Erythroplakia

INTRODUCTION

The primary areas involved in head and neck neoplasms are the nasal cavity and the oral cavity including the lips, buccal mucosa, floor of the mouth, oral tongue, hard palate, and gingivae. The oropharynx including the base of the tongue and tonsils, the nasopharynx, the hypopharynx and the larynx also are common sites of cancer occurrence. Finally, tumors of the salivary gland, thyroid gland, skin of the face, and cervical lymph nodes also constitute a significant proportion of cancers of the head and neck.1 In some of these tumors of the head and neck, resection is not possible. Decisions regarding resection are based on tumor size, location, histology, depth of invasion, staging of the disease, comorbidities, quality of life, and patient preference. Considering all of these factors, each patient will require a customized treatment approach that involves a multidisciplinary team of which physical therapists are an integral part. The following article will describe nonresectable head and neck tumors commonly encountered by the physical therapist in the clinical setting, and provide an overview, based on evidence or current physical therapy management techniques.

EPIDEMIOLOGY

Tumors of the head and neck account for about 4% of all cancers diagnosed in the United States. It was estimated that in 2003 there would be approximately 55,000 new cases of head and neck cancer diagnosed in this country. Of those 55,000, approximately 27% would be of an advanced stage and considered nonresectable.1,2

The incidence rates are twice as high for men compared to women and occur most commonly in the 5th and 6th decades of life.1 For men over the age of 50, the incidence of head and neck cancer is the highest. Despite the fact that the death rates have been on the decline since the 1970s, it was estimated that approximately 14,400 deaths would occur in 2003 due to head and neck cancers.2

RISK FACTORS/ETIOLOGY

It is considered that the etiology and risk factors for the development of head and neck cancers are one in the same. Overwhelmingly, the most important risk factors are tobacco use and alcohol consumption.3 Smokeless tobacco use also is associated with a high incidence of oral carcinogenesis. Approximately 85% of patients that present with head and neck cancer have a history of heavy tobacco and/or alcohol consumption. Concomitant use of alcohol and tobacco use seems to have a synergistic effect that results in a high relative risk of developing head and neck cancer.3 Ethanol has been shown to suppress the efficiency of DNA repair. Nutritional insufficiency, which is common in the alcoholic population, may compound the risk of development of these types of tumors.1 Illicit drugs such as marijuana also are regarded as an etiologic factor. Occupational risks include woodworking, nickel refining, and chronic exposure to textile fibers and asbestos.1

A Canadian study presented by Foulkes and colleagues suggests that familial factors are important in determining individual susceptibility to head and neck cancer. This study found a significantly increased relative risk for developing head and neck cancer if a first-degree relative had squamous cell carcinoma of the head and neck.4

Finally, viruses can play a role in the development of certain head and neck cancers. For example, Epstein-Barr virus is associated with nasopharyngeal cancers. Also, DNA from the human papillomavirus has been found in head and neck tissue.1

CLINICAL PRESENTATION

Head and neck cancer is relatively easy to detect. The warning signs include dysphagia, a chronic ulcer that will not heal, a lump in the neck, and persistent or unexplained bleeding.5,6 In addition, color changes in the mouth known as leukoplakia and erythroplakia can be common premalignant signs. Leukoplakia is a white patch that develops in the oral cavity. Approximately 2% to 5% of all patients with leukoplakia will develop squamous cell carcinoma in the future. The incidence of squamous cell carcinoma in patients that present with erythroplakia, or red patches that develop in the oral cavity, is nearly 30%. Since both of these conditions have the potential to become malignant, they should be monitored closely by the patient and the physician. Other signs and symptoms of head and neck cancer include pain and/or numbness in the face, ear, mouth, and lips. Again these signs should be examined and monitored closely by the patient and his/her physician. Despite these common signs and symptoms, 2 of every 3 patients with head and neck cancer still present at an advanced stage.1,3 Commonly, neglect on the part of the patient is the primary reason for this presentation.

PATHOLOGIC CLASSIFICATION

The upper aerodigestive tract is lined mainly with squamous epithelium. Hence, the most common tumors that occur in the head and neck are squamous cell carcinomas. Adenocarcinomas, or tumors that originate from glandular tissue, are seen occasionally in head and neck cancer. Other, more rare tumors are soft tissue in nature and are classified as leiomyosarcoma, rhabdomyosarcoma, and fibrosarcoma. The rhabdomyosarcomas more commonly occur in children.1

STAGING

Staging describes the extent of the cancer. Especially important is the ability to describe whether or not the disease has spread beyond the confines of the primary site to other parts of the body. Staging assists the physicians with determining disease progression and choosing an appropriate treatment course. The most widely used system used in the United States is the TNM staging system.2

The TNM System involves using the letters T, N, and M to assess tumors by:

* The size of the primary tumor (T);

* The degree to which regional lymph nodes (N) are involved; and

* The absence or presence of distant metastases (M).

