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HEAD AND NECK CANCERS
( By JASCAP )

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Treating head and neck cancers

Treatment Overview

There are three main types of treatment for head and neck cancers:

Two other treatments may sometimes be used:

You may have two or more different treatments. These may be combined together, such as chemotherapy and radiotherapy - this is known as chemoradiation.

For most people, the treatment is aimed at:

  • removing the cancer
  • reducing the chances of the cancer coming back.

Cancers affecting the head and neck are uncommon so people with this type of cancer are usually treated in specialist hospitals. This may mean that you have to travel for your treatment.

How treatment is planned

In most hospitals a team of specialists will decide the treatment that's best for you.

This multidisciplinary team (MDT) includes:

  • an oral and maxillofacial surgeon - a doctor or dentist who specialises in surgery to the mouth and jaws, or an ear, nose and throat (ENT) surgeon
  • an oncologist - a doctor who specialises in cancer treatments such as radiotherapy, chemotherapy and biological therapy
  • a radiologist - a doctor who helps to analyse scans and x-rays
  • a pathologist - a doctor who advises on the type and extent of the cancer
  • a nurse specialist who gives information and support
  • a speech and language therapist
  • a dietitian.

The team will often include a number of other healthcare professionals such as:

  • a dentist or oral hygienist
  • a physiotherapist
  • an occupational therapist
  • a psychologist or counsellor.

Together they will be able to advise you on the best course of action and plan your treatment, taking into account a number of factors. These include your age, general health, and the type and stage of your cancer.

If two treatments are equally effective for the type and stage of cancer - for example, surgery or radiotherapy - your doctors may offer you a choice of treatments. Some people find it very hard to make a decision. If you're asked to make a choice, make sure that you have enough information about the different treatment options, what is involved and the side effects you might have, so that you can decide what the right treatment is for you.

Remember to ask questions about any aspects that you don't understand or feel worried about. You may find it helpful to discuss the benefits and disadvantages of each option with your doctor, specialist nurse, or with our cancer support specialists.

Giving your consent

Before you have any treatment, your doctor will explain the aims of it to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form, you should be given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages
  • any other treatments that may be available
  • any significant risks or side effects

If you don't understand what you've been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it's not unusual for people to need repeated explanations.

It's often a good idea to have a relative or friend with you when the treatment is explained, to help you remember the discussion. You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that hospital staff are too busy to answer their questions, but it's important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it's first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you don't have it. It's essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You don't have to give a reason for not wanting to have treatment, but it can help to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatment

Many people are frightened at the thought of having cancer treatments, particularly because of the potential side effects. Some people ask what would happen if they did not have any treatment.

Although many of the treatments can cause side effects, these can usually be controlled with medicines.

Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation. In people with early-stage head and neck cancer, surgery or radiotherapy is often done with the aim of curing the cancer. Occasionally additional treatments are given to reduce the risk of it coming back.

If the cancer is at a more advanced stage, treatment may aim to cure the cancer, or it may only be able to control it, leading to an improvement in symptoms and a better quality of life. For some people the treatment will have no effect upon the cancer and they will get the side effects with little benefit.

If you've been offered treatment that aims to cure your cancer, deciding whether to accept the treatment may not be difficult. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to make a decision.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor or nurse specialist whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to control any symptoms.

Second opinion

Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Either your specialist, or your GP, will be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. Getting a second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you do go for a second opinion, it may be a good idea to take a relative or friend with you, and have a list of questions ready, so that you can make sure your concerns are covered during the discussion.

Before treatment for head and neck cancer starts

Dental care

You will usually be advised to have a complete dental check-up and any necessary dental work done before your treatment begins. Your cancer doctor may recommend that you see a dentist with experience in treating people who have head and neck cancers, rather than your own dentist.

The dentist or hygienist will give you advice on how to care for your teeth and gums, and check that your teeth are healthy. This is very important because cancer treatment may make your mouth more sensitive and prone to infection, particularly if you have radiotherapy.

