Our topic for today is smoking and mouth cancer.
Mouth cancer is also known as oral cancer, or under different names such as ‘squamous cell carcinoma’, depending on the cells that it affects.
For example, the saliva glands: mouth cancer commonly affects the tongue, however other areas that can also be affected are the lips, the throat, the saliva glands, and even the sinuses.
It’s important to note that 90% of mouth cancers, according to the Mouth Cancer Foundation, are related to patients who smoke. If you are a smoker and you are a heavy drinker, then the risks are multiplied even further. So as already mentioned, the most common site for mouth cancer is the tongue, and usually the side of the tongue or the underneath surface of the tongue.
In the very early stages you won’t be aware at all that there is anything wrong, the person who will notice any early signs is your dentist. As part of your dental examination, they should look at the general overall condition of your mouth including the areas where mouth cancer can occur. In our practice we very recently had a new patient come in who we diagnosed with parotid cancer – your parotid gland is one of the salivary glands, just in the upper cheek area inside the mouth. Unfortunately, it was too late and the patient died some six to ten weeks later.
So the early signs, what are they? The very early signs are two red and white patches, known as leukoplakia. So these white patches or white striations, or red patches and red striations, or a mixture of those, can occur anywhere on the tongue but it’s usually on the side or underneath surface of the tongue. It’s important to note that such a red and white patch does not automatically mean that you have got a cancer growing in your mouth, some red and white patches are not cancerous lesions, however they are known as precancerous conditions or precancerous lesions. This means that although they are not malignant in themselves they are more likely to become malignant.
The other early sign is an ulcer on your tongue which does not seem to be healing, up so if you do have an ulcer on your tongue and after two weeks it is not getting better then that is a good time to go and see your dentist to have it checked out. Many of these will however be related to a sharp filling, or for example a denture rubbing against that part of the mouth where the ulcer is. The simple solution here is to alleviate the cause of the ulcer, so for example polishing sharp fillings, or replacing a broken filling, or adjusting the denture so it’s no longer digging in. They also will then over the next few days gradually get better and disappear altogether. It’s important to go back to your dentist for a review to make sure that the ulcer indeed has disappeared totally, as an ulcer that is not going away by itself could be an indication that something sinister is going on.
In the later stages of mouth cancer, this is where as a patient you will notice certain things that were not there before. These are quite varied and include, for example, a sore throat, or discomfort or pain when swallowing or trying to drink or eat something; some patients sometimes feel they need to clear their throat because they think that something is lodged there. By trying to repeatedly clear the throat, this in itself can make the throat worse so however the important lesson here is to see your dentist and have it examined properly.
As mentioned already, the tongue is the most common area of cancer in the mouth so in the latter stages that tongue can become painful and you can also have difficulty moving the tongue. In addition, you may notice a lump or visibly see bumps on the tongue, usually on the side or underneath.
There are lots of other symptoms indicative of late-stage mouth cancer, these are varied such as a change in the sound of your voice, pain radiating into the ear or into the neck, in latter stages it is not uncommon to find that your teeth start becoming loose in the absence of any dental disease, you may notice in the mirror that there is a swelling in your face or jaw and it has been there for more than several weeks. Patients who wear dentures may notice that the dentures do not fit well anymore, so as a patient you should be vigilant to any signs and perhaps make it a habit once every month for example to have a look inside your mouth. Look at the side of your tongue, lift your tongue up and have a look underneath the tongue, look at the cheeks, look at the palate just to make sure that there is nothing unusual going on. Also feel for any lumps around or underneath your jaw, and if you smoke or drink excessively the best thing is obviously to cut down and stop, but in any case you should be more vigilant because you’re at a higher risk; and also regularly see a dentist who can examine your mouth and alert you if there are any issues.
If we look at the signs of tongue cancer specifically, these symptoms can include pain when swallowing or trying to, the tongue can also sometimes be difficult to move, you may see red and white patches on the tongue, you may get an ulcer which is painful and it’s not healing up well, there may be a lump on the tongue, and finally numbness is usually an indication that something is going on. With an ulcer you can also get bleeding as well, so if you get been bleeding from your mouth, then that is something to be worried about.
