Say ‘ah’ to prevent mouth cancer
National Oral Cancer Awareness Week falls on Nov 18-25. This is an opportune time to increase awareness of oral cancers.
The term “oral cancer” has been used to describe any malignancy that arises from the oral tissues. Squamous cell carcinoma is the most common variety, and it accounts for about 90-95% of oral malignancies.
Oral cancer is the sixth most common form of cancer in the world. It accounts for half a million new cases diagnosed every year, and about a quarter of a million deaths every year.
In any cancer, the prognosis of the disease is measured in terms of five-year survival rates. The five-year survival rate for oral cancer is less than 50%, and this figure has more or less remained static over the last three decades.
Five-year survival rates reported for oral cancer is poorer than colorectal , breast and cervix cancers. The reason for the poor prognosis has been attributed to:
Advanced stage of the disease when the diagnosis is made Distant metastasis of the disease Poor response to chemotherapy However, we wish to highlight that the disease, if diagnosed and treated early, has a five-year survival rate of over 80%.
It is important to understand the reasons why oral cancer is usually diagnosed late. To do this, it is important to keep in mind the varied presentations of oral cancers. It can present as an exophytic growth or an ulcerative or infiltrative growth.
The oral cavity is the most easily accessible part of the body. Hence, logically, oral cancers should be easily detected at the early stage without the need for any costly diagnostic aids. Yet, in the majority of cases, the diagnosis is made late.
To give an example, approximately 80% of the cases that we see in our hospitals are usually in stage 3 or stage 4.
We all have experienced mouth ulcers at some time or other, and we all know how painful these ulcers can be. Those who have had these ulcers know the pain they experience, when eating, speaking or swallowing, etc. Because they are painful, you seek medical treatment almost immediately.
Unfortunately, the early stages of cancerous or malignant ulcers are usually painless or asymptomatic, hence the delay in seeking medical help.
It is evident from our interactions with patients that the reason they seek medical treatment so late is because the ulcer is not painful or asymptomatic. The other common reason is ignorance.
It is worrying that even the very educated are ignorant about mouth cancers.
Warning signs
Any ulcer or a lump which does not heal in two weeks.
Those of us who have experienced mouth ulcers know that these ulcers usually heal within 10-14 days. Hence, it is important that we send the right message. Any ulcer that does not heal needs to be seen by a healthcare practitioner and a biopsy needs to be done to confirm the diagnosis.
Lump or thickening of the oral soft tissues.
Difficulty in chewing, swallowing or eating. Difficulty in moving the jaw or tongue. Numbness of the tongue, lips or mouth. Radiating pain, especially to the ear. The presence of leukoplakia. This is predominantly a white lesion of the oral mucosa that cannot be characterised as any other definable lesion. These lesions have a higher incidence of malignant transformations.
The presence of erythroplakia. This term is used to describe a lesion of the oral mucosa that presents as red areas. These lesions have the highest potential for malignant transformation.
The presence of lichen planus. This lesion has a white and red form and can manifest as different patterns – a lacy pattern, or a raised plaque. Those with areas of ulceration within carries an increased risk of of cancer.
l Oral submucous fibrosis. They can affect any part of the oral mucosa, and is characterised by mucosal rigidity where the normal feel of the pliable soft mucosal feeling is lost. This is clinically manifested by the patient as having difficulty in opening the mouth.
Risk factors
Risk factors can be broadly classified into two main ones: environmental and genetic.
Environmental risk factors include betel quid use, tobacco and alcohol use, excessive exposure to sunlight in fair-skinned people, and certain fungal/viral infections (eg Human Papilloma Virus, Candia albicans).
Genetic risk factors include individuals with a family history of mouth cancers. Other contributing factors include:
Age: Commonly occurs in the fourth to sixth decade of life, with the highest prevalence in the sixth decade of life.
Gender: More common in men than women depending upon the extent of and the type of tobacco habits prevalent. In Malaysia, it is higher among Indian women.
Race/ethincity: In the Malaysian scenario, this is very obvious, with more than 60% of cases occurring in the Indian population.
