Rehabilitation is a very important aspect of treatment of oral cancers. After surgery due to removal of part of tongue, cheek or jaw patients develop problems with speech and swallowing. Even after non-surgical interventions like radiotherapy and chemotherapy patients have lot of discomfort related to swallowing and speech.
By Dr. Akshat Malik
Oral cavity cancers (cancers of mouth) are an important healthcare problem. They are one of the commonest cancers seen in Indian sub-continent. According to GLOBOCAN 2020 data, Lip and Oral Cavity Cancers constitute 10.3% (in both sexes) of all cancers in India and are responsible for 8.8% of the cancer related deaths in India. This implies that every year 1 lakh 35 thousand patients are newly diagnosed and about 75,000 patients die due to oral cancer annually in India.
Oral cavity cancers include the cancers of tongue, buccal mucosa (inner surface of cheek), upper alveolus (upper jaw), lower alveolus (lower jaw), palate and floor of mouth.
• Tobacco consumption is the main cause of oral cavity cancers. Tobacco is used in 2 forms – either smoked or non-smoked. Smokeless tobacco is used by upto 21.4% of India’s population and includes gutkha, khaini, betel quid (paan) etc. Cigarettes, beedi and hookah are the commonly used forms of smoked tobacco.
• Usage of tobacco is associated with thirty times higher chances of developing oral cancers.
• Use of alcohol also increases the likelihood of developing these cancers.
• Areca nut (also called betel nut or supari) present in paan is also a known cancer causing substance responsible for oral cavity cancer.
• Trauma from ill-fitting denture or sharp tooth can also lead to cancer
Patients generally have a history of tobacco use. They present with complaints of non-healing ulcer in tongue or cheek, growth in oral cavity, loosening of tooth, gradual reduction in mouth opening and swelling in neck.
Cancer of oral cavity may be preceded by pre-cancerous conditions such as leukoplakia, erythroplakia or sub-mucous fibrosis. Leukoplakia refers to any whitish patch in oral cavity for which no cause can be found. Erythroplakia refers to a similar reddish patch. Sub-mucous fibrosis refers to whitish bands present in under-surface of cheek associated with increased sensitivity to spicy food and progressive reduction in mouth opening. If a patient presents to a doctor early and refrains from tobacco usage then further progression of these lesions to cancer can be restricted.
When such a patient presents to a cancer centre, a thorough examination of upper aerodigestive tract is done along with examination of neck to rule out other lesions or metastasis (spread of cancer) to neck. A biopsy from the suspicious cancer site is taken and submitted for laboratory examination where a histopatholgoical confirmation of cancer is obtained. FNAC (fine needle aspiration cytology) may also be done from any neck swelling to look for presence of cancer cells.
Radiological tests like CT scan and MRI scan are also required at times to see the extent of spread of cancer to plan further treatment. Besides these, a chest X ray or CT scan is done to rule out the spread of cancer to lungs.
Treatment of these lesions is according to the stage of the disease. Stage I/II lesions may be managed by single modality treatment encompassing surgery or radiotherapy. For these lesions surgery is preferred as they are easily accessible and a single procedure is often required.
Brachytherapy (type of radiotherapy) may be used in selective cases. Stage III/IV lesions require multi-modality treatment which includes surgery followed by radiotherapy and/or chemotherapy. Appropriate reconstruction in form of local, regional or free flaps may be required in these cases. Following surgery, if the defect is small then primary closure is done. Otherwise local or regional flaps are used. Among regional flaps, muscle from chest is commonly used to reconstruct the defect. Free flaps are used when indicated. These involve the use of bone or muscle from leg, thigh and forearm to reconstruct the defect following surgery.
Adjuvant therapy is guided based on adverse histopathological features as seen in final histopathology report. In certain cases, where the general condition of the patient is good but the disease is very extensive or inoperable, upfront chemo-radiotherapy may be considered.
On completion of treatment, the patient is kept on regular follow up to look for any residual disease, recurrence or appearance of any new lesion.
Rehabilitation is a very important aspect of treatment of oral cancers. After surgery due to removal of part of tongue, cheek or jaw patients develop problems with speech and swallowing. Even after non-surgical interventions like radiotherapy and chemotherapy patients have lot of discomfort related to swallowing and speech. Aggressive rehabilitation measures are employed to help the patient regain these functions. Speech and swallowing therapist teach various swallowing maneuvers through which swallowing becomes easier. Regular speech therapy sessions are also taken to teach the patient how to speak better post-treatment. Patients may stay dependent upon semi-solid diet for some time. Persistent encouragement and support from family members is essential to help patient cope up better. Occupational therapy also plays an important role as mouth opening post-treatment reduces. Jaw stretching exercises are utilized to help improve the mouth opening. Following neck dissection physiotherapy in form of neck and shoulder exercises are form an important part of rehabilitation.
Making certain lifestyle changes can help decrease the chances of a person to develop oral cavity cancer. Most important amongst these is tobacco cessation. This includes cessation of both chewable and non-chewable forms of tobacco. Usage of areca nut (supari) and alcohol should also be stopped.
Current tobacco users, addicts should be encouraged to restrain from these products. Addicts who develop withdrawal symptoms on stopping these products can visit de-addiction centres or nearest physician. Nicotine patches, gums are prescribed under supervision to help the addicts let go off their addictions. Counselling services are also offered at such centres.
At present, about one fourth of Indian population consumes tobacco in one form or another. As mentioned earlier oral cavity cancers are the commonest cancers in the Indian sub-continent. GATS 2 survey has found that tobacco users in Punjab have increased in last seven years. This is against the national trend where the number of tobacco users has decreased. In all about 13.4% people in Punjab use tobacco (smoked as well smokeless) presently. In such a scenario, fighting the scourge of tobacco is of utmost importance for prevention of these cancers.
(The author is a Consultant, Head & Neck Oncosurgeon, Max Superspeciality Hospital, Saket, New Delhi. Views expressed are personal and do not reflect the official position or policy of FinancialExpress.com.)