Oral Cancer

Definition

Oral cancer is cancer of the mouth and oropharynx.

Description

Oral cancer also may be called oral and oropharyngeal cancer to include the oropharynx region. Oral cancer can occur in the oropharynx or the oral cavity. The oral cavity is the area that includes the lining of the lips and cheeks, the hard palate, the floor of the mouth, the teeth, gums, the bony roof of the mouth, the area behind the wisdom teeth and the front two-thirds of the tongue. The oropharynx includes the tonsils, soft palate, back of the throat, and the back one-third of the tongue.

Oral cancer results from changes to cells that occur in these tissues of the mouth. But not every change or tumor that develops is oral cancer. Some changes that occur are benign, or noncancerous. They don't invade other tissues. And some changes are cancer, but they begin in other parts of the throat, such as the larynx, or voice box. This is laryngeal cancer, not oral and oropharyngeal cancer.

Demographics

More than 34,000 people were diagnosed with oral cancer in 2007 and about 7,550 people in the United States died from the disease. A study in 2008 showed that the incidence of oral cancer on the rise, particularly in younger men. Risk of oral cancer increases as people get older. Many people with oral cancer use tobacco products and about 70% of those also have reported heavy drinking. The median age at diagnosis of the disease between 2000 and 2004 was 62 years. The median age for those who died from the disease was 68. Worldwide, more than 400,000 new cases of oral cancer are diagnosed each year.

Causes and symptoms

Smoking and drinking alcohol are two of the biggest causes of oral cancer. As many as 90% of people with oral cancer use tobacco. Although cigarette smoking is a big factor for oral cancer, as well as for many other cancers, other types of tobacco use can lead to oral cancer. Tobacco smoke from cigars and pipes also can cause cancer in the mouth and throat, as well as in the voice box, lungs, and other organs. Pipe smoking is particularly risky for cancers of the lips, where the lips touch the pipe stem. Chewing tobacco and snuff products are known to cause cancer of the cheek, gums, and insides of the lips. A dip of chewing tobacco can contain up to five times more nicotine than one cigarette and as many as 28 times the carcinogens. People who use snuff for a long period of time are at particularly high risk.

Drinking alcohol increased a smoker's risk of developing oral cancer if the person is a heavy drinker. The American Cancer Society reports that some studies have shown that heavy drinkers and smokers have as much as a 100-fold risk of developing oral cavity and oropharyngeal cancers as people who do not smoke or drink. Frequent exposure to the sun also can cause lip cancer.

Oral cancers may be found early if a person routinely checks his or her mouth for signs or if a doctor, dentist, or dental hygienist notices something wrong. Symptoms of oral cancer include:

• a sore in the mouth that doesn't heal in about 2 weeks
• white or red patches in the mouth
• lumps or thickening in the cheek
• a feeling that something is caught in the throat or a sore throat that won't go away
• painful swallowing
• voice changes
• bad breath that persists
• loose teeth
• numbness of the tongue or in other area of the mouth
• difficulty moving the tongue or jaw

These types of symptoms don't always indicate oral cancer, but they may be signs of the disease and any that persist for more than a few weeks should be checked by a dentist or physician right away.

Diagnosis

As with any cancer, early detection is important. Regular routine examination is key. Seniors should conduct self-examinations, checking their mouths for the symptoms listed above. Regular visits to a dentist provide the chance for dental hygienists and dentists to note any of the symptoms as well. A physician also may notice an early sign in a regular physical check-up.

An oral cancer examination is relatively quick and painless. Removal of dentures or partials may be required so that the health care provider can see all areas of the mouth and gums. The health care provider will feel the jaw and neck area to check for possible lumps and carefully look at the mouth, face, and lips to check for any signs of cancer. He or she also will look at and feel the insides of the cheeks and lips to check for sores or other signs of oral cancer. A thorough examination also includes a check of the tongue, base of the tongue, floor and roof of the mouth, and the throat. In addition to checking for lumps and hard masses, a health care provider is trained to recognize swollen lymph nodes in the neck.

After taking a patient's medical history and performing a head and neck examination, if a health care provider suspects oral cancer, he or she may order one of several tests, including those listed below.

