Head and neck cancer

Head and neck cancer is a general term for different cancers in this area. These cancers start in the tissues of the head and neck.

For example, in the:

• mouth, which includes the tongue, palate, gums and lips
• throat (the pharynx), which is divided into the nasopharynx, oropharynx and hypopharynx
• nose and sinuses (air-filled spaces in the bones of the face)
• salivary glands, which make saliva
• middle ear, which contains the ear

About 12,200 people are diagnosed with head and neck cancer in the UK every year. This includes cancer of the larynx (voicebox). In the UK, head and neck cancer is the 4th most common cancer in men.

Macmillan Cancer Support, a UK charity, has separate information about cancer of the larynx.

To be sure you have the right information, you need to know which type of head and neck cancer you have. If you're not sure, ask your cancer doctor or specialist nurse.

Other types of cancer can start in the head and neck area, but they're not head and neck cancers. These include:

• thyroid cancer
• oesophageal cancer
• brain tumours
• tracheal cancer

Head and neck cancers are named after two things: the area of the head or neck where they start, and the type of cell involved.

The most common type of head and neck cancer is squamous cell carcinoma. About 9 out of 10 head and neck cancers (90%) start in squamous cells. These cells line the surfaces inside the head and neck, such as the mouth, nose and throat.

Head and neck cancer most often spreads to the lymph nodes in the neck, and this may cause a swollen lymph node there. Lymph nodes are part of the lymphatic system, which helps protect you from infection and disease.

Mouth cancer, also called oral cancer, is one of the most common places for head and neck cancer to start. It can begin anywhere in the mouth, including:

• on the lip
• inside the cheek
• the gums
• the front part of the tongue
• on the floor or roof of the mouth

Nasopharyngeal cancer starts in the upper part of the throat (the pharynx), behind the nose. This area is called the nasopharynx.

The nasopharynx lets air travel from the nose, down through the rest of the throat and into the lungs.

Often the first symptom of nasopharyngeal cancer is a painless swelling or lump in the upper neck.

Oropharyngeal cancer starts in the oropharynx, which is the middle part of the pharynx, just behind the mouth. Air passes through this area, and so does the food you swallow. Muscles here help push food from the mouth down into the gullet (oesophagus).

The oropharynx includes:

• the soft part of the roof of the mouth (soft palate)
• the base or back of the tongue (the part you cannot see)
• the tonsils and the side walls of the throat

Most oropharyngeal cancers develop on the tonsils or the base of the tongue.

Hypopharyngeal cancer starts in the lower part of the pharynx, behind the voice box (larynx). This area is called the hypopharynx. It has muscles that move food into the gullet (oesophagus), which it connects to.

Air also passes along the hypopharynx on its way into the airways to the lung. Cancer of the hypopharynx may be treated in the same way as laryngeal cancer.

The larynx is the voice box. It's a short passageway in front of the hypopharynx, and it contains the vocal cords.

Inside your nose is a space called the nasal cavity. Around it, the bones have small hollow spaces known as paranasal sinuses, and these affect the sound and tone of your voice.

With cancer of the nose and sinuses, the most common symptoms are a blocked nose that doesn't go away (usually on 1 side only) and nosebleeds.

The salivary glands make saliva (spit). The biggest pairs are the parotid glands, which sit at the sides of the mouth, just in front of the ears. This is the most common place for salivary gland cancer to start.

Tumours in the salivary glands aren't always cancer. Some are non-cancerous (benign), but some are cancer.

Cancer of the middle ear is rare. The middle ear is made up of the eardrum and a cavity called the tympanum. Inside the tympanum are 3 small bones, and these connect the eardrum to the inner ear. The tympanum is also joined to the nasopharynx by the eustachian tube.

If your doctor or dentist thinks your symptoms could be linked to cancer, they'll refer you to a specialist doctor. This is usually an oral and maxillofacial surgeon, or an ear, nose and throat (ENT) specialist surgeon.

If a lump in your neck is your only symptom, your doctor may refer you to a one-stop neck lump clinic. There, you can have all the tests needed to check whether the lump is cancer.

These may include:

• an ultrasound neck scan
• removing a sample of tissue from the lump (a biopsy)
• nasendoscopy, a test that looks at the back of your mouth, nose and throat

You may get your results on the same day, or 7 to 10 days later.

