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Cancer, mouth

 

 

Mouth cancer (also known as oral cancer) is an uncommon type of cancer that usually develops on the surface of the tongue, mouth, lips or gums. Less commonly, it can occur in the salivary glands, tonsils and the part of the throat leading from your mouth to your windpipe (the pharynx).

Symptoms of mouth cancer include:

  • red, or red and white, patches on the lining of your mouth or tongue
  • one or more mouth ulcers that do not heal
  • a swelling in your mouth that lasts for more than three weeks

For more information, see Mouth cancer - symptoms.

How common is mouth cancer?

Mouth cancer is uncommon but certainly not rare. There are on average 180 new cases of oral cancer diagnosed in Irealnd each year

The two most significant risk factors for mouth cancer, accounting for an estimated 90% of cases, are:

  • cigarette smoking
  • prolonged and excessive alcohol consumption

People who both drink and smoke have a particularly high risk: they are more than 30 times more likely to develop mouth cancer than people who do not smoke or drink.

The condition is two to three times more common in men than women (possibly because more men misuse alcohol than women). Most cases develop in people aged 40 years or over, with a steep rise in cases in those aged 60-65.

Outlook

Like most types of cancers, the outlook for mouth cancer depends to a large extent on how quickly the cancer is diagnosed and treatment begins.

If diagnosed at an early stage, the outlook for mouth cancer is generally moderate to good. A complete cure is often possible using a combination of chemotherapy, radiotherapy and surgery.

An estimated 70-90% of people with early-stage mouth cancer will live for at least five years after their diagnosis, and many will live for a lot longer.

If diagnosed at an advanced stage, when the cancer has spread out of the mouth and into surrounding tissue, the outlook is poor: only one in five people will live for at least five years after their diagnosis. There were 50 deaths due to mouth cancer in Ireland in 2007.

The most effective way of preventing mouth cancer is to quit smoking if you are a smoker and limit your consumption of alcohol. See Preventing mouth cancer for more information.

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Symptoms of oral cancer include:

  • red, or red and white, patches on the lining of your mouth or tongue
  • one or more mouth ulcers that do not heal after three weeks
  • a swelling in your mouth that lasts for more than three weeks
  • pain when swallowing
  • a tooth, or teeth, that become loose for no obvious reason
  • a persistent pain in the neck
  • a hoarse voice
  • unexplained weight loss
  • unusual changes in your sense of taste
  • earache
  • the lymph nodes (glands) in your neck become swollen

When to seek medical advice

Many of the symptoms listed above can be also caused by less serious conditions, such as minor infections, that do not usually require a medical diagnosis.

It is strongly recommended that you visit your GP if you develop any of the symptoms listed above and they last for more than three weeks. Symptoms of an infection usually clear up much sooner than this. It is especially important to seek medical advice if you are a heavy drinker or smoker.

Dental check-ups

Mouth cancer tends not to cause any noticeable symptoms during the initial stages of the disease.

This is why it is important to have regular dental check-ups, particularly if you are a smoker and/or a heavy drinker, because a dentist may often be able to detect the condition during an examination.

You should have a dental check-up at least every two years. However, more frequent check-ups may be recommended if you have a history of tooth decay or gum disease.

Cancer

Cancer begins with changes in the structure of the deoxyribonucleic acid (DNA) that is found in all human cells. This is known as a genetic mutation. The DNA gives the cells a basic set of instructions, such as when to grow and reproduce.

The mutation in the DNA changes these instructions so that the cells carry on growing. This causes the cells to reproduce uncontrollably, producing a lump of tissue known as a tumour.

How cancer spreads

Most cancers grow and spread to other parts of the body through the lymphatic system. The lymphatic system is a network of vessels and glands (or nodes) that are spread throughout your body, much like your blood circulation system. The lymph glands produce many of the specialised cells needed by your immune system (the body's natural defence against disease and infection).

Most cases of mouth cancer are known as squamous cell carcinomas. These are cancers that begin on the surface level of tissue, such as the tongue, the inside of the mouth and the oropharynx (the area of the throat at the back of your mouth).

