Cancer Symposium Flashcards
What is the Epidemiology of head and neck cancer?
5-10 per 100,000 population in the UK (less than breast and prostate cancer)
M:F 2:1
Peak age : 55-65
Which cancer has the highest prevalance?
Breast, prostate, colorectal, lung and oral
Which cancer is most preventable?
Lung and oral cancer
Which cancer has highest survival rate?
Prostate and breast
Cancer risk factors?
smoking and alcohol (in the UK)
paan (in asia)
Drugs
Human Pappilloma Virus
Fanconi anemia (macrocytic aneamia)
how is HPV transmitted
sexual transmission
more likely in immuno-compromised patients/ patients with transplants
what are the risk factors for fanconi aneamia
inherited
increases risk of developing cancer and genetic mutauions
How did cancer develop?
Normal mucosa –> dysplasia(R+W patches picked up at the dentist-refer) –> canrcinoma in situ –> invasive carcinoma (metastisize)
Takes around 2 – 4 years
It will develop from primary site (tongue) –> regional lymphnodes –> distant metastises
How do you stage for oral cancer?
TNM system
Tumour
Regional lymph nodes
Distant metastises
in which stage is the highest chances of survival?
local tumour stage
in which stage are the lowest chances of survival?
metastases
What are the symptoms of oral cancer?
Pain/ disconfort
May be painless
May be present for a long time- doesnt mean its okay (red and white patches)
What are the signs of oral cancer?
white/red/speckled patches
Ulcers (present for more than 3 weeks + rasied rolled margins)
Lumps (not normal tissue growth)
Unexplained loose teeth
Poorly defined radiolucency on the radiograph
Unexplained bleeding
Rapid bone loss in the absence of chronic periodontitis
Unexplained radiolucency
what are the high risk areas for red and white patches
floor of the mouth
lateral tongue
what are the signs of an ulcer suggesting high risk for cancer?
present for more than 3 weeks
raised, rolled margins
How to determine survival rate for cancer?
Using TNM system
Local = 90% survival
Regional = 60% survival
Distant = 10% survival
How to determine outcomes of treatment?
Using quality of life e.g.
The deeper the invasion the lower the quality of life therefore poor outcome
The higher the stage of cancer the lower the quality of life therefore poor outcome
If conservative surgery is required the higher the quality of life therefore better outcome
Radiotherapy reduces quality of life therefore poor outcome
what is the best case scenario for cancer?
small tumour
easy surgery
no lymph node involvement
no radiotherapy required
Summary
Oral cancer is uncommon
Known risk factors are environmental, not inherited
Disproportionately affects people of deprived background
Disease progression and development follows a reliable pattern
Early cancer can be aymptomatic
Early lesions may be present for years before becoming asymptomatic
Early disease = better survival and better QOL
What questions to ask if patient is diagnosed with oral cancer (father previosly diagnosed with oral cancer too)?
do the have a greater risk of developing it due to the father?
why was the fathers cancer so advanced when diagnosed?
would the father have survived if he had surgery?
why was palliative radiotherapy offered instead of radical radiotherapy?
what can pt do to reduce risk of dying from oral cancer?
what are the organisation of services available for cancer?
white patches, dyplasia, potential malignant lesions –> head and neck cancer MDT –> referral for suspected cancer –> diagnosis and staging of oral cancer
what does a white patch look like?
thickened epithilium and moisture = white patch
what is the differential diagnosis of white patches?
frictional keratosis
lichen planus
chronic hyperplastic candidiasis
idiopathic (geographical longue)
smokers keratosis
acute psudomembronous candidiasis
oral luekoplakia
- difficult to diagnose without biopsy
what is frictional keratosis?
common cause of thickened skin in oral mucosa e.g. occlusal line
what does lichen planus look like?
has a reticular pattern
what is chronic hyperplastic candiasis?
chronic thrush commonly found on buccal mucosa
what is smokers keratosis?
due to heat from smoking - leads to chronic thermal injury on the palate
increases risk of cancer
what is acute pseodomembraneous candiasis?
acute thrush which can be wiped off
what is an oral luekoplakia?
white patch (due to dysplasia)
what steps to take if spot red and white patches?
make a differential diagnosis
refer for specialist opinion
biopsy (difficult to make diagnosis without biopsy)
what does dyplasia suggest?
