Oral Cancer

Additional Info

• Audio File:uab/ua189.mp3
• Doctors:Thomas, Carisssa
• Featured Speaker:Carisssa Thomas, MD, PhD
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4570
• Guest Bio:I am a board-certified otolaryngologist and fellowship trained in head and neck surgical oncology and microvascular reconstruction. My clinical practice focuses on reconstruction after surgery for head and neck cancer, including skin cancers and Mohs defects. I perform the entire range of reconstructive options from local flaps to pedicle/regional flaps to free tissue transfer. 
  
  Learn more about Carisssa Thomas, MD, PhD 
  
  Release Date: February 23, 2021
  Expiration Date: February 23, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no relevant financial relationships with ineligible companies to disclose.
  
  Speakers:
  Carissa M. Thomas, MD, PhD
  Assistant Professor, Head and Neck Surgical Oncology
  
  Dr. Thomas has no relevant financial relationships with ineligible companies to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie: Welcome to UAB MedCast. I'm Melanie Cole. And today. I invite you to listen as we discuss oral cancer. Joining me is Dr. Carissa Thomas. She's a board-certified otolaryngologist and fellowship trained in head and neck surgical oncology and microvascular reconstruction and she's an assistant professor at UAB Medicine.
  
  Dr. Thomas, it's a pleasure to have you join us today. So let's start with a little background on incidence and demographics of oral cancer, the most common pathology. Tell us what you're seeing in the trends.
  
  Dr Carissa Thomas: That's a great place to start. So each year, about 3% of all new cancer cases that are diagnosed are oral cavity cancer. So this would equate to approximately about 53,000 cases per year. Men are disproportionately affected compared to women, but we see it in all races. So roughly about 10,700 patients each year will die of oral cancer.
  
  You know, the five-year overall survival rate is of course dependent on the stage of the cancer at the time of the diagnosis. But if you look at all stages of oral cancer, the overall rate of survival is about 60 to 65%, which we think is quite low. And despite advances in surgical techniques over the years, as well as in radiation delivery, we've had new chemotherapeutics and immunotherapy now, the survival rate really hasn't changed significantly in decades. And so, even more unfortunate is it seems that black patients have a worse survival, and that's likely because of a variety of factors.
  
  Median age at diagnosis is usually the early 60s. But in the last many years, we've been seeing an increasing number of young patients without the typical risk factors that are being diagnosed with oral cancer, especially tongue cancer. And anecdotally, these patients seem to do worse overall. And then finally, the most common pathology that we see in oral cancer is squamous cell carcinoma, which is arising from the mucosal lining of the oral cavity.
  
  Melanie: So then let's talk about risk factors for a minute, because you know, you just briefly touched on it, but what are the risk factors and some signs and symptoms to watch out for?
  
  Dr Carissa Thomas: So the most common risk factor that we've known about for the longest time is tobacco and alcohol use. And the two together have a synergistic effect. Additional risk factors include poor oral hygiene and then also something called betel nut or quid, which is most commonly used in kind of like the Southeast Asia area. But like I mentioned earlier, we are seeing oral cancer in patients who have none of these risk factors. And we really don't know why they're developing oral cancer. And so this really just tells us that we still have a lot to learn about this disease process.
  
  And I also want to always put in a plug that you can reduce a person's risk fairly significantly if you quit smoking. And the studies have shown that if someone quits, they get reduced risk of developing oral cancer as early as one to four years after quitting. And if someone has quit for more than 20 years, then the risk is back down to being equal to that of a non-smoker.
  
  And then, as you mentioned, what are some of the signs and symptoms that we look for? The most common signs and symptoms are usually a non-healing lesion or ulcer in the mouth. Patients can get unilateral otalgia and they can have oral bleeding, obviously pain, sometimes a neck mass, dysphagia, odynophagia and an unintentional weight loss. And we usually say, if any of these signs or symptoms are present for three weeks or more, then an evaluation by an otolaryngologist or a head and neck surgeon is definitely warranted.
  
  Melanie: Well, thank you for that. So tell us a little bit about diagnosis itself, who most often diagnoses this? You said if people have this, they can go see an otolaryngologist. Are dentists involved in this diagnosis? Are they checking for oral cancer these days? And are you working with them? Do they recommend? Give us a little bit of a background on how it's diagnosed.
  