Smoking

If you have a head and neck cancer, your treatment is more likely to be successful if you don't smoke. Continuing to smoke can increase the side effects of treatment. It can also increase the risk of a second cancer growing in the same area, or in other parts of the body, such as the lung, or of the original cancer coming back. Smoking can be a difficult habit to break, especially at times of stress, but if you're able to stop smoking it will help your recovery. There are organisations that can help you. Your GP can also give advice and provide nicotine replacement therapies such as nicotine patches, gums and inhalers on prescription.

Alcohol

Avoiding alcohol, particularly spirits, will also help make your treatment more effective and reduce the risk of uncomfortable side effects.

Surgery for head and neck cancers

Surgery is an important part of treatment and usually aims to remove head and neck cancers completely.

The part of your mouth or throat that the doctor may remove depends on where the tumour is. Very small cancers can often be treated with a simple surgical operation under local or general anaesthetic, or with laser surgery, with no need to stay in hospital overnight.

If the cancer is larger, surgery will often involve a hospital stay and an operation under general anaesthetic.

Sometimes the surgery may involve more than one part of your head and neck, and may cause scarring on your face or neck. Some people may need to have reconstructive surgery to the face.

What to expect from the operation

If you need to have surgery, your doctor will discuss the best type of operation for you, depending on the size and position of your cancer, and whether it has spread. It's important to make sure that you have discussed your operation fully with your surgical team. This will help you to understand exactly what is going to be removed and how this will affect you after the operation - in both the short and the long term.

It's likely that during the operation the surgeon will also remove some of the lymph nodes on one or both sides of the neck, even if they are not swollen. This is called a neck dissection. Sometimes this is done because the nodes may contain a small number of cancer cells that did not show up in the earlier scans.

Flaps and grafts

The surgeon may need to remove part of the mouth, tongue or throat lining and occasionally some facial skin. This can be replaced using a piece of skin taken from another part of the body - usually the forearm or chest. This is known as a skin flap.

If the cancer is affecting part of your jawbone, the affected bone may be removed with the tumour. In this case, you may need to have part of a bone taken from elsewhere in your body to replace the missing jawbone. Usually the bone is taken from the leg. This is known as a bone graft. Your doctor and specialist nurse will be able to give you specific information about this type of operation.

Modern techniques usually enable you to move your jaw again as soon as the operation is over.

Prosthetics

Occasionally, in order to remove the cancer, the doctor may also need to remove some of the facial bones such as the cheekbone or palate. Depending on the extent of the operation, you may be offered an artificial replacement called a prosthesis (false part). This is a specially designed soft plastic replacement for the part of your face that has been removed. The most common prosthesis is an obturator - a denture with an extension that is used to replace the upper jaw.

Modern prostheses can be designed to suit your needs. They will never feel like your own tissue but they can look very realistic and work very well. If you're likely to need a prosthesis, your doctor and specialist nurse will discuss this with you fully before your operation. You will also talk to a prosthetics technician, who will be involved in designing and making your prosthesis.

It's important to discuss your operation fully with your surgical team so that you know what to expect and how it will affect you.

Some people can have surgery as a day patient, particularly when this involves just an examination under anaesthetic or a biopsy. If your surgery is more complicated, you will need to stay in hospital for several days or up to a few weeks. Your stay in hospital will depend on the extent of the surgery and whether or not you have had a skin flap or tissue graft.

After your operation you'll be encouraged to start moving around as soon as possible. This is an essential part of your recovery and, even if you have to stay in bed, it's important to do regular leg movements and deep breathing exercises.

A physiotherapist will explain these to you.

If you have extensive surgery, you may spend some time in intensive care immediately after the operation. This is a ward where you will be closely checked and given intensive nursing care for as long as necessary to help you recover.

Drips, drains and tubes

After the operation, it's likely that you will wake up with a number of drips, drains and tubes attached to you. These will gradually be removed as you recover.

Drips

Most operations to the mouth and throat area can make eating and drinking uncomfortable for a time. Because of this, you'll probably wake up from the operation with an intravenous drip (a tube inserted into a vein in your arm or your neck). This will give fluids and essential nutrients directly into your bloodstream for a few days. It will be removed once you are able to eat and drink again.

Drains

Depending on the extent of your surgery you may have one or two thin plastic drainage tubes leading from the operation site, with bottles attached to them to collect any fluid from the wound site. This helps the wound to heal properly.

