Comprehensive Overview of Head and Neck Cancer

Literature Review:

Head and neck cancer is a collective form of cancer that originates from the squamous cells which line up the mucosal moist surfaces within the head and neck such as the cells that are lining inside the nose, mouth and throat. These forms of cancers are collectively known as “squamous cell carcinomas” occurring around the head and neck area. Cancer can also originate in the salivary glands but the frequency is very rare. The salivary gland comprises of different types of cells which may become cancerous and therefore there are many different forms of salivary gland cancers. The cancer of the head and neck region can be categorized based on the area where it begins: Oral cavity; Pharynx which includes the nasopharynx, oropharynx and the hypopharynx; Larynx; Paranasal sinuses and nasal cavity and the Salivary glands (Hoffman, et al, 1998). This is also known as cancer of the upper aerodigestive tract. For the diagnosis of the neck lump, the application of ultrasonography, fine needle aspiration cytology and core biopsy is suggested as per the NICE, 2017 guidelines. Similarly to determine the primary site of the metastatic nodal squamous cell carcinoma of the unknown origin the application of the fluorodeoxyglucose positron emission tomography is suggested (Prettyjohns, et al, 2017). As per the guidelines of BAHNO 2016 MDT, the management of the head and neck cancer should be done with an optimal strategy that involves a multidisciplinary team which takes into consideration of all the clinical data of the patients along with their preferences and social circumstances. It was observed that in 2013, the Scottish Intercollegiate Guidelines Network had abandoned the ABCD method of grading as every research would not fit into the guidelines. After studying in detail about the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, it was clear the multidisciplinary team did not possess the resources or time to use this methodology (Paleri, et al, 2016).

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Prevalence of patients with cancer at the head and neck regions

Throughout the world, the head and neck cancer cases are approximately higher than 650,000 and it accounts for 330,000 number of deaths per year. The new number of cases of head and neck cancer every year in the United Kingdom are 12,238 which is equivalent to 34 cases per day (within 2015 -2017). There were around 8,500 newly reported cases in the year 2017 and it is considered to be the fourth most common form of cancer among males in the UK (Louie, et al, 2015). In the United States this particular form of cancer estimated for 3% of the malignant cases nearly 53,000 of Americans developing cancer every year, 10,800 cases dies every year. In the European countries, the number of cases that were suffering from the head and neck cancer was about 250,000 cases annually and the numbers of estimated deaths were 63,500 in the year 2012. Males are more prone to get affected with this form of cancer in comparison to female counterparts and the ratio lies within 2:1 to 4:1 (Stenson, 2016). The incidence rate is higher among the males in the various countries such as Hong Kong, France, the central and eastern part of Europe, Italy, Spain, among the African American counterparts of the United States, Brazil. The variation that was observed in the incidence rate of cancer may be attributed to the risk factors such as chewing of tobacco and betel quid, smoking of the bidi or cigarette and with the consumption of alcohol (Sankaranarayanan, et al, 1998). In the Indian subcontinent, the prevalence of mouth and tongue cancers are very common; the nasopharyngeal cancer is prevalent among the population of Hong Kong and the prevalence of pharyngeal/ laryngeal cancers are frequent among the other population. Though the exact cause is unknown it has been strongly associated with Epstein-Barr virus (EBV). The mortality rate associated with this form of cancer is also higher among the population of African American origin (Marur, et al, 2008). The death rate due to the head and neck cancer in the United Kingdom were 3,989 within the span of time 2015 -2017. The survival rate from this particular cancer is 19-59% for above 10 years in England. The number of preventable cases from the head and neck cancer is 46 -88% in the UK. Specifically, the incidence rate of head and neck cancer is high among elderly patients aged between 70 – 74 years within the year 2014 -2016. It was observed that most of the head and neck cancer occurs in the larynx (Louie, et al, 2015).

