Head and neck cancer: Full guide

What is head and neck cancer?

Head and neck cancer is a group of cancers. They start in the mouth, throat, voice box, nose, or sinuses. Most start in the thin, moist lining of these areas. This type is called squamous cell carcinoma.

These cancers can spread to lymph nodes in the neck. A new lump in the neck is often the first sign people notice. Other signs include a mouth sore that does not heal, hoarseness, trouble swallowing, or ear pain.

Tobacco and alcohol cause most head and neck cancers. Using both raises the risk even more. A virus called HPV (human papillomavirus) now causes most throat cancers in the US. Throat cancers caused by HPV usually respond better to treatment.

Many people are cured, especially when the cancer is found early. Treatment can affect how you eat, talk, and swallow. A team of experts will help you through it. Your care team will explain what this means for you.

Types

Mouth (oral cavity) cancer

Starts in the lips, front of the tongue, gums, cheeks, or the floor or roof of the mouth. Surgery is usually the main treatment.

Throat (oropharynx) cancer

Starts in the back of the tongue, the tonsils, or the soft back part of the mouth's roof. It is often found as a painless lump in the neck.

HPV-related throat cancer

A type of throat cancer caused by HPV. It is now the most common type of throat cancer in the US. It often affects people who smoked little or never. It usually responds well to treatment and has its own staging system.

Voice box (larynx) cancer

Starts in the voice box. Cancer on the vocal cords often causes hoarseness early, so it is often found sooner. Keeping your voice is a key goal of treatment when possible.

Lower throat (hypopharynx) cancer

Starts in the lowest part of the throat, next to the voice box and above the food pipe. It is often found later because it may not cause symptoms early.

Nasopharynx cancer

Starts in the upper part of the throat behind the nose. It is linked to the Epstein-Barr virus (EBV) and is more common in parts of Asia and North Africa. It is treated mainly with radiation and chemotherapy, and has its own staging system.

Nose and sinus cancer

Starts in the nasal cavity or the air spaces around the nose. These cancers are rare and are often found later.

Unknown primary

Sometimes cancer is found in a neck lymph node, but the starting place cannot be seen. Tests for HPV or EBV in the node can point to where it started and guide treatment.

Tests you may have

Physical exam and scope

The doctor looks in your mouth and feels your neck. A thin tube with a camera (endoscope) goes through your nose to see your throat and voice box. It is usually done in the office with numbing spray.

Biopsy

Taking a small piece of tissue to look at under a microscope. This is the only way to know for sure it is cancer. A thin needle is often used to sample a neck lump.

Exam under anesthesia

While you are asleep, the surgeon looks closely at your mouth and throat and takes samples. Sometimes the tonsils are removed to look for a hidden cancer.

CT scan

A detailed X-ray that shows the size of the tumor and whether lymph nodes in the neck are involved.

MRI

A scan that uses magnets to make detailed pictures. It is helpful for the nose, sinuses, skull base, and nasopharynx.

PET-CT scan

A scan that uses a small amount of a sugar tracer. Cancer cells take up more of it and light up. It helps show if cancer has spread. It is also often done about 3 months after treatment to check how well it worked.

HPV (p16) and EBV testing

Lab tests on the tumor. A p16 test shows if a throat cancer is caused by HPV. EBV testing is used for nasopharynx cancer. These results change the stage and the treatment plan.

Dental exam

A dentist checks your teeth before radiation. Teeth that cannot be saved are often removed before treatment starts.

Swallowing, nutrition, and hearing checks

A speech and swallowing therapist and a dietitian check how you eat and swallow. If you will get cisplatin (a chemotherapy medicine), a hearing test may be done first.

What the stage means

The stage tells how big the cancer is and how far it has spread. It helps your care team plan treatment.

Most head and neck cancers use stages 1 to 4. Lower numbers mean the cancer is smaller and has not spread far.

HPV-related throat cancer and nasopharynx cancer each have their own staging systems. The same stage number can mean a different outlook in these cancers than in others. Ask your team what your stage means for you.

Stage 1 and 2 (early stage)

The tumor is small. In some cases it has spread to one small lymph node. Surgery alone or radiation alone is often used, with the goal of cure.

Stage 3 and 4 (locally advanced)

The tumor is larger, has grown into nearby parts, or has spread to lymph nodes in the neck. Treatment often combines surgery, radiation, chemotherapy, and sometimes immunotherapy. Cure is still the goal for many people.

HPV-related throat cancer stages

Uses stages 1 to 3 for cancer that has not spread far. Stage 4 means it has spread to distant organs. Many people with stage 1 or 2 have a very good outlook.

Recurrent cancer

Cancer that comes back after treatment. Sometimes it can still be treated with surgery or radiation with the goal of cure.

Metastatic cancer

Cancer that has spread to distant parts of the body, such as the lungs, liver, or bones. Treatment uses medicines that travel through the whole body, such as immunotherapy. The goal is to control the cancer and help you live longer and feel better.

Tumor markers and virus tests

Some lab tests on the tumor help your team understand your cancer and choose treatment.

Unlike some other cancers, most head and neck cancers are not treated with targeted pills based on gene changes. The most important tests look for viruses and for a protein called PD-L1.

HPV (p16)

Shows if a throat (oropharynx) cancer is caused by HPV. HPV-related throat cancers usually respond better to treatment. This test is mainly useful for throat cancer, not for other head and neck sites.

EBV

Shows if a cancer is linked to the Epstein-Barr virus. This points to nasopharynx cancer. Blood tests for EBV can also help track the cancer during and after treatment.

PD-L1 (CPS score)

A protein on cancer cells and some immune cells. It is reported as a number called CPS (combined positive score). The score helps decide if immunotherapy is a good choice, alone or with chemotherapy.

