Wednesday, December 13, 2006

CANCER OF THE MOUTH AND THROAT



The oral cavity (mouth) and the upper part of the throat (pharynx) have roles in many important functions, including breathing, talking, chewing, and swallowing. The mouth and upper throat are sometimes referred to as the oropharynx. The important structures of the mouth and upper throat include the following:
•Lips
•Inside lining of the cheeks (buccal mucosa)
•Teeth
•Gums
•Tongue
•Floor of the mouth
•Back of the throat, including the tonsils (oropharynx)
•Roof of the mouth (the bony front part [hard palate] and the softer rear part [soft palate])
•Area behind the wisdom teeth
•Salivary glands
Many different cell types make up these different structures. Cancer occurs when normal cells undergo a transformation whereby they grow and multiply without normal controls.
•As the cells multiply, they form small abnormalities called lesions. Eventually, they form a mass called a tumor.
•Tumors are cancerous only if they are malignant. This means that, because of their uncontrolled growth, they encroach on and invade neighboring tissues.
•Malignant tumors may spread to neighboring tissues by direct invasion or by traveling along lymphatic vessels and nerves or through the blood stream.
•They may also travel to remote organs via the bloodstream.
•This process of invading and spreading to other organs is called metastasis.
•Tumors overwhelm surrounding tissues by invading their space and taking the oxygen and nutrients they need to survive and function.
Tumors in the mouth and throat include both benign and malignant types.
•Benign tumors, although they may grow and penetrate below the surface layer of tissue, do not spread by metastasis to other parts of the body.
•Benign tumors of the oropharynx are not discussed here.
Premalignant conditions are cell changes that are not cancer but which may become cancer if not treated.
•Dysplasia is another name for these precancerous cell changes.
•Dysplasia can be detected only by taking a biopsy of the lesion. This means to collect a tiny sample of the abnormal area.
•Examining the dysplastic cells under a microscope indicates how severe the changes are and how likely the lesion is to become cancerous.
•The dysplastic changes are usually described as mild, moderately severe, or severe.
The 2 most common kinds of premalignant lesions in the oropharynx are leukoplakia and erythroplakia.
•Leukoplakia is a white or whitish area. It can often be easily scraped off without bleeding. Only about 5% of leukoplakias are cancerous at diagnosis or will become cancerous within 10 years if not treated.
•Erythroplakia is a raised, red area. If scraped, it may bleed. Erythroplakia is generally more severe than leukoplakia and has a higher chance of becoming cancerous over time.
•These are often detected by a dentist at a routine dental examination.
Several types of malignant cancers occur in the mouth and throat.
•Squamous cell carcinoma is by far the most common type, accounting for more than 90% of all cancers. These cancers start in the squamous cells, which form the surface of much of the lining of the mouth and pharynx. They can invade deeper layers below the squamous layer.
•Other less common cancers of the mouth and throat include minor salivary gland tumors and lymphoma.
•Cancers of the mouth and throat do not always metastasize, but those that do usually spread first to the lymph nodes of the neck. From there, they may spread to more distant parts of the body.
About 27,700 new cases of oral cancer will be diagnosed in the United States in 2003. Approximately 7,200 people will die of these cancers during the same period.
•The incidence and death rates attributable to oral cancers have been gradually decreasing over the past 20 years.
•Cancers of the mouth and throat occur in twice as many men as women.
•These cancers can develop at any age but occur most frequently in people aged 45 years and older.
•Incidence rates of mouth and throat cancers vary widely from country to country. These variations are due to differences in risk factor exposures.
Cancer Causes
Tobacco use is by far the most common risk factor for cancers of the mouth and throat. Both smoking and “smokeless” tobacco (snuff and chewing tobacco) increase the risk of developing cancer in the mouth or throat.
•All forms of smoking are linked to these cancers, including cigarettes, cigars, and pipes. Tobacco smoke can cause cancer anywhere in the mouth and throat as well as in the lungs, the bladder, and many other organs in the body. Pipe smoking is particularly linked with lesions of the lips, where the pipe comes in contact with the tissue.
•Smokeless tobacco is linked with cancers of the cheeks, gums, and inner surface of the lips. Cancers caused by smokeless tobacco use often begin as leukoplakia or erythroplakia.
Other risk factors for mouth and throat cancer include the following:
•Alcohol use: At least three quarters of people who have a mouth and throat cancer consume alcohol frequently. People who drink alcohol frequently are 6 times more likely to develop one of these cancers. People who both drink alcohol and smoke often have a much higher risk than people who use only tobacco alone.
•Ultraviolet light exposure: People who spend a lot of time in sunlight, such as those who work outdoors, are more likely to have cancer of the lip.
•Chewing betel nut, a prevalent practice in India and other parts of South Asia, has been found to result in mucosa carcinoma of the cheeks. Mucosa carcinoma accounts for less than 10% of oral cavity cancers in the United States but is the most common oral cavity cancer in India.
•Human papillomavirus (HPV) infection: Several strains of HPV are associated with cancers of the cervix, vagina, vulva, and penis. The link between HPV and oral cancers is not known, but HPV infection is believed to increase the risk of oral cancers in some people.
These are risk factors that can be avoided in some cases. For example, you can choose to not smoke, thus lowering your risk of mouth and throat cancer. The following risk factors are outside of your control:
•Age: The incidence of mouth and throat cancers increases with advancing age.
•Sex: Mouth and throat cancer is twice as common in men as in women. This may be related to the fact that more men than women use tobacco and alcohol.
The relationship between these risk factors and an individual’s risk is not well understood. Many people who have no risk factors develop mouth and throat cancer. Conversely, many people with several risk factors do not. In large groups of people, these factors are linked with higher incidence of oropharyngeal cancers.

