This information is an interpretation of various studies that have been published in medical journals. The information below represents various views of nurses and doctors who serve on the American Cancer Society’s Cancer Information Database Editorial Board. Keep in mind that the information provided in this article is not designed to be taken as medical advice or to replace the opinion and judgment of your personal cancer care team. It is simply designed to help you make informed decisions together with your doctor. The general treatment options that will be discussed may not be what your doctor recommends, and there may be various reasons why. You should take the time to find out what specific treatments doctors recommend for you.
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Surgery is the primary treatment for mouth and throat cancers. Removing the tumor may be less difficult, especially if the cancer is at the early stages and the tumor is small. This is because the mouth and throat are easily exposed, compared to internal organs like the pancreas and gallbladder. Before the operation, and immediately after the diagnosis, doctors will strongly advise mouth and throat cancer patients to stop smoking or consuming oral tobacco products.
Tumor resection involves removing the entire tumor along with a margin of normal-looking tissue around it. The margin is taken to reduce the risk of leaving behind any cancer cells. The method used to remove the primary tumor depends on its size and location. For example, a tumor in the front of the mouth may be easily removed through the mouth. Whereas a larger tumor that has grown into the oropharynx may require an incision in the neck or cutting of the jaw bone (mandibulotomy) to access the tumor.
Mohs surgery, also known as micrographic surgery, may be used to remove some cancers of the lip, particularly those at the very edge. In this procedure, the tumor is removed in thin slices, and each slice is immediately examined under a microscope for the presence of cancer cells. Slices continue to be removed and examined until no cancer cells are seen. This method minimizes the removal of normal tissue and limits the change in appearance caused by the surgery. It requires a specially trained surgeon and may take more time than a standard tumor resection.
Glossectomy is a surgical procedure used to treat cancer of the tongue. For smaller cancers, only a part of the tongue (less than 1/3) may need to be removed, which is called a partial glossectomy. For larger cancers, the entire tongue may need to be removed, which is known as a total glossectomy.
Mandibulectomy, or mandibular resection, involves removing all or part of the jaw bone (mandible). This operation may be necessary if the tumor has grown into the jaw bone. If the tumor is hard to move during examination, it often indicates that the cancer has invaded the jaw bone. Depending on the extent of the invasion, either a partial-thickness mandibular resection (marginal mandibulectomy) or a segmental mandibulectomy may be performed. The removed piece of the mandible can be replaced with a bone from another part of the body, a metal plate, or a bone from a deceased donor.
If cancer has grown into the hard palate (front part of the roof of the mouth), all or part of the involved bone (maxilla) will need to be removed. This operation is called a maxillectomy or partial maxillectomy. The resulting hole in the roof of the mouth can be filled with a special denture called a prosthesis, created by a prosthodontist. Other options to close the gap include a skin graft or a piece of muscle from the forearm or thigh.
Trans-oral robotic surgery (TORS) is increasingly being used to remove cancers of the back of the throat and mouth that might otherwise require a mandibulectomy. The surgeon controls robotic arms with small tools attached to them from a control panel in the operating room, using a camera to guide the removal of the tumor. Robotic surgeries may allow for the complete removal of throat cancers with fewer side effects compared to more standard, open surgeries. It is important to have these procedures performed by experienced surgeons at treatment centers familiar with this approach. A recent debacle involving the popular Da Vinci surgical robot has led to a lawsuit because of injuries from either machine or physician error.
In rare cases, when removing large tumors at the base of the tongue or oropharynx, there may be a risk of food entering the windpipe (trachea) and reaching the lungs, potentially causing pneumonia. This can be prevented by also removing the larynx during the same operation as the cancer removal. This procedure is called a laryngectomy. After laryngectomy, the windpipe is attached to a hole (stoma) made in the skin in the front of the neck, allowing the person to breathe and cough through the stoma (tracheostomy or trach). While normal speech is no longer possible after losing the voice box, people can learn alternative methods of speaking.
Mouth and Throat cancers often spread to the lymph nodes in the neck. A neck dissection or lymph node dissection is performed at the same time as the surgery to remove the main tumor. The goal is to remove lymph nodes that are proven to contain cancer. In some cases, even if there is no definitive proof of cancer spread to the lymph nodes, doctors may recommend an elective lymph node dissection based on the tumor size and the high likelihood of spread. For early-stage mouth and lip cancers, a sentinel lymph node biopsy may be performed at experienced treatment centers to test the lymph nodes for cancer before removing them.
Several types of neck dissection procedures exist, varying in the amount of tissue removed from the neck. The extent of tissue removal depends on the size of the primary cancer and the degree of lymph node involvement.
The most common side effects of any neck dissection include numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. These may be caused by damage to the nerves supplying these areas during the operation. After a selective neck dissection, the nerve may only be injured and can heal over time, with weakness of the shoulder and lower lip potentially resolving after a few months. However, if a nerve is removed as part of a radical neck dissection or due to tumor involvement, the weakness will be permanent. Physical therapy can help improve neck and shoulder movement after any neck dissection procedure.
