In this episode of PodMD, Oral and Maxillofacial surgeon Dr Felix Sim will be discussing the topic of oral cancer, including the different types of oral cancer, how a patient would typically present, the treatment options, the warning signs to look out for, the likelihood of recurrence, when a GP or dentist should refer and more. This is the second part of a two-part podcast series. The first podcast discussed potentially malignant conditions of the oral cavity.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Felix Sim
Dr Felix Sim is an Australian trained Oral and Maxillofacial surgeon, with a special interest in head and neck cancer and complex dental implants and dental rehabilitation.
Felix Sim obtained his undergraduate dental qualification at the University of Sydney in 2001 and medical degree at the University of Melbourne in 2009. He then undertook and completed his specialist training in Victoria in 2015. Following his specialist qualification, Felix was selected to a two-year sub-specialty training in head & neck oncology and microvascular reconstruction in Portland, Oregon, USA.
Aside from his private practice in Glen Iris, Springvale and Werribee, Felix holds public hospital appointments at Monash Hospital, Geelong Hospital and Royal Melbourne Hospital where he is supervisor of registrar training.
Today, we’ll be discussing the topic of Oral Cancer, which is the second podcast in a two-part series. In the previous podcast, we discussed potentially malignant conditions of the oral cavity.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Felix, thanks for talking with us on Pod MD today.
Felix: Thank you for having me.It’s a real great pleasure.
The topic of today’s discussion is about oral cancers. Felix, can you give us a brief overview about oral cancers?
Felix: Yeah sure, so oral cancer comes in many different forms, shapes and sizes. The most common type of oral cancer is a cancer that arises from the lining of the gums and the mouth, and that’s squamous cell carcinoma. By far, probably 85% of oral cancers is squamous cell carcinoma, but one can’t forget the other types of cancers that happen in the mouth, and that’s essentially, you know, minor salivary gland tumors or cancers, you can also have rare forms of cancers like sarcomas that can also occur in the oral cavity, and that’s other osteosarcoma, angiosarcoma which is usually rare form, but by far the most common type of oral cancer that we encounter is the squamous cell carcinoma.
How would a patient with an oral cancer present?
Felix: So for the purpose of this particular podcast, I’m going to focus my discussion on squamous cell carcinoma, because that is probably the most common type of cancer. But I will also have some reference to the other types of cancers as well. Typically a patient with oral cancer will present with non-healing ulcer in the mouth. The most common sites of oral cancer is the tongue, the floor of mouth, but it can also affect the gums, gingiva, buccal mucosa, pallet and lip. That part is the definition of oral cavity. There are cancers that affect the base of tongue, the tonsils. It’s a completely different subsite called oropharyngeal cancers, and that’s usually driven by human papilloma virus in the non-smoking population. It’s a slightly different pathological entity to the typical oral cancers that we would see from smoking and alcohol consumption. So it’s I don’t want, I don’t want to mix the two together because often they would often be treated differently as well.
But typically an oral cancer would present with non-healing ulcer. One can’t also forget that with cancer you can have the tendency to have cancer spread to the lymph nodes. So examination of the lymph nodes is also critical and with oral cancer patients, especially in the advanced stage, can also present with a lump in the neck, that continues to grow larger over a period of time. For the rarer types of forms of cancer, like the minor salivary gland cancers, the most common sight of the minor salivary gland cancers is the pallet, but it can also affect the floor of mouth and the buccal mucosa.
What are the treatment options?
Felix: Well, I think before we talk about treatment options, I need to make sure that I emphasize that early recognition is probably the key, because treatment of an early-stage disease will always lead to better outcomes. Hence that’s why we recorded that first podcast of potentially malignant conditions of the oral cavity. But when it comes to one is diagnosed with oral cancer, well, I think the majority of time we need to then think about what is the intent of treatment. Is it curative intent or palliative intent? With curative intent, treatment almost always it is going to be surgery and that surgery would involve remove the tumor, removal the lymph nodes that are risk of harboring tumor and reconstruction of the defect that’s left by the tumor removal. Palliative intent treatment is usually radiation. Now that’s not my area of specialty, so I’m not going to labor on us talk too much on radiation, but a big area of my practice being oral cancer, I’ll focus a bit more on the treatment of what’s involved with the actual treatment of oral cancer.
So talking about condition, talking about surgery of the to remove the tumor itself. Well, depending on the sub site of the tumor, we would remove the tumor with a good margin tissue and that margin can be 1 to 1.5 centimeters. We know that with certain types of sub sites like the tongue, the floor mouth, the buccal mucosa, the risk of metastasis of that cancer to the lymph nodes is relatively high and the deeper or the more invasive the cancer is, the higher the likelihood is of the lymph nodes being affected. So therefore we would often perform an elective neck dissection to remove the lymph nodes at risk and we know from many trials, both prospective, retrospective and systematic reviews, that this has been shown to improve the survival of patients with oral cancer. When it comes to reconstruction, in this day and age now where we have a big focus on survivorship and a quality of life post treatment of cancer, the reconstruction needs to be aimed at establishing and trying to maximize the function and form following cancer treatment. So work in conjunction with reconstructive surgeons, we will try and replace the tissues that’s been removed.
