Human Papillomavirus and Oral Cancer - Looking Toward the Clinic

6/18/2008
web-based article
Caroline McNeil
JNCI Journal of the National Cancer Institute 2008 100(12):840-842 Head and neck cancer researchers are considering clinical studies, including a proposed cooperative group treatment trial, that would investigate the link between human papillomavirus (HPV) and some oral cancers. Although the studies are still in the planning stage, they mark a new turn toward the clinic for an area that up to now has centered mostly on epidemiologic and laboratory studies.

Over the past decade, population studies have established an association between HPV and some tumors in the oropharynx (tonsils, soft palate, posterior pharynx, and base of tongue). Much remains unknown about the biology and natural history of oral HPV infection, but evidence of its association with these tumors is so strong that the International Agency for Research on Cancer concluded, in a monograph published in December, that there is "sufficient evidence in humans for the carcinogenicity of HPV16 in the oral cavity and oropharynx."

Now researchers are beginning to ponder the clinical implications of this link. Especially intriguing to many are data suggesting that HPV-positive oropharyngeal tumors respond better to treatment than HPV-negative tumors. That finding has given rise to important clinical questions, including the one to be addressed in the proposed trial: Can HPV-positive tumors be treated less aggressively than HPV-negative tumors because of their increased sensitivity to chemotherapy and radiotherapy?

"That's the fundamental question," said Arlene Forastiere, M.D., a professor at the Johns Hopkins Kimmel Cancer Center in Baltimore and a leader in the Eastern Cooperative Oncology Group, which is discussing the possibility of such a trial. "Should they be treated the same or differently?"

The difference in response rates is not the only aspect that sets HPV-positive tumors apart from HPV-negative tumors. Studies suggest that the tumors have different molecular and histologic features, that HPV-positive patients survive longer, and that their risk factors and demographics are distinct. HPV-positive patients are more likely to be young and less likely to smoke cigarettes or use alcohol than HPV-negative oral cancer patients. A prospective study published last year in the New England Journal of Medicine showed that HPV-positive tumors were strongly associated with multiple oral sex partners. Most recently, a case–control study ( J Natl Cancer Inst 2008;100:407–20) showed that HPV-positive oropharyngeal tumors are not influenced by alcohol or tobacco use, setting them apart from HPV-negative tumors, which are strongly associated with drinking and smoking.

"The risk factors are completely distinct and do not overlap," said Maura Gillison, M.D., Ph.D., a Hopkins cancer researcher and lead author on this study as well as the New England Journal of Medicine article. "These are actually completely different cancers that happen to occur in the same place," she said.

Others demur. This is "very groundbreaking work," said Jatin Shah, M.D., chief of the head and neck service at Memorial Sloan-Kettering Cancer Center in New York, "but it remains to be proven that these are distinct pathological entities." Tissue samples from HPV-positive and HPV-negative tumors look alike, he argues. And although HPV-positive patients have a better chance of responding to chemoradiation, the reasons are unknown. "This is a very provocative question," he said. "We need more research in the lab to answer it."

The question is particularly urgent in oropharyngeal cancer because of the acute and prolonged toxicity of current treatments, Shah said. The treatment can result in lifelong problems with swallowing and speech. And for HPV-positive patients, who are more likely to be young, that can mean many decades of severely impaired quality of life.

Still Hypothetical

Nevertheless, Shah and others warn against modifying the standard treatment now. Forastiere, who chairs the head and neck committee of the National Comprehensive Cancer Network, said that "it would be premature to make practice changes ... quite dangerous, really." The cancer network's 2008 treatment guidelines for orophyryngeal cancer will not mention HPV status, she said. "The next steps are really in clinical trials."

The link between HPV and oropharyngeal cancer also raises the possibility of targeting those tumors with a therapeutic vaccine. At Hopkins, Gillison and her colleagues have completed a phase I trial with an experimental treatment vaccine and are now analyzing the data. After 2 years of follow-up, she said, all 18 patients in the trial were doing well.

And if further studies confirm that HPV-positive patients have better response rates and survival, their improved prognosis could affect the staging system for head and neck cancers. Though a long way off, that possibility is already the subject of conjecture. Gillison said that, someday, HPV-positive and HPV-negative tumors might be staged as two separate diseases, in the way that small-cell and non–small-cell lung cancer are.

Shah, who chairs the head and neck section of the American Joint Committee on Cancer, which develops, maintains, and revises the tumor–node–metastasis staging system used in most cancers, said that one possibility would be to consider HPV status as an additional factor that influences prognosis. This factor may be considered in the future, he said, and could be similar to the way additional factors affect stage in other cancers. In thyroid cancer, for instance, anyone younger than 45 years is downstaged to a stage 1 or 2, even with distant metastases.

But HPV's effect on oropharyngeal staging is still hypothetical, Shah emphasized. The joint committee is not considering any changes to the current system. "The time may come when HPV status will be a factor," he said, "but there needs to be a lot more science before that."

Prevention and Screening?

The link between HPV and oropharyngeal cancer also has potential implications for prevention. Will it ever be possible, for instance, to detect precancerous changes in the oropharynx, as in the cervix, with the help of HPV-based screening?

Detecting signs of oral HPV infection is not difficult—in oral rinses, for instance. But finding evidence that the viral DNA has been integrated into oropharyngeal basal cells and identifying submucosal, premalignant changes before they become visible is "a bit trickier," Gillison said.

An even more fundamental barrier to screening is a lack of knowledge on how, or even whether, persistent oral HPV infection progresses to premalignant changes in the oropharynx.

"We don't know what the infection looks like in premalignant cells. We don't know if premalignant lesions in the oropharynx relate to HPV," said Aimee Kreimer, Ph.D., in the division of cancer prevention at the National Cancer Institute in Bethesda, Md. "It's so new. We don't know the natural history of oral HPV infection."

Shah said that studies are needed to show whether oral HPV infection progresses to dysplasia, as it does in cervical cancer. Doing so would take a prospective, longitudinal study of people with HPV infection, followed by visual detection of premalignant changes, he said. Or researchers might look for surrogate markers of progression by using random biopsies. "I don't know if anyone is doing this, but it would be an exciting project," he said. "It's the logical next step."

One smaller step toward understanding the natural history of HPV oral infection is a study, now in a pilot stage, designed to look at the persistence of these infections, Kreimer said. The study will be nested in a larger study—led by Anna Giuliano, Ph.D., at the H. Lee Moffitt Cancer Center in Tampa—which is monitoring men to evaluate anal and penile HPV infections.

Primary prevention of oropharyngeal cancers is another possibility that intrigues HPV researchers. Current HPV vaccines, designed to prevent cervical cancer, could theoretically prevent HPV-positive oropharyngeal cancers as well. Both Merck's Gardasil and GlaxoSmithKline's Cervarix (which was approved in Australia but not yet in the U.S.) target HPV16, which is implicated in most HPV-positive oropharyngeal cancers. And animal studies suggest that vaccination will prevent oral cancers. Hopkins researchers have proposed a prevention study to Merck, but when contacted for this article, a company spokesperson said that it is not currently working on plans for such a trial.

