Head and Neck Cancer: Q&A with Brian Burkey, MD

Dr. Burkey is the Section Head of Head and Neck Surgery and Oncology in the Cleveland Clinic Head & Neck Institute and is the Vice Chairman of the Education Institute. He is also Medical Director for the Cleveland Clinic Center for Consumer Health Information.

Q: A family member was diagnosed with thyroid cancer at 17. The thyroid was removed and she was given radiology isotope treatment. She now has lymph cancer. What are the options for treatment and which type of doctor should she see?

A: Your family member should be evaluated by both a thyroid surgeon and an endocrinologist. Most probably, the best treatment will include surgical removal of lymph nodes and additional radioactive iodine.

At the Cleveland Clinic, both the Endocrine and Head & Neck Institutes have surgeons specializing in the treatment of thyroid cancer. They work closely with the endocrinologists, including presentations at a multidisciplinary thyroid tumor board.

Q: What types of cancers are considered head and neck cancer?

A: Usually, the term “head and neck cancer” is used for cancers that originate in the upper aerodigestive tract, which includes the air and food passages from the lips and nose to the upper trachea and esophagus. Other cancers also include those of the thyroid, lymph nodes, and the soft tissues of the face and neck.

Brain tumors are separate and are treated by neurosurgeons and other cancer specialists.

Q: What can be done for swallowing or eating problems that result from cancer of the tongue and throat? Also, my brother has been waiting nearly two months for treatment to begin. Why would this take so long?

A: In treatment of cancers of the tongue and throat, swallowing and eating is almost always affected. Specialists rely on speech and swallowing pathologists to help in the diagnosis and treatment of these functions, caused by either surgical or nonsurgical treatment of head and neck tumors. They are a vital part of the treatment team.

The beginning of treatment is sometimes delayed due to the need to assess tumor spread and for the removal of nonviable teeth that are in radiation fields, along with healing time.

Q: Can you explain what happens during a retropharyngeal node resection?

A: Retropharyngeal node resection is an uncommon procedure where the lymph nodes behind the pharynx are removed via an incision in the neck and dissection down to the throat; the lymph nodes are then removed, along with associated fat and fibrous tissue.

Care is taken to avoid injury to the great vessels of the neck, including the carotid and jugular vessels.

Q: Is there a way to avoid thyroid cancer? Do dental X-rays increase the risk of developing it?

A: Thyroid cancer is quite common and is more common as people age. For many types, there is no obvious cause.

There are certain types of thyroid cancer that are associated with a familial tendency, and so a family history of thyroid cancer may put a person at increased risk.

Also, exposure to low-level radiation increases that person's risk of thyroid cancer. Examples include radiation given in the past for acne or tonsillitis, treatments that are now obsolete.

Dental X-rays are very low-level radiation and are probably safe in low numbers. They should be used when the information obtained is worth the radiation exposure.

Q: My 20-year-old cousin has cancer in a salivary gland and is having it removed. Will she have to go through chemotherapy and radiation, or does it depend on the stage of the cancer? Also, what would cause someone her age to get this kind of cancer?

A: Salivary gland cancer is relatively uncommon and there is no known reason or risk factor for this disease. Treatment includes surgical removal of the gland and sometimes the nearby lymph nodes.

Depending on the pathology found at the time of surgery, additional radiation and/or chemotherapy may be indicated.

Q: What are the key symptoms of throat cancer? For a couple of months now, I feel like I am swallowing "past something" in the right side of my throat. I do not feel it when I swallow food or drink, only saliva. It is not painful; it’s just there.

A: The key symptoms of throat cancer are trouble swallowing, painful swallowing, ear pain, change in voice, weight loss, and coughing up blood.

Your symptoms could be due to a cancer or, more likely, gastroesophageal reflux. This means that stomach acid can track up the esophagus, causing burns in the throat and symptoms that mimic cancer.

