Understanding Head and Neck Cancer

Head and neck cancer is the umbrella term for a group of cancers that affect the mouth, lips, nose, sinuses, salivary glands, throat and voice box.

  • The most common head and neck cancers start in the mouth, lips or throat.
  • Head and neck cancers are often linked to alcohol and tobacco use. In recent years, infection with human papillomavirus (HPV) has become a leading risk factor.
  • Screenings for head and neck cancers may be done by your regular doctor or dentist, with follow-up care by an ear, nose and throat provider. Then you may be referred to experts at the OHSU Knight Cancer Institute.
  • Head and neck cancer symptoms may be similar to those of less serious conditions.
Illustration of head and neck cancer regions.

What is head and neck cancer?

Most head and neck cancers begin in squamous cells. These flat cells form the surface of the skin and line the mouth, nose, throat and other moist surfaces inside the head and neck. You may hear head and neck cancers referred to as squamous cell carcinomas.

Cancer of the salivary glands is rare. Because these glands have many types of cells, however, many types of tumors can start in them.

Who gets head and neck cancer?

Head and neck cancers account for about 4 percent of all cancers in the United States. They affect about 65,000 people a year. About 75 percent of head and neck cancers are caused by tobacco use and heavy alcohol use. Research also shows a strong link between infection with some strains of HPV and certain throat cancers.

Risks factors that may play a role include:

  • Smoking and drinking: Doctors believe alcohol and tobacco act together to damage tissues in the head and neck. If you use tobacco and have two drinks a day, your risk of head and neck cancer is 20 times greater than if you do not. Tobacco use includes smokeless forms such as snuff, chewing tobacco, betel leaf and paan.
  • HPV: Some types of human papillomavirus, a common virus spread by sexual contact, are linked to throat cancer.
  • Age: Most people are older than 50 when diagnosed. Researchers have seen more cases in younger people, however, as HPV infections become more common.
  • Gender: Head and neck cancers are three times more common in men, which researchers attribute to higher tobacco and alcohol use.
  • Ancestry: People of Asian descent, especially with Chinese ancestry, may be at higher risk of cancer of the upper throat, behind the nose.
  • Radiation exposure: Radiation to the head and neck from X-rays, CT scans or radiation therapy may increase risk.
  • Workplace exposure: Being exposed to wood dust, asbestos, dry cleaning chemicals or other substances at work or routinely over a long time may raise your risk.
  • Health history: A history of acid reflux (heartburn) or a related condition called Barrett’s esophagus may be a risk factor. Having diseases such as aplastic anemia or infection with the Epstein-Barr virus may raise risk.
  • Family history: Most head and neck cancers are not hereditary. A family history of Fanconi anemia, Li-Fraumeni syndrome and other conditions, however, may increase your risk. OHSU is a center of excellence for Fanconi anemia and offers genetic counseling and testing for patients who have this or other inherited conditions.

Survival rates

Survival rates vary by type and stage (whether and how much cancer has spread). Nearly 65 percent of patients with mouth and throat cancers survive at least five years after diagnosis, for example. Some with early throat cancers have rates up to 90 percent.

Other types are difficult to treat, however, and outcomes vary. Statistics are averages and can’t predict the results for individual patients.

Head and neck cancer types

Cancers of the head and neck are categorized by the part of the body where they start. These are the main types:

Mouth: Cancer of the oral cavity is fairly common among head and neck cancers. It may affect:

  • The lips
  • The front two-thirds of the tongue
  • The gums
  • The lining inside the cheeks and lips
  • The bottom of the mouth under the tongue
  • The hard palate (the front portion of the roof of the mouth)
  • The small area of the gum behind the wisdom teeth

Throat: These cancers may affect any of the three parts of the throat, also called the pharynx.

  • Oropharyngeal cancer: Cancer of the middle part of the throat, or oropharynx, may include the soft palate (the back part of the roof of the mouth), the base of the tongue, and the tonsils. This is among the more common types.
  • Hypopharyngeal cancer: Cancer of the lower part of the throat, or hypopharynx, starts beside and behind the voice box. This type is rare, with about 2,500 cases a year in the United States. It most often affects people ages 50 to 60.
  • Nasopharyngeal cancer: Cancer of the upper part of the throat, or nasopharynx, originates behind the nose. This type has not been linked to tobacco and alcohol use.

Voice box: Cancer of the voice box, or larynx, is called laryngeal cancer. It may affect the vocal cords or a small piece of tissue, called the epiglottis. The epiglottis moves to cover the larynx to block food from entering the air passages.

Illustration of the paranasal Sinuses.

Nose: Nasal cancers are divided into two types because they may affect the space inside the nose or the spaces in the bones surrounding the nose.

  • Nasal cavity cancer starts in the opening behind the nose and may run along the top of the roof of the mouth.
  • Paranasal sinus cancer starts in the sinuses, hollow openings in the bones around or near the nose.

Salivary glands: This rare cancer affects only one person in 100,000 each year in the United States. It occurs in the glands that produce saliva. The main salivary glands are in the floor of the mouth and near the jawbone.

Precancerous growths

Your care team may identify precancerous growths or other abnormal cells.