If tests show you have a head and neck cancer, your specialist will arrange more tests. These help find out the size and position of the cancer and whether it has spread. This is called staging. The tests could include the following.

Your doctor may ask for an X-ray of your face or neck, to see whether the head and neck cancer has affected any bones and to check your teeth.

You may also have a chest X-ray. It's done to check your general health and to see if there's anything abnormal in your lungs.

A CT scan takes a series of X-rays and puts them together to build a three-dimensional picture of the inside of your body.

An MRI scan uses magnetism to build up a detailed picture of areas of your body.

A PET-CT scan shows more detail about the part of your body that is being scanned.

If you have oropharyngeal cancer, your doctor will test the cancer cells to see whether the cancer is linked to the human papilloma virus (HPV). The results help your doctor plan the most effective treatments for you. HPV-related head and neck cancers usually have a good outlook.

If you have nasopharyngeal cancer, the cancer cells are tested to see whether it is linked to the Epstein-Barr virus (EBV).

The stage of a head and neck cancer tells you how big it is and whether it has spread from where it started. Staging is a little different for each type of head and neck cancer, and oropharyngeal cancers that are HPV-positive have their own separate staging system.

The grade is decided by a doctor, who looks at how the cancer cells appear under the microscope. This gives an idea of how quickly the cancer may develop.

When you and your doctors know the stage and grade, it's easier to decide on the best treatment for you.

Head and neck cancer isn't common, so you're usually treated in a specialist head and neck unit.

A team of specialists will meet to discuss the best possible treatment for you. This is called a multidisciplinary team (MDT).

They'll also talk to you about preparing for treatment (sometimes called prehabilitation). This may include things like:

• stopping smoking or drinking to make your treatment more effective
• dental checks or dental treatment
• dietary advice to improve your weight
• certain exercises to reduce the risk of side effects

The aim of treatment is to remove or destroy the cancer and reduce the risk of it coming back.

Your treatment depends on:

• where the cancer is
• the type and stage of the cancer
• the best way to maintain appearance, speech and swallowing
• your general health
• your preferences

Your doctor and nurse will explain the benefits and disadvantages of the different treatments. Before you agree (consent) to have treatment, they'll also talk to you about the things to consider when making your decision.

You and your doctor can decide together on the best treatment for you.

Doctors plan your treatment so that the effect on your appearance, speech, swallowing and eating is as little as possible. If treatment is likely to affect any of these, your doctor and nurse will talk to you about it.

They'll explain how long the effect is likely to last and how they can support you. During treatment, you may see different specialists, such as a dentist, a speech or language therapist (SLT) or a dietitian.

Treatment for head and neck cancers may include the following.

Surgery is one of the main treatments for head and neck cancer. Small cancers may be treated with a simple operation or with laser surgery. If the cancer is bigger, the surgeon may also remove the lymph nodes in the neck.

Some people might need reconstructive surgery. Here the surgeon takes tissue from another part of the body to replace the tissue that was taken out of the head and neck.

Chemoradiation means having chemotherapy and radiotherapy together. For locally advanced head and neck cancer, it's often the main treatment.

The chemotherapy helps the radiotherapy work better. Chemotherapy can also be given after surgery.

Chemoradiation can cause severe side effects, so it may not be suitable for everyone.

Radiotherapy can be used on its own to treat small head and neck cancers, or cancers in areas that are harder to reach. More often, though, it's given together with chemotherapy, and this combination is called chemoradiation.

Doctors may give you chemotherapy on its own before radiotherapy or surgery, to shrink the head and neck cancer and help the treatment work better. More often it's given together with radiotherapy, which is called chemoradiation. In some cases chemotherapy is used to control the symptoms of the cancer.

Doctors sometimes use a targeted therapy drug called cetuximab if chemoradiation isn't suitable for you. If the cancer is advanced or has come back, they may sometimes use pembrolizumab and nivolumab, which are immunotherapy drugs. What you are offered will depend on the stage of the cancer.

If a head and neck cancer is small and hasn't spread, surgery can usually treat it. Some people notice small changes to their speech, chewing or swallowing after the operation, but you can usually adapt to these quickly.

Your doctors may suggest radiotherapy instead of surgery if the cancer is in an area that is difficult to reach. They may also suggest it if surgery could cause major changes to your appearance, speech or swallowing.

