• Teodora Todorova

Mouth Cancer


Mouth or oral cancer is where a tumour develops in the lining of the mouth. It can develop on the surface of the tongue, the insides of the cheeks, the roof of the mouth (palate), the lips or gums. Tumours can also develop in the saliva glands, tonsils, and the pharynx. Mouth cancer is the sixth most common cancer in the world. In the UK, around 6800 people are diagnosed with it each year in the UK (about 2% of all cancer diagnosis). Mouth cancer mostly occurs in older people aged 50 to 74.
















Types of mouth cancer


Mouth cancer is categorised by the type of cell the cancer (carcinoma) starts in.

Squamous cell carcinoma is the most common type (9 out of 10 cases). Squamous cells are found in many places on the body, such as the skin and the inside of the mouth. Less common types are:

  • Adenocarcinomas - cancers developing in the salivary glands

  • Sarcomas - grow from abnormalities in the bone, cartilage, muscle or other body tissue

  • Oral malignant melanomas - cancer starts in melanocytes (cells that produce skin pigment); they appear as very dark, mottled swellings that often bleed

  • Lymphomas - grow from lymph gland cells, but can develop in the mouth as well

Causes and development

The two biggest causes of mouth cancer are tobacco and alcohol.

Both substances are carcinogenic (they can damage DNA in cells), so people who smoke and drink have a significantly increased risk of mouth cancer development.


Some other risk factors include:

  • Chewing tobacco - smokeless tobacco products aren’t harmless and can increase the risk of mouth and other types of cancers too (liver, pancreatic, oesophageal)

  • Betel nuts - mildly addictive seeds from the betel palm tree, and are widely used in southeast Asian communities. Have a stimulant effect similar to coffee, but also a carcinogenic effect that raises the risk of mouth cancer, especially if betel nuts are chewed with tobacco (a common practice).

  • Diet - there is evidence that a poor, unbalanced diet (primarily lacking in fruit and vegetables) may increase risk of mouth cancer development

  • Human papilloma virus (HPV) - a family of viruses that affect the skin and moist membranes lining the body (cervix, anus, mouth, throat). HPV infection can happen by sexual contact with a person who’s already infected. There’s evidence that in rare cases, certain types of HPV can cause abnormal tissue growth inside the mouth, triggering mouth cancer

  • Oral hygiene - jagged, broken teeth that cause persistent ulcers or wounds on the tongue, can increase the risk of mouth cancer development

  • Long term UV light exposure - increases the risk of lip cancer

How mouth cancer spreads

  • Directly - can spread out of the mouth and into nearby tissues e.g. surrounding skin or back of the jaw

  • Through the lymphatic system - this system is a series of vessels and glands spread throughout the body, which produce specialised cells needed by the immune system to fight infections

If the mouth cancer spreads to another part of the body, it is called a metastatic oral cancer. The part of the body that it spreads to is called a secondary. The lymph glands in the neck are often the first place for mouth cancer to form secondaries.

Symptoms

  • Sore mouth ulcers that don’t heal within several weeks

  • Persistent lumps in the mouth that don’t go away

  • Persistent lumps in the neck that don’t go away

  • Looseness of teeth, or sockets that don’t heal after extractions

  • Persistent numbness or an odd feeling on the lip or tongue

  • Changes in speech e.g. lisp

  • Pain or difficulty swallowing

  • Bleeding or numbness in the mouth

  • Red or white patches on the lining of the mouth (these are common and very rarely cancerous, but can sometimes turn into cancer so are worth checking with a specialist)

If any of the above symptoms have lasted longer than 3 weeks, it’s strongly recommended to visit your GP or dentist, particularly if you drink and/or smoke regularly.


Diagnosis


If you have symptoms of mouth cancer, your GP or dentist will carry out a physical examination. If they suspect it is present, you’ll be referred to a hospital for further tests.


Neck lump clinic

A one-stop clinic where you can have all the tests needed to check for cancer in a neck lump. Usually an ultrasound scan is done and a sample of tissue is taken from the lump using fine needle aspiration, and nasendoscopy may also be used to look at the back of the mouth.


