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VOL. 5 • NO. 4
© February 2011
Head and neck
CANCER
Though the combination of smoking tobacco and drinking alcohol accounts for nearly three-fourths of all cases, race and gender remain factors Head and neck cancer is typically defined as cancers that occur in a slew of sites — the nasal cavity, the oral cavity, throat and larynx (voice box). It is often referred to as oral cancer. Susan L. Curry stands Of all the cancers, none are as least in front of the commupublicized as cancer of the head and neck. But nity center that bears her if left unchecked, it is just as deadly. name. Curry underwent The American Cancer Society (ACS) minimally invasive surgery estimated that in 2010 there were almost to treat her head and neck 37,000 new cases of cancers of the oral cavity and 8,000 deaths. If cancer of the larynx is cancer four years ago at included, the incidence jumps to 50,000 and Boston Medical Center. more than 11,000 deaths. (Ernesto Arroyo photo) The list of luminaries who are victims of head and neck cancer is long — Sammy Davis Jr., Yul Brynner, movie critic Roger Ebert, Beatle George Harrison and singer Mary Wells. Actor Michael Douglas has recently been added to the list. o her credit, Susan Curry didn’t scream when Gender and race matter. Head and neck she learned she had cancer. cancer is twice as common in men as in women. According to She became very quiet, almost bewildered, the ACS, oral cancers are the eighth most common cancer in all as the doctor described how the disease had men and the sixth most common in black men. Although the invaded her gums, the roof of her mouth and sinuses. It even crept incidence is comparable in black and white men, the death rates into the base of her skull where countless delicate nerves and tell a different story. Black men die of oral cancer at roughly blood vessels travel to the brain. twice the rate of whites, American Indians and Asians and On one level, Curry said she couldn’t help respecting what almost three times the rate of Hispanics. her doctor described as cancer of the head and neck. “Wow!” So significant is the problem in black males that the National Curry recalled thinking to herself. “That bad boy goes anywhere.” Institute of Dental and Craniofacial Research, an arm of the But on a deeper level, she admits that she was confused. “I National Institutes of Health, has developed a campaign — Oral had no idea that you could get cancer of the mouth,” she said. Cancer: What African American Men Need to Know — to
T
increase awareness. Dr. Scharukh Jalisi is the director of the Division of Head and Neck Surgery and Skull Base Surgery at Boston Medical Center. He attributes the gender differences in part to lifestyles. “Men smoke more,” he said, “and indulge in worse habits.” Age is also a factor. The median age at diagnosis is 62; the median age at death is 67 years. The tricky thing about head and neck cancer is that symptoms may occur but are not readily recognized. And there are many, according to the Head and Neck Cancer Alliance — sores in the mouth that do not heal; difficulty swallowing or chewing; prolonged hoarseness or other change in the voice; unusual white or red patches in the mouth and bleeding in the mouth, to name a few. Jalisi stresses to be aware of the symptoms and do a simple self-check. “Feel your neck for lumps,” he says. “Look in your mouth for sores or spots that should not be there. Be alert for pain on swallowing, especially if you’re not sick.” Jalisi cautions if these symptoms do not resolve within a few weeks, they require medical attention. The key is not to delay treatment. “The earlier you detect cancer,” he says, “the less invasive the treatment and the better the outcome.” If caught early, survival and cure rates are high. When localized — meaning it has not spread — 5-year survival rates exceed 82 percent. Once it spreads to the lungs or other sites, survival drops to 32 percent. Tobacco of all kinds — including cigarettes, cigars, pipes and smokeless tobacco — is the biggest risk factor for head and neck cancer. The longer a person smokes, the higher the risk. And it’s not necessary to light up. Contrary to an oft-repeated myth, smokeless tobacco is not safer than cigarettes or cigars, Curry, continued to page 4
Incidence rates by race 15.7
A funny thing happened after Goins’ surgery. She was not able to speak, but that didn’t stop her from communicating. Her daughter walked into her hospital room with a chalk board. “From day one I was ‘talking,’ ” she said. “After that I carried a notebook with me.” It was a year before Goins could talk again Goins, continued to page 4
16.1
10.5 9.6 8.7
Hispanic American Indian
Willia Goins, right, shown with her daughter, Tracy, says that with the help of a prosthesis, she is able to speak after the removal of her larynx due to cancer. (Daryl Goins photo)
DISPARITIES
Although the incidence rates of oral cancer are comparable in black and white men, the death rates are more than 70 percent higher in blacks than whites.