When head and neck cancer is bigger, or has spread to the lymph nodes in the neck, you usually need more than one type of treatment.

Chemotherapy and radiotherapy are often given together, which is called chemoradiation. For some people this is the main treatment.

If you have surgery to remove the cancer, the lymph nodes in the neck may be removed as well. Some people need reconstructive surgery. The aim is to change your appearance as little as possible, and to affect things like swallowing and speech as little as possible.

After surgery, some people have chemoradiation or radiotherapy to treat any cancer cells that are left.

Chemotherapy on its own may also be used to shrink a cancer before radiotherapy or surgery. It can also be used to try to control the cancer and improve symptoms.

A targeted therapy drug called cetuximab is sometimes given with radiotherapy if you can't have chemoradiation. Immunotherapy drugs may sometimes be given on their own. This is usually when the cancer is advanced, or when it comes back after treatment.

When head and neck cancer can't be cured, you may be given treatment to keep the cancer under control for as long as possible and to manage your symptoms. This is usually chemotherapy, targeted therapy or immunotherapy.

Your doctor and specialist nurse will help make sure your symptoms are controlled. This is called supportive or palliative care. You may also see a specialist palliative care doctor or nurse, who can give expert help with your symptoms.

You may have some of these treatments as part of a clinical trial.

After head and neck cancer treatment, you'll have regular follow-up appointments for several years. At these visits your specialist will examine your head and neck, and this is the most important part of your follow-up. Sometimes you may have scans too.

The side effects of treatment can take several months to improve. Always tell your specialist about:

• side effects or symptoms that are still there and aren't getting better
• any new symptoms that don't get better within 2 weeks

Your nurse can tell you what to look out for after treatment. For example, this might be:

• a new ulcer or a lump in your neck
• pain
• difficulty swallowing or speaking

If you notice any symptoms or side effects, contact your doctor or nurse as soon as possible. You don't need to wait until your next appointment.

Side effects of treatment for head and neck cancer may affect how you eat and drink, or your speech. These changes may return to normal, or near normal, as the area recovers from surgery or radiotherapy.

Your speech and language therapist (SLT) and dietitian will assess you. They support you as you learn to cope with any changes.

Late effects are side effects that don't improve, or that develop years after treatment has finished. Your doctor or nurse will explain any likely late effects of your treatment. Not everyone gets late effects, because it depends on the treatment you had.

Head and neck cancer, and the treatment for it, can sometimes affect your sex life. If this worries you, talk to your doctor or nurse and ask them for support.

Some treatments for head and neck cancer can also affect whether you can get pregnant or get someone pregnant. If you're worried about this, it's important to talk with your doctor before you start treatment.

Cancer support organisations have more information on these topics:

• fertility in women after treatment
• fertility in men after treatment
• LGBTQ+ people and cancer treatment

If treatment for head and neck cancer has changed your appearance, your voice, or how you eat and drink, it can also affect your body image. Talk to your nurse if this is a concern for you.

There are different things that can help to improve body image changes.

Even if you already live a healthy life, you may want to make a few positive changes during and after treatment for head and neck cancer. If you smoke or drink alcohol, for example, it's best to avoid smoking and to cut down on alcohol.

Eating well and staying active can improve your health and wellbeing, and they can also help your body recover. If you have any trouble with eating after treatment, your dietitian can help.

Recovery from treatment can take several months. It can be hard if treatment has changed your appearance, how you eat or drink, or your voice. Your body image may also be affected, but there are ways to help you manage any changes.

You may still be coping with difficult feelings. Talk to your family and friends or to health professionals about how you feel. It helps them know how to support your wellbeing.

There are also national support groups that you may find helpful:

• The Mouth Cancer Foundation, which gives information and support to people affected by head and neck cancers
• Changing Faces, which offers advice and information to anyone affected by a change in their appearance
• The Swallows, which offers a 24-hour support line to anyone affected by head and neck cancer
• Salivary Gland Cancer UK, which supports people with rare salivary gland cancers, like adenoid cystic carcinoma, ACC, and unknown carcinoma

Macmillan Cancer Support also has further information to support you. You can:

• phone the Macmillan Support Line on 0808 808 00 00
• chat to Macmillan specialists online
• use the Macmillan head and neck cancer forum, where you can talk to others affected by head and neck cancer, ask questions and share your experience

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