Let’s assume that the symptoms you have are in fact indicative of mouth cancer, so you would probably most likely be referred to see an oral surgeon in hospital.
Cancer is classified so that you know how far it is progressed, and also how likely it is that it can be treated. The one set classification system uses lettering and numbering so the letter T means that a tumour is present, and the letter capital N refers to the lymph nodes in the neck. The letter T is followed with a grading – one two three or four, and the letter N for the lymph nodes has a number – zero one two and three.
So T one refers to the earliest smallest seriousness of the tumour, whereas T four indicates that the cancer is now extensive. Zero means that the cancer has not spread to any lymph nodes, and extensive spreading of the cancer into many lymph nodes is therefore classified as N three. Surgeons may also sometimes grade the cancer as just low, moderate, and high grade and these gradings just indicate how extensive the cancer is.
So let’s look at what causes mouth cancer, there are several risk factors but the most common risk factor, and ninety percent of people who will get mouth cancer will by smoking or chewing tobacco. With smoking, the higher the tolerating of the cigarette the more likely you are to get cancer. Cancer can also occur with smoking cigars, or other drugs such as cannabis, you are still at risk even if you smoke roll-ups as well, plus there is a trend to chew tobacco.
Other risk factors are consuming alcohol in excess, but smoking and alcohol together in excess does increase the risk a lot more. It has also been shown that a diet which is unhealthy in processed foods, high in red meat and low in healthy fruit and vegetables, will also increase your risk. There is also a virus called the HPV – human papilloma virus – which is also related to oral cancer, if there is also a family risk pattern with tongue and mouth cancers, so for example if your mother or father had mouth cancer then you should be more vigilant because you were more likely to get that. In terms of age group, most oral cancers occur in those who are aged 50 are above.
So what should you do if you are concerned that you might have cancer in your mouth or on the tongue? Number one, make an appointment with your dentist as soon as possible. At the appointment, the dentist will examine every part of your mouth with the bright light, and a mirror as well, and also examine your lymph nodes to see if there’s any unusual enlargement or lumps. The tongue is examined on the sides and also underneath, and the dentist will probably ask you to stick your tongue out as far as you can and may even help by with a piece of gauze pulling the tongue far forward so they can look as far back as possible. The dentist will note his findings, and some dentists also use special dye which can help to see if there is anything sinister that may be going on, but if there are any suspicions whatsoever your dentist will make an urgent referral to see an oral surgeon at your local hospital. The oral surgeon in hospital may take a biopsy and take CT scans or an MRI scan which will indicate the extent of any cancer, and if they are spread or not, or whether it’ll spread or not. This is extremely important because if it does spread your chances of survival is a lot lower.
Let’s look at some of the figures from the mouth cancer foundation charity. If the cancer has not spread then after five years you’ve got an 80% chance that you will survive, although this is not much comfort for the other 20%. However, if the cancer has spread after five years you have only about 33% chance of surviving. So two chances in three say that you will die before or during that five-year period if it spreads. So whether the cancer spreads or not is extremely important, and that depends on how early the cancer is detected.
When and how is the tongue cancer treated? The cancer in the tongue usually requires surgery to remove the cancerous lesion, if the lesion is small or medium in size this can be done in a single operation; however if the cancer is very extensive or it has spread then you will need multiple operations and these can be really complicated and even life-threatening within themselves.
If a large part of the tongue needs to be removed then the surgeon will rebuild the tongue using skin or muscle tissue from other parts of the body. The name for the surgery where part or all of the tongue is removed is called ‘glossectomy’. A glossectomy can be partial, or it can be full, the glossectomy procedure will therefore affect your speaking, swallowing, eating, and even breathing so you will need additional rebuilding procedures so then you can carry on functioning as normally as possible.
Although surgery is the most common method to treat the cancer, there is also a place for radiation or chemo therapy treatment which helps to kill any cancerous cells present. So if you do have cancer the success rate really depends on how early it has been spotted, and whether it has spread or not, but the most important factor is to make sure that you have your mouth screened at the dentist regularly for mouth cancer and also if there are any risk factors in your lifestyle that can be changed then that is also the best thing to do. A lot more on mouth cancer can be found on the mouth Cancer Foundation charity website but also on the NHS website as well.