Oral Cancer and Complications of Cancer Therapies _ _____________________________________________
INTRODUCTION Few diagnosed medical conditions evoke as much fear and emo- tion as cancer. The incidence of cancer increases with age, and given the demographics of an aging population, more patients will be diagnosed with cancer annually [1]. The type of malig- nancy, its location, and the presence or absence of metastasis will dictate the options for medical intervention. In the last several decades, tremendous strides have been made in the prevention, diagnosis, and treatment of this group of diseases. When chemotherapy is used to treat organic and systemic malignancies, alterations are commonplace in the cells of the oral epithelium, in those that form the cells necessary for immunocompetence, and in those that produce the formed elements of blood. The tissues within the oral cavity can undergo changes of such a deleterious nature that patients may require temporary respites from chemotherapy. Fortunately, these negative effects usually subside after chemotherapy ends. In the United States in 2024, there will be approximately 58,500 new diagnoses of oral cancer and approximately 12,250 deaths; however, the number of deaths increases when complications of oncologic treatment are taken into consid- eration—nearly one death per hour [2; 3]. This high mortality rate relates to the advanced metastatic stages at which these lesions are usually diagnosed. A challenge should be issued to healthcare professionals to reverse this trend with clinical procedures facilitating early detection. Surgical removal may be an option based on the extent of lesion size, its invasive- ness into the proximate soft and hard tissues, and presence of metastasis into the regional lymph nodes. A postoperative course of radiotherapy may also have deleterious effects. As opposed to chemotherapy, the negative oral effects induced by radiotherapy are usually long-term or permanent. The progression of cancer and the ensuing treatment will compromise the immune systems of most patients. Therefore, problematic oral changes can affect more than oral health. Debilitated and ulcerated oral mucous membranes can be a portal of entry for resident organisms of the oral microflora, with systemic dissemination and sepsis possible. A high degree of morbidity with potentially fatal consequences may ensue. It is imperative that all members of the allied healthcare team who treat these patients are aware of the etiology of these oral problems, available treatment modalities, and the conse- quences of delayed or inappropriate treatment.
ORAL CANCER Oral cancer, in which the primary malignancy arises within the oral cavity, is the eighth most common cancer in men, with incidence rates more than three times as high in men as in women [3]. Incidence has been declining since the 1970s, though it appears to be stable now in men, with women con- tinuing to experience a 0.9% decline per year. The exception is of cases associated with human papillomavirus (HPV) infec- tion, which are increasing in the White population. Oral malignancies diagnosed in their initial stages can be treated more conservatively than their larger, metastatic coun- terparts. Unfortunately, the most common oral malignancy, squamous cell carcinoma, usually remains undetected until it is in its advanced stages. Pain, numbness, swelling, loss of function, and difficulty swallowing, which may appear later in disease progression, often do not accompany the beginnings of oral malignancies. The five-year survival rate of only 69% reflects the trend of late diagnosis [3]. The rich vascular and lymphatic network of the oral cavity, which extends beneath the tongue and into the floor of the mouth, facilitates local, regional, and distant metastasis. Early lesions may be difficult for the clinician to visualize and are often asymptomatic for the patient. Therefore, it is important for healthcare professionals to be familiar with the etiologies and risk factors associated with oral cancers. ETIOLOGIES AND RISK FACTORS Most patients with oral cancer have used tobacco products for prolonged periods of time [4]. Cigarettes, with their multitude of carcinogens, are the most frequent form of tobacco used. However, cigars, pipes, and smokeless tobacco also contain carcinogens; these should not be considered safe alternatives to cigarettes. Although many more people smoke than develop oral cancer, the majority of oral cancers may be attributed to tobacco and/ or alcohol use, either individually or together [4; 5]. The use of alcoholic beverages by those who use tobacco products may enhance the negative effect upon the oral tissues [4]. The desic- cating effects of alcohol provide a prolonged exposure of the carcinogens within tobacco on these tissues. This additional contact time increases the risk of the development of an oral malignancy, such as squamous cell carcinoma, 100 fold [4]. Factors such as immunosuppression and immunocompromise, a family history of cancer, nutritional considerations, alcohol abuse, systemic disease, and the duration and amount of tobacco used are possible reasons some tobacco users develop oral cancer and others do not. Because the majority of patients with oral cancer have a history of tobacco use, the implication of this product’s carcinogens as agents that can cause malignant transformation in the oral tissues is strongly correlated.
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