"Oral Cancer Latest Update"

                                  Oral Cancer Latest Update

Squamous cell carcinomas of the oral cavity (OSCC) originating from the mucosal lip, anterior two thirds of the tongue (oral tongue), buccal mucosa, floor of mouth, hard palate, lower and upper alveolus and gingiva, and the retromolar trigone. (American Joint Committee on Cancer & the Union for International Cancer Control). More than 90% of the oral neoplasm are OSCC.

Oral cancer is a type of head and neck cancer and is any cancerous tissue growth located in the oral cavity. Head and neck cancers are the sixth most common form of cancer globally, and around 500,000 new cases of oral and oropharyngeal cancers are diagnosed annually, three-quarters of which occur in the developing world. Up to 70% of oral cancers are preceded by premalignant oral lesions, such as persistent red or white patches in the mouth. This guideline focuses on the most common sites of oral cancer: the tongue, the insides of the cheeks and the floor of the mouth.

Indian scenario: Oral cancer is the 3rd most common cancer. It is more common in males than females. In fact, it is the most common cancer in males. Oral cancer accounts for 1/3rd of all cancer cases. Also 1/3rd of total burden of oral cancer globally, comes from India. India has the greatest number of oral cancer cases than any other nation worldwide. This may be attributed to the high use of tobacco, alcohol, chewing of betel quid and areca nut products to name a few. The massive burden of oral cancer in India is a great public health challenge. Most of the oral cancer cases in India are detected at an advanced stage when the outcome of treatment is very poor and simultaneously the cost for treatment becomes expensive for the patient and their families. Unaffordable treatment option at later stages of oral cancer is highly prevalent in India. In addition, most rural areas have inadequate access to health services and lack of trained clinicians which makes it even tougher to screen oral cancers atan early stage. Early detection and screening of oral cancers in these rural areas even at the stage of oral potentially malignant disorders (OPMD) could restrict transformation to malignant conditions such as oral squamous cell carcinomas (OSCC).

Oral Potentially Malignant Disorders (OPMD)

WHO Workshop 2005 defined oral potentially malignant disorders as the risk of malignancy being present in a lesion or condition either at time of initial diagnosis or at a future date.

Etiology: No single factor has been identified as the causative factor for potentially malignant disorders. But a number of high-risk factors has been put forwarded which has greater than normal risk of malignancy at a future date.

Epidemiology: Avg. age range 30- 60 years, risk increases with age. OPMDs have traditionally shown a predilection for males. Most common sites for OPMDs in India are buccal mucosa followed by tongue, palate and floor of the mouth. Location of OPMDs differs from distribution of OSCC, for which the tongue, alveolar ridge and floor of mouth are the most common sites.

The average 5-year survival rate of patients with oral cancer is about 50%. The average age at the time of diagnosis is about 60. Oral cancer is among the ten most common cancers but can largely be prevented by reducing exposure to risk factors.

Common disorders

• Leukoplakia

• Oral Submucous Fibrosis

• Lichen Planus

• Erythroplakia

• Palatal Lesions In Reverse Smokers

• Actinic Cheilitis

Rare disorders

• Fanconi’s Anaemia

• Discoid Lupus Erythematosus

• Dyskeratosis Congenita

• Xerderma Pigmentosum

Risk factors for oral cancer / OPMDs

Oral carcinogenesis is a complex, multi-step process that involves both environmental risk factors and genetic factors. It results from an accumulation of both genetic and epigenetic alterations in oncogenes and/or tumor suppressor genes. Some of them listed below:

Tobacco

International Agency for Research on Cancer (IARC) has classified Tobacco as group I carcinogen. The different types of tobacco available in India are classified according to the constituents, method of processing and mode of use. The two most popular forms include smoking tobacco (combustible) and smokeless tobacco (non-combustible). It is the most significant modifiable risk factor for oral cancer. 80-90% of oral cancer cases is directly linked to the use of tobacco.

 

Alcohol

Independently alcohol has 4% attributable risk for oral cancer, whereas tobacco alone contributes 33% of risk and their combined risk (alcohol + tobacco) is reported to be 35% which indicates that both alcohol and tobacco together has a synergistic effect in development of oral cancer.

 Areca Nut

Areca nut is the seed of the areca palm (areca catechu) found in South-East Asia and East Africa. The use of areca nut is an independent risk factor for development of oral malignancy. It has been considered as type I human carcinogen by IARC (International Agency for Research on Cancer).

