How it begins
Cancer begins in cells , the building blocks that make up tissues. Tissues make up the organs of the body. Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn’t need them, and old or damaged cells don’t die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor .
Tumors in the mouth or throat can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:
• Benign tumors : — are rarely a threat to life — can be removed and usually don’t grow back — don’t invade the tissues around them — don’t spread to other parts of the body
• Malignant tumors : — may be a threat to life — can grow back after they are removed — can invade and damage nearby tissues and organs — can spread to other parts of the body
Almost all oral cancers begin in the flat cells ( squamous cells ) that cover the surfaces of the mouth, tongue, and lips. These cancers are called squamous cell carcinomas .
Oral cancer cells can spread by breaking away from the original tumor. They enter blood vessels or lymph vessels , which branch into all the tissues of the body. The cancer cells often appear first in nearby lymph nodes in the neck. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. The spread of cancer is called metastasis .
Risk factors
When you get a diagnosis of cancer, it’s natural to wonder what may have caused the disease. Doctors can’t always explain why one person gets oral cancer and another doesn’t. However, we do know that people with certain risk factors may be more likely than others to develop oral cancer. A risk factor is something that may increase the chance of getting a disease. Studies have found the following risk factors for oral cancer:
• Tobacco : Tobacco use causes most oral cancers. Smoking cigarettes, cigars, or pipes, or using smokeless tobacco (such as snuff and chewing tobacco) causes oral cancer. The use of other tobacco products (such as bidis and kreteks ) may also increase the risk of oral cancer. Heavy smokers who have smoked tobacco for a long time are most at risk for oral cancer. The risk is even higher for tobacco users who are heavy drinkers of alcohol. In fact, three out of four people with oral cancer have used tobacco, alcohol, or both.
• Heavy alcohol use : People who are heavy drinkers are more likely to develop oral cancer than people who don’t drink alcohol. The risk increases with the amount of alcohol that a person drinks. The risk increases even more if the person both drinks alcohol and uses tobacco.
• HPV infection : Some members of the HPV family of viruses can infect the mouth and throat. These viruses are passed from person to person through sexual contact. Cancer at the base of the tongue, at the back of the throat, in the tonsils, or in the soft palate is linked with HPV infection. The NCI fact sheet Human Papillomaviruses and Cancer has more information.
• Sun : Cancer of the lip can be caused by exposure to the sun. Using a lotion or lip balm that has a sunscreen can reduce the risk. Wearing a hat with a brim can also block the sun’s harmful rays. The risk of cancer of the lip increases if the person also smokes.
• A personal history of oral cancer : People who have had oral cancer are at increased risk of developing another oral cancer. Smoking increases this risk.
• Diet : Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer.
• Betel nut use : Betel nut use is most common in Asia, where millions chew the product. It’s a type of palm seed wrapped with a betel leaf and sometimes mixed with spices, sweeteners, and tobacco. Chewing betel nut causes oral cancer. The risk increases even more if the person also drinks alcohol and uses tobacco.
The more risk factors that a person has, the greater the chance that oral cancer will develop. However, most people with known risk factors for oral cancer don’t develop the disease.
Symptoms
Symptoms of oral cancer may include:
• Patches inside your mouth or on your lips: — White patches (leukoplakia) are the most common. White patches sometimes become malignant. — Mixed red and white patches ( erythroleukoplakia ) are more likely than white patches to become malignant. — Red patches ( erythroplakia) are brightly colored, smooth areas that often become malignant.
• A sore on your lip or in your mouth that doesn’t heal
• Bleeding in your mouth
• Loose teeth • Difficulty or pain when swallowing
• Difficulty wearing dentures • A lump in your neck
• An earache that doesn’t go away
• Numbness of lower lip and chin
Most often, these symptoms are not from oral cancer. Another health problem can cause them. Anyone with these symptoms should tell their doctor or dentist so that problems can be diagnosed and treated as early as possible.
Diagnosis
If you have symptoms that suggest oral cancer, your doctor or dentist will check your mouth and throat for red or white patches, lumps, swelling, or other problems. A physical exam includes looking carefully at the roof of your mouth, back of your throat, and insides of your cheeks and lips. Your doctor or dentist also will gently pull out your tongue so it can be checked on the sides and underneath. The floor of your mouth and lymph nodes in your neck will also be checked.