Feeding tube

If eating is likely to be difficult for longer than a few days, the surgeon will do one of two things during the operation, while you are still under the anaesthetic.

You may have a thin tube passed through your nose and throat into your stomach. This is called a nasogastric (NG) tube.

The nurses on the ward will put special high-protein, high-calorie liquid food down the tube at regular times. This will help you to keep your strength up and help your body recover from the operation. The NG tube may need to stay in place for a couple of weeks, until you can eat properly again, and will be removed when you are able to eat by yourself.

You may have a tube that passes directly through the wall of your abdomen into your stomach, near your waist. Liquid food can be passed into the stomach directly through this. This is called a gastrostomy tube. There are two types of gastrostomy feeding tubes: percutaneous endoscopic gastrostomy (PEG) tubes and radiologically inserted gastrostomy (RIG) tubes. For a few people these may be permanent.

We have a factsheet on nutritional support which includes nasogastric, PEG and RIG feeding tubes.

A dietitian will visit you to discuss how much food you need to help with your recovery. They will decide the exact amount and type of food you should be given to replace your normal diet.

Catheter tube

Often a small tube (catheter) is put into your bladder, and your urine is drained through this into a collecting bag. This will save you having to get up to pass urine and it is usually removed after a couple of days.

Tracheostomy tube

Sometimes surgery to the mouth or throat can cause some swelling or bruising to the surrounding tissue, which may make it difficult for you to breathe. In this case the surgeon will create an opening into your windpipe (in the lower part of the neck) called a tracheostomy (or stoma) for you to breathe through.

The tracheostomy will be held open by a small plastic tube a few centimetres long. It will usually be removed when the swelling from your operation goes down and the airway is clear again. This will be explained to you by the specialist nurse or speech and language therapist before you have your surgery.

If you have a tracheostomy you may not be able to talk, because air will not be able to pass through your larynx to produce your voice. Your medical team will make sure that you have a way to communicate during this time.

Pain

You may have some pain or discomfort for a few days after your operation. For example, a neck dissection can often cause shoulder stiffness. It's also possible that the surgery may affect the sensation in your mouth, face, neck or shoulders so that some areas feel numb. This can happen even with a very small operation if some of the small nerves in the area need to be cut.

There are several different types of effective painkillers. If you're unable to eat properly you may be given painkillers by injection or as a liquid that can be injected through your NG or gastrostomy tube. Once you are able to eat and drink properly again, you can be given your painkillers as tablets or a liquid that you drink. It's very important to let your doctor or the nurses on the ward know as soon as possible if you have any pain. If your drugs don't completely relieve your pain, the dose can be increased, or the painkillers changed.

Speech

Some operations to the mouth and throat can affect the way that you speak. Speaking is a very complicated process, as the throat (pharynx), nose, mouth, tongue, teeth, lips and soft palate are all involved in producing speech. Any operation that changes one of these parts of the head and neck may affect your speech. For some people this is hardly noticeable, but for others, speech may be temporarily or permanently altered.

A speech and language therapist will be able to help you with your speech and to adapt to any changes.

Stiff jaw

Some operations to the back of the mouth and throat can lead to a stiff jaw. You will be given exercises to prevent this from becoming a permanent problem.

Specialist types of surgery

Laser surgery may sometimes be used to remove small tumours in the mouth and the pharynx. This may be combined with a light-sensitive drug (sometimes called a photosensitising agent) in treatment known as photodynamic therapy (PDT).

A type of surgery called micrographic surgery or Mohs surgery is sometimes used for cancers of the lip. The surgeon removes the cancer in thin layers, and the tissue that has been removed is examined under a microscope during the surgery. The surgeon will continue to remove more layers until no cancer cells are seen in the tissue. This technique makes sure that all the cancer cells are removed and only minimal healthy tissue is removed.

Preparing to go home

Before you leave hospital you'll be given an appointment to attend an outpatient clinic for check-ups or to plan further treatment, such as radiotherapy. If you need to see any of the other members of the team, such as the speech and language therapist, specialist nurse or the dietitian, you'll also be given appointments to see them. This is a good time to discuss with your doctor any problems you may have after your operation.

