Prognosis and treatment depend on the type of cancer affecting the organ and the stage at which it was diagnosed. In addition, the physician will take into consideration the patient’s health history and characteristics of the cancer.
Prognosis
Prognosis is the estimate that the physician makes of the progression of the disease in each particular case and how it will respond to treatment. Some of the prognostic factors used by the physician in making an estimate are:
- Stage: this is usually measured by the size of the lesion and the level of spread to the surrounding tissues and organs, as described in the section on Staging.
- Size of the tumour: This gives an indication of how far along the tumour has progressed.
- Type of tumour: this is determined after the biopsy or excision of the tumour takes place and the pathologist produces a diagnostic report.
- Spread to the lymph nodes: this is usually an indication that the tumour is metastasizing beyond the local area affected, and also indicates that the disease has a less favourable prognosis.
- Spread to the bones: if the cancer has spread to the skull, it usually indicates a poor prognosis.
- Epstein –Barr virus infection: indicates a poor prognosis.
- Age: people 60 years or older have a poorer prognosis.
- Other health issues: people who have associated health issues such as heart or lung disease might also have a poorer prognosis. This is called comorbidity.
Treatment
Treatment will be designed for each patient’s particular circumstances. Factors that will be decisive include the type and stage of cancer, the spread to either lymph nodes or other organs and tissues, and the patient’s overall health history.
There are several steps that can be taken prior to treatment:
- A speech pathologist should evaluate the patient’s ability to speak and swallow before, during and after treatment, and will provide recommendations about how to preserve normal functions as much as possible, or provide advice in case of impairment.
- A nutritionist should also be a member of the treatment team and should assess the nutritional needs of each patient by establishing a baseline to evaluate the progress of the disease. If at any time during treatment the nutritionist determines that the patient is undernourished, additional nutrition can be provided intravenously or through a feeding tube.
- A dentist should evaluate the condition of the teeth before; during and after treatment since radiation therapy can increase the appearance of cavities and cause bone loss.
- Finding a support group is a good way to navigate the disease process, especially to prevent the accompanying depression that often It is also a good way to learn to manage symptoms and to communicate effectively with the healthcare team.
Surgery
Depending on the type of cancer and its location, a surgical removal of the tumour will be performed. This includes the entire tumour plus the normal adjacent tissues.
- Mohs surgery of the lip allows the surgeon to remove thin sections of skin which is immediately diagnosed until benign cells are found, and then the entire tumour is resected.
- Laser surgery uses a laser beam as a knife to make a clean cut and resect the tumour with as little disturbance of the surrounding tissue as possible.
- In the throat, a new procedure called TORS (Transoral Robotic Surgery) allows the surgeon to operate from inside the mouth in cases of internally located tumours. This procedure is very helpful at preventing post-surgery complications.
- Partial or full mandible or jaw removal will be performed when bone involvement is suspected or confirmed by imaging diagnosis.
- Maxilectomy surgery or the removal of the hard palate, which is replaced by a prosthesis that covers the resulting gap.
- The removal of the voice box is called Laryngectomy and it is carried out to prevent food from reaching the lungs and causing potentially fatal infections. In these cases a tracheostomy or an incision in the throat to allow breathing is performed.
- Neck dissection involves the removal of the lymph nodes in the neck.
- Reconstructive surgery is carried out when the surgery results in the removal of large tumours or the extraction of teeth.
Radiation Therapy
This treatment is used in both small and large tumours and post operatively to prevent recurrence. The main function of radiation therapy is to kill cancer cells or reduce their growth rate. It is also used to relieve cancer symptoms, such as bleeding or difficulty swallowing. There are two types of radiation: external or internal.
External radiation or external beam radiation therapy is delivered from outside the body. This type of radiation is used most often on oral or mouth cancers.
Internal radiation or brachytherapy is applied using surgically implanted metal rods that deliver the radioactive material in or near the cancer tumour.
Chemotherapy
This type of drug therapy is administered via IV (intravenous) or in pill form and it is intended to kill cancer cells anywhere in the body.[1] Chemotherapy is used to shrink tumours and/or stop the cancer from growing and spreading, which helps the patient feel better and live longer.