Rates are per 100,000 men per year 2003 to 2007
Willia Goins, 70, now speaks in a whisper. She had her larynx, or voice box, removed about 14 years ago, and the whisper is as loud as it gets. Goins might speak quietly, but her message comes through loud and clear. “I always had problems with my throat,” she explained. “Even when I was young.” Back then she said she paid no attention to the intermittent pain she had when swallowing and attributed it to the cold weather or perhaps a cold. But as she grew older, the pain continued and got worse with time. Goins finally gave in and visited a doctor. “Something is terribly wrong,” she told her physician. She underwent weeks of testing until the diagnosis was confirmed. “It [cancer] was in my throat,” she said. The doctors warned her that it was possible that her larynx might have to be removed if her throat cancer was extensive. When her initial treatment of chemotherapy failed to solve the problem, she welcomed the surgery. She was 56 at the time. “Maybe I’ve talked enough,” she said. Treatment for oral cancer varies by its location and extent, according to Dr. Scharukh Jalisi, the director of the Division of Head and Neck Surgery and Skull Base Surgery at Boston Medical Center, and may include surgery, radiation and in some cases, chemotherapy. A diverse team of professionals is involved, including oncologists (cancer specialists), dentists, reconstructive surgeons and speech therapists. The team is extensive because of the potential losses suffered from oral cancer. The disease can compromise the ability to speak, swallow and eat, and result in irreversible damage to the area impacted.
DISTURBING
Rates are per 100,000 men per year 2003 to 2007
EFFECTIVE TREATMENTS REQUIRE EARLY DIAGNOSIS
Asian
Whites
Black
6.3
Death rates by race 3.1
3.5
3.7
2.5
Hispanic
Asian
American Indian
Whites
Black
Source: Surveillance Epidemiology and End Results Program National Cancer Institute
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US S ON N What is head and neck cancer? Cancer cells have glitches that keep them alive long past their normal lifespan. The rogue cells multiply again and again, snowballing into a tumor. Over time, they invade nearby tissue, crowding out normal cells. Some may travel to distant sites in the body and spark additional tumors. Usually, the first flickers of trouble for head and neck cancers start in the moist tissue cells lining the mouth, nose and throat.
What causes head and neck cancers? Tobacco and heavy alcohol use are the two key risks for most head and neck cancers, according to the National Cancer Institute. A whopping 85 percent of these cancers are linked to tobacco — cigarettes, cigars, pipe tobacco and smokeless tobaccos like chewing tobacco and snuff. What’s more, using both tobacco and alcohol puts you at greater risk than either of these habits alone. Depending on where the cancer occurs, other risks vary. A few examples are sun exposure (lip cancer), radiation to the head and neck (cancer of the sinuses or nasal cavity) and asbestos (cancer of the voice box). Chewing betel nut — a big health issue in some Asian cultures — causes oral cancer.
What can I do to avoid getting these cancers? The short answer is simple. If you use tobacco, quit. If you drink too much, put a stop to that too. However, as many people know, this advice is easy to give and often much harder to follow. “Tobacco and alcohol can be powerful addictions,” says
Dr. Jan Cook, Medical Director of Innovation & Leadership at Blue Cross Blue Shield of Massachusetts. “Willpower alone is rarely enough to end them. Usually a combination of approaches works best.”