Nasendoscopy

A long, flexible and thin tube with a camera and a light at one end is guided through the nose and into the throat. Usually this is used if the suspected cancerous tissue is inside your nose, throat or voice box. It is a very quick procedure and local anaesthetic may be used to ease discomfort.


Biopsy

A small sample of affected tissue will need to be removed to check if cancer cells are present. The sample is sent to a pathologist to be examined, and reported back whether the cells are cancerous and of what type and grade if so. The main biopsy methods are:

  • Incision and punch biopsy - carried out under local anaesthesia, a small section of the tissue is cut out and the wound is closed with a stitch. Punch biopsy is where the sample removed is particularly small enough so that no stitching is needed.

  • Fine needle aspiration with cytology - used if you have a swelling in the neck that is suspected as a secondary from the mouth cancer. Usually done simultaneously with an ultrasound scan, it is similar to having a blood test, as a small needle is used to draw out a sample of the cells and fluid from the lump

  • Panendoscopy - carried out under general anaesthetic, it’s used to investigate the same areas as nasendoscopy but using larger telescopes that would be uncomfortable if the patient is conscious. Since it gives better access, the procedure can also be used to remove small tumours

If the biopsy confirms mouth cancer, further tests need to be done to check its stage, before any treatment can be planned. The tests will check whether the cancer has spread into adjacent tissue (jaw or skin) and if it has spread into the neck’s lymph glands, and the rest of the body will also be scanned.


Ultrasound neck scan

This test uses sound waves to produce a picture of the patient’s neck and lymph nodes on a screen. Gel is rubbed on the neck and a small device is moved on to the neck, which produces sound waves over the area. The doctor would be looking for any changes in the size or appearance of the lymph nodes in the neck.


CT (computerised tomography) scan

A series of x-rays are used to build up a 3D picture of the inside of the body. The scan takes 10 - 30 minutes and is painless. An injection of a dye may be given, to allow particular areas to be seen more clearly, which can produce feelings of heat for a short period. It is important for patients to inform their doctors if they are allergic to iodine or have asthma, as they could have more serious reactions to the injection.


MRI Scan

This scan uses magnetism to build up a detailed picture of areas of the body. The scanner is a powerful magnet so it is important that the patient informs the clinic if they have any metal implants e.g. pacemakers, surgical clips or bone pins, etc. If the patient has ever worked with metal or in the metal industry, they need to say so as very tiny metal fragments can sometimes lodge in the body. If any metal is present in the body, the MRI cannot be done.


Other tests may include:

  • X-ray

  • Positron emission tomography (PET) scan

Staging

This is a measure of how far the cancer has spread. TNM system staging is used:

  • T - the size of the tumour in the mouth; T1 is the smallest and T4 is the largest or most deeply invasive

  • N - shows if there are secondaries in the neck lymph glands; N0 means none are found, and N1, N2 and N3 indicate the extent of neck secondaries

  • M - refers to whether there are secondaries elsewhere in the body

Grade

Describes how aggressive the cancer is and how fast it’s likely to spread in the future. There are 3 grades:

  • Grade 1 or low grade - cancer cells look like normal cells and are growing slowly

  • Grade 2 and 3 or moderate grade - cancer cells look different from normal cells and their growth is slightly faster

  • Grade 4 or high grade - cancer cells look very different from normal cells, and grow quicker

Staging and grading then determine if you have:

  • Early or local mouth cancer - small and has not spread, so generally curable with a small operation

  • Locally advanced or intermediate mouth cancer - started to spread to nearby tissue or lymph nodes, but still a high chance of cure, though will usually need a long operation and radiotherapy

  • Advanced/secondary/metastatic mouth cancer - spread to other body parts, with lower chances of curing and will definitely need all 3 treatments (surgery, radiotherapy and chemotherapy)

  • Local recurrence - cancer that has come back in the same area after treatment

Treatment


Mouth cancer may affect structures in the body that are important for breathing, eating and speaking, may also affect appearance, and it’s diagnosis is in general a cause of stress for both the patient and their family. Therefore, it’s treatment includes the efforts of not only surgeons and clinical oncologists, but also of dietitians, dentists and psychologists.


