Detecting Oral Cancer: A Guide for Healthcare Professionals

Oral cancer is the 6th most common cancer in men and the 14th most common cancer in women. In the US, oral cancer will be diagnosed in an estimated 30,000 Americans this year and will cause more than 8,000 deaths. The disease kills approximately one person every hour. Oral cancer can spread quickly. The majority of oral cancers are diagnosed in late stages, which accounts for the high death rates. Only half of those diagnosed with the disease will survive more than five years. However, if the cancer is detected early, there is an 80 to 90% chance for survival. It is therefore extremely important to detect oral cancer as early as possible, when it can be treated more successfully, thus enhancing the rate of survival.

Incidence and Survival

Oral or pharyngeal cancer will be diagnosed in an estimated 28,000 Americans this year, and will cause approximately 7,000 deaths. On average, only 59 percent of those with the disease will survive more than five years.

The Importance of Early Detection

Early Detection Saves Lives

With early detection and timely treatment, deaths from oral cancer could be dramatically reduced.

The five-year survival rate for those with localized disease at diagnosis is 81 percent compared with only 30 percent for those whose cancer has spread to other parts of the body.

Early detection of oral cancer is often possible. Tissue changes in the mouth that might signal the beginnings of cancer often can be seen and felt easily.

Warning Signs

Lesions that might signal oral cancer

Two lesions that could be precursors to cancer are leukoplakia (white lesions) and erythroplakia (red lesions). Although less common than leukoplakia, erythroplakia and lesions with erythroplakic components have a much greater potential for becoming cancerous. Any white or red lesion that does not resolve itself in two weeks should be reevaluated and considered for biopsy to obtain a definitive diagnosis

Other Possible Signs and Symptoms:

Possible signs and symptoms of oral cancer that your patients may report include: a lump or thickening in the oral soft tissues, soreness or a feeling that something is caught in the throat, difficulty chewing or swallowing, ear pain, difficulty moving the jaw or tongue, hoarseness, numbness of the tongue or other areas of the mouth, or swelling of the jaw that causes dentures to fit poorly or become uncomfortable

If these problems persist for more than two weeks, a thorough clinical examination and laboratory tests, as necessary, should be performed to obtain a definitive diagnosis. If a diagnosis cannot be obtained, referral to the appropriate specialist is indicated.

Risk Factors
Tobacco/Alcohol Use

Tobacco and excessive alcohol use increases the risk of oral cancer. Using both tobacco and alcohol poses a much greater risk than using either substance alone

Sunlight

Exposure to sunlight is a risk factor for lip cancer

Age

Oral cancer is typically a disease of older people, usually because of their longer exposure to risk factors. Incidence of oral cancer rises steadily with age, reaching a peak in persons aged 65-74. For African Americans, incidence peaks about 10 years earlier.

Gender

Oral cancer strikes men twice as often as it does women.

What You Can Do

A thorough head and neck examination should be a routine part of each patient's dental visit and general medical examination. Clinicians should be particularly vigilant in checking those who use tobacco or excessive amounts of alcohol

Oral Lesions Suspicious for Oral Cancer

The Exam
Figure 1 - Face Figure 2 – Lips
Figure 3 - Labial mucosa Figure 4 - Labial mucosa
Figure 5 - Right buccal mucosa Figure 6 - Left Buccal mucosa
Figure 7 - Gingiva Figure 8 - Tongue dorsum
Figure 9 - Tongue left margin Figure 10 - Tongue right margin
Figure 11 - Tongue ventral Figure 12 - Floor
Figure 13 - Hard palate Figure 14 - Oropharynx
 
Figure 15 - Palpation  

 

Homogenous leukoplakia in the floor of the mouth in a smoker. Biopsy showed hyperkeratosis.
Clinically, a leukoplakia on left buccal mucosa. However, the biopsy showed early squamous cell carcinoma. The lesion is suspicious because of the presence of nodules.
Nodular leukoplakia in right commissure. Biopsy showed severe epithelial dysplasia.
Erythroleukoplakia in left commissure and buccal mucosa. Biopsy showed mild epithelial dysplasia and presence of candida infection. A 2-3 week course of anti-fungal treatment may turn this type of lesion into a homogenous leukoplakia

The Exam Review

The examination is conducted with the patient seated. Any intraoral prostheses are removed before starting. The extraoral and perioral tissues are examined first, followed by the intraoral tissues.

I. The Extraoral Examination

II. Perioral and Intraoral Soft Tissue Examination

The perioral and intraoral examination procedure follows a seven-step systematic assessment of the lips; labial mucosa and sulcus; commissures, buccal mucosa, and sulcus; gingiva and alveolar ridge; tongue; floor of the mouth; and hard and soft palate.

Screening for Oral Cancer

RECOMMENDATION

There is insufficient evidence to recommend for or against routine screening of asymptomatic persons for oral cancer by primary care clinicians. All patients should be counseled to discontinue the use of all forms of tobacco (see Chapter 54) and to limit consumption of alcohol (see Chapter 52). Clinicians should remain alert to signs and symptoms of oral cancer and premalignancy in persons who use tobacco or regularly use alcohol.

