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Treatment side effects

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Depending on the treatment used, people with head and neck cancer may experience the various symptoms and treatment side effects depending on the type and site of the treatment used.[1][2]

Difficulties with eating and drinking

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Even before treatment, tumours themselves may interfere with a person’s ability to eat and drink normally[3] and these may be among the early presenting symptoms.[4] Some treatments can also lead to difficulty with eating and drinking (dysphagia).[3][5] This might lead to feelings of food sticking in the throat, food and drink going down the wrong way (aspiration),[6] taking a long time to chew and swallow food, a change in taste or appetite, and overall changes in enjoyment of eating and drinking.[7]

Chemotherapy can lead to taste changes, nausea and vomiting. It can deprive the body of vital fluids (although these may be obtained through intravenous fluids if necessary). Frequent vomiting can lead to an electrolyte imbalance, which has serious consequences for the proper functioning of the heart. Frequent vomiting can also upset the balance of stomach acids, which has a negative impact on the digestive system, especially the lining of the stomach and esophagus.[citation needed]

Radiotherapy can lead to mucositis, xerostomia,[2] trismus,[8] osteoradionecrosis,[2] changes to dentition, fatigue, oedema[9][10] and radiation-induced acute skin reactions for which creams and films may be given.[11] These effects will depend on the dose and site of the radiotherapy.[12][13][14]  Recent advancements in the way radiotherapy is planned and delivered aim to reduce some of these side effects.[15][16]

Surgery can cause difficulties chewing, swallowing, jaw opening, and other issues depending on the site and site of surgery.

Communication

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Speech may become slurred, hard to understand, or the voice may become hoarse or weak. The impact on communication depends on the site and size of the tumour and the treatments used. The tumour itself may result in changes to the voice for example, which may be among one of the presenting signs and symptoms.[4]

Surgery can lead to changes in the shape and size of the oral structures (tongue, lips, palate) which can impact on how they move to produce speech sounds.[17]

Surgery may result to changes in anatomy or neurology such as removal of a structure or damage to nerves. For example, removal of the larynx (voice box) in a total laryngectomy or damage to the vagus nerve during tumour resection leading to vocal fold paresis or palsy.[18]

Surgery may involve substituting some anatomy with tissue from other areas of the body (soft tissue or bone flap reconstruction). This can lead to changes in sensation and function of this new tissue.[19]

Head and neck cancer treatments can lead to changes in the sound of the voice. The impact of surgery on the voice can depend on the size of the resection and subsequent amount of scarring on the vocal folds.[20] Radiotherapy treatment may improve the voice or worsen it, depending on pre-treatment  voice function, and the site and dose treatment.[21] This may be short- or  long-term depending on the treatment plan.

Upper airway

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Surgery may lead to changes in the way a person breathes either in the short term or long term e.g. through a tracheostomy tube or stoma in the neck (laryngectomy).

Nutrition and hydration

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People may find it hard to eat and drink enough due to the side effects of treatments. These may be associated with chemotherapy, radiotherapy and surgery. Some people might be recommended to have enteral feeding, a method that adds nutrients directly into a person's stomach using a nasogastric feeding tube or a gastrostomy tube.[22][23] The type of tube used is decided on a case-by-case basis with guidance from the treating team.[24] Further research is required to determine the most effective method of enteral feeding to ensure that people undergoing radiotherapy or chemoradiation treatment are able to stay nourished during their treatment.[25]

Rehabilitation and long-term care

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Speech, voice and swallow function

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Rehabilitation targeting changes to speech, voice and swallowing aims to optimise function and help manage long-term effects.[3][26]  Rehabilitation can consist of therapy exercises (sometimes using a tongue pressure device) and compensation strategies. Therapy exercises may involve as breathing techniques or muscle strengthening exercises e.g. for the tongue or larynx (voice box), while compensation strategies can involve texture modification or changes to head postures when voicing or swallowing.[27][28][8][29]

Therapy programmes should be implemented as soon as possible to improve effectiveness.[30][31][32]

Radiation-induced side effects 

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Head and neck cancer treatment can result in late onset changes to function. People can develop radiation-induced osteonecrosis or osteoradionecrosis of the jaw.

