Head and neck cancer refers to a group of biologically similar cancers that start in the upper aerodigestive tract, including the lip, oral cavity (mouth), nasal cavity (inside the nose), paranasal sinuses, pharynx, and larynx. 90% of head and neck cancers are squamous cell carcinomas (SCCHN),^[1] originating from the mucosal lining (epithelium) of these regions.^[2] Head and neck cancers often spread to the lymph nodes of the neck, and this is often the first (and sometimes only) sign of the disease at the time of diagnosis. Head and neck cancer is strongly associated with certain environmental and lifestyle risk factors, including tobacco smoking, alcohol consumption, UV light, particular chemicals used in certain workplaces, and certain strains of viruses, such as human papillomavirus.^[3] These cancers are frequently aggressive in their biologic behavior; patients with these types of cancer are at a higher risk of developing another cancer in the head and neck area.^[3] Head and neck cancer is highly curable if detected early, usually with some form of surgery although chemotherapy and radiation therapy may also play an important role. The 2009 estimated number of head and neck cancer in the US is of 35,720 new cases.^[4]

Classification[link]

Head and neck squamous cell carcinomas (HNSCC's) make up the vast majority of head and neck cancers, and arise from mucosal surfaces throughout this anatomic region. These include tumors of the nasal cavities, paranasal sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.

Oral cavity[link]

Squamous cell cancers are common in the oral cavity, including the inner lip, tongue, floor of mouth, gingivae, and hard palate. Cancers of the oral cavity are strongly associated with tobacco use, especially use of chewing tobacco or "dip", as well as heavy alcohol use. Cancers of this region, particularly the tongue, are more frequently treated with surgery than are other head and neck cancers.

Surgeries for oral cancers include

• Maxillectomy (can be done with or without Orbital exenteration)
• Mandibulectomy (removal of the mandible or lower jaw or part of it)
• Glossectomy (tongue removal, can be total, hemi or partial)
• Radical neck dissection
• Moh's procedure
• Combinational e.g., glossectomy and laryngectomy done together.

The defect is covered/improved by using another part of the body and/or skin grafts and/or wearing a prosthesis.

Nasopharynx[link]

Nasopharyngeal cancer arises in the nasopharynx, the region in which the nasal cavities and the Eustachian tubes connect with the upper part of the throat. While some nasopharyngeal cancers are biologically similar to the common HNSCC, "poorly differentiated" nasopharyngeal carcinoma is distinct in its epidemiology, biology, clinical behavior, and treatment, and is treated as a separate disease by many experts.

Oropharynx[link]

Oropharyngeal squamous cell carcinomas (OSCC) begins in the oropharynx, the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils. Squamous cell cancers of the tonsils are more strongly associated with human papillomavirus infection than are cancers of other regions of the head and neck.

Hypopharynx[link]

The hypopharynx includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis, and have the most adverse prognoses of pharyngeal tumors. They tend to metastasize early due to the extensive lymphatic network around the larynx.

Larynx[link]

Laryngeal cancer begins in the larynx or "voice box." Cancer may occur on the vocal folds themselves ("glottic" cancer), or on tissues above and below the true cords ("supraglottic" and "subglottic" cancers respectively). Laryngeal cancer is strongly associated with tobacco smoking.

Surgery can include partial laryngectomy (removal of part of the larynx) and total laryngectomy (removal of the whole larynx). If the whole larynx has been removed the person is left with a permanent tracheostomy and can learn to speak again in a new way with the help of intensive teaching and speech therapy and/or an electronic device.

Trachea[link]

Cancer of the trachea is a rare malignancy which can be biologically similar in many ways to head and neck cancer, and is sometimes classified as such.

Most tumors of the salivary glands differ from the common carcinomas of the head and neck in etiology, histopathology, clinical presentation, and therapy, Other uncommon tumors arising in the head and neck include teratomas, adenocarcinomas, adenoid cystic carcinomas, and mucoepidermoid carcinomas.^[3] Rarer still are melanomas and lymphomas of the upper aerodigestive tract.

Signs and symptoms[link]

Throat cancer usually begins with symptoms that seem harmless enough, like an enlarged lymph node on the outside of the neck, a sore throat or a hoarse sounding voice. However, in the case of throat cancer, these conditions may persist and become chronic. There may be a lump or a sore in the throat or neck that does not heal or go away. There may be difficult or painful swallowing. Speaking may become difficult. There may be a persistent earache. Other possible but less common symptoms include some numbness or paralysis of the face muscles.

Presenting symptoms include

• Mass in the neck
• Neck pain
• Bleeding from the mouth
• Sinus congestion, especially with nasopharyngeal carcinoma
• Bad breath
• Sore tongue
• Painless ulcer or sores in the mouth that do not heal
• White, red or dark patches in the mouth that will not go away
• Earache
• Unusual bleeding or numbness in the mouth
• Lump in the lip, mouth or gums
• Enlarged lymph glands in the neck
• Slurring of speech (if the cancer is affecting the tongue)
• Hoarse voice which persists for more than six weeks
• Sore throat which persists for more than six weeks
• Difficulty swallowing food
• Change in diet or weight loss

Causes[link]