The treatment will depend on the type and size of the cancer, its grade and how far it’s spread, and the patient’s overall health. If it hasn’t spread beyond the mouth, it may be completely curable with just surgery. Conversely, if it is large or has spread to the neck then surgery, radiotherapy and chemotherapy may be needed to control it.


Surgery

The aim is to remove the affected tissue and minimise damage to the rest of the mouth. If the cancer is advanced, part of the mouth lining may need to be removed and sometimes even facial skin (this can be replaced with skin taken elsewhere from the body). If the tongue is affected, part of it will need to be removed (partial glossectomy), and will be left to heal on its own (usually 3-4 weeks), or will be reconstructed with transplanted tissue. If the cancer has moved into the jawbone, the affected part will need to be removed. Sometimes other bones (e.g. cheekbones) would have to be removed to get rid of the cancer fully. Surgeons now use 3D printing to plan a reconstruction in which the replacement bone is almost an exact match. Replacement bone and muscle is usually taken from the lower leg, hip or shoulder blade. During surgery, the surgeon might also remove lymph nodes near the initial tumour, as a preventive measure in case they contain small numbers of cancer cells that can’t be detected on scans.


Radiotherapy

Doses of radiation are used to kill cancerous cells. In mouth cancer, it is usually done after the surgery to prevent the cancer from returning, while in throat cancer it’s often the first treatment in combination with chemoradiotherapy. There are different types of radiotherapy, but the one used for head and neck cancers is called intensity-modulated radiotherapy (IMRT). IMRT makes use of high-energy rays that precisely target the cancer area, which can reduce side effects.


Radiotherapy is generally performed daily over the course of 6 weeks, depending on the cancer’s size and how far it’s spread. However radiotherapy can also affect healthy tissue and has a number of side effects:

  • Sore, red skin - starts after roughly 2 weeks of treatment for up to 4 weeks after finishing, so it’s recommended to use only soaps, creams and lotion that the patient’s radiotherapy team approves

  • Mouth ulcers

  • Sore mouth and throat - a mouth care routine can help prevent any problems, but the patient’s doctor can prescribe medicine to help if needed

  • Dry mouth - radiotherapy may reduce the amount of saliva being made, which also makes it much more likely for tooth decay to develop. It’s important to keep good oral hygiene to prevent this

  • Loss of or change in taste

  • Loss of appetite

  • Tiredness - common side effect that can last up to several months after treatment. Physical activity can help to balance this

  • Feeling sick

  • Stiff jaw

  • Bad breath

  • Exposed bone

Internal radiotherapy (brachytherapy)

This can be used to treat early stage tongue cancers. It involves placing radioactive implants directly into the tumour, while under general anaesthetic. The implants are then left in for 1 to 8 days, and the cancer cells will receive a much higher dose of radiation than the rest of the mouth. The implants will cause the mouth to become swollen and some pain is usually experienced 5 to 10 days after they are removed.


Chemotherapy

Chemotherapy uses powerful cancer-killing (cytotoxic) medicine, which damages the DNA of the cancer cells, therefore stopping them from dividing. The most often used drugs are cisplatin and fluorouracil (5FU) and are usually given intravenously. Chemotherapy treatment can be given:

  • Before surgery or radiotherapy to shrink the cancer, making it easier to treat

  • At the same time as radiotherapy, making the cancer cells more sensitive to radiotherapy

  • To treat cancer that has spread or come back after a previous treatment

Chemotherapy is given in several treatment sessions and each session is followed by a rest period, so that the patient’s body can recover. However, chemotherapy can have adverse side effects:

  • Tiredness

  • Sore mouth

  • Mouth ulcers

  • Feeling sick

  • Being sick

  • Hair loss

  • Hearing and balance problems

  • Kidney problems

  • Numbness and tenderness of the hands and feet

These side effects stop once treatment is finished. Chemotherapy also weakens the immune system and makes the patient more vulnerable to infection.


