Oral cancer symposium scenarios Flashcards
Case 1:
Samina (25 yrs old)
PCO: Worried about her family risk of oral cancer. Father developed oral cancer at 54 yrs old and died 2 yrs ago. Father was a heavy smoker all his adult life, moderate alcohol consumption, dentally anxious and did not attend dentist regularly. Oral cancer was discovered when he noticed a bleeding spot on the skin of his left chin and attended A&E one weekend. His cancer was very advanced at that stage and had invaded into the bone of his mandible. He was offered radical surgery that would have involved removal of a large part of his mandible and reconstruction with bone from his hip. He declined that and had palliative radiotherapy instead.
Samina SH: pregnant with first child & worried that she is at risk of getting oral cancer and that her children will also be at risk. She smoked 5 cigarettes per day until 2 years ago and then gave up. She does not drink alcohol.
Does Samina have a risk of developing oral cancer because her father had it?
Research shows a slight increase in the risk of mouth and oropharyngeal cancer if you have a very close relative e.g. father, but further research required on this area and we cannot give an exact risk level.
Case 1 - Samina & father with cancer.
Why was her father’s cancer so advanced when it was diagnosed?
Her father did not attend the dentist regularly due to dental anxiety so this resulted in a delay in diagnosis and referral. Other risk factors such as heavy smoking in combination with moderate alcohol levels will have contributed to the advancement of the cancer.
Case 1 - Samina & father with cancer.
Would her father have survived his cancer if he had had surgery?
The cancer was localised to the bone of the mandible. Her father would have likely survived if cancer was removed by radical surgery as this would have prevented further metastases of the cancer.
Case 1 - Samina & father with cancer.
Why was palliative radiotherapy offered instead of radical radiotherapy?
Palliative radiotherapy aims to improve the symptoms. It is a shorter course of treatment than radical radiotherapy.
Radiotherapy is often used once primary site is excised and the surgeon cannot remove anymore tissue due to close proximity to other structures. Therefore, radical radiotherapy would not be appropriate in this case.
Case 1 - Samina & father with cancer.
What can Samina do to reduce her risk of dying from oral cancer?
- Attend dental appointments regularly for oral cancer assessment.
- Educate herself on what to look out for in her mouth e.g. non healing ulcers, white / red patches etc to know when to seek help.
- Avoid smoking & alcohol
- Lead a healthy lifestyle: balanced diet, exercise regularly & get good sleep.
- Avoid direct sunlight / sunbeds
- Avoid stress & learn about stress management.
Case 2: Omar is a 62 year old male. He used to smoke cigarettes but gave up 10 years ago. He drinks only small quantities of alcohol. He attends his dentist regularly.
He has previously been referred to the hospital because of a white patch in the floor of his mouth and a biopsy showed low grade dysplasia. He was reviewed for an annual check up and his dentist noticed a slight change in the floor of mouth lesion which is redder and slightly ulcerated.
What should Mark’s dentist do?
Refer the patient to oral medicine via 2 week wait pathway as the changes of the lesion being red and slightly ulcerated are red flag signs.
Case 2: Omar & low grade dysplasia that changed colour & became ulcerated.
What is the significance of the previous diagnosis of low grade dysplasia?
There is a high risk of progression to cancer - 50% chance to progressing to high grade dysplasia over 4 yrs.
Case 2: Omar & low grade dysplasia that changed colour & became ulcerated.
What investigations will Mark have in order to make a diagnosis?
What tx is he likely to have?
Biopsy to review tissues under microscope.
Tx:
- Surgery
- Depending on the severity of the cancer, possibly radiotherapy and chemotherapy. Finally, he will need rehabilitation to improve his QoL and restore function & aesthetics.
Case 3:
Marjorie is a 58 year old female. She has never smoked cigarettes and drinks alcohol only very occasionally.
She was recently diagnosed with a T4 N2b M0 squamous cell carcinoma of her left hard palate.
