Treatment Options for Head and Neck Cancer

Specialists at Beaumont Cancer Institute form a multidisciplinary team consisting of a head and neck surgeon (ENT or surgical oncologist), a medical oncologist, and a radiation oncologist. If a patient has locally advanced cancer, combined chemotherapy and radiation are typically offered if the patient can tolerate both. For more information about Beaumont's Head & Neck Cancer Multidisciplinary Clinic call 877-BEAT-CANCER (877-232-8226).

Treatment plans optimize radiation to the tumor and involved lymph nodes so that healthy tissues escape high doses. Some early stage cases can be treated locally with radioactive implants (brachytherapy), which increase doses to the tumor and shorten treatment times.

Advances are continually being made in the treatment of head and neck cancer, and patients at Beaumont may be eligible for clinical trials, either approved within the hospital or sponsored by national organizations dedicated to advancing cancer treatment.

Surgery

Surgery generally involves removing tumors and seeing if cancer has spread to the lymph nodes. The type of surgery depends on overall health, tumor location and the stage of cancer.

Radiation

The Radiation Oncology Department at Beaumont features leading edge equipment that is minimally invasive and helps preserve quality of life.

Radiation can be delivered by different types of equipment or procedures, including Intensity Modulated Radiation Therapy (IMRT):

• IMRT allows radiation to be focused on hot spots like tumors, where the dose should be high, and spares nearby normal tissue, such as the saliva glands, jawbone and spinal cord, where doses should be low. Beaumont was one of the first institutions in the world to develop and use IMRT.
• IMRT employs multiple radiation beams of different intensities to maximize doses of radiation to tumors while limiting doses to healthy tissue. This strategy significantly reduces treatment-related side effects and complications. Nearly all cases of advanced head and neck cancer are treated with IMRT at Beaumont.
• IMRT is sometimes called “parotid-sparing” radiation. The parotid gland is one of the large saliva glands. With IMRT, radiation can be directed at the tumor and not at the parotid gland. The result is a much lower risk of treatment-related dry mouth (xerostomia) and a higher probability of long-term tumor control.

The image shows a typical IMRT treatment plan. The colored lines represent targeted beams of radiation of different doses. The parotid glands, shown in yellow on the left and red on the right, are mostly outside the light purple line that marks low-dose radiation. The tumor, colored bright red, sits inside the turquoise line that outlines high-dose radiation.

Click here to view a video clip of IMRT parotid-sparing radiation. Multiple X-ray beams direct radiation to the head and neck. A computer controls the targeting and dose of each beam, so that high-dose radiation is delivered to the tumor but not to other tissues, such as the parotid gland.

Click here to see a movie showing how a tumor is identified and targeted with IMRT. Red identifies the tumor, and blue indicates the tumor and surrounding microscopic disease. Green marks the spinal cord, orange the brainstem, and yellow/pink the saliva glands. Notice how the high-dose radiation beams (turquoise beams) avoid the normal tissue and directly attack the tumor. Slightly lower doses (blue beams) are delivered to lower-risk areas. The salivary glands receive only very low doses, helping to prevent dry mouth.

Only 30 percent of patients experience dry mouth with IMRT, compared to 84 percent treated with conventional external beam radiation. However, using IMRT does not guarantee that dry mouth will not occur. The benefit of IMRT depends, in part, on the area of the neck that requires high-dose radiation.

• head and neck brachytherapy – uses a radiation source temporarily positioned close to the area to be treated. For the 30 to 40 percent of patients with early stage disease, interstitial high-dose brachytherapy may be combined with external beam radiation. “Interstitial” refers to implanting needles or catheters in the area to be treated. The catheters are positioned in the operating room. On an outpatient basis, the catheters are connected to a machine that delivers high-dose radiation to the tumor. Surrounding tissues receive minimal radiation.

At Beaumont, interstitial brachytherapy is used to treat recurrent neck disease in patients previously treated with external beam radiation.

• image-guided radiation therapy using Synergy conebeam CT – The physics staff at Beaumont is known worldwide for its expertise and development of radiation therapy physics. Beaumont physicians developed a treatment machine called Synergy, now distributed all over the world by Elekta Oncology. This machine combines conebeam CT imaging with a standard linear accelerator. Radiation treatment fields and tumors can be seen clearly with the conebeam CT image before beaming on the radiation, which can then be delivered with utmost precision.
• CT scans – Oncologists monitor treatment with regularly scheduled CT scans. Daily conebeam scans provide set-up information, which can be adjusted when necessary by the radiation physicist and oncologist. Regular scans allow treatment to be aimed as accurately as possible, delivering adequate radiation to the tumor while protecting normal tissues. Weekly helical CT scans plot changes in the size and shape of organs and tissues, which may result from tumor shrinkage, tissue swelling or weight loss. Some changes warrant modified treatment plans.

Scans are also being used to evaluate IMRT. An in-house study under way at Beaumont monitors treatments to be sure that IMRT can be safely and accurately delivered according to the prescribed treatment plan.

Side Effects of Radiation Treament

Dental Evaluation
One potential long-term side effect of radiation to the head and neck is reduced saliva production, which results in a dry mouth. Changes in the mouth after radiation therapy greatly increase the chance of developing cavities, and high doses of radiation can slow healing after dental procedures. To minimize dental problems, patients are asked to see a dentist experienced in treating patients with head and neck cancer. The dentist can assess oral health and perform necessary repairs before treatment begins.

The radiation oncologist may also request that the dentist make some thin plastic trays to

• reduce scatter dose radiation in the mouth in patients who have metal fillings
• administer regular fluoride treatments after radiation to decrease the risk of developing cavities

Chemotherapy

Various kinds of chemotherapy drugs are used to treat head and neck cancer. They may be administered orally or through the veins (intravenously). Some chemotherapy acts to “sensitize” cells so that radiation therapy works better. Common side effects of chemotherapy include

• lowered blood counts
• nausea and vomiting
• hair loss

Not all drugs have these side effects, and steps can be taken to manage most side effects.

A medical oncologist oversees chemotherapy and works with other specialists to coordinate care.

Feeding Tube Placement
If radiation or radiation and chemotherapy are planned, the radiation oncologist may recommend placement of a feeding tube. Most patients treated with radiation to the head or neck experience a sore mouth and throat and difficulty swallowing. The irritation can sometimes be so severe that patients lose weight or become dehydrated. Patients taking Amifostine to protect the saliva glands during treatment may experience nausea and vomiting. The tube allows patients to receive nutrition while completing therapy. Receiving adequate nutrition should improve energy levels and overall well-being.

Medication

Medications often accompany treatment for head and neck cancers.

• Salagen – helps increase saliva production during radiation therapy
• Diflucan – an antifungal medication that helps prevent an overgrowth of yeast in the mouth or throat during radiation therapy
• Hormone-regulating medications – replace, increase or suppress hormone production caused by thyroid, parathyroid or pituitary tumors.
• Radioactive iodine therapy – destroys thyroid cancer cells that have not been removed by surgery or have spread to other parts of the body. Small amounts of radioactive iodine are given in capsules or a liquid.