TIPS AND RESOURCES Quitting tobacco • Make a list of great reasons to quit. Smoking is not only unhealthy for you, but second-hand smoke can also ruin the health of those around you — your children, spouse and friends will thank you for quitting. Fewer wrinkles and sweeter breath are also plusses, as are the financial benefits. Calculate your savings at www.smokefree.gov/savings-future.aspx and map out ways to enjoy that cash. • Identify triggers — do you light up after meals or when you’re bored? Think ahead about ways to avoid or squelch those cravings. • Talk to your doctor about tools to help you quit like nicotine replacement products (nicotine patches, gum, lozenges, inhaler or spray) and medicines that help ease cravings. • See if your employer sponsors a free or low-fee program to help you quit. Your health plan may be a great resource as well. • The National Cancer Institute Quit Line or Smokefree. gov can also be helpful. They offer a step-by-step approach to thinking about quitting, preparing to quit, quitting — and staying quit. • Ask family, friends and co-workers to support your efforts by cheering you on, sharing hard-earned tips if they’ve quit and not smoking around you. Joining an online or in-person support group helps, too.
Quitting drinking • Start by asking questions: How much and how often do you drink? The American Cancer Society defines low to moderate use of alcohol as one to two drinks a day for a man or one drink a day for a woman. Has your drinking been harmful in any way? For instance, has it jeopardized your health or your job? Talk to your doctor or check online for quizzes to help you assess your drinking habits and get information on cutting back or stopping. • Consider joining a self-help group. Best known is Alcoholics Anonymous (AA), which outlines a 12-step program for its members to follow and offers plenty of support. An alternative is SMART Recovery (Self-Management and Recovery Training), a nonprofit, non-spiritual group focusing on a range of addictive behaviors. Family members may find Al-Anon or Alateen helpful. • Seek counseling from a substance abuse professional if you cannot stop drinking or need additional support. • Ask your doctor if medicines might help. Medication can often help ease withdrawal symptoms, block the high from alcohol, defuse cravings or relieve depression or anxiety. • Heavy drinkers require a specialized, intensive program, including detoxing to get alcohol out of the body. Be sure to consult your doctor.
KEEPING CHILDREN ON A SAFE PATH Wondering how to keep children from starting to drink or smoke? Start young — preferably before your child experiments with either one — to build a sturdy foundation. • Talk to a school guidance counselor or your child’s doctor about free, helpful programs for parents on guiding healthy behaviors. • Brainstorm with your child about ways to say no to risky behavior. Aim for a full scale of options between “No, thanks” and “Stop asking — I said no.” • Discuss good reasons not to drink or smoke. Ask children what they think and share your beliefs and values. Talk honestly about relatives who had health problems or died due to tobacco or alcohol addictions. Problems like bad breath, yellow teeth and embarrassing behavior may be persuasive, too. • Set expectations for healthy behaviors. Use simple rewards and consequences to encourage good behavior. • Set an example. If necessary, try to quit smoking or drinking too much. • Keep lines of communication open. Check in regularly about how the day went. Ask about plans, friends and activities. • Call your child’s doctor or guidance counselor for more help if you think your child is smoking or drinking.
