Unfortunately, any cancer has the potential to spread to any other part of the body. That’s why cancer is such a frightening disease. In general, oral cavity cancer tends to spread primarily to the lymph nodes of the neck first before it spreads or metastasizes to other areas. The lung is a likely second level of metastasis. Spread to lymph nodes is called locoregional metastasis and spread to the lung (or other organs) called distant metastasis. The likelihood of an oral cavity cancer spreading to lymph nodes depends largely on its size, depth of invasion, and invasion into small nerves and vessels in the area (known in medical terms as perineural and angiolymphatic invasion). Characteristics such as these increase the likelihood of the cancer spreading beyond its original location. Imaging tests — including CT, MRIand PETscans — are all helpful in screening for metastasis. Having said this, however, there are always cancers that break the rules and have unusual patterns of metastasis. So while there are no hard and fast numbers when it comes to predicting metastasis in individual people, for a moderate-sized oral cavity cancer, there is roughly a 20 percent to 30 percent chance that it has spread to the lymph nodes at the time of diagnosis. Q2. I know cigarette smoking puts you at risk for oral cancer, but what about marijuana? Is there an increased cancer risk from smoking marijuana (one or two joints a week)? Marijuana is the most commonly used illegal drug in the United States. Since marijuana smoke contains several of the same carcinogens and co-carcinogens (a chemical or substance that intensifies the effect of a carcinogen) as tobacco tar, there are concerns that smoking marijuana may be a risk factor for tobacco-related cancers. Unfortunately, the current research on cancer and smoking marijuana is mixed. Researchers have shown both negligible risk and an increased risk (in different studies) of head and neck cancer with marijuana use. Many large epidemiologic studies do not seem to show a large increase in oral cancer risk, but quantities and types of marijuana use vary greatly from study to study, and there are confounding factors such as concurrent tobacco smoking in many marijuana smokers, so it is not possible to say whether smoking one or two joints a week will significantly increase your risk for oral cancer. In addition to oral cancer, there is evidence that marijuana use during pregnancy can increase the risk of certain childhood cancers, so all recreational drug use should be stopped when a woman is expecting. Q3. I smoked for 45 years but quit 16 years ago. I have a bad taste in my mouth and my teeth hurt, especially when I’m lying down. My dentist said all is good with teeth and gums except some gingivitis. Could the bad taste and the pain have something to do with oral cancer, and what should I look for? Thank you very much for your reply. Luckily, the vast majority of oral cancer is visible on physical exam, so if you’ve had a thorough evaluation of your mouth, including your teeth and gums, it is unlikely that dental pain and bad taste in your mouth is due to oral cancer. Some signs of oral cancer can include areas in your mouth that don’t heal (such as a persistent ulcer or cold sore), constant bleeding, a growth, white or red plaques, pain that does not go away and difficulty swallowing. If you are still concerned about a particular area around your tooth or gum line, a dental X-ray may be indicated. A biopsy can also be done if there is a lesion in the gingiva (gums). Also, if your gingivitisis severe enough, you may need to consult a periodontist or a dentist who specializes in care of gums. If you are still concerned about the possibility of oral cancer, I would consult an ear, nose and throat specialist. Q4. Should you always ask for a consultation with a plastic surgeon if you’re told you need surgery for oral cancer? When is plastic surgery appropriate? Thanks. Surgery for oral cancers can involve removing a part of the tongue, the floor of the mouth, and even a part of the jaw (mandible) in more advanced cases. The role of a plastics or reconstructive surgeon is to help repair these areas once the surgery to remove the cancer is completed. Reconstructive surgery can be as simple as putting everything back together, or can involve moving tissue from one part of the body to another. This type of surgery often involves microvascular free tissue transfer, whereby soft tissue, bone and other structures are harvested from another site (such as the belly or leg) with the blood supply intact and then reattached, vessels and all, into the new location. Soft tissue is often used to reconstruct structures such as the tongue, and bone is often used to reconstruct the jaw. Alternatively, reconstruction may involve transferring local tissue without the need for microvascular surgery. Often times the cancer surgeon and plastic surgeon will be working together to reconstruct the defect