Risk /Causative Factors:
Some people who have oral cavity or oropharyngeal
cancer have few or no known risk factors, and others who have several risk
factors never develop the disease. Even if someone does have risk factors, it
is impossible to know for sure how much they contributed to causing the cancer.
Tobacco use:
Most people with oral cavity and oropharyngeal
cancers use tobacco, and the risk of developing these cancers is related to how
much and how long they smoked or chewed. Smokers are many times more likely
than non-smokers to develop these cancers. Tobacco smoke from cigarettes,
cigars, or pipes can cause cancers anywhere in the mouth or throat. Pipe
smoking is a predominantly important threat for cancers in the area of the lips
that touch the pipe stem. It is important for smokers who have been treated for
oral cavity or oropharyngeal cancer to quit smoking, even if their cancer seems
to be cured. Long-term smoking greatly increases their risk of emergent a
second cancer of the mouth, throat, larynx (voice box), or lung. Oral tobacco
products (snuff or chewing tobacco) are linked with cancers of the cheek, gums,
and inner surface of the lips. Using oral tobacco products for a long time
poses an especially high risk. These products also cause gum disease, damage of
the bone sockets in the region of teeth, and tooth loss. It is also important
for people who have been treated for oral cavity or oropharyngeal cancer to
give up any oral tobacco products.9
Drinking alcohol:
Drinking alcohol increases the risk of developing
oral cavity and oropharyngeal cancers. About 7 out of 10 patients with oral
cancer are heavy drinkers.
Drinking and smoking together:
The risk of these cancers is even higher in people
who both smoke and drink alcohol, with the highest risk in heavy smokers and
drinkers. According to several studies, the possibility of these cancers in
heavy drinkers and smokers may be as much as 100 times more than the risk of
these cancers in people who don’t smoke or drink.2
Betel quid and
gutka:
In Southeast Asia, South Asia, and certain other
areas of the world, many people chew betel quid, which is prepared with areca
nut and lime wrapped in a betel leaf. Many people in these areas also chew
gutka, a mixture of betel quid and tobacco. People who chew betel quid or gutka
have an increased risk of mouth cancer.
Human papilloma
virus (HPV) infection:
Human papilloma virus (HPV) is a group of viruses.
They are called papilloma viruses because few of them cause a growth
called a papilloma. This Papillomas are
not cancers, and are more commonly called warts. Infection with certain
types of HPV can also cause some forms of cancer, such as cancers of the
cervix, penis, vulva, vagina, anus, and throat. Other types of HPV cause warts
in different parts of the body. HPV can be passed from one person to another
throughout skin-to-skin contact. Another way HPV is spread through sex, including vaginal and anal
intercourse and even oral sex.6
Gender:
Oral and oropharyngeal
cancers are about twice as common in men as in women. This might be because men
have been more likely to use tobacco and alcohol in the past. This is changing,
but the recent rise in HPV-linked cancers has been mainly among younger men, so
it is still likely to occur more often in men in the near future.
Age:
Cancers of the oral cavity and oropharynx usually
take many years to develop, so they are not common in young people. Most
patients with these cancers are older than 55 when the cancers are first found.
But this may be changing as HPV-linked cancers become more common. People with
cancers linked to HPV infection tend to be younger.
Ultraviolet (UV)
light:
Sunlight is the main source of UV light for most
people. Cancers of the lip are more common in people who have outdoor jobs
where they are exposed to sunlight for long periods of time.
Weakened immune
system:
Oral cavity and oropharyngeal cancers are common
in people who have a weak immune system. A weak immune system can be caused by
certain diseases present at birth, the acquired immunodeficiency syndrome
(AIDS), and certain medicines (such as those given after organ transplants).
Diet:
In recent times,
awareness has been aimed towards the diet & its influence on the progress
of precancer & cancer. More sufficiently, the possible role of
micronutrient ingestion with an associated antioxidant effect has been emphasized.
Natural carotinoid compounds; dietary selenium; folate; and vitamins A,C &
E have been stated to offer defensive effects regarding cancer development.
Several studies have found that a diet low in fruits and vegetables have an
increased risk of cancers of the oral cavity.
Lifestyle:
The lifestyle
behaviors of a patient will play a role in determining his or her overall risk
of developing oral and pharengeal cancer. Accordingly, clinicians should
consider reffering to dietary & substances abuse treatment professionals
any patient who engages in high risk behaviours in terms of both alcohol use
& dietary practices. 2,3.
Primary Signs & Symptoms:
On biopsy, the three exophytic masses
turned out to be oral carcinomas, while the surrounding hyperkeratotic area
showed histologic features of oral lichen planus. Skin lesion, lump, or ulcer
that do not resolve in 14 days located:
·
Usually small.