Burden of Suffering

The term “oral cancer” includes a diverse group of tumors arising from the oral cavity. Usually included are cancers of the lip, tongue, pharynx, and oral cavity. The annual incidence of oral cancer in the U.S. is about 11/100,000 population, with a male/female ratio greater than 2:1.1 Oral cancer is responsible for 2% of all cancer deaths in the U.S., and it is projected to account for over 28,000 new cases and about 8,400 deaths in 1995.2

Fifty-three percent of oral cancers have spread to regional or distant structures at the time of diagnosis.1 Overall 5-year survival is 52%, but it ranges from 79% for localized disease to 19% if distant metastases are present.1 The natural history of each type of cancer can be quite different. Cancer of the lip accounts for 11% of new cases of oral cancer but only 1% of deaths. In contrast, cancer of the pharynx accounts for 31% of new cases of oral cancer but 50% of deaths.1 The median age at diagnosis of oral cancers is 64 years, and 95% occur in persons over age 40. About half of all oropharyngeal cancers and the majority of deaths from this disease occur in persons over age 65.1

Use of tobacco in all forms and, to a lesser extent, alcohol abuse are the major risk factors for the development of oral cancer.3 The risk of oral cancer is increased 6–28 times in current smokers,4 and the effects of tobacco and alcohol account for 90% of oral cancer in the U.S.5 In parts of India and Asia where chewing tobacco or betel nut is very common, the incidence of oral cancer is 3 times higher than in the U.S.5 In several areas of India, oral cancer accounts for 40% of all female cancer deaths.5 Other risk factors for oral cancer include occupational exposures, solar radiation (for cancer of the lip), and the presence of premalignant lesions such as leukoplakia or erythroplakia.3 Depending on the degree of histologic abnormality, up to 18% of cases of leukoplakia may develop into invasive cancers over long-term follow-up.5 Patients infected with human immunodeficiency virus are at increased risk of oral cancers, most commonly Kaposi’s sarcoma and non-Hodgkin’s lymphoma.6

Accuracy of Screening Tests

The principal screening test for oropharyngeal cancer in asymptomatic persons is inspection and palpation of the oral cavity. Studies indicate that many oral cancers occur on the floor of the mouth, the ventral and lateral regions of the tongue, and the soft palate, anatomic sites that may be inaccessible to routine visual inspection.7 The recommended examination technique involves a careful visual examination of the oral cavity and extraoral areas using a dental mirror, retracting the tongue with a gauze pad to visualize hard-to-see areas. It also includes digital palpation with a gloved hand for masses. Complete descriptions of the recommended techniques have been published.8 There is little information, however, on the sensitivity of this procedure in detecting oral cancer or on the frequency of false-positive results when a lesion is found. The abbreviated oral inspection that is more typical of the routine physical examination is also of unknown accuracy and predictive value. Studies in India and Sri Lanka have shown that nonphysician basic health care workers, given a short course on screening for oral cancer, can identify oral cancers and their precursors.9, 10 Mehta found a 59% sensitivity and 98% specificity for lesions appropriately referred to dentists by the basic health care workers.9 No outcome data were reported in these studies, and it is unclear how these findings relate to the very different, lower prevalence population of the United States.

Some studies suggest that dentists are more effective than are physicians in routinely performing a complete mouth examination and detecting early-stage oral cancer.11 Older Americans, the population at greatest risk for oral cancer, visit the dentist infrequently, however; physician visits are much more frequent in older persons.12 No studies of the sensitivity and specificity of screening for oral cancer by dentists have been reported. Alternative screening tests for oral cancer have been proposed, such as tolonium chloride rinses to stain suspicious lesions,13, 14 but further research is needed to evaluate the accuracy and acceptability of these techniques before routine use in the general population can be considered.

Effectiveness of Early Detection

No controlled trials of screening for oral cancer that include data on clinical outcomes have been reported. There is consistent evidence that persons with early-stage oral cancer have a better prognosis than those diagnosed with more advanced disease.1, 2 Because of the possible effects of lead-time and length bias, however, these observational data are not sufficient to prove that screening and earlier detection improve the prognosis in patients with oral cancer. Some authors have questioned the effectiveness of early detection in improving prognosis.15 Prospective trials of screening for oral cancer, although difficult and expensive to conduct in the general population, might be feasible in high-risk populations in which the incidence of oral cancer is substantially greater.

Several studies have examined treatment of oral leukoplakia, a form of premalignancy, as a means of preventing oral cancer. Primary treatment of oral leukoplakia and prevention of second primary lesions in patients with treated oral cancer have been studied in several randomized, placebo-controlled chemoprevention trials of high-dose isotretinoin (13-cis-retinoic acid).16-18 These studies demonstrated that isotretinoin was effective in promoting remission of leukoplakia and preventing the occurrence of second primary oral cancers.17 Leukoplakia relapsed in a majority of cases within 3–6 months after discontinuation of therapy, however, and the rate of toxicity of treatment was high (mild to moderate side effects in up to 79% of patients). A trial of alternate maintenance therapies after isotretinoin induction for leukoplakia suggested that low-dose isotretinoin was more effective in maintaining remissions than b-carotene and caused fewer side effects than high-dose therapy: 12% of participants experienced severe toxicity and 42% had moderate toxicity from low-dose isotretinoin, including dry skin, cheilitis, and conjunctivitis.18

Uncontrolled trials using ß-carotene demonstrated variable reductions (up to 71%) in the occurrence of oral leukoplakia and mucosal dysplasia.19-21 In a randomized trial, however, the majority of patients with leukoplakia progressed during b-carotene treatment.18 Although side effects of ß-carotene are minimal, older male smokers who took ß-carotene for 5–8 years experienced slightly higher rates of lung cancer and overall mortality in a recently completed trial in Finland.22 Research is currently in progress on alternative agents (e.g., vitamin E) and combinations of therapies.23