Alcohol^[5] and tobacco use are the most common risk factors for head and neck cancer in the United States. Alcohol and tobacco are likely synergistic in causing cancer of the head and neck.^[6] Smokeless tobacco is an etiologic agent for oral and pharyngeal cancers (oropharyngeal cancer).^[7] Cigar smoking is an important risk factor for oral cancers as well.^[8] Other potential environmental carcinogens include occupational exposures such as nickel refining, exposure to textile fibers, and woodworking. In one large, controlled study, marijuana use was not shown to be associated with oral squamous cell carcinoma.^[9] In another study, marijuana use was shown to be a potential protective factor against the development of head and neck squamous cell carcinoma.^[10] However, cigarette smokers have a lifetime increased risk for head and neck cancers that is 5- to 25-fold increased over the general population.^[11] The ex-smoker's risk for squamous cell cancer of the head and neck begins to approach the risk in the general population twenty years after smoking cessation. The high prevalence of tobacco and alcohol use worldwide and the high association of these cancers with these substances makes them ideal targets for enhanced cancer prevention.

Dietary factors[link]

Dietary factors may contribute. Excessive consumption of processed meats and red meat were associated with increased rates of cancer of the head and neck in one study, while consumption of raw and cooked vegetables seemed to be protective.^[12]

Vitamin E was not found to prevent the development of leukoplakia, the white plaques that are the precursor for carcinomas of the mucosal surfaces, in adult smokers.^[13] Another study examined a combination of Vitamin E and beta carotene in smokers with early-stage cancer of the oropharynx, and found a worse prognosis in the vitamin users.^[14]

Betel-nut[link]

Betel-nut chewing is associated with an increased risk of squamous cell cancer of the head and neck.^[15]

Human papillomavirus[link]

Recent evidence is accumulating pointing to a viral origin for some head and neck cancers.^[16]

Human papillomavirus (HPV), in particular HPV16, is a causal factor for some head and neck squamous cell carcinoma (HNSCC).^[17][18] Approximately 15 to 25% of HNSCC contain genomic DNA from HPV,^[19] and the association varies based on the site of the tumor, especially HPV-positive oropharyngeal cancer, with highest distribution in the tonsils, where HPV DNA is found in (45 to 67%) of the cases,^[20] less often in the hypopharynx (13%–25%), and least often in the oral cavity (12%–18%) and larynx (3%–7%).^[21]

Some experts estimate that while up to 50% of cancers of the tonsil may be infected with HPV, only 50% of these are likely to be caused by HPV (as opposed to the usual tobacco and alcohol causes). The role of HPV in the remaining 25-30% is not yet clear.^[22]

Epstein-Barr virus[link]

Epstein-Barr virus (EBV) infection is associated with nasopharyngeal cancer.^[16] Nasopharyngeal cancer occurs endemically in some countries of the Mediterranean and Asia, where EBV antibody titers can be measured to screen high-risk populations.^[16] Nasopharyngeal cancer has also been associated with consumption of salted fish, which may contain high levels of nitrites.

Gastroesophageal reflux disease[link]

The presence of acid reflux disease (GERD - gastroesphogeal reflux disease) or larynx reflux disease can also be a major factor. In the case of acid reflux disease, stomach acids flow up into the esophagus and damage its lining, making it more susceptible to throat cancer.

Hematopoietic stem cell transplantation[link]

Patients after hematopoietic stem cell transplantation (HSCT) are at a higher risk for oral squamous cell carcinoma. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients.^[23] This effect is supposed to be owing to the continuous life-long immune suppression and chronic oral graft-versus-host disease.^[23]

Other possible causes[link]

There are a wide variety of factors which can put someone at a heightened risk for throat cancer. Such factors include smoking or chewing tobacco or other things, such as gutkha, or paan, heavy alcohol consumption, poor diet resulting in vitamin deficiencies (worse if this is caused by heavy alcohol intake), weakened immune system, asbestos exposure, prolonged exposure to wood dust or paint fumes, exposure to petroleum industry chemicals, and being over the age of 55 years. Another risk factor includes the appearance of white patches or spots in the mouth, known as leukoplakia;^[3] in about ⅓ of the cases this develops into cancer.

Diagnosis[link]

Left inferior internal jugular node metastases with extranodal invasion, two years after brachytherapy of tongue cancer. PET-CT scanning of a male patient in his 30's, 64 minutes after fludeoxyglucose (¹⁸F) was administered, shows some fluff around the tumor.

A patient usually presents to the physician complaining of one or more of the above symptoms. The patient will typically undergo a needle biopsy of this lesion, and a histopathologic information is available, a multidisciplinary discussion of the optimal treatment strategy will be undertaken between the radiation oncologist, surgical oncologist, and medical oncologist.

Histopathology[link]

Throat cancers are classified according to their histology or cell structure, and are commonly referred to by their location in the oral cavity and neck. This is because where the cancer appears in the throat affects the prognosis - some throat cancers are more aggressive than others depending upon their location. The stage at which the cancer is diagnosed is also a critical factor in the prognosis of throat cancer.

Squamous cell carcinoma[link]

Squamous cells are the epithelium (tissue layer) that is the surface cells of much of the body. Skin and mucous membranes are squamous cells. This is the most common form of larynx cancer, accounting for over 90% of throat cancer.^[3] Squamous cell carcinoma is most likely to appear in males over 40 years of age with a history of heavy alcohol use coupled with smoking.

Adenocarcinoma[link]

Adenocarcinoma is a cancer of the columnar epithelium typical of the lower esophagus. It is typical of Barrett's esophagus but may be at another location. Adenocarcinoma is thought of as a product of Barrett's esophagus.

