Keeping on Top of Your Condition
The Oral Cavity
This booklet deals with cancer of the oral cavity (mouth) and the oropharynx
(the part of the throat at the back of the mouth). The oral cavity
includes many parts: the lips; the lining inside the lips and cheeks,
called the buccal
mucosa; the teeth; the bottom (floor) of the mouth under the
tongue; the front two-thirds of the tongue; the bony top of the mouth
(hard palate);
the gums; and the small area behind the wisdom teeth. The oropharynx
includes the back one-third of the tongue, the soft palate, the tonsils,
and the part of the throat behind the mouth. Salivary
glands throughout the oral cavity make saliva, which keeps the
mouth moist and helps digest food.
The oral
cavity
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What Is Cancer?
Cancer is a group of diseases. It occurs when cells become abnormal and
divide without control or order. More than 100 different types of cancer
are known.
Like all organs of the body, the mouth and throat are made up of many
kinds of cells. Cells normally divide in an orderly way to produce more
cells only when the body needs them. This process helps keep the body
healthy.
Cells that divide when new cells are not needed form too much tissue.
The mass of extra tissue, called a tumor,
can be benign
or malignant.
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Benign tumors are not cancer. They can usually be removed, and
in most cases, they don't grow back. Most important, the cells in benign
tumors do not invade other tissues and do not spread to other parts of
the body. Benign tumors usually are not a threat to life.
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Malignant tumors are cancer. They can invade and damage nearby
tissues and organs. Also, cancer cells can break away from a malignant
tumor and enter the bloodstream or the lymphatic
system. This is how cancer spreads and forms secondary tumors in
other parts of the body. The spread of cancer is called metastasis.
When oral cancer spreads, it usually travels through the lymphatic
system. Cancer cells that enter the lymphatic system are carried along by
lymph,
an almost colorless, watery fluid containing cells that help the body
fight infection and disease. Along the lymphatic channels are groups of
small, bean-shaped organs called lymph
nodes (sometimes called lymph glands). Oral cancer that spreads
usually travels to the lymph nodes in the neck. It can also spread to
other parts of the body. Cancer that spreads is the same disease and has
the same name as the original (primary) cancer.
Early Detection
Regular checkups that include an examination of the entire mouth can
detect precancerous
conditions or the early stages of oral cancer. Your doctor and dentist
should check the tissues in your mouth as part of your routine exams.
Symptoms
Oral cancer usually occurs in people over the age of 45 but can develop
at any age. These are some symptoms to watch for:
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A sore on the lip or in the mouth that does not heal;
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A lump on the lip or in the mouth or throat;
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A white or red patch on the gums, tongue, or lining of the mouth;
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Unusual bleeding, pain, or numbness in the mouth;
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A sore throat that does not go away, or a feeling that something is
caught in the throat;
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Difficulty or pain with chewing or swallowing;
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Swelling of the jaw that causes dentures to fit poorly or become
uncomfortable;
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A change in the voice; and/or
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Pain in the ear.
These symptoms may be caused by cancer or by other, less serious
problems. It is important to see a dentist or doctor about any symptoms
like these, so that the problem can be diagnosed and treated as early as
possible.
Diagnosis and Staging
If an abnormal area has been found in the oral cavity, a biopsy
is the only way to know whether it is cancer. Usually, the patient is
referred to an oral
surgeon or an ear, nose, and throat surgeon, who removes part or
all of the lump or abnormal-looking area. A pathologist
examines the tissue under a microscope to check for cancer cells.
Almost all oral cancers are squamous
cell carcinomas. Squamous cells line the oral cavity.
If the pathologist finds oral cancer, the patient's doctor needs to
know the stage, or extent, of the disease in order to plan the best
treatment. Staging
tests and exams help the doctor find out whether the cancer has spread and
what parts of the body are affected.
A patient who needs a biopsy may want to ask the doctor these
questions:
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How much tissue will be removed for the biopsy?
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How long will the biopsy take? Will I be awake? Will it hurt?
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How should I care for the biopsy site afterward?
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How soon will I know the results?
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If I do have cancer, who will talk with me about treatment?
When?