Helpful Resources: • Questions about cancer: 1-800-4-CANCER (1-800422-6237) or online chat or quit line at http://www.cancer. gov/cancertopics/smoking • Quitting tobacco: Call the National Cancer Institute Quit Line at 1-877-448-7848. Or go online at www.smokefree. gov or Blue Cross Blue Shield of Massachusetts website , A Healthy Me at www.ahealthyme.com • Quitting alcohol: Call the Substance Abuse and Mental Health Services Administration for treatment referrals and publications at 1-877-726-4727. Or go online at http://rethink ingdrinking.niaa.nih.gov or the Blue Cross Blue Shield of Massachusetts website, A Healthy Me at www.ahealthyme.com
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Questions & Answers 1. Is head and neck cancer preventable? The answer to this is more complicated than yes or no. We know that there are things which significantly increase the risk of some head and neck cancers, such as tobacco and alcohol use, which account Anand K. Devaiah, M.D., F.A.C.S. for the majority of people Associate Professor struck with this disease. Departments of Otolaryngology - Head and Exposure to occupational Neck Surgery and Neurological Surgery inhalants such as asbestos Boston Medical Center is also a known source. Yet, many cancers of the head and neck are not associated with any known risk factor. That is why it is important to understand the signs and symptoms so that the cancer can be detected early when treatment is more successful. 2. Why does alcohol increase the risk of head and neck cancer? Alcohol causes changes in the function of cells which in turn spur uncontrolled growth and the development of cancer. It can have harmful effects on its own or act synergistically with other cancer-causing agents, most notably tobacco. Alcohol and tobacco are a very dangerous combination and account for roughly 85 percent of the cases of head and neck cancer. 3. Since human papillomavirus (HPV) is a contributing factor for oral cancer, should males as well as females be vaccinated against the virus? We do know that there is a link between HPV and oral cancer and that giving the vaccine to males poses no significant risk of adverse reactions. It seems logical that there is potential benefit to immunizing both genders. This question is under study as researchers determine whether we end up losing more by not immunizing versus immunizing. 4. Does HPV increase the risk of oral cancer in both males and females? At this time, there appears to be increased risk for both men and women, specifically with HPV16.
A closer look Head and neck cancer – although not well known – strikes around 40,000 people each year. Head and neck cancer actually refers to cancers at several different sites: • Lips • Gums • Tongue • Lining of the cheeks • Salivary glands • Roof and floor of the mouth
• Lymph nodes in upper neck • Tonsils • Sinuses • Pharynx (throat) • Nasal cavity • Larynx (voice box)
Image: National Cancer Institute
Signs and symptoms
The following symptoms do not always indicate cancer; an infection or other problem can cause similar warning signs. If they persist, however — more than two weeks — have them checked out.
• Sore throat • Difficulty or pain when swallowing or chewing • Prolonged changes in your voice, such as hoarseness • Ear pain or an earache that does not go away • A sore in your mouth or on your lip that does not heal
• Unusual white or red patches inside your mouth or on your lips • Swelling in the neck or jaw • A lump in the neck • Dentures that no longer fit properly or comfortably • Bleeding in the mouth • A feeling that something is caught in your throat
5. Since snuff or chew is not smoked, is it less likely to cause cancer of the mouth? There is a misperception that smokeless tobacco is safer than cigarettes or cigars. However, smokeless tobacco also contains cancer causing agents and is associated with many cancers of the mouth, including the lip and tongue. It is still harmful and should be avoided. 6. Can some head and neck cancers be found early when survival is higher? Through regular oral exams by a doctor or dentist, it may be possible to find a head and neck cancer when it is smaller in size and before it spreads. When found early the chance for a cure is generally higher. It underscores the importance of early detection and treatment. 7. Should people check their mouths regularly for signs of oral cancer? Yes. Like in other cancers, self-examination is important. Check yourself for areas in your mouth that are painful, swollen or bleeding or for sores that do not heal. These symptoms are not always cancer, but should be evaluated by one’s health care provider to help determine if further investigation into the possibility of cancer is necessary. 8. Why is this type of cancer more fatal in African American males? Many factors can contribute to higher deaths, including — but not limited to — genetics, access to health care and use of available health care resources. It is believed that African American males also present at a more advanced extent of cancer, which makes this more fatal to them. 9. Does a person’s diet play a role in oral cancer development? There have been studies that suggest that a healthy diet may help reduce the risk of developing head and neck cancer, including fruits and vegetables and low-fat foods. Avoiding known cancer causing substances, such as tobacco and alcohol, can also reduce the risk.