Recommendations of Other Groups

The American Cancer Society recommends a cancer checkup that includes oral examination every 3 years for persons over age 20 and annually for those over age 40.24 The Canadian Task Force on the Periodic Health Examination concluded that there was insufficient evidence to include or exclude screening for oral cancer in the periodic health examination of persons in the general population, but suggested that annual oral examination by a physician or dentist should be considered for persons over 60 with risk factors for oral cancer (e.g., smokers and regular drinkers).25 Although the National Institutes of Health no longer issue specific clinical guidelines regarding screening for oral cancer, both the National Cancer Institute and the National Institute of Dental Research support efforts to promote the early detection of oral cancers during routine dental examinations. 8, 26

Discussion

Primary prevention strategies, such as counseling patients regarding the use of tobacco and alcohol, may have a greater impact on the morbidity and mortality associated with oral cancer than measures aimed at early detection. There is good evidence that tobacco use and excessive consumption of alcohol are both independent and synergistic risk factors for oral cancer.3 Over 90% of oropharyngeal cancer deaths are associated with smoking.5 In addition to smoking and alcohol, oral cancer is also associated with the use of snuff and chewing tobacco.27

Oral cancer is a relatively uncommon cancer in the United States. Even among high-risk groups such as smokers, oral cancer accounts for a relatively small proportion (<2%) of all deaths.4 Available screening tests for oral cancer are limited to the physical examination of the mouth, a test of undetermined sensitivity, specificity, and positive predictive value. Despite the strong association between stage at diagnosis and survival, there are few controlled data to determine whether routine screening in the primary care setting leads to earlier diagnosis or reduced mortality from oral cancer. Given the significant morbidity and mortality associated with advanced oral cancer and its treatment, clinicians may wish to include careful examinations for oral cancer in asymptomatic persons at significantly increased risk for the disease (see Clinical Intervention); direct evidence of a benefit of screening in any group, however, is lacking. It is also appropriate to refer patients for regular visits to a dentist, for whom complete examination of the oral cavity is often more feasible (see Chapter 61).

CLINICAL INTERVENTION

There is insufficient evidence to recommend for or against routine screening of asymptomatic persons for oral cancer by primary care clinicians (“C” recommendation). Although direct evidence of a benefit is lacking, clinicians may wish to include an examination for cancerous and precancerous lesions of the oral cavity in the periodic health examination of persons who chew or smoke tobacco (or did so previously), older persons who drink regularly, and anyone with suspicious symptoms or lesions detected through self-examination. All patients, especially those at increased risk, should be advised to receive a complete dental examination on a regular basis (see Chapter 61). All adolescent and adult patients should be asked to describe their use of tobacco (Chapter 54) and alcohol (Chapter 52).

Appropriate counseling should be offered to those persons who smoke cigarettes, pipes, or cigars, those who use chewing tobacco or snuff, and those who have evidence of alcohol abuse. Persons with increased expo - sure to sunlight should be advised to take protective measures when outdoors to protect their lips and skin from the harmful effects of ultraviolet rays (see Chapter 12).

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Paul S. Frame, MD, based on materials prepared for the Canadian Task Force on the Periodic Health Examination by Carl Rosati, MD, FRCSC.

REFERENCES
  1. Ries LAG, Miller BA, Hankey BF, et al, eds. SEER cancer statistics review, 1973–1991: tables and graphs. Bethesda: National Cancer Institute, 1994. (NIH Publication no. 94-2789.)
  2. Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer J Clin 1995;45:8–30.
  3. Vokes EE, Weichselbaum RR, Lippman SM, et al. Head and neck cancer. N Engl J Med 1993;328:184–194.
  4. Centers for Disease Control and Prevention. Cigarette smoking—attributable mortality and years of potential life lost—United States, 1990. MMWR 1993;42:645–649.
  5. Silverman S Jr. Oral cancer. Atlanta: American Cancer Society, 1990.
  6. Epstein JB, Silverman S. Head and neck malignancies associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:193–200.
  7. Mashberg A, Meyers H. Anatomical site and size of 222 early asymptomatic oral squamous carcinomas. Cancer 1976;37:2149–2157.
  8. Department of Health and Human Services, National Cancer Institute. Tobacco effects in the mouth. Bethesda: Public Health Service, 1992. (DHHS Publication no. (NCI) 92-3330.)
  9. Mehta FS, Bhonsle RB, Daftary DK, et al. Detection of oral cancer using basic health workers in an area of high oral cancer incidence in India. Cancer Detect Prev 1986;9:219–225.
  10. Warnakulasuriya KAAS, Nanayakkara BG. Reproducibility of an oral cancer and precancer detection program using a primary health care model in Sri Lanka. Cancer Detect Prev 1991;15:331–334.
  11. Elwood JM, Gallagher RP. Factors influencing early diagnosis of cancer of the oral cavity. Can Med Assoc J 1985;133:651–656.
  12. Fedele DJ, Jones JA, Niessen LC. Oral cancer screening in the elderly. J Am Geriatr Soc 1991;39:920–925.
  13. Mashberg A. Final evaluation of tolonium chloride rinse for screening of high-risk patients with asymptomatic squamous carcinoma. J Am Dent Assoc 1983;106:319–323.
  14. Rosenberg D, Cretin S. Use of meta-analysis to evaluate tolonium chloride in oral cancer screening. Oral Surg Oral Med Oral Pathol 1989;67:621–627.
  15. Williams RG. The early diagnosis of carcinoma of the mouth. Ann R Coll Surg Engl 1981;63:423–425.
  16. Hong WK, Endicott J, Itri LM, et al. 13-cis-retinoic acid in the treatment of oral leukoplakia. N Engl J Med 1986;315:1501–1505.
  17. Hong WK, Lippman SM, Itri LM, et al. Prevention of second primary tumors with isotretinoin in squamous cell carcinoma of the head and neck. N Engl J Med 1990;323:795–801.
  18. Lippman SM, Batsakis JG, Toth BB, et al. Comparison of low dose isotretinoin with beta carotene to prevent oral carcinogenesis. N Engl J Med 1993;328:15–20.
  19. Malaker K, Anderson BJ, Beecroft WA, et al. Management of oral mucosal dysplasia with ?-carotene retinoic acid: a pilot crossover study. Cancer Detect Prev 1991;15:335–340.
  20. Garewal HS. Potential role of ?-carotene in prevention of oral cancer. Am J Clin Nutr 1991;53:294S–297S.
  21. Stich HF, Mathew B, Sankaranarayanan R, et al. Remission of precancerous lesions in the oral cavity of tobacco chewers and maintenance of the protective effect of ?-carotene or vitamin A. Am J Clin Nutr 1991;53:298S–304S.
  22. The Alpha-tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 1994;330:1029–1035.
  23. Benner SE, Winn RJ, Lippman SM, et al. Regression of oral leukoplakia with alpha-tocopherol: a Community Clinical Oncology Program chemoprevention study. J Natl Cancer Inst 1993;85:44–47.
  24. American Cancer Society. Guidelines for the cancer-related checkup: an update. Atlanta: American Cancer Society, 1993.
  25. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care. Ottawa: Canada Communication Group, 1994:838–847.
  26. National Institute of Dental Research. Detecting oral cancer: a guide for dentists. Bethesda: National Institute of Dental Research, 1994.
  27. Connoly GN, Winn DM, Hecht SS, et al. The reemergence of smokeless tobacco. N Engl J Med 1986;314: 1020–1027