  Dr Carissa Thomas: So I think dentists are getting more and more aware of oral cancer. For us, it always seems very common because we see it so often. But in a general dentistry practice, the chances of them actually seeing an oral cavity cancer just based on statistics is quite low. But I think through a lot of the educational efforts that have been ongoing, and I know, you know, here at UAB, our colleagues in oral surgery are very active in educating their dental colleagues. I think we're improving the ability of dentists to recognize this disease. And I think some people have noticed when they go in for their normal dental cleaning, that a lot of dentists are now incorporating a neck exam where they're palpating for lymph nodes and they're doing a more thorough oral cavity exam to look for these lesions.
  
  Unfortunately though, we still do see a lot of patients where we get this very classic story where they've had this painful lesion and everyone thinks it's related to a tooth issue and they've had the tooth extracted and they've had these different procedures done. And only after extended period of time do they finally decide that they need to do a biopsy and diagnose the oral cancer. And so we still have some room to work on our education and just getting this in the forefront of people's minds.
  
  You know, once they come to see us in clinic, our workup is your standard workup that anyone does, a very thorough history and physical exam. One thing we always include is something called a flexible fiberoptic laryngoscopy exam in the office, and that's to assess the entire upper airway including the nasopharynx, the pharynx and the larynx, just because there is the possibility of having a secondary cancer at the same time in a smoker and you want to know that upfront.
  
  And then if a biopsy has not already been done, then we would do the biopsy for the definitive diagnosis and that usually can be done in clinic, but sometimes we do have to go to the operating room and do what we call a direct laryngoscopy to get the tissue that we need.
  
  And then imaging wise, we like to have a CT neck with contrast, to look for extent of the local disease. We also look for regional metastasis too lymph nodes in the neck. And usually, we do some sort of CT chest or PET scan to look for distant metastases within the most common locations being lungs, bone, and liver is what we're looking for.
  
  And then finally, occasionally an MRI is also done and it's helpful to assess the amount of tongue involvement as well as for perineural invasion.
  
  Melanie: Dr. Thomas, we've talked about risk factors, a little bit, signs and symptoms, but what about HPV? And what role does that play in developing oral cancer?
  
  Dr Carissa Thomas: Yeah, that's another really good question because I think people are hearing a lot more about HPV these days, especially as some more famous people have had cancer caused by HPV. So HPV or the human papilloma virus is extremely common viral infection that most people have been exposed to. And the vast majority of people will clear it, but for reasons that we still don't fully understand, there is a small percentage of people who will have a persistent infection and a portion of those people, for again, reasons we don't know, will actually then develop into cancer.
  
  But in the head and neck, the most common site for HPV-mediated disease is actually the oropharynx, so that would be your tonsil and tongue base squamous cell carcinoma cancers, and we don't see it very much in the oral cavity. And for that reason, since HPV-driven cancer in the oral cavity is so rare, we don't even routinely test for it here at UAB. You know, typically when we have a biopsy sample and we're worried about HPV, we send either for HPV testing or its surrogate marker, which is p16. But oftentimes for oral cavity lesions, we don't even look for it because we know that the chances of it being HPV-driven are so low.
  
  Melanie: So interesting and what an exciting time to be in your field. So Dr. Thomas, tell us about standard of care. And if you catch it early or even in the middle, does immunotherapy, you mentioned that a little bit earlier, play a role? Tell us what's new and exciting in treatment options for oral cancer.
  
  Dr Carissa Thomas: So we actually utilize kind of the whole spectrum of treatment for oral cancer. And that spectrum is surgery, radiation, and chemotherapy. Our goal is to try to do a unimodality treatment, especially for those early stage lesions, but sometimes a bi or trimodality therapy is indicated based on the stage or if there are unfavorable pathologic features that are found.
  
  So for oral cancer, surgical excision is the first-line treatment. So that would be tumor extirpation and then a local, regional or microvascular free tissue transfer reconstruction, depending on the size of the lesion. If there are regional metastases and lymph nodes, then that also necessitates a neck dissection at the same time. But we know that even in early stage disease, if the depth of invasion of the tumor is three to four millimeters or greater, that patients, if they have an elective neck dissection upfront, have a better survival compared to observing them and then doing the neck dissection if they develop disease.
  
