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Oral Cancer : Update for the Oral Healthcare Provider

Over 30,000 new cases are expected to be diagnosed in the United States this year alone. With proper intra-oral and extra-oral examinations conducted by a trained healthcare professional, early diagnosis can make all the difference in the management of the patient’s condition, although prevention remains the healthcare provider’s best option. To help avert future incidence, at-risk patients need to be educated by healthcare providers, including on nutritional information and, in the case of tobacco users, the U.S. Public Health Service’s “Five A’s.” Armed with a full understanding of the disease, the oral healthcare professional is the most likely frontline clinician to prevent, diagnose and manage a patient’s oral cancer. Introduction For the purpose of this article, the term “oral cancer” applies to malignancies occurring distal to the vermillion border of the lips in the oral cavity, and some pharyngeal sites, such as the oropharynx and tonsils, that are readily visible or palpable during a comprehensive examination by an oral healthcare provider (OHCP). Oral squamous cell carcinoma (SCCA), arising from the epithelium, comprises 90 percent of oral cancers, with the remaining 10 percent attributed to rare cancers, including salivary gland malignancies, sarcomas, and others. SCCA is the endpoint of an accumulation of alterations in genes responsible for maintaining the integrity of the genome (“caretaker” genes) and/or those responsible for controlling cellular proliferation (“gatekeeper” genes). Such alterations vary and range from subtle changes in DNA sequences to gross chromosomal gains or losses. The precise mechanisms by which these alterations lead to the genetic instability predicting malignant transformation, proliferation, and metastasis remains hotly debated. In general it seems clear that the progression follows a distinct temporal pattern from normal mucosa to precancer (oral epithelial dysplasia) to SCCA (commensurate with invasion into submucosal tissues), and that the majority of the genetic alterations found in SCCA are present in lesions preceding malignant transformation.1,2 Although the time line for pathogenesis is variable, there is an opportunity in most cases to visualize this disease during the premalignant stage where the changes are confined to the epithelial layers, or while the SCCA is at an early stage before it has spread from the primary site. Indeed, in the future it may be possible to detect molecular markers for these genetic mutations before any visual changes are evident. This article provides an update to OHCPs to facilitate early detection, which should translate into a reduction in both the morbidity and mortality of this terrible disease. Epidemiology United States estimates for oral cavity and pharyngeal cancers in 2006 indicate that 30,990 new cases will be diagnosed, 7,430 of which will be terminal.3 From 1975–2002 this data represents a modest yet significant decrease in the annual percentage changes in both incidence and mortality rates. That said, the 2006 data represents 1.5 percent and 5.5 percent increases in incidence and mortality, respectively. The lifetime risk for developing oral and pharyngeal cancer is one in 98. With respect to incidence this translates to an age-adjusted rate of 10.5 in 100,000 men and women per year. Incidence rates increase with age, with 89 percent over the age of 35 and an average age at diagnosis of 63. There has been a significant increase in oral cancer in the under-40 age group.4 In men, oral cavity and pharynx comprise the eighth leading site for cancer in the U.S., with incidence rates (15.5/100,000) that are more than twice those of women (6.4/100,000).5 By race, African American men have the highest incidence rates (19.0/100,000) and the poorest survival outcomes. Oropharyngeal cancers can occur at any subsite, with the tongue presenting the greatest number or occurences. With respect to mortality, there is a similar age, gender, and racial trend: an overall age-adjusted mortality rate of 2.8 in 100,000 men and women per year with higher rates in men (4.2/100,000 versus 1.6/100,000 in women), and the highest rates in African American men (7.1/100,000). However, the most important epidemiologic data is related to survival. Given the easy screening access, it is remarkable that the overall five-year relative survival rate for a patient diagnosed with oral and pharyngeal cancer during the period from 1995–2001 has been estimated to be about 59.4 percent, in stark contrast to breast or prostate cancer which have overall five-year relative survival rates of 88 percent and 100 percent respectively. Only 34 percent of oral and pharyngeal cancers are diagnosed with localized stage disease (i.e., no detectable spread of the primary cancer to regional lymph nodes).5 The importance of early detection is evident when survival rates are stratified by stage: localized disease is associated with the highest five-year relative survival rates (82.1 percent), compared to advanced disease that has spread to regional lymph nodes (51.3 percent) or to distant sites (27.6 percent). In addition to the high mortality of this disease if detected in the advanced stages, it is also important to note that quality of life for patients who do survive is greatly diminished due to the nature of the main treatment options, which include disfiguring surgery and radiation therapy that predict numerous complications.