The risk factors

The use of alcohol and tobacco severely increases the risk of cancers at the head and neck regions. The lifestyle choices of the individuals such as the consumption of cigarettes, pipes, betal nuts and chewing of tobacco makes them more at risk of about 85%. Passive smoking also increases the probability of developing head and neck cancer. Often consumption of a huge amount of alcohol enhances the risk of developing cancer in the mouth, larynx, pharynx and the oesophagus regions. According to a study finding consumption of greater than three alcoholic beverages per day increases the risk of head and neck cancer among both the gender (Freedman, et al, 2007). Among the other factors such as prolonged exposure to sun rays increases the risk of lip cancer and head and neck skin cancer, infection with Human papillomavirus (HPV), the infection or exposure to Epstein-Barr virus (EBV) enhances the risk of cancer at the nasopharyngeal region. Moreover as mentioned earlier, males are at greater risk in comparison to the female counterparts, age higher than 40 years, individuals who maintains the poor quality of dental and oral hygiene, occupational hazards such as inhalation of fumes of paints, asbestos, toxic gaseous chemicals, use of marijuana, a diet which contains a lower amount of vitamins A and B, prevalence of immunocompromised status of the patient and past medical records of head and neck cancer all acts as causal factors for the development of cancer (Spitz, 1994; Gallegos-Hernández, 2006).

Current treatment modalities

The types of treatment available to manage the condition of head and neck cancer are chemotherapy, radiation therapy and surgery. Patients who are in the initial stage of the cancer are usually managed with one modality treatment – Radiation Therapy (RT) or surgery according to the practice guidelines of the United Kingdom. The primary form of treatment may combine both the RT and surgery; chemotherapy is considered to be the adjuvant therapy along with RT/ surgery or RT along with surgery. The combination of all the three modalities of treatment usually depends on the size and stage of the head and neck cancer. A multidisciplinary team should be able to offer all the standard modalities of treatment based on the practice guidelines of the UK. Depending on the clinical manifestations, the patient may be advised for surgery followed by the chemo and radiation therapy. Recent pieces of evidence also suggest that combined course of chemo and RT is more effective than a single course of treatment of both the approaches (Table 1). Drugs which are usually suggested in combination with RT are cetuximab and cisplatin. In certain cases other drugs such as carboplatin, fluorouracil and paclitaxel may be advised for the patient (Brockstein, et al, 2013). The chemotherapy may be applied using a variety of doses such as daily low dose, a moderate amount of dose administered weekly or administration of higher dose at every three to four weeks. One of the two mentioned RT procedures can be used for treatment such as External beam therapy (EBT) and Intensity-modulated RT (IMRT) (Arnold, et al, 2016; Lee, et al, 2007).

Table 1: combined treatment effect of chemo and radiation therapy in comparison to the RT alone among patients with throat cancer:

combined treatment effect

A study conducted with a total number of 90 patients consisting of 51 men and 39 women suffering from the head and neck cancer within the mean age of 64.4 years for a period of over 12 months were included within the study. Among the sample population, 80% of the patients were at first evaluated by the general dentist, oral and maxillofacial group of surgeons and it was reported that 93% of the cases were reported from the oral and maxillofacial surgeons. The 90% of the lesions were located within the oral cavity and 6.6% of the cases were reported to be of the primary form of oropharyngeal cancers. The stage of the cancer patients identified at the time of diagnosis for 64.4% cases was found to be in the early stage (I/II) and 35.6% of the cases were reported to be in the late stage (III/IV). The analysis of the treatment modalities demonstrated that 83.5% of the cases had undergone surgery as the only mode of treatment and the other percentage had undergone both surgery and adjuvant therapy (Alshadwi, et al, 2013).

