Oral cancer remains the sixth most common cancer in the world among men — and it’s growing among Western women — but it’s hardly talked about publicly. No pink ribbons or big media events call attention to it, and no high-profile celebrity survivors have taken it up as a cause.
That doesn’t deter surgeon Ellie Maghami, M.D., head of City of Hope’s Head and Neck Oncology Service. She wants to spread the word about the disease and how vigilance and simple changes in behavior can cut down oral cancer’s devastating impact.
Maghami, a leading expert in the broad array of cancers that can arise in the head and neck, recently spoke with eHope about oral cancer in time for Oral Head & Neck Cancer Awareness Week, April 21 to 27.
EHope: Who runs the greatest risk for oral cancer?
Ellie Maghami, M.D.: Patients who smoke or drink, certainly, and those with excessive sun exposure to the skin of the head and neck (leading to cancer on the lip).
EHope: Are there any factors that pose the greatest threat?
E.M.: Most patients with this cancer are smokers and drinkers. If you smoke two packs a day and don’t drink, your risk increases two-fold. If you drink two ounces of alcohol a day and don’t smoke, your risk increases two-fold. But do both, and your risk for oral cancer is 16 times that of people who don’t smoke and drink. So there’s a public health message there: cessation of smoking and drinking is key.
EHope: What are some other factors for head and neck cancers?
E.M.: There is a well-known link between family history and thyroid cancer, though this is not as well-defined for all other head and neck cancers. Also, men have more oral cancer than women, but that is related to lifestyle and not gender. As women in western societies adopt the same smoking and drinking habits as men, we’re seeing their risk rise to become nearly equal to men’s. And these cancers can arise at nearly any age.
EHope: What about the recent news linking a virus to head and neck cancers?
E.M.: There has always been a well-known link between Epstein-Barr virus and cancer in the upper part of the throat. The recent publicity is related to human papilloma virus as a factor in cancers affecting tonsils and the base of the tongue, and this has been linked to sexual practice.
EHope: Are there warning signs for oral cancer?
E.M.: Warning signs may include white, red patches or sores in the mouth that don’t heal, a loose tooth and difficulty with chewing or swallowing. There are some other symptoms such as nosebleeds, double vision, a change in voice, earache, and skin changes that can indicate other forms of head and neck cancer. A lump in the neck is often the first sign of head and neck cancer. Among adults, any lump in the neck should be cause to see a doctor to rule out cancer.
EHope: Is there any way to perform a self-exam?
E.M.: Certainly, you can inspect your mouth for anything unusual in the area of the mouth that you can see, such as the tongue. You can similarly inspect your skin for any unusual growth, sore, or discoloration. You can feel your neck for any unusual lumps. Vigilant dentists or primary care physicians often may find these lesions early on when they are most amenable to cure before they have had the opportunity to spread to lymph nodes or other parts of the body. As part of Oral Head & Neck Cancer Awareness Week, locations across the country offer screenings annually.
EHope: If I’m concerned, whom should I see for a checkup?
E.M.: People can turn to their primary care physicians and dentists, who may refer them to an ear, nose and throat specialist (also called an otolaryngologist). An exam and biopsy can provide more information.
EHope: If it’s cancer, what’s the next step?
E.M.: Depending on the stage of the cancer, it can mean surgery, radiation, chemotherapy or a combination of treatments. Cancers caught early can be treated successfully through surgery or radiation. But for large tumors or tumors that have spread, treatment can be much more complicated. Unfortunately, most patients are not coming to us with early stage disease, and once cancer has spread to just one lymph node, their chance of survival drops by 50 percent.
EHope: What are recommended treatments?
E.M.: Treatment depends on stage of disease. For early oral cancers surgery or radiation can be considered, although surgery is generally favored unless patients have medical problems that make them unsuitable for surgery. For advanced disease some combination of surgery, chemotherapy and radiation therapy is generally considered, as no single modality of treatment alone is sufficient.
EHope: How are treatments decided?
E.M.: Treatment recommendations depend on the tumor location and type. The National Comprehensive Cancer Network recently released 2008 guidelines that provide a framework for treatment depending on a variety of factors.
Recommendations also depend on “person” factors. What other medical problems exist? What is their occupation? How likely are they to follow through with the treatment plan? Where do they live? What kind of support system they have in place as they cope? Quality-of-life issues are significant, as well. We try to preserve organ function, such as the ability to speak and swallow. Treatments can be very involved and require a lot of individualized planning.
This underscores the importance of experts from a variety of disciplines discussing these cases at what’s called a tumor board. These meetings allow us to talk about all the potential treatments and come to a decision about the best recommendations for each specific patient. This is why patients with these complicated cancers should look to academic institutions and major medical centers for treatment — dedicated resources, facilities and expertise are essential to rendering successful treatment for these patients.
The Head and Neck Tumor Board at City of Hope is a consortium of surgeons, medical and radiation oncologists, radiologists, pathologists, rehabilitation professionals, and psychosocial workers and other ancillary care providers that meet weekly to review patients information and finalize and coordinate treatment plans.
EHope: Are clinical trials an option?
E.M.: Yes. Through clinical trials, physicians are beginning to explore new treatments such as molecular targeted therapies. At City of Hope, we’re evaluating a combination of cisplatin and cetuximab (Erbitux). Cetuximab is a monoclonal antibody against epidermal growth factor receptor, a protein that is over expressed in the majority of oral cancers. We are also considering alternate dosing regimens for these new drugs for any added benefit.
EHope: What’s in the future?
E.M.: One of the challenges is figuring out which treatment will be best for each patient. These are the issues being heavily investigated. The hope is that we will be able to use molecular prognosticators (markers that can be found in tumor cells) to select out patients who will benefit most from surgery versus those who would benefit from a combination of chemotherapy and radiation. That would help decide the best treatment right from the start.
We may be able to have more options for certain subgroups. For example, research has shown that non-smokers who have HPV-positive tumors of the oropharynx (the back of the mouth) actually have a better prognosis than their smoker counterparts with comparable standard therapies. So we ask how we might refine the current standard treatment in the HPV-positive patients.
The research in molecular targeted therapies in head and neck cancer is gaining momentum with exciting prospects for enhancing treatment efficacy and tolerability.
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