Treatment
Treatment is likely to be given in a specialist Head and Neck Cancer unit. A Specialist Head and Neck cancer team consists of surgeons, radiotherapists and other professions allied to medicine. Surgical specialties involved are likely to include Ear, Nose and Throat (ENT), Maxillofacial Surgeon, Plastic Surgeon and possibly a General Surgeon. The team will meet to discuss and plan treatment for individuals with mouth cancer. The surgeons may operate together in complex cases. In advanced disease surgery will be followed by radiotherapy. For example a maxillofacial surgeon or ENT surgeon may remove the cancer and a plastic surgeon may reconstruct the face or inside of the mouth afterwards. Surgery is a commonly used treatment for these cancers and most people will have an operation as part of their treatment.
Surgery
Most people will have surgery to remove the tumour and surrounding area. Laser treatment may be used for smaller cancers – there are unlikely to be any disabling effects from this treatment. Larger tumours are likely to be removed surgically see below:
Cancers of the lip
If the tumour involves the lip only and is small, the enduring effects of the surgery are likely to be minimal. If large areas of the lip have to be removed it is difficult to reconstruct the lip to look like it did before. ‘Flaps’ of tissue can be used to reconstruct the lip, these can be local flaps from the cheek or ‘free’ flaps from elsewhere in the body. Reconstruction can preserve lip function and create an acceptable appearance of the lips.
The lips have several functions which can be compromised, these include:
- Prevent dribbling
- Keep food in the mouth whilst chewing
- Forming words in speech – the role of the lips becomes more important if tongue movement is compromised
Operations used include wide local excision and reconstruction often with skin flaps or skin grafts. Moh’s surgery is a name used for one type of skin or lip cancer surgery. Recovery time from these operations is usually several weeks. If lip function is affected this may improve over many months. The name of the surgery and length of stay in hospital is not important in assessing disabling effects – it is whether appearance or lip function is compromised and whether with therapy e.g. speech therapy this will improve in time or not. Alternative treatment of intermediate or large sized lip cancer with radiotherapy has been as successful as surgery in curing and preserving lip function.
Cancers of the tongue
Removal of part of the tongue is a common treatment of cancer of the tongue; this is called ‘partial glossectomy’. The tongue has several important functions and these are:
- Forming words in speech
- Moving food and drink around the mouth to enable swallowing.
The tongue can be reconstructed and this is will improve ability to eat and swallow but not speech. There are likely to be ongoing disabling effects after this type of surgery if much of the tongue has been removed and the remaining tongue is not free and mobile. Removal of the whole of the tongue is called ‘glossectomy’, this operation is rarely done.
Cancer of the palate and of the gums around the teeth
Tumours may arise on the lining of the mouth on the gums next to teeth or on the hard palate. The lower jaw is a separate bone called the mandible, the lower jaw is much easier to reconstruct using wires, metal plates or bone grafts if bone has to be removed. If a small prosthesis is worn or if dental implants are used there are unlikely to be ongoing disabling effects.
The upper jaw and roof of the mouth are made up of two bones which meet in the middle called the maxillae. These bones make up the upper jaw and the hard palate. Cancers of the gums or palate may extend deeply and these bones may need to be removed as part of surgical treatment. If only part of the upper jaw around the bases of the teeth is removed this can be reconstructed, A prosthesis may need to be worn to replace missing jaw and teeth removed from the area – a prosthesis is a complicated denture which replaces not only teeth but the missing jaw as well. Dental implants may be used if not too much bone is removed.
If the hard palate is removed this opens an abnormal communication between the nose and the mouth. A large prosthesis may need to be worn to recreate the hard palate and separate the nose from the mouth cavity below. If part of the hard palate has been removed and a large prosthesis is being worn there may be ongoing problems especially if there is communication between the nasal cavity and the mouth.
Cross-section of the skull showing the maxilla forming the upper jaw, roof of the mouth and base of the nasal cavity Credit: Medical Art Service Munich, Wellcome Images
Cancer of the oropharynx
Tumours arising in the back of the throat, the tonsil, the soft palate or the back of the tongue are likely to be larger and more advanced than those at the front of the mouth. They are likely to be treated with combination therapy including chemotherapy, surgery and radiotherapy. Those who have surgical treatment are more likely to have ongoing disabling effects from treatment than those undergoing chemotherapy and radiotherapy without surgery.
