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

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Oral cancer occurs when abnormal cells begin to grow within the oral cavity.

These abnormal cells develop due to changes (mutations) in their DNA.

This mutated DNA causes the cells to grow uncontrollably and to survive beyond the normal lifespan of cells.

These masses of cells can form a tumor, and when left untreated, they continue to grow uncontrollably and spread to other parts of the body.

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

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

1. Modifiable factors

• Tobacco
• Betel quid
• Alcohol
• Diet and nutrition
• Mouthwash
• Maté (a tea-like beverage)
• Poor dental status

Note: Tobacco use, including smoking and chewing, is the leading risk factor for head and neck cancers, linked to 85% of cases. Want to quit smoking but are unable to do so? Read This Now

2. Non-modifiable factors

• Family history
• Gender (men are more likely to develop oral and oropharyngeal cancers than women)
• Fair skin
• Age

Note: Oral cancer can develop in people of any age, but is more commonly seen in individuals older than 45 years who have an increased risk for oral cancer. Want to find out if you are at risk of developing cancer? There is a test for that called geneCORE predict – hereditary cancer risk test. This test predicts your risk of up to 22 major cancers. Know More

3. Environmental factors

• Viral infections (HPV, Epstein-Barr Virus, and Herpes Simplex Virus Type 1 have been proposed to be involved in oral cancers)
• Fungal infections
• Prolonged sun exposure
• Syphilis
• Radiation
• Immunosuppression

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

Early detection is crucial for a favorable outcome in any cancer. The diagnosis consists of the following:

1. Physical Examination

• External parts such as lymph nodes, salivary glands, lips, etc., are inspected.
• An internal examination of the mouth is performed to look for irregularities, swelling, and thickening.

2. Histopathological Examination

• Vital staining techniques: Tolonium chloride (also known as toluidine blue) staining is used to detect mucosal abnormalities in the oral cavity.
• Biopsy: A tissue sample is surgically removed from the suspected region and sent to the pathological laboratory for detailed microscopic examination.
• Brush biopsy: Cells from the oral lesion are obtained by scraping the surface mucosa.
• Exfoliative cytology: A simple and noninvasive diagnostic technique for early detection of oral cancer.
• Incisional biopsy: A representative tissue sample is carefully chosen for selective diagnosis.

3. Imaging Techniques

• Magnetic resonance imaging (MRI): Provides details of the oral cavity structures and adjacent parts, aiding in assessing the extent of local and regional spread of the tumor, invasion depth, and lymph node involvement.
• Computed tomography (CT): Uses X-ray radiation and a computer to create pictures of the body to locate the cancerous lesion and determine its spread.
• Positron emission tomography (PET): Determines the spread of tumor cells to the lymph nodes or other body parts.
• Radiological techniques: X-ray is used to determine the spread of cancer to other organs outside the mouth and oropharynx, known as an orthopantomogram (OPG).
• Optical imaging techniques: Include optical coherence tomography and tissue fluorescence imaging, effectively differentiating between cancerous and non-cancerous lesions.

4. Biomarker Detection

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

5. Other Methods

Recent advancements in diagnostic techniques that are rapid and specific for detecting cancer biomarkers include:

• Raman spectroscopy: A safe method used to study materials without damaging them, providing detailed information about their chemical makeup and structure.
• Confocal microscopy: A light-based technique that provides images of important cellular and architectural features of squamous cell carcinoma (SCC).

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The exact cause of oral cancer is unknown, and there can be multifactorial causes. The best way to prevent any kind of cancer is to lead a healthy lifestyle. Other important considerations include:

1. Get cancer screening for early detection
   Early detection of cancer enables more effective and affordable treatment, reducing cancer-related morbidity and mortality. People generally think cancers are fatal; however, many cancers are treatable and even curable, especially with early detection and proper treatment. Know more about other cancer-related myths and facts.
2. Always self-examine yourself
   - Look at the inside of both of your cheeks with a flashlight.
   - Feel those areas with your fingers.
   - Check the floor of your mouth (beneath your tongue) with a flashlight.
   - Examine the floor of your mouth with your finger.
   - Stick out your tongue and examine the top, both sides, and under the surface using a flashlight.
3. Visit your dentist regularly
   As part of your examination, your dentist can look and feel in and around your mouth to detect any unusual lumps or sores early.
4. Stay away from all forms of tobacco
   Smokeless tobacco, such as chewing or snuff tobacco, can cause leukoplakia—gray-white ulcers in the mouth that may turn cancerous and contain chemicals that harm cancer-protective genes.
5. Limit your alcohol intake
   Moderate to heavy alcohol consumption is associated with higher risks of certain head and neck cancers, and reducing intake can be very beneficial.
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 becoming sexually active and to practice safe sex.
7. Protect your lips from the sun
   - Limit sun exposure during peak hours.
   - Wear a protective lip balm with SPF when outdoors.
   - Reapply lip balms after eating or drinking.
   - Use hats that shield your face from the sun.
8. Understand chemoprevention
   Chemoprevention is the use of certain drugs or other substances to help lower a person's risk of developing cancer or to prevent it from returning.
9. Add probiotics to the diet
   Probiotics are live microorganisms that provide health benefits to the host. Recent data on probiotic products show a protective effect against cancer cell activity.
10. Take supplements
    Some supplements can help prevent oral cancer, such as Vitamin C, Vitamin E, Vitamin A, Omega-3 fatty acids, and Carotenoids.