Radiation-induced ‘late effects’ are caused by late radiation-induced fibrosis, cranial neuropathy and/or muscle atrophy.[1][15][33] It can result in devastating changes to speech, voice, swallowing, breathing and mouth opening (trismus). Certain treatments have been associated with increased risk of developing late effects, such as radiotherapy for nasopharyngeal or oropharyngeal cancers, with increased dose of radiotherapy to the pharyngeal constrictors (throat muscles).[33][12][34] Long periods of ‘nil by mouth’, use of gastrostomy tubes[34] and significant neck lymphodema have also been linked to increased risk of fibrosis and dysphagia.[35] A person may present with a sudden onset of swallowing problems (dysphagia) or may experience progressive deterioration of function over a long period of time.[36] Late effects symptoms may go undetected due to reduced sensation and may not be linked to previous head and neck cancer treatment due to the time that has lapsed. Side effects can include dehydration, malnutrition, recurrent chest infections or pneumonias. Monitoring of function should be included in cancer surveillance.[37] In the United Kingdom, the majority of patients will be routinely followed up for 5 years, with a minority being seen routinely beyond this time, based on individual need.[38]

  1. ^ a b "Late effects of head and neck cancer treatment". Macmillan Cancer Support. 1 April 2022. Retrieved 2024-09-24.
  2. ^ a b c Ridge JA, Glisson BS, Lango MN, Feigenberg S, Horwitz EM (2008). "Head and neck tumors." (PDF). In Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (eds.). Cancer management: a multidisciplinary approach (11th ed.). Cmp United Business Media. pp. 39–86. ISBN 978-1-891483-62-2.
  3. ^ a b c Greco, Elissa; Simic, Tijana; Ringash, Jolie; Tomlinson, George; Inamoto, Yoko; Martino, Rosemary (27 April 2018). "Dysphagia Treatment for Patients With Head and Neck Cancer Undergoing Radiation Therapy: A Meta-analysis Review". International Journal of Radiation Oncology*Biology*Physics. 101 (2): 421–444. doi:10.1016/j.ijrobp.2018.01.097.
  4. ^ a b Bradley, Paula T.; Lee, Ying Ki; Albutt, Abigail; Hardman, John; Kellar, Ian; Odo, Chinasa; Randell, Rebecca; Rousseau, Nikki; Tikka, Theofano; Patterson, Joanne M.; Paleri, Vinidh (2024-06-17). "Nomenclature of the symptoms of head and neck cancer: a systematic scoping review". Frontiers in Oncology. 14. doi:10.3389/fonc.2024.1404860. ISSN 2234-943X. PMC 11216301. PMID 38952557.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  5. ^ Patterson, Joanne M.; McColl, Elaine; Wilson, Janet; Carding, Paul; Rapley, Tim (8 April 2015). "Head and neck cancer patients' perceptions of swallowing following chemoradiotherapy". Supportive Care in Cancer. 23 (12): 3531–3538. doi:10.1007/s00520-015-2715-8. ISSN 0941-4355.
  6. ^ Mootassim‐Billah, Sofiana; Van Nuffelen, Gwen; Schoentgen, Jean; De Bodt, Marc; Dragan, Tatiana; Digonnet, Antoine; Roper, Nicolas; Van Gestel, Dirk (1 May 2021). "Assessment of cough in head and neck cancer patients at risk for dysphagia—An overview". Cancer Reports. 4 (5). doi:10.1002/cnr2.1395. ISSN 2573-8348. PMC 8551981. PMID 33932152.{{cite journal}}: CS1 maint: PMC format (link)