Left untreated, the cancerous cells spread out of the mouth or oropharynx and into the lymph nodes in the neck.

The cancer can then spread to other parts of the body, such as the bones or lungs. Cancer that has spread to other parts of the body is known as metastatic cancer.

Smoking and alcohol

The two leading causes of mouth cancer are smoking cigarettes (or other tobacco products, such as pipes or cigars) and drinking too much alcohol. Both of these substances are carcinogenic, i.e. they contain chemicals that can damage the DNA in cells and lead to cancer.

The risks of mouth cancer increase significantly in somebody who is both a heavy smoker and a heavy drinker, as the combined risk of tobacco and alcohol is greater than the sum of their individual risk.

For example, research has shown that if you smoke 40 cigarettes a day, but do not drink alcohol, you are five times more likely to develop mouth cancer than someone who does not drink or smoke.

If you do not smoke, but drink an average of 30 pints a week, your risk also increases by a factor of five.

However, if you smoke more than 40 cigarettes a day and you drink an average of 30 pints a week, you are 38 times more likely to develop mouth cancer.

Other risk factors

Other risk factors for mouth cancer are discussed below.

Smokeless tobacco

Smokeless tobacco is a general term used to refer to a range of products, such as:

  • chewing tobacco
  • snuff - powdered tobacco designed to be snorted
  • snus - a type of smokeless tobacco popular in Sweden, which is placed under your upper lip, where it is gradually absorbed into your blood

Smokeless tobacco products have become increasingly popular i most likely as a result of the 2004 smoking ban.

Smokeless tobacco products are not harmless, as many people mistakenly assume, and many of them increase your risk of developing mouth cancer, as well as other cancers, such as liver cancer, pancreatic cancer and oesophageal cancer

Cannabis

Smoking cannabis has been linked to an increase risk of mouth cancer. Regular cannabis smokers may have a higher risk than tobacco smokers. This is because cannabis smoke contains higher levels of tar than tobacco smoke, and tar is carcinogenic.

Human papilloma virus (HPV)

The human papilloma virus (HPV) is the name of a family of viruses that affect the skin and the moist membranes that line your body, such as those in your cervix, anus, mouth and throat.

Infection with some types of HPV can cause abnormal tissue growth and other changes to the cells, which can lead to the development of cervical cancer.

There is evidence that some types of HPV infection could also cause abnormal tissue growth inside the mouth, triggering some cases of mouth cancer.

It is thought that HPV infection probably causes the cases of mouth cancer in young people who have very few or none of the expected risk factors.

Diet

There is evidence that a diet high in red meat, processed food and fried food can increase your risk of developing laryngeal cancer (cancer of the voice box).

Betel nuts

Betel nuts are mildly addictive seeds taken from the betel palm tree, and are widely used in many southeast Asian ethnic communities, such as people of Indian and Sri Lankan origin.

They have a stimulant effect similar to coffee. Betel nuts also have a carcinogenic effect, which can increase the risk of mouth cancer. This risk is made worse as many people enjoy chewing betel nuts along with tobacco.

Qat

Qat is a green-leafed plant found in Africa and southern Arabia. There is a long tradition in many countries of chewing qat as it has a mild to moderate stimulant effect.

In Ireland, the use of qat is usually limited to people of Somalian, Ethiopian and Yemeni origin.

There is some limited evidence that qat may increase the risk of mouth cancer. But because many people chew qat with tobacco, it is hard to estimate the independent risk factor of qat.

If you have any of the possible symptoms of mouth cancer, your GP will carry out a physical examination and ask you about your symptoms. If a diagnosis of mouth cancer is suspected, you will be referred to a specialist for further testing. This is usually an oncologist (a doctor who specialises in the treatment of cancer) or an ear, nose and throat (ENT) specialist.

Biopsy

It may be necessary to remove a small sample of affected tissue to check for the presence of cancerous cells

There are three main methods used to carry out a biopsy in cases of suspected mouth cancer. They are outlined below.

Punch biopsy

A punch biopsy may be used if the suspected affected area of tissue is in an easily accessible place, such as your tongue or the inside of your mouth.

