Treatment

Your doctors may recommend chemotherapy in combination with radiation therapy if your cancer has spread to nearby tissues or lymph nodes. This may be your main treatment or you might have chemo and radiation after surgery.

Usually chemotherapy medicines are given by infusion into a vein. Some are taken by mouth in pill form. 

Your Fred Hutch team will talk with you about the specific drugs we recommend for you, how you’ll receive them, your treatment schedule and what to expect. We’ll also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout Fred Hutch.

You may have the option of receiving the standard chemotherapy medicines for your disease or participating in a clinical study that explores an innovative approach. Fred Hutch researchers are studying new combinations of chemotherapy medicines to determine which are most effective.

Protons can be controlled with greater precision than X-rays. This means that more energy goes into destroying the tumor and less radiation is delivered to surrounding healthy tissue. For this reason, proton therapy is particularly good for treating tumors near healthy organs, including head and neck tumors.

More than 60,000 Americans are diagnosed annually with head and neck cancer. When treating head and neck tumors it’s critical to protect the delicate organs that surround the tumor. Proton therapy can potentially reduce damage to eyes, optic nerves, salivary glands, and other organs near head and neck tumors, thereby reducing the likelihood of side effects such as blindness, hearing deterioration, and dry mouth. Secondary malignancies are also less likely with proton therapy.

Tobacco (including smokeless tobacco) and alcohol use are the most important risk factors for head and neck cancers. People who use both tobacco and alcohol are at greater risk for developing these cancers than people who use either tobacco or alcohol alone. Over the past decade, an increasing number of young, non- smokers have developed mouth and throat cancer associated with the human papilloma virus, or HPV.

The right-hand images above show proton beam treatment for head-and-neck cancer. The left-hand images shows typical treatment with conventional radiation, in this case VMAT.

Base-of-skull tumors

Base-of-skull tumors include chordomas and chondrosarcomas. Tumors in the base-of-skull region are difficult to treat because they are often close to critical structures such as the brainstem, brain, cranial nerves, and optic nerves. The location of these tumors often makes surgical removal difficult and limits the dose of radiation that can be delivered with standard X-ray radiation treatments. Proton therapy can be particularly appropriate for these tumors because it minimizes radiation exposure to surrounding healthy tissue. Since these tumors are found at a shallow depth, proton therapy is often able to deliver a high dose of radiation precisely to the tumor without affecting tissues of the brain and spinal cord. The more radiation delivered to the tumor the greater the chance of completely destroying it.

The greater precision of proton therapy (left, above) spares healthy organs, allowing a higher dose of radiation to be delivered to base-of-skull tumors. The higher the dose, the better tumor can be controlled.

Head and neck tract tumors most appropriate for proton therapy

• Base of skull tumors (including, but not limited to, anterior, middle, and posterior cranial fossa, sphenoid and temporal bone-related tumors)
• Sino – Nasal cancers (paranasal sinuses and nasal cavity)
• Cancers located near the orbits/eyes
• Nasopharynx cancers
• Small/early oropharyngeal cancers (tonsils, tongue base)
• Select salivary gland tumors (parotid, sub-mandibular and minor salivary glands of the upper aero-digestive tract) 
• Complex skin cancers involving cranial nerves and/or lymph nodes of the neck (with a lateralized primary
• Select patients who have received previous radiation
• Unknown primary cancers (after a thorough surgical work up)

Three-field head and neck treatment technique

Our medical physics and dosimetry teams worked with our radiation oncologists to develop a 3-field treatment technique using pencil beam scanning. This new technique enables us to treat complicated head and neck cancers with multiple dose levels and bi-lateral neck involvement. 

Most people with head and neck cancers receive radiation therapy, either on its own or in combination with surgery or chemotherapy.

• Radiation therapy (also called radiotherapy) uses high-energy radiation in the form of photons (such as X-rays) or subatomic particles (such as electrons, protons or neutrons) to damage the DNA inside your cancer cells. 
• When the DNA sustains enough damage, the cells cannot multiply, and they die. 
• The goal of radiation therapy is to destroy as many cancer cells as possible with the least amount of damage to healthy cells.

As Fred Hutch patient, you will be cared for by radiation oncologists with specialized experience in treating head and neck cancers using state-of-the-art technology. Over the last decade there have been tremendous technical advances in head and neck radiotherapy, and clinical studies are testing newer strategies. 

Depending on the specifics of your cancer, your team may recommend one of several types of radiation therapy.

Intensity-Modulated Radiation Therapy (IMRT)

IMRT is designed so that the beam of X-ray radiation aimed at your tumor conforms closely to the tumor’s size, shape and contours. The beam can be split into smaller beamlets of different strengths to deliver a higher dose of radiation to the tumor and lower doses to nearby healthy tissue. By combining IMRT with image-guided radiation therapy (IGRT), we can deliver very precise radiation therapy to your cancer while sparing normal structures.

Adaptive radiation therapy

Adaptive radiation therapy is the process of varying the radiation plan according to changes in tumor dimensions during treatment. The goal is to cure the cancer while minimizing side effects.

Proton therapy

Proton therapy is an advanced therapy and an important alternative to standard X-ray radiation for many types of cancer (and some noncancerous tumors). 

Head and neck cancers are frequently located close to critical structures, such as your optic nerves, eyes, brain stem and spinal cord. The advantage of using protons to treat these cancers is that doctors can target high doses of radiation at the cancer while sparing the sensitive structures nearby. This may reduce side effects. Our Proton Therapy facility is the first and only facility in the Northwest to offer this treatment. 