The unique thing about oral cavity cancer compared to other cancers of the body is that involves soft tissue, involves hard tissue, both bone and teeth, that all of which serve a particular function. So there’s unique challenges in reconstruction of defects of the oral cavity to not only replace soft tissue, but also be able to replace the bone and potentially in future rehabilitate so that patients can be dentate again. Once all that treatment is done, depending on the actual stage of the tumor, depending on the presence of any adverse features like Perineural invasion or lymphovascular invasion and the presence of metastasis and lymph nodes, radiation with or without chemotherapy is also another adjunct that we would use to treat oral cancer.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Felix: There’s been exciting developments in the last, probably 5 to 10 years in the treatment of head and neck cancer, and that’s immunotherapy. So immunotherapy is essentially a treatment that is aimed to boost the body’s immune system so that it recognises cancer as a foreign antigen and attack that. It’s had great success in cutaneous or skin cancer, but unfortunately for oral cancer or mucosal SCC, the response rate is still not quite as good when compared to cutaneous conditions, cutaneous SCC.
So there’s still ongoing trials and developments in utilizing immunotherapy as an adjunct to treat oral cancer, but not to replace it. I think for now surgery is probably still the mainstay of treatment, but in the palliative setting or in patients with unresectable or who have distant metastasis, immunotherapy has been given, but the response rate has only been somewhere in the vicinity of 15 to 20% for mucosal SCC, whereas the response rate for cutaneous SCC have been up to 50%.
So the other exciting development of treatment of oral cancer is probably not so much the actual treatment of cancer itself, but in the reconstruction and with the advances and computer modeling and 3D printing, we’re now able to actually virtually planned not only the resection but the reconstruction of the actual new jawbone. So that has been shown to improve operative time, improve the outcomes and accuracy and also improve the number of operations one requires to eventually lead to dental rehabilitation, because nowadays there’s a big focus on survivorship as I mentioned.
So we always have to take focus not only in treating the cancer, but actually treating the cancer and maximizing the patients quality of life by being able to adequately rehabilitate them both in shape, form and function, and that function includes being able to give patients teeth again, after they’ve been removed from following their cancer operation.
Are there any warning signs a GP or dentist or their patient can look out for?
Felix: Yes, so as I mentioned before I think the number one sign for the that one can’t ignore is a non-healing ulcer. A non-healing ulcer within the tongue, within the floor, tongue is by far the most common side of oral cancer, so any non-healing ulcers that persist after two weeks warrants a presentation to a GP, warrants a presentation to dentists, who will then be able to assess, look at it and then refer if appropriate or if needed.
The ulcer itself can often be traumatic, but it is important to actually be able to actually examine the other things like risk factors, If patient is a heavy smoker, heavy drinker, then usually they would have a high-risk factor for oral cancer and that would also ring alarm bells so that a referral, an early referral would be indicated.
Apart from visual inspection, the other part is to also put your finger on the ulcer as well, because induration or firmness around the edges of the ulcer is usually a red flag for a more sinister type of condition. So always palpate the ulcer and if it’s if you can’t differentiate the actual ulcer on texture and and consistency from the adjacent tissue, then it’s less concerning, but if you can actually feel a difference that there’s firmness, there’s induration, that is very concerning.
The other part that I think is worth mentioning is that unfortunately, in the last five years it’s been recognized that there has been an increased incidence in younger patients. When I say younger I’m talking about the under 45s who were not necessarily smokers or drinkers, that develop all cavity cancer, and unfortunately females more than males tend to be affected as well. And this has been a worrying trend at all, head and neck surgeons and cancer surgeons have been recognizing worldwide.
In fact, recently there’s been a study published that’s multicenter from Singapore, and the Life House in Sydney that had recognized the increasing incidence of the female population under 45 that have been affected, who were previously non smokers that have been affected by oral cancer, so I think we need to keep an eye on this space, and there’s certainly lots of research looking into the to the to the causation of these these groups of patients who are not necessarily traditional smokers and drinkers and why they develop all cancer.
But I think as a demographic just because you’re under 60 or under 40 and you never smoke doesn’t necessarily mean that you cannot develop oral cancer. So I think the big thing is to going back to the the length of time, if it doesn’t heal after two weeks, don’t ignore it.
What is the likelihood of recurrence of the condition?
Felix: Well, I think with any cancer, there’s always going to be a chance of recurrence. So the treatment doesn’t end once you have your surgery and your radiation, all patients will have an onco surveillance program. Essentially that whereby their patients be reviewed three monthly or sometimes 6 weekly, for the first probably 12 months. We know that early-stage cancers with good treatment will have the best outcomes and the high survival rates.
