What is oral cancer?

The oral cavity consists of lips, tongue, floor of the mouth, retromolar trigone, hard palate, alveolar ridge and buccal mucosa. Cancers of the oral cavity account for approximately one-third of all types of head and neck cancers. Men are twice as likely to get oral cancer as compared to women, and the average age of oral cancer patients is 60-70 years.

What are the risk factors associated with oral cancer?

In India, chewing betel nuts is the leading cause of oral cancer, followed by smoking.

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There is a strong relationship between the smoking and the development of cancers of the oral cavity. Almost 80-90% of all oral cancer patients have some history of smoking. In fact, tobacco users have 25 times higher risk of developing oral cancer than non-users. Quitting smoking can significantly reduce the risk of oral cancer. This risk is reduced by approximately 50% if the person quit smoking for more than 9 years at a stretch.

Reverse smoking is associated with an increased risk of cancers of the hard palate.

Reverse smoking refers to a specific smoking habit, where the burnt or burning end of a hand-rolled tobacco leaf is placed inside the mouth instead of the unlit/filtered end. This is practiced in a some parts of Andhra Pradesh (India) and Philippines.

Other important notes on the risks associated with oral cancer:

  • A combination of smoking and alcohol consumption can increase the risk of oral cancer by up to 3 to 4 times
  • Approximately 4-6% of cases occur in younger patients, which suggests genetic predisposition
  • Ultraviolet radiation exposure has been associated with an increased risk of cancers of the lips
  • Viral infections (with HPV and HSV) can be responsible for oral cancer
  • Some syndromes such as plummer vinson syndrome, xeroderma pigmentosa, ataxia telangiectasias, bloom's syndrome and fanconi anaemia are also associated with oral cancer
  • Premalignant conditions such as leukoplakia (the appearance of whitish patches), erythroplakia (the appearance of red patches) and oral submucous fibrosis, are associated with an increased risk of oral cancer

What are the signs and symptoms of oral cancer?

Many cases of oral cancer are usually detected at an advanced stage. This is because the initial symptoms are extremely vague, non-specific and can indicate another less-serious disease, unless identified to be cancerous by an oncologist or a general physician.

Common signs and symptoms of oral cancer:

  • The most common symptom of oral cancer is a painless ulcer that gradually increases in size over a period of time
  • In advanced stages, the patient may complain of pain in and around the ulcer
  • Loss of appetite and loss of weight are also noticed in advanced stages
  • In case cancer has spread (metastasised), patients may complain of cough, difficulty in breathing, nausea, vomiting, abdominal pain and bone pain
  • Patients may also exhibit mild-to-severe symptoms such as excessive salivation, throat pain, difficulty in swallowing, difficulty in speaking and in chewing food, difficulty in opening mouth, bleeding from ulcer, swelling in neck, persistent ear pain and change in voice

How is oral cancer diagnosed?

The flow of diagnosis for oral cancer patients, is as follows:

  • Complete medical history and physical examination
  • Indirect laryngoscopy to rule out any other secondary cancers
  • CT scan or an MRI scan of the head and neck region to understand the extent of the disease
  • Routine lab examinations such as complete blood work (CBC), liver and kidney function tests
  • Chest X-ray (to rule out lung metastasis)
  • PET CT scan (if there is risk of distant metastasis)

How is oral cancer treated?

The treatment of oral cancer depends on the stage at which the disease is diagnosed. The primary treatment modalities are surgery and radiation. Chemotherapy is generally not administered alone; It is rather given as adjuvant or neoadjuvant chemoradiotherapy (CRT). Systemic chemotherapy can be advised to patients who exhibit recurrent or metastatic oral cancer, if not amenable to surgery or radiation.

Treatment of early stage oral cancer

Stage 1 and 2 are generally considered as early stage. Primary surgery and definitive radiation are both valid treatment options for early stage oral cancer. Surgery is usually preferred over radiation as it leads to better treatment outcomes.

Both external beam radiation therapy (EBRT) and brachytherapy have an important role to play in the treatment of early stage oral cavity cancers. Small tumors can be treated using an intra-oral cone or by administering interstitial brachytherapy.

In early stage oral cancer, both the primary tumor and the involved lymph nodal groups should be treated. Surgery for oral cancer can either be a wide local excision or a partial excision of involved part with some reconstruction (if required depending on the size of the tumor). This type of surgery is usually followed by an elective neck dissection.

After surgery, a final biopsy is performed and adjuvant radiation is advised to patients who exhibit positive margins of residual tumors, multiple lymph node involvement, or other high-risk features. Conformal radiation therapy techniques are preferred over standard radiotherapy in order to decrease the potential side effects of the treatment.

Treatment of locally advanced oral cancer

Stage 3 and 4 oral cancer are considered to be locally advanced stages of oral cancer. Such patients are considered to be at a high risk of local recurrence if treated with either surgery or radiation therapy alone. Hence, a  combined modality approach is usually advised.

When the tumor can be operated, a surgery is advised followed by postoperative radiation therapy or chemoradiotherapy. When the tumor is found to be inoperable, definitive radiation therapy or chemoradiotherapy is advised.

Treatment of recurrent or metastatic oral cancer

Metastatic oral cancer refers to a stage of the disease where the cancer has spread to nearby or distant organs such as the lungs, liver, bones or the brain. Such stages are harder to treat as compared to earlier stages of oral cancer.

Recurrent oral cancer refers to a condition where patients’ cancer returns after completing their first line of treatment. This could be anytime post treatment i.e. days, weeks, months or years post treatment.

For patients who have not received any systemic therapy during their original treatment and are generally in a good health condition, combination chemotherapy is usually suggested with platinum combination regimens. A single agent chemotherapy drug can also be offered to such patients.

For patients who have received systemic chemotherapy during their initial treatment, further chemotherapy or immunotherapy can be advised. Whenever possible, patients are encouraged to get enrolled in a relevant clinical trial that is recruiting nearby. Other treatment options could be palliative radiation or palliative surgery to relieve patients’ symptoms.

In general, the outcome for metastatic or recurrent oral cancer patients is very poor, with an average survival rate of 6 to 12 months.

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