Nutritional support is considered to be an essential part of management for head and neck regions cancer patients. According to the UK National multidisciplinary guidelines, a specialist dietitian is recommended among the multidisciplinary team for the treatment of patients with head and neck cancer. A validated nutrition assessment tool has to be used such as the MUST (Malnutrition Universal Screening Tool) to identify the patients who are at risk of malnutrition. Pre-treatment assessment should be provided before any implementations of interventions to improve the condition of the patient who are undernourished or at the risk of malnutrition. For patients who scored the status of good nourishment should be provided with dietetic assessment and other interventions during any stage of the treatment (Talwar, et al, 2016). As patients of head and neck cancer suffer from complications of malnutrition, anorexia, the treatment procedures hamper the nutritional intake of the patient xerostomia or dysphagia, alterations in the rate of metabolism induced due to the inflammation, tumour and therapy. Weight loss is another problem observed among these patients. These are considered to be the side effects which affect the nutritional status of the patient. Langius, et al, 2013, conducted a cohort study of 1799 head and neck cancer patients treated with the application of RT were included for investigation between January 2000 -2009. The chief inclusion criterion for the study was curative RT as the only option or postoperatively. Initially, the patients were treated with usual three-dimensional conformal radiotherapy until the clinical appearance of the parotid gland occurred later. The data were collected prospectively by the radiotherapist and based on the equation: current weight-usual weight) / usual weight x 100%, following four groups were categorised: no weight loss observed, weight loss ≤ 5% and weight loss between 5 -10% and > 10% weight loss. Langius, et al, 2013 reported that before and after the administration of RT weight loss can be considered to be as the significant predictive factor. This may be attributed to the presence of malnutrition among 63% of the patients before the treatment process had started and during the ongoing treatment process, the treatment-related toxicities such as dysphagia resulted in difficulties and discomfort while eating as reported by a group of authors of several studies. However several other authors had stated that the prevalence of malnutrition rises during the time of treatment rises to 41 -88%. The author also reported that weight loss may also continue as the squeal of radiation therapy (Nayel et al, 1992; Unsal et al, 2006; Langius et al, 2010).

Author Ng, et al, 2004 reported about the nutritional consequences among the nasopharynx cancer (NPC) patients who have undergone RT for treatment purpose. The study included 38 patients which included 8 women and 30 men within the age 33 -71 years along with their detailed clinical records. In this study the patients were provided with the standard plan of care for treatment involving the nutritional support, educating the patients about the possible side effects of RT by the attending clinician, group counselling about the nutritional requirements of the patient before the onset of RT and the assessment of the patient every week by the clinician during the phase of RT. The patients were not advised with the prophylactic tube feeding. The following parameters were recorded such as the bodyweight, BMR, records about the diet intake, the composition of the body, the level of physical activity using questionnaires at regular intervals of time and the findings were statistically analysed. The outcomes of the study revealed that the BMI observed at end RT was 21.5 ± 3.7 kg/m^2 (range: 13.7-27.9 kg/m^2) and it was appreciably lower than the pre-RT. Initially, the calorie intake of the patients declined; from post-treatment however, the recovery rate in the body weight was running behind the recovery rate of dietary intake and 82% of the patients reported severe weight loss even after 6 months of RT. The study highlighted the nutritional improvements of the patients with Nasopharynx cancer (NPC) undergoing the RT. Similarly, another study conducted by Qi Zeng et al, 2016 also reported that the critical weight loss is a significant and independent factor for the long term survival among the NPC patients. This statement can be supported by an author Shen, et al, 2013 who reported that high weight loss is associated with poor survival rate and lower BMI among NPC patients.

