Rehabilitation management of head and neck cancers

Author(s): Christian Custodio, MD and Sasha Knowlton MD

Originally published:09/20/2013

Last updated:04/03/2017

1. DISEASE/DISORDER:

Definition

Head and neck cancers (HNC) include cancer that arises in the nasal cavity, sinuses, oral cavity (lips, mouth, tongue, hard palate, gums) salivary glands, pharynx (nasopharynx, oropharynx including base of tongue, tonsils, soft palate and hypopharynx) or larynx.1

Epidemiology

Globally, there are over 600,000 new cases each year of head and neck cancer affecting the oral cavity, lip, nasopharynx, pharynx and larynx.2 Head and neck cancer accounts for approximately 3% of all cancers in the United States, with the most commonly diagnosed types of head and neck cancer involve the tongue, tonsils and oral cavity.3 In 2012, there were over 300,000 new cases of oral cavity cancer and over 86,000 new cases of nasopharyngeal cancer in the world.The overall incidence of head and neck cancer remained stable from 1987-1991 to 2002-2006 in the United States.3  Specifically, the incidence of cancers of the oral cavity has not changed since 2003 and the incidence for laryngeal cancers has continued to decrease.5

The incidence of head and neck cancer diagnosis increases after the age of 45.Men are more than twice as likely to be diagnosed with head and neck cancer compared to women. 3 The lifetime risk of developing oral cavity or pharyngeal cancer in the United States is approximately 1%.6

The five year survival rate improved from 52.7% in 1982-1986 to 65.9% from 2002-2006 for all types of head and neck cancer. 3 Currently, the five year survival rate for oral cavity and pharyngeal cancer in the United States is 64%.6

Risk factors and Prevention

The use of tobacco products and alcohol contribute to a significantly large proportion of head and neck cancer cases.5 Tobacco products and cigarette smoking have a known dose-response relationship contributing to the development of head and neck cancers.7 Alcohol and tobacco use have a multiplicative relationship for the development of head and neck cancer.8 Certain types of human papillomavirus (HPV), especially HPV types 16 and 18, are responsible for over 50% of oropharyngeal cancers. 5

Additional risk factors that have been identified include:

  • Premalignant lesions such as leukoplakia and erythroplakia, and possibly lichen planus9
  • Inherited conditions such as Fanconi anemia, Li-Fraumeni syndrome, ataxia telangiectasia and Bloom’s syndrome9
  • Epstein Barr virus in nasopharyngeal carcinomas10
  • Occupational exposure such as formaldehyde in nasopharyngeal carcinomas11
  • Sunlight exposure12
  • Genetics/Family history of HNC12,13
  • Low body mass index13
  • Higher number of sexual partners13
  • Use of betel quid12

There are no current screening tests for head and neck cancers that are routinely used. 5,12

Preventative methods for head and neck cancer include:

  • Diet, including increased fruit and vegetables14
  • Good oral hygiene15
  • Tobacco cessation12
  • Public and professional education12

Pathophysiology

Most HNC are pathologically identifiable as squamous cell tumors that are positive for keratin.15 These types of HNC follow a pattern of hyperplasia, dysplasia, in situ carcinoma followed by invasive cancer, and may be preceded by erythroplakia or leukoplakia.15 Variants of squamous cell HNC include verrucous carcinoma (low-grade, usually in oral cavity), basaloid carcinoma (aggressive and associated with HPV), spindle cell, adenoid and small cell.15

For nasopharyngeal cancers, there are three main types: keratinizing squamous cell carcinoma, nonkeratinizing carcinoma and lymphoepitheliod/undifferentiated carcinoma; conversely, there are a number of different histologic types of sinus and salivary gland cancers.15

Disease Presentation

There are a number of symptoms and signs associated with head and neck cancer. The presenting complaints are dependent on the location of the primary tumor. Hoarseness can suggest laryngeal cancer and dysphagia can suggest pharyngeal cancer.13 Common symptoms and signs of head and neck cancer include13:

  • Hoarseness13
  • Sore throat13
  • Stridor13
  • Dysphagia13
  • Dysphonia13
  • Neck mass13
  • Ear pain or effusion13
  • Nasal or ear congestion15
  • Oral, nonhealing ulcer13,15
  • Mouth lesion that is white or red in color13
  • Cranial nerve palsy13

The most common metastases sites are bone, lung and liver.15

Staging head and neck cancer is dependent on the type of tumor, extent of disease, and the presence of nodal or metastatic disease; the formal tumor staging of this information is based upon the combination of this information.15 The American Academy of Otolaryngology-Head and Neck Surgery published a reference guide in 2014 to stage head and neck cancer based upon unique tumor (T), nodal (N) and metastases (M) characteristics.16 Staging is important for prognostication.13