However, other studies may provide some data on this issue. Kreimer said that the NCI is considering adding an oral HPV component to its follow-up study of women in Costa Rica who participated in a trial of GlaxoSmithKline's prevention vaccine. The study would compare the prevalence of oral HPV infection among women who received the vaccine with women who did not.

More studies—of all kinds—are likely. The NCI head and neck steering committee will convene a state-of-the-science meeting in November to help identify and prioritize research needs, said Claudio Dansky Ullmann, M.D., NCI's lead for head and neck cancer trials, who serves on the steering committee. "We will bring the top experts in this area to discuss the current status of things and, we hope, to lay a platform plan for the development of future translational and clinical studies to advance the field," he said.

And there seems little doubt that some of those studies, such as the proposed treatment trial, will explore whether HPV-positive and HPV-negative patients should be treated differently. "We find the data indicating that HPV-positive and HPV-negative cancers are distinct disease entities to be compelling," Forastiere wrote in an e-mail. "Consequently, we are factoring this into clinical research questions and trial designs going forward." (www.oralcancerfoundation.org)

Primary Tumors Can Drive the Growth of Distant Cancers

6/23/2008
web-based article
staff
Biocompare Life Science News (www.biocomare.com) Primary tumors can encourage the growth of stray cancer cells lurking elsewhere in the body that otherwise may not have amounted to much, according to a new study in the June 13 issue of the journal Cell, a publication of Cell Press. As people age, most may have such indolent cancer cells given the sheer number of cells in the body, although their rarity makes them impossible to detect, the researchers said.

The primary tumors under study, which were derived from human breast cancers, seem to "instigate" the growth of other cancers by mobilizing bone marrow cells, which then feed the secondary tumors' growth, they report.

One key to the process is the secretion of a substance known as osteopontin by the instigating tumor, a finding that may have therapeutic implications. Indeed, the researchers noted that osteopontin is present at elevated levels in women with metastatic breast cancer, supporting the notion that the new findings may hold clinical significance.

"If metastases depend on stimulation by primary tumors, interception of the signal through neutralizing antibodies" might block cancer spread, said Robert Weinberg of the Massachusetts Institute of Technology. "That's still speculative, but it's an interesting idea to ponder," he added, noting that treatments today don't specifically target metastases, which are responsible for the vast majority of cancer deaths.

The researchers noted that while the effects of the tumor microenvironment has been much studied, much less was known about how the systemic environment in the body contributes to tumor growth. Several earlier reports had shown that assorted bone marrow-derived cells can be incorporated to various extents into the supportive framework, or stroma, of tumors. However, it wasn't clear whether tumors actively recruit stromal cells by directly perturbing other cell reservoirs, such as the bone marrow, or whether tumors are just passive recipients of stromal cell precursors that normally circulate throughout the body.

In the new study, the researchers injected "instigating" human tumor cells into mice along with indolent "responding" cancer cells also derived from humans. Those indolent cells formed vigorously growing tumors only in the presence of the instigating tumor cells, they reported. They found further evidence that the instigating tumor somehow perturbs the makeup of the bone marrow, although Weinberg said they don't really know how that happens. They also show that osteopontin is necessary to the process, but that it does not act alone.

Finally, they showed that the same instigation process can encourage the growth of disseminated metastatic cancer cells. Instigating breast tumors in the mice also drove the growth of implanted fragments of human colon tumors, a finding that they said shows the generality of the physiologic signaling.

Nonetheless, the researchers said they don't yet know how universal this systemic instigation of tumor growth might be. Still, the findings challenge the "prevailing view that primary tumors suppress the growth of derived metastases," Weinberg said. "We argue they can foster cancer's spread by activating bone marrow that is then recruited by distant metastases."

The findings also have important implications for the preclinical study of human cancers, Weinberg emphasized.

"The ability of instigating tumors to foster the growth of a human colon tumor surgical specimen underscores the powers of systemic instigation," the researchers wrote. "Indeed, to our knowledge, methods to expedite the growth of human tumor surgical specimens in vivo have not been previously described. These results suggest that the presently described procedure can be used to study aspects of human tumor biology that would otherwise be difficult if not impossible to study.

"In the longer term, identification of additional tumor-derived factors that perturb the host systemic environment in one way or another may allow one to predict the effects that a given primary tumor type has on the outgrowth of indolent cancer cells that have disseminated to distant sites."

George Moore, 88; doctor linked mouth cancer to chewing tobacco

6/23/2008
Los Angeles, CA
Thomas H. Maugh II
Los Angeles Times (www.latimes.com) Dr. George E. Moore, the cancer researcher who was among the first to link chewing tobacco to mouth cancer and who built the Roswell Park Memorial Institute in Buffalo, N.Y., into a major cancer research center, died May 19 in Conifer, Colo. He was 88. The cause of death was bladder cancer, according to his family.

George E. Moore also discovered the use of fluorescent and radioactive materials to diagnose and localize brain tumors, was a pioneer in the use of chemotherapy to treat breast cancer, and developed techniques for growing tumor cells in a laboratory.

When Moore did his first studies of tobacco chewing in the 1950s, there was little strong evidence linking smoking and lung cancer and virtually none tying tobacco to other cancers.

In a seminal 1954 paper, Moore and colleagues from Roswell Park and the University of Minnesota reported on 40 men who suffered from oral cancer. They found that 26 of them had chewed tobacco, most for 15 years or longer. The paper presented the first evidence that chewing tobacco could be as lethal as smoking it.

Extending their studies, they also found that many people who chewed but did not yet have mouth cancer had gum irritation and leukoplasia -- white spots or patches on the interior of the mouth that are often a forerunner of cancer.

His discoveries put Moore on the leading edge of tobacco research for more than 15 years, but it was hard work because of the efforts of tobacco companies. When he tried to procure tobacco seedlings so he could grow his own plants, for example, he was unsuccessful until the husband of a woman he had treated for breast cancer provided some.

In his later life, he was pessimistic about his effort.

"With all of our scientific things, working as hard as we did, I don't think we influenced smoking very much," he told the Denver Post. "I think it became a socially accepted thing not to smoke, and that did more to change smoking habits than all of our scientific things."

George Eugene Moore was born Feb. 22, 1920, in Minneapolis. He attended the University of Minnesota, receiving his medical degree in 1947 and a doctorate in surgery in 1950.

He spent his early career at the University of Minnesota Medical School and at age 32 was named head of Roswell Park, then a struggling research institute with two aging buildings.

By the time he left in 1967, the institute, now known as the Roswell Park Cancer Institute, had grown to cover seven city blocks.

"He was a role model for oncologists and a highly successful administrator," said Dr. Donald L. Trump, current president and chief executive of the institute.

Moore left the institute when he was appointed director of public health research for the state of New York. He held the post until 1973, when he moved to Denver to join the University of Colorado School of Medicine. He spent the rest of his career there.

When Moore began his research, the primary treatment for breast cancer was surgical removal of the tumor. In the early 1960s, working with Dr. Rudolph Noer of the University of Louisville, Moore began supplementing surgery with the chemotherapeutic drug thiotepa.

They found that the drug could prevent or delay the recurrence of tumors in many patients. Unfortunately, it also triggered premature menopause; the drug gave way to more effective agents. But their study was among the first to show that chemotherapy could be useful in treating breast tumors.