VELScope

Researchers supported by the National Institute of Dental and Craniofacial Research, part of the National Institutes of Health, report that their initial success using a customized optical device that allows dentists to visualize in a completely new way whether a patient might have a developing oral cancer. The device is called a Visually Enhanced Lesion Scope (VELScope), and it's a simple, hand-held device that emits a cone of blue light into the mouth that excites various molecules within our cells, causing them to absorb the light energy and re-emit it as visible fluorescence. Remove the light, and the fluorescence of the tissue is no longer visible:

Because changes in the natural fluorescence of healthy tissue generally reflect light-scattering biochemical or structural changes indicative of developing tumor cells, the VELScope allows dentists to shine a light onto a suspicious sore in the mouth, look through an attached eyepiece, and watch directly for changes in color. Normal oral tissue emits a pale green fluorescence, while potentially early tumor, or dysplastic, cells appear dark green to black.

Testing the device in 44 people, the results of which are published online in the Journal of Biomedical Optics, the scientists found they could distinguish correctly in all but one instance between normal and abnormal tissue. Their diagnoses were confirmed to be correct by biopsy and standard pathology.

Every hour every day one person dies of oral cancer in America. Oral Squamous Cell Carcinomas (OSCC) make up over 90% of all oral cancers, and because of its appearance it has been difficult to differentiate from the other relatively benign lesions of the oral cavity. Early OSCC and potentially malignant lesions can appear as a white patch (leukoplakia, or as a reddened area (erythroplakia), or as a red and white (erythroleukoplakia) mucosal change under standard white light examination. However, these cellular changes are often non-detectable to the human eye (even with magnification eyewear) under standard lighting conditions. Often, when the lesion becomes visible, it has advanced to invasive stages. The high mortality rate is directly related to the lack of early detection of potentially malignant lesions. When diagnosis and treatment are performed at or before a Stage 1 carcinoma level, the survival rate is more than 90%.

Clearly, this device can save lives. It belongs in every dentist office and in every ENT office, as well.

Currently, the early detection of oral cancer depends on a thorough oral cancer examination, usually by a dentist or other qualified health care provider, for possible signs and symptoms of this disease. Scientists are working on technologies and biomarkers for the early detection of oral cancer. Saliva, an easy-to-obtain and non-invasive body fluid, has recently been shown to harbor highly informative biomarkers for oral cancer detection. Scientists in Dr. David Wong's laboratory at the School of Dentistry at UCLA have discovered that seven RNAs, molecules that carry information in cells, when found in saliva are very useful for oral cancer detection. The saliva oral cancer RNA signature has been tested in over 300 saliva samples from oral cancer patients and healthy people, and the signature is always present in higher levels in the saliva of oral cancer patients than in saliva from healthy people, with an overall accuracy rate of about 85%.

The next important step is to turn these scientific findings into clinical tests that can be used for early oral cancer detection. Today, at the 35th Annual Meeting of the American Association for Dental Research, Wong's research team is reporting for the first time that they have developed a standardized "Saliva RNA Test for Oral Cancer" ready for clinical usage. The "Saliva RNA Test" has been tested in 100 oral cancer and healthy people, and it has been confirmed that four saliva oral cancer RNA biomarkers are highly accurate in detecting oral cancer, at around 82%. This is the first standardized saliva-based test for clinical oral cancer detection and will have enormous clinical value in reducing the mortality and morbidity for oral cancer patients, as well as improving their quality of life.

In a related study, further illustrating the importance of saliva as a diagnostic tool, scientists at the National Institute of Dental and Craniofacial Research (NIDCR), one of the Federal Government's National Institutes of Health (NIH), have studied the protein profile in the saliva of patients with Sjogren's syndrome, an autoimmune disorder in which the immune system cells attack the saliva- and tear-producing glands, causing them to become inflamed. Patients suffer from constant dryness of the mouth and eyes, as well as many other systemic problems. In this recent study, the scientists analyzed saliva from patients with and without Sjogren's syndrome to find out whether the amounts and types of salivary proteins differed. They found that saliva from the patients with Sjogren's has both increased amounts of proteins related to inflammation and a decreased amount of proteins produced by salivary glands. Future studies are planned to determine whether these protein levels could be useful in diagnosing Sjogren's syndrome.