Secondary or associated conditions and complications

  • Pain
  • Lymphedema of the neck, face, or upper extremities
  • Mucositis
  • Xerostomia
  • Trismus
  • Osteoradionecrosis
  • Dysphonia
  • Dysphagia
  • Facial nerve palsy
  • Other cranial nerve palsy
  • Musculoskeletal neck and shoulder impairments, including cervical dystonia, dropped head/neck extensor weakness, shoulder dysfunction and pain, scapular winging
  • Neuromuscular impairments including myopathy, radiculopathy, plexopathy and neuropathy.
  • Fatigue
  • Radiation fibrosis

2. ESSENTIALS OF ASSESSMENT

History

A comprehensive history should be taken from an individual with head and neck cancer. An oncologic history, including date of diagnosis, type of cancer, location and extent of cancer and prior surgeries including lymph node removal should be obtained. This history should also include dates and types of chemotherapy along with the total radiation dose, fractions, location and timing of radiation. Functional and social history by a physiatrist should investigate whether impairments with speech, swallowing, pain, difficulty with mouth opening, mouth dryness, nasal stuffiness or discharge, facial swelling, or difficulty with neck or shoulder movement or activities of daily living exist. Physiatrists also need to inquire about issues regarding social isolation, vocational difficulties, home environment and individual support systems.

Physical examination

  • Comprehensive examination of the head, neck and oral cavity, including status of oral cavity/dentition, pharynx and larynx, presence of oral lesions, skin lesions, tongue mobility and strength, masseter and temporalis pain or spasticity, and lymphadenopathy17
  • Oral aperture must be measured post-treatment. Normal is ~35-40 mm.
  • Complete neurological exam, focusing on cranial nerve examination for presence of nerve palsy. The motor and sensory examination need to pay special attention to the face, shoulders and neck.
  • Neck, shoulder, upper extremity musculoskeletal exam, focusing on range of motion for flexion, extension, abduction, rotation
  • Presence of lymphedema of the upper extremities post-treatment

Functional assessment

  • Formal swallowing evaluation
  • Nutritional level and appropriateness of diet should undergo assessment
  • Psychosocial issues need to be addressed given possible disfigurement.

Laboratory studies

Initial work up of head and neck cancer should include a complete blood count and electrolyte analysis. Liver function tests and measurements of nutritional status (such as prealbumin) and thyroid function tests are important to ascertain in pre-treatment planning.17

Patients can be tested for HPV or EBV. Depending on tumor location and extension, biopsy can be performed under local anesthetic or fine needle aspiration of a suspicious lymph node.17

Imaging

Initial imaging studies should include a computed tomography (CT) of the skull base through the diaphragm.13 Magnetic resonance imaging (MRI) can be performed for oral cavity and oropharyngeal tumors and for investigation tumor extension through the laryngeal cartilage.13 Direct visualization of the pharynx and larynx can be achieved with direct laryngoscopy followed by fiberoptic/rigid telescope examination.17

Under the direction of an oncologist, additional imaging studies such as positron emission tomography (PET) scans can be performed for staging.13 Imaging for biopsy with ultrasound or a tracer can also be used when necessary.13

Supplemental assessment tools

Objective measures to assess swallowing can be used in dysphagia or odynophagia, such as fiberoptic endoscopic evaluation of swallowing (FEES) or videofluroscopic swallow study (VFSS). In certain circumstances electrodiagnostic studies, including nerve conduction studies and needle electromyography can be used to evaluate for spinal accessory nerve or facial nerve impairment and recovery prognosis.

Early predictions of outcomes

Anatomically, the head and neck region consists of several distinct structures and tumor sites. The goal of treating HNC is to maximize disease control, improve survival and limit functional impairment.15 Surgery aims to resect tumor with negative margins while radiation doses can be > 70 Gy to the primary tumor and in lesser amounts after surgery or to other nodal regions.15 Surgery, radiation and chemotherapy, while intended to provide adequate and successful disease control, can result in a number of side effects which will be discussed later.15

Survival is clearly dependent on initial staging of the disease along with primary tumor site and histology. Earlier tumor stages (stage I and II) are associated with better survival in general.15 HPV positive cancers tend to have a better prognosis.18

Social role and social support system

Most large head and neck oncology programs are associated with support groups. A newly diagnosed head and neck cancer patient will likely benefit from the ability to meet with other patients who have undergone similar treatment programs.

Like most patients with a diagnosis of cancer, head and neck cancer patients undergo a variety of emotions and physical challenges. Surgery, radiation and chemotherapy cause fatigue and additional impairments, including those of cosmesis. During and after treatment, adjustments in societal and familial roles may occur.

