What is cancer?
Cancer is a disease where abnormal cells grow out of control and spread quickly, forming a mass called a tumour. Tumours can be non-cancerous (benign) or cancerous (malignant). Sometimes cancer cells break away from the original tumour and travel to other areas of the body, where they keep growing and go on to form new tumours. This is called metastasis.
What is head and neck cancer?
Head and neck cancer describes a range of tumours that originate in the head and neck area. These areas exclude the brain and the eye. These cancers can start in the:
- In the nose or sinuses (nasal and paranasal carcinoma)
- At the back of the nose (naso-pharyngeal carcinoma)
- In the mouth including the tongue, the gums and roof or floor of mouth (oral cavity carcinoma, tongue carcinoma)
- On the lips (lip carcinoma)
- Back of mouth (oropharyngeal carcinoma)
- Tonsils (tonsillar carcinoma)
- Throat (hypopharyngeal carcinoma)
- Larynx / voice box (laryngeal carcinoma)
- Salivary glands (salivary carcinoma)
What are the symptoms of head and neck cancer?
Symptoms depend a lot on where exactly the cancer originates from. It is important to note that all the symptoms listed can be caused by conditions that are not cancerous.
A lump in the neck
Cancers that begin in the head or neck usually spread to lymph nodes or the glands in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by an ENT doctor as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas and blood cancers. Such lumps are generally painless and continue to enlarge steadily.
Change of voice
Most cancers in the larynx cause some changes in voice. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse or notice voice changes for more than two weeks, see the ENT doctor.
A growth or sore in the mouth
Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after 2 weeks should be evaluated by a dentist or ENT doctor. The dentist or ENT doctor can determine if a biopsy (tissue sample test) is needed.
Bringing up blood
This is often caused by something other than cancer. However, tumours in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician
Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods and sometimes liquids difficult. The food may “stick” at a certain point and then either goes through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by an ENT doctor. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a scope) will be performed to find the cause.
Changes in the skin
If there is a sore on the lip, lower face, or ear that does not heal, consult a dermatologist or ENT doctor. Any mole that changes size, colour, or begins to bleed may mean trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist, ENT doctor or other physician.
Persistent ear ache
Constant pain in or around the ear when you swallow can be a sign of infection or tumour growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness, or a lump in the neck. These symptoms should be evaluated by an ENT doctor.
What causes head and neck cancer?
The two greatest factors that increase the risk of head and neck cancer are tobacco and alcohol.
- Tobacco: This is the leading cause of head and neck cancer. It includes all tobacco products, including cigarettes, cigars, pipes, smokeless tobacco, chewing tobacco, snuff and betel quid
- Alcohol: Frequent or heavy consumption of any type of alcohol, such as beer, wine, or liquor, also raises the risk
While tobacco and alcohol play a significant role in head and neck cancer, other risk factors include:
- HPV infection: HPV is a sexually transmitted infection and it increases the risk of oropharyngeal cancers (cancers of the back of the mouth)
- Prolonged sun exposure: prolonged exposure to harmful UV light increases the risk of skin and lip cancer
- EBV infection: Epstein-Barr virus, a life-long infection, is a cause of infectious mononucleosis and other illnesses. It lays dormant in the cells of the throat and immune system. It can raise the risk of cancers in the nose, behind the nose (NPC), and cancers of the salivary glands.
- Male gender: head and neck cancer is 2-3 times more common in men than in women
- Age: head and neck cancer is more common the older one gets
- Poor dental and oral hygiene: poor dental hygiene has been linked to head and neck cancer
- Environmental and occupational exposure
- GERD and LPR: this may increase the risk of head and neck cancer.
- Weakened immune system: a poor immune system from conditions like HIV increase the risk of head and neck cancer
- Environmental/occupational exposure: Exposure to certain chemicals and substances, including asbestos, wood dust, and paint fumes, increase a person’s risk of developing head and neck cancer.
How can I lower my risk of getting head and neck cancer?