Prevention[link]

Avoidance of recognised risk factors (as described above) is the single most effective form of prevention. Regular dental examinations may identify pre-cancerous lesions in the oral cavity.

When diagnosed early, oral, head and neck cancers can be treated more easily and the chances of survival increase tremendously.

It is expected that HPV vaccines may reduce the risk of HPV induced head and neck cancer.^[24]

Management[link]

General considerations[link]

Improvements in diagnosis and local management, as well as targeted therapy, have led to improvements in quality of life and survival for head and neck cancer patients since 1992.^[25]

After a histologic diagnosis has been established and tumor extent determined, the selection of appropriate treatment for a specific cancer depends on a complex array of variables, including tumor site, relative morbidity of various treatment options, patient performance and nutritional status, concomitant health problems, social and logistic factors, previous primary tumors, and patient preference. Treatment planning generally requires a multidisciplinary approach involving specialist surgeons and medical and radiation oncologists.

Several generalizations are useful in therapeutic decision making, but variations on these themes are numerous. Surgical resection and radiation therapy are the mainstays of treatment for most head and neck cancers and remain the standard of care in most cases. For small primary cancers without regional metastases (stage I or II), wide surgical excision alone or curative radiation therapy alone is used. More extensive primary tumors, or those with regional metastases (stage III or IV), planned combinations of pre- or postoperative radiation and complete surgical excision are generally used. More recently, as historical survival and control rates are recognized as less than satisfactory, there has been an emphasis on the use of various induction or concomitant chemotherapy regimens.

Patients with head and neck cancer can be categorized into three clinical groups: those with localized disease, those with locally or regionally advanced disease, and those with recurrent and/or metastatic disease. Comorbidities (medical problems in addition to the diagnosed cancer) associated with tobacco and alcohol abuse can affect treatment outcome and the tolerability of aggressive treatment in a given patient.

Many different treatments and therapies are used in the treatment of throat cancer. The type of treatment and therapies used are largely determined by the location of the cancer in the throat area and also the extent to which the cancer has spread at time of diagnosis. Patients’ also have the right to decide whether or not they wish to consent to a particular treatment. For example, some may decide to not undergo radiation therapy which has serious side effects if it means they will be extending their lives by only a few months or so. Others may feel that the extra time is worth it and wish to pursue the treatments.

Surgery[link]

Surgery as a treatment is frequently used in most types of head and neck cancer. Usually the goal is to remove the cancerous cells entirely. This can be particularly tricky if the cancer is near the larynx and can result in the patient being unable to speak. Surgery is also commonly used to resect (remove) some or all of the cervical lymph nodes to prevent further spread of the disease. A novel approach uses harvested hematopoietic stem cells (blood stem cells) and other harvested cells (if necessary, a silicon alloy can also be used or can be used in place of the cells) from the lining of the patient's stomach to form a new section of a trachea or esophagus.^{[citation needed]}

CO2 laser surgery is also another form of treatment. Transoral laser microsurgery allows surgeons to remove tumors from the voice box with no external incisions. It also allows access to tumors that are not reachable with robotic surgery. A microscope helps the surgeon clearly view the margins of the tumor, minimizing the amount of normal tissue removed or damaged during surgery. This technique helps give the patient as much speech and swallowing function as possible after surgery.^[26]

Radiation therapy[link]

Radiation therapy is the most common form of treatment. There are different forms of radiation therapy, including 3D conformal radiation therapy, intensity-modulated radiation therapy, and brachytherapy, which are commonly used in the treatments of cancers of the head and neck. Most patients with head and neck cancer who are treated in the United States and Europe are treated with intensity-modulated radiation therapy using high energy photons.

Chemotherapy[link]

Chemotherapy in throat cancer is not generally used to cure the cancer as such. Instead, it is used to provide an inhospitable environment for metastases so that they will not establish in other parts of the body. Typical chemotherapy agents are a combination of Taxol and Carboplatin. Erbitux is also used in the treatment of throat cancer.

Taxotere (Docetaxel) based chemotherapy has shown a very good response in locally advanced head and neck cancer. Taxotere is the only taxane approved by US FDA for Head and neck cancer, in combination with cisplatin and fluorouracil for the induction treatment of patients with inoperable, locally advanced squamous cell carcinoma of the head and neck.^[27]

While not specifically a chemotherapy, Amifostine is often administered intravenously by a chemotherapy clinic prior to a patient's IMRT radiotherapy sessions. Amifostine protects the patient's gums and salivary glands from the effects of radiation. It should be noted that one of the side effects of Amifostine is that it could protect tumors. Another reason to use the newer more precise and better tumor damaging PMRT treatments.

Photodynamic therapy[link]

Photodynamic therapy may have promise in treating mucosal dysplasia and small head and neck tumors.^[3] Amphinex is giving good results in early clinical trials for treatment of advanced head and neck cancer.^[28]

Targeted therapy[link]

Targeted therapy, according to the National Cancer Institute, is "a type of treatment that uses drugs or other substances, such as monoclonal antibodies, to identify and attack specific cancer cells without harming normal cells." Some targeted therapy used in squamous cell cancers of the head and neck include cetuximab, bevacizumab, erlotinib, and reovirus.