International Association for Dental Research
http://www.dentalresearch.org

Cytobrush Biopsy

Dentists now have an easy painfree way to detect oral cancer at its earliest stages. Cytobrush biopsy, is a technique which underwent clinical trials at the University of Philadelphia//School of Dental Medicine that showed it to be a significant advance over previous cytology (PAP smear-type) tests.

According to Martin S. Greenberg, professor and chairman or oral medicine early detection is our most important weapon in our fight against oral cancer. The survival rate for this prevalent cancer is only 40 per cent overall, but survival rates increase to greater than 80 per cent if the cancer is found early. With the engineers and cytologists at Oral Scan Systems, a New York-based health devices company, a dentist who finds an area of concern runs a small round brush - similar to a mascara wand over the suspicious lesion.

“The bristles are like those on a toothbrush,” Greenberg said. “They can penetrate and get a better sampling of cells than the old scraping technique.” The sample is sent to a lab where it is scanned using advanced computer technology. Suspicious slides are tagged for further evaluation by a technician. The computer is so exacting, Green berg said, that the false negative rate, which was as high as 30 per cent using the scraping method, dropped to nil in the clinical trials.

Patient Information

Oral Cancer

The mouth and throat

This booklet is about cancers that occur in the mouth (oral cavity) and the part of the throat at the back of the mouth (oropharynx). The oral cavity and oropharynx have many parts:

Understanding cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:
Oral cancer

Oral cancer is part of a group of cancers called head and neck cancers. Oral cancer can develop in any part of the oral cavity or oropharynx. Most oral cancers begin in the tongue and in the floor of the mouth. Almost all oral cancers begin in the flat cells (squamous cells) that cover the surfaces of the mouth, tongue, and lips. These cancers are called squamous cell carcinomas.

When oral cancer spreads (metastasizes), it usually travels through the lymphatic system. Cancer cells that enter the lymphatic system are carried along by lymph, a clear, watery fluid. The cancer cells often appear first in nearby lymph nodes in the neck.

Cancer cells can also spread to other parts of the neck, the lungs, and other parts of the body. When this happens, the new tumor has the same kind of abnormal cells as the primary tumor. For example, if oral cancer spreads to the lungs, the cancer cells in the lungs are actually oral cancer cells. The disease is metastatic oral cancer, not lung cancer. It is treated as oral cancer, not lung cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Oral cancer: Who's at risk?

Doctors cannot always explain why one person develops oral cancer and another does not. However, we do know that this disease is not contagious. You cannot "catch" oral cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop oral cancer. A risk factor is anything that increases your chance of developing a disease.

The following are risk factors for oral cancer:

Quitting tobacco reduces the risk of oral cancer. Also, quitting reduces the chance that a person with oral cancer will get a second cancer in the head and neck region. People who stop smoking can also reduce their risk of cancer of the lung, larynx, mouth, pancreas, bladder, and esophagus. There are many resources to help smokers quit:

Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer. Scientists also are studying whether infections with certain viruses (such as the human papillomavirus) are linked to oral cancer.

If you think you may be at risk, you should discuss this concern with your doctor or dentist. You may want to ask about an appropriate schedule for checkups. Your health care team will probably tell you that not using tobacco and limiting your use of alcohol are the most important things you can do to prevent oral cancers. Also, if you spend a lot of time in the sun, using a lip balm that contains sunscreen and wearing a hat with a brim will help protect your lips.

See your oral and maxillofacial surgeon if you have any of these signs. If the oral and maxillofacial surgeon agrees that something looks suspicious, a biopsy may be recommended. A biopsy involves the removal of a piece of the suspicious tissue, which is then sent to a pathology laboratory for a microscopic examination that will accurately diagnose the problem. The biopsy report not only helps establish a diagnosis, but also enables the doctor to develop a specific plan of treatment.

Oral Cancer

Because the mouth is a region where changes can be easily seen, oral cancer can be detected in its early stages. Performing a self examination regularly will help in the early recognition and detection of oral cancer, and increase the chance for cure.

Factors That May Cause Cancer

Research has identified a number of factors that may contribute to the development of oral cancer.The most common are the use of tobacco and alcohol. Others include poor oral hygiene, irritation caused by ill-fitting dentures and rough surfaces on teeth, poor nutrition, some chronic infections and combinations of these factors.

Studies have shown that the death rate from oral cancer is about four times higher for cigarette smokers than for nonsmokers. It is also widely believed in the medical field that the heat generated by smoking pipes and cigars irritates the mouth and can lead to lip cancer.

Those at an especially high risk of developing oral cancer are over 40 years of age, heavy drinkers and smokers, or users of smokeless tobacco, including snuff.

Perform a Self-Exam Monthly

Oral and maxillofacial surgeons recommend that everyone perform an oral cancer self-exam each month. If you are at high risk for oral cancer — smoker, consumer of alcohol, user of smokeless tobacco, or snuff — you should see your general dentist or oral and maxillofacial surgeon for an annual exam.

