11 Oral Cancer

Question 1

Describe the distribution of oral cancer based on type.

Answer 1

> 90% is Squamous Cell Carcinoma, also called Epidermoid Carcinoma.

Question 2

What is the typical rate of occurrence and survival rate for patients affected with oral cancer?

Answer 2

Squamous Cell Carcinoma: 30k new cases every year. 9k die every year. Average survival rate at 5yrs is 50%. 5th lowest survival rate and the rate is not improving as it has in other types of cancer.

Question 3

Describe the age distribution and typical popluation affected by oral cancer

Answer 3

Affects all ages, but the peak is from 50 -70. Increasing incidence under age 40!!! Affects more males than females 2:1. Risk factors correlate with incidence.

Question 4

What are seven risk factors for oral cancer?

Answer 4

actinic radiation, tobacco products, alcohol abuse, infectious agents (HPV), immunocuppression, genetic defects, environmental contacts

Question 5

Oral cancer risk factor: Actinic radiation

Answer 5

sun damage - lip cancers only

Question 6

Oral cancer risk factor: smoked tobacco products

Answer 6

Smoked tobacco:
- In 75% of cases of oral cancer, the patient was/is a smoker
- Longer duration of smoking = increased incidence of cancer
- Increased usage of tobacco = increased incidence of cancer
- Risk for cigars and pipe smoking essentially = risk for cigarettes (for intraoral squamous
cell carcinoma)

Question 7

Oral cancer risk factor: smokeless tobacco products

Answer 7

Smokeless tobacco:
- A much lower incidence of development of carcinoma when compared with smoked
tobacco
- Usually associated with prolonged use of smokeless products
- Cancer develops in the site of placement of the quid
- Moist vs dry snuff is the critical determinant in carcinogenicity
- Typically 20-30 years usage

Question 8

Oral cancer risk factor: alcohol abuse

Answer 8

Statistically a greater risk factor than tobacco
Risk > 2 pack per day smokers

Effects of alcohol

• Drying agent (alters epithelial metabolism)
• Solvent effects
• Contaminants

More factors come into play as potential causes

• Nutritional deficiencies are common
• Detoxification of carcinogens hindered by liver disease

Question 9

What constitutes alcohol abuse?

Answer 9

What constitutes abuse:
- A total of 6 alcohol equivalents per day
Alcohol equivalents:
- One shot (1.5 oz) “hard” liquor
- One glass (6 oz) wine
- One glass/can (12 oz) beer

Question 10

Oral cancer risk factor: immunosupression

Answer 10

A healthy immune system seeks out and destroys cells in the pre-cancerous stages
Factors that degrade the immune system lead to increased cancer incidence:
-Aging!!
-Chronic nutritional deficiency
-Disease states
-Therapeutic intervention

(see details in lecture on each)

Question 11

Oral cancer risk factor: genetic defects (syndrome association and family disposition)

Answer 11

Syndrome associations include basal cell nevus syndrome and gardner’s syndrome. (A specific syndrome associated with oral squamous cell carcinoma has not been reported however)
Family disposition-family history increases risk by about 25x

Question 12

Oral cancer risk factor: environmental contacts

Answer 12

carcinogenic chemicals, foods and/or additives, heat

Question 13

Oral cancer risk factor: infectious agents (HPV)

Answer 13

chronic candidal infection?, HPV 16 and 18 (today, nearly 80% of throat cancer is due to HPV). Any chronic disease state resulting in continuous stimulation of the immune system can result in accumulated genetic defects–>potential cancerous changes)

Question 14

What are some ways the patient can decrease morbidity and mortality of squamous cell carcinoma?

Answer 14

healthy diet, healthy lifestyle, avoid known risk factors, know warning signs, regular screening exams

Question 15

What are some ways the health care provdier can decrease morbidity and mortality of squamous cell carcinoma?

Answer 15

educate patients, regular screening exams, improved screening tools, early detection (find early, while small, and before metastasis)

Question 16

Describe warning signs for oral/head and neck squamous cell carcinoma using the “CAUTION” acronym.

Answer 16

C-Change in sensation/numbness
A-A sore that will not heal
U-Unexplained hoarseness and/or difficulty swallowing
T-Thickening or a lump of recent onset
I-Inability to pronounce certain sounds or slurring of speech
O-Obvious change in a mole, wart, or discolored area
N-Nagging cough

Question 17

Describe clinical presentation of squamous cell carcinoma

Answer 17

white plaque (leukoplakia), red plaque-like (erythroplakia), ulcerated, exophytic mass

Question 18

Describe clinical presentation of leukoplakia

Answer 18

White plaque

Question 19

Describe clinical presentation of erythroplakia

Answer 19

Red plaque-like, Smooth, velvety surface,Slightly raised margin, White surface speckling

Question 20

Describe ulcererated characteristic of squamous cell carinoma

Answer 20

Often with a raised, rolled border

Often with a very deep, central crater

Question 21

What does exophytic mass refer to?

Answer 21

Often with an irregular surface texture

Question 22

Describe clinical presentation of early lesions.

Answer 22

Earliest lesions do NOT show characteristic features that increase index of suspicion!!!

Question 23

Describe clinical presentation of advanced lesions.

Answer 23

Advanced lesions:
Firm to hard (indurated)
Non-movable (bound down to adjacent tissues)
Irregular, exophytic growth with poorly defined margins
Non-healing ulceration
Rolled borders are particularly ominous
Pain

Question 24

List the high risk sites for oral cancer.

Answer 24

Lower lip
Posterior lateral border of the tongue,Floor of the mouth (Males mostly Increasing incidence in females though) Tonsillar pillars

Question 25

Recognize the potential for oral cancer anywhere in the oral cavity.

Answer 25

It occurs everywhere!!!

Question 26

Describe the TNM staging system

Answer 26

T-tumor size (1-4 depending on size of tumor)
N-nodal metastasis (0-3 depending on lymph node involvement)
M-metastatic spread (0-1 depending on metastasis)

Question 27

Describe the STNMP staging system

Answer 27

S-site of primary tumor
T-tumor size
N-nodal metastasis
M-metastatic spread
P-pathologic grade of the tumor

Question 28

Classify five year survival rate by stage of disease.

Answer 28

Stage 1: 77-85%
Stage 2: 66-76%
Stage 3: 41-44%
Stage 4: 9-20%

Question 29

What are some key principles of early diagnosis?

Answer 29

identify and document abnormalities, identify risk factors and eliminate them where possible, follow up, and biopsy unless the lesion resolves

Question 30

What are some variations in treatment for patients with oral squamous cell carcinoma?

Answer 30

Selection of treatment depends on the stage of the disease and location of the cancer. Modes of therapy: surgical, radioation, chemotherapy, or a combination

Question 31

Describe potential complications of surgical treatment.

Answer 31

functional deficit, impaired nutrition, post-surgical infection, speech impairment, drooling, facial deformity

Question 32

Describe potential complications of radiation therapy.

Answer 32

dermatitis, mucositis and ulceration, decreased salivation, impaired nutrition, difficulty swallowing, taste alteration, infection (candidiasis/bacterial)

Question 33

Describe potential complications of chemotherapy.

Answer 33

mucositis and ulceration, xerostomia, infection (fungal/viral/bacterial), bleeding (anemia), N/V/D, loss of apetitie and neurotoxicity

Question 34

Name (and be able to discuss) four long-term complications of oral cancer treatment.

Answer 34

Xerostoma, osteoradionecrosis, trismus/fibrosis, alopecia