Special otolaryngology exams

Often, a health care provider will refer a patient to a physician who specializes in oral cancers. The specialist might be identified by one of several names and subspecialties, such as oral and maxillofacial surgeon, head and neck surgeon, otolaryngologist, or ear, nose, and throat doctor. This specialist is trained in the diseases of the head and neck area. He or she can use small mirrors or small fiberoptic tubes that can be inserted through the mouth or nose to observe areas deep within the throat and neck. These procedures are called indirect or direct pharyngoscopy and laryngoscopy, depending on the area the physician observes and the tools used.

A procedure called panendoscopy is used if suspicion of oral cancer is high. The physician uses endoscopes to look at all the areas of the mouth, throat, oropharynx, larynx, esophagus, and passageways to the lungs. It is usually performed under general anesthesia . If the physician finds a tumor, a biopsy of the tissue will be taken at that time.

Imaging examinations

Imaging examinations may be used to help determine if there is a possibility of cancer, and once oral cancer is diagnosed by biopsy, imaging examinations can help physicians determine the stage of the cancer. Dental x-rays can provide early clues about problems in the mouth or throat. Chest x-rays might offer clues concerning the spread of oral cancer. An upper GI series with barium contrast can be used to help determine if oral cancer has spread to the digestive tract. Computed tomography (CT) scans provide detailed, cross-sectional views of organs and tissues. They can provide good images of lymph nodes and other tissues or help determine cancer spread. Magnetic resonance imaging examinations do not use radiation, but take a long time to complete. They are not often used for oral cancer diagnosis and staging. New devices combine CT scanning and positron emission tomography (PET) scanning to better pinpoint cancers and to track tumors' response to treatments.

Blood tests

There are no blood tests to detect oral cancer, but a physician may order blood tests to detect spread of cancer or certain conditions associated with cancer and its treatment.

Biopsy

Biopsy is the only examination that can provide a certain diagnosis of oral cancer. A biopsy is the microscopic evaluation of cells and identification of cancer cells. The tissue sample can be obtained through a variety of techniques. These vary from exfoliative biopsy, which involves scraping a small sample of tissue off and placing the cells onto a slide, to incisional biopsy, which usually involves surgery and general anesthesia for the patient. The type of biopsy used depends on several factors, such as the location of the mass under study. In recent years, many biopsies have been performed with a technique called fine needle aspiration biopsy. Using a thin needle, a physician draws fluid out of a mass and a pathologist examines the tissue in the fluid for cancer.

QUESTIONS TO ASK YOUR DOCTOR

• Is smokeless tobacco as harmful as smoking cigarettes?
• How can I get help quitting tobacco?
• What is the stage of my disease? What is the severity?
• What are the side effects of the treatments you are proposing?

Treatment

A team of health care providers will plan treatment for oral cavity and oropharyngeal cancer. Recommended treatment will depend on factors such as the cancer's stage when diagnosed, location of the tumor, and the patient's age and health condition. The standard treatment for oral cancer generally involves surgery and radiation therapy, but other treatments may be considered. Some patients might receive a combination of treatments.

Surgery

If a patient has surgery for oral cancer, it will involve removal of the cancerous mass, as well as some of the healthy tissue around the mass. This helps ensure that all of the cancerous cells have been removed. Surrounding bone might have to be removed, as well as nearby lymph nodes if they show signs of cancer spread. Surgery for oral cancer can also involve plastic surgery to rebuild areas of the mouth that are removed. A patient might need dental implants , skin grafts, or other plastic surgery to improve appearance after surgery to remove oral cancer masses.

Radiation therapy

Radiation therapy can be used after surgery to kill any remaining cancerous cells. Radiation therapy might also be used as the only treatment for oral cancer. There are several types of radiation therapy, including external beam radiation therapy, which aims high-energy x-ray beams generated by a machine outside the body directly at the cancerous tumor. Another type of radiation therapy is brachytherapy, which is sometimes called internal radiation therapy. A radiation oncologist implants a radioactive material inside or near a tumor for a certain amount of time. The radioactive material kills the tumor cells.

Chemotherapy

More advanced oral cancer can be treated with chemotherapy . Chemotherapy can help shrink tumors and is used in treating cancer that has spread throughout the body. The drugs used in chemotherapy can be injected or taken by mouth.