If you have a gastrostomy tube you may go home with it. This is likely to happen if you need radiotherapy treatment after your surgery because the treatment can cause soreness in the mouth and throat area, making it difficult to eat. Before you go home the nurses will be able to teach you or your carers how to look after the gastrostomy tube. They can also arrange for a district nurse to visit you at home.

Radiotherapy for head and neck cancers

Radiotherapy for head and neck cancers is usually given in combination with chemotherapy. This is known as chemoradiation. This may be used instead of or after surgery.

There is good evidence that this combined treatment is more effective than using either chemotherapy or radiotherapy alone. However, radiotherapy may sometimes be used alone if a person is not fit or well enough to have chemoradiation.

You might find it helpful to read our booklet about radiotherapy, which gives information about the treatment and how to cope with side effects.

Radiotherapy can be given in two ways:

  • From outside the body as external beam radiotherapy (a beam of x-rays or electrons from a large machine called a linear accelerator). This is the most common way of giving radiotherapy to the head and neck area.
  • By implanting radioactive material into the tumour and leaving it there for a few days. This is known as internal radiotherapy, interstitial radiotherapy or brachytherapy.

External radiotherapy for head and neck cancer

External radiotherapy treats cancer by using doses of high-energy x-rays to destroy the cancer cells while doing as little harm as possible to normal cells.

How treatment is given

The treatment is usually given every weekday in the hospital radiotherapy department, with a rest at the weekend. You may sometimes have treatment more than once a day, and occasionally you may also have treatment at the weekend.

It's important to follow the scheduled treatment plan and avoid any unnecessary gaps in your course of treatment. The treatment will usually last 3-7 weeks, depending on the type and size of the cancer. Your radiotherapy doctor (clinical oncologist) will discuss the treatment with you.

Conformal radiotherapy (CRT) is the most common type of external radiotherapy used for the treatment of head and neck cancers. A special attachment to the radiotherapy machine carefully arranges the radiation beams to match the shape of the cancer. Shaping the radiotherapy beams reduces the radiation received by surrounding healthy cells. This can reduce the side effects of the radiotherapy treatment (such as a dry mouth) and may allow higher doses to be given, which could be more effective. Another type of radiotherapy known as intensity- modulated radiotherapy (IMRT), which is similar to conformal radiotherapy, may be used in some hospitals.

Planning your treatment

To ensure that the radiotherapy is as effective as possible, it has to be carefully planned by a clinical oncologist. It's a very precise treatment and it's important that you are able to lie still, in exactly the same position, for each treatment.

To help you do this, you may need to wear a see-through Perspex® or plastic device called a 'mould', „shell' or „mask' that helps to keep your head and shoulders as still as possible. The mould allows you to see and breathe normally, but it may make some people feel claustrophobic. It's important to let the doctor or nurse know if you suffer from claustrophobia. You will only have the mould in place for a few minutes at a time, and most people soon get used to wearing it.

Patient getting Radiotherapy treatment

You may need to wear a clear, plastic mask for a few minutes at a time, to hold your head still during treatment.

Your mould will be made on one of your first visits to the radiotherapy department. The radiographer (the person who gives the treatment) will explain the whole process to you before starting.

Treatment planning is a very important part of radiotherapy and several visits may be needed.

You will have a CT (computerised tomography) scan taken of the area to be treated. A CT scan takes lots of images from different angles to build up a three- dimensional picture of the area. At the same time radiographers will take measurements from you which are needed for treatment planning. This session will usually take about 45-60 minutes and you will need to wear your radiotherapy mould.

Sometimes you may also need to go to the hospital's scanning department to have an MRI scan. This uses powerful magnetic fields to give a detailed picture of part of your body, which can give additional useful information.

The radiographer's measurements and the information from the scans are fed into the radiotherapy planning computer to help your doctors plan your treatment more precisely.

Marks are drawn on the mould (or sometimes on your skin) to help the radiographer position you accurately, and show where the rays are to be directed. If the marks are on your skin they must stay there throughout your treatment, but they can be washed off once your course of treatment is finished. Sometimes a few small, permanent marks (tattoos) may be made on your skin. The marks are tiny and will only be done with your permission.

