(Includes lips, gums, buccal mucosa, floor and roof of mouth, front two thirds of the tongue and oropharynx)
Facts and figures of oral cancer
16th most common cancer in the UK. Higher incidence in men, male to female ratio of 2:1. Age related, although varies with gender. An average of approximately 15% of cases diagnosed in males is in the 75+years age group and 71% in the 50-74 age group. However, in women an average of 29% of cases is diagnosed in the 75+years age group and 59% in the 50-74 age group.
Cancer of the tongue is the most common mouth cancer, about 1,900 cases a year diagnosed in the UK. Oropharynx tumours are uncommon and tend to affect those aged between 40 and 70 years of age. Risk factors include smoking, chewing tobacco or betel quid, high alcohol intake (particularly spirits), poor diet, poor dental hygiene, exposure to HPV and low immunity. Skin cancers are also common on the head and neck including lips as they are related to sunlight (UV exposure).
Approximately 90% of all head and neck cancers are squamous cell carcinomas commonly arising in the mucosal lining of the oral cavity. Head and neck cancers tend to spread quickly to the lymph nodes in the neck.
Oral cancer symptoms
- Non healing ulcers.
- Persistent mouth pain or discomfort.
- Abnormal looking patches in the mouth or throat.
- Difficulty in swallowing (dysphagia).
- Speech problems and /or difficulties in moving the jaw.
- Lumps in the mouth or throat.
- Lump or non-healing sore on the lip.
- Swelling/lumps in the neck.
- Weight loss.
- Bad breath.
- Unexplained loose teeth.
- Unexplained bleeding or numbness in the mouth.
Diagnosis of oral cancer
Investigations may include:
- Physical examination.
- Blood tests.
- Chest x-ray.
- Biopsy – tissue samples taken from the affected area.
- Endoscopy- tissues samples may be taken for biopsy.
- Fine needle aspiration (FNA) - if there are any lumps/swelling in the neck which could indicate possible node involvement) a thin needle may be used to collect cells from the area for analysis.
- CT scan.
- MRI scan.
Oral cancer treatment
Depends on several factors:
- The type of tumour.
- The position of the tumour.
- The size and depth of the tumour.
- The stage of the cancer.
- General health.
Surgery is frequently used for mouth cancers but it is influenced by the size and position of the tumour and whether the lymph nodes are known to be involved or if there is a risk of spread to them. Surgery and radiotherapy are both effective in treating early stage disease and it is possible that radiotherapy may be recommended if surgery will result in chronic side effects such as speech impairment or loss of senses such as taste or smell or disfigurement.If surgery is performed, the malignant tissue will be removed as well as a surrounding margin of healthy tissue to try and reduce the risk of recurrence.
Due to the fact that head and neck cancers tends to spread to the neck lymph nodes, biopsies would normally be performed during surgery and if found to be involved, the nodes are usually removed on either one or both sides of the neck ( neck dissection). Neck dissections may be recommended if the tumour is 4cm or more even if the node biopsy is negative for malignant cells. Radiotherapy may be recommended post-surgery (adjuvant radiotherapy) to eradicate any remaining cancer cells and reduce the risk of recurrence.
Radiotherapy may be recommended as first choice for oral cancer, especially if surgery is not possible or will result in permanent side effects or disfigurement. As previously described, radiotherapy may be post-surgery but it is now being used more frequently in combination with chemotherapy (chemoradiation) particularly if the disease has spread to the surrounding tissues. However, the side effects from chemoradiation can be quite severe and therefore patients need to be generally in good health to tolerate the treatment.
Radiotherapy can have unpleasant chronic side effects which includes a dry mouth (xerostomia- most common late side effect) due to the potential damage to the salivary glands where saliva is produced. However, trials have proved that in suitable cases where Intensity Modulated Radiotherapy (IMRT) has been used to treat head and neck cancers the incidence of xerostomia is significantly reduced.
Image Guided Radiotherapy (IGRT) also enables the radiotherapy to be precisely delivered to the intended area which reduces potential radiation dose to healthy tissues and allows the radiography team to monitor any changes in the patients shape. This is important as head and neck patients often lose weight during treatment which can affect the aligning of the radiotherapy treatment.
In some cases, it may be necessary to make a new headshell and replan the patient’s radiotherapy treatment It is important to achieve precise alignment for accuracy in delivering radiotherapy, therefore in most cases it is necessary for a ‘headshell’ to be produced. This is achieved by using a specialised thermoplastic material which can be heated in warm water and then is laid over the patient’s face to form an accurately fitting customised shell which can then be used for the planning CT scan and for all the radiotherapy treatments. It is a painless procedure which is clearly explained by the radiographers prior to the procedure.
Radiotherapy is sometimes used in advanced disease to relieve symptoms such as difficulty in breathing or swallowing by shrinking the tumour if it is obstructing structures in the region.
Chemotherapy may be advised in combination with radiotherapy or if the disease has spread to other parts of the body or if it has recurred after surgery and/or radiotherapy. Trials are researching into the use of chemotherapy before surgery or radiotherapy with the intention of shrinking the tumour but this is not commonly used at present. The two most commonly used drugs are Cisplatin and 5 fluorouracil (5FU).
Cetuximab is a biological therapy referred to as a monoclonal antibody which acts by blocking areas on the surface of the cancer cells to restrict their growth. It has been proven that combining cetuximab with radiotherapy has increased survival rates for patients with advanced head and neck cancers compared to receiving solely radiotherapy; subsequently it may be used in patients not fit for chemoradiation. It is also used in combination with chemotherapy for squamous cell carcinomas that have recurred or progressed.