The area is first injected with a local anaesthetic to numb it. The doctor will then cut away a small section of affected tissue and remove it with tweezers.

The procedure is not painful but can feel a little uncomfortable.

Fine needle aspiration (FNA)

A fine needle aspiration (FNA) is a type of biopsy that can be used if it is suspected that a swelling in your neck is the result of mouth cancer.

During a FNA, the doctor will insert a sharp needle into the lump and draw out a small sample of tissue and fluids. The sample is then checked for cancerous cells.

Local anaesthetic is used to numb your neck, so an FNA is not painful. However, it can be uncomfortable and you may have some bruising after the procedure.

Further tests

If the biopsy shows the presence of cancer, further testing will be required to check how advanced it is and how far it has spread. This is known as the stage of the cancer.

Cancer spreads from the site of the initial tumour into the lymphatic system. The lymphatic system is a series of vessels and glands (or nodes) that are spread throughout your body, much like your blood circulation system. These glands produce many of the specialised cells needed by your immune system.

Once the cancer reaches the lymphatic system, it is capable of spreading to any other part of your body, including your bones, blood and organs. However, it is uncommon for mouth cancer to spread any further than the surrounding lymph nodes, although in some cases it may also spread to surrounding bones, such as the jaw bone, and in some cases your lungs.

Therefore, the tests will examine your lymph nodes, bones and the tissue near the site of your initial tumour to check for the presence of other tumours.

The tests that may be used include:

A PET scan involves injecting a part of your body with a radioactive 'tracer' chemical that can be seen on a special camera.

Further biopsies on nearby lymph nodes may also be carried out.

Biopsy
A biopsy is a test that involves taking a small sample of tissue from the body so it can be examined.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Tissue
Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.  
Ulcers
An ulcer is a sore break in the skin, or on the inside lining of the body.
X-rays
An X-ray is a painless way of producing pictures of inside the body using radiation.

Your care team

Hospitals operate multidisciplinary teams (MDTs) for the treatment of mouth cancer. An MDT may include different specialists, including:

  • a surgeon
  • a clinical oncologist (specialist in the non-surgical treatment of cancer, using techniques such as radiotherapy and chemotherapy)
  • a pathologist (specialist in diseased tissue)
  • a radiologist (specialist in radiotherapy)
  • a dentist
  • a dietitian
  • a social worker
  • a speech and language therapist

You may also be assigned a clinical nurse specialist (CNS) who specialises in the treatment of mouth cancer. The CNS will be your first point of contact between you and the members of the MDT. The CNS will provide information and advice about your treatment plan and the various support services available.

Your treatment plan

Your recommended treatment plan will depend on how far the cancer has spread. In general the mainstay of treatment is either surgery or radiotherapy,or a combination,with chemotherapy added for selected patients.

If the cancer has not spread from beyond the mouth or oropharynx (the area of the throat at the back of your mouth), it may be possible to treat the cancer using surgery alone. With early cancers, the aim is treat with one form of treatment alone.

If the cancer has spread to other parts of the body, then achieving a cure is unlikely. However, it is possible to slow the progress of the cancer and help relieve symptoms by using surgery with or without radiotherapy afterwards,or radiotherapy alone .Only a a small proportion of patients will benefit from having chemotherapy.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Before treatment begins

Before treatment for mouth cancer begins, you will be given a full dental examination and any necessary dental work will need to be carried out. The radiotherapy will make your teeth more sensitive and vulnerable to infection, so it is important to have a good level of dental hygiene before treatment begins.

A hygienist can also give you advice on how to maintain good dental hygiene. If you are smoking and drinking alcohol, it is recommended that you stop, because quitting will increase the chances of your treatment being successful.For information and advice see the Health A-Z topics on Quitting smoking and Treating alcohol misuse.

The mainstay of treatment is either surgery or radiotherapy or a combination, with chemotherapy added in for selected cases

Surgery

For mouth cancer, the aim of surgical treatment is to remove any affected tissue while minimising damage to the rest of the mouth.

