Head and Neck Cancer Treatments
Prior to starting your radiation treatment, it is important for you to visit your dentist and to have any needed dental treatment completed. Dental treatment after radiation treatment can be complicated by slow healing and can be a risk of infection.
Side effects of radiation treatment often happen to a patient because their mouth is not healthy before the radiation treatment begins. Not all mouth problems can be avoided with radiation treatment. Side effects may include:
- Dry mouth
- A lot of cavities
- Sore gums and mouth
- Jaw stiffness and jaw bone changes
- Loss of taste
During your treatment, it is important to stay away from food or objects that may cut or cause cavities. They include sharp, crunchy foods that could scrape or cut your mouth as well as toothpicks, foods that are hot, spicy, or high in acid like citrus fruits and juices which can irritate your mouth. Also avoid sugary foods like candy or soda that could cause cavities, alcoholic drinks and all tobacco products.
Keeping Your Mouth Healthy During Radiation Treatment
Visiting your dentist prior to your first radiation treatment is the first step to keeping your mouth healthy. Once you begin your radiation treatment it is important to examine your mouth each day looking for any sores or changes that might occur. These tips can help prevent and treat a sore mouth:
- Drink a lot of water and suck ice chips.
- Use sugarless gum or sugar-free hard candy.
- Use a saliva substitute to help moisten your mouth.
- Clean your mouth, tongue, and gums use and extra-soft toothbrush after every meal and at bedtime.
- Use a fluoride toothpaste.
- Avoid mouthwashes with alcohol in them.
- Floss your teeth gently every day. If your gums bleed and hurt, avoid the areas that are bleeding or sore, but keep flossing your other teeth.
- Rinse your mouth several times a day with a solution of 1/4 teaspoon each of baking soda and salt in one quart of warm water. Follow with a plain water rinse.
- Dentures that don't fit well can cause problems. Talk to your cancer doctor or dentist about your dentures.
- Take small bites of food, chew slowly, and sip liquids with your meals.
- Eat moist, soft foods such as cooked cereals, mashed potatoes, and scrambled eggs.
- If you have trouble swallowing, soften your food with gravy, sauces, broth, yogurt, or other liquids.
- Call your doctor or nurse when your mouth hurts and work with them to find medicines to help control the pain.
It is often a part of standard treatment for head or neck cancer patients and is often used along with chemotherapy.
Intensity-Modulated Radiation Therapy (IMRT)
IMRT is an advanced method of radiation therapy that ‘modulates’ (or is able to vary the intensity) of the dose of radiation to the tumor while minimizing the dose to the surrounding normal structures. This is achieved through computer-controlled machines and multiple beams of radiation from different angles. The radiation beams shape can change during treatment, bending around healthy tissues to target just the cancerous tissue. The result is a ‘cloud’ of radiation that is designed to conform to the three-dimensional shape of the tumor while reducing the radiation dose to the surrounding normal parts of the head and neck. This helps to reduce the risk of side-effects which can show up during treatment and also helps to reduce the risk of developing injury to important functions such as saliva production and swallowing.
The radiation planning process involves the correct identification of the anatomical location of the tumor and the normal structures in the patient. Physicians use diagnostic imaging tools including computed tomography (CT), positron emission tomography (PET) and magnetic resonance imaging (MRI) in addition to physical findings. The radiation therapy is typically administered in a series of daily appointments (Monday through Friday) over five to seven weeks. In order to increase treatment precision, the patient is immobilized with the help of a custom fitted mask. The mask is made during the radiation “planning session” and is molded to fit the individual patient. The mask is made of a thermoplastic material which is soft when heated and becomes rigid when it cools.
Types of chemotherapy:
- Neoadjuvant chemotherapy (chemotherapy ONLY, given prior to radiation or surgery): a drug treatment given to cancer patients before radiation or surgery. The aim is to reduce the size of the tumor and decrease distant metastasis, hoping to improve the success of additional treatments. At Johns Hopkins, a combination of cisplatin, docetaxal and 5 FU (Fuorouracil) is used primarily for patients with bulky, locally advanced squamous cell cancers of the head and neck. These tumors are typically found in the mouth, tonsils, base of the tongue, hypopharynx, and larynx. In certain patients with undifferentiated sinonasal cancers (rare cancers of the nasal cavity or sinuses) and esthesioneuroblastomas (a rare cancer of the upper nasal cavity), a combination of cisplatin and etoposide is used.
- Concurrent chemoradiation (chemotherapy and radiation together): it is the administration of a drug during radiation therapy.