Moore also developed chemical solutions that could be used to grow tumor cells in a laboratory, refusing to patent the technique so that it could be widely used. In the basement of his Denver office were nearly 1,000 such tumor lines, some of which had been kept alive 20 to 30 years. He called them "patients in a bottle."

Moore had a variety of interests outside oncology. He dabbled in metalworking, creating a 7-foot-tall sculpture of the cross-section of a cell that he displayed in his frontyard.

He also studied the geology of Colorado and was a past president of the Colorado Mineral Society.

He met his wife of 63 years, the former Lorraine P. Hammell, while hitchhiking to an airport outside Minneapolis to take flying lessons.

In addition to his wife, he is survived by two sons, Allan of Acton, Mass., and Donald of Conifer; three daughters, Cathy of Tucson, Laurie of Davis, Calif., and Linda of Golden, Colo.; two brothers, John of Minneapolis and Robert of San Jose; a sister, Elizabeth Severson of Minneapolis; eight grandchildren; and three great-grandchildren.

Mouth cancer checks DO happen, say dentists

6/23/2008
London, England
staff
Dentistry.uk.co A report revealing an alarming number of dental patients going without mouth cancer checks has prompted a tide of protest from dentists throughout the UK. The survey revealed that 71% of people said their dentist had never checked them for the condition. And 87% said their dentist had never even spoken to them about it.

Dr Nigel Carter, chief executive of the British Dental Health Foundation (BDHF), said: ‘Mouth cancer is a very serious condition.

‘It kills more than cervical cancer and testicular cancer combined, and yet a staggering 23% of people have never even heard of it.

‘The problem here appears to be twofold. First, not enough dentists are carrying out the checks, and second, those that do carry them out are failing to communicate this to their patients, missing a perfect opportunity to educate them on the dangers of mouth cancer.

‘NHS dentists are expected to carry out dental check-ups in a very short space of time, and it appears that many do not feel they have the time to carry out this important activity.'

The National Mouth Cancer Survey questioned 500 adults across 10 UK cities in April 2008 and was coducted by the BDHF and Medicash.

However, Mr Gill, a partner at Dean Road Dental Practice in South Shields, said: ‘It is something that is done, but not said.

‘When having a good look around the mouth, we look for these things. It is what we do. It is part of our job.'

Mr Gill has only come across three cases of mouth cancer in the 15 years he has been qualified.

He added: ‘It is not something you see often, but it is on the increase due to alcohol and smoking, and that is a concern. We check every patient, full stop.'

Dr Amarjit Gill, who works at a practice in Nottingham, said: ‘I'm sure dentists are checking, but maybe just not telling the patient.

‘The important thing for patients is to feel empowered and ask if they are worried about anything.

‘When you use the word 'cancer' with people, it sends shockwaves.'

Dr Gill said all his patients knew he checked for the disease and made them aware of it.

Mouth cancer kills one in two people that develop the condition but with early detection survival chances increase to nine out of ten.

Dentists are trained to spot the early signs of mouth cancer that can include ulcers that do not heal, lumps and red or white patches in the mouth.

Self-examination can also be beneficial.

Treatment of Patients with Clinically Lymph Node-negative Squamous Cell Carcinoma of the Oral Cavity

6/24/2008 Seoul, South Korea Won Il Jang et al.

Japanese Journal of Clinical Oncology 2008 38(6):395-401 Objective:
To evaluate treatment outcome and to determine optimal treatment strategy for patients with clinically lymph node-negative (N0) oral cavity squamous cell carcinoma (SCC).

Methods:
Two hundred and twenty-seven patients with oral cavity SCC received radiotherapy with curative intent. We retrospectively analyzed 69 patients with clinically N0 disease. Forty-three patients were treated with surgery followed by radiotherapy (S+EBRT) and 26 with radiotherapy alone (EBRT). The median doses administered were 63.0 Gy for S+EBRT and 70.2 Gy for EBRT.

Results:
The rates of occult metastasis were 60% for T1, 69% for T2, 100% for T3 and 39% for T4, respectively, among patients who underwent neck dissection. A contralateral occult metastasis occurred only in two patients. The median follow-up was 39 months (range, 6–170 months). The 5-year overall survival (OS), disease-free survival (DFS), local control (LC) and regional control (RC) rates for all patients were 56, 50, 66 and 79%, respectively. The 5-year OS, DFS, LC and RC rates were 67/39% (P < 0.01), 66/24% (P < 0.01), 87/30% (P < 0.01) and 73/89% (P = 0.11) for S+EBRT/EBRT, respectively.

Conclusions:
The risk for occult neck metastasis is high in patients with oral cavity SCC; therefore, elective neck treatment should be considered. Excellent RC for subclinical disease can be achieved with radiotherapy alone. However, external beam radiotherapy alone to primary tumor resulted in poor LC and combined treatment with surgery and radiotherapy appeared to be a better treatment strategy.

Authors:
Won Il Jang1, Hong-Gyun Wu1,4,5, Charn Il Park1,4,5, Kwang Hyun Kim2, Myoung-Whun Sung2, Myung-Jin Kim3, Pill-Hoon Choung3, Jong-Ho Lee3 and Jin-Yong Choi3

Authors affiliations:
1 Department of Radiation Oncology, Seoul National University College of Medicine, Seoul
2 Department of Otolaryngology and Head and Neck Surgery, Seoul National University College of Medicine, Seoul
3 Department of Oral and Maxillofacial Surgery, Seoul National University College of Dentistry, Seoul
4 Cancer Research Institute, Seoul National University College of Medicine, Seoul
5 Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Republic of Korea

Oral Cancer At A Glance

Oral Cancer At A Glance

• Oral cancer is caused by tobacco (smoking and chewing) and alcohol use.
• A sore in the mouth that does not heal can be a warning sign of oral cancer.
• A biopsy is the only to know whether as abnormal area in the oral cavity is cancer.
• Treatment of oral cancer depends on the location, size, type, and extent of the tumor, as well as the age and health of the patient.
• Surgery to remove the tumor in the mouth is the usual treatment for patients with oral cancer.

SOURCE: National Institutes of Health, National Cancer Institute, www.cancer.gov

National Cancer Institute information resources

National Cancer Institute information resources

You may want more information for yourself, your family, and your doctor. The following National Cancer Institute (NCI) services are available to help you.

Telephone

Cancer Information Service (CIS) Provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information Specialists translate the latest scientific information into understandable language and respond in English, Spanish, or on TTY equipment.

Toll-free: 1-800-4-CANCER (1-800-422-6237)
TTY: 1-800-332-8615

Internet

http://cancer.gov
The NCI's Cancer.gov™ Web site provides information from numerous NCI sources. It offers current information on cancer prevention, screening, diagnosis, treatment, genetics, supportive care, and ongoing clinical trials. It also provides information about NCI's research programs and funding opportunities, cancer statistics, and the Institute itself. Cancer.gov provides live, online assistance through LiveHelp. Cancer.gov is at http://cancer.gov on the Internet.

http://www.smokefree.gov
The Tobacco Control Research Branch of NCI, in collaboration with the Centers for Disease Control and Prevention and the American Cancer Society, created a smoking cessation Web site. It offers online quitting advice through NCI's LiveHelp service. It also provides national and state telephone quitline numbers and access to printed materials about quitting tobacco. It is located on the Internet at http://www.smokefree.gov.

