Oral cancer

Symptoms Of Oral Cancer

Oral cancer presents itself with the following symptoms:

• Sore on the lip or in the mouth that doesn't heal

• Pain in the mouth 

• Lump or thickening in the lips, mouth, or cheek

• White or red patch on the gums, tongue, tonsil, or lining of the mouth

• Sore throat 

• Difficulty in chewing or swallowing

• Trouble moving the jaw or tongue

• Numbness of the tongue, lip, or other areas of the mouth

• Swelling or pain in the jaw

• Poor fitting of the dentures 

• Loosening of the teeth 

• Pain around the teeth and gums

• Changes in the voice

• Lump or mass in the neck or back of the throat

• Loss of weight

• Ear pain

Oral cancer if caught early has a high probability of survival. Know more about the early warning signs.
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Types Of Oral Cancer

There are multiple types of oral cancer and are generally categorized by the type of cell cancer (carcinoma) starts to grow in. They include:

1. Squamous cell carcinoma

This is the most common type of mouth cancer. The earliest form of squamous cell cancer is called carcinoma in situ. This means that the cancer cells are only in the top layer of cells lining cells.

2. Adenocarcinoma

Is a cancer that develops inside the tissue of the salivary gland, which grows from abnormalities in bone, cartilage, muscle, or other tissue cancer that starts in the cells that produce skin pigment or color (melanocytes). 

3. HPV-related cancers

Infection with certain high-risk types of the human papillomavirus (HPV) causes most of the squamous cell cancers of the oropharynx (called HPV-positive cancer). HPV is rarely associated with oral cavity cancer. 

4. Verrucous carcinoma

This is a rare type of squamous cell cancer that is most often found in the gums and cheeks. It's slow-growing cancer that hardly ever spreads to other parts of the body.

5. Other types of oral cavity cancers

• Minor salivary gland cancers: These can start in the glands in the mouth and throat lining. 
• Lymphomas: The tonsils and base of the tongue contain immune system (lymphoid) tissue, where cancers called lymphomas can start.
• Leukoplakia and erythroplakia: These are possible precancerous conditions where certain types of tissue changes can be seen in the mouth or throat.

6. Benign (not cancer) tumors

• Peripheral giant cell granuloma: Is the most common oral giant cell lesion appearing as a soft tissue purplish-red nodule.
• Fibroma: These are tumors made up of fibrous tissue that can occur almost anywhere in and on the body.
• Granular cell tumor: A rare type of soft tissue tumor that usually begins in the cells that hold nerve cells in place.
• Schwannoma: A rare type of tumor that forms in the nervous system.
• Neurofibroma: A type of nerve tumor that forms soft bumps on or under the skin. 
• Pyogenic granuloma: It is a noncancerous, raised tumor on your skin or mucous membranes.
• Oral hemangioma: These are benign tumors that develop due to the proliferation of the inner layers of cells around the oral cavity.

Causes Of Oral Cancer

Oral cancer occurs when abnormal cells begin to grow within the oral cavity. These abnormal cells develop because of changes (mutations) in their DNA. This mutated DNA dictates the cells to grow uncontrollably and to continue living after normal cells die. These masses of cells can form a tumor and when left untreated, these cells continue to grow out of control and spread to other parts of the body.

Numerous risk factors or possible causative agents for the development of oral cancer.

Risk Factors For Oral Cancer

Oral cancer is one of the most common types of cancer and is associated with several risk factors. They include:

A. Modifiable factors

1. Tobacco: Using tobacco, including cigarettes, cigars, pipes, chewing tobacco, and snuff, is the single largest risk factor for head and neck cancer and is associated with 85% of head and neck cancers.

2. Betel quid: Studies have demonstrated that chewing is not only to be a risk factor for cancers of the oral cavity and pharynx and oral potentially malignant disorders (OPMD) but also can cause other cancers and adverse health effects.

3. Alcohol: Alcohol has been implicated in the development of oral cancer. Alcoholic beverages have been considered carcinogenic to humans causing, in particular, tumors of the oral cavity, pharynx, larynx, esophagus, and liver.