You can lower your risk of getting head and neck cancer in several ways:
- Don’t smoke. If you smoke, quit. Quitting smoking, it lowers the risk for cancer.
- Don’t use smokeless tobacco products.
- Limit the amount of alcohol you drink.
- If you are 26 years old or younger, talk to your doctor about HPV vaccines. These vaccines were developed to prevent cervical and other genital cancers. HPV vaccines also may prevent some kinds of head and neck cancer.
- Use condoms during oral sex, which may help lower the chances of giving or getting HPV.
- Use lip balm that contains sunscreen, wear a wide-brimmed hat when outdoors.
- Visit the dentist regularly. Checkups often can find head and neck cancers early, when they are easier to treat
Is there a test for head and neck cancer?
Getting to a diagnosis starts with a history and a physical examination of the area of concern.
If the history and physical examination make the ENT doctor less suspicious that your lesion is cancer, he or she might try some medications and rehabilitation before jumping to a diagnosis of cancer.
If the ENT doctor raises the possibility of head and neck cancer, a cancer work up is initiated. The tests ordered vary depending on the symptoms.
A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. A fine needle aspirate is done is commonly done if you have a lump in the neck. The doctor puts a thin needle in the lump and removes a small sample of tissue. Then a pathologist looks at the tissue under a microscope. These are the only ways to be certain if you have cancer.
If the diagnosis is cancer, the ENT doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in an operating room), endoscopy (a tube with a camera passed down your nose, throat or windpipe), imaging procedures (Xrays, ultrasound, CT scans or MRIs), and laboratory tests. Knowing the stage of the disease helps the ENT doctor plan treatment.
If you came to the ENT doctor after having a lesion removed and found it was cancer only after having the lesion removed, the doctor might skip some of the tests and jump to follow-up or additional treatment.
Be sure to bring all the reports and images with you from any prior treatment or if it is for a second opinion.
How are head and neck cancers staged?
Staging is a process that tells the doctor if the cancer has spread and if it has, how far. It depends on the severity of the original tumour, and whether the cancer has spread to lymph nodes or distant parts of the body. Staging is an important step in evaluating treatment options. Staging is slightly different for each specific type of head and neck cancer, but can be generalized as follows:
- Stage 0: Also called “carcinoma in situ,” meaning it has not yet invaded nearby tissue.
- Stage 1: Cancer has invaded nearby tissue, but has not yet spread to lymph nodes or other parts of the body
- Stage 2: Cancer has grown even deeper into nearby tissue, but still has not spread to lymph nodes or other parts of the body.
- Stage 3: Cancer has either grown much deeper into surrounding tissue or started to spread to one lymph node.
- Stage 4a: Cancer has grown completely through surrounding tissue into adjacent structures (such as tissue, cartilage, bone, or nerves) and may have spread to a few lymph nodes OR cancer has spread to more than one lymph node.
- Stage 4b: Cancer has spread (metastasized) to other parts of the body.
How are head and neck cancers treated?
In deciding which treatment strategy would be suitable for an individual patient, important considerations include location of the cancer, stage of disease, ability to tolerate treatment, expected functional outcomes and associated illnesses.
Treatment options depend on one or more of the following:
- Surgery: If surgery is selected as the best treatment option, the treatment goals will be to remove as much of the cancer as possible in addition to preserving form and function of surrounding anatomic structures. If surrounding anatomic structures are damaged during the removal of the tumour, reconstructive surgery will be performed to rebuild or restore the structure, function and cosmetic appearance of the structures that were removed. Surgery to aid in breathing and eating may be performed as well.