An oral examination is performed using a bright light and a mirror:

  • remove any dentures
  • look and feel inside the lips and the front of gums
  • tilt head back to inspect and feel the roof of your mouth
  • pull the cheek out to see its inside surface as well as the back of the gums
  • pull out your tongue and look at all of its surfaces
  • feel for lumps or enlarged lymph nodes (glands) in both sides of the neck including under the lower jaw
Early Detection and Treatment Provide a Better Chance for Cure

When performing an oral cancer self-examination, look for the following:

  • white patches of the oral tissues — leukoplakia (figure a)
  • red patches — erythroplakia
  • red and white patches — erythroleukoplakia (figure b)
  • a sore that fails to heal and bleeds easily
  • an abnormal lump or thickening of the tissues of the mouth (figures c and d)
  • chronic sore throat or hoarseness
  • difficulty in chewing or swallowing
  • a mass or lump in the neck (figure e)

See your oral and maxillofacial surgeon if you have any of these signs. If the oral and maxillofacial surgeon agrees that something looks suspicious, a biopsy may be recommended. A biopsy involves the removal of a piece of the suspicious tissue, which is then sent to a pathology laboratory for a microscopic examination that will accurately diagnose the problem. The biopsy report not only helps establish a diagnosis, but also enables the doctor to develop a specific plan of treatment.

What are the symptoms of oral cancer?

Early detection

Your regular checkup is a good time for your dentist or doctor to check your entire mouth for signs of cancer. Regular checkups can detect the early stages of oral cancer or conditions that may lead to oral cancer. Ask your doctor or dentist about checking the tissues in your mouth as part of your routine exam.

Symptoms

Common symptoms of oral cancer include:

Anyone with these symptoms should see a doctor or dentist so that any problem can be diagnosed and treated as early as possible. Most often, these symptoms do not mean cancer. An infection or another problem can cause the same symptoms.

Diagnosis of oral cancer

If you have symptoms that suggest oral cancer, the doctor or dentist checks your mouth and throat for red or white patches, lumps, swelling, or other problems. This exam includes looking carefully at the roof of the mouth, back of the throat, and insides of the cheeks and lips. The doctor or dentist also gently pulls out your tongue so it can be checked on the sides and underneath. The floor of your mouth and lymph nodes in your neck also are checked.

If an exam shows an abnormal area, a small sample of tissue may be removed. Removing tissue to look for cancer cells is called a biopsy. Usually, a biopsy is done with local anesthesia. Sometimes, it is done under general anesthesia. A pathologist then looks at the tissue under a microscope to check for cancer cells. A biopsy is the only sure way to know if the abnormal area is cancerous.

If you need a biopsy, you may want to ask the doctor or dentist some of the following questions:

Treatment for oral cancer

Staging

If the biopsy shows that cancer is present, your doctor needs to know the stage (extent) of your disease to plan the best treatment. The stage is based on the size of the tumor, whether the cancer has spread and, if so, to what parts of the body.

Staging may require lab tests. It also may involve endoscopy. The doctor uses a thin, lighted tube (endoscope) to check your throat, windpipe, and lungs. The doctor inserts the endoscope through your nose or mouth. Local anesthesia is used to ease your discomfort and prevent you from gagging. Some people also may have a mild sedative. Sometimes the doctor uses general anesthesia to put a person to sleep. This exam may be done in a doctor's office, an outpatient clinic, or a hospital.

The doctor may order one or more imaging tests to learn whether the cancer has spread:

Treatment

Many people with oral cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and your treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor—to take part in the discussion, to take notes, or just to listen.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat oral cancer include oral and maxillofacial surgeons, otolaryngologists (ear, nose, and throat doctors), medical oncologists, radiation oncologists, and plastic surgeons. You may be referred to a team that includes specialists in surgery, radiation therapy, or chemotherapy. Other health care professionals who may work with the specialists as a team include a dentist, speech pathologist, nutritionist, and mental health counselor.

Getting a second opinion

Before starting treatment, you might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if you or your doctor requests it.

There are a number of ways to find a doctor for a second opinion:

You may want to ask the doctor these questions before treatment begins:

Preparing for treatment

The choice of treatment depends mainly on your general health, where in your mouth or oropharynx the cancer began, the size of the tumor, and whether the cancer has spread. Your doctor can describe your treatment choices and the expected results. You will want to consider how treatment may affect normal activities such as swallowing and talking, and whether it will change the way you look. You and your doctor can work together to develop a treatment plan that meets your needs and personal values.

You do not need to ask all your questions or understand all the answers at once. You will have other chances to ask your doctor to explain things that are not clear and to ask for more information.

Methods of treatment

Oral cancer treatment may include surgery, radiation therapy, or chemotherapy. Some patients have a combination of treatments.

At any stage of disease, people with oral cancer may have treatment to control pain and other symptoms, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called supportive care, symptom management, or palliative care. Information about supportive care is available on NCI's Web site at http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.

You may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.

Surgery

Surgery to remove the tumor in the mouth or throat is a common treatment for oral cancer. Sometimes the surgeon also removes lymph nodes in the neck. Other tissues in the mouth and neck may be removed as well. Patients may have surgery alone or in combination with radiation therapy.

You may want to ask the doctor these questions before having surgery:

Radiation therapy

Radiation therapy (also called radiotherapy) is a type of local therapy. It affects cells only in the treated area. Radiation therapy is used alone for small tumors or for patients who cannot have surgery. It may be used before surgery to kill cancer cells and shrink the tumor. It also may be used after surgery to destroy cancer cells that may remain in the area.

Radiation therapy uses high-energy rays to kill cancer cells. Doctors use two types of radiation therapy to treat oral cancer:

Some people with oral cancer have both kinds of radiation therapy.

