Tuesday, 26 July 2011

Treating Oral Cancer

Published in Panorama



Treating Oral Cancer



One out of every two to three smokers get some form of cancer. To a large extent, the incidence of oral cancer depends on the culture of a people and the area they come from, since it is mainly related to the habits of smoking and chewing tobacco, says Dr.Penti Grohn, Oncologist, Welcare Hospital Dubai.


Oral cancer is basically related to the oral mucosa inside the mouth, tongue and going back to the larynx and pharynx. However, usually when we talk of oral cancer, it is usually inside the mouth, mucosal membrane and the tongue, explains Dr.Grohn. This implies the floor and roof of the mouth, tongue, gums, cheeks and lips may be affected. The cancer cells invade and destroy the local structures through the medium of the blood and lymphatic systems and destroy other parts of the body. One of the most common forms of oral cancers is that of the lining of the mouth and the sides of the tongue being the commonest site, followed by the area under the tongue.


There is no genetic predisposition to oral cancer and while it can affect people at any age, it mostly affects people above the age of sixty, reveals Dr.Grohn. “But in Europe, we also have people who have the habit of inserting tobacco between their lips and gingival or gums. This can cause oral cancer even in the very young age groups of people, as young as twenty or thirty years. This is because the tobacco causes constant irritation to the mucosa. This apart, sometimes we also have some viruses causing oral cancer. The other risk factors include caries in the teeth and infection in the mucosal membrane.”


According to Dr.Srinivasan, Radiation Oncologist practicing in Chennai, even young children may become afflicted with oral cancer, for reasons yet unknown.


When and how the symptoms of oral cancer manifest, depends on the exposure to the various chemicals causing it, opines Dr.Grohn. “For instance, if a certain individual has been exposed to such chemicals for over five years, it results in a certain condition whereby the mucosal membrane is white in colour and is indicative of a pre-cancerous stage. Also, there may be some ulcer which could be a very, very dangerous sign of the starting of the basic cancer. So when the mucosal membrane is white, we always suspect oral cancer and it is also that early stage in the disease and hence curable completely.”


The white spots can progress to the ulcerated stage in a matter of a few weeks to a few months, reveals Dr.Grohn. The extent to which oral cancer can spread, reveals Dr.Grohn, “Usually it invades to the depth of the oral tissues, but it can also very easily spread to the lymph nodes of the neck and in the very advanced stages, it can cause problems in the liver.”


According to Dr.Srinivasan, while there are no specific tumor markers for oral cancers. An ulcer which is around 2cm in diameter or more, with inverted edges, irregular in shape and with its base indurated to the tongue muscle, rapidly growing in size, is suggestive of tumor.


There are stages through which the disease progresses, reveals Dr.Srinivasan. “During Stage 1, the cancer is confined to the area of involvement and the tumor, is relatively small in size. The II stage involves the lymph nodes, the area of drainage of the tumors. The final stage involves metastis, when the cancer has infected the blood stream. Say for a particular tumor in the tongue: T1 is a tumor measuring less than 2cm, T2 ranges between 2 – 4 cm and so on. T4 tumor will be one which involves the muscles of the tongue, where there will be complete fixation of tongue and the patient is unable to move his tongue; alternatively, it may involve the adjacent bones or skin. Similarly, the number of nodes at the site of the nodes is important in determining the extent of severity. Finally, the Metastis stage is reached when the cancer goes to the blood. The tongue cancer, for example spreads downward to the lungs through the blood vessels. This is the last stage when nothing can be done except palliate the prevailing symptoms and delay progression of the disease.”


According to Dr.Srinivasan, “The presentation of symptoms itself forms the first stage in diagnosis. So clinical evaluation which indicates the rapidity of progression and site of the ulcer will provide the first clue. If the case involves the bone, X-Ray of the bone is necessary. Alternately, a CT Scan will better delineate the extent and area of bone involvement. Where soft tissues are involved, an MRI will reflect the layer by layer involvement. These imaging techniques will provide an idea of the extent and stage of involvement. However, the one and only answer confirming malignancy or otherwise, is biopsy. And unless a biopsy is done, it is not ethical to term a patient as suffering from cancer & begin treating him.”


Once diagnosed, treatment modalities available are surgery, Radiotherapy and Chemotherapy, reveal Drs.Grohn and Srinivasan. This depends firstly on the grade of the cancer since grade indicates prognosis of the disease, according to which treatment can be managed. If it is a low grade disease, its extent is limited and if it is only the primary stage, being confined to the area of involvement alone, surgery may be the first choice after which we wait and see the response. Here again, the age of the patient plays an important role since for younger people, removal of the affected part is not generally advised, opines Dr.Srinivasan.


If the disease is a high grade one, it is aggressive in nature, involving, say 3 or more nodes, then a combination of attack is required, using surgery, chemotherapy and radiotherapy. Generally, a single modality of treatment may not be found very effective.
However, in each case, the treatment adopted will firstly consider the anatomy of the patient, whether it is to be preserved or not. For a young child, unless unavoidable, it is almost always preserved. Moreover, young children respond very well to chemotherapy alone. Soft tissue tumors respond well to both radio- and chemotherapies. However, for an adult, if it is a primary bone tumor, surgery would be a better choice since the entire bone can be removed and an artificial metal prosthesis can be fitted which will give an almost normal appearance, reveals Dr.Srinivasan.


Side-effects of chemotherapy may be most acute, but temporary and causing minimal damage to the patient, assures Dr.Srinivasan. For the period for which patient is under the treatment, he will experience severe vomiting, hair loss and mucositis. Besides, it can cause bone marrow suppression which leaves the body open to infections due to lowered immunity. However, this condition can be well treated by administering blood and bone transfusion.


The adverse effects from radiotherapy are long term, almost persisting till the end of a person’s life. For children in particular, this is a last resort measure when chemotherapy and surgery where needed, have failed to show any favourable results. Firstly, when given to children, radiotherapy can arrest bone growth. Secondly it can lead to complications later on, like fibrosis, or the anatomy is altered in a way which brings on a limp in the child. Ensuring quality life rather than just increasing survival rate is of as much importance as effecting cure from any of these methods, emphasizes Dr.Srinivasan.


Is it possible to prevent oral cancer? While there is no preventive medicine as yet, good oral hygiene, preventing infection and avoiding risk factors could be the only preventive measures taken, opines Dr.Grohn.



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