The best quality data are available for cetuximab since the 2006 publication of a randomized clinical trial comparing radiation treatment plus cetuximab versus radiation treatment alone.^[29] This study found that concurrent cetuximab and radiotherapy improves survival and locoregional disease control compared to radiotherapy alone, without a substantial increase in side effects, as would be expected with the concurrent chemoradiotherapy, which is the current gold standard treatment for advanced head and neck cancer. Whilst this study is of pivotal significance, interpretation is difficult since cetuximab-radiotherapy was not directly compared to chemoradiotherapy. The results of ongoing studies to clarify the role of cetuximab in this disease are awaited with interest.

Another study evaluated the impact of adding cetuximab to conventional chemotherapy (cisplatin) versus cisplatin alone. This study found no improvement in survival or disease-free survival with the addition of cetuximab to the conventional chemotherapy.^[30]

However, another study which completed in March 2007 found that there was an improvement in survival.^{[citation needed]}

The EXTREME (Erbitux in First-Line Treatment of Recurrent or Metastatic Head & Neck Cancer) study is a European multicenter phase III trial to determine whether adding cetuximab improves the impact of platinum-based chemotherapy. Between December 2004 and March 2007, researchers enrolled 442 patients in 17 countries who had stage III or IV recurrent and/or metastatic SCCHN, and who were not candidates for further surgery or radiation. About half of the patients had cancer in their pharynx (throat), and a quarter in their larynx (voice box), but none in the nasopharynx (upper part of the throat). The patients averaged 57 years of age. Only about 10 percent were women. Patients were randomly assigned to receive either chemotherapy (222 patients) or the same chemotherapy with cetuximab (220 patients). Chemotherapy consisted of 5-fluorouracil plus either carboplatin or cisplatin. Results: Patients treated with cetuximab reduced their risk of dying by 20 percent, surviving a median of 10.1 months compared to 7.4 months for those receiving chemotherapy alone.^{[citation needed]}

A 2010 review concluded that the combination of cetuximab and platin/5-fluorouracil should be considered the current standard first-line regimen.^[31]

Head and neck cancer clinical trials employing bevacizumab, an inhibitor of the angiogenesis receptor VEGF, were recruiting patients As of March 2007^[update].

Erlotinib is an oral EGFR inhibitor, and was found in one Phase II clinical trial to retard disease progression.^[32] Scientific evidence for the effectiveness of erlotinib is otherwise lacking to this point. A clinical trial evaluating the use of erlotinib in metastatic head and neck cancer is recruiting patients as of March, 2007.

Reovirus is an oncolytic virus that targets RAS activated cancer cells. Trial update on November 2008 showed stable disease or better in the first eight of nine patients with refractory head and neck cancer [2]. Phase II trials are ongoing in England and the USA with phase III trials planned.

Prognosis[link]

Although early-stage head and neck cancers (especially laryngeal and oral cavity) have high cure rates, up to 50% of head and neck cancer patients present with advanced disease.^[33] Cure rates decrease in locally advanced cases, whose probability of cure is inversely related to tumor size and even more so to the extent of regional node involvement. Consensus panels in America (AJCC) and Europe (UICC) have established staging systems for head and neck squamous cancers. These staging systems attempt to standardize clinical trial criteria for research studies, and attempt to define prognostic categories of disease. Squamous cell cancers of the head and neck are staged according to the TNM classification system, where T is the size and configuration of the tumor, N is the presence or absence of lymph node metastases, and M is the presence or absence of distant metastases. The T, N, and M characteristics are combined to produce a “stage” of the cancer, from I to IVB.^[34]

Residual deficits[link]

Even after successful definitive therapy, head and neck cancer patients face tremendous impacts on quality of life.^[35] Despite marked advances in reconstructive surgery and rehabilitation, intensity-modulated radiotherapy (IMRT) and conservation approaches to certain malignancies, some patients continue to have significant functional deficits.^[36]

Problem of second primaries[link]

Survival advantages provided by new treatment modalities have been undermined by the significant percentage of patients cured of head and neck squamous cell carcinoma (HNSCC) who subsequently develop second primary tumors. The incidence of second primary tumors ranges in studies from 9.1%^[37] to 23%^[38] at 20 years. Second primary tumors are the major threat to long-term survival after successful therapy of early-stage HNSCC. Their high incidence results from the same carcinogenic exposure responsible for the initial primary process, called field cancerization.

Throat cancer has numerous negative effects on the body systems.

Digestive system[link]

As it can impair a person’s ability to swallow and eat, throat cancer affects the digestive system. The difficulty in swallowing can lead to a person to choke on their food in the early stages of digestion and interfere with the food’s smooth travels down into the esophagus and beyond.

The treatments for throat cancer can also be harmful to the digestive system as well as other body systems. Radiation therapy can lead to nausea and vomiting, which can deprive a body of vital fluids (although these may be obtained through intravenous fluids if necessary). Frequent vomiting can lead to an electrolyte imbalance which has serious consequences for the proper functioning of the heart. Frequent vomiting can also upset the balance of stomach acids which has a negative impact on the digestive system, especially the lining of the stomach and esophagus.

Respiratory system[link]

In the cases of some throat cancers, the air passages in the mouth and behind the nose may become blocked from lumps or the swelling from the open sores. If the throat cancer is near the bottom of the throat it has a high likelihood of spreading to the lungs and interfering with the person’s ability to breathe; this is even more likely if the patient is a smoker, because they are highly susceptible to lung cancer.