Staging generally includes dental x-rays
and x-rays of the head and chest. The doctor may also want the patient to
have a CT
(or CAT) scan. A CT scan is a series of x-rays put together
by a computer to form detailed pictures of areas inside the body. Ultrasonography
is another way to produce pictures of areas in the body. High-frequency
sound waves (ultrasound), which cannot be heard by humans, are bounced off
organs and tissue. The pattern of echoes produced by these waves creates a
picture called a sonogram. Sometimes the doctor asks for MRI
(magnetic resonance imaging), a procedure in which pictures are created
using a magnet linked to a computer. The doctor also feels the lymph nodes
in the neck to check for swelling or other changes. In most cases, the
patient will have a complete physical examination before treatment
begins.
Treatment
After diagnosis and staging, the doctor develops a treatment plan to
fit each patient's needs. Treatment for oral cancer depends on a number of
factors. Among these are the location, size, type, and extent of the tumor
and the stage of the disease. The doctor also considers the patient's age
and general health. Treatment involves surgery,
radiation
therapy, or, in many cases, a combination of the two. Some
patients receive chemotherapy,
treatment with anticancer drugs.
For most patients, it is important to have a complete dental exam
before cancer treatment begins. Because cancer treatment may make the
mouth sensitive and more easily infected, doctors often advise patients to
have any needed dental work done before treatment begins.
Most people with cancer want to learn all they can about their disease
and their treatment choices so they can take an active part in decisions
about their medical and dental care. The doctor is the best person to
answer their questions. Also, the patient may want to talk with the doctor
about taking part in a research study of new treatment methods. Such
studies, called clinical
trials, are designed to improve cancer treatment.
Many patients find it useful to make a list of questions before seeing
the doctor. Taking notes can make it easier to remember what the doctor
says. Some patients also find that it helps to have a family member or
friend with them -- to take part in the discussion, to take notes, or just
to listen.
Before treatment begins, the patient may want to ask the doctor these
questions:
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What are my treatment choices? Which do you recommend for me?
Why?
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What are the risks and possible side effects of each treatment?
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What are the expected benefits of each kind of treatment?
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What can be done about side effects?
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Would a clinical trial be appropriate for me?
There is a lot to learn about cancer and its treatment. Patients do not
need to ask all their questions or understand all the answers at once.
They will have many chances to ask the doctor to explain things that are
not clear and to ask for more information.
Planning Treatment
Treatment decisions can be complex. Before starting treatment, the
patient may want to have another doctor review the diagnosis and treatment
plan. A short delay will not reduce the chance that treatment will be
successful. There are a number of ways to find a doctor for a second
opinion:
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The patient's doctor or dentist may suggest a specialist who treats
oral cancer.
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The Cancer Information Service, at 1-800-4-CANCER, can tell callers
about cancer centers and other NCI-supported programs in their area.
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Patients can get the names of specialists from their local medical or
dental society, a nearby hospital, or a medical or dental school.
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The Directory of Medical Specialists lists doctors' names
along with their specialty and their background. This resource is
available in most public libraries.
Methods of Treatment
Patients with oral cancer may be treated by a team of specialists. The
medical team may include an oral surgeon; an ear, nose, and throat
surgeon; a medical
oncologist; a radiation
oncologist; a prosthodontist;
a general dentist; a plastic
surgeon; a dietitian; a social worker; a nurse; and a speech
therapist.
Surgery to remove the tumor in the mouth is the usual treatment
for patients with oral cancer. If there is evidence that the cancer has
spread, the surgeon may also remove lymph nodes in the neck. If the
disease has spread to muscles and other tissues in the neck, the operation
may be more extensive.
Before surgery, the patient may want to ask the doctor these
questions:
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What kind of operation will it be?
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How will I feel after the operation? If I have pain, how will you
help me?
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Will I have trouble eating?
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Where will the scars be? What will they look like?
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Do you expect that there will be long-term effects from the
surgery?
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Will there be permanent changes in my appearance?
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Will I lose my teeth? Can they be replaced? How soon?
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If I need to have plastic surgery, when can that be done?
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Will I need to see a specialist for help with my speech?
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When can I get back to my normal activities?
Radiation therapy (also called radiotherapy) is the use of
high-energy rays to damage cancer cells and stop them from growing. Like
surgery, radiation therapy is local
therapy; it affects only the cells in the treated area. The energy
may come from a large machine (external
radiation). It can also come from radioactive materials placed
directly into or near the tumor (internal
radiation). Radiation therapy is sometimes used instead of surgery
for small tumors in the mouth. Patients with large tumors may need both
surgery and radiation therapy.