Print materials

You can order National Cancer Institute (NCI) publications by writing to the address below:

Publications Ordering Service
National Cancer Institute
Suite 3036A
6116 Executive Boulevard, MSC 8322
Bethesda, MD 20892-8322

Some NCI publications can be viewed, downloaded, and ordered from http://cancer.gov/publications on the Internet. If you are in the United States or one of its territories, you may order these and other NCI booklets by calling the Cancer Information Service at 1-800-4-CANCER.

National Institute of Dental and Craniofacial Research information resources

The National Oral Health Information Clearinghouse

This Clearinghouse is a service of the Federal Government's National Institute of Dental and Craniofacial Research (NIDCR). NIDCR's mission is to promote the general health of the American people by improving their oral, dental, and craniofacial health. Through the conduct and support of research and the training of researchers, the NIDCR aims to promote health, prevent diseases and conditions, and develop new diagnostics and therapies.

NIDCR directs the health awareness campaign, Oral Health, Cancer Care, and You: Fitting the Pieces Together. The campaign addresses the importance of preventing and managing the oral side effects of cancer treatments. It is a partnership among NIDCR, NCI, National Institute of Nursing Research, and Centers for Disease Control and Prevention.

NIDCR can supply free information about oral cancer and taking care of your mouth during cancer treatment. Booklets are available in English and Spanish:

Chemotherapy and Your Mouth
Head and Neck Radiation Treatment and Your Mouth
Quimioterapia y la Boca (Chemotherapy and Your Mouth)
Su Boca y el Tratamiento de Radiación en la Cabeza y el Cuello (Head and Neck Radiation and Your Mouth)

Materials may be obtained by contacting the Clearinghouse:
National Institute of Dental and Craniofacial Research
National Oral Health Information Clearinghouse
Attn: OCCT
1 NOHIC Way
Bethesda, MD 20892-3500
Tel: 301-402-7364

Materials are also available online at http://www.nidcr.nih.gov under "health information."

Researchers from University of Minnesota publish findings in oral cancer

6/25/2008
Minneapolis, MN
staff
NewsRX (www.newsrx.com) According to a study from the United States, "Whole human saliva possesses tremendous potential in clinical diagnostics, particularly for conditions within the oral cavity such as oral cancer. Although many have studied the soluble fraction of whole saliva, few have taken advantage of the diagnostic potential of the cells present in saliva, and none have taken advantage of proteomics capabilities for their study."

"We report on a novel proteomics method with which we characterized for the first time cells contained in whole saliva from patients diagnosed with oral squamous cell carcinoma. Our method uses three dimensions of peptide fractionation, combining the following steps: preparative IEF using free flow electrophoresis, strong cation exchange step gradient chromatography, and microcapillary reverse-phase liquid chromatography. We determined that the whole saliva samples contained enough cells, mostly exfoliated epithelial cells, providing adequate amounts of total protein for proteomics analysis. From a mixture of four oral cancer patient samples, the analysis resulted in a catalogue of over 1000 human proteins, each identified from at least two peptides, including numerous proteins with a role in oral squamous cell carcinoma signaling and tumorigenesis pathways. Additionally proteins from over 30 different bacteria were identified, some of which putatively contribute to cancer development. The combination of preparative IEF followed by strong cation exchange chromatography effectively fractionated the complex peptide mixtures despite the closely related physiochemical peptide properties of these separations (pI and solution phase charge, respectively). Furthermore compared with our two-step method combining preparative IEF and reverse-phase liquid chromatography, our three-step method identified significantly more cellular proteins while retaining higher confidence protein identification enabled by peptide pi information gained through IEF," wrote H.W. Xie and colleagues, University of Minnesota.

The researchers concluded: "Thus, for detecting salivary markers of oral cancer and possibly other conditions of the oral cavity, the results confirm both the potential of analyzing the cells in whole saliva and doing so with our proteomics method."

Support for people with oral cancer

Support for people with oral cancer

Living with a serious disease such as oral cancer is not easy. You may worry about caring for your family, keeping your job, or continuing daily activities. You may have concerns about treatments and managing side effects, hospital stays, and medical bills. Doctors, nurses, and other members of the health care team can answer your questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful if you want to talk about your feelings or discuss your concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group. The NCI's fact sheets "Cancer Support Groups: Questions and Answers" and "National Organizations That Offer Services to People With Cancer and Their Families" tell how to find a support group. See "National Cancer Institute Information Resources" for ordering information.

The Cancer Information Service can provide information to help patients and their families locate programs, services, and publications.

The promise of cancer research

Doctors all over the country are conducting many types of clinical trials. These are research studies in which people volunteer to take part. In clinical trials, doctors are testing new ways to treat oral cancer. Research has already led to advances, and researchers continue to search for more effective approaches.

People who join clinical trials may be among the first to benefit if a new approach is shown to be effective. And if participants do not benefit directly, they still make an important contribution to medical science by helping doctors learn more about the disease and how to control it. Although clinical trials may pose some risks, researchers do all they can to protect their patients.

Researchers are testing anticancer drugs and combinations of drugs. They are studying radiation therapy combined with drugs and other treatments. They also are testing drugs that prevent or reduce the side effects of radiation therapy.

If you are interested in learning more about joining a clinical trial, you may want to talk with your doctor. You may want to read Taking Part in Clinical Trials: What Cancer Patients Need To Know. The NCI also offers an easy-to-read brochure called If You Have Cancer…What You Should Know About Clinical Trials. These NCI publications describe how research studies are carried out and explain their possible benefits and risks. NCI's Web site includes a section on clinical trials at http://cancer.gov/clinicaltrials with general information about clinical trials and detailed information about specific studies. The Cancer Information Service at 1-800-4-CANCER or at LiveHelp at http://cancer.gov can answer questions and provide information about clinical trials. Another source of information about clinical trials is http://clinicaltrials.gov.

Follow-up care for oral cancer

Follow-up care for oral cancer

Follow-up care after treatment for oral cancer is important. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained in the body after treatment. The doctor monitors your recovery and checks for recurrence of cancer. Checkups help ensure that any changes in your health are noted. Your doctor will probably encourage you to inspect your mouth regularly and continue to have exams when you visit your dentist. It is important to report any changes in your mouth right away.

Checkups include exams of the mouth, throat, and neck. From time to time, your doctor may do a complete physical exam, order blood tests, and take x-rays.

People who have had oral cancer have a chance of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for those who use tobacco or who drink alcohol heavily. Doctors strongly urge their patients to stop using tobacco and drinking to cut down the risk of a new cancer and other health problems.

The NCI has prepared a booklet for people who have completed their treatment to help answer questions about follow-up care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for making the best use of medical visits. It describes how to talk to your health care team about creating a plan of action for recovery and future health.