More advanced stage diseases will have poor outcomes pressure when they have lymph node metastasis and their surveillance program would often be tailored depending on the stage of the actual disease, but in the general rule, in my practice I would see all cancer patients three monthly in the first two years and then extending that to six monthly, probably in the next two years, up to the five year mark, where we’ll probably see them anually, and it’s usually at that point of time, after five years, that would probably give the stamp of cure, but we know that lifelong there is always a risk of developing a second malignancy. So that’s why I think annual surveillance via your specialist will probably still be indicated.
When should a GP or dentist refer?
Felix: So I think, to keep it simple, a GP or dentist should refer when you are encountered with non-healing ulcer in the oral cavity that has not healed after two weeks. And make 2 weeks as a Standard Time frame. Most aphthous ulcers or sores in the mouth would heal after about a week but if anything persist after two weeks, then I think you should refer them for a biopsy.
In the era of COVID, I think we probably should tailor this in the era of COVID, whereby sometimes often patients will be seen by Telehealth, or patients may have symptoms and may not be able to come in within that two-week time frame. Don’t forget them and don’t lose them in the radar, always try and follow up, say if it’s three weeks of if you have to isolate for seven days and so be it. I think 2 weeks is probably should be the time frame that if you had a non-healing ulcer or the lump in the neck that doesn’t go away, then refer them.
What role does the GP or dentist play in the treatment of the condition?
Felix: Well that’s that’s that’s quite a big question. I think we can speak on a whole podcast on actual roles of GPS and dentists in cancer patient care, but I think in terms of the purpose of this particular podcast, I’m going to keep on emphasizing the early recognition and detection. That’s where the main role for the treatment. Supportive care following treatment, well, the journey that thepatient goes through for treatment oral cancer is, like with any cancer, is tough. Often GPs and dentist probe won’t be seeing them too much in the acute phase of treatment.
Dentists would often be called upon if the patient requires radiation for a dental check prior to them starting radiation, some radiation. Some cancer centers would have their own dental oncology unit such as Peter Maccallum Cancer Center, however not all cancer centers have that, so a dentist would often be called upon to do a dental check and identify any problems that can be addressed before radiation starts.
If there’s teeth to be removed, often we would try and removed at the time of surgery, so that it minimizes risk of any future operations that patients require prior to their radiation. Following treatment, I think it’s important that dentists in particular, being the primary oral health care providers, recognize that patients with who has had previous radiation or cancer treatment in the mouth will often have side effects of that treatment and those side effects of treatment include xerostomia or dry mouth. And sometimes you would have limitation in mouth opening, but Xerostomia does lead to an increased risk of dental caries or decay.
So I think it’s important for dentist to be able to implement a tailored program for head and neck cancer survivors who have had radiation to the oral cavity in the head and neck, such as flouride for example, application of fluoride, high dose fluoride to the teeth to improve oral hygiene. Maybe more frequent visits, rather than six months, doing it three monthly to optimize their oral healthcare, because, and this is a whole topic that’s completely separate and that we can talk hours and hours upon, is the managing the complications and the side effects of cancer treatment like long term side effects, because the main aim is we want to minimize the need for say removal of teeth in the radiated field, to minimize the risk of osteoradionecrosis because that in itself is a quite complex treatment and can cause significant deterioration in quality life of these cancer patients.
So I think the the role of GP and dentist number one is probably the early recognition and detection and referral and then on the other side, is actually maintaining the health of the oral cavity following treatments to minimize long term side effects and issues such as osteoradionecrosis.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on oral cancer.
Felix: The key take home message, I think take a message number one is that, I’m sorry to harp on this again, but I think this is key is early detection early recognition improves to better outcomes. So for the GP’s dentists I think 2 weeks, if you have a non-healing ulcer after two weeks please refer for a biopsy. And that referral can be through to an oral maxillofacial surgeon, it can be to an oral medicine specialist. It can be to an ENT specialist, it doesn’t matter which specialists refer to. I think you need to refer to a specialist who can be able to carry out the approach biopsy.
Take a message number two. There is an increasing worrying trend that the nonsmoking, nondrinking younger adults in their mid 40s can also develop oral cancer. So just because you’re young just because you don’t smoke does not mean that you’re immune from having oral cancer.The same rule applies, if you have a non healing ulcer that still persist after two weeks, do not ignore, refer.
Take our message number 3, cancer can spread to lymph nodes. So always examine the neck, examine the neck to see if there’s any lymph nodes or cervical adenopathy. If there’s any lumps or bumps in the in the neck that that’s there and it persists beyond two weeks, because please refer as well, for a biopsy or FNA because there are some cases where patients may not actually complain of pain from the ulcer. All they may complain of a little lump that you don’t feel. So it’s important to examine the neck and as well.
And finally, I think from this is more from a clinical perspective an examination POV. Don’t just look at the ulcer, but also put your finger on it. Meaning that palpate it and examine the texture of the ulcer to make sure that there’s if there’s any firmness, induration and that that is on the worrying red flag sign that warrants prompt referral.
Thanks for your time and the insights you’ve provided.
Felix: Thank you so much