- Radiotherapy: Radiotherapy uses high energy rays produced by a machine to kill cancer cells. One advantage of radiation over surgery is that it can be administered on an outpatient basis, which means you will not have to be admitted to the hospital. Also, it avoids the risks of general anaesthesia during surgery, which is particularly important in patients with many medical problems or even just one severe medical problem. Also, radiation therapy as a treatment allows for the possibility of organ preservation; for example, patients can be treated for cancer of the larynx (voice box) without the need to remove the larynx. One disadvantage of radiation is that patients need to come into a treatment facility five days per week for six to eight weeks (though this schedule can vary). Also, there are a number of side effects, both immediate and long-term, that need to be considered
- Chemotherapy: Chemotherapy is the use of drugs to target rapidly growing cells in an effort to destroy cancer cells. In many cases, chemotherapy can be delivered on an outpatient basis. This means you go to a special chemotherapy infusion centre for the day. The frequency you will need to receive chemotherapy and how long will be determined by your doctor and may change from the original plan depending on what type of side-effects you have and how the tumour responds. In some cases, the chemotherapy might be administered once per week for three weeks. In other cases, it might be delivered three days in a row and then every week for a few weeks.
What are the side effects of treatment?
- Surgery: Surgery retains a pivotal role in management of head and neck cancers. Side effects are both general and specific to the location of the tumour. They include:
- Anaesthesia risks
- Infections-wound contamination
- Blood loss-blood loss is inevitable though it can be minimised by surgical techniques or treated with a blood transfusion
- Air embolus-this is air entering into the blood stream, it is very rare but serious.
- Chyle leak-damage to the thoracic duct leads to a chyle leak.
- Nerve damage-nerves may be inadvertently damaged because of extensive tumour involvement and removal. Repair may be done immediately or later or rehabilitation instituted.
- Radiotherapy: There are number of side effects of radiation therapy. The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation.
- Xerostomia (dry mouth)-The most common long-term side effect of radiation therapy for the treatment of head and neck cancer is xerostomia (dry mouth). It occurs when salivary glands are radiated or in the line of radiation. Aside from being bothersome to patients, including making it difficult to eat and speak, there is great risk of dental cavities and dental disease because saliva helps prevent dental disease.
- Osteoradionecrosis (bone death)-This is necrosis (or death) of bone that has been exposed to radiation. The bone often becomes exposed through the skin or mucosa and can progress to an actual fracture of the bone. Osteoradionecrosis (ORN) can cause severe pain as well as chronic and persistent infections. Treatment is essentially by visiting a dentist before radiotherapy to make sure the teeth are in the best possible health.
- Odynophagia (and mucositis)-This is pain with swallowing. It can be caused as the mouth and throat lining starts sloughing off and becomes inflamed (mucositis).
- Skin changes-Patients will usually lose hair in the region that received radiation.
- Hypothyroidism-The thyroid gland is located immediately in front of many parts of the throat. Therefore, damage to the thyroid gland can occur following radiation for head and neck cancers. This will result in hypothyroidism, or an underactive thyroid, which can actually be quite delayed in its presentation. Feeling tired and weight gain are the common complaints.
- Pharyngoesophageal stenosis-This can be another delayed problem caused by radiation. Pharyngoesophageal (PE) stenosis is an area of narrowing in the throat or oesophagus (feeding tube). This narrowing can make it difficult to eat, particularly solid food.
- Secondary cancers-Paradoxically, even though radiation is used to treat cancer, years later it can actually result in new cancers appearing. The risk increases with high dosage and greater time since treatment. The secondary cancer can be quite different from the original. Secondary cancers are rare.
- Chemotherapy: You will almost certainly experience side effects from chemotherapy. While chemotherapy targets cancer cells, these medications can also cause damage to normal cells. Finding the right balance can be difficult, and your medical oncologist will speak to you about those issues. Also, while some side effects are common to most chemotherapies, other side effects are specific to certain drugs.
The most common side effects are:
- Mucositis- This is inflammation and ulceration of the lining of your mouth and throat. Mucositis can cause severe pain and difficulty with eating and drinking
- Hearing loss- Associated symptoms might include ringing in the ears (tinnitus).
- Kidney problems-This is a problem with all chemotherapy drugs.
- Nausea and vomiting-This is common and you might require additional medication to reduce the nausea.
