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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 10-17

Public health significance of head and neck cancer – A narrative review

1 Department of Public Health and Epidemiology, University of Miami, Miami, FL, USA
2 Department of Malaria and Vectors Born Disease, Directorate of Disease Surveillance and Control, MOH, Oman
3 Department of Periodontics, Faculty of Dentistry, Sebha University, Faculty of Dentistry, Sebha University, Sebha, Libya

Date of Web Publication28-May-2020

Correspondence Address:
Fatma Ahmed
Department of Public Health and Epidemiology, University of Miami, Miami, FL
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/dmr.dmr_4_20

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Head and neck cancers (HNCs) are a term describing the biologically heterogeneous group of cancers that affect the upper aerodigestive tract and share a common anatomic origin. HNC is one of the most prevalent types of cancers globally. This narrative review is based on a comprehensive search of Medline, Google Scholar, the Cochrane Database of Systematic Reviews, and other electronic databases. The scientific literature in English language dealing with HNCs with relevance to public health significance was reviewed. Various topics of controversy in dealing with the public health significance of HNC have been highlighted in this report in context to the needs of the HNC patients. The search revealed significant gaps in public health delivery for HNC patients. Moreover, conclusively, we recommend that the health-care professionals should be better trained to handle the needs of HNC patients.

Keywords: Head and neck cancer, oncology, oral cancer, quality of life

How to cite this article:
Ahmed F, Marshoudi SA, Peeran SW. Public health significance of head and neck cancer – A narrative review. Dent Med Res 2020;8:10-7

How to cite this URL:
Ahmed F, Marshoudi SA, Peeran SW. Public health significance of head and neck cancer – A narrative review. Dent Med Res [serial online] 2020 [cited 2021 Jun 14];8:10-7. Available from: https://www.dmrjournal.org/text.asp?2020/8/1/10/285212

  Introduction Top

Head and neck cancers (HNCs) are a term describing the biologically heterogeneous group of cancers that affect the upper aerodigestive tract and share a common anatomic origin.[1],[2],[3] HNCs include those that affect the lips, oral cavity, pharynx, larynx, paranasal sinuses, and salivary glands.[4]

  Incidence and Prevalence Top

HNC comprise up to 3% of all cancers in the United States with an estimated 63,000 people affected and 13,000 deaths in 2017.[5],[6] They are the seventh most common cancers globally, accounting for over 500,000 new cases annually and affect males more than females.[1],[7],[8],[9] HNCs are described based on the cell type they start with. Most of the HNCs are squamous cell carcinomas[10] HNC is believed to be a preventable disease caused by the exposure of epithelium to carcinogens such as tobacco and alcohol or human papillomavirus (HPV), the common sexually transmitted infection.[1],[10],[11],[12],[13],[14],[15],[16],[17] Further, in South Asia, an innocuously appearing nut, betel nut, which is habitually chewed in some communities is one of the leading causes of oral cancers.[18],[19],[20] Recent studies suggest a simultaneous decline in tobacco-associated carcinomas and an increase in HPV-mediated carcinomas, especially among younger males.[3],[21],[22],[23],[24]

  Cost of Healthcare in Head and Neck Cancer Patients Top

HNCs may affect various aspects of human life. They result in a direct cost due to screening, diagnosis radiotherapy (RT), chemotherapy, surgery, long-term supportive care, and follow-up care as well as indirect costs such as reduced workforce participation, early death, and the resultant loss of productivity.[25],[26] Thus, costs of HNC for individual patients are substantial and the cumulative public health burden is colossal.[27] Mariotto et al. estimated that the surviving cancer patients in the US to be 18.1 million cancer and the associated costs of cancer care to be 157.77 billion US dollars in 2020 for US.[28] It was estimated that 3.6 billion was spent on HNC care in the US in 2014.[29],[30] The initial HNC treatment costs for an individual patient are 41,980 and 39,179 USD among females and males, respectively. Further, the continuing annual costs per HNC patient, female and males were 4826 USD and 4001 USD, respectively.[28],[31] In another study which used commercial and Medicare Data, a 6-month adjusted cost was 60,414 USD for metastatic HNC and 21,141 USD for recurrent disease in 2008.[32] Further, studies in developed European countries showed similar costs of HNC. In a study in Germany, they found 4,898 inpatient rehabilitations for HNC patients in 2008 and cost including direct as well as the indirect cost was €365.78 million.[33]

