Oral cancer - symptoms and treatment

Most oral cancers are asymptomatic in their early stages but as the malignancy progresses the symptoms may include those shown in Table 5.1.

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Symptoms will vary according to the site of the tumour, for example, pain is often the first symptom of cancer of the tongue, either in the tongue or referred to the ear, whereas discomfort and difficulty in swallowing may indicate a tumour in the pharynx. White or red patches on the oral mucosa may indicate a cancerous or precancerous condition, and biopsy is essential for the diagnosis of any oral cancer. a Leukoplakia is more common than erythroplakia, but the latter is much more likely (75-90% of cases) to be premalignant or malignant and should be excised and checked histologically. 1 Up to 10% of leukoplakias become malignant over a ten year period and some may regress spontaneously making their management difficult. 2 A recent Cochrane review concluded that there is no effective treatment for preventing malignant transformation of leukoplakia: treatment with beta carotene and vitamin A retinoids was associated with significant rates of clinical resolution of the lesion but there was a high rate of relapse. 3

Although the majority of squamous cell carcinomas are slow growing (though a few may be very aggressive), most oral cancer patients are diagnosed at a late stage in their disease. The overall prognosis would be considerably improved if patients could be diagnosed at an earlier stage. Small and early oral cancers are highly curable but many patients, particularly when their cancer is diagnosed at an advanced stage, have to cope with the sometimes debilitating consequences of their treatment. These may include difficulties with speaking, chewing and swallowing and facial disfigurement. Prognosis is best for patients with cancer of the lip, the most accessible site for treatment.

Recent guidelines for improving services for head and neck patients have been published by the National Institute for Clinical Excellence (NICE). 4-6 Previous treatment guidelines have also been published. 7-9 One of the key recommendations of the NICE guidance is that services for head and neck patients should be centralised b so that patients with these relatively rare cancers receive specialist care. The need to provide a complete service from pre-treatment assessment through treatment to rehabilitation is highlighted and patients should be treated within multi-disciplinary teams including clinical oncologists, specialist surgeons, radiologists, clinical nurse specialists, speech therapists, dieticians and prosthetics experts. Participation in multicentre clinical trials should also be encouraged and supported.

The main forms of curative treatment are surgery and radiotherapy. 10 For small tumours the choice of treatment depends on several factors including the site, the risk of hidden disease, the need to preserve function, other side-effects, medical resources and patients’ wishes. If there is a risk of hidden disease, radiotherapy may be used but if the tumour is small and well defined, surgery may be better. For larger tumours, combined therapy will be applied. Chemotherapy was previously reserved for palliation but may now be used curatively in patients with advanced disease to enhance the effects of radiation (chemoradiation). 11 There is still some debate over the treatment of oral cancers and meanwhile some patients are almost certainly receiving less than optimal treatment. Trials are ongoing to evaluate the best form of radiotherapy and other treatments. 12

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aOral lesions are also associated with HIV infection but this is outside the scope of this report.

bin cancer centres serving populations of over a million patients.