- Rash- The rash looks similar to acne. Fortunately, the rash goes away after stopping treatment, and there is no significant pain or problems related to rashes
- Neuropathy- This is a nerve problem that usually starts as a feeling of numbness or tingling in the fingers or toes. It can also feel like an electric bolt that shoots down an arm or a leg. It may not be bothersome and easy to deal with; or it may be severe enough to stop the drugs.
Other side effects include:
- Diarrhea / constipation
- Low blood counts
- Loss of appetite
- Bleeding problems
- Sexual and fertility changes
- Urination changes
- Memory changes
The cancer journey
If you have recently been diagnosed with a head and neck cancer, there are some initial steps you can make to get prepared. Some common challenges you may meet in the course of the disease s well as treatment are difficulty with feeding, swallowing and breathing.
Strategies for success to optimize speaking and swallowing include assessment prior to treatment by:
- Evaluation by a speech pathologist– Changes in voice and swallowing are common during and after treatment Evaluation by a speech pathologist may be done prior to treatment, especially to obtain baseline measurements of your ability to speak and swallow as well as to assess the likelihood of your experiencing side-effects in your voice or ability to speak as a result of your treatment. The speech pathologist can also provide you with recommendations to preserve your ability to swallow, which may include changes in your oral hygiene routine. In addition, you can learn swallowing exercises and practice them during therapy to maintain your ability to swallow
- Evaluation by a nutritionist– Patients with head and neck cancer are often undernourished before initiating treatment, which may be due to complications associated with the tumour. Many patients with head and neck cancer may experience weight loss during the course of the disease. Therefore, a nutritionist may assess your nutritional needs at your baseline and periodically throughout the course of your cancer journey. The nutritionist can provide you with strategies for treatment-associated side effects that may disrupt eating through the course of treatment. If your nutritionist determines that you are currently not getting adequate nutrition at any time during the course of your disease, you may temporarily receive nourishment intravenously or through a feeding tube.
- Evaluation by a dentist– Radiation therapy has been associated with an increase in cavities and bone loss. Prior to treatment, you should have a dental evaluation. If you are likely to receive radiation therapy, then prophylactic fluoride treatment should be done to protect your teeth during treatment and for the rest of your life, which can decrease the likelihood of developing cavities
Understanding your diagnosis
Cancer is diagnosed from the biopsy. Staging is done to determine the extent of the disease, the treatment options as well as prognosis.
A 5 year survival rate of head and neck cancers is given below.
|Table. Five Year Relative Survival for Head and Neck Cancer in the USA, by Stage|
|Stage at Diagnosis||Stage Distribution (%)|
|Localized, Stage I-II||82.4%|
|Regional, Stage III||57.3%|
|Distant, Stage IV||34.9%|
|From Howlander, SEER, 2012|
Understanding the treatment plan
The treatment options depend on the location, type and stage of the head and neck cancer, comorbid diseases and patient values and priorities. The 3 main treatment options are surgery, chemotherapy and radiotherapy in combination or stand alone. Staying on top of the treatment plan involves assessment by a speech pathologist, nutritionist and dentist prior and during treatment.
Life during treatment
During your treatment, you will likely experience treatment-related side effects.
The following side effects can worsen during the course of treatment and can negatively impact your quality of life:
- Changes in your speech (e.g., hoarseness, loss of voice)1
- Changes in hearing; over 85 percent of patients with head and neck cancer who had chemoradiation therapy experienced hearing loss
- Decreased salivation, which often increases dental caries and other dental problems
- Problems swallowing (e.g., delayed swallowing or other complications)
- Decreased ability to eat
Fatigue has been ranked by patients as having the strongest impact on quality of life. Strategies to reduce cancer-related fatigue include:
- Assess and report the level of fatigue daily. You may want to consider using a diary or worksheet to monitor fatigue. Report the severity of fatigue (none, minor, moderate, advanced) that you are experiencing and other related observations that you may have, such as the times of the day when you may have more or less fatigue.
- Plan and schedule routines or activities during the time of day when you are likely to have the least fatigue.