  Mortality Top

HNC patients are characterized by high levels of comorbidity, increased risk of psychosocial distress, and an exposure to highly toxic treatment strategies.[34] Hence, deaths in HNC patients can be due to cancer as well as noncancer causes. The noncancer causes that predispose HNC patients to death include advanced age and comorbid cardiopulmonary diseases.[35],[36] Mortality in HNC patients can also be due to treatment-related mortality such as sepsis, organ failure, pulmonary embolism, aspiration pneumonia, surgical complications, or vascular disease.[35],[36],[37] Due to the above-mentioned reasons, the death among the HNC patients can be rapid and unpredictable.[38] The past decades have witnessed a steady decline in the US of HNC mortality, despite a stable incidence.[36],[39],[40],[41] In addition, the incidence of HNC in African Americans has reduced considerably over the past two decades and is now lower than that in whites. The mortality rate has also seen a downtrend among African Americans, but it remains higher than that in whites.[39] Among the HNC, squamous cell carcinomas are the most common ones in incidence as well as in mortality.[38],[42] Patients with recurrent and metastatic HNC have poorer survival rates, a median overall survival for patients with recurrent and/or metastatic squamous cell HNC remains <1 year despite available advancements in treatment.[43]

  Quality of Life in Head and Neck Cancer Patients Top

Quality of life (QoL) is reflective of the patient's point of view about his/her general well-being. It is a subjective, multidimensional concept that includes physical, occupational, social functional, and psychological well-being. It encompasses within it both positive and negative features of life.[44],[45],[46] The World Health Organization defines QoL as an “individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.[47],[48],[49] It is of paramount consideration in the management of HNC.[50] The head and neck region is an anatomically complex and functionally significant region. HNC patients encounter various challenges prior and post HNC treatment, including dysphagia, pain, xerostomia, dietary restrictions, physical restrictions, and psychological stress besides facial disfigurement and problems in sexual life.[45],[46] HNC problems can cause profound long-term adverse effects on the QoL of a patient for many years even after treatment. QoL in HNC patients is affected by different factors, such as patient's age, occupation, performance, status, comorbid medical conditions, compliance, pathology, and its extension and advance, timing of presentation, availability of experienced specialists in the required fields, relative impact of the treatment options such as extensive surgical resection, neck dissection, and postoperative radiation.[50],[51] The major problem experienced by the HNC patients is pain. It requires high levels of attention by the clinicians to improve their QoL.[51] Studies have shown varying results with QoL in HNC patients with some finding no improvement in the QoL in HNC patients despite intervention.[46] In a prospective study, Mehanna and Morton found that at 10 years following diagnosis, overall QoL (life satisfaction), decreased significantly in HNC patients.[52] The Institute of Medicine in 2001 constituted a report titled Crossing the Quality Chasm: A New Health System for the 21st Century reporting on a national initiative to improve the quality of care and consequently QoL in the US. The aims articulated in the report emphasized increasing safety and avoiding injuries to the HNC patients, delivering services based on scientific knowledge, to deliver treatment which is individualized and tailor-made for patients, timely delivery of patient care, increasing efficiency, and avoiding wastage of care delivery. The report also articulated placing emphasis on equitable delivery of care which is devoid of variance of health-care delivery based on personal characteristics, patient gender, ethnicity, geography, and socioeconomic status.[53],[54]