Smokeless tobacco ups oral cancer risk 80 pct - WHO

Smokeless tobacco ups oral cancer risk 80 pct - WHO

Chewing tobacco and snuff are less dangerous than cigarettes but the smokeless products still raise the risk of oral cancer by 80 percent, the World Health Organisation's cancer agency said on Tuesday.

The review of 11 studies worldwide showed people who chewed tobacco and used snuff also had a 60 percent higher risk of oesophagus and pancreatic cancer.

The researchers sought to quantify the risk of smokeless tobacco after a number of studies differed on just how dangerous the products were, said Paolo Boffetta, an epidemiologist at the WHO's International Agency for Research on Cancer.

"What we did was try to quantify the burden of smokeless cancer," he said in a telephone interview. "This has never been attempted in such a systematic way before."

The researchers, who published their findings in Lancet Oncology, did this by looking at population-wide studies and trials of both humans and animals.

They found frequency of use varies greatly both across and within countries, depending on sex, age, ethnic origin and economic background, and were highest in the United States, Sweden and India.

They also found that while snuff and chew were less dangerous than smoking because they were not linked to lung cancer, getting cigarette users to switch was not good public policy.

"If all smokers did this there would be a net benefit," Boffetta said. "The point is we don't know whether this would happen and there is no data to suggest these smokers would stop or switch."

Oral Cancer (Reconstruction and rehabilitation)

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 replaced.

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 oral cavity from the chest, arm, or leg. The plastic surgeon uses this tissue for repair.

If you are thinking about reconstruction, you may wish to consult with a plastic or reconstructive surgeon before your treatment 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

The 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. Rehabilitation may include being fitted with a dental prosthesis (an artificial dental device) and having dental implants. It also may involve speech therapy, dietary counseling, or other services.

Sometimes surgery to rebuild the bones or tissues of the mouth is not possible. A dentist with special training (a prosthodontist) may be able to make you a prosthesis to help you eat and talk normally. You may need special training to learn to use it.

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. Often speech therapy continues after you return home.

Oral Cancer (Nutrition)

Nutrition

Eating well during cancer treatment means getting enough calories and protein to prevent weight loss, regain strength, and rebuild healthy tissues. But eating well may be difficult after treatment for oral cancer. Some people with cancer find it hard to eat because they lose their appetite. They may not feel like eating because they are uncomfortable or tired. A dry or sore mouth or changes in smell and taste also may make eating difficult.

If your mouth is dry, you may find that soft foods moistened with sauces or gravies are easier to eat. Thick soups, puddings, and milkshakes often are easier to swallow. Nurses and dietitians can help you choose the right foods. Also, the National Cancer Institute booklet Eating Hints for Cancer Patients contains many useful ideas and recipes. The "National Cancer Institute Information Resources" section tells how to get this publication.

After surgery or radiation therapy for oral cancer, some people need a feeding tube. A feeding tube is a flexible plastic tube that is passed into the stomach through an incision in the abdomen. In almost all cases, the tube is temporary. Most people gradually return to a regular diet.

To protect your mouth during cancer treatment, it helps to avoid:

• Sharp, crunchy foods like taco chips
• Foods that are hot, spicy, or high in acid like citrus fruits and juices
• Sugary foods that can cause cavities
• Alcoholic drinks

Side effects of treatment for oral cancer

Side effects of treatment for oral cancer

Because treatment often damages healthy cells and tissues, unwanted side effects are common. These side effects depend mainly on the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects. Booklets such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients may be viewed, downloaded, and ordered from http://cancer.gov/publications. These materials also may be ordered by calling the Cancer Information Service at 1-800-4-CANCER.

The National Institute of Dental and Craniofacial Research (NIDCR) also provides helpful materials. Head and Neck Radiation Treatment and Your Mouth, Chemotherapy and Your Mouth, and other booklets are available from NIDCR. See "National Institute of Dental and Craniofacial Research Information Resources" for a list of publications.

Surgery

It takes time to heal after surgery, and the time needed to recover is different for each person. You may be uncomfortable 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 is common to feel tired or weak for a while. 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 the 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. Reconstructive or plastic surgery may be done to rebuild the bones or tissues of the mouth. (See "Reconstruction.")

Radiation therapy

Almost all patients who have radiation therapy to the head and neck area develop oral side effects. That is why it is important to get the mouth in good condition before cancer treatment begins. Seeing a dentist two weeks before cancer treatment begins gives the mouth time to heal after dental work.

The side effects of radiation therapy depend mainly on the amount of radiation given. Some side effects in the mouth go away after radiation treatment ends, while others last a long time. A few side effects (such as dry mouth) may never go away.

Radiation therapy may cause some or all of these side effects:

• Dry mouth: 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: Radiation can cause major tooth decay problems. 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 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 baking soda and 1/8 teaspoon salt in one cup of warm water. After you rinse with this solution, follow with a plain water rinse.
• Sore throat or mouth: Radiation therapy can cause painful ulcers and inflammation. 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.
• Sore or bleeding gums: It is important to brush and floss teeth gently. You may want to avoid areas that are sore or bleeding. To protect your gums from damage, it is a good idea to avoid the use of toothpicks.
• Infection: Dry mouth and damage to the lining of the mouth from radiation therapy can cause infection to develop. It helps to check your mouth every day for sores or other changes and to tell your doctor or nurse about any mouth problems.
• Delayed healing after dental care: Radiation treatment may make it hard for tissues in the mouth to heal. It helps to have a thorough dental exam and complete all needed dental treatment well before radiation therapy begins.
• Jaw stiffness: Radiation can affect the chewing muscles and make it difficult for you to open your mouth. You can prevent or reduce jaw stiffness by exercising your jaw muscles. Health care providers often 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 do not 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.
• Changes in the sense of taste and smell: During radiation therapy, food may taste or smell different.
• 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 directed at the neck may cause your larynx to swell, causing voice changes and the feeling of a lump in your throat. Your doctor may suggest medicine to reduce this swelling.
• Changes in the thyroid: Radiation treatment 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.
• Skin changes in the treated area: The skin in the treated area may become red or dry. Good skin care is important at this time. It is helpful to expose this area to the air while protecting it from the sun. Also, avoid wearing clothes that rub the treated area, and do not shave the treated area. You should not use lotions or creams in the treated area without your doctor's advice.
• Fatigue: You may become very tired, especially in the later weeks of radiation therapy. Resting is important, but doctors usually advise their patients to stay as active as they can.

Although the side effects of radiation therapy can be distressing, 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 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 also cause bleeding in the mouth and a deep pain that feels like a toothache. The problems you have depend on the type and amount of anticancer drugs you receive, and how your body reacts to them. You may have these problems only during treatment or for a short time after treatment ends.

Generally, anticancer drugs affect cells that divide rapidly. In addition to cancer cells, these rapidly dividing cells include the following:

• Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired.
• Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but sometimes the new hair is somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.

Treatment for oral cancer

Methods of treatment

Oral cancer treatment may include surgery, radiation therapy, or chemotherapy. Some patients have a combination of treatments.

At any stage of disease, people with oral cancer may have treatment to control pain and other symptoms, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called supportive care, symptom management, or palliative care. Information about supportive care is available on NCI's Web site at http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.

You may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.

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. Patients may have surgery alone or in combination with radiation therapy.

