A 42-year-old female temporary resident came to see me having had a sore throat and difficulty swallowing for a few weeks. She looked unkempt and had a very poor dental status. She was homeless and admitted to a high alcohol intake but denied smoking.
On examination, I noticed an ulcerated area on the side of her tongue, which she attributed to a broken tooth nearby. The lesion made me suspect an oral cancer and I referred her to a specialist.
Oropharyngeal cancers account for less than 5 per cent of all cancers in the UK and the average GP will only see one case every seven years. Men are more at risk and about 80 per cent of patients with mouth cancers are over 50 years old.
Patients may present in unusual settings, for example out of hours or at A&E with dental problems. Despite the poor prognosis, oropharyngeal cancer is mostly preventable and the public should be made aware of this.
Although there have been significant improvements in chemotherapy and surgical techniques, the disease is challenging to treat since most patients present with advanced disease, have secondary tumours and suffer from co-morbidities. Mortality rate is 60 per cent within five years.
Lifestyle risk factors
Smoking cigarettes increases the risk at least tenfold, while smoking pipes and cigars might be more risky. Chewing tobacco or betel nut adds a particularly high risk.
Drinking more than 12 units of alcohol per day increases the risk of cancer by 15 times; in combination with smoking the risk may rise to more than 40 times baseline.
Dental hygiene plays a role, as does persistent low-level trauma, for example badly fitting dentures. There are still no conclusive findings as to what extent an infection with HPV contributes directly to the risk for oropharyngeal cancer.
The symptoms of oropharyngeal cancer can be general, sometimes vague and non-specific. The best-known ‘red flags’ are ulceration or discoloured patches, which might be painful or painless, lasting more than three weeks, or voice changes and hoarseness lasting more than six weeks.
Pain or numbness of the tongue or oral cavity, dysphagia for more than three weeks, and (unilateral) swelling of the neck or in the mouth should be explored. There also might be unexplained and persistent ear pain, cough, nasal swelling or sore throat.
The tongue (mainly the lateral border), the lips and the floor of the mouth account together for more than two-thirds of all sites for cancers in the oropharyngeal region and merit particular attention.
Definite diagnosis is usually reached by biopsy, but CT or MRI scans are performed to assess the size and extent of the lesion. It is usually worth requesting basic blood tests and a routine chest X-ray as part of the referral.
Treatment options are surgery and therapeutic, or palliative radiotherapy when indicated. In many cases, treatment is invasive and may cause the patient significant physical and psychological distress. Chemo-therapy is not commonly used except in lymphomas.
If there are affected lymph nodes, then a neck dissection is usually discussed. This procedure might be considered unnecessary because the general prognosis in such a case is likely to be poor.
Complications can include persistent pain and trismus, bleeding, infections, the formation of fistulas or strictures, and swallowing and speech problems. These may lead to clinical depression. The disfiguring cosmetic effects are often very stressful to cope with for the patient and families or carers.
Patients often need long-term rehabilitation and support with ongoing input from speech and language therapy, dieticians and palliative care.
This patient had oral cancer which was successfully treated.
Dr Jacobi is a salaried GP in York
Mouth Cancer Awareness Week runs from 12–18 November
Men and those aged over 50 are most at risk of developing mouth cancer.
Smoking, drinking and dental hygiene play an important role in the development of mouth cancer.
Red-flag symptoms include ulceration or discoloured patches and voice changes.
The tongue, lips and the floor of the mouth are the most common sites for cancer and should be explored carefully.
Mortality rate is 60 per cent within five years.
Mouth Cancer Foundation — www.rdoc.org.uk
Cancer Research UK http://info.cancerresearchuk.org/healthyliving/openuptomouthcancer