  Treatment Kinds Top

The primary options available for HNC treatment are surgery, radiation therapy, systemic therapy including chemotherapy and molecularly targeted agents; the targeted therapy.[10],[55] The selection of treatment options in HNC treatment largely depends on the stage, location, and severity of the neoplasm along with the general health consideration of the patient.[56] A single-modality treatment is generally sufficient to manage the HNC in the early stages, whereas a multidisciplinary approach is necessary in HNC with advanced stages of the neoplasm.[8]

Surgery remains the first and foremost option for the treatment of in early-stage HNC patients. The neoplasm in such patients can be treated with surgery without functional impairment.[8] In cases with oral cancer, it remains the mainstay of therapy even in advanced stages of the disease.[17] Some of the various surgical procedures that are undertaken in the treatment of HNC are partial glossectomy, “commando” procedure, transoral laser surgery, various types of neck dissections including selective neck dissection, modified radical neck dissection, radical neck dissection, extended radical neck dissection, and reconstructive surgery.[17],[57] The side effects of the surgery depend on the location and type of surgery carried over and may include difficulty in chewing, swallowing, speaking, damage to the adjacent nerves, and facial disfigurement.[58]

RT is the use of high-energy radiation to destroy cancer cells by causing DNA damage at a cellular level or by an indirect effect of free radical formation.[57],[59] It remains a viable tool in treatment of HNC.[60] However, advances in surgical techniques and reconstructive options have led to a decrease in the use of RT.[57] RT for HNC patients can be classified into external irradiation and brachytherapy.[61] External beam radiation therapy with or without concomitant brachytherapy is used in HNC patients as an alternative to surgery.[17] Hyperfractionated RT with platinum-based chemotherapy (PC) is used in the treatment of recurrent squamous cell HNC.[8] Moreover, RT is also used as palliative therapy for treating symptomatic metastatic sites.[62] RT often follows with side effects including reversible ones such as mucositis and dysgeusia (taste loss) and the irreversible lifelong challenges with hyposalivation, xerostomia, radiation-related caries (RRC), progressive periodontal loss, soft-tissue necrosis, and osteoradionecrosis (ORN).[63],[64],[65] These side effects of RT are dose-related and have an immense detrimental effect on the QoL of the HNC patients.[65],[66]

Chemotherapy employs drugs and it destroys all rapidly dividing cells such as the cancer cells, usually by stopping their ability to grow and divide.[67],[68] Conventionally, it has been used in HNC therapy. PC with either cisplatin or carboplatin is used as the first-line treatment in cases of inoperable recurrent or metastatic HNC. In cases of squamous cell HNC, PC along with 5-fluorouracil and cetuximab has been shown to result in increased overall median survival.[62],[69],[70],[71]

Targeted therapy is similar to conventional chemotherapy. However, the pharmacological agents in the case of targeted therapy are designed to specifically inhibit cancer cell growth, increase their death, and restrict their spread without harming normal cells.[67],[68] Cetuximab (Erbitux) is an IgG1 monoclonal antibody. It binds to a protein on the surface of the cancer cells, inhibits the epidermal growth factor receptor and thus stops them growing and dividing. Hence, it is used a target therapy to treat the colorectal cancer and HNCs. It is generally administered in conjunction with RT.[67],[68],[72]

The tumor cells prevent detection and elimination by the suppression of the host immune system. Immune checkpoint inhibitors (ICIs), a recent addition in cancer therapeutics, interrupt the immunosuppressive pathways called inhibitory checkpoints used by cancer cells.[73] This immunotherapy has evolved as an attractive treatment option for recurrent and metastatic HNC with encouraging preliminary data from studies involving ICIs (e.g., pembrolizumab and nivolumab) and toll-like receptor agonists (e.g., motolimod).[43] Asymptomatic HNC patients with a low disease burden, are often treated with single-agent regimens to keep the side effects of therapy at the minimum. In case of recurrent and metastatic squamous cell HNC commonly used drugs for treatment include docetaxel, paclitaxel, cetuximab, capecitabine, pemetrexed, and methotrexate.[62]