- You may consider entrusting a caregiver to perform some daily tasks for you.
- Initiate and maintain a daily exercise program. In a study evaluating exercise among patients with head and neck cancer. Even low impact exercise, such as walking daily, has been found to reduce fatigue, improve quality of life and enable patients to perform activities of daily living.
- Evaluate your psychosocial needs with a counsellor or psychologist and consider initiating treatments, such as regular counselling or therapy.
- Consider using medications.
Changes in eating
Several factors can cause changes to your eating during cancer treatment. Some of these include the following:
- Problems swallowing, which can be caused by the location of the tumour
- Nausea and/or vomiting, which are often side effects associated with chemoradiation therapy
- Changes in the perception of taste or smell
- Changes in salivation, such as decreased salivation or changes in the saliva quality
- Decreased appetite
- Inflammation of the membranes in the mouth (mucositis); severe mucositis sometimes causes pain, which in turn negatively impacts the desire to eat
If you experience any of these problems and your nutritional needs are not being met, there are various solutions that your nutritionist and health care professionals may suggest, which are as follows:
- If you experience a loss of appetite, eat smaller meals more often.
- Eat or drink foods that are rich in the nutrients that you need.
- Use nutritional supplements, such as protein powders or nutrition “shakes,” to boost your caloric intake.
- There may be a need for temporary treatment to help you meet your nutritional needs, which include the use of a feeding tube or an IV.
- Manage treatment-associated side effects. For example, if you experience decreased salivation as a side effect of radiation therapy, there are medications that can stimulate salivary production
Working during cancer treatment
You may need to take time off from work as you are undergoing therapy for cancer. In addition, cancer-related fatigue can be so severe that it disrupts the ability to do daily activities, let alone work. A person may be unable to perform his or her job during this time. Discuss with your employer or HR manager about medical leave or unpaid leave or any other measure to protect your job during your absence.
Life after treatment
The post-treatment time period is from the completion of treatment through two years after the completion period. Your post-treatment care will involve periodic follow-up visits with your doctor to make sure your cancer does not return. You may also need ongoing rehabilitation for speaking, swallowing and nutritional needs.
Patients who were administered chemotherapy and radiation therapy also exhibit swallow impairments at baseline, such as decreased tongue strength or delayed swallowing. However, in the first three months after chemoradiation therapy, patients worsened. The impact of surgery on swallowing varies greatly depending on the extent of the cancer removal (ablation) and the type and sophistication of the reconstruction surgery performed. All patients with swallowing deficits, however, should receive rehabilitation, which includes specific swallowing and strengthening exercises.
The following may be useful if you have impaired swallowing and/or mucositis and decreased salivation post-treatment:
- Avoid spicy foods, especially if you have mucositis.
- If decreased salivation is disrupting your ability to eat, consult your physician to see if you can use medication to stimulate salivary production.
- It is possible that you may need to obtain nutrients through a feeding tube or an IV.
Navigating your finances
Maintaining health insurance coverage during an illness that interferes with one’s ability to work full time can be challenging. You may need to learn more about your particular type of insurance coverage and what steps you can take to maintain your insurance during your cancer journey.
The path to remission
If a patient experiences complete remission, the primary symptoms associated with head and neck cancer should disappear or at least be markedly improved; there should be no evidence of the primary tumour on physical exam and CT or MRI scans should also have no evidence of disease at the site of the tumour or in other areas of the body.
Although you may now be in remission, it is critical that you continue to be vigilant to find out if the cancer returns or if a secondary cancer grows. There is a higher probability of cancer returning (recurrence) or a new cancer occurring in the first few years.
Although this may be stressful and cause anxiety for you, it is best to identify cancer at an early stage.
Therefore, you will need to undergo periodic follow-up physicals, scans and other tests according to a schedule.
If you have been successfully treated for cancer that is in remission, but it returns, you have what is called recurrent cancer. Recurrent cancer can occur near the original site of the tumour, known as recurrent locoregional cancer, or at distant sites in the body, known as recurrent metastatic cancer.