Radiation therapy may be given before or after surgery. Before surgery,
radiation can shrink the tumor so that it can be removed. Radiation after
surgery is used to destroy cancer cells that may remain.
For external radiation therapy, the patient goes to the hospital or
clinic each day for treatments. Usually, treatment is given 5 days a week
for 5 to 6 weeks. This schedule helps protect healthy tissues by dividing
the total amount of radiation into small doses.
Implant radiation therapy puts tiny "seeds" containing radioactive
material directly into the tumor or in tissue near it. Generally, an
implant is left in place for several days, and the patient will stay in
the hospital in a private room. The length of time nurses and other
caregivers, as well as visitors, can spend with the patient will be
limited. The implant is removed before the patient goes home.
Before radiation therapy, a patient may want to ask the doctor these
questions:
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When will the treatments begin? When will they end?
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How will I feel during therapy?
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What can I do to take care of myself during therapy?
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Can I continue my normal activities?
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How will my mouth and face look afterward?
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Will I need a special diet? For how long?
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If my mouth becomes dry, what can I do about it?
Chemotherapy is the use of drugs to kill cancer cells.
Researchers are looking for effective drugs or drug combinations to treat
oral cancer. They are also exploring ways to combine chemotherapy with
other forms of cancer treatment to help destroy the tumor and prevent the
disease from spreading.
Clinical Trials
Researchers are developing treatment methods that are more effective
against oral cancer, and they are also finding ways to reduce side effects
of treatment. When laboratory research shows that a new method has
promise, doctors use it to treat cancer patients in clinical trials. These trials are designed to
answer scientific questions about the new approach and to find out whether
it is both safe and effective. Patients who take part in clinical trials
make an important contribution to medical science and may have the first
chance to benefit from improved treatment methods.
Clinical trials to study new treatments for oral cancer are under way
in hospitals throughout the country. Some trials involve ways to shrink or
destroy the primary tumor. In others, scientists are testing ways to
prevent the cancer from coming back in the mouth or spreading to other
parts of the body. Still others involve treatments to slow or stop cancer
that has already spread.
Researchers are studying the timing of treatments and new ways to
combine various types of treatment. For example, they are trying to
increase the effectiveness of radiation therapy by giving treatments twice
a day instead of once a day. They are also working with hyperthermia
(heat) and with drugs called radiosensitizers
to try to make cancer cells more sensitive to radiation. Researchers are
also using drugs to help protect normal cells from radiation damage. In
addition, they are exploring various new anticancer drugs and drug
combinations.
People who have had oral cancer have an increased risk of getting a new
cancer of the mouth or another part of the head or neck. Doctors are
trying to find ways to prevent these new cancers. Some research has shown
that a substance related to vitamin A may prevent a new cancer from
developing in someone who has already been successfully treated for oral
cancer.
Oral cancer patients who are interested in taking part in a trial
should talk with their doctor.
One way to learn about clinical trials is through PDQ
, a computerized resource developed
by the National Cancer Institute. PDQ contains information about cancer
treatment and an up-to-date list of trials all over the country. The
Cancer Information Service, at 1-800-4-CANCER, can provide PDQ information
to patients and the public.
Side Effects of Treatment
It is hard to limit the effects of cancer treatment so that only cancer
cells are removed or destroyed. Because healthy cells and tissues may also
be damaged, treatment often causes side effects.
The side effects of cancer treatment vary. They depend mainly on the
type and extent of the treatment and the specific area being treated.
Also, each person reacts differently. Some side effects are temporary;
others are permanent. Doctors try to plan the patient's therapy to keep
side effects to a minimum. They also watch patients very carefully so they
can help with any problems that occur.
Surgery to remove a small tumor in the mouth usually does not cause any
lasting problems. For a larger tumor, however, the surgeon may need to
remove part of the palate, tongue, or jaw. Such surgery is likely to
change the patient's ability to chew, swallow, or talk. The patient may
also look different.
After surgery, the patient's face may be swollen. This swelling usually
goes away within a few weeks. However, removing lymph nodes can slow the
flow of lymph, which may collect in the tissues; this swelling may last
for a long time.
Before starting radiation therapy, a patient should see a dentist who
is familiar with the changes this therapy can cause in the mouth.