after surgery. Reconstructive surgeons in the head and neck can be either plastic surgeons or head and neck surgeons depending on their experience, training and expertise. Whether or not you need a consultation for a plastic surgeon will depend on the extent of the surgery and plans for reconstruction. I would discuss these issues with your surgeon. Q5. I had a partial hemiglossectomy with neck dissection and have had excessive saliva ever since. I was wondering when this will stop, because it makes it very difficult to talk and eat. Both submandibular and sublingual salivary glands produce saliva that empties into the mouth. These glands are located below your jaw and empty into areas just below your tongue in the floor of your mouth. One of the reasons you may be having excessive saliva after tongue surgery may be due to the fact that the ducts that connect these glands to the floor of the mouth may not be functioning to control the flow of saliva. This should improve with time as your body heals these areas. Check with your surgeon. Q6. I heard that mouth cancer has a higher proportion of deaths (compared to the number of cases) than breast cancer. Is that true? Why do you think that is? In the last 40 years, there have been tremendous improvements in the care of oral cancer. These include advances in surgeries to remove the cancer and reconstruction for cosmetic and functional rehabilitation. Radiation and chemotherapy have improved our ability to control even very advanced cancers with newer drugs and newer techniques that deliver radiation without some of the side effects seen in the past. Targeted therapies (drugs that attack the cancer cells at the molecular level) are starting to come into wider use and hold great promise for the future. However, despite these advances, the overall survival from head and neck cancer is still very low. Unlike more common cancers, such as lung and breast cancer that have received more public attention and government research funding, cancer of the head, neck and oral cavity is rarer, and knowledge about this often deadly disease is lacking. Physicians like myself are trying to change this through patient education, raising public awareness, and pursuing active clinical and basic science research in the field. You can help by educating yourself and others about this disease and raising public awareness of this problem. Smoking cessation is one concrete example of a way to help stem the tide of head and neck cancer deaths in this country. Q7. My father has squamous cell cancer of the throat, tongue and cheek. It has also been found on his rib. He has a feeding tube and a tracheotomy. Recently his mouth has become terribly swollen. The doctors aren’t giving us any answers. He can’t even brush his teeth. What can this be and what can be done? If your father is currently getting chemotherapy and radiation, or has recently completed treatment, he may have mucositis. This is a known side effect of radiation to the oral cavity and is like getting a bad sunburn inside your mouth. The cells that line the mouth turn over every three days or so and are replaced by new cells. Radiation and chemotherapy can accelerate that process so that large areas of the tongue, inner lining of the cheek, and roof of the mouth can all become raw and exposed. This can then lead to inflammation and infection as the protective lining of the mouth is compromised. A gentle mouth rinse with salt water can help keep the mouth clean. There are also prescription and over-the-counter oral rinses that can help. Some radiation oncologists will prescribe Trental (pentoxifylline) and vitamin A to reduce post-radiation scar tissue. There is some evidence that this combination of drugs can also decrease the severity and duration of the mucositis. I would discuss these options with your doctors. Q8. My daughter (who is 42) noticed a bump on the left side of her tongue about five weeks ago. She went to her dentist right away and he sent her to an oral surgeon. The biopsy came back as oral cancer. Her surgeon feels that she will be okay. The tumor was removed, as well as her lymph nodes on the left side. She doesn’t yet know if the lymph nodes were positive. What’s next for her? Are her chances better because she caught it early? Treatment for oral cancer depends on its stage. Early stage cancers that are limited to the oral cavity may be treated by surgery alone. More advanced cancers that involve a larger area of the oral cavity and/or have spread to lymph nodes in the neck may require multimodal therapy that includes surgery, radiation and chemotherapy. Other factors that determine the need for more aggressive treatment are pathologic features of the cancer itself: How deep is it invading? Is it invading any small blood vessels, lymph vessels or nerves? How many lymph nodes are involved and how large are the lymph nodes? Cancers that have these features can behave more aggressively and may require