  7. ^ Patterson, Joanne M.; Lu, Liya; Watson, Laura-Jayne; Harding, Sam; Ness, Andy R.; Thomas, Steve; Waylen, Andrea; Waterboer, Tim; Sharp, Linda (20 May 2021). "Trends in, and predictors of, swallowing and social eating outcomes in head and neck cancer survivors: A longitudinal analysis of head and neck 5000". Oral Oncology. 118: 105344. doi:10.1016/j.oraloncology.2021.105344.
  8. ^ a b Charters, E; Dunn, M; Cheng, K; Aung, V; Mukherjee, P; Froggatt, C; Dusseldorp, Jr; Clark, Jr (29 January 2022). "Trismus therapy devices: A systematic review". Oral Oncology. 126: 105728. doi:10.1016/j.oraloncology.2022.105728. ISSN 1879-0593. PMID 35104753.
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  11. ^ Burke, G.; Faithfull, S.; Probst, H. (7 January 2022). "Radiation induced skin reactions during and following radiotherapy: A systematic review of interventions". Radiography. 28 (1): 232–239. doi:10.1016/j.radi.2021.09.006.
  12. ^ a b Duprez, Fréderic; Madani, Indira; De Potter, Bruno; Boterberg, Tom; De Neve, Wilfried (2013-02-22). "Systematic Review of Dose–Volume Correlates for Structures Related to Late Swallowing Disturbances After Radiotherapy for Head and Neck Cancer". Dysphagia. 28 (3): 337–349. doi:10.1007/s00455-013-9452-2. ISSN 0179-051X.
  13. ^ Eisbruch, Avraham; Schwartz, Marco; Rasch, Coen; Vineberg, Karen; Damen, Eugene; Van As, Corina J.; Marsh, Robin; Pameijer, Frank A.; Balm, Alfons J.M. (2004-12-01). "Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: Which anatomic structures are affected and can they be spared by IMRT?". International Journal of Radiation Oncology*Biology*Physics. 60 (5): 1425–1439. doi:10.1016/j.ijrobp.2004.05.050.
  14. ^ Nguyen, N.P.; Moltz, C.C.; Frank, C.; Vos, P.; Smith, H.J.; Karlsson, U.; Dutta, S.; Midyett, F.A.; Barloon, J.; Sallah, S. (March 2004). "Dysphagia following chemoradiation for locally advanced head and neck cancer". Annals of Oncology. 15 (3): 383–388. doi:10.1093/annonc/mdh101.
  15. ^ a b Patterson, J. M. (2019-05-21). "Late Effects of Organ Preservation Treatment on Swallowing and Voice; Presentation, Assessment, and Screening". Frontiers in Oncology. 9. doi:10.3389/fonc.2019.00401. ISSN 2234-943X. PMC 6536573. PMID 31165044.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  16. ^ Roe, Justin W.G.; Carding, Paul N.; Drinnan, Michael J.; Harrington, Kevin J.; Nutting, Christopher M. (13 November 2015). "Swallowing performance and tube feeding status in patients treated with parotid‐sparing intensity‐modulated radiotherapy for head and neck cancer". Head & Neck. 38 (S1). doi:10.1002/hed.24255. ISSN 1043-3074.
  17. ^ Baehring, Erikka; McCorkle, Ruth (2012-12-01). "Postoperative Complications in Head and Neck Cancer". Clinical Journal of Oncology Nursing. 16 (6): E203–E209. doi:10.1188/12.CJON.E203-E209. ISSN 1092-1095.
  18. ^ Wang, Hsing-Won; Lu, Cheng-Chieh; Chao, Pin-Zhir; Lee, Fei-Peng (2022-10-22). "Causes of Vocal Fold Paralysis". Ear, Nose & Throat Journal. 101 (7): NP294–NP298. doi:10.1177/0145561320965212. ISSN 0145-5613.
  19. ^ Homer, J J; Fardy, M J (12 May 2016). "Surgery in head and neck cancer: United Kingdom National Multidisciplinary Guidelines". The Journal of Laryngology & Otology. 130 (S2): S68–S70. doi:10.1017/S0022215116000475. ISSN 0022-2151. PMC 4873928. PMID 27841115.{{cite journal}}: CS1 maint: PMC format (link)