In cases when the cancer doesn’t go away, chemotherapy is given on ongoing basis to control the disease as a chronic condition.
When the disease is at an advanced stage, chemotherapy can also be used as palliative treatment to improve quality of life and help the person feel better. For example, anti-nausea treatments or pain medicines are palliative, and can be used at all stages of the treatment. (American Cancer Society)
Targeted therapy
Targeted therapy attacks specific cancer cells, leaving normal cells relatively untouched compared to chemotherapy and radiation therapy. Among these therapies are monoclonal antibodies, which is a type of protein made in the laboratory that can bind to cancer cells and make them susceptible to destruction by the immune system. They may be used alone or to carry drugs for targeted treatment or radioactive therapy substances.
Radiosensitizers
Radiosensitizers are drugs that make tumour cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers may kill more tumour cells. (NIH National Cancer Institute)
Clinical Trials
Patients may be able to enroll in clinical trials (research studies that test new methods of screening, prevention, diagnosis, or treatment of a disease) after diagnosis or after beginning their treatment. Patients who take part in clinical trials also help improve the way cancer will be treated in the future. In addition to getting a potential benefit in the progression of their disease, they help in the creation of new knowledge. (NIH National Cancer Institute)
Complications of treatment
Complications of treatment have to do with how chemotherapy and/or radiation affect the tissues and structures of the head and neck region.
- Oral complications: cancer treatments slow or stop the growth of fast growing cells, and cancer cells as well as normal cells in the lining of the mouth grow quickly, so anti-cancer treatment can stop them from growing. This slows down the ability of oral tissue to repair itself and fight infections. Radiation therapy may break down the tissues, including bone, and both chemotherapy and radiation may upset the balance of good bacteria in the mouth, which may lead to infections and tooth decay. That is why it is so important to have medical and dental checkups before starting treatment.
- Fatigue or lack of energy can be caused by both the cancer and its treatment, and it is characterized by a feeling of heaviness that won’t be alleviated with regular sleep and rest.
- Malnutrition is very common among patients with head and neck cancers. Complications from surgery, chemotherapy and radiotherapy may all lead to poor nutrition and the need for supplemental forms of food intake. Most patients receiving these treatments will need a feeding tube in the first three to four weeks after treatment. Sometimes the tube is placed into the stomach or small intestine through an incision (cut) made on the outside of the abdomen.
- Mouth and jaw stiffness can also contribute to malnutrition, oral infections and tooth decay as well as emotional problems, such as depression resulting from problems speaking and eating.
- Swallowing problems are very common in patients with head and neck cancers. In addition to poor nutrition, other complications include pneumonia and other respiratory problems, side effects from pain medication, such as constipation, and moderate to severe emotional problems.
- Tissue and bone loss can result from radiation therapy that can destroy blood vessels within the bone, making it fragile and prone to infection or fractures.
(NIH National Cancer Institute)
Management of symptoms
Cancer Care Ontario offers a symptom and side effect management guide that allows the patient to control their symptoms by answering a series of questions. Called “Your Symptoms Matter,” this tool is based on the Edmonton Symptom Assessment System-r (ESASr) that asks nine questions related to the most common symptoms to be rated from 0 to 10, 0 the least and 10 the most frequent, depending on how intense or painful a symptom is. This guide also provides an outline of the body so that the exact location of the symptom can be identified.
Life after treatment
Rehabilitation is a very important part of the life of the survivor, and it will vary depending on the extent of the tumour and the treatment received. This may include physical therapy, dietary counselling, speech therapy and/or learning to take care of a stoma (an opening in the throat to allow breathing after laryngectomy). In some cases, the patient will need reconstructive surgery or prosthesis (artificial dental or facial part) to restore appearance, speech and/or swallowing that will be aided by a speech pathologist. When difficulty eating is a consequence of treatment, a feeding tube may be placed into the stomach, either through the nose or the abdomen. This will require nursing care.
[1] Santhanam, Kausalya, and Rebecca J. Frey. “Oral Cancers.” The Gale Encyclopedia of Cancer: A Guide to Cancer and Its Treatments, edited by Kristin Fust, 4th ed., vol. 2, Gale, 2015, pp. 1295-1303. Gale Virtual Reference Library