You may want to ask the doctor these questions before having surgery: What kind of operation do you recommend for me? Do I need any lymph nodes removed? Why? How will I feel after the operation? How long will I be in the hospital? What are the risks of surgery? Will I have trouble speaking, swallowing, or eating? Where will the scars be? What will they look like? Will I have any long-term effects? Will I look different? Will I need reconstructive or plastic surgery? When can that be done? Will I lose my teeth? Can they be replaced? How soon? Will I need to see a specialist for help with my speech? When can I get back to my normal activities? How often will I need checkups? Would a clinical trial be appropriate for me?

Radiation therapy

Radiation therapy (also called radiotherapy) is a type of local therapy. It affects cells only in the treated area. Radiation therapy is used alone for small tumors or for patients who cannot have surgery. It may be used before surgery to kill cancer cells and shrink the tumor. It also may be used after surgery to destroy cancer cells that may remain in the area.

Radiation therapy uses high-energy rays to kill cancer cells. Doctors use two types of radiation therapy to treat oral cancer:

• External radiation: The radiation comes from a machine. Patients go to the hospital or clinic once or twice a day, generally 5 days a week for several weeks.
• Internal radiation (implant radiation): The radiation comes from radioactive material placed in seeds, needles, or thin plastic tubes put directly in the tissue. The patient stays in the hospital. The implants remain in place for several days. Usually they are removed before the patient goes home.

Some people with oral cancer have both kinds of radiation therapy.

You may want to ask the doctor these questions before having radiation therapy: Which type of radiation therapy do you recommend for me? Why do I need this treatment? When will the treatments begin? When will they end? Should I see my dentist before I start treatment? If I need dental treatment, how much time does my mouth need to heal before radiation therapy starts? What are the risks and side effects of this treatment? What can I do about them? How will I feel during therapy? What can I do to take care of myself during therapy? How will my mouth and face look afterward? Are there any long-term effects? Can I continue my normal activities? Will I need a special diet? For how long? How often will I need checkups? Would a clinical trial be appropriate for me?

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. It is called systemic therapy because it enters the bloodstream and can affect cancer cells throughout the body.

Chemotherapy is usually given by injection. It may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a hospital stay may be needed.

You may want to ask the doctor these questions before having chemotherapy:

• Why do I need this treatment?
• Which drug or drugs will I have?
• How do the drugs work?
• Should I see my dentist before I start chemotherapy? If I need dental treatment, how much time does my mouth need to heal before the chemotherapy begins?
• What are the expected benefits of the treatment?
• What are the risks and possible side effects of treatment? What can I do about them?
• When will treatment start? When will it end?
• Will I need to stay in the hospital? How long?
• How will treatment affect my normal activities?
• Would a clinical trial be appropriate for me?

Treatment for oral cancer

Treatment for oral cancer

Staging

If the biopsy shows that cancer is present, your doctor needs to know the stage (extent) of your disease to plan the best treatment. The stage is based on the size of the tumor, whether the cancer has spread and, if so, to what parts of the body.

Staging may require lab tests. It also may involve 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 have 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.

The doctor may order one or more imaging tests to learn whether the cancer has spread:

• Dental x-rays: An x-ray of your entire mouth can show whether cancer has spread to the jaw.
• Chest x-rays: 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 the mouth, throat, neck, or elsewhere in the body show up on the CT scan.
• MRI: A powerful magnet linked to a computer is used to make detailed pictures of your body. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether oral cancer has spread.

Treatment

Many people with oral cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and your treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor—to take part in the discussion, to take notes, or just to listen.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat oral cancer include oral and maxillofacial surgeons, otolaryngologists (ear, nose, and throat doctors), medical oncologists, radiation oncologists, and plastic surgeons. You may be referred to a team that includes specialists in surgery, radiation therapy, or chemotherapy. Other health care professionals who may work with the specialists as a team include a dentist, speech pathologist, nutritionist, and mental health counselor.

Getting a second opinion

Before starting treatment, you might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if you or your doctor requests it.

There are a number of ways to find a doctor for a second opinion:

• Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
• The Cancer Information Service, at 1-800-4-CANCER, can tell you about nearby treatment centers.
• A local or state medical or dental society, a nearby hospital, or a medical or dental school can usually provide the names of specialists in your area.
• The American Board of Medical Specialties (ABMS) has a list of doctors who have had training and exams in their specialty. You can find this list in the Official ABMS Directory of Board Certified Medical Specialists. The directory is available in most public libraries. Or you can look up doctors at http://www.abms.org. (Click on Who's Certified.)
• The American Dental Association (ADA) Web site provides a list of dentists by specialty and location. The ADA Member Directory is available on the Internet at http://www.ada.org.
• The NCI provides a helpful fact sheet on how to find a doctor called "How To Find a Doctor or Treatment Facility If You Have Cancer." It is available on the Internet at http://cancer.gov/publications.

You may want to ask the doctor these questions before treatment begins: What is the stage of the disease? Has the cancer spread? If so, where? What are my treatment choices? Which do you recommend for me? Will I have more than one kind of treatment? What are the expected benefits of each kind of treatment? What are the risks and possible side effects of each treatment? How will treatment affect my normal activities? Will I be given anything to control side effects? How long will treatment last? Will I have to stay in the hospital? What is the treatment likely to cost? Is this treatment covered by my insurance plan? Would a clinical trial (research study) be appropriate for me? (See "The Promise of Cancer Research" for more information about clinical trials.) Should I try to quit smoking?

Preparing for treatment

The choice of treatment depends mainly on your general health, where in your mouth or oropharynx the cancer began, the size of the tumor, and whether the cancer has spread. Your doctor can describe your treatment choices and the expected results. You will want to consider how treatment may affect normal activities such as swallowing and talking, and whether it will change the way you look. You and your doctor can work together to develop a treatment plan that meets your needs and personal values.

You do not need to ask all your questions or understand all the answers at once. You will have other chances to ask your doctor to explain things that are not clear and to ask for more information.

Diagnosis of oral cancer

If you have symptoms that suggest oral cancer, the doctor or dentist checks your mouth and throat for red or white patches, lumps, swelling, or other problems. This exam includes looking carefully at the roof of the mouth, back of the throat, and insides of the cheeks and lips. The doctor or dentist also gently pulls out your tongue so it can be checked on the sides and underneath. The floor of your mouth and lymph nodes in your neck also are checked.

If an exam shows an abnormal area, a small sample of tissue may be removed. Removing tissue to look for cancer cells is called a biopsy. Usually, a biopsy is done with local anesthesia. Sometimes, it is 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 cancerous.

If you need a biopsy, you may want to ask the doctor or dentist some of the following questions:

• Why do I need a biopsy?
• How much tissue do you expect to remove?
• How long will it take? Will I be awake? Will it hurt?
• How soon will I know the results?
• Are there any risks? What are the chances of infection or bleeding after the biopsy?
• How should I care for the biopsy site afterward? How long will it take to heal?
• Will I be able to eat and drink normally after the biopsy? (www.medicinenet.com)

What are the symptoms of oral cancer?