At Johns Hopkins, this treatment is considered the standard of care in the following circumstances:
- For localized squamous cell carcinomas (those that have not spread beyond the sinuses, mouth, throat, and the neck) that cannot be completely removed with surgery. This is termed unresectable cancer.
- For patients who have had their cancer completely removed by surgery but are at high risk for recurrence of cancer – in this situation, surgery is followed by chemoradiation.
- For patients with locally advanced larynx cancer (cancer of the voicebox that has spread to nearby tissue or lymph nodes) that would necessitate the removal of the larynx – in this situation, chemoradiation may be appropriate to try to preserve the patient’s natural voice; surgery is then reserved for recurrence of cancer in the larynx or if the cancer is not completely eradicated by chemoradiation.
- For certain patients with cancers of the oropharynx (ex. tonsil, tongue) – chemoradiation instead of surgery may be appropriate to preserve speech/swallowing abilities.
The Head and Neck Cancer Center
The Johns Hopkins Head and Neck Cancer Center is dedicated in providing the highest quality of care to patients with head and neck cancer diagnosis.
Whenever possible, oncology surgeons at Johns Hopkins aim to use minimally invasive surgical techniques to best preserve patients’ function and appearance. Small tumors sometimes can be removed during outpatient surgeries under local or general anesthesia. If the cancer is larger, a patient most likely would need to stay in the hospital following surgery. Your physicians will discuss the best type of operation for you, depending on the size and location of your cancer, and whether it has spread.
Procedures used to remove tumors:
- Transoral Endoscopic Surgery- Many patients with smaller tumors in the mouth, throat and voice box may be candidates for tumor removal through the mouth (transoral). This is a minimally invasive technique that avoids incisions through the neck or face. These procedures result in less swelling, less scarring and a lower risk of infection. It also helps preserve function and appearance. Patients may be able to eat right after surgery, and even if their voice is affected it may be still be functional.
Our team has much experience in transoral surgery using both the laser and the surgical robot (transoral robotic surgery or TORS).
- Neck Dissection with Nerve Preservation- Neck dissection operations take out lymph nodes that may have cancer, on one or both sides of the neck through an incision in the neck. Traditionally, surgeons have removed tissue from five areas or levels in the neck, sometimes resulting in significant impairment to shoulder function and producing accompanying pain and numbness. With advances in the field, there are now several types of neck dissections, varying based on what structures are affected by cancer and need to be removed.
When possible, a modified or selective neck dissection procedures can now be performed. Whenever possible the involved lymph nodes are removed, sparing the sternocleidomastoid muscle (a long muscle in the neck that rotates the neck and flexes the head), the spinal accessory nerve (a nerve that carries messages from the central nervous system to two major neck muscles) and the internal jugular vein (a major blood vessel that drains blood from the head, brain, face and neck and sends it toward the heart).
In the selective procedures, surgeons operate on fewer areas, preserving function in the shoulder, and can sometimes leave the sensory nerves, preventing numbness, especially in the earlobe.
Most procedures must be done on an inpatient basis, with patients staying in the hospital for one night. In some cases, patients may go home the same day.
- Transoral Robotic Surgery (TORS)- Surgery is one option for treating oropharynx tumors – cancers occurring in the throat, base of the tongue, and tonsils. Conventionally, removing tumors through surgery required a very large neck incision and cutting of the bottom jaw. This left patients with difficulty in swallowing and speaking. Today, advances in surgical equipment have made it possible to reach orophayrngeal tumors through incisions in the mouth by using robotic technology.
- Who Benefits?- Patients that may benefit most from robotic procedures include those with early stage tumors with little or no lymph node involvement in the neck. Approximately 10 to 20 percent of patients with oropharygeal tumors may be considered ideal candidates for the procedure. Patients who smoke tobacco or have HPV negative tumors are especially encouraged to receive a primary surgical treatment for their cancer as these cancers often do not respond as well to radiation and chemotherapy.
- What are the Benefits?- Studies have shown that the outcomes of such procedures – called transoral robotic surgery – result in swallowing and speech function that is as good or better than other surgical methods, but without disfiguring scars. While up to 20 percent of patients who receive combination chemotherapy and radiation may have feeding tubes inserted for an average of five years, zero to 5 percent of patients undergoing transoral procedure need the tubes during the same time.
- Pairing Surgery with Radiation- Most patients undergoing TORS for oropharyngeal cancer still need to receive radiation therapy. But since the tumor has been surgically removed, radiation doses are generally lower than for patients who receive combined chemotherapy and radiation regimens.
The Johns Hopkins Head and Neck Cancer Surgery
The Johns Hopkins Head and Neck Cancer Surgery provides a comprehensive surgical care and treatment in head and neck cancers.