If your doctor or dentist does not find the cause of your symptoms, you may be referred to a specialist.
An ear, nose, and throat specialist can see the back of your nose, tongue, and throat by using a small, long-handled mirror or a lighted tube.
Sometimes pictures need to be made with a CT scan or MRI to find a hidden tumor.
The removal of a small piece of tissue to look for cancer cells is called a biopsy. Usually, a biopsy is done with local anesthesia . Sometimes, it’s done under general anesthesia . A pathologist then looks at the tissue under a microscope to check for cancer cells. A biopsy is the only sure way to know if the abnormal area is cancer.
Staging
If oral cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment.
When oral cancer spreads, cancer cells may be found in the lymph nodes in the neck or in other tissues of the neck. Cancer cells can also spread to the lungs, liver, bones, and other parts of the body.
When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells as the primary (original) tumor. For example, if oral cancer spreads to the lungs, the cancer cells in the lungs are actually oral cancer cells. The disease is called metastatic oral cancer, not lung cancer. It’s treated as oral cancer, not lung cancer.
Doctors sometimes call the new tumor “distant” or metastatic disease. Your doctor may order one or more of the following tests:
• X-rays : An x-ray of your entire mouth can show whether cancer has spread to the jaw. Images of your chest and lungs can show whether cancer has spread to these areas.
• CT scan : An x-ray machine linked to a computer takes a series of detailed pictures of your body. You may receive an injection of dye. Tumors in your mouth, throat, neck, lungs, or elsewhere in the body can show up on the CT scan.
• MRI : A powerful magnet linked to a computer is used to make detailed pictures of your body. An MRI can show whether oral cancer has spread.
• Endoscopy : The doctor uses a thin, lighted tube ( endoscope ) to check your throat, windpipe, and lungs . The doctor inserts the endoscope through your nose or mouth. Local anesthesia is used to ease your discomfort and prevent you from gagging. Some people also may be given a mild sedative. Sometimes the doctor uses general anesthesia to put a person to sleep. This exam may be done in a doctor’s office, an outpatient clinic, or a hospital.
• PET scan : You receive an injection of a small amount of radioactive sugar. The radioactive sugar gives off signals that the PET scanner picks up. The PET scanner makes a picture of the places in your body where the sugar is being taken up. Cancer cells show up brighter in the picture because they take up sugar faster than normal cells do. A PET scan shows whether oral cancer may have spread.
Doctors describe the stage of oral cancer based on the size of the tumor, whether it has invaded nearby tissues, and whether it has spread to the lymph nodes or other tissues:
• Early cancer : Stage I or II oral cancer is usually a small tumor (smaller than a walnut), and no cancer cells are found in the lymph nodes.
• Advanced cancer : Stage III or IV oral cancer is usually a large tumor (as big as a lime). The cancer may have invaded nearby tissues or spread to lymph nodes or other parts of the body.
Treatment
People with early oral cancer may be treated with surgery or radiation therapy .
People with advanced oral cancer may have a combination of treatments. For example, radiation therapy and chemotherapy are often given at the same time.
Another treatment option is targeted therapy . The choice of treatment depends mainly on your general health, where in your mouth or throat the cancer began, the size of the tumor, and whether the cancer has spread.
Many doctors encourage people with oral cancer to consider taking part in a clinical trial . Clinical trials are research studies testing new treatments. They are an important option for people with all stages of oral cancer.
Your doctor may refer you to a specialist, or you may ask for a referral.
Specialists who treat oral cancer include:
• Head and neck surgeons
• Dentists who specialize in surgery of the mouth, face, and jaw ( oral and maxillofacial surgeons)
• Ear, nose, and throat doctors (otolaryngologists)
• Medical oncologists
• Radiation oncologists
Other health care professionals who work with the specialists as a team may include a dentist, plastic surgeon, reconstructive surgeon, speech pathologist, oncology nurse, registered dietitian, and mental health counselor. Your health care team can describe your treatment choices, the expected results of each, and the possible side effects .
You’ll want to consider how treatment may affect eating, swallowing, and talking, and whether treatment will change the way you look. You and your health care team can work together to develop a treatment plan that meets your needs.