Mouth and Throat Cancer Symptoms
People with an oropharyngeal cancer may notice any of the following symptoms:
•A painless lump on the lip, in the mouth, or in the throat
•A sore on the lip or inside the mouth that does not heal
•A painless white or red patch on the gums, tongue, or lining of the mouth
•Unexplained pain, bleeding, or numbness inside the mouth
•A sore throat that does not go away
•Pain or difficulty with chewing or swallowing
•Swelling of the jaw
•Hoarseness or other change in the voice
•Pain in the ear
These symptoms are not necessarily signs of cancer. They may be caused by many other less serious conditions.
When to Seek Medical Care
If you have any of the symptoms of head and neck cancer, make an appointment to see your primary care provider or your dentist right away.

Exams and Tests
Cancers of the mouth and throat are often found on routine dental examination. If your dentist should find an abnormality, he or she will probably refer you to a specialist in ear, nose, and throat medicine (an otolaryngologist) or recommend that you see your primary health care provider right away.
If you have symptoms that suggest a possible cancer, or if an abnormality is found in your oral cavity or pharynx, your health care provider will immediately begin the process of identifying the type of abnormality.
•The goal will be to rule out or confirm the diagnosis of cancer.
•He or she will interview you extensively, asking questions about your medical and surgical history, the medications you take, your family and work history, and your habits and lifestyle, focusing on the risk factors for oropharyngeal cancers.
At some point during this process, you will probably be referred to a physician who specializes in treating cancers of the mouth and throat.
•Many cancer specialists (oncologists) specialize in treating cancers of the head and neck, which includes cancers of the oropharynx.
•It is your right to seek treatment where you wish.
•You may want to consult with two or more specialists to find one who makes you feel most comfortable.
You will undergo a thorough examination of the head and neck to look for lesions and abnormalities. A mirror exam and/or an indirect laryngoscopy (see below for explanation) will most likely be done to view areas that are not directly visible on examination, such as the back of the nose (nasopharyngoscopy), the throat (pharyngoscopy), and the voice box (laryngoscopy).
•The indirect laryngoscopy is performed with the use of a thin, flexible tube containing fiberoptics connected to a camera. The tube is moved through the nose and throat and the camera sends images to a video screen. This allows your physician to see any hidden lesions.
•In some cases, a panendoscopy may be necessary. This includes endoscopic examination of the nose, throat, and voice box as well as the esophagus and airways of the lungs (bronchi). This is done in an operating room while you are under general anesthesia. This gives the most exhaustive possible examination and can permit biopsies of areas suspicious for malignancy.
•The complete physical examination will look for signs of metastatic cancer or other medical conditions that could affect the diagnosis or treatment plan.
No blood tests can identify or even suggest the presence of a cancer of the mouth or throat. The appropriate next step is biopsy of the lesion. This means to remove a sample of cells or tissue (or the entire visible lesion if small) for examination.
•There are several techniques for taking a biopsy in the mouth or throat. The sample can be simply scraped from the lesion, removed with a scalpel, or withdrawn with a needle.
•This can sometimes be done in the medical office; other times, it needs to be done in a hospital.
•The technique is dictated by the size and location of the lesion and by the experience of the person collecting the biopsy.
•If you have a mass in your neck, that may be sampled as well, usually by fine-needle aspiration biopsy.
After the sample(s) is removed, it will be examined by a doctor who specializes in diagnosing diseases by examining cells and tissues (pathologist).
•The pathologist looks at the tissue under a microscope after treating it with special stains to highlight certain abnormalities.
•If the pathologist finds cancer, he or she will identify the type of cancer and report back to your health care provider.
If your lesion is cancer, the next step is to stage the cancer. This means to determine the size of the tumor and its extent, that is, how far it has spread from where it started. Staging is important because it not only dictates the best treatment but also your prognosis for survival after treatment.
•In oropharyngeal cancers, the stage is based on the size of the tumor, involvement of the lymph nodes in the head and neck, and evidence of spread to distant parts of the body.
•Like many cancers, cancers of the oral cavity and pharynx are staged as 0, I, II, III, and IV, with 0 being the least severe (cancer has not yet invaded the deeper layers of tissue under the lesion) and IV being the most severe (cancer has spread to an adjacent tissue, such as the bones or skin of the neck, to many lymph nodes on the same side of the body as the cancer, to a lymph node on the opposite side of the body, to involve critical structures such as major blood vessels or nerves, or to a distant part of the body).
Stage is determined from the following information:
•Physical examination findings
•Endoscopic findings
•Imaging studies - X-rays (including a Panorex, a panoramic dental x-ray), CT scan, MRI, and, occasionally, a nuclear medicine scan of the bones to detect metastatic disease