Others[link]

Like any cancer, metastasization affects many areas of the body, as the cancer spreads from cell to cell and organ to organ. For example, if it spreads to the bone marrow, it will prevent the body from producing enough red blood cells and affects the proper functioning of the white blood cells and the body's immune system; spreading to the circulatory system will prevent oxygen from being transported to all the cells of the body; and throat cancer can throw the nervous system into chaos, making it unable to properly regulate and control the body.

Symptoms and side effects[link]

Patients with head and neck cancer may experience the following symptoms and treatment side effects:^[3]

• Eating problems
• Pain associated with lesions
• Mucositis
• Nephrotoxicity and ototoxicity
• Xerostomia
• Gastroesophageal reflux
• Radiation induced osteonecrosis of the jaw

Epidemiology[link]

Age-standardized death from oro-pharyngeal per 100,000 inhabitants in 2004.^[39]

  no data

  less than 2

  2-4

  4-6

  6-8

  8-10

  10-12

  12-14

  14-16

  16-18

  18-20

  20-25

  more than 25

The number of new cases of head and neck cancers in the United States was 40,490 in 2006, accounting for about 3% of adult malignancies. 11,170 patients died of their disease in 2006.^[40] The worldwide incidence exceeds half a million cases annually. In North America and Europe, the tumors usually arise from the oral cavity, oropharynx, or larynx, whereas nasopharyngeal cancer is more common in the Mediterranean countries and in the Far East. In Southeast China and Taiwan, head and neck cancer, specifically nasopharyngeal cancer is the most common cause of death in young men.^[41]

• In 2008, there were 22,900 cases of oral cavity cancer, 12,250 cases of laryngeal cancer, and 12,410 cases of pharyngeal cancer in the United States.^[3]
• In 2002, 7,400 Americans were projected to die of these cancers.^[42]
• More than 70% of throat cancers are at an advanced stage when discovered.^[43]
• Men are 89% more likely than women to be diagnosed with, and are almost twice as likely to die of, these cancers.^[42]
• African Americans are disproportionately affected by head and neck cancer, with younger ages of incidence, increased mortality, and more advanced disease at presentation.^[33] Laryngeal cancer incidence is higher in African Americans relative to white, Asian and Hispanic populations. There is a lower survival rate for similar tumor states in African Americans with head and neck cancer.^[3]
• Smoking and tobacco use are directly related to oropharangeal (throat) cancer deaths.^[44]
• Head and neck cancer increases with age, especially after 50 years. Most patients are between 50 and 70 years old.^[3]

See also[link]

• Adenoid cystic carcinoma - a type of salivary gland cancer
• Burkitt's lymphoma - a type of lymphoma that affects the head and neck
• Dermatofibrosarcoma protuberans - a type of sarcoma that may involve the head and neck
• Hodgkin's disease - a lymphoma that often involves the lymph nodes in the neck
• Cancer of the larynx
• Paraganglioma - usually found in the head and neck region
• Skin cancers - may involve the head and neck
• Thyroid cancer
• Metastatic tumor of jaws

References[link]

Further reading[link]

1. Brook I. (2010) My Voice: A Physician’s Personal Experience with Throat Cancer. Creatspace Publishing. ISBN 1-4392-6386-8

2. Karni R, Haughey B, Transoral Laser Microsurgery: A New Approach for Occult Primaries of the Head and Neck, Laryngoscope, In Press February 2011.

3. Rich J, Liu J, Haughey B, Swallowing Function after Transoral Laser Microsurgery (TLM) ± Adjuvant Therapy for Advanced Stage Oropharyngeal Cancer, Laryngoscope, In Press February 2011.

4. Haughey BH, Hinni ML, Salassa JR, Grant DG, Rich JT, Milov S, Lewis Jr JS, Krishan M, Transoral Laser Microsurgery as Primary Treatment of Advanced Stage Oropharynx Cancer: A United States Multicenter Study, Head and Neck, Epub ahead of print February 2011. http://onlinelibrary.wiley.com/doi/10.1002/hed.21669/pdf

5. Rich JT, Milov S, Lewis Jr, JS, Thorstad WL, Adkins DR, Haughey BH, Transoral Laser Microsurgery (TLM) ± Adjuvant Therapy for Advanced Stage Oropharyngeal Cancer: Outcomes and Prognostic Factors, Laryngoscope, Volume 119, No. 9, pp 1709–1719, September 2009. http://onlinelibrary.wiley.com/doi/10.1002/lary.20552/pdf

6. Hinni M, Salassa J, Grant D, Pearson B, Hayden R, Martin A, Christiansen H, Haughey B, Nussenbaum B, Steiner W, Transoral Laser Microsurgery for Advanced Laryngeal Cancer, Archives of Otolaryngology-Head and Neck Surgery, Volume 133, No 12, pp 1198–1204, December 2007. http://archotol.ama-assn.org/cgi/reprint/133/12/1198

External links[link]

• Head and Neck Cancer at MedlinePlus
• Head and Neck Cancer Information
• Head and Neck Cancer: Questions and Answers
• Cancer Management Handbook: Head and Neck Tumors
• RadiologyInfo The radiology information resource for patients: Head and Neck Cancer
• A Video of a Physician who is a Head and Neck Cancer Patient Discusses his Personal Experiences
• Clinically reviewed head and neck cancer information for patients, from Cancer Research UK