Operations may be needed to restore the structure of areas affected by more extensive surgeries to remove cancer. While small tumors usually don't require reconstructive surgery, larger tumors may cause defects in the mouth, throat, or neck that need repair. Skin grafts from the thigh or other areas can be used to repair small defects. But larger defects may require more tissue, such as a piece of muscle with or without skin from nearby areas like the chest or upper back. Advances in microvascular surgery have expanded the options for reconstructing the oral cavity and oropharynx, allowing tissue from other parts of the body to replace parts of the mouth, throat, or jaw bone. Examples include:
A tracheostomy or trach is a stoma (hole) made through the skin in the front of the neck and attached to the trachea (windpipe) to help a person breathe. If significant swelling is expected in the airway after cancer removal, a short-term tracheotomy (using a small plastic tube) may be performed to facilitate breathing until the swelling subsides. If the cancer is blocking the throat and is too large to remove completely, a permanent tracheostomy may be necessary to bypass the tumor and allow comfortable breathing. A permanent tracheostomy is also required after a total laryngectomy.
Cancers in the oral cavity and oropharynx may hinder swallowing, leading to malnutrition and weakness, which can make completing treatment more difficult. A gastrostomy tube (G-tube) is a feeding tube inserted through the skin and muscle of the abdomen directly into the stomach. It can be placed during an operation or endoscopically (percutaneous endoscopic gastrostomy, or PEG tube). PEG tubes can be used for as long as needed and can be removed when normal eating resumes. For short-term swallowing problems, a nasogastric feeding tube (NG tube) may be an option, which goes through the nose, down the esophagus, and into the stomach. Patients and families are taught how to use the tube and home health nurses may visit to ensure comfort with tube feedings.
Before radiation treatment, a dental evaluation is necessary. Depending on the radiation plan and the condition of the teeth, some or all teeth may need to be removed by the head and neck surgeon or an oral surgeon. If left in and exposed to radiation, broken or infected teeth can cause problems such as infections and areas of necrosis in the jaw. If part of the jaw bone is removed and reconstructed with bone from another part of the body, the surgeon might place dental implants where prosthetic teeth can be attached to the bone. This could either be at the same time as the mandible reconstruction or at a later date.
Mouth and Throat cancer surgeries carry the risk of the following potential side effects:
More serious side effects may include:
Special procedures also carry specific risks:
Partial tongue removal may affect speech clarity and swallowing, but most people can still speak. Speech therapy can often help with these problems. However, when the entire tongue is removed, patients lose the ability to speak and swallow. Reconstructive surgery and a comprehensive rehabilitation program, including speech therapy, may help some people regain the ability to swallow and speak well enough to be understood.
Laryngectomy, which removes the voice box, leaves a person without the normal means of speech. There are several ways to restore one's voice, which are discussed in more detail in the Laryngeal and Hypopharyngeal Cancer section. After a laryngectomy, the person breathes through a stoma (tracheostomy) in the front of the lower neck. This means that the air breathed in and out will no longer pass through the nose or mouth, which normally helps moisten, warm, and filter the air. As a result, the air reaching the lungs will be dryer and cooler, potentially irritating the breathing tube lining and causing thick or crusty mucus buildup. It is crucial to learn how to care for the stoma. This includesusing a humidifier, suctioning, and cleaning, as well as taking precautions to keep water and small particles out of the windpipe.
Some head and neck cancers are treated with operations that remove part of the facial bone structure. This can have a significant effect on self-perception, speech, and swallowing due to the visible changes. It is important to discuss these changes with your doctor before surgery to prepare and explore available options afterward. Recent advances in facial prostheses and reconstructive surgery can help improve appearance and speech clarity, which can greatly benefit a person's self-esteem.
Radiation therapy uses high-energy X-rays or particles to destroy cancer cells or slow their growth. It can be used alone as the main treatment for small cancers or for people who cannot undergo surgery. It may also be used after surgery (adjuvant therapy), either alone or with chemotherapy (chemoradiation), to kill any remaining cancer cells and lower the risk of recurrence. In some cases, radiation therapy may be used before surgery (neoadjuvant therapy) with chemotherapy or after chemotherapy to shrink larger cancers, potentially allowing for less extensive surgery. Additionally, radiation therapy can be used with a targeted drug for larger cancers if chemotherapy is not an option. This helps ease symptoms of advanced cancer, or to treat cancer that has recurred after treatment.
Before starting radiation therapy, it is important to see a dentist to ensure your mouth is healthy and to address any potential issues that may arise during treatment. A dentist may recommend removing certain bad teeth before radiation therapy to reduce the risk of infection. During and after treatment, a dentist can help monitor and treat any problems that may occur, such as infection or tooth and bone damage.