Radiation therapy can make the mouth sore. It can also cause changes in
the saliva and may reduce the amount of saliva, making it hard to chew and
swallow. Because saliva normally protects the teeth, mouth dryness can
promote tooth decay. Good mouth care can help keep the teeth and gums
healthy and can make the patient feel more comfortable. The health care
team may suggest the use of a special kind of toothbrush or mouthwash. The
dentist usually suggests a special fluoride program to keep the teeth
healthy. To help relieve mouth dryness, the health care team may suggest
the use of artificial saliva and other methods to keep the mouth moist.
Mouth dryness from radiation therapy goes away in some patients, but it
can be permanent.
Weight loss can be a serious problem for patients being treated for
oral cancer because a sore mouth may make eating difficult. Your doctor
may suggest ways to maintain a healthy diet. In many cases, it helps to
have food and beverages in very small amounts. Many patients find that
eating several small meals and snacks during the day works better than
trying to have three large meals. Often, it is easier to eat soft, bland
foods that have been moistened with sauces or gravies; thick soups,
puddings, and high protein milkshakes are nourishing and easy to swallow.
It may be helpful to prepare other foods in a blender. The doctor may also
suggest special liquid dietary supplements for patients who have trouble
chewing. Drinking lots of fluids helps keep the mouth moist and makes it
easier to eat.
Some patients are able to wear their dentures during radiation therapy.
Many, however, will not be able to wear dentures for up to a year after
treatment. Because the tissues in the mouth that support the denture may
change during or after treatment, dentures may no longer fit properly.
After treatment is over, a patient may need to have dentures refitted or
replaced.
Radiation therapy can also cause sores in the mouth and cracked and
peeling lips. These usually heal in the weeks after treatment is
completed. Often, good mouth care can help prevent these sores. Dentures
should not be worn until the sores have healed.
During radiation therapy, patients may become very tired, especially in
the later weeks of treatment. Resting is important, but doctors usually
advise their patients to try to stay reasonably active. Patients should
match their activities to their energy level. It's common for radiation to
cause the skin in the treated area to become red and dry, tender, and
itchy. Toward the end of treatment, the skin may become moist and "weepy."
There may be permanent darkening or "bronzing" of the skin in the treated
area. This area should be exposed to the air as much as possible but
should also be protected from the sun. Good skin care is important at this
time, but patients should not use any lotions or creams without the
doctor's advice. Men may lose all or part of their beard, but facial hair
generally grows back after treatment is done. Usually, men shave with an
electric razor during treatment to prevent cuts that may lead to
infection. Most effects of radiation therapy on the skin are temporary.
The area will heal when the treatment is over.
The side effects of chemotherapy depend on the drugs that are given. In
general, anticancer drugs affect rapidly growing cells, such as blood
cells that fight infection, cells that line the mouth and the digestive
tract, and cells in hair
follicles. As a result, patients may have side effects such as
lower resistance to infection, loss of appetite, nausea, vomiting, or
mouth sores. They also may have less energy and may lose their hair.
The side effects of cancer treatment are different for each person, and
they may even be different from one treatment to the next. Doctors,
nurses, and dietitians can explain the side effects of cancer treatment
and can suggest ways to deal with them.
Rehabilitation
Rehabilitation is a very important part of treatment for patients with
oral cancer. The goals of rehabilitation depend on the extent of the
disease and the treatment a patient has received. The health care team
makes every effort to help the patient return to normal activities as soon
as possible. Rehabilitation may include dietary counseling, surgery, a
dental prosthesis,
speech therapy, and other services.
Sometimes, a patient needs reconstructive and plastic surgery to
rebuild the bones or tissues of the mouth. If this is not possible, a
prosthodontist may be able to make an artificial dental and/or facial part
(prosthesis). Patients may need special training to use the device.
Speech therapy generally begins as soon as possible for a patient who
has trouble speaking after treatment. Often, a speech therapist visits the
patient in the hospital to plan therapy and teach speech exercises. Speech
therapy usually continues after the patient returns home.
Followup Care
Regular followup exams are very important for anyone who has been
treated for oral cancer. The physician and the dentist watch the patient
closely to check the healing process and to look for signs that the cancer
may have returned. Patients with mouth dryness from radiation therapy
should have dental exams three times a year.
