How Big is Your Mouth?

In terms of cancer diagnosis, the “mouth” or “oral cavity” ranges from the lips to the last molar, including the cheeks, gums, teeth, the part of the tongue that is visible in a mirror (the front 2/3), the hard palate (bony roof of the mouth).

Anything located behind the last molar is part of the “oropharynx,” including the base of the tongue, the tonsils, the soft palate, and the back wall of the throat.

There are also 3 major salivary glands considered separate entities as well as those of the jaw bones and muscles. The area the cancer originates (begins) in determines the type of cancer it is.

What is Cancer?

All cancer is caused by abnormal cell division in the body’s tissue. Normally, cells divide and reproduce in an orderly manner and on a timely basis. If a cell mutates, it passes along the abnormalities to the cells it reproduces. Abnormal cells reproduce at a faster rate than normal healthy ones, causing an excess of certain cells and a deficit (shortage) of others. The excess cells group together and create a mass known as a “tumor”. Tumors are either malignant (cancerous) and able to metastasize (spread) into surrounding tissues and other parts of the body or stationary and benign (non-cancerous). Benign tumors are usually surgically removed.

Finding Oral Cavity Cancer

A large number of these cancers are discovered during routine examinations by a dentist or doctor, or by self-examination. Like most cancers, the earlier it is detected, the better the prognosis (outlook for recovery). Some cancers cause symptoms to show up early and sometimes no symptoms appear until the cancer is in an advanced stage.

Other times the symptoms are mistaken for another disease. Many of the following signs and symptoms can be caused by other conditions or by benign growths. It is recommended to see a dentist or doctor if you suffer from any of these things for two weeks or more:

• A lump in the cheek
• A sore throat or constant feeling that something is caught in the throat
• Difficulty chewing and/or swallowing
• Numbness of the tongue or other area of the mouth
• Loose teeth
• Changes in voice
• A lump in the neck
• Difficulty moving the tongue or jaw
• Continuous bad breath
• A sore in the mouth that will not heal (most common symptom)
• Perpetual pain in the mouth (another very common symptom)
• Leukoplakia or erythroplakia

Leukoplakia is a white patch in the mouth or throat; erythroplakia is a slightly raised red area that easily bleeds. At the time of their discovery, these patches may be harmless, cancerous, or a precancerous condition known as dsyplasia.

Approximately 25% of leukoplakias are either cancerous or precancerous when discovered, in comparison with 70% of erythroplakia cases. The odds of either growing into cancer depend on the DNA content of the cells. Normal DNA may become cancer, but the chance of it doing so is low. On the other hand, if the DNA is abnormal, the chance of the leukoplakia or erythroplakia becoming cancer is very high.

Diagnosing Mouth Cancer

If there is a suspicion of cancer, you will be referred to an otolaryngologist (ear, nose, and throat specialist), or possibly an oncologist (cancer doctor) who specializes in those areas. You will be given a complete head and neck exam, which consists of the following:

• Nasopharyngoscopy (the back of the nose)
• Laryngoscopy (the voice box)
• Pharyngoscopy (the throat)

For these procedures, special fiberoptic scopes (thin, flexible, lighted tubes inserted through the nose or mouth) and mirrors are used for a closer look at the affected areas. People with oral or oropharyngeal cancer are at higher risk for other cancers of the head and neck, so the larynx and the lymph nodes are also carefully examined.

In some cases, a panendoscopy is required. This is a very thorough exam of the oral cavity, esophagus, larynx, oropharynx, and the trachea and bronchi (airways for breathing that lead to the lungs). This is done in the hospital and you are put to sleep for the procedure. If a tissue sample of the tumor has not already been taken (biopsy), the surgeon will remove a piece during this exam.

To be certain of cancer (or the absence of it), a tissue sample must be observed by a pathologist, a doctor who specializes in examining cells and tissues in order to diagnose diseases and illnesses. The method used for the biopsy, and where it is performed (office or hospital) depends on several factors, including the size and location of the lesion. The sample may be taken with a needle (FNA-fine needle aspiration), removed with a scalpel (incisional biopsy), or scraped off the area (similar to a PAP smear).

Another part of the complete examination includes looking for signs that the cancer has metastasized to other organs. This is done using imaging tests such as the following:

Chest x-ray: a picture of inside your chest to see if cancer has spread to your lungs.

Magnetic resonance imaging (MRI): a scan done with radio waves and magnets instead of x-rays for detailed images of internal areas in the body.

Computed tomography (CT or CAT scan): an advanced form of x-ray that takes a lot of pictures as it rotates around you. A contrast dye is injected into your veins before the procedure so that your organs will show up better.

Positron emission tomography: A special camera is used with a radioactive sugar to highlight cancerous cells in the body.