Cetuximab

A new type of medication (known as biologic or antibody), which is sometimes used instead of chemotherapy. It doesn’t cause all of chemotherapy’s side effects and is normally used alongside radiotherapy. Cetuximab targets proteins on the surface of cancer cells, called epidermal growth factor receptors. These receptors help the cancer grow, and by targeting them, the cancer is prevented from spreading. However this treatment is generally not cost effective, and is usually only used on people that are in a good state of health (likely to make a good recovery) or unable to have chemotherapy (e.g. because they’re pregnant or have kidney disease). It is common for skin reactions such as acne to occur during initial treatment.


Photodynamic therapy (PDT)

This may be recommended if there are damaged mouth tissues that are close to turning into cancer, or the cancer is in very early stage. PDT can be used to temporarily control cancer, if it has been decided that further normal treatment won’t provide a cure or benefit. PDT involves taking a medicine that makes the skin and other tissues sensitive to light, especially cancerous tissue. After receiving the medicine, light is shone on the cancer using lasers and this destroys the surface of the cancer. After this, the patient has to stay in a dark room for 7 days with no light at all (including TV and bed light), otherwise exposure at this period will cause serious sunburn to the patient.


Impact

Mouth cancer can have lasting effects on its sufferers, both physically and emotionally. Physical complications can include changes to the appearance of the mouth, difficulty swallowing (dysphagia), and speech problems.


Changes to appearance

Any surgeries done to the jaw, tongue, mouth, lips or throat can change a person’s appearance. However, that doesn’t necessarily mean that the patient will have a lot of scars. Even with big operations, scars can fade over time and become difficult to see. Surgeons aim to make scars as minimally invasive as possible. If any bone needs to be removed from the face, then the surgical team will rebuild it afterwards. Scarring from lip surgery may be more apparent, and the patient may have to ultimately cope with the change in their look. Nevertheless, it can be very difficult for someone to accept the changes in the way they look and as a result of this to then have strong and mixed emotions on the topic of their self image.


Meeting both new and familiar people after a face surgery can be a stressful experience, especially in the initial period after the surgery. It can therefore be essential for a patient to talk and be open with friends and family about the issue and how it makes them feel. It can also help to approach this change by accepting that some people in the patient’s daily surroundings might initially be surprised with the change of their appearance and ask questions, but also that these people themselves might be unsure and uncomfortable with speaking on the topic.


In the end, one of the best strategies to this change is for the patient to give themselves enough time to come to terms with this change and to baby-step the way that they adjust mentally to it, whether that is being more open with those close to them, exposing themselves by going out a bit more or reflecting on their own feelings about how people perceive them, and what impact they allow that to have on them.


Dysphagia

A test called videofluoroscopy will be done by a speech and language therapist to assess the patient’s swallowing reflex. The test is done by swallowing food and liquid with a special dye inside them, while a moving x-ray being taken. The dye then shows up on x-ray, and through this the therapist can see the patient’s swallowing reflex and asses if there’s a risk of food or liquid entering the lungs while eating or drinking. If there is a risk, the patient will have to be fed using gastronomy for a short period, where a feeding tube is directly passed through to the stomach, until they re-learn how to swallow properly.


Speech

Speaking is a complex function of muscles, bones and tissue in the mouth. Radiotherapy and surgery can affect a patient’s speaking abilities by making it difficult to pronounce certain sounds. A speech and language therapist can aid a recovering patient to improve their speech through special vocal exercises.


Emotional impact

Though in the present there is a bigger awareness and familiarity of cancer and its impacts, its diagnosis is still a highly personal experience to the patient and their family. Patients with cancer can have big swings in moods between feeling low after e.g. a diagnosis, and then feeling up after seeing that treatment is working, then down again as the side effects start to appear. This constant emotional strain can lead to the development of depression, so it is important for a cancer patient to pay attention to their mental state and how they are coping with the situation, but in general to also have a support network of family and friends around them during their period of treatment. Of course, there is no right or wrong way to deal with having cancer and every person’s approach would be individual to their situation, but knowing that there is an outlet to express their feelings of the situation (whether that’s through friends/family, a local support group or a therapist) can be of great benefit in bringing back a sense of control and responsibility over the situation.


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