·
On the tongue,
lip, or other mouth areas.
·
Most often pale
colored, may be dark or discolored.
·
Early sign may be
a white patch (leukoplakia) or a red patch (erythroplakia)
on the soft tissues of the mouth.
·
May be painless
initially.
·
Usually develop a
burning sensation or pain when the tumor is advanced.
·
Behind the wisdom
tooth.
·
Even behind the
ear.
Additional symptoms that may be associated
with this disease:
·
Tongue problems
while moving.
·
Difficulties in
swallowing.
·
Mouth sores
Pain and paraesthesia
are late symptoms:
In its early stages, oral cancer can be treated in
up to 90% of cases. Nevertheless, if the cancer is not detected, it can spread
to other parts of the body and become more difficult or nearly becomes
impossible to treat. The oral cancer screening head and neck exam is one of the
most critical components of a routine dental hygiene and dental exam. Dental
hygienists and dentists can alert patients to suspicious growths and changes,
noted during head and neck exams, and recommend them to seek medical care.5
Prevention and
control of Oral cancer:
Now there is sufficient understanding of the
causes to prevent at least one third of all cancers worldwide. Information is
also available that would permit the early detection and effective treatment.
Valuable ideas exist for the relief of pain and the provision of palliative
care to all cancer patients in need and of support to their families, even in
low-resource settings.
Nonetheless, this knowledge is not always put into
practice. Efforts that taken to prevent and control cancer is vulnerable due to
low-priority frequently given to the disease by governments and health
departments. For example, primary prevention, early detection and palliative
care are often neglected in favour of treatment-oriented approaches, even in
cases where these approaches are not cost-effective and cause not inevitable
human suffering. Another example is the failure to take into consideration the
social inequalities related to cancer prevention and control.
The general goal of oral cancer prevention and
control is to reduce the incidence and mortality of cancer and to pick up the
quality of life of cancer patients and their families.
Not all cases of oral cavity and oropharyngeal
cancer can be prevented, but the risk of developing these cancers can be
greatly reduced by avoiding certain risk factors.
Bound smoking and drinking:
Tobacco and alcohol are among the most important
risk factors for these cancers. Not starting to smoke is the best way to limit
the risk of getting these cancers. Quit tobacco also greatly lowers your risk
of developing these cancers, even after many years of use. The same is true of
heavy drinking. Limit how much alcohol you drink, if you drink at all.9,10.
Avoid HPV infection:
The risk of infection of the mouth and throat with
the human papilloma virus (HPV) is increased in those who have oral sex and
multiple sex partners. These infections are also more common in smokers, which
may be because the smoke damages their immune system or the cells that line the
oral cavity. These infections are common and rarely cause symptoms. Although
HPV infection is linked to oropharyngeal cancer, most people with HPV
infections of the mouth and throat do not go on to develop this cancer. In
addition, many oral and oropharyngeal cancers are not related to HPV infection.
In recent years, vaccines that reduce the risk of infection with certain types
of HPV have become available. These vaccines were originally meant to lower the
risk of cervical cancer, but they have been shown to lower the risk of other
cancers linked to HPV as well, such as cancers of the anus, vulva, and vagina.
HPV vaccination may also lower the risk of mouth and throat cancers, but this
has not yet been proven. Since these vaccines are only effective if given
before someone is infected with HPV, they are given when a person is young,
before they are likely to become sexually active. For more information see our
document HPV Vaccines.6
Limit exposure to ultraviolet
(UV) light:
Ultraviolet radiation is an important and
avoidable risk factor for cancer of the lips, as well as for skin cancer. If
possible, limit the time you spend outdoors during the middle of the day, when
the sun’s UV rays are strongest. If you are out in the sun, wear a wide brimmed
hat and use sunscreen and lip balm with a sun protection factor (SPF) of at
least 15.
Eat a healthy diet:
A poor diet has been linked to oral cavity and
oropharyngeal cancers, although it’s not exactly clear what substances in
healthy foods might be responsible for reducing the risk of these cancers. In
general, eating a healthy diet is much better than adding vitamin supplements
to an otherwise unhealthy diet. The American Cancer Society recommends eating a
healthy diet that emphasizes plant foods. This includes eating at least 2½ cups
of vegetables and fruits every day. Choosing whole-grain breads, pastas, and
cereals instead of refined grains, and eating fish, poultry, or beans instead
of processed meat and red meat may also help lower your risk of cancer. See the
American Cancer Society Guidelines on Nutrition and Physical Activity for
Cancer Prevention for our full guidelines.