multimodal therapy. If your daughter did not have any risk factors for oral cancer (such as tobacco or alcohol abuse), it may be worthwhile to check for evidence of human papilloma virus (HPV) infection. HPV is a known cause of some oral and oropharyngeal cancers and the presence of HPV can predict a better overall prognosis in some patients. Q9. I’ve read that alcohol use contributes to some kinds of cancer. How much alcohol is too much? Both smoking and excessive alcohol consumption have been linked to cancer. In the head and neck, alcohol use combined with smoking can have a greater risk of developing cancer than either smoking or drinking alone. There appears to be a synergistic effect in the mouth whereby the alcohol acts to break down the protective layer of cells lining your mouth, allowing the carcinogens found in cigarettes direct exposure to deeper tissues. This can result in an often deadly form of oral cancer. According to the American Cancer Society, oral cancers are six times more common in alcohol users than nonusers. Research shows that men who have two alcoholic drinks a day and women who have one alcoholic drink a day have an increased risk of developing certain cancers. (Read more about alcohol and cancer at the American Cancer Society’s Web site.) In order to reduce your risks, if you smoke, you should stop smoking. There is no safe amount of cigarettes. If you drink, only drink in moderation. Distilled spirits in general have higher alcohol content than wine and beer, which can lead to more damage to the lining of your mouth, but excessive wine and beer consumption can also lead to increased cancer risks. Q10. I am a dental hygienist and do an oral cancer screening on all my patients. Are there questions I can ask related to nerve sheath tumors or is there a way to feel them? Also are there courses that teach the best way to perform a thorough oral cancer screening on patients? Many Web sites, including the National Cancer Institute, offer detailed information about screening for head and neck cancer. Also, if there is a dental school or medical school close by, that might be a good place to gain some practical experience in performing a thorough head and neck exam. At the University of Colorado, I have both medical and dental residents who spend time with me learning about head and neck cancer. The Yul Brynner Head and Neck Cancer Foundation sponsors an Oral, Head and Neck Cancer Awareness Week every year — in fact, it’s this week, April 21-27. Many hospitals offer free head and neck cancer screening as part of the awareness week. This may be a good opportunity for you to help as well as gain some practical experience. Q11. Can you please explain what ViziLite treatment is? I used smokeless tobacco for five years, and my dentist wants me to do this treatment. ViziLite system is designed to improve visualization and early detection of oral cancers. The system uses a dilute acetic acid oral rinse followed by a special heat-free light that is designed to enhance the features of early cancers. In theory, this should allow your doctor or dentist to visualize precancerous areas in your mouth that are not visible by standard methods. Recent studies, however, have not demonstrated an appreciable increase in detection rates of precancerous lesions using the ViziLite system. So the decision whether or not to add this to your evaluation should be discussed with your doctor or dentist. Using smokeless tobacco is a known risk factor for developing precancerous and cancerous lesions in the lining of your mouth, so you should quit the chew! In many ways, smokeless tobacco is just as dangerous — if not more dangerous — to your oral health as cigarette smoking. If you are currently using or have used smokeless tobacco in the past, you should have regular checkups with your doctor or dentist. Q12. At my last dental appointment, the dentist noticed that my back upper molar was extremely sensitive as well as the surrounding gum area. When she touched it,it felt like she was touching live nerves. My X-rays showed nothing wrong with my teeth. (When I brush my teeth, they are not sensitive at all in that area.) So she wanted me to come back for an oral cancer screening. I was just wondering what the procedure was in doing that screening. Thanks! Oral cancer screening can range from a thorough examination and visual inspection of the various structures of the mouth to a biopsy (taking a tissue sample) of suspicious areas. Some dentists are using a special light to visualize early changes in the lining of the mouth and directing biopsies to those areas. ViziLite is one such commercially available product. Sometimes, certain dyes are used to make tissue changes more visible. After this initial exam, your dentist may then refer you to a head and neck surgeon or an oral surgeon for further tests or evaluation if suspicious areas are found. Learn more in the Everyday Health Oral, Head, and Neck Cancer Center.