Cultural, social and religious traditions are very important contributing factors. For example, in general, the Malays do not take
alcohol, while they chew betel quid and use tobacco. On the other hand, the Chinese use tobacco and alcohol, but do not use betel quid, while the Indians often use all the three. This explains why there is such a vast difference in the incidence among the Indian population.
l Diet: Scientific studies have shown that populations with a diet rich in fresh fruits, vegetables and olive oil have a lower cancer incidence. This is very evident from studies emerging from the East European block of countries like Romania, Hungary and Czechoslovakia. Over the last two decades, these East European countries have experienced an increased incidence of oral cancers while their counterparts in the Mediterranean countries have shown a decreasing trend. The only explanation to this trend is that the Mediterranean countries use a diet rich in fresh fruits and vegetables with olive oil while the East European countries lack this in their diet.
Treating oral cancer
Oral cancer can present as an ulcer or as an exophytic growth, and can occur anywhere in the oral mucosa (which is not painful initially). It usually occurs as a deep ulcer which does not heal even after two weeks, which bleeds on touch, with indurated or hard margins, and with the edges usually raised. It is commonly associated with swollen lymph nodes.
Oral cancer is conventionally treated by surgery, radiotherapy or chemotherapy. Treatment can be a combination of the above three methods, depending on the stage of the disease and the extent of spread.
Surgery and radiotherapy is usually the preferred choice of treatment, while chemotherapy is less effective in oral cancers.
With the advent of newer chemotherapeutic drugs, some of the lesions are showing good response. The decision to treat by one or all the three methods depends upon the patients medical condition and the ability to withstand the treatment, and whether they are planning for a curative or palliative outcome.
In any form of cancer, the outcome is usually stated as a five-year survival rate. The five-year survival rate for oral cancer is 80% in the early stages and in localised disease.
Once the cancer has spread to the lymph glands in the neck region, this five-year survival rate drastically decreases to 40%, and the five-year survival becomes less than 20% once the disease has spread to other organs, what we call metastasis of the disease.
Hence, it is very important that these lesions are picked up early and treated appropriately for better outcomes.
Like any other cancer, there is a lot of research is being carried out globally as well as in Malaysia. The Oral Cancer Research coordinating Centre (OCRCC) and the Cancer Research Initiative Foundation (CARIF) are currently carrying out numerous research in this field.
Some of the work has been directed towards identifying tumour markers in oral cancer. Identifying the tumour markers opens up a whole new phase in identifying prognosis and managing the disease.
Like any other cancer, there are a few things one can do to prevent the disease. First of all, abstaining from betel quid, tobacco, and alcohol can play a big role in preventing the disease.
The second thing you can do is mouth self examination. We would like to suggest that at least once in a fortnight, take an additional two minutes to stand in front of the mirror and have a proper look in your mouth. Look for any lumps or bumps in the mouth, any ulcer or break in the continuity of the mucosa.
Also look for any change in the colour of the mucosa, like a white or red patch or any white patterns. Seek medical treatment for any ulcer which has not healed within two weeks.
There are approximately seven steps to systematically examine your mouth:
1. Look at the lips with your mouth open and closed.
2. Look at the inner aspect of your upper and lower lips by pulling your lips outwards.
3. Look on the inner aspect of your cheeks on both sides.
4. Examine the roof of your mouth, including the soft palate.
5. Protrude your tongue and take a look on the surface of the tongue and also on both the sides of the tongue.
6. Lift your tongue up and look under the surface of the tongue and on the inner aspect of your teeth.
7. Feel for any swollen glands in the head and neck region.
8. Lastly, maintain good oral hygiene and visit your dentist every six months (or at least once a year).
The Oral Health division of the Health Ministry conducts outreach screening camps either individually or in conjunction with other NGOs. Take the time to visit one of these camps and get your mouth looked into to allay your fears.
You can also visit your dental healthcare practitioner and they would be able to make appropriate specialist referrals.
To conclude, if there is one message we wish to leave, it is seek professional help if you have noticed any lump or an ulcer which has not healed within two weeks. Remember that if you seek professional help early, it will help in the early diagnosis and early management of the problem, which gives a better outcome.