Wear properly fitted dentures:
Avoiding sources of oral irritation (such as
dentures that don’t fit properly) may also Lower your risk for oral cancer.8,9,10,1113
Treatment:
Based on the stage and location of the tumor, you may have different
types of doctors on your treatment team. These doctors may include:
· An otolaryngologist (also known as an ear, nose, and
throat, or ENT doctor): a surgeon who treats certain diseases of the head and
neck.
· An oral and maxillofacial surgeon: a dental surgeon
who treats diseases of the mouth, teeth, and jaws.
· A radiation oncologist: a doctor who treats cancer
with radiation therapy.
· A medical oncologist: a doctor who treats cancer with
medicines such as Chemotherapy or targeted therapy.
The main treatment options for people with oral and oropharyngeal
cancers are:
· Surgery
· Radiation therapy
· Chemotherapy
· Targeted therapy
· Palliative treatment
These all may be used either in
combination or alone, depending on the stage and location of the tumor. In
general, surgery is the first treatment for cancers of the oral cavity, and may
be followed by radiation or combined chemotherapy and radiation. Oropharyngeal
cancers are usually treated with a combination of chemotherapy and radiation.
It is important to take time and think about all choices. When patient choose a
treatment plan, consider overall health, the type and stage of the cancer, the
chances of curing the disease, and the possible impact of the treatment on
important functions like speech, chewing, and swallowing. The next few sections
describe the various types of treatments and how they are used for oral cavity
and oropharyngeal cancers.
1. Surgery :
Several types of operations can be used to treat oral cavity and
oropharyngeal cancers. Depending on where the cancer is and its stage,
different operations may be used to eradicate the cancer. After cancer is
removed, reconstructive surgery can be done to help restore the appearance and
function of the areas affected by the cancer or its treatment.
Tumor resection:
In a tumor resection, the entire tumor and an area of normal-appearing
tissue around it is removed .The area of normal tissue is removed to reduce the
chance of any cancer cells being left behind. The main (primary) tumor is
removed using a method determined by its size and location. For example, if a
tumor is in the front of the mouth, it can be removed relatively easily through
the opening of the mouth. But sometimes a larger tumor (especially when it has
grown into the oropharynx) needs to be removed through an incision in the neck
or by cutting the jaw bone with a special saw to provide access to the tumor (mandibulotomy). Based on the location
and size of the tumor, one of the operations listed here may be needed to
remove it.
Mohs micrographic surgery (for some cancers of the
lip):
Some cancers of the lip may be removed by Mohs surgery, also known as micrographic surgery. The tumor is
removed in very slim slices. Each slice is looked at right away under
the microscope to see if there are cancer cells. More slices are removed and
examined until no cancer cells are seen. This method can reduce the
amount of normal tissue removed with the tumor and limit the change in
appearance the surgery causes. It requires a surgeon trained in the technique
and may take more time than a standard tumor resection.
Glossectomy (removal of the tongue):
Glossectomy may be needed to treat cancer of the tongue. For smaller
cancers, only part of the tongue may need to be removed (partial glossectomy).
For larger cancers, the entire tongue may need to be removed (total
glossectomy).
Mandibulectomy (removal of the jaw bone):
For a mandibulectomy (or mandibular resection), the surgeon removes all
or part of the jaw bone (mandible). This operation may be needed if the tumor
has grown into the jaw bone.
Maxillectomy:
If cancer has grown into the hard palate (front part of the roof of the
mouth), all or part of the involved bone (maxilla) will need to be removed.
This operation is called a maxillectomy
or partial maxillectomy.
Robotic surgery:
Increasingly, trans-oral robotic surgery (TORS) is being used to resect
cancers of the throat (including the oropharynx). Since the more standard, open
surgeries for throat cancer can cause a number of problems, these cancers have
often been treated with chemotherapy combined with radiation (called chemoradiation) over the past decade.
Laryngectomy (removal of the voice box):
Very rarely, surgery to remove large tumors of the tongue or oropharynx
may also require removing tissue that a person needs to swallow normally. As a
result, food may enter the windpipe (trachea) and reach the lungs, where it can
cause pneumonia. When this is a significant risk, sometimes the voice box
(larynx) is removed during the same operation as the one to remove the cancer.
Neck dissection:
Cancers of the oral cavity and oropharynx often spread to the lymph
nodes in the neck. Removal these lymph nodes (and other nearby tissues) is
called a neck dissection or
lymph node dissection and
is done at the same time as the surgery to remove the main tumor. The goal is
to remove lymph nodes proven or likely to contain cancer. There are several
types of neck dissection procedures, and they differ in how much tissue is removed
from the neck. The amount of tissue removed depends on the primary cancer’s
size and how much it has spread to lymph nodes.