  • Tumors in the lymph nodes: Cancer does not begin in lymph nodes (tissues that serve as filters for the immune system) but may spread to them. When this occurs in the neck and it’s not clear where the tumor started, it is called metastatic squamous neck cancer with occult primary.
  • Benign (noncancerous) growths: More than a dozen types of benign tumors may develop in the mouth, throat or neck. They can be in a variety of cells and from various causes. Most of the time, they are not life-threatening or likely to return. Surgery to remove them is the most common treatment.
  • Leukoplakia or erythroplakia: Grey or white patches of abnormal cells are called leukoplakia. Raised red patches are called erythroplakia. These may be a precancerous condition called dysplasia or an early-stage cancer. A sample must be removed to check for cancer.

Head and neck cancer symptoms

Head and neck cancer can cause symptoms similar to those of less serious conditions. See your doctor if any of these lasts longer than usual:

  • A mouth sore that does not heal and/or bleeds easily
  • A hoarse or sore throat, or a change in your normal voice
  • A lump or swelling in your neck
  • Trouble swallowing, moving your jaw or chewing
  • Frequent nosebleeds, a stuffy nose or sinus infections that do not improve with treatment
  • Loose teeth or dentures that no longer fit
  • Skin variations, such as a sore or mole that changes shape and color

Symptoms by type

Different body parts may exhibit more specific symptoms. Talk to your doctor if you experience the following:

  • A white or red patch on your gums, tongue or mouth lining
  • A swollen jaw that causes dentures to fit poorly
  • Unusual bleeding or pain
  • Trouble breathing or speaking
  • Pain when swallowing
  • Frequent headaches, pain or ringing in the ears
  • Pain in the neck or throat that doesn’t go away
  • Trouble hearing
  • Pain when swallowing
  • Ear pain
  • Blocked sinuses that do not clear
  • Chronic sinus infections that do not respond to antibiotics
  • Nose bleeds
  • Frequent headaches, swelling or other discomfort around your eyes
  • Pain in the upper teeth or problems with dentures
  • Swelling under the chin or around your jawbone
  • Numbness or paralysis in your face muscles
  • Persistent pain in your face, chin or neck

Screening

Annual exam: Since most head and neck cancers begin in the mouth, often in the tongue, experts recommend a thorough yearly exam. This is especially important for heavy smokers and drinkers 50 and older. Screenings are also important for younger nonsmokers, however, because people in their 20s and 30s with a human papillomavirus strain called HPV-16 account for a recent rise in some throat cancers.

How it works: Your doctor or dentist may use a mirror and small light to examine your mouth, tongue and throat. Or the provider may use a fiber-optic tool called an endoscope to look inside your nose and where your nose and throat connect.

Additional tests: If your provider thinks you might have cancer, he or she will suggest additional tests such as X-rays, cell scrapings or a biopsy (removing a small tissue sample for analysis).

Staging

No two head and neck tumors are the same. Staging helps your care team decide on treatment options by determining the extent of your cancer. A cancer’s stage is determined using:

  • A physical exam
  • Imaging scans, such as CT or MRI
  • Biopsy of a tumor or lymph nodes that may be affected
  • For certain tumors, analysis of the cancer's genetic makeup (genomic analysis)

The following is the staging for the most common cancers of the head and neck, those that start inside the mouth.

The tumor is up to 2 centimeters across and has a depth of infiltration (how far it has invaded tissue next to it) of 5 millimeters or less.

One of the following applies:

  • The tumor is no bigger than 2 centimeters and has a depth of infiltration of more than 5 millimeters but no more than 10 millimeters.
  • The tumor is larger than 2 centimeters but no bigger than 4 centimeters, and the depth of infiltration is no more than 10 millimeters.

One of the following applies:

  • The tumor is larger than 4 centimeters, or it’s any size and has a depth of infiltration of more than 10 millimeters.
  • The tumor can be any size. Cancer has spread to one lymph node, is contained in it, and is no larger than 3 centimeters.

Stage IVA: One of the following applies:

  • The tumor is moderately advanced, growing into nearby bones or tissues such as the floor of the mouth. Cancer has either not spread to lymph nodes or it has spread to one node on the same side of the body, is no larger than 3 centimeters and is contained in the node.
  • The tumor may range from smaller than 2 centimeters to moderately advanced. Cancer has spread to one of the following:
    • One lymph node on the same side of the body, with cancer no larger than 3 centimeters but extending outside the node.
    • One lymph node on the same side of the body, with cancer larger than 3 centimeters but no larger than 6 centimeters and contained in the node.
    • Two or more lymph nodes on the same side, with no cancer larger than 6 centimeters and all contained in the nodes.
    • Two or more lymph node on the opposite side of the body or on both sides, with none larger than 6 centimeters and all contained in the nodes.

Stage IVB: One of the following applies:

  • The tumor is any size or spread, and cancer has spread to one of the following:
    • One lymph node, with cancer larger than 6 centimeters and contained in the node.
    • One lymph node on the same side of the body, with cancer larger than 3 centimeters and extending outside the node.
    • Two or more nodes on either or both sides of the body, with any cancer extending outside a node.
    • Any node on the opposite side of the body, with cancer extending outside the node.
  • The tumor has advanced spread in the head and neck, reaching areas such as the base of the skull and/or around the carotid artery. Lymph nodes can have any involvement, from none to extensive.

Stage IVC: Cancer has spread to distant parts of the body.

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