Early detection

Your regular checkup is a good time for your dentist or doctor to check your entire mouth for signs of cancer. Regular checkups can detect the early stages of oral cancer or conditions that may lead to oral cancer. Ask your doctor or dentist about checking the tissues in your mouth as part of your routine exam.

Symptoms

Common symptoms of oral cancer include:

• Patches inside your mouth or on your lips that are white, a mixture of red and white, or red
  • 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 won't heal
• Bleeding in your mouth
• Loose teeth
• Difficulty or pain when swallowing
• Difficulty wearing dentures
• A lump in your neck
• An earache

Anyone with these symptoms should see a doctor or dentist so that any problem can be diagnosed and treated as early as possible. Most often, these symptoms do not mean cancer. An infection or another problem can cause the same symptoms.

Oral cancer

Oral cancer is part of a group of cancers called head and neck cancers. Oral cancer can develop in any part of the oral cavity or oropharynx. Most oral cancers begin in the tongue and in the floor of the mouth. 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.

When oral cancer spreads (metastasizes), it usually travels through the lymphatic system. Cancer cells that enter the lymphatic system are carried along by lymph, a clear, watery fluid. The cancer cells often appear first in nearby lymph nodes in the neck.

Cancer cells can also spread to other parts of the neck, the lungs, and other parts of the body. When this happens, the new tumor has the same kind of abnormal cells as the primary tumor. For example, if oral cancer spreads to the lungs, the cancer cells in the lungs are actually oral cancer cells. The disease is metastatic oral cancer, not lung cancer. It is treated as oral cancer, not lung cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Oral cancer: Who's at risk?

Doctors cannot always explain why one person develops oral cancer and another does not. However, we do know that this disease is not contagious. You cannot "catch" oral cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop oral cancer. A risk factor is anything that increases your chance of developing a disease.

The following are risk factors for oral cancer:

• Tobacco: Tobacco use accounts for most oral cancers. Smoking cigarettes, cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral cancer. The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. Heavy smokers who use tobacco for a long time are most at risk. The risk is even higher for tobacco users who drink alcohol heavily. In fact, three out of four oral cancers occur in people who use alcohol, tobacco, or both alcohol and tobacco.
• Alcohol: People who drink alcohol are more likely to develop oral cancer than people who don't drink. The risk increases with the amount of alcohol that a person consumes. The risk increases even more if the person both drinks alcohol and uses tobacco.
• 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 head and neck cancer: People who have had head and neck cancer are at increased risk of developing another primary head and neck cancer. Smoking increases this risk.

Quitting tobacco reduces the risk of oral cancer. Also, quitting reduces the chance that a person with oral cancer will get a second cancer in the head and neck region. People who stop smoking can also reduce their risk of cancer of the lung, larynx, mouth, pancreas, bladder, and esophagus. There are many resources to help smokers quit: The Cancer Information Service at 1-800-4-CANCER can talk with callers about ways to quit smoking and about groups that offer help to smokers who want to quit. Groups offer counseling in person or by telephone. Also, your doctor or dentist can help you find a local smoking cessation program. Your doctor can tell you about medicine (bupropion) or about nicotine replacement therapy, which comes as a patch, gum, lozenges, nasal spray, or inhaler. The "National Cancer Institute Information Resources" section has information about the Federal Government's smoking cessation Web site, http://www.smokefree.gov. For additional information, please read Smoking and Quitting Smoking.

Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer. Scientists also are studying whether infections with certain viruses (such as the human papillomavirus) are linked to oral cancer.

If you think you may be at risk, you should discuss this concern with your doctor or dentist. You may want to ask about an appropriate schedule for checkups. Your health care team will probably tell you that not using tobacco and limiting your use of alcohol are the most important things you can do to prevent oral cancers. Also, if you spend a lot of time in the sun, using a lip balm that contains sunscreen and wearing a hat with a brim will help protect your lips.

Oral cancer

Oral cancer is part of a group of cancers called head and neck cancers. Oral cancer can develop in any part of the oral cavity or oropharynx. Most oral cancers begin in the tongue and in the floor of the mouth. 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.

When oral cancer spreads (metastasizes), it usually travels through the lymphatic system. Cancer cells that enter the lymphatic system are carried along by lymph, a clear, watery fluid. The cancer cells often appear first in nearby lymph nodes in the neck.

Cancer cells can also spread to other parts of the neck, the lungs, and other parts of the body. When this happens, the new tumor has the same kind of abnormal cells as the primary tumor. For example, if oral cancer spreads to the lungs, the cancer cells in the lungs are actually oral cancer cells. The disease is metastatic oral cancer, not lung cancer. It is treated as oral cancer, not lung cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Oral cancer: Who's at risk?

Doctors cannot always explain why one person develops oral cancer and another does not. However, we do know that this disease is not contagious. You cannot "catch" oral cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop oral cancer. A risk factor is anything that increases your chance of developing a disease.

The following are risk factors for oral cancer:

• Tobacco: Tobacco use accounts for most oral cancers. Smoking cigarettes, cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral cancer. The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. Heavy smokers who use tobacco for a long time are most at risk. The risk is even higher for tobacco users who drink alcohol heavily. In fact, three out of four oral cancers occur in people who use alcohol, tobacco, or both alcohol and tobacco.
• Alcohol: People who drink alcohol are more likely to develop oral cancer than people who don't drink. The risk increases with the amount of alcohol that a person consumes. The risk increases even more if the person both drinks alcohol and uses tobacco.
• 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 head and neck cancer: People who have had head and neck cancer are at increased risk of developing another primary head and neck cancer. Smoking increases this risk.

Quitting tobacco reduces the risk of oral cancer. Also, quitting reduces the chance that a person with oral cancer will get a second cancer in the head and neck region. People who stop smoking can also reduce their risk of cancer of the lung, larynx, mouth, pancreas, bladder, and esophagus. There are many resources to help smokers quit: The Cancer Information Service at 1-800-4-CANCER can talk with callers about ways to quit smoking and about groups that offer help to smokers who want to quit. Groups offer counseling in person or by telephone. Also, your doctor or dentist can help you find a local smoking cessation program. Your doctor can tell you about medicine (bupropion) or about nicotine replacement therapy, which comes as a patch, gum, lozenges, nasal spray, or inhaler. The "National Cancer Institute Information Resources" section has information about the Federal Government's smoking cessation Web site, http://www.smokefree.gov. For additional information, please read Smoking and Quitting Smoking.

Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer. Scientists also are studying whether infections with certain viruses (such as the human papillomavirus) are linked to oral cancer.

If you think you may be at risk, you should discuss this concern with your doctor or dentist. You may want to ask about an appropriate schedule for checkups. Your health care team will probably tell you that not using tobacco and limiting your use of alcohol are the most important things you can do to prevent oral cancers. Also, if you spend a lot of time in the sun, using a lip balm that contains sunscreen and wearing a hat with a brim will help protect your lips.

