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Oral cancer can be referred to as: Tongue cancer, lip cancer, gum cancer, palate cancer, floor of mouth cancer, cheek cancer, and buccal cancer.
Oral cancer is a term used to address malignancies in the oral cavity, and is the most common of all head and neck cancers. The oral cavity is the region between an individual’s lips and their soft palate. When discussing oral cavity cancer, there are different subsites that may be used to better define the site of location better guiding management decisions: lips, tongue, the alveolus (gums), the buccal mucosa (inner cheek), floor of mouth, and hard palate. The vast majority of cancer arising in the oral cavity involve the epithelial lining. It is within this lining that the cells begin to abnormally proliferate and replicate causing an overgrowth of cells and subsequent tumors. Not all lesions are malignant, with each type of lesions guided by different managing principles.
Type of Cancer. The overwhelming majority of cancers of the oral cavity are squamous cell carcinoma. However there are other cancers that also occur in this region that are on the differential diagnosis that must be considered
The causes of tumor growth in the oral cavity is likely multifactorial with many contributing factors. Overall, the chronic and long-term use of irritants such as tobacco and alcohol are the leading causes of oral cavity cancers. Other predisposing factors include the use of Betel Nut (prominent in India and Southeastern Asian countries), UV light exposure (lip cancer), marijuana, poor dentition, genetic predisposition, and Human papilloma virus (HPV).
Oral cavity cancers may present in different forms, but generally speaking they are often times found in earlier stages due to earlier detection by patients or other healthcare providers during routine examinations.
Pain. Frequently patients may present with sores in or around their mouth that are painful and longstanding that do not resolve over time. As lesions increase in size, they may become increasingly painful, and may not respond to normal pain medications.
Lesions. Patients or other healthcare providers (e.g. dentists) may notice a lesion that does not resolve or appear abnormal. These lesions may appear as patches, sores, ulcerations, plaques, or masses. Sores that do not resolve in 2-3 weeks usually require further evaluation by a specialist with potential for further workup.
Bleeding. Bleeding from a site within the oral cavity may be a presenting sign. Often times, chronically irritated skin may bleeding due to infections, chronic irritation (brushing), or dentures. However, bleeding from a particular site or lesion should be evaluated by a specialist.
Speaking and Swallowing Difficulties. The presence of a tumor or lesion often times will impact a patients ability to speak or swallow. As lesions grow in size, patients may find it difficult to open their mouths (trismus), chew, or move their tongue. Tongue lesions may also impact a patients ability to properly articulate words.
Poorly Fitting Dentures. Patients may find increasing difficulty in the use of dentures. This usually occurs in patients with hard palate lesions that prevent the proper fitting of their dentures.
Tooth Problems. Lesions involving the gum line may result in invasion of the tooth socket. This may cause tooth pain there is involvement of the nerves, or may even cause the tooth to become loose or fall out. Also, a non-healing site of a previously extracted tooth may also be a sign of an underlying cancer.
Lump in the Neck. Rarely cancers of the oral cavity can present as a single or multiple lumps in the neck. These enlarged nodes may be reactive due to tumor or an associated infection, or may be a sign of regionally metastatic disease
The most common risk factors of developing oral cancer is tobacco use (both smoking and smokeless tobacco), and chronic alcohol use. Other causes may relate to Betel Nut (prominent in India and Southeastern Asian countries), UV light exposure (lip cancer), marijuana, poor dentition, genetic predisposition, and Human papilloma virus (HPV).
Diagnosis and Workup. In addition to routine history and physical examination, the physician may perform ancillary tests and procedures in order to confirm the presence and type of oral cavity cancer, as well as to determine the presence of second primary cancers (SPC) or the spread of malignant disease elsewhere.
Biopsy. Often times the first step in the diagnosis of an oral cavity cancer is to perform a biopsy. Several types of biopsies may be performed, in the clinic or operative setting depending on how easily visualized the lesion is, its size, and patient preferences. Taking a biopsy will confirm the presence of abnormal cells under microscopic view, and is imperative in making the diagnosis of oral cavity cancer.
Blood Work. The physician may elect to perform routine blood analysis to assist in determining the presence of oral cavity cancer or other present diseases. Blood work may not be necessary, and the decision to obtain blood work is individualized to every patient.
Imaging. Oftentimes a physician may elect to obtain imaging that will help in better understanding the presence of cancer and any other underlying issues. Imaging may be performed of the primary site, or of the general region to better define disease extent. The physician may elect to obtain further imaging in situations in which they are concerned for local invasion (e.g. into bone, muscle, adjacent sites), or regional invasion (to the neck). Imaging is not necessary in the diagnosis of all oral cavity cancers, and the decision to obtain imaging or the type of imaging will be best dictated by each patient’s individualized care.
Treatment Plan. Depending on the site of disease, the clinical staging, and patient factors (co-morbid health conditions, patient preferences) a patient specific treatment plan should be outlined. Broadly speaking there are 3 types of treatment that can be used in combination or separately depending on the type and stage of cancer. The decision to embark on a particular treatment plan should be made involving a multidisciplinary team of doctors (surgeons, radiation oncologists, and medical oncologists) and the patient. Patient specific goals and outcomes should be defined, with a thorough discussion of the risks, benefits, and alternatives of all the separate treatment types.
Surgery. Surgery involves the operative extirpation of tumor and all involved tissue obtaining clear margins (i.e remove any evidence of disease present). The vast majority of oral cavity cancers are treated with surgery initially. Early staged cancers, Stage I or II, can be treated with surgery alone. Depending on the location the surgery can be used with reconstructive options if the defect cannot be closed using simple techniques.
Radiation. Radiation can be performed in three settings, definitive and (neo)adjuvant.
Chemotherapy. The use of systemic medications is used adjunctively with either surgery or radiation, and is used to target disease distant from the local site. It is not used as a primary treatment modality as it does not facilitate eradication at the primary site. Chemotherapy is often used in circumstances of advanced disease (Stage III or IV), or when certain risk factors for distant disease are present. Such risk factors include lymphnodes with disease that have extended out of their capsule (not contained), positive surgical margins, or involvement of nerves.
Other Considerations. Specific attention should be given to the presence or absence of neck disease in the patient. Oral cavity cancer has a higher percentage of occult disease (disease not present on imaging or physical examination). Part of the treatment algorithm is to determine if the neck should be treated.
The best method to prevent the development of oral cancer is to avoid irritants and carcinogens such as tobacco and alcohol. Additionally, proper dental hygiene and frequent visits to the dentist may reduce the risk of developing cancer, or help in obtaining an early stage diagnosis.
If oral cancer is left untreated will continue to progress and cause significant detriment to a patient’s health. As the tumor grows patients will experience progressive worsening of their ability to swallow, speak, and breathe. Ultimately this can cause severe nutritional problems, airway problems, speech impediment, and ultimately result in the untimely death of a patient.
Dr. Mourad is a Head and Neck Surgeon with advanced training in reconstructive surgery. He performs all aspects of head and neck cancer surgery including minimally invasive and reconstructive procedures. He is also a leader in his field with two published books, numerous book chapters, and more than 40 peer-reviewed publications in the scientific literature. He frequently speaks at national and international conferences to help in advancing this field. Most importantly, Dr. Mourad is empathetic to the needs of his patients. He views the ability to treat his patients to be nothing short of an honor and a privilege.