Head and neck cancer treatments

A range of treatments and technologies are available to treat head and neck cancers, including radiation, surgery and chemotherapy, as well as immunotherapy and targeted therapy. Your multidisciplinary team of head and neck cancer experts will answer your questions and recommend treatment options based on your unique symptoms, diagnosis and needs.

Several factors may influence a treatment plan, including the cancer's location and stage, your overall health, age and personal preferences.

Throughout the process of treatment, multiple types of doctors may play a role in creating and executing your treatment plan, including:

• Surgical oncologist, who treats cancer by performing surgery
• Radiation oncologist, who treats cancer using radiation therapy
• Medical oncologist, who treats cancer using drugs such as chemotherapy
• Plastic surgeon, who performs surgery to help restore or reconstruct tissue
• Maxillofacial prosthodontist, who is an expert in performing surgery to restore tissue in the head and neck
• Otolaryngologist, who treats problems in the ear, nose and throat
• Dental oncologist, who is an expert in treating cancer in the mouth and the surrounding area

As a group, your care team develops a well-rounded treatment plan that is appropriately suited for you. Many other health-care providers may also help with your cancer care, including nurses, physical therapists, pharmacists, counselors, dietitians and social workers.

Patients with head and neck cancer may work with specific medical professionals that are not typically a part of the care team for other types of cancer, such as speech-language pathologists. The treatments for head and neck cancer, and the cancer itself, sometimes cause problems with essential functions such as speaking and swallowing. Speech-language pathologists are experts at working with you to improve or regain these abilities if they were affected by treatment.

Treatment options for head and neck cancer may include:

Immunotherapy

Drugs called checkpoint inhibitors are designed to help the body's immune system identify and kill tumor cells. These drugs work by disrupting signaling proteins that allow cancer cells to disguise themselves from the immune system. Immunotherapy may not be used to treat all patients, and responses to the treatment may vary. Immunotherapy may also be used in combination with other cancer treatments.

While the use of immunotherapy for head and neck cancer is currently limited, Opdivo^® (nivolumab) and Keytruda^® (pembrolizumab) are checkpoint inhibitors that may help treat some types of advanced cancers in the head and neck. Your care team may recommend these drugs if you have advanced laryngeal cancer that has metastasized (spread to distant areas of the body) or recurred (come back after treatment). Nivolumab and pembrolizumab are also being studied as a potential treatment for metastatic or recurrent oropharyngeal cancer. However, since research is ongoing, oropharyngeal cancer patients may need to enroll in a clinical trial to access these drugs.

Some of the more common side effects of nivolumab and pembrolizumab include:

• Tiredness
• Stomach upset
• Poor appetite
• Joint pain
• Rashes

Less frequently, patients may experience more severe effects, such as infusion or autoimmune reactions. Infusion reactions are similar to an allergic reaction and come with symptoms such as:

• Facial flushing
• Rashes
• Dizziness
• Fever
• Chills
• Difficulty breathing

Autoimmune reactions occur when immunotherapy drugs send the immune system into overdrive, prompting it to attack healthy cells. Autoimmune reactions are potentially life-threatening and can damage vital organs, including the liver, kidneys, lungs and intestines.

Targeted therapies

These are drugs designed to block the growth and spread of cancer by attacking specific proteins and preventing cancer cells from dividing or by destroying them directly. One potential target in head and neck cancer is the epidermal growth factor receptor, or EGFR, which is a protein found on the surface of many types of cancer cells. Your doctor may suggest using an EGFR-targeted drug in combination with chemotherapy or radiation therapy for head and neck cancers, such as laryngeal or hypopharyngeal cancer.

Your care team may recommend the following targeted therapies to treat some types and stages of head and neck cancer.

• Tumor-agnostic therapy: This may be used to treat cancers that share specific changes in their genetic code (mutations). Vitrakvi^® (larotrectinib), for example, targets mutations in the NTRK genes. These mutations are present in several types of cancer. Larotrectinib may be a treatment option for head and neck cancers with these mutations under the following circumstances:
  • The cancer is metastatic, or doctors are unable to remove it with surgery.
  • Other treatments have been unsuccessful.
• Monoclonal antibodies: Some targeted therapies use monoclonal antibodies, which are human-made proteins that mimic the proteins produced and used by your immune system. These proteins are designed to target cancer cells and block the mechanisms by which cancer grows. Erbitux^® (cetuximab) is one monoclonal antibody that may be a treatment option for some types and stages of head and neck cancer, including recurrent and metastatic oropharyngeal cancer. It’s also being studied as a potential treatment option for metastatic or recurrent laryngeal cancer.

Side effects of targeted therapy may vary depending on the type, and some reactions are more common than others. A temporary rash on your face and chest is one of the more common side effects of cetuximab. Less frequently, cetuximab causes fatigue, headaches, stomach upset and fever. On rare occasions, a patient may develop a severe allergic reaction to cetuximab. Doctors may prescribe preventive medicines before the first treatment to avoid this.