Mouth and Throat Cancer Treatment
After you have been evaluated by a surgical or radiation oncologist to treat your cancer, you will have ample opportunity to ask questions and discuss which treatments are available to you.
•Your doctor will present each type of treatment, give you the pros and cons, and make recommendations.
•Treatment for head and neck cancer depends on the type of cancer and whether it has affected other parts of the body. Factors such as your age, your overall health, and whether you have already been treated for the cancer before are included in the treatment decision-making process.
•The decision of which treatment to pursue is made with your doctor (with input from other members of your care team) and your family members, but ultimately, the decision is yours.
•Be certain you understand exactly what will be done and why, and what you can expect from your choices. With oral cancers, it is especially important to understand the side effects of treatment.
Like many cancers, head and neck cancer is treated on the basis of cancer stage. The most widely used therapies are surgery and radiation therapy. Chemotherapy is used in some advanced cases. Your treatment plan will be individualized for your specific situation.
•Your medical team may include an ear, nose, and throat surgeon; an oral surgeon; a plastic surgeon; and a specialist in prosthetics of the mouth and jaw (prosthodontist), as well as a specialist in radiation therapy (radiation oncologist) and medical oncology.
•Because cancer treatment can make your mouth sensitive and more likely to be infected, your doctor will probably advise you to have any needed dental work done before your treatment.
•Your team will also include a dietitian to ensure that you get adequate nutrition during and after your therapy.
•A speech therapist may be needed to help you recover your speech or swallowing abilities after treatment.
•A physical therapist may be needed to help you recover function compromised by loss of muscle or nerve activity from the surgery.
•A social worker, counselor, or member of the clergy will be available to help you and your family cope with the emotional, social, and financial toll of your treatment.
Medical Treatment
Your treatment falls into 2 categories: treatment to fight the cancer and treatment to relieve the symptoms of the disease and the side effects of the treatment (supportive care).
Surgery is the treatment of choice for early stage cancers and many later stage cancers. The tumor is removed, along with surrounding tissues, including but not limited to the lymph nodes, blood vessels, nerves, and muscles that are affected. For more information, see Surgery.
Radiation therapy involves the use of a high-energy beam to kill cancer cells.
•Radiation can be used instead of surgery for many stage I and II cancers, because surgery and radiation have equivalent survival rates in these tumors. In stage II cancers, tumor location determines the best treatment. The treatment that will have the fewest side effects is usually chosen.
•Stage III and IV cancers are most often treated with both surgery and radiation. The radiation is typically given after surgery. Radiation after surgery kills any remaining cancer cells.
•External radiation is given by precisely targeting a beam at the tumor. The beam goes through the healthy skin and overlying tissues to reach the tumor. These treatments are given at the cancer center. Treatments are usually given once a day, 5 days a week, for about 6 weeks. Each treatment takes only a few minutes. Giving radiation this way keeps the doses small and helps protect healthy tissues. Some cancer centers are experimenting with giving radiation twice a day to see if it increases survival rates.
•Unfortunately, radiation affects healthy cells as well as cancer cells. Damage to healthy cells accounts for the side effects of radiation therapy. These include sore throat, dry mouth, cracked and peeling lips, and a sunburn-like effect on the skin. It can cause problems with eating, swallowing, and speaking. You may also feel very tired during, and for some time after, these treatments. External beam radiation can also affect the thyroid gland in the neck, causing your level of thyroid hormone to be low. This can be treated.
•Internal radiation therapy (brachytherapy) can avoid these side effects in some cases. This involves implanting tiny radioactive "seeds" directly into the tumor or in the surrounding tissue. The seeds emit radiation that destroys tumor cells. This treatment takes several days, and you will have to stay in the hospital during the treatment.
Chemotherapy is the use of powerful drugs to kill cancer cells.
•Chemotherapy alone may shrink these tumors, but the effect does not last for long.
•In head and neck cancers, chemotherapy is used in combination with radiation therapy and surgery for large or extensive cancers and in combination with radiation therapy in other head and neck cancers depending on the site.
•The side effects depend on which drugs are given. Common side effects include nausea and vomiting, severe heartburn-type pain, diarrhea, hair loss, mouth sores, loss of appetite, fatigue or weakness, and increased risk of infection.
Treatment of recurrent tumors, like that of primary tumors, varies by size and location of the recurrent tumor. The treatment given previously is also taken into account. For instance, a site already treated by external radiation therapy may be difficult to treat a second time with external radiation.
Weight loss is a common effect in people with head and neck cancers. Discomfort from the tumor itself, as well as the effects of treatment on the chewing and swallowing structures and the digestive tract, often prevents eating.
Medications will be offered to treat some of the side effects of therapy, such as nausea, dry mouth, mouth sores, and heartburn.
You will probably see a speech therapist during and for some time after treatment. The speech therapist helps you learn to cope with the changes in your mouth and throat after treatment so that you can eat, swallow, and talk.