After treatment completion of head and neck cancer, the return to work rate is 61.9% of those employed at the time of diagnosis.19  Fatigue was listed as the most frequent reason to not return to work; however, of those who discontinued work after treatment, 40.7% returned to work within one year of treatment.19

Professional Issues

Physiatrists should counsel and educate the patient and family about the disease, its treatment and expected impairments. Advanced directives may need to be discussed depending on prognosis.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Impairment and Treatment Overview

The aim of treatment for HNC is to maximize locoregional control and survival while minimizing functional and cosmetic alteration.15 Surgery and radiation therapy aim to provide curative control while chemotherapy is used as a combined modality treatment.15

The goal of rehabilitation is to reduce the different impairments, which may include:

  • Pain: There is a high prevalence of pain in head and neck cancer patients before and after surgery, radiation and chemotherapy20
  • Difficulty chewing21
  • Dysphagia: Difficulty swallowing can occur pre-treatment or post-treatment with surgery, radiation and chemotherapy, resulting in aspiration, silent aspiration or poor nutritional status; one study demonstrated a prevalence of 59%21-22
  • Xerostomia: There is a high prevalence after chemotherapy, radiation and surgery resulting in sticky saliva and dysphagia21
  • Mucositis21
  • Impaired dentition21
  • Decreased sense of taste21
  • Trismus: Reduced mouth opening impairs oral hygiene and speech, nutrition, and other aspects of swallowing. Treatment approaches include jaw stretching in therapy, exercises, or with devices.23-24  Devices such as TheraBite orDynasplint can also increase mouth opening to various degrees.25-26
  • Loss of voice: Commonly seen post-surgically; in one study, 52% of patients were affected21-22
  • Lymphedema: Increased head, facial and extremity swelling occurs as a result of damage to the lymphatic system during treatment; can treat with manual drainage, massage and bandaging and compression garments.23
  • Speech dysfunction
  • Chemotherapy-induced peripheral neuropathy23
  • Neck and shoulder dysfunction: Radical neck dissection can involve multiple structures including the sternocleidomastoid, spinal accessory nerve, jugular veins, and anterior and posterior triangle lymphatic groups23  Neck and shoulder weakness and stiffness can be improved with physical therapy to lengthen muscles, improve range of motion and strength and reduce pain.23
  • Difficulty with ADLs: 30% of patients in one study required assistance with “every day functioning”22, which can be treated with occupational therapy.

Quality of Life and Functional Assessments

There are a number of HNC-related quality of life questionnaires, and no gold standard questionnaire exists; for example, there are 19 questionnaires that address functional status and well-being while 11 questionnaires assessed the treatment-related effects of surgery, chemotherapy and radiation.27 

As a result, a recent systematic review recommended that researchers consider the psychometric and study design/objectives when selecting the desired quality of life questionnaire for the head and neck cancer population.27

Coordination of care

A multi-disciplinary team should manage each patient individually. Team members should include medical, surgical and radiation oncologists, cancer physiatrists, physical and occupational therapists, speech language pathologists, dentists, social workers, psychologists, and other specialists as necessary.

Patient & family education

Patients should be counseled to quit tobacco and alcohol use. Patients and family members should also be educated about the need for follow up, possible impairments, and the rehabilitative strategies available to them for treatment.

Support groups can be valuable for peer to peer education and support.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Monitored exercise is beneficial in the treatment of cancer-related fatigue and should be recommended to HNC patients. Preoperative assessments of nutritional and functional status are beneficial in reducing postoperative debility. Preoperative assessment of cervical, oral and shoulder range of motion and education on exercises can help mitigate postoperative impairments.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Constant changes in the approach to cancer patients using targeted-based therapy will impact the impairments seen in the head and neck cancer population and will require adjustments to managing these patients. Minimally invasive surgeries as well as improved radiation strategies will hopefully reduce the numbers of impairments in the HNC population.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

Preventative methods to reduce impairments resulting from treatments, including surgery, chemotherapy and radiation, require further research.