She was treated with a combination of surgery to remove the tumour and reconstruct her palate, a neck dissection and post-operative chemo-radiotherapy. Before her radiotherapy she had some lower posterior teeth removed in order to reduce the risk of complications from her radiotherapy. She does not attend the dentist regularly.
What is a neck dissection, why did Marjorie have this as well as removal of her tumour?
If a tumour metastasises from the primary site to the lymph nodes, a neck dissection is performed where the LN are removed. Marjorie had both of these treatments to prevent the further growth and metastases of the cancer.
Case 3: Marjorie & Squamous cell carcinoma.
- Why did Marjorie have chemo-radiotherapy? What does this treatment involve?
- Why did she need to have teeth removed from her lower jaw?
Chemo-radiotherapy is provided in combination to amplify the effect of treatment to kill the tumour. Chemotherapy destroys cancer cells throughout the bloodstream. Radiotherapy uses radiation to destroy cancer cells in a localised area.
Due to the risk of osteonecrosis of the jaw (ONJ) -> chemo-radiotherapy affects bone healing.
Case 3: Marjorie & Squamous cell carcinoma.
- What follow up will she be offered?
- every month for first year, every 2 months for second year, every 3 months at 3rd year, 4-6 months for 4th year, yearly follow up at 5th year (depending on her dental risk levels)
Case 3: Marjorie & Squamous cell carcinoma.
- What problems might she encounter as a result of her treatment?
- Functional – reduced ability to chew, swallowing difficulties
- Aesthetic concerns also affecting face
- Emotional / mental health – having to wear dentures, surviving cancer, invasive tx etc.
- Xerostomia / mucositis/ pain due to chemo-radiotherapy
- Increased caries risk = may need restorations = restorative cycle
- Osteoradionecrosis risk
- Changes to ST / HT – painful
-Oropharyngeal thrush
Case 3: Marjorie & Squamous cell carcinoma.
What could a dentist do to help her after cancer tx?
-Preventative measures to avoid further disease – OHI, diet advice, smooth sharp bone / teeth to avoid painful ulcers.
-Pain management – difflam spray, using sponge to clean mouth, soft brushes, t.paste: Oranurse (non-foaming / non irritant)
-Restorations as required to remove caries & seal cavities.
-F.varnish application 3/12 if caries risk is high, High F toothpaste.
-Rehabilitation – construction of dentures / placing implants etc.
-Recalls appropriate to risk. Monitor via clinical and radiographic assessment e.g. looking out for red flags such as cancer recurrence, ORN, caries, periodontal disease.
Case 4:
Neil (38 year old male), earns minimum wage working part time in a supermarket.
SH: single parent with two children under 5. He also is a carer for his mother who lives nearby. He lives in a deprived neighbourhood. He does not own a car or have access to one. His nearest NHS dentist is 3 bus-rides away. He cannot afford to pay privately and the NHS practice is not taking on new patients.
He has smoked 20 cigarettes per day all of his adult life and drinks 3 litres of cider every week.
He does not attend the dentist regularly.
MH: high blood pressure, high cholesterol, has an abnormal glucose tolerance (pre-diabetic).
Recently he has noticed a white patch on the left side of his tongue. It is not painful and he cannot remember when it first appeared.
- Apart from oral cancer what other diseases is Neil at risk of developing?
Shared risk factors such as head & neck cancer, lung cancer, leukaemia, stomach cancer, kidney / liver / pancreas / colon cancer to due the smoking. Other diseases he is at risk of due to alcohol levels include depression & anxiety, memory loss, liver damage / hepatitis / cirrhosis, liver cancer, fertility issues, stroke etc.
Case 4: Neil & white patch on LHS of tongue.
What factors about Neil’s life may have an impact on his risk of developing cancer?
- Low socio-economic status
- Stress (single father, carer for his mother)
- Smoking – 20/day for most his adult life.
- Alcohol: roughly 15 units/week.
- Irregular attendance at the dentist
- MH: high BP, high cholesterol. Heart disease increases your risk of developing cancer.