Fast neutron therapy

Neutron therapy has been shown to be very effective against cancers that are resistant to standard X-ray radiation, such as salivary gland tumors. There are two advantages to using neutrons instead of photons or protons. 

• Neutron beams are much more powerful. They deposit about 20 to 100 times as much energy into the target tissue. 
• Neutron beams are more likely to damage both strands of a cancer cell’s DNA, rather than only one strand, making it harder for the cells to repair themselves and survive. 

UWMC is the only place in the United States to offer neutron therapy, and doctors here are internationally recognized for their neutron therapy expertise. In addition to salivary gland cancer, we sometimes use neutron therapy to treat cancers that are resistant to conventional radiation therapy, such as sarcoma, melanoma and thyroid or other cancer, especially when surgery is not an option. Read more about fast neutron therapy on the UW Medicine website.

Surgery is an important treatment for most head and neck cancers. We use the latest techniques to remove your tumors and restore your appearance and function.

Surgeons at the Otolaryngology–Head and Neck Surgery Center at University of Washington Medical Center (UWMC) treat Fred Hutch patients. They are national leaders in head and neck cancer surgery, performing a high volume of complex procedures every year. 

Depending on the specific features of your cancer, you might have:

• Minimally invasive surgery
• Traditional open surgery
• Reconstructive surgery

Minimally invasive head and neck surgery

Minimally invasive procedures are usually used for upper-airway tumors. These procedures are done through your mouth or nose so you don’t need incisions in your face or neck. Whenever possible, our surgeons opt for this method. Patients typically return home in only a day or two.

Your surgeon may use a variety of tools and technologies to assist with your surgery. For example, they may use a thin tube with a light and a lens (endoscope) to reach a tumor through your mouth and remove it with a laser (transoral laser microsurgery). 

The newest technique for tumors at the back of the tongue or in the throat is transoral robot-assisted surgery (TORS), also called transoral robotic surgery. 

• Removing these tumors used to require a large incision in the neck and lower jaw, and many patients had trouble swallowing or speaking afterward. 
• Now, using the da Vinci Surgical System, or da Vinci robot, we can remove tumors in this area through your mouth. UWMC was the first to bring robot-assisted surgery using da Vinci to our region.
• Your surgeon uses hand and foot controls to move robotic arms that hold a camera and surgical instruments. 
• The system allows your surgeon to perform very precise, complex motions.

Traditional open surgery

If minimally invasive surgery is not an option for you because of your tumor’s location or size, your surgeon will use a traditional open approach, making an incision in your face or neck. This type of surgery may be more involved and take longer. Your recovery may take longer as well. 

With new open techniques, surgeons strive not only to remove the cancer (and lymph nodes, if needed) but also to avoid disturbing important nerves, muscles and blood vessels in your neck and shoulder area.

Reconstructive surgery

Not everyone who has surgery to remove head or neck cancer needs reconstructive surgery. But for those who do, UW Medicine reconstructive surgeons are experts in their field.

State-of-the-art reconstruction can help to minimize changes in your appearance caused by your cancer or your treatment.

• Using a team approach, your oncology surgeon and a reconstructive surgeon will work together during one operation to both remove your cancer and complete any reconstruction you need. 
• The combined operation means you’ll be under anesthesia and in surgery for significantly less time that you would be for two separate operations. 
• After surgery, a team of nurses, speech pathologists and social workers will help you recover and rehabilitate.

One reconstructive technique is free-flap surgery, in which surgeons remove skin, bone or other tissue from one part of your body to reconstruct another part. For example, if you need part of your jaw removed, UW Medicine surgeons may reconstruct your jaw using bone from your leg, hip or shoulder blade. Even your tongue can be reconstructed with tissue from another part of your body.

Great advances have been made in using prosthetics to restore parts of the body that need to be altered or removed. 

• For patients who have their larynx removed, doctors can implant a tracheoesophageal puncture prosthesis (TEP) in a small hole made between your windpipe (trachea) and esophagus. A TEP restores your ability to deliver air from your lungs into your throat to produce speech. 
• Another option for restoring vocal ability is an electrolarynx — a device placed against your neck to help produce sound that comes out through your mouth.

Learn More About Reconstructive Surgery 

After surgery

We will do everything we can to prevent or minimize side effects you might experience from surgery and will provide care to help you heal well and deal with any side effects that do occur. 

If surgeons cannot save or restore certain important structures while also removing your cancer, or if you have trouble with chewing, swallowing, speaking or other functions after surgery, we have specialists to help. They include speech and swallowing pathologists, physical therapists, occupational therapists, dietitians and lymphedema specialists (who perform specialized massage and compression to manage chronic swelling called lymphedema). Your team will talk with you in detail about your unique situation, what to expect and what treatments or services might help you.

Your pathology report, which provides details about the tissue that was removed, will be available when you return in a week for a follow-up visit with your surgeon. Decisions about any further cancer treatment, such as radiation therapy or chemotherapy, will be based on the findings in your report, including:

• What kind of tumor you had
• How large it was
• Whether all of the cancer was removed 
• Whether cancer had spread to lymph nodes in your neck

Targeted therapies are newer cancer treatments that work more selectively than standard chemotherapy. They target a gene or protein responsible for allowing cancer to grow, they seek out and damage cancer cells, or they prompt your immune system to attack particular cells (also called immunotherapy).

The landscape of treatment for head and neck cancers is evolving rapidly, with immunotherapies approved for some people with these cancers and additional options available through clinical trials. Your Fred Hutch team will advise you about any targeted therapies, including immunotherapies, that may be effective in your particular situation.