Oral Cancer: Risk factors and Management. #2

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Hello steemians , welcome to my blog again. In my last post I started discussion on Oral cancer, what it means, its prevalence worldwide and various predisposing/risk factors for oral cancer. Today I am going to be enlightening us on the various ways of preventing and treatment of oral cancer.

Prevention
There are four levels of prevention; primordial, primary, secondary and tertiary prevention. These levels of prevention can be achieved through efforts of individuals and by mass education especially by Government.

Primordial prevention
This level of prevention involves avoiding things that could result in the emergence and establishment of social, economic and cultural practices that are known to contribute to elevated risk of diseases such as Oral Cancer e.g. delay onset of tobacco use and alcohol, and eradication of cultural uses of tobacco and alcohol ( e.g appeasing ancestral spirit etc). Also abstaining from hazardous habits, strong government policy on risk factors (tobacco, alcohol and chemical uses), development of healthy lifestyles, dietary control (fruits and Vegetables) and control of Infections.

Primary prevention

This involves limiting the incidence of disease by controlling causes and risk factors. This can be achieved by either limiting the exposure of people to the risk factors or by increasing their resistance to it through vaccination or chemo-prevention. In achieving this, Oral Health Education and Promotion must be done aggressively at all levels of government formation. i.e Local, State and Federal.

Secondary prevention
The aims of secondary level of prevention is to cure the patients and reduce sequalae/complication that can arise from the disease condition. To achieve this,embark on;

• Early diagnosis throughScreening and treatment.
• Self Oral examination
• Natural history of disease wide gap between early signs and full blown disease.

Tertiary
The aim of this level of prevention is to reduce the progress or complications of established disease e.g. surgery, chemotherapy, Radiotherapy and Rehabilitation- obturators, dentures, implant, speech therapy, home and job adjustments etc

Types of strategies
Population

• High risk- Tobacco cessation programmes (Screening is required to identify this group)
  Screening is the process of by which an un-recongnised disease or condition are identified in a specify population with the aid of rapid test.
  Types:Mass Screening: whole population
  Mutiple/miltiphasic:
  Targetted: exposed individuals and workers
  Case finding/ opportunistic screening: in Oral diagnosis
  Toluidine blue is popular choice of test

Prognostic factors for Oral Cancer

• Size of tumour (T)
• Degree of lymph node involvement (N)
• Presence/absence of Metastasis (M)
• Site of Tumour (S)
• Histopathologic Grading of Tumour (P)
• Tumour growth rate (Velocity of Growth -V)
• Depth Of Spread/ thickness of tumour(D)
• Age– The Young / The Elderly poor prog
• Gender Males –poorer prognosis because of Hormonal and attitude of males to health generally.

Treatment

Goals of treatment

• To achieve a dx-free state
• Achieve acceptable QOL
• Prolong life with acceptable quality of life in case of failure of cure

The stage of oral cancer at the time the patient is treated is the most significant factor in determining the likely outcome of treatment hence clinical staging should always proceed treatment planning. After
proper assessment clinical examination and staging, the surgeon may need to institute some preliminary measures such as-

• Pain control (analgesics).
• Infection control (bed rest, antibiotics).
• Adequate nutrition (dietary advice).
• Informed consent.

The various definitive treatment modalities are:

• Surgery.
• Radiotherapy.
• Chemotherapy.
• Or any combination of these.
  The initial treatment is very critical because it affects greatly the ultimate cure rate. The physician or surgeon who first treats the patient has the best and often the only opportunity to prevent recurrence of cancer
  New methods includes;
• CRYO / LASER SURGERY
• IMUNNOTHERAPY
• GENE THERAPY

SURGERY
It is the oldest therapy.Most important treatment of choice in most cancers (80%-90% of cancers) and successful definitive treatment . it is curative with cure rates between 30-40%. However,early presentation (size of tumour) is very critical to its success as early diagnosis offers a great chance of cure.To be successful it should be radical i.e removal of all diseased tissue with an adequate margin of healthy tissue. (1-2cm) or block resection of tissue to decrease chances of contamination.

Advantages of surgery

• Can ensure total removal of tumour.
• Good for small tumours.
• Also good for salvage procedure when radiotherapy has failed.
• Radical neck dissection (RND) is the treatment of choice for patients with cervical node involvement.
• Surgical specimen available for examination
• Frozen section method can ensure adequate removal
• Mainstay of treatment with new & Versatile reconstructive techniques

Disadvantages

• Aesthetics--Mutilation-morbidity.
• Functional & cosmetic deficits/ impairment.
• Most surgeries require admission & G.A.

RADIOTHERAPY

This refers to medical application of ionizing radiation for the clinical treatment of human diseases. It may be curative or palliative and may be used alone or in combination.

Mechanism
Radiation causes damage to DNA by inducing ionization. This effect affect both normal & tumour cells. If cells are unable for repair this damage by the time of their next division, they die during mitosis. Since cancer cells divide more rapidly and are less efficient in cell repair they are affected more by ionizing radiation than normal cells

Advantages of Radiotherapy:

• Painless.
• No mutilating surgery hence cosmetically better.
• Out-patient treatment more feasible.
• Irradiation of clinically negative neck and primary site after surgery is often used to sterilize micro-metastastis.
• Possibility of treating multiple 1 ⁰ malignancies

Disadvantages
Side effects of radiotherapy.

• Mucositis due to radiation effect on rapidly dividing cells.
• Rampant caries.
• Loss of taste.
• Xerostomia.
• Skin pigmentation, skin atrophy.
• Subcutaneous fibrosis.
• Osteoradionecrosis
• While surgery and/or radiotherapy are loco-regional therapy, chemotherapy is a systemic therapy.
• True benefits of chemotherapy are somehow limited. Except in few chemosensitive tumours like:
• Burkitts lymphoma.
• Hodgkins lymphoma.
• Leukemias.

CHEMOTHERAPY

It may be given in addition to surgery or radiation treatment (adjuvant) or before other treatment (neo-adjuvant) to reduce the chances of micro-metastasis. It may serve as a palliative measure.The draw back for chemotherapy is that tumours respond differently to same regime hence results are not always predictable.

Advantages

• Improves local control of disease & micro-metastasis.
• Tumour can be eradicated totally (e.g. Tx of Burkitts lymphoma) with presentation of normal tissues.
• Useful and rapid palliation of symptoms of untreated patients with primary tumours.

Disadvantages

• Result not predictable.
• Dangerous unpleasant effects hence should be administered by experienced oncologist.
• Many side effects-myelo-suppresion, Neuro-toxicity and pulmonary fibrosis e.t.c
• Development of resistance to drugs by tumour cells is frequently seen.

CONCLUSION
Oral cancer has remained an enigma to the medical and dental practice. It has continued to pose a challenge of incurability to the physician and surgeon despite concerted effort to effect a cure through development of modern methods of diagnosis and treatment. Early presentation is very critical to its success as early diagnosis offers a great chance of cure.

Thank you for reading.

Please Note: All pictures used in this post are free for usage.

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