4. Diet and nutrition: The relationship between diet and nutrition to the risk of cancer development has been established by several epidemiological and laboratory studies.

5. Mouthwash: The use of mouthwash has also been implicated to cause oral cancer. Mouthwashes usually contain alcohol as a solvent for other ingredients or as a preservative that increases the risk of causing oral cancer.

6. Maté: It is a tea‑like beverage and has been shown to be an independent cause of the development of oral and pharyngeal cancers.

7. Poor dental status: Like sharp/fractured teeth due to caries/trauma, and chronic ulceration from an ill‑fitting denture have been suggested to promote cancer in the presence of other risk factors like smoking and alcohol consumption.

B. Non- modifiable factors

1. Family history: Genetic predisposition has been shown to be an important risk factor in the development of oral cancer. 

2. Gender: Men are more likely to develop oral and oropharyngeal cancers than women.

3. Fair skin: Fair skin is linked to a higher risk of lip cancer.

4. Age: This type of cancer can develop in people of any age, but is seen more in individuals older than 45 years who have an increased risk for oral cancer.

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C. Environmental factors

1. Viral infections: Studies have shown that Human Papilloma Virus (HPV) has been associated as a risk factor in oral cancer, especially HPV type 16. Other oncogenic virus species i.e., Epstein-Barr Virus and Herpes Simplex Virus Type 1 have been proposed to be involved in oral cancers.
   
   

2. Fungal infections: Fungal infections caused by Candida species, in particular, Candida albicans have been implicated in the pathogenesis of oral precancerous lesions that have higher chances of developing into cancer.
   
   

3. Prolonged sun exposure: High exposure to the sun, without sun protection measures, is linked with cancer in the lip area. 
   
   

4. Syphilis: Tertiary syphilis has been known to predispose to the development of oral cancer along with other risk factors such as tobacco and alcohol. 
   
   

5. Radiation: Studies have shown a relationship between exposure to ionizing radiation and the later development of salivary gland tumors. 
   
   

6. Immunosuppression: Individuals whose immune system is compromised due to human immunodeficiency virus (HIV), transplant, and other disorders are more prone to develop oral cancers.

Diagnosis Of Oral Cancer

Diagnosing oral cancer at an early stage is the key to a better prognosis. TNM stands for tumor, node, and metastases. It is one of the staging systems doctors use for mouth cancer. It includes:

Primary tumor (T)

• TX: Tumor cannot be assessed

• T0: No evidence of primary tumor

• Tis: Carcinoma in situ (CIS)- a group of abnormal cells that are found only in the place where they first formed in the body

• T1: Tumor 2 cm or less in greatest dimension

• T2: Tumor more than 2 cm but not more than 4 cm in greatest dimension

• T3: Tumor more than 4 cm in greatest dimension

• T4a: A moderately advanced local disease. 

• T4b: Very advanced local disease.

Regional lymph nodes (N)

• NX: Cannot be assessed

• N0: No regional lymph node metastasis ( spread of cancer)

• N1: Metastasis in a single lymph node on one side (ipsilateral), 3 cm or less in greatest dimension

• N2: Metastasis as specified in:

  • N2a: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension.

  • N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension

  • N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.

• N3: Metastasis in a lymph node more than 6 cm in greatest dimension.

Distant metastasis (M)

• MX: Distant metastasis cannot be assessed

• M0: No distant metastasis.

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The diagnosis consists of the following:

A. Physical examination

The primary and the most crucial assessment for oral cancer is the physical examination, which usually consists of two steps – systematic visual examination and palpation. Primarily, the external parts such as lymph nodes, salivary glands, lips, etc. are inspected, and subsequently, an internal examination of the mouth is performed to look for irregularities, swelling, and thickening.

B. Histopathological examination

Histopathology is used to assess the aggressiveness of tumors with high invasive potential. It includes:

1. Vital staining techniques: Visual tissue staining is an adjunct technique used in the diagnosis of cancer. Tolonium chloride (also known as toluidine blue) staining is used to detect mucosal abnormalities in the oral cavity. 
   