 Human Papilloma Virus (HPV) infection

Different HPV types are associated with malignant lesions of the oral cavity. The high-risk types are 16, 18, 31 and 33 that are seen in almost 99% of HPV linked oral cancers. Relation between a subtype of HPV 16 and oropharyngeal cancers has been reported by IARC (International Agency for Research on Cancer).

Other factors: oral cancer may also be caused due to chronic irritation or trauma, nutritional deficiency, genetic predisposition, candidal infection, poor oral hygiene, mouthwashes, immunosuppression, exposure to sun/ ultraviolet radiations and occupational risk. Out of all these, poor oral hygiene is a prominent risk factor in India.

 Warning sign & symptoms

• Persistent / recurrent ulcer, red / white / mixed red and white lesions on lips or at any site in oral cavity (tongue, buccal / labial mucosa, hard / soft palate, gingiva, tonsil etc.)

• One or more swollen lymph nodes in neck.

• Cyst in oral cavity.

• Restricted mouth opening.

• Ulcers / lesions of oral cavity persisting more than 3 weeks despite of treatment.

• Pain / discomfort while movement of jaws or tongue.

• Difficulty in swallowing or speaking.

• Altered taste.

• Burning sensation while eating or difficulty in mouth opening.

• Numbness of tongue.

• Xerostomia.

• Changes in voice and sore throat beyond 6 weeks

 Oral Mapping

Using this simple tool printed on a sheet, one can easily mark the specific location / site(s) of one or more suspicious lesion present in oral cavity. It can be helpful in recording the findings during oral screening. To use this tool effectively, one need to be familiar with all the landmarks of the oral cavity. The more we practice using the oral map diagram, easier it will become to use this for recording findings.

 

Taking medical and dental history: vital in identifying the high-risk population.

•Helps in identifying high risk population and also providing positive life style counselling to those who are indulged in risk behaviours and practices.

•Must include the history of tobacco use: current / former user, duration of use, product use (smoking /  SLT), frequency of use.

• Use of alcohol or other substance: duration, frequency, which product?

• Any existing co-morbidities? Cancer/ DM/ HTN/ cardiac/ asthma etc

• Ongoing treatment / medication if any?

• Family history of cancer.

• Any known drug allergy?

• Significant weight loss during recent past (may be in last 1 year)

• History of hospitalisation in last 12 months.

 Dental History: must include the following.

•When you last visited dentist?

•Are you struggling with any dental problem during last one year? If yes, what was it? Treatment sought? What treatment? From whom?

• Difficulty in swallowing, bleeding gums.

• Presence of recurrent ulcer(s) / red / white lesions. H/o any red / white / mixed lesion or patch or ulcer in any part of oral cavity.

• Burning sensation while having food.

• Difficulty / restricted mouth opening

• Swelling in mouth / neck.

 Oral visual examination: Understanding and then doing the process

After detailed medical and dental history, one should proceed to oral visual examination (OVE). It plays a key role in identifying or screening those with any abnormal finding present and ultimately referring those to other designated centres for further investigation, diagnosis and treatment. OVE of high-risk patients is crucial in detection of positive findings and referral. One should understand that OVE is different from clinical examination of oral cavity. It can be done in normal incandescent light. It is easy, affordable, reliable and reproducible.

The OVE has two components:

•Extra oral examination: It should include a visual inspection of the face and neck for any significant or noticeable change in colour, swelling or asymmetry. The examination also includes palpating the regional lymph nodes. Any lumps, swelling, tenderness or abnormalities should also be noted.

 

• Intra oral examination: Before we start, the subject should be asked to remove dentures or any removable dental prosthesis if any. The intraoral examination involves careful visual inspection and palpation of oral cavity landmarks in a systematic manner.

Where we can conduct the OVE? the settings?

•Examination of the oral cavity should be carried out with adequate lighting from an external source such as fixed or head-mounted examination lights or hand-held flashlights, supplemented by room lighting. It can also be done in outdoor setting if there is adequate natural light and a comfortable sitting position with appropriate height adjusted according to the examiner.

           

 What we need to perform OVE? The instruments?

• Mouth mirror: for better visualisation of indirect field

• Tongue depressor / retractor. To depress or retract the tongue making other landmark more visible

• Gauge piece: required to dry some part in order to observe the colour change and texture.

• Gloves and mask for examiner to reduce the risk for infection.