You may want to ask the doctor these questions before having radiation therapy:

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. It is called systemic therapy because it enters the bloodstream and can affect cancer cells throughout the body.

Chemotherapy is usually given by injection. It may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a hospital stay may be needed.

You may want to ask the doctor these questions before having chemotherapy:

Side effects of treatment for oral cancer

Because treatment often damages healthy cells and tissues, unwanted side effects are common. These side effects depend mainly on the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects. Booklets such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients may be viewed, downloaded, and ordered from http://cancer.gov/publications. These materials also may be ordered by calling the Cancer Information Service at 1-800-4-CANCER.

The National Institute of Dental and Craniofacial Research (NIDCR) also provides helpful materials. Head and Neck Radiation Treatment and Your Mouth, Chemotherapy and Your Mouth, and other booklets are available from NIDCR. See "National Institute of Dental and Craniofacial Research Information Resources" for a list of publications.

Surgery

It takes time to heal after surgery, and the time needed to recover is different for each person. You may be uncomfortable for the first few days after surgery. However, medicine can usually control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

It is common to feel tired or weak for a while. Also, surgery may cause tissues in your face to swell. This swelling usually goes away within a few weeks. However, removing lymph nodes can result in swelling that lasts a long time.

Surgery to remove a small tumor in the mouth may not cause any lasting problems. For a larger tumor, however, the surgeon may remove part of the palate, tongue, or jaw. This surgery may change your ability to chew, swallow, or talk. Also, your face may look different after surgery. Reconstructive or plastic surgery may be done to rebuild the bones or tissues of the mouth. (See "Reconstruction.")

Radiation therapy

Almost all patients who have radiation therapy to the head and neck area develop oral side effects. That is why it is important to get the mouth in good condition before cancer treatment begins. Seeing a dentist two weeks before cancer treatment begins gives the mouth time to heal after dental work.

The side effects of radiation therapy depend mainly on the amount of radiation given. Some side effects in the mouth go away after radiation treatment ends, while others last a long time. A few side effects (such as dry mouth) may never go away.

Radiation therapy may cause some or all of these side effects:

Although the side effects of radiation therapy can be distressing, your doctor can usually treat or control them. It helps to report any problems that you are having so that your doctor can work with you to relieve them.

Chemotherapy

Chemotherapy and radiation therapy can cause some of the same side effects, including painful mouth and gums, dry mouth, infection, and changes in taste. Some anticancer drugs can also cause bleeding in the mouth and a deep pain that feels like a toothache. The problems you have depend on the type and amount of anticancer drugs you receive, and how your body reacts to them. You may have these problems only during treatment or for a short time after treatment ends.

Generally, anticancer drugs affect cells that divide rapidly. In addition to cancer cells, these rapidly dividing cells include the following:

Nutrition

Eating well during cancer treatment means getting enough calories and protein to prevent weight loss, regain strength, and rebuild healthy tissues. But eating well may be difficult after treatment for oral cancer. Some people with cancer find it hard to eat because they lose their appetite. They may not feel like eating because they are uncomfortable or tired. A dry or sore mouth or changes in smell and taste also may make eating difficult.

If your mouth is dry, you may find that soft foods moistened with sauces or gravies are easier to eat. Thick soups, puddings, and milkshakes often are easier to swallow. Nurses and dietitians can help you choose the right foods. Also, the National Cancer Institute booklet Eating Hints for Cancer Patients contains many useful ideas and recipes. The "National Cancer Institute Information Resources" section tells how to get this publication.

After surgery or radiation therapy for oral cancer, some people need a feeding tube. A feeding tube is a flexible plastic tube that is passed into the stomach through an incision in the abdomen. In almost all cases, the tube is temporary. Most people gradually return to a regular diet.

To protect your mouth during cancer treatment, it helps to avoid:

Reconstruction

Some people with oral cancer may need to have plastic or reconstructive surgery to rebuild the bones or tissues of the mouth. Research has led to many advances in the way bones and tissues can be replaced.

Some people may need dental implants. Or they may need to have grafts (tissue moved from another part of the body). Skin, muscle, and bone can be moved to the oral cavity from the chest, arm, or leg. The plastic surgeon uses this tissue for repair.

If you are thinking about reconstruction, you may wish to consult with a plastic or reconstructive surgeon before your treatment begins. You can have reconstructive surgery at the same time as you have the cancer removed, or you can have it later on. Talk with your doctor about which approach is right for you.

Rehabilitation

The health care team will help you return to normal activities as soon as possible. The goals of rehabilitation depend on the extent of the disease and type of treatment. Rehabilitation may include being fitted with a dental prosthesis (an artificial dental device) and having dental implants. It also may involve speech therapy, dietary counseling, or other services.

Sometimes surgery to rebuild the bones or tissues of the mouth is not possible. A dentist with special training (a prosthodontist) may be able to make you a prosthesis to help you eat and talk normally. You may need special training to learn to use it.

If oral cancer or its treatment leads to problems with talking, speech therapy will generally begin as soon as possible. A speech therapist may see you in the hospital to plan therapy and teach speech exercises. Often speech therapy continues after you return home.

Follow-up care for oral cancer

Follow-up care after treatment for oral cancer is important. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained in the body after treatment. The doctor monitors your recovery and checks for recurrence of cancer. Checkups help ensure that any changes in your health are noted. Your doctor will probably encourage you to inspect your mouth regularly and continue to have exams when you visit your dentist. It is important to report any changes in your mouth right away.

Checkups include exams of the mouth, throat, and neck. From time to time, your doctor may do a complete physical exam, order blood tests, and take x-rays.

