Alcohol--the neglected risk factor in head and neck cancer

Alcohol remains second only to cigarette smoking as a risk factor for head and neck cancer worldwide. The increase in incidence in head and neck cancer in a number of countries appears linked at least in part to contemporaneous rises in alcohol consumption. The relative increase in risk in women may also relate to increasing alcohol consumption. Women may be particularly sensitive to alcohol-induced tumours in the oral/oropharyngeal sites. The risk is dose related, but with a non-linear increase for heavy drinkers (>100 g i.e. 12 units/day). The type of alcoholic beverage consumed seems less important. Potential mechanisms include local toxic cellular proliferation; carcinogenic action of metabolites e.g. acetaldehyde or impurities; induction of enzymes which activate procarcinogens; reduction of the protective retinoic acid; genetic polymorphism may play a part in certain geographic locations. Alcohol is also linked to stage at presentation, risk of second primary and the occurrence of comorbidity. Public awareness of the risks of alcohol remains disappointingly low. Those in identifiable high-risk groups should perhaps be targeted specifically for counselling.     

Nutritional challenges in head and neck cancer

In head and neck cancer patients malnutrition impacts on quality of life, complications of therapy and also prognosis, in part via altered immunity. Dysphagia assessment is extremely valuable but more work is needed to optimize the rehabilitation of the incompetent swallow in this particular patient group. Proper nutritional assessment is mandatory pre-/peri-/post-treatment. The range and palatability of nutritional supplements has greatly increased over the past few years. Many of the early problems of percutaneous gastrostomy feeding have been addressed but complication rates still remain high. As accelerated radiotherapy and chemoradiation techniques become more widely advocated, nutrition is likely to become increasingly important. The authorship includes two otolaryngologists, a nutritionist and a speech and language therapist with an interest in head and neck dysphagia, thereby aiming to provide a broad perspective of these issues. However, there appears to be a lack of prospective evaluation of many aspects of dysphagia/nutrition in head and neck cancer, which needs to be addressed.