At the beginning of your treatment you'll be given instructions on how to look after the skin in the area being treated. You will be told whether you can wash the marked areas of skin.

Tracheostomy tube

Very occasionally, radiotherapy to the mouth or throat can cause swelling to the surrounding tissue which may make it difficult for you to breathe during the treatment.

If this is likely to happen, your doctors will arrange for you to have a tracheostomy before your radiotherapy treatment starts. The tracheostomy is usually temporary.

During the treatment

Before each session of radiotherapy, the radiographers will position you carefully on the couch, with the mould fitted, and make sure you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room, but you'll be able to signal to the radiographers who will be watching you from the next room.

You will have to lie still while the treatment is given, but you will not feel the radiotherapy; it's similar to having an x-ray.

External radiotherapy does not make you radioactive, and it's perfectly safe for you to be with other people, including children, throughout your treatment.

Side effects of radiotherapy

Radiotherapy can cause some temporary side effects. Although these may be worse if you have your treatment combined with chemotherapy, they will usually gradually disappear after the treatment has finished.

If you continue to smoke during your treatment these side effects are likely to be worse, so if you can stop smoking this will help your recovery.

You may have some of the side effects listed below:

Sore skin

The skin over your face and neck is very likely to gradually redden or darken and become sore (like sunburn). This starts after about two weeks of treatment and may last for 2-4 weeks after the treatment has finished. Sometimes the skin will peel or break. The radiotherapy team will tell you how to look after your skin as some chemicals can make the skin more sensitive to radiation. It's very important to use only soaps, creams and lotions that are recommended by the radiotherapy staff.

Rarely, the skin in the treated area may break down and become moist. The radiotherapy team can give you advice if this happens.

Sore mouth and throat

Your mouth and throat will probably become sore and inflamed after a couple of weeks of treatment and you may develop some mouth ulcers. Your voice may also become hoarse. You may become sensitive to very strong flavours and possibly to extreme heat and cold. Eating food may become difficult and swallowing painful.

You will be given advice on how to look after your mouth during your treatment. It's important to follow this advice. Your doctor can prescribe mouthwashes and protective gels that coat the lining of the mouth, and painkillers to help ease any discomfort.

Your specialist nurse or dietitian will advise you on how to change your diet to make eating more comfortable. For example, you'll be encouraged to eat soft food and to avoid smoking, drinking spirits and eating hot or spicy foods. Drinking plenty of bland, cool fluids like milk and water, or sucking ice cubes, will help to keep your mouth moist. You'll be able to discuss any problems with eating and drinking with a specialist nurse or dietitian.

Once the course of radiotherapy has finished, your mouth will gradually heal and most people get back to eating normally a few weeks after the treatment has finished. However, the effects of the radiotherapy occasionally make the throat too uncomfortable for a person to eat or drink and they may need to be fed by

a nasogastric or a gastrostomy tube during the treatment and for a period of time after treatment has finished.

Loss of taste

If part, or all, of your mouth is treated, your sense of taste will quickly change during the radiotherapy. Some people either lose their sense of taste completely or find that everything tastes the same (usually rather metallic or salty, or like cardboard).

Although your sense of taste should recover, it may take many months for it to return to normal after the treatment.

Loss of appetite

Some people lose their appetite as a general effect of radiotherapy. A sore, dry mouth can also make eating difficult. If you are eating less, it's a good idea to supplement meals with nutritious high-calorie drinks such as Complan® and Build- up® (these are available on prescription or can be bought from a pharmacy or some larger supermarkets). You could also try baby foods, which are soft but also high in protein and calories.

If you're unable to eat solids your doctor or nurse may prescribe supplement drinks, such as Ensure® or Fortisip®, which are complete meals in liquid form.

You will be able to discuss any problems with your diet with the dietitian or specialist nurse at the hospital.

We can provide you with more information and helpful tips on how to eat well when you have lost your appetite.