The mouth and throat (Cancer)

This booklet is about cancers that occur in the mouth (oral cavity) and the part of the throat at the back of the mouth (oropharynx). The oral cavity and oropharynx have many parts:

• Lips
• Lining of your cheeks
• Salivary glands (glands that make saliva)
• Roof of your mouth (hard palate)
• Back of your mouth (soft palate and uvula)
• Floor of your mouth (area under the tongue)
• Gums and teeth
• Tongue
• Tonsils

Understanding cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

• Benign tumors are not cancer:
  • Benign tumors are rarely life-threatening.
  • Generally, benign tumors can be removed, and they usually do not grow back.
  • Cells from benign tumors do not invade the tissues around them. Cells from benign tumors do not spread to other parts of the body.
• Malignant tumors are cancer:
  • Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
  • Malignant tumors often can be removed, but sometimes they grow back.
  • Cells from malignant tumors can invade and damage nearby tissues and organs.
  • Cells from malignant tumors can spread to other parts of the body. The cells spread by breaking away from the original cancer (primary tumor) and entering the bloodstream or lymphatic system. They invade other organs, forming new tumors and damaging these organs. The spread of cancer is called metastasis.

ORAL CANCER

ORAL CANCER - Emerging trends

Emerging trends in the area of oral cancers include:

Prevention Since the early 1980s, incidence and death rates for oral cancers have been decreasing. Although cigarette smoking among young people increased significantly during the 1990s, recent data suggest that this increase has leveled off and begun to decline. If this trend has reversed, the chance of developing oral cancer will be significantly lower in the next generation.

Tumor growth factors Researchers have discovered naturally occurring proteins in the body, called growth factors, that promote cell growth. Some oral cancer cells grow especially fast because they contain more growth-factor receptors than normal cells. New drugs are being developed to block the effects of these growth-promoting proteins. Some of the drugs are now being tested in clinical trials.

Chemotherapy Researchers are testing new methods of administering chemotherapy drugs to develop more effective treatments against advanced oral cancers. For example, one study is measuring the effects of injecting chemotherapy drugs directly into the tumor, while another is evaluating the effect of injecting chemotherapy drugs into the blood vessels that feed the oral cancer.

Radiation Clinical trials are testing the effectiveness of new twice-a-day radiation regimens in treating oral cancers. Initial work in this area has found high cure rates with some of the new regimens when the cancer has been detected at an early stage. There has also been progress in reducing dry mouth, one of the most common side effects of radiation.

Additional resources

To learn more about oral cancer and the American Cancer Society’s programs, please call 1-800-ACS-2345 (toll free), or visit our Web site at www.cancer.org.

Additional information on oral cancer may be found at:

• National Cancer InstituteCancer Information ServiceToll-free number: 1-800-4-CANCERWeb site: www.cancer.gov

• Oral Cancer FoundationTelephone: 949-646-8000Web site: www.oralcancerfoundation.org

Bottom line

Most oral cancers could be prevented if people did not use tobacco or drink heavily. Quitting tobacco and limiting alcohol use sharply reduce any risk of developing oral cancer, even after many years of use. Many oral cancers may be found early by a combination of routine screening examinations by a doctor or dentist and by self-examination.

Oral cancer

ORAL CANCER - Basic description

Cancer can affect any part of the oral cavity, including the lips, tongue, mouth, and throat. There are two kinds of oral cancer: oral cavity cancer, which starts in the mouth, and oropharyngeal cancer, which develops in the part of the throat just behind the mouth (called the oropharynx).

The most common symptom of oral cancer is a sore in the mouth that bleeds easily and does not heal. Another common sign of oral cancer is pain in the mouth that does not go away. Other signs and symptoms include:

• A lump or thickening in the cheek

• A white or red patch on the gums, tongue, tonsil, or lining of the mouth

• A sore throat or a feeling that something is caught in the throat

• Difficulties in chewing, swallowing, or moving the tongue or jaw

Many of these signs and symptoms may be caused by other cancers or by less serious problems. It is important to see a doctor or dentist if any of these conditions lasts more than two weeks.

Opportunities

Prevention Most oral cancers can be prevented by avoiding risk factors, primarily tobacco and alcohol use. Smoking, smokeless tobacco, and alcohol substantially increase the risk of developing oral cancer. Quitting tobacco and limiting alcohol use significantly lower the risk of developing these cancers, even after many years of use. In addition, eating a healthy, balanced diet with at least five servings of fruits and vegetables every day may provide some protection against oral cancer. Finally, lip cancers can be prevented by avoiding unprotected sun exposure, as well as pipe and cigar tobacco.

Detection The American Cancer Society recommends that primary care doctors and dentists examine the mouth and throat as part of a routine cancer-related checkup. Dentists and primary care doctors have the opportunity, during regular checkups, to see abnormal tissue changes and to detect cancer at an early, curable stage. Many doctors and dentists also recommend that people, especially those at higher risk, take an active role in the early detection of these cancers by doing monthly self-examinations. This means using a mirror to check for any of the signs and symptoms of cancer in the mouth and throat.

Treatment Radiation therapy and surgery are the main methods of treating oral cancers. In advanced cancer, chemotherapy may be used in combination with either treatment.

Statistics

The five-year relative survival rate represents the percentage of patients who live at least five years after diagnosis, whether disease-free, in remission, or under treatment (after excluding people who die of other causes from these calculations). It does not imply that five-year survivors have been permanently cured of cancer. Localized cancer represents cancer that, at the time of diagnosis, had not spread to additional sites within the body. Typically, the earlier cancer is detected and diagnosed, the more successful the treatment, thus enhancing the survival rate.

Who is at risk?

Gender Oral cancers are more than twice as common in men as in women. This is because men are more likely to use tobacco and alcohol over long periods of time and in large enough doses to cause these cancers.

Age The likelihood of developing oral cancer increases with age, especially after age 35. Half of all oral cancers are diagnosed in people older than 68 years.

Other risk factors

• 90% of patients with oral cancers use tobacco. The risk of developing these cancers increases with the amount smoked or chewed and the duration of the habit. Smokers are six times more likely than nonsmokers to develop these cancers.

• 75% to 80% of all patients with oral cancer drink alcohol frequently. These cancers are about six timesmore common in drinkers than in nondrinkers.

• More than 30% of patients with cancers of the lip have outdoor jobs associated with prolonged exposure to sunlight.

• A diet low in fruits and vegetables is associated with an increased risk of developing cancer of the oral cavity.

• Human papillomavirus (HPV) may contribute to the development of approximately 20% to 30% of oral cancer cases.

Quality-of-life issues

From the time of diagnosis, the quality of life for every cancer patient and survivor is affected in some way. The American Cancer Society has identified four quality-of-life factors that affect cancer patients and their families; these factors are social, psychological, physical, and spiritual.

The concerns that patients and survivors most often express are fear of recurrence; chronic and/or acute pain; sexual problems; fatigue; guilt for delaying screening or treatment, or for doing things that may have caused the cancer; changes in physical appearance; depression; sleep difficulties; changes in what they are able to do after treatment; and the burden on finances and loved ones. People with oral cancers often feel social stigma and guilt associated with their history of tobacco and alcohol use, as well as self-consciousness due to the disfiguring effects of some oral cancers.

In recent years, the quality of life for those who are living with cancer has received increased attention. No one has to make the cancer journey alone. The American Cancer Society Cancer Survivors Network® is an online community for people with cancer and their families and friends. To participate, visit www.cancer.org.

ORAL CANCER

ORAL CANCER

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