Michael Douglas
Douglas at the 2012 Tribeca Film Festival
Born	Michael Kirk Douglas (1944-09-25) September 25, 1944 (age 67) New Brunswick, New Jersey, United States
Occupation	Actor, producer
Years active	1966–present
Spouse	Diandra Luker (1977–2000) Catherine Zeta-Jones (2000–present)
Children	Cameron Douglas (with Diandra Luker) Dylan Michael Douglas (with Catherine Zeta-Jones) Carys Zeta Douglas (with Catherine Zeta-Jones)
Parents	Kirk Douglas, Diana Dill
Relatives	Joel Douglas (brother) Peter Douglas (half-brother) Eric Douglas (half-brother, deceased) Anne Buydens (stepmother)

Michael Kirk Douglas (born September 25, 1944) is an American actor and producer, primarily in movies and television. He has won three Golden Globes and two Academy Awards; as producer of 1975's Best Picture, One Flew Over the Cuckoo's Nest, and as Best Actor in 1987 for his role in Wall Street. Douglas received the AFI Life Achievement Award in 2009.^[1] He is the eldest of actor Kirk Douglas's four sons.

Early life and education[link]

Douglas was born in New Brunswick, New Jersey, the first child of actor Kirk Douglas and Bermudian-born actress Diana Dill. His paternal grandparents were Jewish immigrants from Gomel in Belarus (at that time a part of the Russian Empire).^[2] His mother was from Devonshire Parish, Bermuda; Douglas's maternal grandfather, Lieutenant Colonel Thomas Melville Dill, served as Attorney General of Bermuda and was commanding officer of the Bermuda Militia Artillery.^[3] Douglas has a younger brother, Joel Douglas (born 1947), and two paternal half-brothers, Peter Douglas (born 1955) and Eric Douglas (1958–2004), from stepmother Anne Buydens.

Douglas attended The Allen-Stevenson School in New York City, The Choate Preparatory School (now Choate Rosemary Hall) in Wallingford, Connecticut. He received his B.A. in drama from the University of California, Santa Barbara in 1968, where he was also the Honorary President of the UCSB Alumni Association. He studied acting with Wynn Handman at The American Place Theatre in New York City.^[4]

Career[link]

Early years[link]

Douglas started his film career in the late 1960s and early 1970s, appearing in little known films like Hail, Hero! and Summertree. His first significant role came in the TV series The Streets of San Francisco from 1972 to 1976, where he starred alongside Karl Malden. Douglas later said that Malden became a "mentor" and someone he "admired and loved deeply".^[5] After Douglas left the show, he had a long association with his mentor until Malden's death on July 1, 2009. In 2004, Douglas presented Malden with the Monte Cristo Award of the Eugene O'Neill Theater Center in Waterford, Connecticut, for the Lifetime Achievement Award.

In 1975, Douglas received from his father, Kirk Douglas, the rights to the novel One Flew Over the Cuckoo's Nest. Michael went on to produce the film of the same name with Saul Zaentz.^[6] Kirk Douglas considered playing the starring role himself, having starred in an earlier stage version, but chose against it, considering himself too old. The lead role went instead to a young Jack Nicholson, who would go on to win the Academy Award for Best Actor. Douglas won the Award for Best Picture for producing the film.

After leaving Streets of San Francisco in 1976, Douglas played a hospital doctor in the medical thriller Coma (1978), and in 1979 he played the role of a troubled marathon runner in Running. In 1979, he both produced and starred in The China Syndrome, a dramatic film co-starring Jane Fonda and Jack Lemmon about a nuclear power plant accident (the Three Mile Island accident took place 12 days after the film's release). The film was considered "one of the most intelligent Hollywood films of the 1970s."^[4]

Success in Hollywood[link]

Douglas at the 1987 Cannes Film Festival.

Douglas' acting career was propelled to fame when he produced and starred in the 1984 romantic adventure comedy Romancing the Stone. It also helped launch Kathleen Turner to stardom, reintroduced Douglas as a capable leading man, and gave director Robert Zemeckis his first box-office success. The film also starred Danny DeVito, a personal friend of Douglas' since they had shared an apartment in the 1960s. ^[7] It was followed a year later by a sequel, The Jewel of the Nile, which he also produced.

The year 1987 saw Douglas star in the horror thriller Fatal Attraction with Glenn Close. That same year he played tycoon Gordon Gekko in Oliver Stone's Wall Street for which he received an Academy Award as Best Actor. He reprised his role as Gekko in the sequel Wall Street: Money Never Sleeps in 2010, also directed by Stone.^[8]

Douglas again teamed with Kathleen Turner and Danny DeVito for the 1989 film The War of the Roses. In 1989, he starred in Ridley Scott's international police crime drama Black Rain opposite Andy García and Kate Capshaw. The film was shot in Osaka, Japan.^[9]

In 1992, Douglas had another successful starring role when he appeared alongside Sharon Stone in the film Basic Instinct. The movie was a box office hit, and sparked controversy over its depictions of bisexuality and lesbianism. In 1994, Douglas and Demi Moore starred in the hit movie Disclosure focusing on the topic of sexual harassment with Douglas playing a man harassed by his new female boss. Other popular films he starred during these decade were Falling Down, The American President, The Ghost and the Darkness, The Game (directed by David Fincher), and a remake of Alfred Hitchcock's classic – Dial M for Murder – titled A Perfect Murder. In 1998, Douglas received the Crystal Globe award for outstanding artistic contribution to world cinema at the Karlovy Vary International Film Festival.^[10]

In 2000, Douglas starred in Steven Soderbergh's critically acclaimed film Traffic, opposite Benicio del Toro and future wife Catherine Zeta-Jones. That same year, he also received critical acclaim for his role in Wonder Boys as a professor and novelist suffering from writer's block. He was nominated for a Golden Globe Award for Best Actor in a Drama as well as several other awards from critics.