Dry mouth

You may notice that you can't produce as much saliva as before the treatment. The lining of your mouth and throat may become dry and this can make eating and speech difficult. You may also notice a feeling of sticky mucus in the throat, as sometimes radiotherapy makes the saliva thick and stringy, which can be very distressing. To reduce the dry feeling, you may find it helpful to drink fluids regularly and to use an artificial saliva spray. Wiping small amounts of vegetable or olive oil on the inside of your cheeks may also help.

Although you may start to produce some saliva again within a few months of treatment, it's important to be aware that the problem might continue for some time. If your mouth, throat or the upper part of your neck is being treated, your mouth may become permanently dry.

We have more information about coping with a dry mouth.

Dental care

During your treatment you will need to see your dentist regularly, because your mouth may become drier, more sensitive and easily irritated. You may also be more prone to tooth decay. You should follow the dental hygiene advice that you are given, such as brushing regularly with a soft toothbrush or gauze. You will usually be asked to apply fluoride gel to your teeth every day, either as a mouthwash or in special gum shields, to help protect your teeth from decay.

If your dentist recommends that one of your teeth needs to be removed, you should be referred to a specialist oral and maxillofacial surgeon for advice and treatment.

Hair loss

For most people, radiotherapy for cancers of the head and neck will not make their hair fall out, or the amount of hair loss will be very slight. It's unusual to lose any hair from the scalp during radiotherapy for head and neck cancers, as hair only falls out where the x-ray beam enters and leaves your body. For most people this will be limited to parts of the face and neck. Only the hair very close to the tumour is likely to be permanently lost, so men will lose their beard permanently in those areas of skin that become red or dark and sore during treatment. Hair loss can occur when tumours around the eyes and ears are treated.

Your doctor will advise you if permanent hair loss is likely in your case, and can tell you where it is likely to occur.

Tiredness

You may find that the treatment makes you feel very tired. During your treatment it's important to get as much rest as you can, especially if you have to travel a long way each day for your treatment.

Feeling sick (nausea)

Sickness is more likely to affect people who have combined chemotherapy and radiotherapy treatment. If it's a problem your doctor can prescribe anti-sickness medicines (anti-emetics).

Stiff jaw

If you have radiotherapy to the back of your throat (nasopharynx), the muscles used to open and close your mouth can become stiff.

You will be shown mouth-opening exercises that you should do at least twice a day. There are also specialist aids available to help you exercise your jaw. Your doctor, specialist dentist, or speech and language therapist can give you advice about exercises and where to buy an exercise aid.

Bad breath

This is usually caused by changes to your saliva and it can be reduced by regular mouth care and mouthwashes. It may also be caused by an infection in your mouth, which is common during radiotherapy treatment. If you have bad breath let your doctor or specialist nurse know. They can look inside your mouth to see if you have an infection, which can then be treated with antibiotic or antifungal medicine.

All these side effects can be upsetting and difficult at times. However, it’s helpful to remember that many are temporary and will gradually disappear.

Most side effects occur towards the middle and end of the course of treatment and continue during the first couple of weeks after your treatment has finished. The effects can be mild or more troublesome, depending on the dose of radiotherapy and the length of your treatment. Your doctor or specialist nurse will be able to advise you on what to expect, and can offer treatment and support to help relieve any side effects.

Internal radiotherapy for head and neck cancers

In some people, such as those who have small cancers of the tongue, internal radiotherapy may sometimes be used instead of surgery.

Internal radiotherapy (also called interstitial radiotherapy, implant therapy or brachytherapy) involves putting radioactive material directly into the cancer. In this treatment radioactive needles or wires are inserted into the cancer while you are under a general anaesthetic. Over a few days, the needles or wires give a high dose of radiotherapy directly to the tumour from the inside.

You will need to stay, and be cared for, in a single room in hospital for a few days, until the doctor has removed the radioactive needles or wires from your body. Visitors will be restricted and although it will be safe for your family and close friends to visit you for short periods, children and pregnant women will not be allowed to visit. This is to avoid any chance of them being exposed to even tiny amounts of radiation.

The doctors and nurses caring for you will also only be able to stay in your room for short periods at a time. This is because they may be looking after several people having internal radiotherapy treatment and they need to keep their exposure to the low level of radioactivity to a minimum.