Photodynamic therapy (PDT) is a newly emerging, minimally invasive therapeutic modality which is clinically approved for cancer therapy.[74],[75] PDT is based on the principle that light has the ability to interact with certain substances called photosensitizers which are light activatable to produce cytotoxic species. When a photosensitizer absorbs light energy of a specific wavelength, in the presence of light, photochemical reactions take place. The end products of these reactions, singlet oxygen and other reactive oxygen species, directly damage biomolecules, and subcellular organelles and consequently produce cell death. Thus, PDT a two-stage procedure, that starts with administration of photosensitizer followed by a locally directed light exposure, is employed for confined tumor destruction.[74] In addition, because of cancer, the QoL will be affected either directly or indirectly and as a result there will be oral health needs and care is required.

  Oral Health-related Complications of Head and Neck Cancer Patients Top

Salivary gland function

Saliva in the oral cavity serves the important role of maintaining the oral and general homeostasis.[76] Radiation induces damage to the salivary glands diminishes both amount of salivary output as well as affects its quality.[77] This, salivary hypofunction predisposes HNC patients to oral discomfort or pain, difficulty in speaking, chewing, or swallowing, xerostomia, and retrograde infection of the salivary glands.[76],[78],[79]

Radiation-related caries

RRC is an aggressive and clinically seen side effect of RT.[80] RRC development is suggested to be an indirect effect of radiation-induced salivary gland damage.[79],[81] As damage to salivary glands with concomitant hyposalivation and alteration to the chemical composition of saliva are common irreversible side-effect of RT in HNC.[63],[64],[82] An alteration in the oral microbiota with an increase in the number of cariogenic bacteria following RT is also noticed.[64] Moreover, the tooth substrate is also affected by the direct exposure of radiation, altering and compromising the structural and mechanical properties of enamel, coronal dentin as well as root dentin.[83],[84],[85] Further, the intake of soft and carbohydrate-rich diet along with poor oral hygiene could contribute to the progress of this atypical caries.[80] RRC is generally encountered clinically in the cervical and incisal area of the tooth. The pattern of RRC appears as a “cervical ring” and hence does not appear like caries in patients who have not been exposed to radiation.[63],[80] This characteristic appearance of involving more than one surface gives it the name “caries circularis.”[86] As radiation-related caries remains a lifelong, irreversible threat, robust programs should be put in place for its prevention.[87] A recent review by Hong et al. stated that cancer patients, post-RT had the highest DMFT (Decayed Missing and Filled teeth) compared to those post-chemotherapy and healthy controls.[88],[89] The review also showed that the use of fluoride products and chlorhexidine rinses was of benefit.[88]

Disfigurement due to head and neck cancer

HNC involves the most visible and recognizable parts of a human being.[90] HNC patients at times face extensive treatment protocols including surgery with excision of the affected tissue.[91] Thereby, HNC patients could suffer facial disfigurement and experience substantial psychological trauma. Further, partners of HNC patients can be psychologically distressed. It can also have an impact on partners.[92],[93],[94],[95],[96],[97] Reconstructive surgery to improve the QoL of HNC patients along with patient counseling to overcome anxieties and calm emotional reactions and partner and public education are necessary.[91],[98],[99],[100]


ORN of the jaws is an infrequent complication.[101] It is avascular, aseptic necrosis of the jaws caused as a late complication of RT for HNC.[102],[103] ORN is characterized by bone tissue necrosis, decreased bone density with fractures, destruction of bony cortex, and loss of spongiosa trabeculations in spongy bone and failure to bone healing.[104],[105] It is seen in HNC patients who receive more than 6000 cGy (centigrays) of ionizing radiation even decades after treatment.[106] ORN increases in incidence in HNC patients who are tobacco smokers or use bisphosphonates.[107] Moreover, ORN affects mandible more than maxilla as mandible has dense bone and is poorly vascularized when compared to maxilla.[64] Dental trauma such as extractions, periodontal disease, denture induce trauma can trigger ORN in post-RT patients.[108],[109] Hence, extractions are to be carried over in HNC patients prior to RT.[110],[111]