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

1. Surgical management
   • Surgery for primary tumors: Surgery is advised for early-stage tumors, while advanced stages require surgery or chemoradiotherapy. Tumor removal methods depend on its location and extent.
   • Surgery for neck dissection: Neck dissection detects any spread of cancer in the early stage and removes the majority of affected lymph nodes.
   • Other surgeries:
     • Glossectomy (partial or total removal of the tongue)
     • Mandibulectomy (surgery for oral cancer in the jawbone)
     • Maxillectomy (removal of a part or all of the bony roof of the mouth)
2. Surgery in case of recurrence Recurrence rates in the oral cavity are 30%. Salvage (or 'rescue') surgery refers to surgical treatment after the failure of initial treatment.
3. Reconstruction The oral cavity is a complex site made up of several structures critical for speech, swallowing, and appearance. Successful reconstruction should address all three aspects and must be tailored to the site of the defect.
4. 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. Types of radiation therapy include:
   • External-beam radiation therapy: The most common type of radiation, 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 close to the tumor.
5. Chemotherapy Chemotherapy (chemo) is treatment with anti-cancer drugs that are injected into a vein or taken by mouth, allowing 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 frequently used drugs include:
   • Methotrexate
   • Capecitabine
   Types of chemotherapy include:
   • Adjuvant chemotherapy: Given after surgery, sometimes combined with radiation therapy, to kill remaining cancer cells and prevent recurrence.
   • Neoadjuvant or induction chemotherapy: Given before surgery with or without radiation to shrink larger cancers, making surgery easier and allowing for less tissue removal.
6. Chemoradiation Chemoradiation is chemotherapy given simultaneously with radiation. It has been shown to shrink oral cavity and oropharyngeal tumors that are not widespread but are too advanced for surgery.
7. Targeted therapy This involves the use of medicines that target proteins in cancer cells, destroying them or slowing their growth. Cetuximab is the most commonly used drug for this therapy.
8. Immunotherapy This therapy uses medicines to enhance a person’s immune system, enabling it to find and destroy cancer cells more effectively. It typically works on specific proteins involved in the immune system to boost the immune response.

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There are certain 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 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 the lips.
• Saffron (Kesar): Studies have reported the antioxidant, anti-cancer, anti-inflammatory, antidepressant, antihistamine, and memory-enhancer effects of saffron in animal models.
• Cinnamon (Dalchini): It has numerous biological functions such as antioxidant, antibacterial, anti-inflammation, anti-diabetes, and anti-tumor activity.

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

1. Complications from Surgery

• 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.

2. Complications from Chemotherapy or Radiotherapy

• Pain
• Bleeding
• Osteoradionecrosis
• Inflammation of the mucosa
• Dry mouth (xerostomia)
• Difficulty in swallowing and speaking
• Reduced oral intake and malnutrition
• Increased infections due to decreased immunity

When considering alternative and complementary treatments for any type of cancer, it is essential to communicate with your medical team, as some alternative therapies may be contraindicated within the treatment plan. An alternative therapy that has proven beneficial in managing oral cancer is:

• Photodynamic therapy (PDT)

Photodynamic therapy utilizes a drug activated by light, known as a photosensitizer or photosensitizing agent, to destroy cancer cells. Studies suggest that for superficial tumors (up to 2 mm), PDT is effective, while for tumors deeper than 10 mm, interstitial PDT (iPDT) may serve as an alternative.

Note: This therapy is an adjunct to treatment and does not replace medical interventions.

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

1. Get all the emotional support

   It is normal to feel depressed, anxious, or worried upon learning that cancer is part of your life. Everyone benefits from support, whether from friends, family, religious groups, support groups, or professional counselors.

2. Take post-treatment follow-up very seriously

   Patients with oral cancer are at risk for recurrences and cancer in other parts of the body. 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
3. 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 treatments include symptom-relief medication, nutrition, relaxation, emotional and spiritual support, and activities that bring joy.

4. Quit smoking

   Smoking is the leading cause of death due to oral cancer. It is crucial to quit smoking because even individuals with early-stage oral cavity or oropharyngeal cancer are at risk of developing a new smoking-related cancer if they continue to smoke.

5. Get proper rehabilitation

   Radiation, surgery, and certain chemotherapy drugs can lead to problems with speech, swallowing, and hearing. Rehabilitation is required to maintain quality of life. Therapists that can assist you include:

   • Speech therapists: Knowledgeable about speech and swallowing problems and can help you learn to manage them.
   • Audiologists: Specialists in hearing who can help you with devices to improve your hearing if treatment has affected your hearing capacity.
6. Keep health insurance and copies of your medical records

   Maintaining health insurance after treatment is essential to cover the costs of tests and doctor visits. While no one wants to consider cancer returning, it’s important to stay prepared.

7. Manage cancer care expenses

   Cancer treatment can be costly, and unexpected expenses may arise, adding financial stress for patients and families. Seek financial assistance from social workers who can guide you on available benefits or grants and assist with the claiming process to ease the financial burden.

Tips for caregivers:

• Encourage and provide mental support to the patient
• Understand the course of treatment
• Talk with empathy and a positive attitude to the patient
• Help the patient with household chores
• Handle insurance and billing issues for them
• Assist the patient in managing their symptoms and side effects
• Coordinate medical appointments and ensure medications are given on time
• Assist the patient in maintaining personal care and hygiene
• Attend to the patient's needs

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