The safety measures and visiting restrictions might make you feel isolated, frightened and depressed at a time when you might want people around you. If you have these feelings it's important that you let the staff looking after you know. It can help to have plenty of reading material and things to keep you occupied while you are in isolation. The isolation only lasts while the radioactive needles or wires are in place (usually 1-8 days). Once they are removed, the radioactivity disappears and it's perfectly safe to be with other people.

Side effects

While the needles or wires are in place, the tissues around them will become swollen. This usually settles by the time they are removed.

The treated area will become sore about 5-10 days after the needles or wires have been removed and this may last for several weeks. During this time, you may find it easier to eat soft foods.

While your mouth is sore it will help to avoid:

  • smoking
  • drinking spirits
  • eating hot or spicy foods.

Drinks like milk and water will help to keep your mouth moist. Your doctor can prescribe special mouthwashes and medicines to help to relieve any discomfort.

Chemotherapy for head and neck cancers

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.

Chemotherapy drugs work by disrupting the growth of cancer cells. The chemotherapy drugs are usually given by injection into a vein (intravenously). As the drugs circulate in the bloodstream, they can reach cancer cells all over the body. Our booklet on chemotherapy discusses the treatment and its side effects in more detail. We also have factsheets about individual drugs and their particular side effects.

For the treatment of head and neck cancers, chemotherapy is normally given at the same time as radiotherapy. This is known as chemoradiation.

Chemotherapy may also be given before chemoradiation treatment, which is known as induction chemotherapy.

Very occasionally chemotherapy is given before surgery to shrink the tumour and make it easier to remove.

Side effects of chemotherapy

Chemotherapy can cause some temporary side effects, which are described below. Although these may be worse with combined radiotherapy treatment, they will usually gradually disappear after the treatment has finished.

Lowered resistance to infection (neutropenia)

Chemotherapy can temporarily reduce the production of white blood cells in your bone marrow, making you more prone to infection.

This effect can begin about seven days after treatment has been given and your resistance to infection usually reaches its lowest point about 10-14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal before your next cycle of chemotherapy is due.

  • You should contact your doctor or the hospital straight away if:
  • your temperature goes above 38°C (100.4°F)
  • you suddenly feel unwell (even with a normal temperature).

You will have a blood test before having more chemotherapy to make sure that your cells have recovered. Occasionally it may be necessary to delay your treatment if your blood count is still low.

Bruising or bleeding

The chemotherapy can reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, and bleeding gums.

Anaemia (low number of red blood cells)

While having chemotherapy you may become anaemic. This may make you feel tired and breathless. Blood transfusions may be given if you become anaemic due to chemotherapy.

Feeling sick (nausea) and vomiting

Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or greatly reduce nausea and vomiting. If the sickness is not controlled, or continues, tell your doctor, who can prescribe other anti-sickness drugs which may be more effective.

Hair loss

Not all chemotherapy drugs cause hair loss. Hair may be lost completely or may just thin. You can ask your doctor if the drugs you are having are likely to cause hair loss. If you do lose your hair, you may want to wear a wig - you can ask your doctor or nurse to arrange for you see a wig specialist.

You may prefer to wear a bandana, hat or scarf.

If your hair does fall out, it will almost always grow back over a period of 3-6 months once the chemotherapy has finished.

We have a booklet on coping with hair loss, which has useful tips on wigs and head coverings, and dealing with the emotional effects of hair loss.

Sore mouth and small mouth ulcers

Some chemotherapy drugs cause your mouth to become sore and you may also develop mouth ulcers. Regular mouthwashes are important and your nurse will show you how to use these properly.

If you don't feel like eating meals, you can supplement your diet with nutritious drinks or soups. A wide range of drinks is available and you can buy them at most chemists. You can ask your doctor to refer you to a dietitian for advice about diet.

Tiredness

Chemotherapy affects different people in different ways. Some are able to lead a normal life during their treatment, while many find they become very tired and have to take things more slowly. Just do as much as you feel like doing and try not to overdo it.

Although they may seem hard to bear at the time remember that these side effects are temporary and will usually disappear, in time, once your treatment is over.

Photodynamic therapy for head and neck cancers

Photodynamic therapy (PDT) uses a combination of laser light of a specific wavelength and a light-sensitive drug to destroy cancer cells.

