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Cancer Medicine ::

Nasopharyngeal Cancer

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. The team may include medical oncologists, radiation oncologists, surgeons, otolaryngologists (ear, nose, and throat doctors), maxillofacial prosthodontists (specialists who perform restorative surgery in the head and neck areas), dentists, physical therapists, speech pathologists, mental health professionals, nurses, dietitians, and social workers.

Many cancers of the nasopharynx can be cured, especially if found early. The main treatment of NPC is radiation therapy, often given in combination with chemotherapy. This approach may be called concomitant chemoradiotherapy. Surgery for NPC is occasionally used, mainly to remove lymph nodes after chemoradiotherapy or to treat NPC that has recurred (come back after initial treatment). Descriptions of the most common treatment options for nasopharyngeal cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health.

Although curing the cancer is the primary goal of treatment, preserving the function of the nearby organs and tissues is also very important. When doctors plan treatment, they also consider how treatment might affect a person’s quality of life, including how a person feels, looks, talks, eats, and breathes. 

Radiation therapy

Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation therapy is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

External-beam radiation therapy is a radiation beam aimed at the tumor. It is the most common type used to treat NPC. A method of external radiation therapy, known as intensity-modulated radiation therapy (IMRT), allows for more effective doses of radiation therapy to be delivered while reducing the damage to healthy cells and causing fewer side effects. Another type of external-beam radiation therapy is called proton therapy (also called proton beam therapy), using protons rather than x-rays. At high energy, protons can destroy cancer cells. Proton therapy may be used as part of the treatment for some skull-base tumors to further limit the radiation dose to nearby structures, such as the optic (eye) nerves and brainstem; proton therapy may be an option for advanced NPC that is located close to parts of the central nervous system (brain and spinal cord). 

Stereotactic radiosurgery delivers radiation therapy precisely to the tumor using a machine called a gamma knife. This can be used to treat a tumor that has invaded the base of the skull or a tumor that has recurred at the base of the brain or skull.

Internal radiation therapy involves tiny pellets or rods containing radioactive materials that are surgically implanted in or near the cancer site. The implant is left in place for several days while the person stays in the hospital. This approach is most often used to treat cancers that have recurred after initial treatment. It may also be used to treat the original tumor.

Before beginning radiation treatment for any head and neck cancer, people should receive a thorough examination from an oncologic dentist (a dentist experienced in treating people with head and neck cancer). Since radiation therapy can cause tooth decay, damaged teeth may need to be removed. Often, tooth decay can be prevented with proper treatment from a dentist before beginning cancer treatment. After radiation therapy for NPC, dental care should continue to help prevent further dental problems. People may receive fluoride treatment to prevent dental caries (cavities). 

Other side effects of radiation therapy to the head and neck include redness or skin irritation in the treated area, dry mouth or thickened saliva from damage to salivary glands, bone pain, nausea, fatigue, mouth sores, and/or sore throat. In addition, there may be pain or difficulty swallowing; loss of appetite, due to a change in sense of taste; hearing loss, due to buildup of fluid in the middle ear; and buildup of earwax that dries out because of the radiation therapy’s effect on the ear canal. Radiation therapy may also cause a condition called hypothyroidism in which the thyroid gland (located in the neck) slows down and this causes people to feel tired and sluggish and gain weight. Every patient who receives radiation therapy to the neck area should have his or her thyroid checked regularly. There are numerous studies underway to find ways to reduce or better relieve the side effects of radiation therapy. Talk with your doctor before treatment begins about ways to prevent or reduce side effects, as well as how side effects will be treated by the health care team if they do happen. 

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. Chemotherapy may be given orally (by mouth), intravenously (in a vein), or through an injection into a muscle, under the skin, or directly into the cancerous tumor.

The combination of chemotherapy and radiation therapy is commonly used to treat NPC. The use of chemotherapy as a first treatment before radiation therapy is also being studied.

In chemotherapy, each drug or combination of drugs can cause specific side effects, and it is important to talk with your doctor about which side effects to expect and if any may be permanent. Side effects of chemotherapy may include fatigue, nausea, vomiting, hair loss, dry mouth, diarrhea and/or constipation, and loss of appetite, often due to a change in sense of taste. In addition, it can weaken the immune system and cause open sores in the mouth, which can lead to infection. In general, chemotherapy in combination with radiation therapy increases such side effects. Nutritional support may be necessary during treatment due to these side effects.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. It is occasionally used for NPC, but it is not a common treatment choice because the area is hard to reach and lies close to cranial nerves and blood vessels. A surgical oncologist is a doctor who specializes in treating cancer using surgery.