Risk • Tobacco use • Heavy alcohol use • Combined tobacco and alcohol use • HPV infection
factors • Sun (cancer of the lip) • Exposure to chemicals, such as asbestos • Poor diet — lacking in fruits and vegetables
The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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Curry, continued from page 1 and has been found to contain 28 or more chemicals that cause cancer. Curry admitted that she smoked for several years a long time ago, but her youngest son, who is now in his 30s, cured her of the habit. When he was just 3 years old, he asked her why she smoked. She didn’t have an answer and said she stopped almost immediately. It’s not surprising then that Curry, 76, had more questions that answers. “Where did it come from?” she wondered. “How could that happen?” It started four years ago with an irritation
Scharukh Jalisi, M.D., F.A.C.S. Director Head and Neck Oncologic Surgery and Skull Base Surgery Boston Medical Center
on her gums on the upper right side. “Something was there that shouldn’t have been,” she remembered. She had difficulty wearing her dentures. It got to the point that she said she felt better without them. Her home treatments of baking soda did not work. Nor did adjustment and realigning of her dentures by the dentist. What Curry did not know at the time is that dentures that no longer fit properly or comfortably can be a sign of head and neck cancer. Curry was planning to attend a family reunion and wanted to be able to eat the good food she knew would be plentiful. When she visited the doctor before her affair she received unexpected news. A biopsy revealed that the gum irritation was actually an intrusive cancer. “The gums were the tip of the iceberg,” said Jalisi, her surgeon. Curry underwent surgery and radiation. She says she counts her blessings. Because of the extent of her cancer she was expecting a debilitating and deforming surgery. She was in for a surprise.
She underwent minimally invasive skull base surgery, a less intrusive type of surgery, and when she awoke, she had no scars as proof of treatment. “There wasn’t a scratch,” she said. Jalisi says much has changed in the last decade in the treatment of head and neck cancer — fortunately for the better. Years ago, he explains, the treatment was often disfiguring. But different approaches, including use of robotic surgery — a type of minimally invasive surgery — have improved the outcomes. Although the hazards of tobacco use are well known, it is less well known that alcohol also is linked to cancers of the mouth, throat and larynx. Ethanol, the type of alcohol found in beer, wine and distilled spirits, such as scotch, is the guilty party here, so the type of alcoholic beverage is not the problem. Experts theorize that alcohol acts as an irritant in the mouth and throat and may even act as a solvent, paving the way for tobacco to damage cells. Tobacco or alcohol by itself is damaging enough, but the combination of the two packs a double wallop and has more dire effects than either drinking or smoking alone, according to the ACS. Three out of four people with oral cancer have used tobacco, alcohol or both. But the face of oral cancer is changing a bit. It is still more common in males, but younger men are now stricken in higher numbers — and not necessarily because of tobacco or alcohol. Another culprit has emerged — the human papillomavirus, or HPV, the virus responsible for genital warts and cervical cancer. Recent studies suggest that multiple sex partners and especially oral sex may increase the risk of cancers of the tongue, tonsils and throat. A 2007 report in the New England Journal of Medicine found that men and women who reported having six or more oral sex partners had an almost nine fold increased risk of developing cancer of the tongue and tonsils. Jalisi cautions that more research is required to understand fully the connection between oral cancer and HPV. As far as Curry is concerned she may never fully understand all of oral cancer’s complexities. What she does know is that her life has returned to almost normal. She does have dry mouth following her surgery and radiation, and must use a special toothpaste and mouthwash. Cold wind hurts her face. She now wears dentures that are built up on the right side to take the place of gum tissue that was removed. But other than that she says life is good. She remains very involved in her community. And her nine children and 10 grandchildren keep her hopping. “God wasn’t ready for me,” she said.
Photo by Vannessa Carrington/Mass. Eye and Ear
Oral, Head and Neck Cancer Awareness Week is May 8 – 14.