Types of roles[link]

According to film historian and critic David Thomson, Douglas was capable of playing characters who were "weak, culpable, morally indolent, compromised, and greedy for illicit sensation without losing that basic probity or potential for ethical character that we require of a hero."^[11] Critic and author Rob Edelman points out similarities in many of Douglas's roles, writing that in some of his leading films, he personified the "contemporary, Caucasian middle-to-upper-class American male who finds himself the brunt of female anger because of real or imagined sexual slights."^[4]

These themes of male victimization are seen in films such as Fatal Attraction (1987), with Glenn Close, War of the Roses (1989), with Kathleen Turner, Basic Instinct (1992), Sharon Stone, Falling Down (1993), and Disclosure (1994), with Demi Moore. For his characters in films such as these, "any kind of sexual contact with someone other than his mate and the mother of his children is destined to come at a costly price."^[4] Edelman describes his characters as the "Everyman who must contend with, and be victimized by, these women and their raging, psychotic sexuality."^[4]

Conversely, Douglas also played powerful characters with dominating personalities equally well: as Gordon Gekko, in the Wall Street franchise, he acted the role of a "greedy yuppie personification of the Me generation," convinced that "greed is good;" in Romancing the Stone and The Jewel of the Nile, he played an idealistic soldier of fortune; in The Star Chamber (1983), he was a court judge fed up with an inadequate legal system, leading him to become involved with a vigilante group; and in Black Rain (1989), he proved he could also play a Stallone-like action hero as a New York City cop.^[4]

Actor and producer[link]

Having become recognized as both a successful producer and actor, he describes himself as "an actor first and a producer second." He has explained why he enjoys both functions:

"I love the fact that on one side, with acting, you can be a child — acting is wonderful for its innocence and the fun. . . On the other side, producing is fun for all the adult kinds of things you do. You deal in business, you deal with the creative forces. As an adult who continues to get older, you like the adult risks. It's flying without a net, taking chances and learning. I was never good in economics or business — had no business background, you know, and I like it."^[12]

He has also offered reasons why he has become successful in both acting and producing:

"I think I'm a chameleon. I think it's something that I possibly inherited early on as a child going back and forth between two families. I know that whether it's right or wrong, I have an ability to sort of fit into a lot of different situations and make people feel relatively comfortable in a wide range without giving up all my moral values. I think that same chameleonlike quality can transfer into films. I think if you can remember the reason you got involved with it in the first place and try to keep that impulsive, instinctive feeling even when you're being beaten down or exhausted or waylaid, you'll be successful."^[12]

Recent years[link]

Douglas in June 2004

In 2003, Douglas starred in It Runs in the Family, which featured three generations of his family (his parents, Kirk and Diana, as well as his own son, Cameron). The film, although a labor of love, was not successful, critically or at the box office. Douglas starred in the solid commercial action flick Don't Say a Word, then the poorly received action-thriller The Sentinel in 2006. During that time, he also guest-appeared on the episode, "Fagel Attraction", of the popular television sitcom Will and Grace, as a gay cop attracted to Will Truman (Eric McCormack); the performance earned Douglas an Emmy Award nomination for Outstanding Guest Actor in a Comedy Show.

Douglas was approached for Basic Instinct 2, but he declined to participate in the project. He said:

"Yes, they asked me to do it a while ago, I thought we had done it very effectively; [Paul] Verhoeven is a pretty good director. I haven't seen the sequel. I've only done one sequel in my life, The Jewel of the Nile, from Romancing The Stone. Besides, there were age issues, you know? Sharon still looks fabulous. The script was pretty good. Good for her, she's in her late-40s, and there are not a lot of parts around. The first one was probably the best picture of her career—it certainly made her career and she was great in it".^[13]

Future engagements[link]

Douglas is rumored to appear in Tragic Indifference, a courtroom thriller based on a landmark liability case against Ford Motor Company, according to Variety. Douglas will play the attorney who took Ford to court on behalf of a single mother from Texas who was paralyzed and nearly died after an accident. The trial exposed the automaker's indifference to flaws in its Sport Utility Vehicles (SUV). The movie will be based on Adam Penenberg's 2003 book of the same name. Douglas will play Attorney Tab Turner, who represented Donna Bailey after the Ford Explorer SUV she was riding in rolled over following a Firestone tire failure.^[14]

On December 17, 2007 it was announced that Douglas would announce the introduction to NBC Nightly News, some two years after Howard Reig, the previous announcer, retired.^[15]

Personal life[link]

Family[link]

Douglas in 2012 at a Vanity Fair party with his wife, Catherine Zeta-Jones

After filming Summertree (1971), he began dating actress Brenda Vaccaro. The relationship lasted for about six years.^[16]

In March 1977,^[17] 33 year old Douglas married 19 year old Diandra Luker, the daughter of an Austrian diplomat.^[18] They had one son, Cameron, born in 1978. In 1995 Diandra filed for divorce^[18] and was awarded $45 million as her settlement.^[19]