Surgery
Oral surgery for cancer may be simple or very complicated. This depends on how far the cancer has spread from where it started.
•Cancers that have not spread can often be removed quite easily, with minimal scarring or change in appearance.
•If the cancer has spread to other structures, those structures must also be removed. This may include small muscles in the neck, lymph nodes in the neck, salivary glands, and nerves and blood vessels that supply the face. Structures of the jaw, chin, and face, as well as teeth and gums, may also be affected.
If any of these structures are removed, your appearance will change. The surgery will also leave scars that may be visible. These changes can sometimes be extensive. A plastic surgeon may take part in the planning or in the operation itself to minimize these changes. Reconstructive surgery may be an option to restore tissues removed or altered by surgery.
Removal of tissues and the resulting scars can cause problems with the normal functions of your mouth and throat. These disruptions may be either temporary or permanent. Chewing, swallowing, and speaking are the functions most likely to be disrupted.
Next Steps:-Follow-up

After surgery, you will see your surgeon, radiation oncologist, or both if you received chemotherapy. You will also follow-up with your medical oncologist.
You will also continue to see your medical oncologist according to a schedule he or she will recommend.
•You may go through staging tests after completing treatment to determine how well the treatment worked and if you have any residual cancer.
•Thereafter, at regular visits, you will undergo physical examination and testing to make sure the cancer has not come back and that a new cancer has not appeared.
•At least 5 years of follow-up care is recommended, and many people choose to continue these visits indefinitely.
•Report any new symptoms to your oncologist immediately—Do not wait for the next visit.
Speech and swallowing therapy will continue for as long as needed to restore these functions
Prevention
The best way to prevent head and neck cancer is to avoid the risk factors.
•If you use tobacco, quit. Do not substitute “smokeless” tobacco for smoking. Pipe and cigar smoking are not safer than cigarette smoking.
•If you drink alcohol, do so in moderation. Do not use both tobacco and alcohol.
•If you work outdoors or are otherwise frequently exposed to sunlight (ultraviolet radiation), protect yourself with clothing that blocks the sun. Apply sunscreen to your face (including a lip balm with sunscreen), and wear a wide-brimmed hat.
•Avoid sources of oral irritation, such as ill-fitting dentures. If you wear dentures, remove and clean them every day. Have your dentist check their fit regularly.
•Eat a balanced diet to avoid vitamin and other nutritional deficiencies. Make sure you eat foods with plenty of vitamin A, including fruits, vegetables, and supplemented dairy products. Do not take very high doses of vitamin A supplements, which may actually be harmful.
Ask your dentist or primary care provider to check your oral cavity and pharynx regularly to look for precancerous lesions and other abnormalities. Report any symptoms such as persistent pain, hoarseness, bleeding, or difficulty swallowing.

Outlook
The average 5-year survival rate for people who undergo treatment for head and neck cancer has been reported at 56%. The 10-year survival rate is 41%. About 80% of people treated for these cancers survive for at least 1 year. More accurate percentages depend on the tumor location, staging, type of treatment, and the presence of other medical conditions.
