Introduction

Head and neck cancer covers diverse malignancies affecting areas in the head and neck, like the oral cavity, larynx, nasal cavity, sinuses, and salivary glands. These cancers significantly impact patients' quality of life as they affect breathing, speech, swallowing, and appearance. In the UK alone, head and neck cancers amount to 3% of cancer cases, with around 12,000 diagnosed annually. Early detection and a multidisciplinary treatment approach are crucial for improving survival rates and patient outcomes. Localised tumours detected early significantly improve survival rates compared to advanced-stage cancers. Managing head and neck cancer is multidisciplinary, involving oncologists, surgeons, radiologists, speech therapists, nutritionists, and mental health professionals to aid and support patient recovery. This collaboration ensures comprehensive care, addressing not only the disease but also the psychological and physical consequences of the treatment.¹ 

Types of head and neck cancers

Head and neck cancer is categorised by the location in the body, each presenting different challenges in prognosis and treatment.²

Oral cavity cancer includes cancer of the tongue, gums, lining of the inner cheeks, and the bottom of the mouth. Oral cancers are generally linked to the use of tobacco, heavy alcohol consumption, and human papillomavirus infections (HPV). 

Pharyngeal cancer is located in the pharynx and is divided into three regions: the nasopharynx, oropharynx, and hypopharynx.

Nasopharyngeal, located in the upper part behind the nose, Epstein-Barr virus contributes to the risk of developing nasopharyngeal cancer.³

The oropharynx, located in the part of the pharynx that includes the tonsils and base of the tongue, is strongly linked to HPV.

The hypopharynx, the lower part of the pharynx. This type of cancer is harder to diagnose in early stages due to its subtle symptoms early on, and is typically diagnosed in the later stages. 

Laryngeal cancer affects the voice box; symptoms are persistent hoarseness, difficulty breathing and painful swallowing. Early stages of laryngeal cancer have high recovery rates with speech therapy and voice-preserving treatments.

Nasal cavity and paranasal sinus cancer is a rare type that occurs in air-filled spaces around the nasal cavity. It develops in the lining of these cavities, and its symptoms can be mistaken for chronic sinusitis, leading to a delayed diagnosis. 

Salivary gland cancer can develop in the major glands, the parotid, submandibular, or sublingual regions, or in the minor salivary glands. These tumours are variable in behaviour and can be slow-growing or aggressive, or fast-growing.²

Key risk factors and prevention strategies

Understanding the risk factors for head and neck cancer is crucial for prevention and early detection.

Primary risk factors:

Tobacco: The use of tobacco from smoking cigarettes, cigars, or shisha pipes, or the use of non-smoking tobacco like chewing tobacco and tobacco pouches like snus, significantly increases the risk. Exposure harms the mucosal membrane in the mouth, throat, and larynx. These substances damage DNA, leading to mutations and uncontrolled growth. With the rise of smokeless tobacco variations such as snus or snuff, these have direct contact with the oral cavity and deliver higher doses of nicotine and carcinogens directly to the oral cavity.⁴

Alcohol consumption: Heavy drinking is a major risk factor, especially when combined with tobacco use. These two synergistically increase the likelihood of head and neck cancer. Ethanol, the main ingredient in alcohol, can alter DNA, causing damage, interfering with its cell repair mechanism, and impairing the immune function. This is due to the alcohol being metabolised in the body and turning into acetaldehyde. Excessive alcohol consumption irritates the lining of the mucosa, making the lining more sensitive to absorbing carcinogens. Using both alcohol and tobacco accelerates cancer development and leads to more aggressive tumour behaviour. 