If the doctor suspects that the cancer has spread to the lymph nodes, a neck dissection (the surgical removal of lymph nodes) may be necessary. In the specific instance of undifferentiated carcinoma of the nasopharynx, neck dissection is occasionally needed. A neck dissection may cause numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. The side effects are caused by injury to nerves in the area. Depending on the type of neck dissection, weakness of the lower lip and arm may go away in a few months. However, it is possible that weakness will be permanent if a nerve is removed or damaged as part of a dissection. Facial disfigurement may need to be addressed using reconstructive (or plastic) surgery. Before your operation, talk with your surgeon in detail about what you can expect and if another surgery will be needed for reconstruction.

Palliative/supportive care 

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible.     

Recurrent NPC

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Recurrent NPC is usually treated with radiation therapy, chemotherapy, and/or sometimes surgery. Chemotherapy is used for people whose cancer has recurred in distant sites and who were previously treated with radiation therapy only. Chemotherapy may also be used together with radiation therapy (chemoradiotherapy) to improve the effectiveness of the radiation therapy. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. For instance, a clinical trial of biologic therapy (immunotherapy) may be an option .

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic NPC

If cancer has spread to another location in the body, it is called metastatic cancer.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. 

Your health care team may recommend a treatment plan that includes a combination of radiation therapy and chemotherapy. Sometimes, surgery may be recommended as well. Supportive care will also be important to help relieve symptoms and side effects.

If disease-directed treatment is not successful, this may also be called advanced cancer. This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. 

If treatment fails

Recovery from NPC is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Clinical Trials

Doctors and scientists are always looking for better ways to treat patients with NPC. To make scientific advances, doctors create research studies involving people, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments, such as new chemotherapy drugs, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating NPC. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with NPC.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. 

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. 

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends.

Coping with Side Effects

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for NPC are described in detail within the Treatment section. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with NPC. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. 

After Treatment

After treatment for NPC ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. 

People treated for NPC should receive regular follow-up medical and dental examinations to check for signs that the NPC has come back (recurred) or there is a secondary cancer (a different type of cancer). During follow-up visits, doctors may check thyroid functioning, vision, and hearing to detect any cranial nerve damage from treatment. They may also take an MRI or CT scan six to eight weeks after treatment, called a baseline study. If NPC comes back, the baseline study will help them track when the changes began. Most recurrences of NPC happen in the first two to three years after treatment, so follow-up visits will be more frequent during those years.

People who have had NPC have a higher risk of developing a secondary cancer. Researchers are evaluating the benefits of using chemotherapy as a way to prevent second cancers (called chemoprevention).

Follow-up visits will also help manage any late or long-term side effects from cancer treatment, such as buildup of earwax. Periodic ear examinations are necessary to remove buildup of dried earwax. Prevention of dental cavities is also important. Fluoride application is recommended whenever the oral cavity and the salivary glands receive radiation treatment.

Rehabilitation is a major part of follow-up care after head and neck cancer treatment. People may receive physical therapy and speech therapy to regain skills, such as speech and swallowing. Supportive care to manage symptoms and maintain nutrition during and after treatment may be recommended. Some people may need to learn new ways to eat or to eat foods prepared differently. People may look different, feel tired, and be unable to talk or eat the way they used to. Many people experience depression. The health care team can help people adjust and connect them with both physical and emotional support services.

People recovering from NPC are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. 

Latest Research

Doctors are working to learn more about nasopharyngeal cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Biologic therapy. Biologic therapy (also called immunotherapy) is designed to boost the body’s natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function. Treatment based on the specific biologic characteristics of a tumor is being used with increasing frequency and being tested in clinical trials. People should talk with their doctors about the availability of these studies. 

Combining therapies. As outlined in Treatment, doctors continue to research the best combinations of different types of therapies (such as radiation therapy, chemotherapy, and surgery) for different stages of NPC.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current nasopharyngeal cancer treatments in order to improve patients’ comfort and quality of life. This includes ways of relieving “dry mouth” (xerostomia), mouth sores, pain and other side effects.

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