The best way to distinguish is to see a head and neck specialist for an exam in the office, which can help differentiate between benign and malignant causes of your symptoms.

Q: Which head and neck cancer do you consider to be most difficult to treat?

A: Any head and neck cancer may be difficult to treat if it is diagnosed at a late stage, which is why it is important to see a head and neck specialist if you are having worrisome symptoms.

Q: What are the “red flag” symptoms when looking at head and neck cancers?

A: The keys symptoms of head and neck cancer are trouble swallowing, painful swallowing, ear pain, change in voice, weight loss, an unexplained lump in the face and neck, coughing up blood, and pain/numbness in an area of the face and neck.

Q: If cancer is found in a lymph node in another area of the body, in this case the chest, what specialty would be included in the care of the patient?

A: In thyroid cancer, chest metastases are treated with radioactive iodine. This procedure is overseen by endocrinologists and nuclear medicine specialists.

Q: Do all types of head and neck cancer require surgery?

A: Head and neck cancer can be treated in three general ways: surgery, radiation therapy, and/or chemotherapy. Surgery may be done through an incision or endoscopically. The type of cancer, its site, and its stage determines the best treatment.

Again, specialists in head and neck cancer are best able to provide this information once all the factors have been evaluated.

Q: Do you work in conjunction with oncology?

A: Most all head and neck surgeons work closely with a medical and radiation oncologist, and I am no exception. The team approach to patient care invariably will provide the best cancer and functional results.

Q: Is head and neck cancer preventable?

A: Yes. The best ways to prevent head and neck cancer is to avoid tobacco use in all forms—smoking and chewing—and to drink in moderation. Smoking and drinking together increases your risk significantly.

These two factors make up the greatest risk factors for head and neck cancer. However, more than 80% of head and neck cancers are preventable with these lifestyle choices. If you currently smoke and stop, your chance of developing cancer will continue to decrease every year over a 20-year period.

Q: What kind of research is being done?

A: The answer depends upon the specific area of interest. Much research and education is taking place in all areas of prevention and treatment of head and neck cancer. One good source of new information is on the website of the American Head and Neck Society [www.headandneckcancer.org].

Q: How long does it take for thyroid cancer to turn into lymph cancer?

A: Thyroid cancer may travel to lymph nodes and require treatment at that site. Not all cancers will travel to lymph nodes and even small cancers may travel quickly, so there is not a perfect answer to your question.

However, in general, the lymph nodes should be evaluated in the workup of all thyroid cancer.

Q: Have you any knowledge of head or neck cancerous masses resolving without medical intervention? Can they just go away?

A: There are always sporadic reports of tumors that resolve on their own, but these are very rare indeed. The tumor where this is most commonly reported is melanoma of the head and neck skin, where spontaneous resolution will occur in a very small subset of patients. However, this again is a very rare occurrence and active treatment of cancer is always preferable where cure is desired.

Q: My brother has squamous cell cancer. I have read medical journal articles on the benefits of using advanced nutraceutical supplements before, during, and after chemotherapy and radiation. They supposedly make the good cells stronger and the cancer cells weaker. What is your thinking here?

A: This is an emerging field in the adjuvant treatment of head and neck cancer. However, the research is certainly in its infancy and many people in this country are wary of potential side effects and dilution of more standard treatments.

I would never substitute unproven treatments for proven treatments, but I am supportive of anything that may improve the overall immune capabilities of an individual without causing significant side effects.

The details of the potential treatment depend on the specifics; as always, the devil is in the details.

Q: Are there any long-term effects of the radiation treatment I am receiving?

A: If the radiation treatment is given daily over six to seven weeks, then there are long-term side effects. The most common side effect is acute swelling and tenderness of the lining of the mouth and throat. Most patients will also develop a dry mouth and lack of saliva that may last forever. Thus, good care of any remaining teeth after radiation therapy is essential, as is long-term follow-up with a dentist.