People who have had oral cancer have a chance of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for those who use tobacco or who drink alcohol heavily. Doctors strongly urge their patients to stop using tobacco and drinking to cut down the risk of a new cancer and other health problems.

The NCI has prepared a booklet for people who have completed their treatment to help answer questions about follow-up care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for making the best use of medical visits. It describes how to talk to your health care team about creating a plan of action for recovery and future health.

Support for people with oral cancer

Living with a serious disease such as oral cancer is not easy. You may worry about caring for your family, keeping your job, or continuing daily activities. You may have concerns about treatments and managing side effects, hospital stays, and medical bills. Doctors, nurses, and other members of the health care team can answer your questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful if you want to talk about your feelings or discuss your concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group. The NCI's fact sheets "Cancer Support Groups: Questions and Answers" and "National Organizations That Offer Services to People With Cancer and Their Families" tell how to find a support group. See "National Cancer Institute Information Resources" for ordering information.

The Cancer Information Service can provide information to help patients and their families locate programs, services, and publications.

The promise of cancer research

Doctors all over the country are conducting many types of clinical trials. These are research studies in which people volunteer to take part. In clinical trials, doctors are testing new ways to treat oral cancer. Research has already led to advances, and researchers continue to search for more effective approaches.

People who join clinical trials may be among the first to benefit if a new approach is shown to be effective. And if participants do not benefit directly, they still make an important contribution to medical science by helping doctors learn more about the disease and how to control it. Although clinical trials may pose some risks, researchers do all they can to protect their patients.

Researchers are testing anticancer drugs and combinations of drugs. They are studying radiation therapy combined with drugs and other treatments. They also are testing drugs that prevent or reduce the side effects of radiation therapy.

If you are interested in learning more about joining a clinical trial, you may want to talk with your doctor. You may want to read Taking Part in Clinical Trials: What Cancer Patients Need To Know. The NCI also offers an easy-to-read brochure called If You Have Cancer…What You Should Know About Clinical Trials. These NCI publications describe how research studies are carried out and explain their possible benefits and risks. NCI's Web site includes a section on clinical trials at http://cancer.gov/clinicaltrials with general information about clinical trials and detailed information about specific studies. The Cancer Information Service at 1-800-4-CANCER or at LiveHelp at http://cancer.gov can answer questions and provide information about clinical trials. Another source of information about clinical trials is http://clinicaltrials.gov.

National Cancer Institute information resources

You may want more information for yourself, your family, and your doctor. The following National Cancer Institute (NCI) services are available to help you.

Telephone

Cancer Information Service (CIS) Provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information Specialists translate the latest scientific information into understandable language and respond in English, Spanish, or on TTY equipment.

Toll-free: 1-800-4-CANCER (1-800-422-6237)
TTY: 1-800-332-8615

Internet

http://cancer.gov
The NCI's Cancer.gov™ Web site provides information from numerous NCI sources. It offers current information on cancer prevention, screening, diagnosis, treatment, genetics, supportive care, and ongoing clinical trials. It also provides information about NCI's research programs and funding opportunities, cancer statistics, and the Institute itself. Cancer.gov provides live, online assistance through LiveHelp. Cancer.gov is at http://cancer.gov on the Internet.

http://www.smokefree.gov
The Tobacco Control Research Branch of NCI, in collaboration with the Centers for Disease Control and Prevention and the American Cancer Society, created a smoking cessation Web site. It offers online quitting advice through NCI's LiveHelp service. It also provides national and state telephone quitline numbers and access to printed materials about quitting tobacco. It is located on the Internet at http://www.smokefree.gov.

Print materials

You can order National Cancer Institute (NCI) publications by writing to the address below:

Publications Ordering Service
National Cancer Institute
Suite 3036A
6116 Executive Boulevard, MSC 8322
Bethesda, MD 20892-8322

Some NCI publications can be viewed, downloaded, and ordered from http://cancer.gov/publications on the Internet. If you are in the United States or one of its territories, you may order these and other NCI booklets by calling the Cancer Information Service at 1-800-4-CANCER.

National Institute of Dental and Craniofacial Research information resources

The National Oral Health Information Clearinghouse

This Clearinghouse is a service of the Federal Government's National Institute of Dental and Craniofacial Research (NIDCR). NIDCR's mission is to promote the general health of the American people by improving their oral, dental, and craniofacial health. Through the conduct and support of research and the training of researchers, the NIDCR aims to promote health, prevent diseases and conditions, and develop new diagnostics and therapies.

NIDCR directs the health awareness campaign, Oral Health, Cancer Care, and You: Fitting the Pieces Together. The campaign addresses the importance of preventing and managing the oral side effects of cancer treatments. It is a partnership among NIDCR, NCI, National Institute of Nursing Research, and Centers for Disease Control and Prevention.

NIDCR can supply free information about oral cancer and taking care of your mouth during cancer treatment. Booklets are available in English and Spanish:

Chemotherapy and Your Mouth
Head and Neck Radiation Treatment and Your Mouth
Quimioterapia y la Boca (Chemotherapy and Your Mouth)
Su Boca y el Tratamiento de Radiación en la Cabeza y el Cuello (Head and Neck Radiation and Your Mouth)

Materials may be obtained by contacting the Clearinghouse:

National Institute of Dental and Craniofacial Research
National Oral Health Information Clearinghouse
Attn: OCCT
1 NOHIC Way
Bethesda, MD 20892-3500
Tel: 301-402-7364

Materials are also available online at http://www.nidcr.nih.gov under "health information."

Oral Cancer At A Glance

SOURCE: National Institutes of Health, National Cancer Institute, www.cancer.gov