Once the T, N, and M are determined, a stage of I, II, III, or IV is assigned:

* Stage I cancers are small, localized, and usually curable.

* Stage II and III cancers typically are locally advanced and/or have spread to local lymph nodes.

* Stage IV cancers usually are metastatic (have spread to distant parts of the body) and generally are considered inoperable.

Table 1 shows the combination of tumor stage and nodal involvement in approximating the overall stage of the patient's cancer no matter where the tumor may be located.7 The table is adapted from the UPMC Cancer Center.

PROGNOSIS

A 2002 study conducted by Doweck et al looked at tumor volume as a prognostic indicator of outcomes for patients with advanced head and neck cancer. A retrospective study was conducted and it was hypothesized that primary tumor volume correlated with local disease control and survival. They found that in patients with a primary tumor volume greater than 19.6cc. survival was only 14.1% as compared with 41.5% survival for those with a tumor volume less than 19.6cc.8

Another area of investigation centers around the use of biological markers to accurately predict patient prognosis following the development of head and neck cancers. The use of biological markers found in the patient's serum would be less invasive and traumatic for predicting outcomes compared with the current prognostic staging method of cervical lymph node dissections. Researchers at the University of Pittsburgh Cancer Institute performed a preliminary study to examine specific biological markers that may accurately predict prognosis in head and neck cancer.9 Protein markers, transforming growth factor alpha (TGF-Alpha) and its receptor, and epidermal growth factor receptor (EGFR) are known to be overproduced in some tumors including head and neck cancer. In this report, all patients studied with head and neck cancer had elevated protein expression of the abovementioned markers.9 This study would seem to suggest that overproduction biological markers appears to predict clinical outcomes as accurately as cervical lymph node dissection, the traditional staging method. This molecular diagnostic method may allow physicians to accurately stage and predict outcomes in a less invasive way.

TREATMENT

Management of advanced head and neck cancer involves a multidisciplinary approach. Current treatment modalities include radiation and chemotherapy.10 Both of these approaches can be conducted together or separately. Often, in nonresectable cancer cases, radiation and chemotherapy are palliative in nature attempting to prolong the duration and enhance the quality of life of the patient. In some cases, radiation and chemotherapy are implemented in hopes of shrinking the size of the currently nonresectable tumor. If successful, surgical resection would then be attempted.3

In patients that are receiving radiation and or chemotherapy, many treatment-induced complications can occur. The oral complications from radiation therapy are listed in Table 2.

Radiation therapy is anatomically site-specific and the complications mentioned above are therefore localized to the area being irradiated. The degree of damage is dependent on the amount, duration, and fractionation of the treatment regimen. secondary to the damage that radiation treatments inflict (including tissue necrosis and osteonecrosis), it is often necessary that the patient undergo preradiation dental extractions to prevent possible complications.

Chemotherapy complications overlap with many of the radiation therapy side effects. In addition, chemotherapy intervention may cause several other side effects including: nutritional compromise, nausea and vomiting, oral hemorrhage, thrombocytopenia, neuropathy (commonly drop foot induced from chemotherapy), profound fatigue, and eventual neutropenia and immunosuppression.12 All of these complications should be taken into account as the physical therapist assesses and evaluates patients with advanced head and neck cancer to achieve safe and effective rehabilitation outcomes.

PHYSICAL THERAPY INTERVENTIONS/CONCERNS

Acute Care Setting

Physical therapists are an integral part of the cancer rehabilitation team in the acute care setting. The role of the physical therapist in acute care management of individuals with nonresectable head and neck cancers should focus on symptom management, prevention of complications, and promotion of physical function through implementing early exercise strategies. Although treatment complications such as pain and fatigue are common, early physical therapy interventions can successfully minimize and potentially prevent these treatment-related symptoms. It has been well documented that immobility affects virtually every organ system, the result of which is a steady decline in functional mobility.13 Pulmonary function, skin integrity, endurance, and strength are all compromised by patients staying in bed. The decline in physical function can lead to a more rapid onset of fatigue. The simple act of getting patients up and out of bed can reduce the deleterious effects of immobilization. One side benefit of increasing physical activity is the potential for enhanced independence and improved social interactions, which may reduce psychological symptoms or anxiety, depression, and loss of self esteem.14 Enabling patients to discover that they can be independent in the face of their cancer diagnosis is an important part of the therapeutic process.