Get screened for head and neck cancer. It’s free, quick and painless. Boston Medical Center
Tufts Medical Center
Mass Eye and Ear
Moakley Building Lobby 830 Harrison Avenue Date: April 2 Time: 8 a.m. - noon 617-638-8265
860 Washington Street Date: May 12 Time: 2:30 – 4:30 p.m.
243 Charles Street Date: May 13 Time: TBA 617-573-3340
Dedham Family Dental Dr. Helaine Smith 30 Milton Street, Dedham Date: May 11 Time: 9 a.m. – 1 p.m. 781-326-4600
617-636-1664
Mass General Hospital Voice Center One Bowdoin Square, 11th Floor Date: May 13 Time: 9 a.m. – 1 p.m. 617-726-0218
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Remember to call ahead to confirm time and date of screenings.
ANOTHER GOOD REASON TO VISIT THE DENTIST
“All you have to do is open your mouth.” — The Head and Neck Cancer Alliance
The oral cancer examination is painless and quick … and life-saving. When cancers of the head and neck are found early, the cure rate is high. Annual screenings by a doctor or dentist should be a part of your regular physical or dental checkup. The provider: • Inspects your face, neck, lips and mouth. • Feels the area under your jaw and the sides of your neck, checking for unusual lumps. • Asks you to stick out your tongue to check for swelling, color and texture. • Using gauze, lifts your tongue and pulls it from one side, then the other. • Checks the roof and floor of your mouth and the back of your throat. • Feels and examines the insides of your lips and cheeks for red or white patches. • Places one finger on the floor of your mouth and, with the other hand under your chin, presses down to check for unusual lumps or sensitivity. Source: National Institute of Dental and Craniofacial Research
diagnosis of cancer was confirmed. In October 2006 Tucker underwent surgery to have the cancer removed. “We with the assistance of a prosthesis and thought everything was all right,” he said. But speech therapy. a few months later the pain — and the cancer Her surgery was followed by radiation. She has had no treatment since then — and that — recurred in the same spot, but now involved the lymph nodes. was 14 years ago. He underwent another surgery to remove In hindsight Goins realizes that her smoking probably played a role in her disease. She’s the tumor and lymph nodes followed by seven weeks of radiation. cured of that habit. “You don’t want to pick up That was almost four years ago and a cigarette after you’ve had a throat operation,” Tucker has had a clean bill of health since then. she explained. Checkups have been good. He had a couple Kenneth Tucker still marvels at the fact that he had oral cancer though he says he never of scares when white spots appeared in his mouth, but a fungus was to blame. Red and smoked. His age of 46 at the time of diagnosis white spots in made his situation the mouth can even more unusual, be signs of oral since the median age cancer. at diagnosis of oral Tucker’s cancer is 62. day-to-day life Tucker, who is has changed. now 49, remembers The radiation the story well. “I impaired his started having pain salivary glands, and bleeding in my resulting in dry right cheek when I mouth. “Every chewed and brushed 30 minutes I my teeth,” he said. have to drink He noticed a red water,” Tucker spot on the inside of explained. He his right cheek, but also uses dental chalked it up to a trays filled with sore of some kind. fluoride gel 10 When his home After two surgeries for cancer of the mouth, minutes each remedies of salt Kenneth Tucker has returned to work in the day to decrease water and peroxide shipping and receiving department at Volvo provided no cure, Parts North America. (Derrick J. Haire photo) the risk of dental decay. Saliva he knew he had a prevents the buildup of bacteria in the mouth problem. The pain intensified. that can lead to caries. Every morning he bites Tucker admitted that he had never heard into a tool that he says allows him to release of oral or head and neck cancer. He said that his jaws. cancer was the farthest thing from his mind. “Jaws stiffen from radiation,” he Fortunately, he had a dental appointment explained. the following month and credits the dental When he could finally return to work hygienist for her keen observation — and luck. The hygienist’s mother had cancer of Tucker knew he was on his way. He’s become the mouth, and the red spot looked suspia preacher of sorts at work. When he sees young men who dip, or use smokeless tobacco, ciously familiar. he has a few choice words. Her suspicions were correct. The dentist “You take a look at me,” he warns. “You took a look and didn’t like what he saw. An don’t want to go through what I went through.” oral surgeon biopsied the sore. A week later a
Goins, continued from page 1
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