 

Oral visual examination of oral cavity: The process

Once the subject is seated in an appropriate and comfortable position with necessary

instruments and settings ready. Start the examination by following the steps listed below:

•Lips, labial mucosa and labial vestibule: Retract the lower lip towards yourself gently with gloved hands, using thumb and index finger. Observe for color andconsistency both externally and intraoral. Presence of any lesion or ulcer. Look for distinction of vermilion border, labial frenum. Palpate the tissue of lips to rule out any abnormality like bullae, mucocele etc. Repeat the process for upper lip and labial mucosa.

• Buccal mucosa: ask the patient to open the moth wide, but not to full stretch, retract the cheek using mouth mirror at corner of the mouth (one can do it with finger also). Look for color, consistency, ulcer or lesion if any, red / white patch. Palpate the buccal tissue to determine normal muscle function.

• Gingiva: ensure proper retraction of labial mucosa to make gingiva visible and look for color, texture, contour, margins, signs of bleeding or swelling, ulcer or lesion.

  

• Hard Palate: ask the subject to tilt the head slightly backwards and open the mouth wide. In direct vision look for colour, swelling, ulcer or lesion. Also palpate the hard palate using index finger. The anterior part of the hard palate can be seen by mirror by in-direct vision.

• Soft palate: to examine the soft palate, try to hold the tongue downwards using mouth mirror and ask the patient to say “aah”.

• Dorsal surface of tongue and lateral borders: ask the subject to protrude the tongue and touch the chin. Try to hold the tongue using tongue depressor to examine the whole of dorsum.

• Ventral surface of the tongue and floor of the mouth: ask the subject to open the mouth wide and try to point the the tip of tongue towards hard palate. Look for any lesion or ulcer, colour, white or red patch. Ask the subject to move the tongue right and left side to examine borders. Using gauge piece dry the floor of the mouth and examine for colour, ulcer or lesion and also palpate using index finger while holding the chin with other hand.

Recording the findings

Next step should be charting and recording the positive findings. Proper documentation is very important, it helps the point of referral in further investigation, diagnosis and treatment.

These findings can be recorded on the referral sheet or documents.

Following points should be noted while documenting the findings of your screening:

•All demographic details of the subject

•Separate medical and dental history: highlighting the risk factors if present

•Detailed description of each finding: for example: if there is a suspicious lesion on

right buccal mucosa, examiner should describe the lesion under following headings:

✓ Site

✓ Size: length and width in cm (approx.)

✓ Colour of the suspicious lesion: white, speckled, red, homogeneous vs nonhomogeneous

✓ Outline / Margins: discrete vs diffuse.

✓ Texture: smooth, slightly wrinkled, flat, raised, dome shaped; granular,

verrucous, ulcerated, indurated

✓ Single vs multiple lesions

✓ Onset, duration, aggravating and/or relieving factors

✓ Improved, unchanged or worse over time

Explaining the findings to the subjects

After the completion of OVE and recording of the findings, examiner should discuss this observation with subject. Following points should be kept in mind while explaining the findings to the subject:

•Tell the subject that there are some suspicious lesions found after examination. There is absolute need of further evaluation and treatment.

•Be clear that subject should not get a message that he / she is having oral cancer. Instead, it should be clear and loud that he / she is at higher risk of having oral cancer.

•Counsel the subject that the lesions are different from any ordinary ulcer which may be self-limiting or heals by itself, they require specific confirmatory diagnosis followed by treatment.

Counselling the subjects

• Advise the subject to stop use use of tobacco (in any form), use of alcohol immediately.

• Give Very Brief Advice (VBA) for tobacco cessation. Components of VBA include:

✓ Ask: Do you smoke? Or do you use tobacco chewable (smokeless tobacco) products?

✓ Advise: On the best way to quit, advise them to quit with the help of medication and counselling from a specialist.

✓ Act: Based on patient’s response, if interested ask them to work from today, with the help of resource available and family support to adopt the plan to quit. Also guide them to seek help from nearest Tobacco cessation centre.

• Counselling for avoiding all risk factors. Eg. Alcohol, poor oral hygiene etc.

• Improving dietary and lifestyle habits.

Referral

Referral route should be clear and must be explained to patient verbally and also to be handed over in written along with necessary records of the screening. All the subjects with positive findings (suspicious lesions / extra oral asymmetry or any other deviated findings from normal must be referred to designated specialist health care facility centres.

 

Oral Cancer Causes, Symptoms, Diagnosis, Treatment

Dr. Mayank Chandrakar is a writer also. My first book "Ayurveda Self Healing: How to Achieve Health and Happiness" is available on Kobo and Instamojo. You can buy and read. 

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The Third Book "Vision for a Healthy Bharat: A Doctor’s Dream for India’s Future" is recently launch in India and Globally in Kobo and Instamojo.

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