   

2. Biopsy: A tissue sample is removed surgically from the suspected region and sent to the pathological laboratory for a detailed microscopic examination.
   
   

3. Brush biopsy: In brush biopsy, cells from the oral lesion are obtained by scraping the surface mucosa. 
   
   

4. Exfoliative cytology: Exfoliative cytology is a simple and noninvasive diagnostic technique for the early detection of oral cancer.
   
   

5. Incisional biopsy: In this type of biopsy, a representative sample of the tissue is carefully chosen for selective diagnosis. 

C. Imaging techniques

Several advanced imaging techniques are used for the diagnosis of oral cancer.

1. Magnetic resonance imaging (MRI): MRI provides the details of the structures in the oral cavity along with adjacent parts. The soft-tissue discrimination by MRI aids in assessing the extent of local and regional spread of the tumor, invasion depth, and extent of involvement of lymph nodes.
   
   

2. Computed tomography (CT): The CT scan uses x-ray radiations and a computer to create pictures of the body to locate the cancerous lesion and determine its spread to the other parts of the body.
   
   

3. Positron emission tomography (PET): The PET scan is used to determine the spread of tumor cells to the lymph nodes or other parts of the body.
   
   

4. Radiological techniques: X-ray is used to determine the spread of cancer to the other organs outside of the mouth and oropharynx. The x-ray done for oral cancer is known as an orthopantomogram (OPG).
   
   

5. Optical imaging techniques: These include optical coherence tomography and tissue fluorescence imaging that can effectively differentiate between cancerous and non-cancerous lesions. 

D. Biomarker detection 

Biomarkers are used for the early detection of oral cancer. Biomarkers in general are components of the cells present in body fluid or tumor cells that are overexpressed during the onset of the disease. 

E. Other methods

In recent years, significant advancements have been reported in diagnostic techniques that are rapid and specific for the detection of cancer biomarkers. They include:

1. Raman spectroscopy: It is a non-destructive chemical analysis technique that provides detailed information about the chemical structure.
   
   

2. Confocal microscopy: This is another light-based technique that provides images of many important cellular and architectural features of squamous cell carcinoma (SCC).
   
   

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Prevention Of Oral Cancer

The exact cause of oral cancer is unknown and there can be multifactorial causes. The best way of preventing any kind of cancer is to lead a healthy lifestyle. Other things to keep in mind include:

1. Get cancer screening for early detection

Cancers detected at early stages can be treated more successfully. Delay in diagnosis has an effect on cancer-related morbidity and mortality. Therefore, screening and early clinical diagnosis help to provide more safe and cheap treatments. 

2. Always self-examine yourself

It is another way to detect oral cancer at an early stage. You can do this by:

• Looking at the inside of both of your cheeks with your flashlight

• Feeling those areas with your fingers

• Checking floor of your mouth (beneath your tongue) with your flashlight

• Examining the floor of your mouth with your finger

• Sticking out your tongue, examine the top, both sides, and under the surface using your flashlight.

3. Visit your dentist regularly

Seeing your dentist regularly is key to maintaining good oral health. As part of your examination, your dentist can look and feel in and around your mouth and any unusual lumps or sores can be detected early. 

4. Stay away from all forms of tobacco

Chewing, smokeless, and snuff tobacco, which is placed directly in the mouth, can create gray-white ulcers called leukoplakia in the mouth that can become cancerous. Smokeless tobacco also contains chemicals known to damage a gene that protects against cancer.

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5. Limit your alcohol intake

Moderate to heavy alcohol consumption is associated with higher risks of certain head and neck cancers, and reducing the intake can be very beneficial.

Note: Avoid the combination of alcohol and tobacco. Research shows that people who use both alcohol and tobacco have much greater risks of developing oral cancer than people who use either alcohol or tobacco alone. Know more about other cancer-related myths and facts.
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6. Get vaccinated for HPV

Human papillomavirus (HPV), particularly HPV16, is strongly associated with oropharyngeal cancers, especially those at the back of the mouth. The best way to prevent HPV is to get vaccinated before you become sexually active, and also practice safe sex. 