Oral cancer and its treatment can lead to other health problems.
For example, radiation therapy and chemotherapy for oral cancer can cause dental problems. That’s why it’s important to get your mouth in good condition before cancer treatment begins.
See a dentist for a thorough exam one month, if possible, before starting cancer treatment to give your mouth time to heal after needed dental work.
Before, during, and after cancer treatment, you can have supportive care to control pain and other symptoms, to relieve the side effects of therapy, and to help you cope with the feelings that a diagnosis of cancer can bring.
You can get information about supportive care on the NCI Web site at http://www. cancer.gov/cancerinfo/coping and from the NCI Cancer Information Service at 1–800–4– CANCER or LiveHelp (http://www.cancer.gov/help) .
Surgery
Surgery to remove the tumor in the mouth or throat is a common treatment for oral cancer.
Sometimes the surgeon also removes lymph nodes in the neck. Other tissues in the mouth and neck may be removed as well.
You may have surgery alone or in combination with radiation therapy. It takes time to heal after surgery, and the time needed to recover is different for each person. You may have pain for the first few days after surgery. However, medicine can usually control the pain.
Before surgery, you should discuss the plan for pain relief with your doctor or nurse.
After surgery, your doctor can adjust the plan if you need more pain relief. It’s common to feel tired or weak for a while after surgery.
Also, surgery may cause tissues in your face to swell. This swelling usually goes away within a few weeks. However, removing lymph nodes can result in swelling that lasts a long time.
Surgery to remove a small tumor in your mouth may not cause any lasting problems.
For a larger tumor, however, the surgeon may remove part of the palate, tongue, or jaw. This surgery may change your ability to chew, swallow, or talk.
Also, your face may look different after surgery. You may have reconstructive or plastic surgery to rebuild the bones or tissues of the mouth.
Radiation
Therapy Radiation therapy uses high-energy rays to kill cancer cells. It’s an option for small tumors or for people who can’t have surgery. Or, it may be used before surgery to shrink the tumor. It also may be used after surgery to destroy cancer cells that may remain in the area.
Doctors use two types of radiation therapy to treat oral cancer. Some people with oral cancer have both types:
• External radiation therapy : The radiation comes from a machine. Some treatment centers offer IMRT , which uses a computer to more closely target the oral tumor to lessen the damage to healthy tissue. You may go to the hospital or clinic once or twice a day, generally 5 days a week for several weeks. Each treatment takes only a few minutes.
• Internal radiation therapy ( implant radiation therapy or brachytherapy ): Internal radiation therapy isn’t commonly used for oral cancer. The radiation comes from radioactive material in seeds, wires, or tubes put directly in the mouth or throat tissue. You may need to stay in the hospital for several days. Usually the radioactive material is removed before you go home.
The side effects of radiation therapy depend mainly on the amount of radiation given. Radiation therapy may cause mouth and dental problems:
• Sore throat or mouth : Radiation therapy can cause painful ulcers and inflammation in the mouth and throat. Your doctor can suggest medicines to help control the pain. Your doctor also may suggest special rinses to numb the throat and mouth to help relieve the soreness. If your pain continues, you can ask your doctor about stronger medicines.
• Dry mouth : A dry mouth can make it hard for you to eat, talk, and swallow. It can also lead to tooth decay. You may find it helpful to drink lots of water, suck ice chips or sugar-free hard candy, and use a saliva substitute to moisten your mouth.
• Tooth decay : Cavities may be a significant problem after radiation therapy. Good mouth care can help you keep your teeth and gums healthy and can help you feel better. — Doctors usually suggest that people gently brush their teeth, gums, and tongue with an extra-soft toothbrush and fluoride toothpaste after every meal and before bed. If brushing hurts, you can soften the bristles in warm water. — Your dentist may suggest that you use fluoride gel on your teeth before, during, and after radiation treatment. — It also helps to rinse your mouth several times a day with a solution made from 1/4 teaspoon of baking soda and 1/4 teaspoon of salt in one quart of warm water. After you rinse with this solution, follow with a plain water rinse.
• Sore or bleeding gums : It’s important to brush and floss teeth gently. You may want to avoid brushing and flossing areas that are sore or bleeding. To protect your gums from damage, avoid using toothpicks.