Chemotherapy

These treatments for head and neck cancer are typically reserved for patients whose cancer has metastasized to the bones or elsewhere in the body.

As a treatment for head and neck cancer, your care team may recommend chemotherapy in a variety of ways. Patients with certain types and stages of head and neck cancer may be given chemotherapy as their primary treatment, before surgery or after surgery. However, in all of these cases, chemotherapy is often combined with radiation therapy. When chemotherapy and radiation therapy are given simultaneously, the treatment is called chemoradiation. In some cases, combining these two therapies may be more successful at shrinking tumors and improving outcomes than either option alone.

When doctors recommend chemotherapy or chemoradiation for head and neck cancer, it’s typically for advanced cancers in stage 3 or 4. One of the more common chemotherapy drugs used for head and neck cancer is Platinol® (cisplatin). However, there are many other options, depending on the circumstances.

Chemotherapy or chemoradiation may be a part of your treatment plan if you have:

• Hypopharyngeal cancer (all stages)
• Laryngeal cancer (all stages)
• Lip and oral cavity cancer (stage 3 and higher)
• Nasopharyngeal cancer (stage 2 and above)
• Paranasal sinus and nasal cavity cancers (all stages)

During the process of harming cancer cells, chemotherapy drugs may also damage healthy cells, which results in side effects. Not all patients treated with chemotherapy experience the same side effects. Side effects vary depending on the patient, the type of chemotherapy drugs used, and the duration of treatment.

In general, however, chemotherapy may cause side effects such as:

• Upset stomach (nausea, vomiting, diarrhea)
• Sores in the mouth
• Hair loss
• Poor appetite
• Unintended weight loss

Chemotherapy may also reduce the levels of blood cells in the body, making patients more prone to infections (due to a lack of white blood cells), bleeding and bruising (due to a lack of platelets), and excessive tiredness or shortness of breath (due to a lack of red blood cells).

Radiation therapy

This treatment delivers high doses of radiation to tumor cells in the head and neck using technology designed to reduce damage to healthy tissue and organs. By focusing the radiation directly on the tumor, these therapies may reduce the risk of common side effects associated with head and neck cancer treatment.

Radiation therapy can be delivered in two main ways:

• Externally (external beam radiation therapy), which sends radiation toward the cancer using a machine outside the body
• Internally (internal radiation therapy), which involves placing a radioactive substance inside the body near the tumor

Most often, radiation therapy is delivered externally. However, internal radiation therapy may be a treatment option for some lip and oral cavity cancers, often in combination with external radiation therapy.

Within the broader category of external beam radiation, there are different subtypes.

• Intensity-modulated radiation therapy (IMRT): This external beam radiation therapy uses a specialized computer to create 3-D images of the tumor. Then, these images help create multiple radiation rays that are directed toward the tumor from different angles, with varying intensity levels. The accuracy of the beams allows doctors to use higher intensity beams, while causing less damage to healthy cells than some other methods of radiation therapy. IMRT may be a treatment option for some cases of oropharyngeal cancer and recurrent nasopharyngeal cancer.
• Hyperfractionated radiation therapy: This therapy uses smaller doses of radiation compared with standard radiation therapy, and the doses are given twice a day rather than once a day. Receiving this therapy through a clinical trial may be an option for some patients with laryngeal cancer, metastatic or recurrent oropharyngeal cancer, and stage 3 or 4 lip and oral cavity cancers.

Radiation therapy is one of the main treatment options for nearly all head and neck cancer types and stages. For early-stage head and neck cancers, doctors often suggest radiation, surgery or both. Advanced-stage cancers are frequently treated with chemoradiation or surgery followed by chemoradiation. However, this treatment approach isn’t ubiquitous across all types and stages of head and neck cancer, and there are many other options depending on the circumstances.

It’s estimated that doctors recommend either surgery or radiation therapy as the main treatment for about 30 percent to 40 percent of all patients with early-stage head and neck cancers, according to the Journal of the National Comprehensive Cancer Network. However, some types of head and neck cancer may respond better to one option over the other.

Radiation therapy alone may be a treatment option for:

• Some types of paranasal sinus and nasal cavity cancers, particularly in the early stages
• Some types of lip and oral cavity cancer, particularly in the early stages
• All stages of nasopharyngeal cancer
• All types of stage 1 and 2 laryngeal cancer
• All stages of oropharyngeal cancer
• Some types of salivary gland cancer

This isn’t a comprehensive list of all situations where radiation therapy alone is used to treat head and neck cancer. For example, radiation therapy alone may also be a treatment option for advanced-stage hypopharyngeal cancer, but typically only when the tumor cannot be successfully removed by surgery.