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7. Protect your lips from the sun 

If you have a history of severe sunburns, take extra care with your lips. Just as skin can burn easily, the lips are also sensitive to the sun. Some of the tips include:

• Limiting sun exposure during the peak hours of 10 a.m. and 2 p.m

• Wearing a protective lip balm with SPF when stepping out

• Reapplying lip balms after you eat or drink

• Using hats that shield your face from the sun.

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8. Maintain a healthy lifestyle

There are a lot of cancer prevention clinical trials that aim to find out whether actions people take can prevent cancer. These may include eating fruits and vegetables, exercising, quitting smoking, or taking certain medicines, vitamins, minerals, or food supplements.

9. Understand chemoprevention 

This is a promising plan to inhibit, suppress, or control the growth of cancer cells. Chemoprevention is the use of certain drugs or other substances to help lower a person's risk of developing cancer or keep it from coming back.

10. Add probiotics to the diet

Recently published studies assessed microbial compositions in patients with OSCC. Probiotics are live microorganisms that provide a health benefit to the host. Recent data on probiotic products show a protective effect against cancer cell activity.

11. Take supplements

There are some natural products to prevent oral cancer such as: 

• Vitamin C

• Vitamin E

• Vitamin A

• Omega-3 fatty acids 

• Carotenoids

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Specialist To Visit

Cancer is not a single disease but a group of related diseases. Hence, it requires comprehensive care. Doctors that take care of patients with oral cancer and help in diagnosing and formulating a treatment plan are:

• Dentists

• Otolaryngologists

• Oncologists

• Radiation oncologists

• Medical oncologists

Otolaryngologist is a doctor who specializes in diseases that affect the ears, nose, and throat. An oncologist is a doctor who treats cancer and provides medical care for a person diagnosed with cancer. A radiation oncologist is a doctor who uses radiation to treat cancer whereas a medical oncologist uses chemotherapy and other medicines to treat cancer.

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Treatment Of Oral Cancer

Any kind of cancer requires multidisciplinary treatment that includes surgery, chemotherapy, and radiation, alone or in combination. Oral cancer treatment includes:

A. Surgical management 

• Surgery for primary tumors: Surgery is recommended for patients with early-stage tumors and surgery or definitive concurrent chemoradiotherapy for those with advanced-staged tumors. Approaches to the removal of the tumor and the surrounding structures are dictated by the location and extent of invasion.

• Surgery for neck dissection: Neck dissection detects any spread of cancer in the early stage and removes the majority of affected lymph nodes. In patients with early-stage tumors, the decision to proceed to elective neck dissection (END) is based on a greater than 20% probability of the presence of cancer cells in the lymph nodes. Alternatives to END include

  • Observation

  • Elective radiation

  • Sentinel lymph node biopsy

• Other surgeries:

  • Glossectomy (partial or total removal of your tongue)

  • Mandibulectomy (surgery for oral cancer in your jawbone)

  • Maxillectomy (removal of a part or all of the bony roof of your mouth).

Surgery in case of recurrence

Recurrence rates in the oral cavity is 30%, and Salvage (or 'rescue') surgery is used to refer to surgical treatment after failure of initial treatment in various scenarios including treatment of delayed neck metastasis, recurrent primary tumors, or even spread of cancer to the lungs.

Reconstruction

The oral cavity is a complex site made up of several structures critical for speech, swallowing, and appearance. To be deemed successful, reconstruction should attempt to address all three, and it must be tailored to the site of the defect. 

Radiation

Radiation therapy uses X-rays to destroy or damage cancer cells, making them unable to proliferate. Radiotherapy is mainly used in patients with locally advanced oral cancer.

