Oral Cancer

The mouth and throat

This booklet is about cancers that occur in the mouth (oral cavity) and the part of the throat at the back of the mouth (oropharynx). The oral cavity and oropharynx have many parts:

• Lips



• Lining of your cheeks



• Salivary glands (glands that make saliva)



• Roof of your mouth (hard palate)



• Back of your mouth (soft palate and uvula)



• Floor of your mouth (area under the tongue)



• Gums and teeth



• Tongue



• Tonsils

Understanding cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

• Benign tumors are not cancer:



• Benign tumors are rarely life-threatening.



• Generally, benign tumors can be removed, and they usually do not grow back.



• Cells from benign tumors do not invade the tissues around them.



• Cells from benign tumors do not spread to other parts of the body.



• Malignant tumors are cancer:



• Malignant tumors are generally more serious than benign tumors. They may be life-threatening.



• Malignant tumors often can be removed, but sometimes they grow back.



• Cells from malignant tumors can invade and damage nearby tissues and organs.



• Cells from malignant tumors can spread to other parts of the body. The cells spread by breaking away from the original cancer (primary tumor) and entering the bloodstream or lymphatic system. They invade other organs, forming new tumors and damaging these organs. The spread of cancer is called metastasis.

Oral cancer

Oral cancer is part of a group of cancers called head and neck cancers. Oral cancer can develop in any part of the oral cavity or oropharynx. Most oral cancers begin in the tongue and in the floor of the mouth. Almost all oral cancers begin in the flat cells (squamous cells) that cover the surfaces of the mouth, tongue, and lips. These cancers are called squamous cell carcinomas.

When oral cancer spreads (metastasizes), it usually travels through the lymphatic system. Cancer cells that enter the lymphatic system are carried along by lymph, a clear, watery fluid. The cancer cells often appear first in nearby lymph nodes in the neck.

Cancer cells can also spread to other parts of the neck, the lungs, and other parts of the body. When this happens, the new tumor has the same kind of abnormal cells as the primary tumor. For example, if oral cancer spreads to the lungs, the cancer cells in the lungs are actually oral cancer cells. The disease is metastatic oral cancer, not lung cancer. It is treated as oral cancer, not lung cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Oral cancer: Who's at risk?

Doctors cannot always explain why one person develops oral cancer and another does not. However, we do know that this disease is not contagious. You cannot "catch" oral cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop oral cancer. A risk factor is anything that increases your chance of developing a disease.

The following are risk factors for oral cancer:

• Tobacco: Tobacco use accounts for most oral cancers. Smoking cigarettes, cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral cancer. The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. Heavy smokers who use tobacco for a long time are most at risk. The risk is even higher for tobacco users who drink alcohol heavily. In fact, three out of four oral cancers occur in people who use alcohol, tobacco, or both alcohol and tobacco.



• Alcohol: People who drink alcohol are more likely to develop oral cancer than people who don't drink. The risk increases with the amount of alcohol that a person consumes. The risk increases even more if the person both drinks alcohol and uses tobacco.



• Sun: Cancer of the lip can be caused by exposure to the sun. Using a lotion or lip balm that has a sunscreen can reduce the risk. Wearing a hat with a brim can also block the sun's harmful rays. The risk of cancer of the lip increases if the person also smokes.



• A personal history of head and neck cancer: People who have had head and neck cancer are at increased risk of developing another primary head and neck cancer. Smoking increases this risk.

Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer. Scientists also are studying whether infections with certain viruses (such as the human papillomavirus) are linked to oral cancer.

If you think you may be at risk, you should discuss this concern with your doctor or dentist. You may want to ask about an appropriate schedule for checkups. Your health care team will probably tell you that not using tobacco and limiting your use of alcohol are the most important things you can do to prevent oral cancers. Also, if you spend a lot of time in the sun, using a lip balm that contains sunscreen and wearing a hat with a brim will help protect your lips.

What are the symptoms of oral cancer?

Early detection

Your regular checkup is a good time for your dentist or doctor to check your entire mouth for signs of cancer. Regular checkups can detect the early stages of oral cancer or conditions that may lead to oral cancer. Ask your doctor or dentist about checking the tissues in your mouth as part of your routine exam.

Symptoms

Common symptoms of oral cancer include:

• Patches inside your mouth or on your lips that are white, a mixture of red and white, or red



• White patches (leukoplakia) are the most common. White patches sometimes become malignant.