Most side effects of radiation therapy are related to the area where the radiation was aimed. For head and neck cancer, this means that important functions such as speaking and swallowing may be affected. Before undergoing radiation therapy for head and neck cancer, ask your care team about the potential side effects and what resources may help you manage them. For example, your doctor may suggest that you see a dentist who can monitor for radiation-related tooth decay, or a speech-language pathologist to help you regain the ability to speak and swallow normally if the treatment affects these functions.

The general side effects of radiation therapy to the head and neck region may include:

• Trouble swallowing
• Voice changes
• Poor appetite
• Changes in sense of taste
• Dry mouth
• Mouth sores
• Thickened saliva
• Nausea
• Earaches
• Stiff jaw
• Swelling, drooping or changes in the texture of the skin near the treatment area

Surgery

Surgery is often the first-line treatment option for head and neck cancers. Some patients may be treated with surgery alone; for other patients, combining head and neck cancer surgery with radiation therapy and/or chemotherapy may be appropriate.

Below are some of the types of operations that doctors may use for the treatment of head and neck cancer.

• Laryngopharyngectomy and partial laryngopharyngectomy: A laryngopharyngectomy is a surgical operation that removes the voice box (larynx) and a portion of the throat (pharynx). A partial laryngopharyngectomy also removes a part of the throat but only some of the voice box, allowing patients to retain their ability to speak. All stages of hypopharyngeal cancer may be treated with one of these surgeries. The primary treatment options for stage 1 and 2 hypopharyngeal cancer are laryngopharyngectomy with neck dissection (removing the lymph nodes and other tissues in the neck) or partial laryngopharyngectomy. Both options are sometimes combined with a high dose of radiation therapy aimed at the lymph nodes in the neck.
• Neck/lymph node dissection: As mentioned above, neck dissection is a procedure to remove the lymph nodes of the neck and some other tissue. Other than hypopharyngeal cancer, this operation may be used on other head and neck cancer types, such as lip and oral cavity cancer. It’s an important option if your doctor knows or suspects the cancer has spread to the lymph nodes.
• Wide local excision: This surgical procedure involves removing the cancer and a portion of healthy tissue that surrounds it. It may be used to treat lip and oral cavity cancer, particularly in the early stages.
• Plastic surgery: Surgery for head and neck cancer may sometimes change your facial functions or appearance. Plastic surgery is designed to repair or restore damaged facial features. Doctors may recommend plastic surgery for functional or cosmetic reasons. Some patients may opt to undergo plastic surgery because they dislike how their treatment disfigured a part of their face or neck. Others, such as those with hypopharyngeal cancer, may need plastic surgery if treatment involved removing the entire hypopharynx. In this case, plastic surgery may help the patient breathe, talk or eat.
• Transoral robotic surgery: A newer approach to surgery, this procedure involves a surgeon directing a tiny robot arm into the mouth and throat to take out cancer with the use of a three-dimensional camera. This method is currently being studied as a potential treatment option for oropharyngeal cancer.

The potential risks and side effects vary widely depending on the type of surgery performed. Before undergoing surgery for head and neck cancer, it’s important to ask your doctor about your surgical options and the potential benefits and risks.

In general, surgery for head and neck cancer may cause:

• Voice changes
• Speech changes
• Loss or change in hearing
• Difficulty chewing
• Swallowing issues
• Swelling in and around the surgical site, which may affect breathing
• Disfigurement

Recurrent head and neck cancer

When cancer comes back after treatment ends, it’s referred to as recurrent cancer. Head and neck cancer may return in the same place of origin (local recurrence) or somewhere else (distant recurrence).

The treatment options for recurrent head and neck cancer depend on the type of cancer and its location. If recurrent cancer is suspected, you may need to undergo another round of diagnostic testing to restage the cancer and determine its location.

The treatment options for recurrent cancer are often similar to those used for the original cancer.

• Recurrent laryngeal cancer is treated like metastatic laryngeal cancer. The treatment options include surgery with or without radiation therapy, radiation therapy alone, chemotherapy, immunotherapy or a new treatment being tested in a clinical trial.
• Recurrent hypopharyngeal cancer treatments also mimic the treatment for metastatic hypopharyngeal cancer and include surgery, radiation therapy, chemotherapy or a clinical trial of chemotherapy.

Clinical trials

New treatments for head and neck cancers are constantly being studied and tested in clinical trials, which offer a way for doctors to find new and potentially better options and for eligible patients to try innovative approaches. The National Cancer Institute provides a database where you may research potential opportunities.

City of Hope may have clinical trials available to eligible patients with head and neck cancers. Your doctor can provide more information on the process and help you decide whether enrolling in a clinical trial is right for you.

Learn more about surgery for head and neck cancer

Read about flexible robotic surgery for head and neck cancer