Trismus is characterized by restricted mouth opening due to a decrease in the range of motion of the mastication muscles.[77],[112] Surgery or RT involving the muscles of mastication and temporomandibular joints can cause trismus and can adversely affect QoL in HNC patients.[64],[113],[114],[115] It is a common late-term side-effect of RT.[115]

  Oral Health Care Guidelines for Head and Neck Cancer Patients Top

Given the above factors that affect the oral health care of the patients as a result of HNC and the treatment complications, it is necessary to provide suitable oral health care that will help the patients to avoid the complications. HNC is a complicated disease. The oral health needs of HNC are wide ranging which include early detection of oral malignancy, treatment of the oral complications of HNC and its treatment and maintenance of oral hygiene and plaque control in HNC.[116],[117]

Plaque control

Dental plaque is the primary cause of the most common dental ailments, dental caries and periodontal disease and also contributes to HNC risk.[118],[119] Diagnosis and treatment of HNC has a severe negative impact on psychosocial functioning of the patients and causes a relatively high rate of depression among HNC patients.[120],[121],[122] HNC and its treatment can also lead to mutilation of oral tissues. Thus, rendering oral hygiene maintenance and plaque control an uphill task. Therefore, plaque control and oral hygiene maintenance in HNC patients are of significance.[64]

Guidelines for oral health care in head and neck cancer patients

The guidelines for oral hygiene and health care among HNC cancer patients provided by the National Institute of Dental and Craniofacial Research include several recommendations.[123] First, the guidelines include regular use of a soft toothbrush after every meal and before going to sleep, as well as regular but careful use of dental floss while avoiding hurting the periodontal tissues. Another recommendation is the use of alcohol-free mouth rinse and fluoride gels. The guidelines also include avoidance of alcohol, tobacco products, spicy food, and sweetened drinks. Finally, jaw exercise could be of help in patients with jaw stiffness following radiation.[123] Assessing and promoting knowledge of these guidelines among HNC patients can be an important part of health promotion.

  Factors That May Promote or Act as Barrier to Oral Health Care among Head and Neck Cancer Patients Top

However, some factors may promote or act as barriers to oral health care among HNC patients such as the need/availability of access to dental care and dental literacy among HNC patients.

Access to dental care

Access to oral health care is important for HNC patients.[124] Many HNC patients can have poor oral hygiene even before the diagnosis of HNC. The disease can compound the poor oral hygiene status, with depression of patient and with the mutilation of oral tissues both by disease as well as treatment. Yet, the number of HNC patients surviving the disease and living longer has also increased with advancements in treatment.[124],[125] This requires attention to be given to oral health care. Dental health professionals with sound knowledge to address HNC patients' needs should be part of the team of professionals that provide cancer care.[124],[125] Dental health-care providers should be at the cancer center, nearby hospital dental programs or in community.[125]

Dental health literacy

An adequate and accurate knowledge of the dental caries, periodontal disease among HNC patients their burden, as well as the oral complications due to HNC and its treatment, is necessary part of the dental literacy of the HNC patients. The dental health-care provider should provide oral hygiene instructions regarding brushing and flossing. Oral hygiene practices should be taught and reinforced both before and after cancer therapy is imparted.[126] Dental education and treatment of dental ailments prior to cancer therapy can minimize some oral complications of cancer treatments.[127]

Further, it is also important that dental professionals are aware of and understand the methods for care of HNC patients.[127] They must possess a thorough knowledge of prevention and treatment of complications that arise from cancer therapy.[125] Studies have shown that many dental health professionals have inconsistent knowledge.[128],[129],[130],[131],[132],[133],[134],[135],[136] Hence, there is also a need to improve the knowledge and impart the required skills among the dental professionals to serve HNC patients.

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Conflicts of interest

There are no conflicts of interest.

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