Oral cancer (mouth cancer) starts in the inner lining of the mouth. India carries 75% of the global disease burden for oral cancer. This is because of the widespread and rampant use of tobacco in our country, which is the number one causative factor for most cancers, especially oral cancer.
Symptoms:
Oral cancer starts either as an ulcer that grows inwards or as a mass that grows outwards from the inner lining of the mouth. It is important to note that oral cancer is initially painless. Only when it increases in size do the symptoms appear. From the mouth, oral cancer can spread to the lymph nodes, which are glands in the neck. Once it reaches there, it takes the form of a lump that can be seen or felt in the neck. Based on the growth pattern and spread of cancer, there are seven warning signs that one must be aware of. If these signs persist for two or three weeks, then it is time to see a specialist.
A swelling, thickening, lump, or ulcer inside the mouth – on the inner cheek, gums, tongue or palateDevelopment of a white, red or velvety looking patch in the mouth, particularly in somebody who consume tobaccoUnexplained bleeding in the mouthDifficulty in chewing or swallowing, speaking or moving the tongue or jawPersistent ear painPoor-fitting dentures which fit well previouslyLump in the neck, which occurs when cancer grows in the neck
Causes and risk factors:
Tobacco – Either in the smoked form like cigarettes, cigars, beedis, pipes or smokeless / chewed forms like pan or gutka. One of the key risk factors for oral cancer among the youth in India is the consumption of gutka and pan.Alcohol – Even mild to moderate levels of alcohol consumption increase the risk of developing oral cancer. In people who consume both tobacco and alcohol, the risk is synergistic and multiplicative.Supari – creates a Condition called oral submucous fibrosis where the lining of the mouth becomes white, hard, and inelastic. This condition is a significant trigger for developing oral cancer.
Testing:
Testing for oral cancer is undertaken with a twofold objective – To confirm that the cancer is present in the mouth and simultaneously determine the extent of cancer (“staging”). For diagnosis of oral cancer, a biopsy (a small piece about the size of a pea or smaller) is taken from the suspicious lesion in the mouth and is sent to the lab for examination. A common myth is that a biopsy results in the spread of cancer. However, there is no scientific evidence to support this claim and this misinformation needs to be urgently addressed. A biopsy is an important test for confirmation of cancer with assurance and accuracy.
Once the diagnosis is done, the next step is to determine the extent or stage of cancer. Staging considers both the size and the spread of cancer. There are 4 stages for oral cancer, each indicating an increasing burden of cancer. The clinical examination is important for assessing the extent of cancer and is supplemented with imaging tests like CT scans, MRIs, or PET scans. The choice and chances of success of treatment for cancer depend significantly on the burden of cancer or the stage it is in.
Treatment:
The treatment options available for oral cancer include – surgery, radiation (energy rays), and chemotherapy (medicines). The preferred or most effective treatment is surgery and is often the principal modality. Surgery involves the removal of cancer in the mouth often with a small margin of healthy or normal-looking tissue around it. The need for a safety margin when removing mouth cancer is to try and ensure complete removal of cancer, including parts that may not be visible to the naked eye. Along with the removal of cancer in the mouth, the lymph nodes in the neck would also be generally removed. Some patients require radiation or chemotherapy following surgery.
What has changed dramatically, particularly in the last decade, is our ability to reconstruct the surgical defect created after the removal of cancer in the mouth. This is using microvascular free tissue transfer (“free flaps”) which has vastly improved the cosmetic and functional outcomes. Tissues from any other part of the body (for example leg skin) which are similar to the removed portion of the mouth (for example inner cheek skin), are harvested along with their artery and vein. The harvested tissues (“flap”) is then contoured to match the surgical defect in the mouth. It is then sutured in the mouth to fill the defect and the vein and artery are joined to corresponding vein and arteries of the neck to re-establish the blood flow which keeps the flap alive. Free flaps can be harvested that have skin, muscle, bone or any combination of these. The principal is to replace “like for like”. Additionally, one of the new marriages we see between technology and medicine, particularly for surgeries that include removal of the jaw bone due to cancer involvement, is the use of CAD-CAM based planning with 3D printing. This provides the best match of the shape for the reconstructed portion of the jaw. This level of reconstruction of highly personalized with the flap being contoured to the patient’s original shape of the jaw
With improved reconstruction, we have been able to vastly improve the quality of life of our patients. This allows them to return back to a healthy and fulfilling personal, social and professional life
For world cancer awareness month, two messages regarding oral cancer are worth repeating. One, oral cancer is majorly preventable. 80% of the disease would disappear if tobacco use would cease. And two, If you or someone you know, develops any of the warning signs of mouth cancer then seek an expert opinion without delay. The treatment is most effective when the cancer is small and at an early stage.
The author is Director, Head and Neck Oncology , Cancer Institute Medanta Hospital, Gurgaon. Views are personal
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