Nutrition/Dietetic concerns

Treatments for oral cancer can affect how a senior eats. Surgery can cause temporary pain that interferes with eating or the complication of infection, which also can affect ability to eat. Radiation therapy for oral cancer might cause soreness in the mouth and throat, making it difficult to eat following treatment. Radiation therapy for oral cancer can also affect the salivary glands, causing dry mouth . Chemotherapy can cause loss of appetite, nausea and vomiting, which can lead to changes in diet or the need for drugs to combat nausea. A dietitian can advise a senior on proper nutrition after treatment for oral cancer. People with oral cancer will need to consider giving up smoking and drinking alcohol.

Therapy

A dentist and related health professionals can help a senior with oral cancer to overcome possible complications of the cancer and treatment. For example, a dentist can help prevent serious mouth problems that can occur from jaw stiffness by demonstrating jaw muscle exercises. Dental hygiene needs can change as a result of treatment and more regular dental visits may be needed. Other health professionals can be involved in helping a senior learn to use certain muscles and for functions such as speech and chewing. Occupational and physical therapists, speech pathologists, nurses, social workers, and dental assistants are often involved in therapy and health care instruction.

KEY TERMS

Biopsy —Removal and microscopic examination of living tissue to diagnose disease.

Carcinogen —A substance or agent capable of causing cancer.

Oropharyngeal —Pertaining to the oropharynx, the area of the head and neck that includes the tonsils, soft palate, back of the throat, and the back one-third of the tongue.

Prognosis

The prognosis for seniors with oral cancer depends on the location and stage of the cancer and the patient's overall health. Age is a factor for risk of dying from oral cancer. In 2000–2004, approximately 58% of all U.S. deaths from oral cancer occurred in men and women age 65 and older. Another 22.8%occurred in people age 55–64. Trends in deaths from oral cancer have improved slightly since about 1980. Those who quit smoking or using other tobacco products usually improve their prognoses.

Prevention

Not all risk factors for oral cancer can be prevented, but the two largest risk factors can be modified to lower risk of oral cancer. Since tobacco use is responsible for most cases or oral cancer, not smoking cigarettes or using other forms of tobacco helps prevent oral cavity and oropharyngeal cancer. People who use tobacco and also drink beer and hard liquor increase their risk more, so avoiding these alcoholic beverages can help decrease risk. Minimizing exposure to sunlight can also lower risk of lip cancer. People who have had oral cancer once and use tobacco can develop a second cancer in the oral cavity or nearby. Chemoprevention can help prevent such second cancers. This is the use of drugs, vitamins , or other agents to help prevent the spread of the cancer cells or to help keep them from coming back. There is a possible link between the human papillomavirus (HPV) and oral cancer, so avoiding infection with HPV might help prevent oral cancer.

Caregiver concerns

After treatment for oral cancer, there can be short-term and long-term side effects and disabilities that a patient can experience. A care giver might have to provide care when a patient returns home following surgery, or simply provide emotional support if a treatment causes altered appearance or disability. Care givers might also have to help patients with more advanced stages of oral cancer make difficult decisions concerning treatment and end-of-life choices.

Resources

BOOKS

Santhanam, Kausalya. Oral Cancers. Gale Encyclopedia of Cancer Ed. Ellen Thackery. Vol. 2, 795–801. Detroit MI: Gale, 2002.

PERIODICALS

Baldauf, Sarah. “Stopping Oral Cancer.” U.S. News & World Report 144.6(Feb. 25, 2008): p.58.

OTHER

All About Oral Cavity and Oropharyngeal Cancer. http://www.cancer.org/docroot/CRI/CRI_2x.asp?sitear-ea=& dt=60 American Cancer Society, 2007.

Oropharyngeal Cancer Treatment. http://www.cancer.gov/cancertopics/pdq/treatment/oropharyngeal/patient- National Cancer Institute, 2007.

The Oral Cancer Exam. http://www.nidcr.nih.gov National Institute of Dental and Craniofacial Research, 2005.

ORGANIZATIONS

American Cancer Society, 1599 Clifton Rd. NE, Atlanta, GA, 30329, (800)866-228-4327, www.cancer.org.

The Oral Cancer Foundation, 3419 Via Lido #205, Newport Beach, CA, 92663, (949) 646-8000, (949) 496-3331, [email protected], www.oralcancerfoundation.org.

Teresa G. Odle