HPV, particularly the HPV16 strain, is a leading cause of oropharyngeal cancers, more evident in the younger and non-smoking population. This virus promotes cancer development by integrating its DNA into host cells. This leads to the mutated cells producing oncoproteins, which cause cancer by disabling tumour suppressor genes such as P53.⁵

Prevention methods:

• HPV vaccination: The Gardasil 9 vaccination is highly effective in preventing HPV-related head and neck cancers, specifically oropharyngeal cancer. It is recommended for adolescents aged 11-12 to have the vaccine before the risk of potential exposure, with booster vaccines available up to the age of 26 and consideration for adults up to the age of 45 at higher risk. The vaccine is nearly 90% effective in preventing HPV-related cancers, like cervical, anal, and genital
• Tobacco use cessation: Stopping the use of tobacco is the leading preventable cause of head and neck cancer. Effectively discontinuing the use of tobacco products includes nicotine replacement therapies, like using patches or gum, prescription medication, like varenicline and bupropion, and behavioural support through counselling. Identifying and avoiding triggers, like stress, can help improve the success rate of this 
• Alcohol moderation: UK guidelines recommend limiting alcohol intake to 14 units weekly, equivalent to approximately 6 pints of beer, spread over three or more days. Practical methods to reduce alcohol consumption are alternative alcohol-free or low-percentage beverages and setting limits. High-risk individuals should be much stricter with this. Monitoring consumption through online apps and seeking medical support for problematic drinking can significantly lower the risk of head and neck cancer 
• Maintaining oral health: Essential prevention methods include daily brushing and flossing to remove plaque buildup and potential carcinogenic bacteria, and 6-month dental visits. A dentist can identify precancerous lesions during routine check-ups and physical examinations; biopsies can be performed when needed⁶

Symptoms and diagnostic procedures

Common signs are:

• A persistent sore throat which does not go away with the usual treatment of drugs 
• A change in voice, typically becoming more hoarse, lasting longer than two weeks
• Dysphagia, difficulty swallowing, or a feeling of something being stuck in your throat
• Unexplained weight loss
• Mouth ulcers which are not healing and are recurrent
• Lumps in the neck, which can indicate lymph node metastasis, indicate the stage of cancer⁷

Diagnosis:

• Clinical head and neck examinations are carried out, which include a laryngoscopy (a camera tube inserted through the mouth into the larynx) or nasendoscopy (a camera inserted through the nose) 
• Imaging techniques, like CT/MRI scans, assess tumour size and spread; PET-CT detects distant metastases to determine how far the cancer has spread
• Biopsies: Tissue samples are taken for histopathology, a staining technique used to confirm whether cancer is present 
• HPV testing is more common for oropharyngeal tumours. P16 immunohistochemistry detects a protein linked to HPV, which is flagged by P16, while HPV-DNA testing looks for the virus’s genetic code. These tests are performed to improve treatment outcomes 

Emerging therapies

Radiation therapy is often the first-line treatment. It involves high-energy beams precisely targeting the cancer cells whilst protecting surrounding healthy tissue. Before undergoing this therapy, patients undergo a process where a custom plastic mask is created, which holds the head and neck in the same position during therapy for each session. There are two main types: a standard external beam radiation and an IMRT, which shapes the radiation beams to match the structure of the tumour, which helps reduce the side effects.⁸

Chemotherapy frequently complements radiation, especially for more advanced stages of cancer. The most common chemotherapy drugs are cisplatin, carboplatin, and 5-FU, which work in the body by destroying fast-growing cancer cells. Despite effectiveness, these treatments may cause temporary yet manageable side effects like nausea, fatigue, and increased infection risk. Immunotherapy, namely pembrolizumab and nivolumab, boosts the immune response against cancer cells, allowing your body’s immune system to recognise and attack recurrent cancer cells and metastasis.^9,10 

For certain patients, targeted therapy with drugs such as cetuximab offers a more precise approach compared to chemotherapy, which affects all rapidly dividing cells.. It works by blocking epithelial growth factor, which fuels tumour growth. This therapy works well with radiotherapy to maximise treatment and minimise side effects.¹¹

Summary

Head and neck cancers affect areas like the mouth, throat, and voice box, significantly impacting speech, swallowing, and breathing. In the UK, these cancers account for 3% of cases annually, with early detection crucial for a better prognosis. Major types of this cancer are linked to lifestyle and environmental factors such as smoking and excessive alcohol consumption, and also HPV. Treatment combines radiation (using custom masks for precision), chemotherapy (cisplatin), immunotherapy (pembrolizumab), and targeted therapy (cetuximab). A multidisciplinary approach addresses both physical and emotional needs, with recent advances improving survival rates and quality of life. Lifestyle changes and regular check-ups remain vital for prevention and early detection.