Neck dissection – this operation removes lymph nodes and other tissue from the neck, it can make the neck look asymmetrical – it can be done at the time of the initial surgery or at a later date. A neck dissection may be done on one or both sides of the neck. During the operation a nerve controlling movement of the shoulder – accessory nerve - may have to be sacrificed. The effects of this include a painful stiff shoulder and difficulty lifting the affected arm above the head.
Recovery from surgery
Time spent in hospital recovering may vary from a few days to several weeks depending on type of surgery and whether any rehabilitation is needed afterwards. Most people will be able to eat and drink normally and communicate by the time they leave hospital. Those who have had major surgery or reconstructive surgery are more likely to have ongoing problems with eating and drinking and speech when they leave hospital. Those who are having adjuvant treatment in addition to surgery are likely to have a more prolonged recovery. Some may require additional feeding with an indwelling gastrostomy tube for 3-6 months whilst such treatment takes place.
Those who need help with speech will receive ongoing rehabilitation with a speech therapist as an outpatient. Rarely eating will continue to be difficult and a feeding gastrostomy tube may be needed, this can be temporary or permanent. There are details about problems with eating and drinking and speech under care and mob. The Head and Neck specialist cancer nurse is likely to be the best source of information on on-going disabling effects and needs.
Radiotherapy
May be used as a treatment by itself or after surgery or in combination with chemotherapy - so-called chemoradiation therapy. It is usually given daily over 6-7 weeks. In addition to the normal side effects of radiotherapy, the specific effects on the mouth include mucositis – a painful dry inflamed mouth, which may make speaking and eating difficult. These side effects resolve when treatment is complete. The advantage of radiotherapy treatment alone is that the functions of the tongue and lip are not affected by the treatment and surgery can still be used later if the cancer returns. External beam radiotherapy may be given with brachytherapy at the same time. Long term side effects of radiotherapy tend to begin some months too many years after the initial treatment and get worse with time.
Long term side effects of radiotherapy to the mouth include:
- Xerostomia – over time the salivary glands stop producing saliva because of radiation damage, this can occur many months after treatment has finished and is a permanent effect. Saliva is not produced in normal quantities and the mouth becomes very dry with thick stringy mucus. Dryness of the mouth can cause very bad dental decay and bad breath. Eating is likely to be difficult and may be painful. Speaking and eating may only be possible with constant sips of water. Discomfort from a dry mouth may disrupt sleep.
- Taste – may be lost over time due to radiation damage. This can cause aversion to food and in severe cases malnutrition and nutritional deficiencies.
- Skin changes – abnormal pigmentation of the face and neck as a result of radiotherapy can have severe psychological consequences in terms of social avoidance and depression.
Pain
- Dental caries – widespread and severe resulting in loss of teeth
- Osteonecrosis – literally means bone death, this may affect the upper or lower jaw, and the symptoms are pain, loose teeth or numbness. The jaw bone may also break, and in some cases has to be treated surgically.
- Trismus – inability to open the jaw, usually because of pain. This can also be caused by scarring and fibrosis of the muscles of mastication (chewing), causing restricted mobility of the lower jaw. This may be due to radiotherapy, surgery, or tumour invasion. Some people may require use of mechanical devices to stretch the jaws, and this should be used frequently throughout the day (approximately seven 15 minute sessions per day). Some patients can only open their mouth a minimal amount (i.e. a few millimetres) and may be reliant on gastrostomy feeding or liquid diet. Oral hygiene may also be a problem. Trismus can affect speech when severe.
Chemotherapy
This is likely to be given in more advanced disease; usually for cancers of the tonsil/base of tongue. Chemotherapy will typically be given over 3 cycles in combination with radiotherapy, but other regimes are used. Treatment usually takes 9 weeks in total. Drugs that are used include:
- Cisplatin/Carboplatin
- 5-Fluorouracil
- Docetaxel (Taxotere)
Biological therapy
- Cetuximab may be used to treat cancer in the mouth, common side effects include skin rashes and flu like symptoms.
Treatment of recurrent cancer
Cancer that has returned sometime after successful treatment is more difficult to treat. In general, if someone has had surgery they will go on to have chemo and or radiotherapy and if they have previously had radiotherapy they will go on to have surgery as treatment of their recurrence. The outcome of treatments is much worse in terms of survival and side effects of therapy are likely to be worse and more enduring Lifetime awards are appropriate in these cases if needs are identified.
Amended November 2008