Other forms of surgery

If your cancer is more advanced, it may be necessary to remove part of your mouth lining and, in some cases, facial skin. The removed skin can be replaced using a skin flap. This is a piece of skin that is taken from your forearm or chest, which is then grafted (joined) to the affected area.

If your tongue is affected, part of the tongue will have to be removed. This is known as a partial glossectomy. The tongue is then reconstructed using grafted tissue.

If the cancer has spread to your jawbone it will need to be surgically removed. The jawbone can be replaced by taking some bone from another part of your body and grafting it in place.

Occasionally, other bones, such as cheekbones, may have to be removed to completely remove the cancer. These bones can be replaced with prosthetics, which are molded pieces of plastic that are designed to replicate the shape and appearance of any removed bones. Modern prosthetics are usually very realistic. Although they will take time to get used to, your physical appearance should be largely unaffected.

During surgery, your surgeon may remove lymph nodes that are near the site of the initial tumour. This is known as a neck dissection. Neck dissections are often carried out as a preventative measure, as the nodes may contain small amounts of cancerous cells that cannot be detected through testing.

Radiotherapy

Radiotherapy uses doses of radiation to kill cancerous cells. It may be possible to remove the cancer using radiotherapy alone, but it is usually used after surgery to prevent the cancer from reoccurring.

While it kills cancerous cells, radiotherapy can also affect healthy tissue, and it has a number of side effects, including:

  • sore, red skin (like sunburn)
  • mouth ulcers
  • sore mouth and throat
  • dry mouth
  • loss of, or changes in, taste
  • loss of appetite
  • tiredness
  • nausea
  • stiff jaw
  • bad breath

Your care team will monitor any side effects that you have and, where possible, provide treatment for them. For example, protective gels can be used to treat mouth ulcers, and there are medicines that treat the symptoms of dry mouth.

The side effects of radiotherapy can be distressing, but most of them will pass once the radiotherapy is complete.

The radioactive implants will cause your mouth to become swollen, and you will experience some pain 5-10 days after the implants are removed. However, the pain should subside within a few weeks. During this time, you may find it more comfortable to eat cool, plain, soft foods, and avoid drinking spirits or smoking.

Chemotherapy

Chemotherapy is often used in combination with radiotherapy when the cancer is widespread, or if it is thought there is a significant risk of the cancer returning.

Chemotherapy involves the use of powerful cancer-killing medicines. These medicines damage the DNA of the cancerous cells, interrupting their ability to reproduce.

The medicines that are used in chemotherapy can sometimes damage healthy tissue as well as the cancerous tissue. Adverse side effects are common.

Side effects of chemotherapy can include:

  • sore mouth
  • mouth ulcers
  • nausea
  • vomiting
  • hair loss
  • tiredness

The side effects should stop once the treatment has finished.

Chemotherapy can also weaken your immune system and make you more vulnerable to infection.

Chemotherapy
Chemotherapy is a treatment of an illness or disease with a chemical substance, e.g. in the treatment of cancer.
Counselling
Counselling is guided discussion with an independent trained person, to help you find your own answers to a problem or issue.
Radiotherapy
Radiation therapy uses X-rays to treat disease, especially cancer.
Tissue

Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.

 

Dysphagia

Dysphagia means difficulty swallowing. It is easy to take for granted your ability to swallow food and liquid but, in reality, the process relies on a complex interaction of muscles, which can be easily disrupted.

Surgery and radiotherapy can affect your tongue, mouth or throat, resulting in dysphagia. Dysphagia is a potentially serious problem because aside from the risk of malnutrition, there is a chance that small particles of food could enter your airways and become lodged in your lungs. This can trigger a chest infection, known as aspiration pneumonia. 

For more information, see the Health A-Z topic on dysphagia.

Videofluoroscopy

If you are having problems with your swallowing, your swallowing reflex will need to be assessed by a speech and language therapist (SLT). One way that a SLT can assess this reflex is to perform a test known as a videofluoroscopy.

A videofluoroscopy involves adding a special dye to liquid and food, which you swallow. The special dye enables the SLT to study your swallowing reflexes by using X-rays and checking whether there is a risk of food entering your lungs.