• Infection : Dry mouth and damage to the lining of your mouth from radiation therapy can cause infection to develop. Check your mouth every day for sores or other changes, and tell your doctor or nurse about any mouth problems.
• Delayed healing after dental care : It’s important to have all needed dental treatment completed one month before radiation therapy to allow time for the mouth to heal. Dental treatment after radiation therapy can be complicated by slow healing and the risk of infection.
• Jaw stiffness : Radiation therapy can affect the chewing muscles and make it difficult for you to open your mouth. Ask your health care team to show you how to prevent or reduce stiffness by exercising your jaw muscles. For example, they may suggest opening and closing the mouth as far as possible (without causing pain) 20 times in a row, 3 times a day.
• Denture problems : Radiation therapy can change the tissues in your mouth so that dentures don’t fit anymore. Because of soreness and dry mouth, some people may not be able to wear dentures for as long as one year after radiation therapy. After the tissues heal completely and your mouth is no longer sore, your dentist may need to refit or replace your dentures. In addition to mouth and dental problems, radiation therapy aimed at the head and neck may cause other problems:
• Fatigue : You may become very tired, especially in the later weeks of radiation therapy. Resting is important, but doctors usually advise people to stay as active as they can.
• Changes in how food tastes and smells : Radiation therapy for oral cancer may cause food to taste or smell different. These changes can last for several months, especially if radiation therapy is given at the same time as chemotherapy.
• Changes in voice quality : Your voice may be weak at the end of the day. It may also be affected by changes in the weather. Radiation therapy directed at the neck may cause your larynx (voice box) to swell, causing voice changes and the feeling of a lump in your throat. Your doctor may suggest medicine to reduce this swelling.
• Skin changes in the treated area : The skin in the treated area may become red or dry. Good skin care is important. It’s helpful to expose this area to the air while protecting it from the sun. Also, avoid wearing clothes that rub the treated area, and don’t shave the treated area. You should not use lotions or creams in the treated area without your doctor’s advice. These skin changes should go away when treatment ends, but a long-term effect is that hair may not grow back in the moustache or beard area.
• Weight loss : You may lose weight if you have eating problems from a sore throat and trouble swallowing. Your health care team may suggest a feeding tube to help prevent weight loss.
• Changes in the thyroid : Radiation therapy can affect your thyroid (an organ in your neck beneath the voice box). If your thyroid does not make enough thyroid hormone , you may feel tired, gain weight, feel cold, and have dry skin and hair. Your doctor can check the level of thyroid hormone with a blood test. If the level is low, you may need to take thyroid hormone pills.
Some side effects in the mouth go away after radiation therapy ends, but others last a long time.
A few side effects (such as dry mouth) may never go away. Although the side effects of radiation therapy can be upsetting, your doctor can usually treat or control them. It helps to report any problems that you are having so that your doctor can work with you to relieve them.
Chemotherapy
Chemotherapy uses drugs to kill cancer cells. The drugs that treat oral cancer are usually given through a vein ( intravenous ). The drugs enter the bloodstream and travel throughout your body. Chemotherapy and radiation therapy are often given at the same time. You may receive chemotherapy in an outpatient part of the hospital, at the doctor’s office, or at home. Some people need to stay in the hospital during treatment. Chemotherapy and radiation therapy can cause some of the same side effects, including painful mouth and gums, dry mouth, infection, and changes in taste. Some anticancer drugs can cause bleeding in the mouth and a deep pain that feels like a toothache.
The side effects depend mainly on which drugs are given and how much.
Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:
• Blood cells : When drugs lower the levels of healthy blood cells, you’re more likely to get infections, bruise or bleed easily, and feel weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug.
• Cells in hair roots : Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture.
• Cells that line the digestive tract : Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.
Your health care team can give you medicines and suggest other ways to help with these problems. Some drugs used for oral cancer can cause tingling or numbness in the hands or feet. You may have these problems only during treatment or for a short time after treatment ends. You may wish to read the NCI booklet Chemotherapy and You .
Targeted Therapy
Some people with oral cancer receive a type of drug known as targeted therapy. It may be given along with radiation therapy or chemotherapy.