People with a mouth and throat cancer have a chance of developing another head and neck cancer or cancer in a neighboring region such as the voice box (larynx) or esophagus (the tube between the throat and the stomach). Regular follow-up examinations and prevention are extremely important.
Support Groups and Counseling
Living with cancer presents many new challenges for you and for your family and friends.
•You will probably have many worries about how the cancer will affect you and your ability to "live a normal life," that is, to care for your family and home, to hold your job, and to continuing the friendships and activities you enjoy.
•Many people feel anxious and depressed. Some people feel angry and resentful; others feel helpless and defeated.
For most people with cancer, talking about their feelings and concerns helps.
•Your friends and family members can be very supportive. They may be hesitant to offer support until they see how you are coping. Don't wait for them to bring it up. If you want to talk about your concerns, let them know.
•Some people don't want to "burden" their loved ones, or they prefer talking about their concerns with a more neutral professional. A social worker, counselor, or member of the clergy can be helpful if you want to discuss your feelings and concerns about having cancer. Your doctor should be able to recommend someone.
•Many people with cancer are profoundly helped by talking to other people who have cancer. Sharing your concerns with others who have been through the same thing can be remarkably reassuring. Support groups of people with cancer may be available through the medical center where you are receiving your treatment. The American Cancer Society also has information about support groups all over the United States.

For More Information
For more information about support groups, contact the following agencies:
•American Cancer Society - (800) ACS-2345
•National Cancer Institute, Cancer Information Service - (800) 4-CANCER [(800) 422-6237)]; TTY (for deaf and hard-of-hearing callers) (800) 332-8615

Web Links
American Academy of Otolaryngology—Head and Neck Surgery
American Cancer Society
American Speech-Language-Hearing Association - For information on problems after cancer treatment
National Cancer Institute
National Institute of Health's Clinical Trials database – For information about clinical trials in cancer treatment

Synonyms and Keywords
buccal mucosa, cigarette smoking, dysplasia, erythroplakia, hard palate, head and neck cancer, leukoplakia, lips, mouth, oral cancer, oral cavity, oropharyngeal cancer, oropharynx, pharynx, precancerous lesion, premalignant lesion, salivary glands, smokeless tobacco, smoking, soft palate, squalors cell carcinoma, throat, tongue, tonsils, cancer of the mouth and throat, mouth cancer, throat cancer

Authors and Editors
Author: Prajoy Kadkade, MD, Assistant Professor of Surgery, Division of Otolaryngology/Head & Neck Surgery, Department of Surgery, State University of New York at Stony Brook Medical Center and affiliated Northport Veterans Affairs Medical Center.

Coauthor(s): Kathryn L Hale, MS, PA-C, Medical Writer, eMedicine.com, Inc.

Editors: William M Lydiatt, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Rick Kulkarni, MD, Assistant Professor of Medicine, David Geffen UCLA School of Medicine; Director of Informatics, Department of Emergency Medicine, UCLA/Olive View-UCLA Medical Center.

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