The patient may need to see a dietitian if weight loss or eating
problems continue. Most doctors urge their oral cancer patients to stop
using tobacco and alcohol to reduce the risk of developing a new
cancer.
Support for Cancer Patients
Living with a serious disease isn't easy. Cancer patients and those who
care about them face many problems and challenges. Finding the strength to
cope with these difficulties is easier when people have helpful
information and support services.
Cancer patients may worry about holding a job, caring for their family,
or starting new relationships. Worries about tests, treatments, hospital
stays, and medical bills are common. Doctors, nurses, and other members of
the health care team can help calm fears and ease confusion about
treatment, working, or daily activities. Also, meeting with a nurse,
social worker, counselor, or member of the clergy can be helpful for
patients who want to talk about their feelings or discuss their
concerns.
Friends and relatives, especially those who have had personal
experience with cancer, can be very supportive. Also, many patients find
it helpful to discuss their concerns with others who are facing similar
problems. Cancer patients often get together in support groups, where they
can share what they have learned about cancer and its treatment and about
coping with the disease. It is important to keep in mind, however, that
each patient is different. Treatments and ways of dealing with cancer that
work for one person may not be right for another -- even if they both have
the same kind of cancer. It is always a good idea to discuss the advice of
friends and family members with the doctor.
Often, a social worker at the hospital or clinic can suggest groups
that can help with rehabilitation, emotional support, financial aid,
transportation, or home care.
What the Future Holds
Patients and their families are naturally concerned about what the
future holds. Sometimes they use statistics to try to figure out whether
the patient will be cured or how long he or she will live. It is important
to remember, however, that statistics are averages based on large numbers
of patients. They cannot be used to predict what will happen to a certain
patient because no two cancer patients are alike. The doctor who takes
care of the patient knows his or her medical history and is in the best
position to discuss the person's outlook (prognosis).
People should feel free to ask the doctor about their chance of
recovery, but not even the doctor knows for sure what will happen. When
doctors talk about surviving cancer, they may use the term remission
rather than cure. Even though many patients with oral cancer recover
completely, doctors use this term because oral cancer can recur.
Causes and Prevention
Scientists at hospitals and medical centers all across the country are
studying this disease to learn more about what causes it and how to
prevent it. Doctors do know that no one can "catch" cancer from another
person: it is not contagious. Two known causes of oral cancer are
tobacco and alcohol use.
Tobacco use -- smoking cigarettes, cigars, or pipes; chewing tobacco;
or dipping snuff -- accounts for 80 to 90 percent of oral cancers. A
number of studies have shown that cigar and pipe smokers have the same
risk as cigarette smokers. Studies indicate that smokeless tobacco users
are at particular risk of developing oral cancer. For long-time users, the
risk is much greater, making the use of snuff or chewing tobacco among
young people a special concern.
People who stop using tobacco -- even after many years of use -- can
greatly reduce their risk of oral cancer. Special counseling or self-help
groups may be useful for those who are trying to give up tobacco. Some
hospitals have groups for people who want to quit. Also, the Cancer
Information Service and the American Cancer Society may have information
about groups in local areas to help people quit using tobacco.
Chronic and/or heavy use of alcohol also increases the risk of oral
cancer, even for people who do not use tobacco. However, people who use
both alcohol and tobacco have an especially high risk of oral cancer.
Scientists believe that these substances increase each other's harmful
effects.
Cancer of the lip can be caused by exposure to the sun. The risk can be
avoided with the use of a lotion or lip balm containing a sunscreen.
Wearing a hat with a brim can also block the sun's harmful rays. Pipe
smokers are especially prone to cancer of the lip.
Some studies have shown that many people who develop oral cancer have a
history of leukoplakia,
a whitish patch inside the mouth. The causes of leukoplakia are not well
understood, but it is commonly associated with heavy use of tobacco and
alcohol. The condition often occurs in irritated areas, such as the gums
and mouth lining of smokeless tobacco users and the lower lip of pipe
smokers.
Another condition, erythroplakia,
appears as a red patch in the mouth. Erythroplakia occurs most often in
people 60 to 70 years of age. Early diagnosis and treatment of leukoplakia
and erythroplakia are important because cancer may develop in these
patches.
People who think they might be at risk for developing oral cancer
should discuss this concern with their doctor or dentist, who may be able
to suggest ways to reduce the risk and plan an appropriate schedule for
checkups.
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
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