• Mixed red and white patches (erythroleukoplakia) are more likely than white patches to become malignant.



• Red patches (erythroplakia) are brightly colored, smooth areas that often become malignant.



• A sore on your lip or in your mouth that won't heal



• Bleeding in your mouth



• Loose teeth



• Difficulty or pain when swallowing



• Difficulty wearing dentures



• A lump in your neck



• An earache

Anyone with these symptoms should see a doctor or dentist so that any problem can be diagnosed and treated as early as possible. Most often, these symptoms do not mean cancer. An infection or another problem can cause the same symptoms.

Diagnosis of oral cancer

If you have symptoms that suggest oral cancer, the doctor or dentist checks your mouth and throat for red or white patches, lumps, swelling, or other problems. This exam includes looking carefully at the roof of the mouth, back of the throat, and insides of the cheeks and lips. The doctor or dentist also gently pulls out your tongue so it can be checked on the sides and underneath. The floor of your mouth and lymph nodes in your neck also are checked.

If an exam shows an abnormal area, a small sample of tissue may be removed. Removing tissue to look for cancer cells is called a biopsy. Usually, a biopsy is done with local anesthesia. Sometimes, it is done under general anesthesia. A pathologist then looks at the tissue under a microscope to check for cancer cells. A biopsy is the only sure way to know if the abnormal area is cancerous.

Treatment for oral cancer

Staging

If the biopsy shows that cancer is present, your doctor needs to know the stage (extent) of your disease to plan the best treatment. The stage is based on the size of the tumor, whether the cancer has spread and, if so, to what parts of the body.

Staging may require lab tests. It also may involve endoscopy. The doctor uses a thin, lighted tube (endoscope) to check your throat, windpipe, and lungs. The doctor inserts the endoscope through your nose or mouth. Local anesthesia is used to ease your discomfort and prevent you from gagging. Some people also may have a mild sedative. Sometimes the doctor uses general anesthesia to put a person to sleep. This exam may be done in a doctor's office, an outpatient clinic, or a hospital.

The doctor may order one or more imaging tests to learn whether the cancer has spread:

• Dental x-rays: An x-ray of your entire mouth can show whether cancer has spread to the jaw.



• Chest x-rays: Images of your chest and lungs can show whether cancer has spread to these areas.



• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your body. You may receive an injection of dye. Tumors in the mouth, throat, neck, or elsewhere in the body show up on the CT scan.



• MRI: A powerful magnet linked to a computer is used to make detailed pictures of your body. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether oral cancer has spread.

Treatment

Many people with oral cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and your treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat oral cancer include oral and maxillofacial surgeons, otolaryngologists (ear, nose, and throat doctors), medical oncologists, radiation oncologists, and plastic surgeons. You may be referred to a team that includes specialists in surgery, radiation therapy, or chemotherapy. Other health care professionals who may work with the specialists as a team include a dentist, speech pathologist, nutritionist, and mental health counselor.

Getting a second opinion

Before starting treatment, you might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if you or your doctor requests it.

There are a number of ways to find a doctor for a second opinion:

• Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.



• The Cancer Information Service, at 1-800-4-CANCER, can tell you about nearby treatment centers.



• A local or state medical or dental society, a nearby hospital, or a medical or dental school can usually provide the names of specialists in your area.



• The American Board of Medical Specialties (ABMS) has a list of doctors who have had training and exams in their specialty. You can find this list in the Official ABMS Directory of Board Certified Medical Specialists. The directory is available in most public libraries. Or you can look up doctors at http://www.abms.org. (Click on Who's Certified.)



• The American Dental Association (ADA) Web site provides a list of dentists by specialty and location. The ADA Member Directory is available on the Internet at http://www.ada.org.



• The NCI provides a helpful fact sheet on how to find a doctor called "How To Find a Doctor or Treatment Facility If You Have Cancer." It is available on the Internet at http://cancer.gov/publications.

Preparing for treatment

The choice of treatment depends mainly on your general health, where in your mouth or oropharynx the cancer began, the size of the tumor, and whether the cancer has spread. Your doctor can describe your treatment choices and the expected results. You will want to consider how treatment may affect normal activities such as swallowing and talking, and whether it will change the way you look. You and your doctor can work together to develop a treatment plan that meets your needs and personal values.

You do not need to ask all your questions or understand all the answers at once. You will have other chances to ask your doctor to explain things that are not clear and to ask for more information.