If this is the case, it may be necessary in the short-term to provide you with a feeding tube, which will be directly connected to your stomach. The SLT will teach you exercises so that you can 'relearn' how to swallow properly.

Your ability to swallow will improve as you learn the exercises and the damaged tissue is allowed to heal. However, there is a chance that your swallowing reflex will never fully recover.

In some circumstances, you may have to alter your diet in order to make swallowing easier. A nutritionist can give you with dietary advice.

Speech therapy

Much like swallowing, your ability to speak clearly is governed by a complex interaction of muscles, bones and tissue, including your tongue, teeth, lips and soft palate (a section of tissue that is found at the back of the mouth).

Radiotherapy and surgery can affect this process and make it difficult to pronounce certain sounds. In severe cases, you may have problems making yourself understood.

A SLT will help you improve your verbal communication skills by teaching you a series of exercises that develop your range of vocal movements. It will also teach you new ways of producing sounds.

Tobacco

If you are currently using tobacco, you should quit. Tobacco comes in various forms, including:

  • cigarettes
  • pipe tobacco
  • cigars
  • cigarillos
  • snuff (powdered tobacco that is designed to be snorted into the nose)
  • chewing tobacco

All of these products will increase your chances of developing mouth cancer, as well as lung and bladder cancer and other serious health conditions, such as heart disease and stroke.

Quitting smoking (or using other tobacco products) will bring both short- and long-term health benefits. For example, if you go without smoking for 10 years, your risk of developing mouth cancer will be the same as somebody who has never smoked.

If you decide to stop smoking, your GP will be able to refer you to an HSE Stop Smoking Service, which will provide you with dedicated help and advice about the best ways to give up smoking. You can also call the National Smokers Quitline at 1850 201 203, or log on to www.quit.ie, or the HSE facebook page at www.facebook.com/hsequit.

The specially trained helpline staff can offer you free expert advice and encouragement.

If you are committed to giving up smoking but do not want to be referred to a stop smoking service, your GP can prescribe medical treatment to help with any withdrawal symptoms after you quit.

Alcohol

Make sure you stay within the recommended guidelines for alcohol consumption. This will reduce your risk of developing mouth cancer and other serious health conditions.

The recommended weekly limits of alcohol consumption are:

  • 21 standard drinks of alcohol for men
  • standard drinks for women

A standard drink of alcohol is equal to about half a pint of normal strength beer, a small glass of wine or a pub measure of spirits.

Contact your GP if you find it difficult to moderate your drinking. Counselling services and medication can help you to reduce your alcohol intake.

See Alcohol misuse - treatment for more information and advice.

Diet

Research has shown that eating a 'Mediterranean-style diet' can reduce your risk of getting mouth cancer. This is a diet that is high in fresh vegetables (particularly tomatoes), citrus fruits, olive oil and fish.

Eating five portions of a variety of fruit and vegetables a day will also help to prevent mouth cancer, as well as other types of cancer. Fruit and vegetables contain special chemicals known as antioxidants, which some scientists believe can help protect cells from becoming damaged. Leafy vegetables, such as lettuce, spinach and cabbage, are thought to provide the most protection against cancer.

Self-examination

If you are in a high-risk group for getting mouth cancer, check your mouth regularly for symptoms of cancer. If detected early enough, treatment for mouth cancer is much more likely to be successful and relatively non-invasive. High-risk groups include:

  • smokers (or other tobacco users), especially if you have been a smoker for many years
  • heavy drinkers (more than 4 units a day)
  • men
  • those aged 40 years or over

Use a mirror to check the inside of your mouth, your tongue and the space under your tongue for any changes in colour. Run your finger around your mouth and tongue to check for any lumps. Report anything unusual to your dentist or GP.

Also have a dental check-up at least once every two years. More frequent check-ups may be required if you have a history of dental problems, such as tooth decay or gum disease. Your dentist will be able to advise you.

Lesions
A lesion is an abnormal change in an organ or body tissue because of injury or disease.
Ulcers
An ulcer is a sore break in the skin, or on the inside lining of the body.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.