The light-sensitive drug (the photosensitising agent) is injected into a vein. It circulates in the bloodstream and is taken up by cells throughout the body. The drug is taken up by cancer cells more than by healthy cells. It doesn't do anything until it is exposed to laser light of a particular wavelength. When a laser is shone onto the cancer, the drug is triggered to interact with oxygen, which then destroys the cancer cells.

There is a delay of four days between the injection and the activation of the drug using laser light. The laser light used in PDT is focused through a fibre-optic tube, and is shone for only a few minutes. The doctor holds the fibre-optic tube very close to the cancer so that the correct amount of light is delivered and the PDT causes the minimum amount of damage to normal, healthy cells.

In early-stage cancer of the head and neck, PDT may be used to try to cure the cancer and is usually given as part of research trials. PDT can sometimes be used to shrink an advanced cancer to reduce symptoms, but it cannot cure an advanced cancer.

Your doctor can advise you whether PDT may be an appropriate treatment in your situation.

Side effects of PDT

After injection of the photosensitising drug, people are highly sensitive to light. They need to take precautions to avoid exposure of their skin and eyes to direct sunlight or bright indoor lighting for a set period (usually about two weeks). Appropriate clothing and eyewear must be worn to prevent reactions to light.

Other temporary side effects may include pain (which can be controlled with painkillers), swelling of the treated area, difficulty in swallowing and bleeding.

We have a separate factsheet about PDT which you may find useful.

Biological therapies for head and neck cancers

Biological therapies use substances that are produced naturally in the body to destroy cancer cells.

There are several types of biological therapy that may be used to treat head and neck cancers. These include monoclonal antibodies and cancer growth inhibitors. Biological therapies are mainly given as part of cancer research trials.

Monoclonal antibodies

Monoclonal antibodies are drugs that recognise and attach to specific proteins (receptors) that are found in particular cancer cells or in the bloodstream.

Some cancer cells have receptors known as epidermal growth factor receptors (EGFR). When growth factors attach to the receptor, the cancer cell is stimulated to grow and divide. The monoclonal antibody cetuximab (Erbitux®) locks onto the EGFR and may prevent the cancer cell from growing and dividing. It may also make the cancer cells more sensitive to the effects of radiotherapy.

Cetuximab is sometimes used, in combination with radiotherapy, to treat squamous- cell head and neck cancers that have begun to spread into surrounding tissues (locally-advanced cancer). It's given as a drip (infusion) into a vein.

We have a factsheet about cetuximab.

Other monoclonal antibodies are also being used in trials.

Your doctor or nurse will be able to tell you more about any drugs that are being used in trials and if you are suitable for a trial.

Cancer growth inhibitors

In order to grow and divide, cancer cells „communicate' with each other using chemical signals. Cancer growth inhibitors interfere with this process and so affect the cancer's ability to develop. Cancer growth inhibitors, such as gefitinib (Iressa®), have been used in trials to treat some types of head and neck cancer that have come back after initial treatment. It's still not known how effective these drugs are because trial results are not yet available.

Research - clinical trials for head and neck cancers

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.

Clinical trials may be carried out to:

  • test new treatments, such as new chemotherapy drugs and biological therapies (such as gene therapies or cancer vaccines)
  • look at new combinations of existing treatments, or change the way they are given, to make them more effective or to reduce side effects
  • compare the effectiveness of drugs used to control symptoms
  • find out how cancer treatments work
  • see which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study.

Usually, several hospitals around the country take part in these trials. It's important to bear in mind that some treatments that look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits.

If you decide not to take part in a trial your decision will be respected and you do not have to give a reason. There will be no change in the way that you are treated by the hospital staff and you will be offered the standard treatment for your situation.

This process is described in more detail in our booklet on understanding cancer research trials.

Blood and tumour samples

Blood samples and tumour biopsies may be taken to help make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. If you're taking part in a trial you may also be asked to give other samples which may be frozen and stored for future use, when new research techniques become available. These samples will have your name removed from them so you can't be identified.

The research may be carried out at the hospital where you are treated, or it may be at another hospital. This type of research takes a long time, so you are unlikely to hear the results. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.


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