REFERENCES

  1. Head and Neck Cancer; National Cancer Institute; http://www.cancer.gov/cancertopics/types/head-and-neck; Accessed date January 24, 2013
  2. Ferlay J, Shin HR et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. IJC. 2010. 27(12):2893-2917.
  3. Pulte D and H Brenner. Changes in Survival in Head and Neck Cancers in the Late 20th and Early 21st Century: A Period Analysis. The Oncologist. 15:994-1001.
  4. Torre LA, Bray F, et al. Global cancer statistics, 2012.CA: A Cancer Journal for Clinicians. 65(2): 87-108.
  5. National Cancer Institute: A Snapshot of Head and Neck Cancer. http://www.cancer.gov/research/progress/snapshots/head-and-neck. Accessed August 30, 2016.
  6. NIH/National Cancer Institute Surveillance, Epidemiology, and End Results Program (SEER) Stat Fact Sheets: Oral Cavity and Pharynx Cancer. http://seer.cancer.gov/statfacts/html/oralcav.html.   Accessed August 30, 2016.
  7. Hashibe M, Brennan P, et al. Alcohol Drinking in Never Users of Tobacco, Cigarette Smoking in Never Drinkers, and the Risk of Head and Neck Cancer: Pooled Analysis I nthe International Head and Neck Cancer Epidemiology Consortium. J Natl Cancer Inst. 2007. 99:777-789.
  8. Hashibe M, Brennan P, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the INHANCE consortium. Cancer Epidemiol Biomarkers Prev. 18(2):541-550.
  9. Shaw R and N Beasley. Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology. 2016. 130 (Suppl S2): S9-S12.
  10. Tobias JS. Cancer of the head and neck. BMJ. 1994; 308: 961-966.
  11. Vaughan TL, Stewart PA, et al. Occupational exposure to formaldehyde and wood dust and nasopharyngeal carcinoma. Occup Environ Med. 57(6):376-384.
  12. Day TA, Chi A, Neville B, Hebert JR. Prevention of Head and Neck Cancer. Current Oncology Reports. 7(2):145-153.
  13. Mehanna H et al. Head and neck cancer- Part 1: Epidemiology, presentation and prevention. Clinical Review. 2010:341:c4684.
  14. Freedman ND, Park Y, et al. Fruit and vegetable intake and head and neck cancer risk in a large United States prospective cohort study. Int J Cancer. 122(10):2330-2336.
  15. Locati L, Lim SH, Patel S, Pfister DG. Evaluation and treatment of head and neck cancer. In: Stubblefield MD, O’Dell MW, eds. Cancer Rehabilitation Principles and Practice. New York, NY: Demos; 2009:291-301.
  16. Deschler DG, Moore MG, Smith RV, eds. Quick Reference Guide to TNM Staging of Head and Neck Cancer and Neck Dissection Classification, 4th ed. Alexandria, VA: American Academy of Otolaryngology–Head and Neck Surgery Foundation, 2014.
  17. Hamoir M, Vander Poorten V et al. Initial work-up in head and neck squamous cell carcinoma. B-ENT. 2005. 1 Suppl.:129-132.
  18. Mehanna H, West CML et al. Head and neck cancer – Part 2: Treatment and prognostic fators. 2010:341: c4690.
  19. Buckwalter AE, Karnell LH et al. Patient-reported factors associated with discontinuing employment following head and neck cancer treatment. Arch Otolaryngol Head Neck Surg. 133(5):464-470.
  20. Macfarlane TV, Wirth T et al. Head and Neck Cancer Pain: Systematic Review of Prevalence and Associated Factors. 2012. J Oral Maxillofac Res. 3(1): el
  21. List MA and SP Bilir. Functional Outcomes in Head and Neck Cancer. Seminars in Radiation Oncology. 14(2):178-189.
  22. Lokker ME, Offerman MPJ, et al. Symptoms of patients with incurable head and neck cancer: Prevalence and impact on daily functioning. Head Neck. 35:868-876.
  23. Guru K, Manoor UK, and SS Supe. A Comprehensive Review of Head and Neck Cancer Rehabilitation: Physical Therapy Perspectives. Indian J Palliat Care. 18(2):87-97.
  24. Pauli N, Fagerberg-Mohlin B et al. Exercise intervention for the treatment of trismus in head and neck cancer. Acta Oncologica. 53(4): 502-509.
  25. Kamstra JI, Roodenburg JLN et al. TheraBite exercises to treat trismus secondary to head and neck cancer. Supportive care in cancer. 21(4):951-957.
  26. Barañano BF, Rosenthal EL, et al. Dynasplint for the management of trismus after treating upper aerodigestive tract cancer: A retrospective study. Ear, Nose & Throat Journal. 90(12): 584-590.
  27. Ojo B, Genden EM et al. A Systematic Review of Head and Neck Quality of Life Assessment Instruments. Oral Oncol. 48(10):923-937.

Original Version of the Topic

Nandita S. Keole, MD. Rehabilitation management of head and neck cancers. 09/20/2013.

Author Disclosure

Christian Custodio, MD
Nothing to Disclose

Sasha Knowlton MD
ACRM Cancer Rehabilitation Networking Group: Communications officer.

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