2.Radiation therapy for oral
cavity and oropharyngeal cancer:
In Radiation therapy high-energy x-rays or particles are used to
destroy cancer cells or slow their growth rate. Radiation therapy can be used
in several situations for oral and oropharyngeal cancers:
· It is the main treatment for small cancers.
· Patients with larger cancers may need both surgery and
radiation therapy or a combination of radiation therapy and chemotherapy or a
targeted drug
· After surgery, radiation therapy can be used, either
alone or with chemotherapy, as an additional (adjuvant) treatment to try to
kill any minute deposit of cancer that may not have been removed during
surgery. This is known as adjuvant
radiation therapy.
· Radiation may be used (along with chemotherapy) to try
to shrink some larger cancers before surgery. This is called neoadjuvant therapy. In some cases
this makes it possible to use less radical surgery and remove less tissue.
· Radiation therapy can also be used to relieve symptoms
of more advanced cancer, such as pain, bleeding, trouble swallowing, and
problems caused by bone metastases.
3.Chemotherapy for oral cavity
and oropharyngeal cancer:
Chemotherapy (chemo) is the use of anti-cancer drugs to treat cancer.
For oral cavity and oropharyngeal cancers, the drugs are given into a vein or
taken by mouth, which allows them to enter the bloodstream and reach cancer
that has spread to organs beyond the head and neck. It may be used in several
different situations:
· Chemo (typically combined with radiation therapy) may
be used instead of surgery as the main treatment for some cancers.
· Chemo (combined with radiation therapy) may be given
after surgery to try to kill any small deposits of cancer cells that may have
been left behind. This is known as adjuvant chemotherapy.
· Chemo (sometimes with radiation) may be used to try to
shrink some larger cancers before surgery. This is called neoadjuvant or induction chemotherapy. In some cases
this makes it possible to use less radical surgery and remove less tissue. This
can lead to fewer serious side effects from surgery.
· Chemo (with or without radiation) 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 the cancer for as long as possible and to help
relieve any symptoms the cancer is causing. The chemo drugs used most often for
cancers of the oral cavity and oropharynx are:
· Cisplatin
· Carboplatin
· 5-fluorouracil (5-FU)
· Paclitaxel (Taxol®)
· Docetaxel (Taxotere®)
Other drugs that are used less often include
· Methotrexate
· Ifosfamide (Ifex®)
· Bleomycin
A chemo drug may be used alone or combined with other drugs. Combining
drugs can often shrink tumors more effectively, but will likely cause more side
effects. A commonly used combination is cisplatin and 5-FU. This combination is
more effective than either drug alone in shrinking cancers of the oral cavity
and oropharynx. Another combination often used is cisplatin, 5-FU, plus
docetaxel.
Doctors give chemotherapy in cycles, with each period of treatment
followed by a rest period to allow the body time to recover. Each chemotherapy
cycle typically lasts for a few weeks. For cancers of the head and neck (such
as oral cavity and oropharyngeal cancers), chemo is often given at the same
time as radiation (known as chemoradiation).
Cisplatin alone is usually the preferred chemo drug when given along with
radiation. Some doctors prefer to give the radiation and chemo before surgery.
However, the side effects can be severe and may be too much for some patients.
In patients whose cancers are too advanced for surgery but not widespread,
chemo and radiation given together might produce a better outcome than
radiation alone. But this combined approach can be hard to tolerate, especially
for people in poor health.7,9,10.12,13.
CONCLUSION:
A multifaceted approach that integrates health education, tobacco and
alcohol control, early detection, and early treatment is needed to reduce the
burden of this eminently preventable cancer. Improving awareness among the
general public and primary care practitioners, investing in health services to
provide screening and early diagnosis services for tobacco and alcohol users,
and providing adequate treatment for those diagnosed with invasive cancer are
critically important oral cancer control measures. The dangers posed to oral
health from smoking and chewing tobacco are well documented within the dental
literature but the public’s lack of knowledge of the risks is a concern.
Dentists are encouraged to disseminate information on the subject as widely as
possible and improve existing screening programmes to ensure that the public is
made aware of these risks, especially those within high-risk groups. Given that
the effects of many oral diseases are reversible, and more specifically that
the survival rates for early diagnosed oral cancers are high, gives much ground
for future optimism. However it is vital that more is done to ensure that
public awareness of tobacco-related oral diseases continues to improve and more
people are regularly screened. The combination of providing opportunistic
advice, particularly to stop smoking, together with regular screening will reduce
the overall morbidity and mortality from oral cancer and other mouth disorders,
and will dramatically improve the quality of life of those people who are at
greatest risk of these diseases.
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ISSN-
2231–5640 (Print) www.asianpharmaonline.org