Although definitive radiation therapy can be used for oral cancer, it is not routinely used because of elevated rates of Osteoradionecrosis (bone death due to necrosis) associated with the higher therapeutic doses required compared with doses for postoperative adjuvant therapy. Types of radiation therapy include:

• External-beam radiation therapy: The most common type of radiation in which the radiation is given from a machine outside the body. 

• Internal-beam radiation therapy: When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Brachytherapy involves the application of a radioactive source in close proximity to the tumor. 

Chemotherapy

Chemotherapy (chemo) is treatment with anti-cancer drugs that are injected into a vein or taken by mouth, which allows them to enter the blood and reach most parts of the body. Drugs used for chemotherapy include:

• Cisplatin

• Carboplatin

• 5-fluorouracil (5-FU)

• Paclitaxel (Taxol)

• Docetaxel (Taxotere)

• Hydroxyurea

Other less often used drugs include:

• Methotrexate

• Capecitabine

Types of chemotherapy include:

• Adjuvant chemotherapy: It is given after surgery and is sometimes combined with radiation therapy. The goal is to kill cancer cells that might have been left behind at surgery because of the smaller size and also prevents recurrence.

• Neoadjuvant or induction chemotherapy: This is given before surgery with or without radiation to shrink some larger cancers to make surgery easier and remove less tissue. This can lead to fewer serious side effects and problems from surgery.

Note: For advanced cancer, chemo (with or without radiation therapy) can be used to treat cancers that are too large or have spread too far to be removed by surgery. The goal is to slow the growth of cancer.

Chemoradiation

Chemoradiation is chemotherapy given at the same time as radiation. It has been shown to shrink oral cavity and oropharyngeal tumors that are not widespread but are too advanced for surgery. Generally, this approach is hard to tolerate, especially for people in poor health.

Targeted therapy

It is the use of medicines that target or are directed at proteins in cancer cells by destroying cancer cells or slowing their growth. Some targeted drugs, for example, monoclonal antibodies, work in more than one way to control cancer cells and may also be considered immunotherapy because they boost the immune system. Cetuximab is the most commonly used drug for this therapy.

Immunotherapy

This therapy uses medicines to help boost a person’s own immune system to find and destroy cancer cells more effectively. It typically works on specific proteins involved in the immune system to enhance the immune response.

B. Non-surgical management

This type of management is used to preserve the organs, although surgery is the mainstay of therapy for advanced-stage oral cancer.

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Home-care For Oral Cancer

The news of oral cancer can be devastating. Cancer not only affects the body but has a serious effect on the mind as well. General treatment guidelines include an early diagnosis, correction of predisposing factors, and maintaining good oral hygiene. Apart from these, some of the things that the patients can do at home that can help manage the symptoms of treatment include:

• Quit smoking

• Stay away from alcohol

• Take enough rest post any surgical procedure

• Be physically active

• Talk to a counselor

• Adopt a healthy behavior

• Getting emotional support from loved ones

• Follow all the instructions given by doctors

• Eat a well balanced and nutritious diet

• Find hobbies that make you happy

• Add nutritional supplements to the diet

• Always indulge in safe sex

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Tips for caregivers

There are numerous resources available for the patient and their families, battling with oral cancer. Tips that the caregivers can follow to help the patient in difficult times include:

• Encouraging and providing mental support to the patient

• Understanding the course of treatment

• Talking with empathy and positive attitude to the patient

• Helping the patients with household chores

• Handling insurance and billing issues for them

• Helping the patient manage their symptoms and side effects

• Coordinating their medical appointments and giving medications on time

• Assisting the patient in maintaining personal care and hygiene

• Taking care of patients' needs.

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Complications Of Oral Cancer

Complications occur either due to untreated disease and subsequent spread of the tumor or commonly due to side effects of treatment. These include:

Complications from surgery

Surgery involving tumor excision, neck dissection, and free flap reconstruction carries the risk of the following:

• Failure of the flap

• Damage to local motor and sensory nerves

• Paralysis of the vocal cords

• Restriction of the range of motion of the jaws

• Difficulty in speaking

• Improper wound healing

• Potential long-term requirement of feeding tubes

• Patients may require an extended stay in intensive care. 

