Head and neck cancer: beware of smoking and alcohol

Smoking and alcohol consumption, as well as HPV infection, are the main causes of head and neck cancer. Oncologist Leonor Abreu Ribeiro discusses the need for prevention and reviews the innovations available for the treatment of this tumor.

Head and neck cancer: care with tobacco and alcohol

It is the sixth cancer with the highest number of new cases diagnosed in 2020, both in the world and in Portugal, according to data from the International Agency for Research on Cancer, and in our country alone it was responsible for 4.41% of cancer deaths. But despite these figures, there is still a need to raise public awareness of this disease. That’s why on July 27, we celebrate World Head and Neck Cancer Day.

From the outset, it is important to understand that there are different tumors taken into account in the commonly used designation. According to Leonor Abreu Ribeiro, oncologist at the CUF Tejo Hospital in Lisbon, “head and neck cancer includes all malignant tumors of the oral cavity, pharynx and larynx, as well as other anatomical areas with their own peculiarities, such as the sinuses, nasal cavity, salivary glands – which include the parotid gland – and thyroid gland”. Among these, the most common are tumors of the oral cavity, pharynx (which includes the oropharynx, hypopharynx and nasopharynx) and larynx.

The people most affected are men in the age group between 60 and 70 years and the explanation lies in the most common factors for the development of this disease: “The main risk factors are tobacco and alcohol, with the amount and number of years of consumption during a person’s life counting towards the risk. If there is an association, that is, when in the same person these two factors exist together, the risk is not double, but multiplicative.”

Another risk factor – which, in some parts of the world, tends to occupy the first place, as the specialist points out – is infection by the human papilloma virus (HPV). “This can lodge preferentially in the oropharynx and remain there for many years, contributing to local molecular and cytological alterations, favoring the appearance of atypical cells,” explains the doctor, who is also a member of the Board of Directors of the Head and Neck Cancer Study Group, pointing out that “in Portugal, there are cases of HPV-positive tumors in people who also smoke and drink, so that the effect of these three main risk factors is added.

Prevention is fundamental

Knowing so clearly the factors that lead to the appearance of this cancer, it is easy to conclude that its prevention is possible and fundamental. “Primary prevention consists of eliminating the risk factors, reducing the incidence of lesions”, explains Leonor Abreu Ribeiro, according to whom “stopping smoking and alcohol also reduces the frequency of recurrence”. [reaparecimento] of tumors in people who have already suffered from them and who are free of disease after treatment.” According to the oncologist, “recurrences are common in the first two to five years, especially in the first three years,” and “if during treatment, especially with radiation and chemotherapy, people continue to smoke and drink, they run a greater risk of treatment failure.”

The prevalence of HPV is increasing, especially among young people, which is why the National Cancer Institute stresses the importance of avoiding this infection, as HPV can affect the skin and moist membranes, such as those in the mouth and throat. It should be noted that the HPV vaccine is included in the national vaccination program and should be given to girls and boys at age 10.

Symptoms that deserve attention

Symptoms that may raise suspicion of head and neck cancer vary depending on the location of the disease, and the main problem is that “they may be confused with other benign conditions such as inflammation or infection.” Thus, the doctor draws attention to the following symptoms, but only if they “persist after an initial treatment – assuming it is an inflammation or infection – of two to three weeks”. In this case, that is, if the symptoms persist, the person should consult a doctor. Among the most common signs, he highlights:

  • Whitish, reddish and/or ulcerated lesion in the oral cavity or oropharynx;
  • Hoarse voice, nasal obstruction or nasal discharge, especially if bloody;
  • Pain on swallowing;
  • Swelling of the face or neck.

More than just the physical

The impact of head and neck cancer is significant, and not only because of the consequences it has on the patient’s physical health, but also psychologically. This is due to the fact that the dimensions affected by this tumor are numerous. “The impact is significant precisely because it affects functions such as speech, chewing, swallowing or breathing, as well as the modification of the body image of the face and neck.”advances the doctor, adding that the disease “can compromise everything from a family or social event, such as a family dinner or an outing to the cafe, for example, to the exercise of the profession, in the case of tasks related to public assistance or teaching, among many other examples.”

In this sense, he warns of the care that must be taken in the choice of therapeutics: “What will be desirable is to obtain a long survival of our patients without active disease, associated with a good quality of life, that is, a physical and functional state as close as possible to that before the disease.” To this end, when a treatment is defined, it “must be the best in terms of evidence of success, that is, in terms of response with curative intent or control of the advanced situation, depending on the clinical situation in question, but without ever forgetting the possible long-term consequences, that is, the so-called late effects of the therapy,” he details.

What options therapeutic exist?

Treatment is based on three pillars, which can be used individually or in combination, depending on the clinical case: surgery, which often includes reconstructive surgery with the collaboration of the plastic surgery specialty; radiation therapy, guided by the radioncology specialty; and systemic treatment, which is the responsibility of medical oncology. “The choice of treatment or its sequence depends on the location, the size of the tumor, its relationship with neighboring structures, the volume of neck lymph nodes affected by the disease and the existence or not of an attack on other organs at a distance, the so-called distant metastases, “explains the specialist. It is this assessment that will determine the stage of the tumor, she recalls, stressing that the stage of the disease “must be integrated with the characteristics of the patient himself, taking into account his other previous diseases, his age and his general condition.” “Today, it is unthinkable to define a therapeutic strategy without taking into account all these data and after discussion in a multidisciplinary therapeutic decision group,” he emphasizes.

Treatment is based on three pillars, which can be used individually or in combination, depending on the clinical case: surgery, which often includes reconstructive surgery with the collaboration of the plastic surgery specialty, radiotherapy, guided by the radioncology specialty, and systemic treatment, the latter being the responsibility of medical oncology.

Innovations that improve the prognosis

Many advances have been made in recent years, responsible for ensuring better therapeutic responses to patients, from improved surgical and radiotherapy techniques to new drugs. Among these, the doctor points out that “recently, after the discovery of proteins associated with the interaction between the tumor and our immune system, there have been great advances in immunotherapy,” which has led to two drugs already approved in the United States and Europe for the treatment of advanced disease, with specific indications. Leonor Abreu Ribeiro explains that the use of these drugs to treat locally advanced disease is still under study, but “there are great expectations and hopes for their use in this phase, to allow a reduction in the volume of the disease before surgery, to test the biology of the tumor and its sensitivity to these drugs, allowing for better results and local responses in terms of control of the disease locally and remotely.” According to him, this is the hope of developing a more effective treatment for this pathology, which currently has a high morbidity and mortality rate.

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