A routine blood test is also part of the examination. No blood test can diagnose oral cancers, but the results are useful for determining the overall health of the patient as well as any secondary conditions.

Staging the Cancer

Every cancer has a staging system. This simply means categorizing the cancer according to how far along it has advanced. The stage determines the treatment options and the prognosis (survival probabilities) of the patient. The lower the stage, the better the outlook.

Stage 0

At this stage, cancerous cells are found only in the shallow top layer of the oral or oropharyngeal tissue and have not spread.

Stage I

At this stage, the tumor is 2cm or smaller and has not spread.

Stage II

The tumor is between 2cm and 4cm but has not spread.

Stage III

The tumor is either larger than 4cm, or it is any size and has spread to a lymph node on the same side of the head or neck as the primary tumor.

Stage IVA

A tumor of any size that has invaded adjacent structures, may or may not have moved to a lymph node on the same side of the head or neck, or it has spread to lymph nodes on both sides of the neck and those lymph nodes are smaller than 6cm.

Stage IVB

The tumor is any size and has spread to lymph nodes larger than 6cm but has not metastasized to distant sites.

Stage IVC

The tumor is any size, may or may not have spread to lymph nodes, but has spread out to other sites.

The following statistics or the relative 5-year survival rates come from the American Cancer Society and apply to lip, oral, and oropharynx cancers.

Stage I 83%

Stage II 73%

Stage III 62%

Stage IV 47%

Treatment

Your doctor will discuss treatment options with you, taking into consideration among other things the type and stage of the cancer, your overall health, and the chances of attaining a cure. Treatments for mouth and oropharynx cancers usually include one or more of the following procedures:

• Surgery: the cancer is removed, along with surrounding affected tissues.
• Chemotherapy: “anti-cancer” drugs that can be administered through the mouth, through the vein, through the skin as a shot, and/or through the spine.
• Radiation therapy: external radiation uses a machine to target a beam at the tumor. With internal radiation, tiny pieces of radioactive material are placed into or near the tumor.
• Depending on your individual situation, your doctor may also talk to you about clinical trials of medication in the testing phase.

Mouth Cancer Risk Factors and Prevention

A risk factor is anything that increases a person’s chance of getting a disease.

• Tobacco use is the most common risk factor for cancers of the mouth and throat. Smokers are at much higher risk for mouth cancer than non-smokers. Approximately 90% of mouth and oropharyngeal cases occur in smokers. Users of smokeless tobacco (snuff and chewing tobacco) are 50 times more likely than non-users to get cancers of the gums, cheeks, and inner lips.
• Second-hand smoke is a risk factor of cancers in general.
• Alcohol, when used frequently increases the risk of cancer to not only the mouth, but also the throat, esophagus (food pipe), pancreas, and stomach.
• Poor dental hygiene: the bacteria found in saliva create plaque (waste products that stick to and harden on the teeth). Plaque itself does not create cancer, but it does create an environment where other chemicals (like the ones found in smoke) can settle in. Such irritants stimulate excess cell division in the mouth, and the more the more they divide, the more likely it is that one of them will become cancerous.
• Poor nutrition is a risk factor for mouth and oropharynx cancers, specifically a diet low in fruits and vegetables.
• Ultraviolet light exposure: People exposed to a lot of sun are at a higher risk of lip cancer. Over 30% of all lip cancer patients have jobs that require them to work outdoors in the sunlight.
• Betel nut chewing is a popular practice in India and other parts of South Asia. This practice is strongly associated with tooth loss and mouth cancer, specifically in the cheeks.
• Some sexually transmitted infections and viruses can lead to cancer. Such infections cause slow healing mouth sores, which in turn forces chronic cell division as the tissue attempts to heal itself.
• A compromised immune system, related to other medical conditions or treatments of other medical conditions.
• Plummer-Vinson syndrome is responsible for a very small number of oral cancers. This is a rare combination of iron deficiency and abnormalities of the fingernails, esophagus, tongue, and red blood cells.
• A history of cancer in the area that ranges from the nose and mouth to the lungs and stomach (the aero-digestive tract).
• Gender: cancers of the throat and mouth are twice as common in men as women, which may or may not be due to the fact that more men use tobacco and alcohol.

While it’s safe to say that some factors are out of your hands, like age and gender, it’s also safe to say (and smart to accept) that many of the risk factors are completely in your control. Practice healthy oral hygiene and good nutrition, slap on that sunscreen and protective lip balm, spit out that Betel nut, protect your private parts, and the most obvious one of all: stay away from tobacco products.

The American Cancer Society estimates that over 4,900 men and 2,400 women will lose their lives to these cancers in 2005. Over 29,000 new cases will spring up to take their place. Maybe you already know there are a thousand good reasons to quit smoking. Now you have one thousand and one.