  20. ^ Colizza, Andrea; Ralli, Massimo; D’Elia, Chiara; Greco, Antonio; de Vincentiis, Marco (3 May 2022). "Voice quality after transoral CO2 laser microsurgery (TOLMS): systematic review of literature". European Archives of Oto-Rhino-Laryngology. 279 (9): 4247–4255. doi:10.1007/s00405-022-07418-3. ISSN 0937-4477. PMC 9363323. PMID 35505113.{{cite journal}}: CS1 maint: PMC format (link)
  21. ^ Heijnen, B. J.; Speyer, R.; Kertscher, B.; Cordier, R.; Koetsenruijter, K. W. J.; Swan, K.; Bogaardt, H. (19 September 2016). "Dysphagia, Speech, Voice, and Trismus following Radiotherapy and/or Chemotherapy in Patients with Head and Neck Carcinoma: Review of the Literature". BioMed Research International. 2016: 1–24. doi:10.1155/2016/6086894. ISSN 2314-6133.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  22. ^ Nugent B, Lewis S, O'Sullivan JM (January 2013). "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy". The Cochrane Database of Systematic Reviews. 2013 (1): CD007904. doi:10.1002/14651858.CD007904.pub3. PMC 6769131. PMID 23440820.
  23. ^ Bossola, Maurizio; Antocicco, Manuela; Pepe, Gilda (22 May 2022). "Tube feeding in patients with head and neck cancer undergoing chemoradiotherapy: A systematic review". Journal of Parenteral and Enteral Nutrition. 46 (6): 1258–1269. doi:10.1002/jpen.2360. ISSN 0148-6071.
  24. ^ Talwar, B; Donnelly, R; Skelly, R; Donaldson, M (12 May 2016). "Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines". The Journal of Laryngology & Otology. 130 (S2): S32–S40. doi:10.1017/S0022215116000402. ISSN 0022-2151. PMC 4873913. PMID 27841109.{{cite journal}}: CS1 maint: PMC format (link)
  25. ^ Nugent B, Lewis S, O'Sullivan JM (January 2013). "Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy". The Cochrane Database of Systematic Reviews. 2013 (1): CD007904. doi:10.1002/14651858.CD007904.pub3. PMC 6769131. PMID 23440820.
  26. ^ Banda, Kondwani Joseph; Chu, Hsin; Kao, Ching-Chiu; Voss, Joachim; Chiu, Huei-Ling; Chang, Pi-Chen; Chen, Ruey; Chou, Kuei-Ru (2021-02). "Swallowing exercises for head and neck cancer patients: A systematic review and meta-analysis of randomized control trials". International Journal of Nursing Studies. 114: 103827. doi:10.1016/j.ijnurstu.2020.103827. {{cite journal}}: Check date values in: |date= (help)
  27. ^ Arrese, Loni C.; Schieve, Heidi (2019), Doyle, Philip C. (ed.), "Dysphagia Management of Head and Neck Cancer Patients: Oral Cavity and Oropharynx", Clinical Care and Rehabilitation in Head and Neck Cancer, Cham: Springer International Publishing, pp. 313–328, doi:10.1007/978-3-030-04702-3_19, ISBN 978-3-030-04701-6, retrieved 2024-09-23
  28. ^ Speyer, Renée; Baijens, Laura; Heijnen, Mariëlle; Zwijnenberg, Iris (17 September 2009). "Effects of Therapy in Oropharyngeal Dysphagia by Speech and Language Therapists: A Systematic Review". Dysphagia. 25 (1): 40–65. doi:10.1007/s00455-009-9239-7. ISSN 0179-051X. PMC 2846331. PMID 19760458.{{cite journal}}: CS1 maint: PMC format (link)
