Treatment for tongue cancer

Dr Mark Torres-Holmes details the treatment decision-making process and the likely phases of treatment.

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The best treatment decisions are made involving the patient with a multi-disciplinary team which includes the head and neck surgeon, radiation oncologist, medical oncologist, radiologist, pathologist, dental team, speech and swallow therapist, dietitian, physician, anaesthesiologist and plastic reconstructive surgeon. Patients and their cancer are discussed at a weekly meeting and the best plan for the patient is decided upon. This plan is presented to patients and another discussion is had whether the recommended plan agrees with the patient’s goals.

Goals of treatment

The most common goals of cancer treatment are curative, meaning: getting rid of the cancer, preventing it from coming back and preserving as high a quality of life as possible. The primary tools to achieve these goals include surgery, radiation and chemotherapy or a combination thereof. Sometimes the goal isn’t to go for cure but to rather focus on quality and dignity of life only.

Surgery

Primary curative treatment is often surgical excision. This is done in one of two ways: either with cautery or with a carbon dioxide laser done under a microscope.

The goal of surgery is to remove the tumour completely with clear margins while preserving as much of the vital structures of the tongue as possible. Frozen section pathology in theatre helps increase clear margin rate.

The tongue often doesn’t require reconstruction due to it’s amazing healing and compensatory ability, but when more than half of the tongue is removed, it does significantly impact the patient’s ability to talk, chew and swallow. Hence, the need for soft tissue free flap reconstruction at the same time. Sometimes a part of the mandible needs to be removed if it’s involved by cancer and this can be reconstructed with the patient’s own fibula bone as a free flap.

If there is already confirmed cancer in the neck lymph nodes before surgery, the neck dissection is more extensive than if there are no obvious nodes in the neck, but a neck dissection is still necessary in the latter situation. Removal of all neck disease as well as the at-risk neck nodes is the goal, preserving the vital structures of the neck such as nerves.

Patients can expect to stay three to seven days in hospital depending on other illnesses and complications. Physicians, intensivists and dietitians are often involved to manage and decrease the risks associated with having major head and neck surgery.

Radiation

Post-operative radiation may be needed three to six weeks after surgery if there are worrying signs on the final histology such as: very advanced disease, positive margins, perineural or lymphovascular invasion and multiple positive neck nodes or extranodal extension of tumour out of the nodes.

If indicated, chemotherapy is added to the radiation weekly because it’s a radiosensitiser making the radiation more effective. It does increase the negative effects of the treatment though. There are both short- and long-term negative treatment effects. The short-term effects include dry mouth; change or loss of taste; sores in the mouth (mucositis) and loss of appetite. Long-term effects could be difficulty swallowing and teeth problems.

If during the pre-treatment discussion the multi-disciplinary team thought there might be a high chance of radiation being recommended, then pre-treatment visits to a few other colleagues is recommended. These include the dental and swallow team.

Radiation side effects to the teeth can be reduced by preparing patients appropriately before treatment begins, possibly involving teeth cleaning, but sometimes removal of bad teeth, and/or dental implants are recommended. Swallow exercises help to keep the chewing and swallow mechanism intact, making it less likely that tube feeding will be necessary during treatment.

Surveillance

Once the treatment phase is over, surveillance involves seeing the head and neck surgeon and treatment team often during the first two years, usually every two to four months. Clinical examination and radiological imaging will be used to pick up any recurrences early and surgery is usually considered the best form of salvage. If surgery isn’t possible there are palliative chemotherapy or radiation options, but with the increasing use of immunotherapy in select patients, we have seen some hopeful results.

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