Dating since March 1999, Douglas married Welsh actress Catherine Zeta-Jones on November 18, 2000. They were both born on September 25, though 25 years apart. Zeta-Jones says that when they met in Deauville, France, Douglas used the line "I want to father your children."^[20] They have two children, Dylan Michael (born August 8, 2000) and Carys Zeta (born April 20, 2003).^[21]

They planned on renewing their wedding vows in 2010 as part of their 10th wedding anniversary. The idea was hers, and came after Douglas was found to have advanced stages of cancer. One report notes that "Michael was in tears when she suggested it to him," and he sees it as a “wonderful expression of love.”^[22]

Douglas, the son of a Jewish father and an Anglican mother, has declared no religious affiliation.^[23]

Citizenship[link]

Douglas is a U.S. citizen by birth in the United States and has Bermudian Status^[24] through his mother's birth in Bermuda.

Skiing accident and rehab[link]

In 1980, Douglas was involved in a serious skiing accident which sidelined his acting career for three years. In September 1992, the same year Basic Instinct came out, he underwent treatment for alcoholism and drug addiction at Sierra Tucson Center.

Legal problems[link]

In 1997, New York caddy James Parker sued Douglas for $25 million.^[25] Parker accused Douglas of hitting him in the groin with an errant golf ball, causing Parker to lose a testicle and his job. The case was later settled out of court.^[26]

Stalking[link]

In 2004, Douglas and Zeta-Jones took legal action against stalker Dawnette Knight, who was accused of sending violent letters to the couple that contained graphic threats on Zeta-Jones' life. Testifying, Zeta-Jones said the threats left her so shaken she feared a nervous breakdown.^[27] Knight claimed she had been in love with Douglas and admitted to the offences, which took place between October 2003 and May 2004. She was sentenced to three years in prison.

Health problems[link]

It was announced on August 16, 2010, that Douglas was suffering from throat cancer and will undergo chemotherapy and radiation treatment.^[28] On August 31, 2010 Douglas appeared on Late Show with David Letterman and confirmed that the cancer was at stage IV, the most advanced stage.^[29] Douglas attributed the cancer to a combination of stress, his previous alcohol abuse, and years of heavy smoking.^[30]

In November 2010, Douglas was put on a special weight gain diet by his doctors due to the excessive weight loss leaving him weak.^[31] On January 11, 2011, he said in an interview that the tumor was gone. He admitted that the illness and aggressive treatment had caused him to lose 32 lbs in weight.^[32] He will have to have monthly screenings because there is a very high chance that the cancer could return over the course of the next two to three years.^[33] Although Douglas has described the cancer as throat cancer, many doctors believe he was actually diagnosed with oropharyngeal cancer.^[34][35]

Activism[link]

Opening of an exhibition by the Comprehensive Nuclear-Test-Ban Treaty Organization entitled "Putting an End to Nuclear Explosions". From left to right: Michael Douglas, Marty Natalegawa, Ban Ki-moon, Taib Fassi Fihri and Sergio de Queiroz Duarte.

Political activities[link]

Douglas and Zeta-Jones hosted the annual Nobel Peace Prize concert in Oslo, Norway, on December 11, 2003. They acted as co-masters of ceremony in the concert celebrating the award given to Iranian human rights activist Shirin Ebadi. In 2006, Douglas was awarded an honorary Doctor of Letters (D.Litt.) from the University of St. Andrews in Scotland.

He is an advocate of nuclear disarmament, a supporter of the Nuclear Age Peace Foundation, and sits on the Board of Directors of the anti-war grantmaking foundation Ploughshares Fund. In 1998, he was appointed UN Messenger of Peace by Secretary-General Kofi Annan.^[36] He is a notable Democrat and has donated money to Barack Obama, Christopher Dodd, and Al Franken.^[37] He has been a major supporter of gun control since John Lennon was murdered in 1980.^[38]

In 2006 he was a featured speaker in a public service campaign sponsored by a UN conference to focus attention on trade of illicit arms, especially of small arms and light weapons. Douglas made several appearances and offered his opinions:

"The conference is an opportunity for UN member states to build on the Program of Action and to encourage countries to strengthen their laws on the illicit trade, . . . an issue that affects us all . . .[and] while owning guns is a legal right in most countries, the illegal trade in guns continues to fuel conflict, crime and violence."^[39]

A few years earlier, in 2003, Douglas hosted a "powerful film" on child soldiers and the impact of combat on children in countries such as Sierra Leone. During the documentary film, Douglas interviewed children, and estimated that they were among 300,000 other children worldwide who have been conscripted or kidnapped and forced to fight. Of one such child he interviewed, Douglas stated, "After being kidnapped by a rebel group, he was tortured, drugged, and forced to commit atrocities."^[39] Douglas discussed his role as a Messenger Peace for the UN:

"I'm in an enviable position . . . When I talk about movies I can talk about messages of peace, and infuse them into the entertainment pages."^[39]

Humanitarian initiatives[link]

In 2009 Douglas joined the project Soldiers of Peace, a movie against all wars and for global peace.^[40][41]

Douglas lent his support for the campaign to release Sakineh Mohammadi Ashtiani, the Iranian woman, who after having been convicted of committing adultery, was given a sentence of death by stoning.^[42]

Filmography[link]

References[link]