Complications from chemo or radiotherapy 

Chemotherapy and radiation can result in a wide range of debilitating, chronic symptoms. Specifically, in the oral cavity, patients may experience the following:

• Pain

• Bleeding

• Osteoradionecrosis

• Inflammation of the mucosa

• Dry mouth is also known as xerostomia

• Difficulty in swallowing and speaking

• Reduced oral intake and malnutrition

• Increased infections due to decreased immunity.

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Alternative Therapies For Oral Cancer

When considering alternative and complementary treatments for any kind of cancer, it is very important to communicate with your medical teams as some of the alternative therapies may be contraindicated from the treatment plan. Alternative therapies, that can prove beneficial in managing or preventing early-stage of oral cancer include:

Herbal therapy

Herbal medicines are plant-based products used as traditional and domestic medicines and food additives. Some of the herbs with anti-cancer effects include:

• Curcumin or Turmeric (Haldi): It suppresses the tumor activity and consequently reduces tumor growth and metastasis. 
  
  

• Ginger (Adrak): It can be used as a therapeutic agent in UV-induced skin diseases, including cancer of lips.
  
  

• Saffron (Kesar): Studies have reported the antioxidant, anti-cancer, anti-inflammatory, antidepressant, antihistamine, and memory-enhancer effects of saffron in animal models.
  
  

• Cinnamon (Chakla): It has numerous biological functions such as antioxidant, antibacterial, anti-inflammation, anti-diabetes, and anti-tumor activity. 
  
  

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Photodynamic therapy (PDT) 

Living With Oral Cancer

Living with oral cancer may seem very difficult, but a good support system along with a positive attitude can help the patients cope with the diagnosis and treatment. Some of the things that can prove to be beneficial include:

Getting all the emotional support

It is normal to feel depressed, anxious, or worried when you get to know that cancer is a part of your life. Some people are affected more than others, but everyone can benefit from help and support from other people like:

• Friends and family

• Religious groups

• Support groups

• Professional counselors

Take post-treatment follow-up very seriously

Patients with oral cancer are at risk for recurrences and cancer in the other parts of the body. After completion of the treatment, patients should be followed up at regular intervals to detect any signs of recurrence. Regular dental visits and endoscopies can help detect any early signs.
Endoscopy and other tests are generally done:

• Every 1 to 3 months during the first year

• Every 2 to 6 months during the second year

• Every 4 to 8 months during the 3rd to 5th years

• Every year after the 5th year

Give importance to palliative care

Oral cancer causes severe physical, psychosocial and spiritual pain to patients and their families. Palliative care focuses on improving how you feel during treatment by managing symptoms. Palliative care along with treatment for cancer has shown greater results with less severe symptoms, a better quality of life, and more satisfaction with treatment. Palliative treatments vary widely and often include: 

• Medication to relieve the symptoms

• Nutritional changes

• Relaxation techniques

• Emotional and spiritual support

• Encouraging the patient to do things they love.

Quit smoking

Smoking is the leading cause of death due to oral cancer and if you had trouble quitting smoking before treatment, your doctor may recommend counseling as well as medication to help you. It is very important to quit smoking because even people with early-stage oral cavity or oropharyngeal cancer are at risk of a new smoking-related cancer if they continue to smoke. 

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Get proper rehabilitation

Radiation, surgery, and certain chemo drugs can lead to problems with speech, swallowing, and hearing. Speech, hearing, and swallowing rehabilitation are required to maintain the quality of life.
Therapists that can help you include:

• Speech therapists: Who are knowledgeable about speech and swallowing problems and can help you learn to manage them. 

• Audiologist (a specialist in hearing): Who can help you with devices to improve your hearing if the treatment has affected your hearing capacity.

Keep health insurance and copies of your medical records

Even after treatment, it’s crucial to keep health insurance, as tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

Also if you see a new doctor at some point of the treatment who doesn’t know about your medical history, your medical records can give the new doctor the details of your diagnosis and treatment.