Author García-Peris, et al, 2005 aimed to explore the malnutrition level of patients with the head and neck cancer because of the location of the tumour and coadjuvant therapy. The study investigated the resting energy expenditure (REE) during the chemotherapy and compared this measured value with the Harris-Benedict (HB) formula. The assessment of nutrition included anthropometry and tetrapolar bioimpedance. Measurements were taken at regular intervals such as at 2, 4, 6 weeks during treatment, at the end of the treatment and after the treatment. The outcome of the study indicated lowered BMI during the treatment phase 24.7± 4.4 kg/m2. The value of REE measured with the HB formula showed a significant decrease during and after the chemotherapy (García-Peris, et al, 2005). Similarly, other studies conducted by Ahmed, et al, 2013, Peñas, et al, 2019 and Talwar, et al, 2016 also studied about the nutritional management of the head and neck cancer patients and they all highlighted that the nutritional interventions should begin before the treatment process and should be continued after the completion of the treatment for the appropriate health outcomes of the patients. The guidelines for the nutritional analysis were commissioned and supported financially by the ESPEN and the European Partnership for Action Against Cancer (EPAAC). In general cancer patients are moderately hypermetabolic showing the excess energy expenditure in between 138 - 289 kcal/day. Therefore, the total energy expenditure and the requirement of protein for the non-obese ambulatory head and neck cancer patients by using the actual body weight can be evaluated as below: the energy and protein requirement should be 30–35 kcal/kg/day and 1.2 g/kg/day respectively for the patients who are receiving the radiotherapy or chemotherapy. The recommended values may differ based on the degree of malnutrition, obesity, post-operative energy requirements. Based on the Parenteral and Enteral Nutrition Group guidelines (PENG), there are three major methods of nutritional support namely oral, enteral and parenteral. Though the use of parenteral nutrition is generally not employed for the head and neck cancer patients it may be used if required. The nutritional interventions during the surgical process should be considered as fast recovery is needed after the surgery process and this should be considered at all stages from diagnosis to survivorship. There is also a different nutritional requirement for the preoperative and postoperative conditions (Talwar, et al, 2016; Arends, et al, 2017; Talwar, et al, 2016; National Collaborating Centre for Acute Care (UK, 2006; Talwar, et al, 2012).

The literature highlights the importance and prevalence of nutritional assessment and intervention of patients of head and neck cancer undergoing the RT and chemotherapy were also assessed based on the systemic literature review.

The study presents the different forms of head and neck cancers, their root causes and their prevalence throughout the world. The study also discussed the current treatment modalities in short for the head and neck cancers. Following the new Parenteral & Enteral Nutrition Group guideline, it will assess the feasibility of estimating nutritional requirements.

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References:

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Nayel, H., El-Ghoneimy, E. and El-Haddad, S., 1992. Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition (Burbank, Los Angeles County, Calif.), 8(1), pp.13-18.

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Langius, J.A., Doornaert, P., Spreeuwenberg, M.D., Langendijk, J.A. and Leemans, C.R., 2010. Radiotherapy on the neck nodes predicts severe weight loss in patients with early stage laryngeal cancer. Radiotherapy and Oncology, 97(1), pp.80-85.

Zeng, Q., Shen, L.J., Guo, X., Guo, X.M., Qian, C.N. and Wu, P.H., 2016. Critical weight loss predicts poor prognosis in nasopharyngeal carcinoma. BMC cancer, 16(1), p.169.

Shen, L.J., Chen, C., Li, B.F., Gao, J. and Xia, Y.F., 2013. High weight loss during radiation treatment changes the prognosis in under-/normal weight nasopharyngeal carcinoma patients for the worse: a retrospective analysis of 2433 cases. PLoS One, 8(7).

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Alshadwi, A., Nadershah, M., Carlson, E.R., Young, L.S., Burke, P.A. and Daley, B.J., 2013. Nutritional considerations for head and neck cancer patients: a review of the literature. Journal of Oral and Maxillofacial Surgery, 71(11), pp.1853-1860.

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Ng, K., Leung, S.F., Johnson, P.J. and Woo, J., 2004. Nutritional consequences of radiotherapy in nasopharynx cancer patients. Nutrition and cancer, 49(2), pp.156-161.

García-Peris, P., Lozano, M.A., Velasco, C., de La Cuerda, C., Iriondo, T., Bretón, I., Camblor, M. and Navarro, C., 2005. Prospective study of resting energy expenditure changes in head and neck cancer patients treated with chemoradiotherapy measured by indirect calorimetry. Nutrition, 21(11-12), pp.1107-1112.

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