Cetuximab (Erbitux) was the first targeted therapy approved for oral cancer. Cetuximab binds to oral cancer cells and interferes with cancer cell growth and the spread of cancer. You may receive cetuximab through a vein once a week for several weeks at the doctor’s office, hospital, or clinic.
During treatment, your health care team will watch for signs of problems. Some people get medicine to prevent a possible allergic reaction. Side effects may include rash, fever, headache, vomiting, and diarrhea. These effects usually become milder after the first treatment. You may find it helpful to read the NCI fact sheet Targeted Cancer Therapies .
Nutrition
Your diet is an important part of your treatment for oral cancer. You need the right amount of calories, protein, vitamins, and minerals to maintain your strength and to heal.
However, when you have oral cancer, it may be difficult to eat. You may be uncomfortable or tired, and you may have a dry mouth, have trouble swallowing, or not feel like eating.
You also may have nausea, vomiting, constipation, or diarrhea from cancer treatment or pain medicine.
Tell your health care team if you’re having any problems eating, drinking, or digesting your food. If you’re losing weight, a dietitian can help you choose the foods and nutrition products that will meet your needs. You may want to read the NCI booklet Eating Hints . It contains many useful ideas and recipes.
If your mouth is sore, you may find that you want to avoid acidic foods, such as oranges and tomatoes. Also, to protect your mouth during cancer treatment, it helps to avoid sharp, hard foods, such as chips.
If your mouth is dry, you may find that soft foods moistened with sauces or gravies are easier to eat. Smooth soups, puddings, milkshakes, and blended fruit smoothies often are easier to swallow. Also, meal replacement products (such as instant breakfast, Boost ® , or Ensure ® ) may be helpful.
Keep in mind that a dry mouth puts you at greater risk for tooth decay (cavities). Rinse your mouth often, especially after eating or drinking sweet foods.
If there’s a chance that swallowing will become too difficult for you, your dietitian and doctor may recommend another way for you to receive nutrition. For example, after surgery or during radiation therapy for oral cancer, some people need a temporary feeding tube. A feeding tube is a flexible tube that is usually passed into the stomach through an incision in the abdomen. A liquid meal replacement product (such as Boost or Ensure) can be poured through the tube at mealtime. When not in use, the small tube attached to your stomach is not visible to others.
Reconstruction
Some people with oral cancer may need to have plastic or reconstructive surgery to rebuild the bones or tissues of the mouth. Research has led to many advances in the way bones and tissues can be rebuilt. Some people may need dental implants . Or they may need to have grafts (tissue moved from another part of the body). Skin, muscle, and bone can be moved to the mouth from the chest, arm, or leg. The plastic surgeon uses this tissue for repair.
If you’re thinking about reconstruction, you may wish to consult with a plastic or reconstructive surgeon before your treatment for oral cancer begins. You can have reconstructive surgery at the same time as you have the cancer removed, or you can have it later on. Talk with your doctor about which approach is right for you.
Rehabilitation
Your health care team will help you return to normal activities as soon as possible. The goals of rehabilitation depend on the extent of the disease and type of treatment.
If oral cancer or its treatment leads to problems with talking, speech therapy will generally begin as soon as possible. A speech therapist may see you in the hospital to plan therapy and teach speech exercises. Speech therapy may continue after you return home.
Some people will need a prosthesis to help them talk and eat as normally as possible. A prosthesis is an artificial device that replaces the missing teeth or tissues of the mouth. For example, if part of the palate is removed, a dentist with special training (a prosthodontist ) may be able to fit you with a plastic device that replaces the missing tissue.
Follow-up care
You’ll need regular checkups of your mouth, throat, and neck after treatment for oral cancer. Checkups help ensure that any changes in your health are noted and treated if needed. Checkups may include a physical exam, blood tests, chest x-rays, or CT scans. If you have any health problems between checkups, you should contact your doctor. People who have had oral cancer have a chance of developing a new cancer. A new cancer is especially likely for those who use tobacco or who drink alcohol heavily. Doctors strongly urge people to stop using tobacco and stop drinking alcohol to cut down the risk of a new cancer and other health problems. You may find it helpful to read the NCI booklet Facing Forward: Life After Cancer Treatment . You may also want to read the NCI fact sheet Follow-up Care After Cancer Treatment .