HPV DNA blood test

A blood test that looks for bits of HPV from the tumor. Some doctors use it after treatment to watch for cancer coming back. Ask your team if it is right for you.

Main treatments

Surgery

Removing the tumor and a rim of healthy tissue. It is the main treatment for most mouth cancers. Some throat cancers can be removed through the mouth with a robot (TORS). Surgeons can often rebuild the area using tissue from another part of your body.

Neck dissection

Surgery to remove lymph nodes in the neck. It checks for and removes cancer that has spread there. It may be done with surgery on the main tumor or after radiation.

Radiation therapy

High-energy beams that kill cancer cells. It is usually given 5 days a week for about 6 to 7 weeks. Modern methods like IMRT aim the beams closely to spare healthy parts, such as the saliva glands.

Chemoradiation

Chemotherapy given during the same weeks as radiation. The chemotherapy makes radiation work better. Cisplatin is the most common medicine used. It can be the main treatment. It can also follow surgery when the cancer is more likely to come back.

Organ preservation

For many voice box and throat cancers, chemoradiation can treat the cancer while keeping the voice box. Surgery is saved in case the cancer does not go away or comes back. For some large tumors, removing the voice box (laryngectomy) is the better choice.

Immunotherapy before and after surgery

Some people have stage 3 or 4A cancer that can be removed. For them, pembrolizumab may be given before surgery and continued after. This is used when the tumor has a PD-L1 score of 1 or higher.

Immunotherapy for advanced cancer

For cancer that has come back or spread, immunotherapy (such as pembrolizumab or nivolumab) is a main treatment. It may be given alone or with chemotherapy, depending on your PD-L1 score.

Chemotherapy and cetuximab

Chemotherapy may be given before other treatment to shrink a large tumor, or for advanced cancer. Cetuximab is an antibody medicine. It is sometimes used with radiation when cisplatin is not safe for you, or for advanced cancer.

Nasopharynx cancer treatment

Usually radiation, often with chemotherapy before or during it. For advanced nasopharynx cancer, chemotherapy plus an immunotherapy medicine is often used.

Clinical trials

Research studies that test new treatments. For HPV-related throat cancer, some trials test lower doses of treatment to reduce side effects. Ask if a trial is right for you.

Supportive (palliative) care

Care focused on comfort, symptoms, and quality of life. It can be given at any stage, along with cancer treatment.

Common side effects and what helps

Mouth sores and sore throat

Radiation can cause painful sores in the mouth and throat, called mucositis. Rinse often with a salt and baking soda mouthwash. Ask about numbing mouthwash and pain medicine so you can keep eating and drinking.

Dry mouth

Radiation can damage the saliva glands. Dry mouth can last a long time after treatment. Sip water often, use a humidifier at night, and try sugar-free gum or saliva substitutes. Ask about medicines that help make saliva.

Thick mucus

Saliva can become thick and sticky. Drink plenty of fluids and rinse often. A humidifier and salt water rinses can help loosen it.

Trouble swallowing

Swelling and scarring from treatment can make swallowing hard. A speech and swallowing therapist can teach exercises to do before, during, and after treatment. Keep swallowing as much as you safely can, even small sips, to keep the muscles working.

Weight loss and feeding tubes

Pain and trouble swallowing can make eating hard. A dietitian can help with soft, high-calorie foods and nutrition drinks. Some people need a feeding tube for a while to get enough food and water. Most people can stop using the tube after they heal.

Taste changes

Food may taste different, bland, or metallic. Taste often gets better slowly over months after treatment. Try different flavors, sauces, and cool foods.

Dental problems and jaw bone damage

Dry mouth raises the risk of cavities. Radiation can also weaken the jaw bone. Brush gently, use fluoride as your dentist advises, and see your dentist regularly for life. Tell any dentist you had radiation before you have a tooth pulled.

Skin changes

The skin on your neck can get red, dry, and sore, like a sunburn. Use only the creams your team suggests. Wear soft collars and protect the area from the sun.

Hearing loss and ringing ears

Cisplatin can affect hearing and cause ringing in the ears. It can also affect the kidneys and cause numbness in the hands and feet. Tell your team about any changes.

Neck stiffness, swelling, and low thyroid

Scarring can make the neck stiff, and fluid can build up (lymphedema). Physical therapy and gentle stretching help. Radiation can also cause a low thyroid, so your blood will be checked over time.

Immune side effects

Immunotherapy can cause swelling in healthy organs like the lungs, bowels, liver, skin, or hormone glands. Tell your team about new cough, diarrhea, rash, or feeling unwell. Early treatment helps.

Fatigue

Feeling very tired is common, especially near the end of radiation. Short walks can help. Rest when you need to, and ask others for help.

Living with and after head and neck cancer

If you smoke or drink alcohol, stopping is one of the best things you can do. It helps treatment work, lowers side effects, and lowers the chance of a new cancer. Ask your team for help. Medicines and counseling make quitting more likely to work.

Keep doing your swallowing and jaw exercises after treatment. Keep seeing your dentist. These habits help protect how you eat and speak for years to come.

You will have regular checkups, often with a scope exam and scans. These look for cancer coming back and for new cancers in the head, neck, or lungs. Your thyroid will also be checked with blood tests.

Healing takes time. Swallowing, taste, and energy often improve slowly over many months. Some changes, like dry mouth, may last. Your team can help you manage them.

Changes in how you look, talk, or eat can be hard. It is normal to feel sad, worried, or alone. Support groups, counselors, and social workers can help you and your family. Speech therapists can help if your voice has changed.

HPV vaccines can help prevent HPV-related cancers in the future. Ask your family's doctors whether children and young adults in your family should get it.