Head and neck cancer: Why is it common in India? Symptoms, causes and more

Beatles singer George Harrison was in his early 50s when he noticed an unusual lump in his throat. He was eventually diagnosed with throat cancer, which is a type of 'Head and neck cancer' and the reason for his developing it was attributed to his history of smoking. In our country too, head and neck cancer – which encompasses a diverse group of malignancies affecting the oral cavity, pharynx, larynx, nasal cavity, and paranasal sinuses – has become a health burden due to high rates of tobacco and alcohol consumption, with the added challenge of varying public health resources and awareness across regions. Let's explore the causes, symptoms, and advances in treatment for head and neck cancers, with a particular focus on India and Kerala.

What causes head and neck cancer?
While smoking and alcohol use are often cited as the reasons that trigger the ailment, it has a variety of risk factors in addition to them. Here's what global health organisations observe about it:
Tobacco and alcohol use
Tobacco and alcohol use are the primary risk factors for head and neck cancers in India. According to the World Health Organization (WHO), India has one of the highest rates of tobacco consumption globally, including both smoking and smokeless forms such as betel quid and khaini. Tobacco smoke contains carcinogens that damage DNA in cells, while alcohol acts as a solvent, enhancing the carcinogenic effects of tobacco. The combined use of these substances significantly increases the risk of developing cancers of the oral cavity, pharynx, and larynx. In Kerala, a state with high tobacco use rates, the prevalence of head and neck cancers is notably high. The Kerala State Tobacco Control Cell reports that around 35% of adults in the state use tobacco in some form, contributing to elevated cancer rates. This state-specific data underscores the urgent need for targeted prevention and cessation programs.

Human Papillomavirus (HPV)
HPV, especially HPV-16, is a notable risk factor for oropharyngeal cancers. In India, HPV-related cancers are on the rise, although they are less prevalent compared to tobacco-related cancers. HPV-16 and HPV-18 are responsible for the majority of HPV-related head and neck cancers. According to a study published in the *Indian Journal of Medical Research*, HPV prevalence in oropharyngeal cancers in India ranges between 10-20%, lower than in Western countries but still significant.
Occupational exposures
Occupational exposures to certain chemicals and dust also contribute to head and neck cancer risks. In India, industries such as construction and textiles expose workers to asbestos, wood dust, and formaldehyde, increasing their cancer risk. The International Agency for Research on Cancer (IARC) highlights that asbestos is a known carcinogen, and exposure to it is linked to increased incidence of head and neck cancers.

Dietary factors
Diets low in fruits and vegetables, along with deficiencies in essential nutrients such as vitamin A and beta-carotene, are associated with an increased risk of head and neck cancers. In India, where dietary patterns can be deficient in these nutrients, this factor is of particular concern. The National Institute of Nutrition (NIN) reports that inadequate intake of fruits and vegetables is prevalent in many regions, including Kerala, contributing to higher cancer risks.
Genetic factors
Genetic predisposition also plays a role. While genetic syndromes like Fanconi anaemia and Li-Fraumeni syndrome are rare, family history of head and neck cancers can increase individual risk. However, genetic factors are less commonly highlighted compared to environmental and lifestyle factors in the Indian context.

Types and symptoms
Head and neck cancers in India are classified based on their anatomical location and include:
Oral cavity cancer: This includes cancers of the lips, tongue, floor of the mouth, and gums. Symptoms often include persistent sores or lumps in the mouth, difficulty chewing or swallowing, and voice changes. In India, oral cavity cancers are among the most common, largely due to high rates of tobacco use.
Pharyngeal cancer: Divided into nasopharyngeal, oropharyngeal, and hypopharyngeal cancers. Symptoms can include sore throat, pain or difficulty swallowing, ear pain, and nasal obstruction. Nasopharyngeal cancer is relatively rare but can be associated with HPV infection.

Laryngeal cancer: Affects the larynx or voice box. Symptoms include hoarseness or changes in voice and difficulty swallowing. This type of cancer is often linked to tobacco and alcohol use.
Nasal cavity and paranasal sinus cancer:
Symptoms may involve nasal obstruction, frequent nosebleeds, and facial pain or swelling. These cancers are less common but can be associated with occupational exposures.
Salivary gland cancer:
Symptoms include swelling or lumps in the jaw, mouth, or neck. This type of cancer can be challenging to diagnose early due to its subtle symptoms.

Diagnosis and treatment
Diagnosis: Accurate diagnosis of head and neck cancers typically involves a combination of physical examination, imaging studies (such as CT scans, MRI, and PET scans), and biopsy procedures. Early detection is crucial and is often facilitated by regular dental check-ups and screenings for high-risk individuals. The Indian Council of Medical Research (ICMR) emphasizes the importance of early diagnosis in improving treatment outcomes and survival rates.

Treatment
Treatment options are tailored to the cancer’s location, stage, and the patient’s overall health. The primary treatment modalities include:
Surgery: Surgical resection of the tumour is often necessary and may involve removing part of the oral cavity, pharynx, or larynx, as well as neck dissection to remove affected lymph nodes. In advanced cases, reconstructive surgery may be needed.
(Dr Deepthi TR is a Specialist in Early Cancer Detection and Prevention, Oncure Preventive and Healthcare Centre Kannur)