increased risk to progression to cancer
50% chance to progressing to high grade dysplasia over 4 yrs
need a close follow up for patients with dysplasia diagnosis
what are the problems with the organisation of cancer services?
problem 1: difficult to tell benign from malignant
early diagnosis = good outcome
benign white patches are more common
- make referral easier and quicker
problem 2: need to standardise care
coordinate referral, dignosis, staging and surgery
- improving outcomes by having a 2 week wait referral if urgent
what is a 2 week wait referral?
pt seen within 2 weeks
most pts DONT have cancer
biopsy if needed
if pt has cancer- diagnosis and treatment plan within 31 days
first treatment within 62 days
what does the MDT consist of
- surgeons
- oncologists
- pathologists
- radiologists
- dentist
- hygeinist
- technician
- nurses
what happens in the 2 week wait referral?
biopsy
diagnosis and staging (to check advancement)
how to check advancement of cancer?
clinical assessment and radiographic imaging of primary site and regional lymphnodes
how is distant metastises detected?
using radiographic imaging
CT scan of the lung, liver and adrenal area
why is oral cancer staging important?
-for patient prognosis:
- dictates tx
-estimate survival: regional lymph nodes has 60% chance of survival
how is oral cancer treated?
surgery at the primary site +/ regional lynphnodes +/ recontruction
radiotherapy
chemotherapy
rehabilitation
follow p
In surgery how do we ensure parts of the tumour havent been left?
remove 1.5 mm all the way around the tumour
which incision for cancer surgery will have better healing
primary site incision - good outcome with resections
whats the treatment if the cancer has spread to regional lympnodes?
lymph nodes removed by surgery
how do we reconstruct after surgery?
use a flap of muscle fat or skin and stich it in the mouth
e.g anterior-thigh flap used to fill a gap and aid function
when is radiotherapy used?
-if disease is very extensive
-if excised as much as possible but still cant remove infected areas
-lypmh node involvement: extracapsular spread: tumour is invading out of the capusle of lymph nodes
how long does radiotheraphy last?
for 6-7 weeks 5 days a week
what are the side effects of radiotherapy?
skin reactions
mucositis (cant eat or drink)
oropharangeal thursh
xerostomia (increases caries risk)
osteoradionecrosis
what happens in osteoradionecrosis?
end arteries are obliterated and get blocked
leads to chronic necrosis
Bone unable to heal
smelly and infected mouth :(
what does chemotherapy involve?
3 types of medications:
- cicplatin
- 5-flouracil
- cetuximab
affects cell division and blood supply to tumour
amplifies the effects of radiotherapy but affect normal cells too
side effects of chemotherapy?
bleeding
bruising
infection
deafness
exacerbate effects of radiotherapy
effects of cancer treatment?
loss of teeth (especially post mandible)
changes in soft tissues
changes in hard tissues
dry mouth
caries risk
osteoradionecrosis risk
what is the role of a dentist in MDT?
removal of teeth
denture making
managing hard and soft tissues
managing caries risk and ORN
when is follow up appropriate after cancer tx?
risk of relapse highest in 1-3 years after cancer tx. 5 yrs is baseline
dentl rehab is longer - caries management/tooth loss/ reoccurances
according to statistics oral cancer survival is lower in ______ areas
most deprived areas
which area has the highest risk of cancer development?
poorer areas have a higher risk of developing cancer
areas of higher deprivation are more likely to have ______
late presentations of cancer
if submandibular gland is blocked by tumour, what symptoms will you have?
pain at meal times
what are the patient factors delaying tx for cancer?
change occurs –> pt experiences change –> recognize its abnormal –> realize significance –> decide to seek help
what are dentist/doctor factors delaying tx of cancer?
examination by dentist –> decide whther or not to refer –> refer –> hospital appt –> biopsy
what is the treatment delay in tx cancer?
diagnosis
staging
tx plan
tx
how to reduce patient delay in cancer tx?
patint awareness
public awareness
pop screening (everyone)
oppurtunistic screening (dentist/GP)
targetted screening (high risk groups)
what is the biggest source of delay in cancer tx?
patient delay
how to minimize referral delay ?
clinician awareness
2www
what is targetted screening for breast cancer?
radio graphic assessment for females above the age of 50
what is the screening for lung cancer?
chest Xray/CT scan
what is the screening for oral cancer?
visual inspection
who is most at risk for developing oral cancer?
age 55-65 years
smokers