The best way to handle the possibility of recurrence is to remain vigilant for several years following the end of your treatment. See your doctor regularly for follow-up visits and imaging to reassure yourself that you remain cancer-free or to detect a recurrence as early as possible. Just as it was with your initial diagnosis, the earlier you detect the cancer, the better your prognosis will be.
You should take all possible steps to reduce the risk of cancer recurrence. Stopping smoking and drinking should reduce your risk of cancer recurrence.
Treatment options for head and neck cancer that returns but only in a small amount (eg, locoregional recurrence) include any of the following: surgery, radiation therapy, chemoradiation therapy or chemotherapy. However, whether or not your tumour was previously treated with radiation therapy will now guide current treatment decisions. The treatment goal for locoregional recurrent disease is usually to cure the disease; however, the recurrent disease is harder to treat if the tumour is large, inoperable and/or previously treated with radiation therapy and therefore excluded from additional radiation therapy.
Prognosis for recurrent widespread (ie, metastatic) head and neck cancer is unfortunately very poor.
Life after cancer
Many head and neck cancer survivors recover very well, both physically and emotionally, and are able to return to a life that is very similar to what was normal before their cancer journeys began. Others find a “new normal” and settle into their altered lifestyles with relative poise. You may even find that many aspects of your life improve as your appreciation for your wellness and time with loved ones increases. Even so, you may encounter ongoing challenges directly related to your experience with head and neck cancer. This is not unusual, so it is important to recognize when you may need help from a counsellor, psychotherapist, physical therapist or nutritionist to restore your quality of life to the best it can be.
Whether you recover well or continue to struggle with challenges related to your head and neck cancer, life after cancer is ultimately what you make of it. Cancer survivors typically advise other survivors to take pride in what they have overcome, value their wellness and find meaning in what they do with the rest of their lives.
If your initial diagnosis was for advanced (stage IV) head and neck cancer, your likelihood of survival within five years is low; out of patients similarly diagnosed with advanced head and neck cancer, 65 percent were deceased within five years. Although this may not be hopeful for you, awareness of this information should enable you to begin making your end-of-life choices.
You may want to reflect upon a few questions so that you can make end-of-life decisions:
- What type of medical care do you desire at the end of your life?
- Where do you want to die and how do you want to die?
Palliative care can be defined as therapy that treats symptoms, but extending life is not the goal of palliative care.
Hospices provide care for patients when they typically have six months or less left to live and provide comfort to a patient at the end of his or her life. Hospices are not intended to provide therapy that cures or extends the patient’s life. This care may be done at the patients home or in a specialized setting.
Questions to ask the doctor
One of your biggest allies in battling cancer is your ENT doctor and cancer doctor (oncologist). Questions are your primary resource to gain a better understanding of your disease and enhance your quality of care. Well-thought-out questions can help you get the most out of your appointments and can make all the difference. Here are some questions you may want to ask:
- What type of head & neck cancer do I have? Where is the tumour located?
- What diagnostic tests do I need? What do they involve?
- Can you explain my pathology report and test results to me?
- What is the stage of the disease? What is the prognosis?
- What is the goal of treatment? What are my treatment options?
- What are the benefits of each treatment?
- What are the risks and side effects of each treatment?
- How will my condition be monitored during treatment?
- Do you have any advice on managing side effects? What can I do to take care of myself during treatment?
- What is treatment recovery like?
- What should I tell other people (kids, parents, siblings, friends, etc.) about my cancer when they ask?
- What will my follow-up appointment schedule be like?
The content on the Nairobi ENT website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions.
- The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers.
- The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Detection, Prevention and Risk Reduction.
- The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Supportive Care
- Shah, Jatin P., and William Lydiatt. “Treatment of cancer of the head and neck.” CA: a cancer journal for clinicians 45.6 (1995): 352-368.
- Kerawala, Cyrus J., and Manolis Heliotos. “Prevention of complications in neck dissection.” Head & neck oncology 1.1 (2009): 35.