  29. ^ Hutcheson, Katherine A.; Barrow, Martha P.; Plowman, Emily K.; Lai, Stephen Y.; Fuller, Clifton David; Barringer, Denise A.; Eapen, George; Wang, Yiqun; Hubbard, Rachel; Jimenez, Sarah K.; Little, Leila G.; Lewin, Jan S. (2018-05). "Expiratory muscle strength training for radiation‐associated aspiration after head and neck cancer: A case series". The Laryngoscope. 128 (5): 1044–1051. doi:10.1002/lary.26845. ISSN 0023-852X. PMC 5823707. PMID 28833185. {{cite journal}}: Check date values in: |date= (help)CS1 maint: PMC format (link)
  30. ^ Govender, Roganie; Smith, Christina H.; Taylor, Stuart A.; Barratt, Helen; Gardner, Benjamin (10 January 2017). "Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises". BMC Cancer. 17 (1). doi:10.1186/s12885-016-2990-x. ISSN 1471-2407. PMC 5223405. PMID 28068939.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  31. ^ Govender, Roganie; Wood, Caroline E.; Taylor, Stuart A.; Smith, Christina H.; Barratt, Helen; Gardner, Benjamin (19 April 2017). "Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory". Dysphagia. 32 (4): 559–569. doi:10.1007/s00455-017-9799-x. ISSN 0179-051X. PMC 5515965. PMID 28424898.{{cite journal}}: CS1 maint: PMC format (link)
  32. ^ Rodriguez, Ana Maria; Komar, Alyssa; Ringash, Jolie; Chan, Catherine; Davis, Aileen M.; Jones, Jennifer; Martino, Rosemary; McEwen, Sara (2019-08-14). "A scoping review of rehabilitation interventions for survivors of head and neck cancer". Disability and Rehabilitation. 41 (17): 2093–2107. doi:10.1080/09638288.2018.1459880. ISSN 0963-8288.
  33. ^ a b Hutcheson, Katherine A.; Yuk, Maggie; Hubbard, Rachel; Gunn, Gary B.; Fuller, C. David; Lai, Stephen Y.; Lin, Heather; Garden, Adam S.; Rosenthal, David I.; Hanna, Ehab Y.; Kies, Merrill S.; Lewin, Jan S. (28 April 2017). "Delayed lower cranial neuropathy after oropharyngeal intensity‐modulated radiotherapy: A cohort analysis and literature review". Head & Neck. 39 (8): 1516–1523. doi:10.1002/hed.24789. ISSN 1043-3074. PMC 5511776. PMID 28452175.{{cite journal}}: CS1 maint: PMC format (link)
  34. ^ a b Paleri, Vinidh; Roe, Justin W. G.; Strojan, Primož; Corry, June; Grégoire, Vincent; Hamoir, Marc; Eisbruch, Avraham; Mendenhall, William M.; Silver, Carl E.; Rinaldo, Alessandra; Takes, Robert P.; Ferlito, Alfio (4 July 2013). "Strategies to reduce long‐term postchemoradiation dysphagia in patients with head and neck cancer: An evidence‐based review". Head & Neck. 36 (3): 431–443. doi:10.1002/hed.23251. ISSN 1043-3074.
  35. ^ Jeans, Claire; Brown, Bena; Ward, Elizabeth C; Vertigan, Anne E (2021-04-01). "Lymphoedema after head and neck cancer treatment: an overview for clinical practice". British Journal of Community Nursing. 26 (Sup4): S24–S29. doi:10.12968/bjcn.2021.26.Sup4.S24. ISSN 1462-4753.
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  37. ^ Rocke, John; Mclaren, Oliver; Hardman, John; Garas, George; Smith, Matthew E; Ishii, Hiro; Constable, James; Tikka, Theofano; Wie Liu, Zi; Williams, Richard; Integrate (UK ENT Trainee Research Network) (31 October 2019). "The role of allied healthcare professionals in head and neck cancer surveillance: A systematic review". Clinical Otolaryngology. 45 (1): 83–98. doi:10.1111/coa.13471. ISSN 1749-4478.
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