Speech, swallowing, and mastication can all be affected by nonresectable head and neck cancer. The speech pathologist should be consulted to specifically address these problems.15 Communication can be facilitated by language boards and electrolaryngeal devices where appropriate. The physical therapist should monitor the patients' lab values including oxygen saturation, hemoglobin, RBC, WBC, and platelet levels daily to track changes that can occur during treatment and be cognizant of how those changes will affect therapy. Neutropenia can predispose the patient to infections and appropriate precautions, including medical isolation of the patient if necessary, should be undertaken. Platelet levels have long been a source of debate regarding exercise. Patients with platelet counts above 100,000 can engage in normal activities and exercise. With levels between 40,000 and 60,000, heavy resistive exercises should be avoided, but the use of stationary bicycle and low weight resistive exercise are acceptable. With a count between 20,000 and 40,000, low intensity exercise, ambulation, and ADL activities are indicated. With levels below 20,000, the risk of bleeding increases. Even at these low levels, ambulation alone may be indicated to avoid the complications of bed rest.16

Postural education is important; scapulothoracic depression and protraction should be avoided with proper instruction.17 Gentle range of motion of the cervical region can be attempted if the tumor burden is not large and patient comfort permits. Overzealous exercise should be avoided. An aggressive approach as is needed for post neck dissection patients is not needed in patients who are unresectable. Orthotic devices, when necessary, should be prescribed and fit carefully, usually to put the scapula into retraction. However, many devices are cumbersome and uncomfortable to wear. Pain control is always paramount.17

As with any patient in the acute care setting, it is important to recognize the tenuous nature of their condition. Typically this population is profoundly ill and therefore their presentation is very different from that of a surgical candidate. Compliancy can be an issue and goals for therapy should be set with this in mind. As always, diligence, patience, and communication should always be used to achieve optimal functional outcomes for this population.

REFERENCES

1. Murphy GP, Lawrence W Jr., Lenhard RE, Jr. American Cancer Society Textbook of Clinical Oncology. 2nd ed. Atlanta, Ga: American Cancer Society; 1995:311-341.

2. American Cancer Society. Cancer Facts and Figures 2003. Available at: www.americancancersociety.org. Accessed February 1, 2004.

3. Cann C, et al. Epidemiology of squamous cell cancer of the head and neck. Otolaryngol Clin North Am. 1985 Aug; 18(3): 367-388.

4. Foulkes WD, et al. Familial risks of squamous cell carcinoma of the head and neck: retrospective case-control study. Br Med J. 1996;313:716-721.

5. Daly K. Oral cancer, everyday concerns. Am J Nurs. August 1979.

6. NIH Publication. Oral Health Cancer and You. 2002:No.02-4362.

7. UPMC Cancer Center. Head and Neck Cancer Staging. Available at: www.upmccancercenters.com. Accessed February 1, 2004.

8. Doweck I, et al. Tumor volume predicts outcome for advanced head and neck cancer treated with targeted chemoradiotherapy. Laryngoscope. 2002;112(10):1742-1749.

9. Grandis JR, et al. Eevels of TGF -alpha and EGFR protein in head and neck squamous cell carcinoma and patient survival. J Natl Cancer Inst. 1998;90(11):824-832.

10. Calais G, et al. Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma. J National Cancer Institute. 1999;91(24):2081-2085.

11. The National Cancer Institute 2004. Oral Complications of Chemotherapy and Head/Neck Cancer. Available at: www.nci.nih.gov/cancerinfolpdq/supportivecare/oralcomplications/. Accessed February 1, 2004.

12. Tisch L, et al. Cellular immune defect caused by postsurgical radiation therapy in a patient with head and neck cancer. Otolaryngol Head Neck Surg. 1998.

13. Newton S, et al. Cancer related fatigue: how nurses can help combat this most common symptom. Am J Nurs. 2001;101 suppl:31-34.

14. Mock V, Hassey DK, Meares CJ, et al. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum. 1997;24(6):991-1000.

15. Cyr TG. The role of the speech language pathologist in cancer rehabilitation. Rehab Oncol. 1991;9(2):12-13.

16. Zavadsky AJ .Platelet disorders and their implications on physical therapy intervention. Rehab Oncol. 2001;19(3):11-13.

17. Schwartz LM, Weingarten DL, Shappell JE. Head and neck rehabilitation. Rehab Oncol. 2000;18(1):21-22.

Mary Beth O'Reilly, SPT

Cancer Rehabilitation, Medical College of Virginia, Virginia Commonwealth University

Copyright Rehabilitation in Oncology 2004
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