the appropriate surgical procedure. A stage I tumor is well localized and has a better chance of control with proper resection (surgery) followed by radiation and/or chemotherapy. Although generally SNUC tumor has a poor prognosis, the sooner it is identified and treated the better the control of the disease.
Head and Neck Cancer: Side Effects of Treatment
Mainship: Dr Kahn did a neck dissection for my neck cancer. I had radiation for seven weeks, and chemotherapy at Indiana University Health. I was unable to do the radiation at Cleveland Clinic although that was my strong preference. I am three months and one week post-treatment as of March 22.
I still have significant fatigue, loss of taste, dry mouth and chills. I had a contrast CAT scan that was ‘clean’ two weeks ago. Are my post-treatment symptoms normal this far out? Is there any treatment and tests that I could get at Cleveland Clinic that would help these post-treatment problems?
Mumtaz_Khan,_MD: The symptoms that you describe are typically related to the effects of radiation therapy and chemotherapy. These may take a while to improve. Dry mouth is probably the only side effect of radiation therapy that remains. These symptoms may continue for a few more months, but after the first year they typically start to settle down. There are no specific tests available. However, your nutritional status and general well-being is very important. Low thyroid function may sometimes contribute to the low levels of energy too.
Treatment for Lymph Node Metastases
tuesday: Does spread to a local lymph note always mean that a head and neck paraganglioma such as a carotid body tumor has metastasized and that radiation is warranted?
Mumtaz_Khan,_MD: The presence of paraganglioma in an adjacent lymph node does indicate metastatic disease. However, radiation is not always warranted. It is dependent on the age of the patient as well as other disease characteristics like the size of tumor, margins of excision, number of lymph nodes involved, etc.
Cancer Prevention After Treatment
Mainship: After treatment is there anything I can do to help prevent the cancer from returning? I had HPV-related cancer, of unknown primary location, with two lymph nodes involved.
Mumtaz_Khan,_MD: Once treatments are completed, a clinical follow-up is the most important part of cancer surveillance. From the patient standpoint, smoking cessation is the only preventive measure. Routine follow-up visits with your physician will ensure serial (consecutive) evaluations and a chance to identify a possible occurrence as soon as possible. Imaging studies are typically performed to evaluate a new sign or symptom or a clinical finding picked up by your doctor.
Smoking Cessation Programs
best of the best: I know that head and neck cancers are often caused by using tobacco. I want to quit, but I don’t know where to begin. If I am able to quit, do my chances for these types of cancer decrease or has the damage already been done?
Mumtaz_Khan,_MD: There are numerous smoking cessation programs that your primary care physician or oncologist would be able to help you with. These are very effective for determining what works best for an individual. Unfortunately, even after quitting your chance of developing a smoking-related disease is higher compared to a nonsmoker. However, the longer you have abstained from tobacco, the likelihood of developing a cancer decreases.
Moderator: I'm sorry to say that our time with Cleveland Clinic expert Dr. Mumtaz Khan is now over. Thank you Dr. Khan for taking your time to answer our questions today about head and neck cancers.
Mumtaz_Khan,_MD: Thank you all for your very interesting questions. I wish you all the very best. If there is anything we can do, please let us know.
If you would like to make an appointment with Dr. Khan or any of our other specialists in the Head & Neck Institute, please call 800.223.2273 x45800 or request an appointment online by visiting www.clevelandclinic.org/appointments.
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