  So most of these patients end up getting lymph nodes removed from their neck, even without an obvious lymph node that's involved with cancer. And then if you have a tumor kind of at the midline or crossing over the midline, then we take out lymph nodes on both sides of the neck or do a bilateral neck dissection.
  
  And then after surgery, post-operative radiation treatment is usually indicated if they have a large tumor, if they have bone invasion, a lymphovascular invasion, perineural invasion, multiple positive lymph nodes or extranodal extension or a closer positive margin on the resection specimen. And then we add chemotherapy to that radiation if there is extranodal extension in the lymph nodes or those closer positive margins.
  
  Immunotherapy is kind of our newest and most exciting treatment modality that's come into head and neck cancer in the last probably I would say decade now. At the moment, it's only officially approved for recurrent or unresectable disease and we've seen that these immune checkpoint inhibitors can prolong survival with pretty tolerable side effects.
  
  But unfortunately, only approximately 15% of head and neck cancer patients will actually respond to immunotherapy. And we're still trying to find a robust marker to predict responders. So we definitely have some work yet to do in this area kind of understanding how immunotherapy fits in, if it could be a primary treatment modality and figuring out which patients are actually going to be good responders, or if we can change their biology somehow to make them a good responder.
  
  Melanie: Dr. Thomas, one overlooked, slightly overlooked, aspect of this type of cancer are the devastating effects of appearance and function on a patient and are among some of the most disabling and socially isolating defects of cancer. When you are talking to other providers, what would you like them to know about the goals that you've been speaking about for treatment and protecting those vital structures, function and form, and the sensitivity of this type of cancer for the patient?
  
  Dr Carissa Thomas: Yeah. I mean, I think you hit it right on the head, like the side effects of our treatment are very devastating to patients because it impacts their speech, it impacts their swallow, and it can impact their appearance as well. I think obviously catching the cancers early means less treatment, which means better outcomes for speech and swallow. And so that sort of having an awareness of this possibility and recognizing some of these signs and symptoms early and getting them in to see an otolaryngologist early would be great so we could limit the amount of treatment we have to give.
  
  And then I think the secondary part of it is just realizing that a lot of these patients need lifelong therapy to help with these side effects. And a lot of the therapy is speech therapy. We also do a lot of lymphedema treatment, which is a lot of massage to the neck and the face to both help with appearance and swallowing. But you can't really ever say like these patients don't need any more therapies. This is kind of lifelong. We need to keep them plugged in to the medical system and we need to keep making sure that they're getting the therapy they need and the exercises they need to get the best outcome possible.
  
  Melanie: And as we wrap up, is there anything exciting you'd like to share with other providers as far as research developments that are ongoing at UAB and what you would like them to know about referral?
  
  Dr Carissa Thomas: Yeah, I think there are a lot of exciting and active areas of research going on right now at UAB related to oral cancer and kind of covering the whole spectrum of the disease process. And so going back to immunotherapy, we are actively participating in a lot of the trials that are examining using immunotherapy as a first-line treatment for oral cancer.
  
  We also are active looking at different imaging modalities that might help us in the operating room and actually achieve clear margins at the time of tumor resection. And that would limit the need potentially for chemotherapy afterwards and some of the side effects from that.
  
  We have other people looking at treatment of these long-term side effects of radiation, such as lymphedema. And we have a trial starting soon where they're going to look at like an at-home massage system to help with lymphedema treatment. And we have different trials looking at osteoradionecrosis.
  
  And then finally, myself personally, I'm really excited because my interest lies in the role of the oral cavity microbiome and oral cavity cancer. And seeing how that community of bacteria in your mouth changes when you have cancer and how it might impact cancer progression, prognosis, and also the response to immunotherapy.
  
  And the other area that we're looking at actively is how the oral cavity microbiome as well as the gut microbiome might contribute to the pain that these cancer patients experience and to see if there's anything that can be modified to potentially reduce the need for narcotics or opioids.
  
  Melanie: It's so interesting. What an informative episode, Dr. Thomas. Thank you so much for joining us today.
  
  A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
  
  
• Hosts:Melanie Cole, MS