External Beam Radiation Therapy or EBRT is the most common type of radiation treatment for cancer. It focuses radiation from an external source onto the cancer. Before EBRT, a somewhat flexible but sturdy mesh head and neck mask might be made to hold your head, neck, and shoulders in the same position for each treatment. Some people might feel confined while wearing this mask and might need medication to help them relax during the treatment. The mask can sometimes be adjusted to be less constricting, and options should be discussed with the radiation oncologist. A bite block might also be fitted to hold in your mouth during treatment. The procedure itself is painless and lasts only a few minutes, although the setup time to get you into place for treatment often takes longer.
Because radiation carries the risk of harming healthy tissue along with cancer cells, special, more precise types of EBRT are used for treating mouth and throat cancers:
Brachytherapy uses small radioactive pellets that are embedded into the tumor or beside it to kill it with minimal damage to surrounding tissue. However, brachytherapy is not primarily used for mouth and throat cancer treatments. However it is more commonly utilized in cases of cancer recurrence, should the cancer come back after treatment.
Your appetite might dwindle due to difficulty in swallowing, which can lead to poor nutrition. Incorporation of more liquid foods and supplements into your diet may be necessary, especially if damage to your throat is extensive.
Permanent dry mouth due to damaged salivary glands may result in constant discomfort, swallowing problems, and jaw damage. It can also cause tooth decay, which will require constant fluoride treatments to prevent.
If an infected or broken tooth is not removed before radiotherapy, it may cause damage to the jaw bone down the line. This can be quite painful and might require additional surgery.
Thyroid problems may arise after radiation therapy for mouth and neck cancers since the thyroid is located in the same region of the body. If the thyroid is damaged, hormone production will be disrupted. You will need to take appropriate amounts of external hormones regularly to maintain proper body function.
Lymphedema, which is a swelling and firmness in the neck and head area can happen if there is damage to the lymph nodes, especially if there was also a surgical removal performed. Massages and physical therapy may be necessary to mitigate pain.
Radiation in the neck region can damage the carotid artery and cause a fatal blood clot. Constant monitoring and post-treatment care should be scheduled properly so that the doctor can see if there is damage to this area that warrants intervention.
Chemotherapy involves using potent anti-cancer drugs that are administered through infusions or pills to kill cancer cells. Chemo is given in cycles, with rest periods in between, because it is highly dangerous when taken long-term. This is because chemo drugs not only cancer cells but also any fast-growing and fast-dividing cells, which may include hair and bone marrow.
Chemoradiation is the process of combining chemotherapy with radiation therapy for increased treatment potency. But while the efficacy of the treatment is increased, the potential side effects and the drain on the body are also amplified. For Mouth and throat cancers, the following drugs may be used alone or in combination, depending on the doctor's assessment:
The following side effects are common for chemotherapy:
Drug-specific side effects:
Targeted drugs are drugs that can attack specific gene changes or functions that may be helping cancer to grow and spread. For mouth and throat cancer, drugs that can target EGFR changes may be used.
Epidermal Growth Factor Receptors (EGFR) are proteins that help cancer grow and divide. For Mouth and throat cancer, the drug known as Cetuximab, which is a monoclonal antibody, is used because these cancers have higher rates of EGFR. This is administered intravenously and may be combined with radiation therapy, or even cisplatin to increase treatment efficacy.
Potential Side Effects of Cetuximab:
Immunotherapy involves the use of special drugs that can turn off the immune checkpoint proteins that prevent your immune system from attacking healthy cells and tissue. Immune checkpoint inhibitors are drugs that can target these checkpoint proteins and turn them off to allow the immune system to attack cancer more vigorously. Cancer can sometimes hide behind these checkpoint proteins so by loosening the safeties on them, your body will be able to combat cancer better.
For mouth and throat cancer, drugs called PD-1 inhibitors are used. Pembrolizumab and Nivolumab are drugs that target PD-1 which is a protein in the T-cells that prevent them from attacking other cells. Blocking these proteins boosts immune response, shrinks the cancer and slows tumor growth.
These drugs are given as an infusion and are usually the first treatments administered in cases of recurring cancer.
Side effects of PD-1 Inhibitors:
The more serious side effect to watch for is an autoimmune reaction. This may cause the immune cells to go crazy and cannibalize the healthy cells, tissue, and organs in the body. Once this happens, the patient will need immunosuppressants, usually in the form of corticosteroids. Constant monitoring after and during the treatment is necessary for you to be able to inform the doctor if this reaction develops.
If you or a loved one have suffered from a misdiagnosis or delayed diagnosis for your mouth and throat cancer or from negligence during your treatment that caused you more harm, contact us at 833-PORTER9, or e-mail us at info@porterlawteam.com to discuss the details of our experience representing other clients and the results we were able to obtain in the past for clients who are suffering as you are. In many ways, our results speak for themselves, and we will stand ready to help you and your family in your time of greatest need.
