Diagnostic, Treatment To Fight Against Cancer
India has one of the highest incidences of oral cancer in the world with an incidence as high as 17.1 per 100000 among men and 7.6 per 100000 among women. The 5-year survival of early oral cancer ranges from 54 per cent -60.2 per cent, while the survival drops drastically to 3.1 per cent-3.3 per cent in advanced stages. Unfortunately, 60 per cent of patients present in an advanced stage with limited treatment options and dismal survival. Even when the total cost of lost productivity due to premature death is calculated, India spends the highest cost per cancer for oral cancers. Oral cavity consists of various subsites like tongue, buccal mucosa, hard palate, the floor of the mouth and retromolar trigone area. Various types of cancers affect the oral cavity but 90 per cent of cancers are comprised of squamous cell carcinoma and its variants.
Tobacco consumption either in the form of smoking or chewing is the main etiologic factor for squamous cell carcinoma. Risk of developing oral cancer ranges from 1.07 to as high as 17.1 per cent depending on the form of tobacco usage with maximum risk for bidi smoking and chewable tobacco. Even though tobacco and alcohol are both known to independently cause oral cancers, when used together have a synergist effect. In spite of advances in the management of oral cancer, survival in these cancers has remained unchanged for decades. If the outcome of oral cancer has to improve then early detection and prevention play a pivotal role. Awareness regarding signs of early cancer, risks associated with habits like tobacco usage and alcohol consumption that causes oral cancer also aids in improving survival in the long run.
Signs and symptoms of oral cancer:
The commonest and one of the earliest sign of oral cancer is a non-healing ulcer in the oral cavity. An ulcer is a break in the continuity of the oral mucosa, which has an irregular surface and margins. Even after adequate management, an ulcer that doesn’t respond should mandate a biopsy to rule out cancer. Bleeding from the ulcer especially during brushing must also raise the suspicion. The commonest misbelief is that oral cancer presents as a painful lesion. But the fact is, it presents as a painless ulcer/ swelling in the oral cavity. Pain is usually a late symptom of cancer. It may happen due to local infection of the cancerous lesion or due to infiltration of tumour into the deeper tissue. Neck swelling may occur due to metastasis (spread) of cancer to the lymph nodes in the neck. Inability to open the mouth (trismus), loss of sensation over the lip, difficulty in speech articulation (dysarthria), pain while chewing and swallowing may occur but are most often associated with advanced-stage disease.
Diagnosis and workup
A biopsy of the lesion to pathologically prove the presence of cancer along with imaging evaluation with CT scan, MRI scan or PET Scan is done based on the location/stage of the disease. Imaging of the head and neck region is advised to study the extent of tumour
spread and extent lymph nodal involvement. MRI scans give better anatomical details with respect to soft tissue and hence is advised to study the tumour extends into the tongue, spaces around the oral cavity and spread along the nerves. CT scan is advised to get better bony detail of the jaws. In advanced stages of oral cancer, cancer may spread to lungs and hence a distant metastatic workup is done with CT of the chest or WB PET CT scan.
Treatment:
Treatment of oral cancers is complex owing to the various subsites in the oral cavity, anatomical constraints of the region and also functionality of the organ. The ultimate goal of treating oral cancer is the eradication of the disease, restore the function, minimalize treatment sequel and also prevent the occurrence of new second primary cancers. Surgery forms the primary treatment modality in oral cancers. Surgery consists of resection of the primary tumour in the oral cavity and also neck dissection. In early-stage cancers single modality treatment with surgery will suffice. In advanced-stage tumours multimodality treatment in the form of postoperative radiotherapy and chemotherapy is advised.
Reconstructive surgery is indicated when there is functional and aesthetic loss of structures of the oral cavity. Various forms of reconstructive surgery are available from local to regional to free flaps. There has been a drastic improvement in the quality of life of oral cancer patients with the advent of microvascular free flap reconstruction and rehabilitation. Large three-dimensional defects of the oral cavity with multiple components like skin, soft tissue and bone can be easily replaced with free flaps where a single flap has multiple components that are vascularized and can effectively and functionally restore oral cavity defects. Optimal rehabilitation following reconstructive in the form of swallowing exercises and restoration of the dentition by use of Osseointegrated dental implants can be done.
Various factors related to tumour and patients, influence the treatment choice and outcome. Tumour factors like size, location of the tumour, proximity to the jaw bone, previous treatment, spread to lymph nodes all play an important role in treatment decision and reconstructive options. Patient’s acceptance, compliance and ability to tolerate the entire treatment determine the outcome of the disease.
The mainstay of current therapy for oral cancers is surgery followed by radiation therapy for oral cancer patients. Advances in surgical and radiation techniques have drastically improved the quality of life in these patients. When presented early most of the oral cancers are curable with minimum morbidity. Early detection, cessation of tobacco use, awareness and screening for oral cancer plays an important role in improving outcome in oral cancer patients.
_20241122180531_original_image_7.webp)