Sore throat has signs of oral cancer

Oral cancers are relatively rare and have a high mortality rate. However, most are preventable, says Dr Tillman Jacobi

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.

Symptoms

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.

Diagnosis

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

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

Learning points

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. 

Resources

NICE — www.nice.org.uk/page.aspx?o=233550

Mouth Cancer Foundation — www.rdoc.org.uk

Cancer Research UK http://info.cancerresearchuk.org/healthyliving/openuptomouthcancer

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

Care home vaccination to begin as Scottish minister says Pfizer vaccine packs can be split up

Care home vaccination to begin as Scottish minister says Pfizer vaccine packs can be split up

Vaccination of care home residents against COVID-19 will start on 14 December in...

How will the COVID-19 vaccination programme get underway?

How will the COVID-19 vaccination programme get underway?

Following the MHRA's approval of Pfizer/BioNTech's COVID-19 jab the government has...

NHS must keep doctors who returned in pandemic as overseas supply dries up, says GMC

NHS must keep doctors who returned in pandemic as overseas supply dries up, says GMC

Doctors who rejoined the NHS workforce in the pandemic must be urged to stay to help...

GPs unlikely to begin COVID-19 vaccination for 'at least two weeks', says BMA

GPs unlikely to begin COVID-19 vaccination for 'at least two weeks', says BMA

GP practices are unlikely to receive stocks of COVID-19 vaccine 'for at least another...

JCVI confirms priority groups for COVID-19 vaccination

JCVI confirms priority groups for COVID-19 vaccination

The Joint Committee on Vaccination and Immunisation (JCVI) has published a final...

MHRA approves Pfizer/BioNTech jab paving way for COVID-19 vaccination to start

MHRA approves Pfizer/BioNTech jab paving way for COVID-19 vaccination to start

The MHRA has approved the Pfizer/BioNTech COVID-19 vaccine for use in the UK and...