Background

Oral cancer has been identified as a significant public health threat. Systematic evaluation of the impact of this disease on the US population is of great importance to health care providers and policy makers.

Methods

This study used the National Cancer Data Base (NCDB) to evaluate associations between demographic and disease characteristics, treatment, and survival for patients with oral cavity cancer in the United States. Of patients diagnosed between 1985 and 1996, 58,976 were extracted from the NCDB. ANOVAs were performed on selected cross-tabulations, and relative survival was used to calculate outcome

Results

Median age of patients was 64.0 years. Men made up 60.2% of patients. Pathologic diagnosis was squamous cell carcinoma (SCC) in 86.3% of cases. Younger patients had a much higher frequency of non-SCC, and this was related to survival in these patients. African-Americans (independent of income), lower income patients, and patients with higher grade disease were seen more frequently with advanced-stage SCC. Five-year relative survival for SCC cases was lower for older patients, men, and African-Americans.

Conclusions

This study addressed many issues related to oral cancer that have been previously discussed in the literature. The demographic, site, stage, histologic, and survival data available for this large number of cases in the NCDB allowed an accurate characterization of the contemporary status of oral cancer in the United States. © 2002 John Wiley & Sons, Inc.

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What is oral cancer?

Cancer is defined as the uncontrollable growth of cells that invade and cause damage to surrounding tissue. Oral cancer appears as a growth or sore that does not go away. Oral cancer — which includes cancers of the lips, tongue, cheek, floor of the mouth, hard and soft palate, sinuses, and pharynx (throat) — can be life-threatening if not diagnosed and treated early.

What are the signs and symptoms of oral cancer?

The following are the common signs and symptoms:

•           Swellings/thickenings, lumps or bumps, rough spots/crusts/or eroded areas on the lips, gums, or other areas inside the mouth

•           The development of velvety white, red, or speckled (white and red) patches in the mouth

•           Unexplained bleeding in the mouth

•         Unexplained numbness, loss of feeling, or pain/tenderness in any area of the face, mouth, or neck

•           Persistent sores on the face, neck, or mouth that bleed easily and do not heal within two weeks

•           A soreness or feeling that something is caught in the back of the throat

•           Difficulty chewing or swallowing, speaking, or moving the jaw or tongue

•           Hoarseness, chronic sore throat, or changes in the voice

•           Ear pain

•           A change in the way your teeth or dentures fit together – a change in your “bite”

•           Dramatic weight loss

If you notice any of these changes, contact your dentist immediately for a professional examination.

I recently noticed a whitish patch in my mouth. Is this oral cancer?

This whitish patch could be leukoplakia. Leukoplakia, a condition caused by excess cell growth, can form on the cheeks, gums, or tongue. Leukoplakia is commonly seen in tobacco users, in people with ill-fitting dentures, and in those who have a habit of chewing on their cheek. This condition can progress to cancer. Red patches in the mouth (called erythroplakia) are less common than leukoplakia but have an even greater potential for being cancerous. Any white or red lesion in your mouth should be evaluated by your dentist.

Who gets oral cancer and what are the risk factors for oral cancer?

According to the American Cancer Society, men face twice the risk of developing oral cancer as women, and men who are over age 50 face the greatest risk. The rate of development of cancer of the oral cavity and pharynx began to decline in the late 1970s and has continued to decline throughout the 1990s in both African Americans, and white males and females.

Risk factors for the development of oral cancer include:

•     Cigarette, cigar, or pipe smoking — Smokers are six times more likely than non-smokers to develop oral cancers.

•          Use of smokeless tobacco products (for example, dip, snuff, or chewing tobacco) — Use of these products increase the risk of cancers of the cheek, gums, and lining of the lips.

•           Excessive consumption of alcohol — Oral cancers are about six times more common in drinkers than in non-drinkers.

•           Family history of cancer

•           Excessive exposure to the sun — especially at a young age

It is important to note that more than 25% of all oral cancers occur in people who do not smoke and who only drink alcohol occasionally.

How is oral cancer diagnosed?

Your dentist will conduct an oral cancer screening exam, which is a routine part of a comprehensive dental examination. More specifically, your dentist will feel for any lumps or irregular tissue changes in your neck, head, face, and oral cavity. When examining your mouth, your dentist will look for any sores or discolored tissue, as well as check for or ask you about the signs and symptoms mentioned above.

Your dentist might perform an oral brush biopsy if he or she sees tissue in your mouth that looks suspicious. This test is painless and involves taking a small sample of the tissue and analyzing it for abnormal cells. Alternatively, if the tissue looks even more suspicious, your dentist might recommend a scalpel biopsy. This procedure usually requires local anesthesia and might be performed by your dentist or a specialist referred by your dentist. These tests are necessary to detect oral cancer early, before it has had a chance to progress and spread.

How is oral cancer treated?

Oral cancer is treated the same way many other cancers are treated; that is with surgery to remove the cancerous growth followed by radiation therapy and/or chemotherapy (drug treatments) to destroy any remaining cancer cells.

What can I do to prevent oral cancer?

You can take an active role in preventing oral cancer or detecting it early, should it occur.

•           Conduct a self exam at least once a month. Using a bright light and a mirror, look and feel your lips and front of your gums. Tilt your head back and look at and feel the roof of your mouth. Pull your checks out to view the inside of your mouth, the lining of your cheeks, and the back gums. Pull out your tongue and look at all surfaces. Examine the floor of your mouth. Look at the back of your throat. Feel for lumps or enlarged lymph nodes in both sides of your neck and under your lower jaw. Call your dentist’s office immediately if you notice any changes in the appearance of your mouth or any of the signs and symptoms mentioned above.

•           See your dentist on a regular schedule. Even though you might be conducting frequent self exams, sometimes dangerous spots or sores in the mouth can be very tiny and difficult to see on your own. The American Cancer Society recommends oral cancer screening exams every three years for people over age 20 and annually for those over age 40. During your next dental appointment, ask your dentist to perform an oral exam. Early detection can improve the chance of successful treatment.

•           Don’t smoke or use any tobacco products and drink alcohol in moderation. (Refrain from binge drinking.)

•           Eat a well balanced diet.

•          Limit your exposure to the sun. Repeated exposure increases the risk of cancer on the lip, especially the lower lip. When in the sun, use UV-A/B-blocking sun protective lotions on your skin as well as your lips.

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Lung, oropharyngeal and oral cavity cancer are the most common cancer sites observed by Indian registries.1 These cancer sites are causally related to the use of tobacco in different forms.2 In India, the use of tobacco is common in the form of chewing and smoking of bidis and cigarettes.3

Two studies are available from India on the role of bidi smoking in the development of lung cancer.4,5 A few studies, mainly from West Maharashtra and South India, have reported the risk of oropharyngeal and oral cavity cancer and smoking and oral use of tobacco,6,7,8 but no study has been reported from central India.

In the present study three cancer sites (lung, oropharynx and oral cavity) were investigated using a common protocol and data from the Bhopal Cancer Registry. The risk of tobacco use, particularly bidi smoking and chewing, was estimated for these three sites. A study on tobacco use in this population is particularly important as it suffered exposure to methyl-isocyanate gas due to a chemical accident in 1984 and thus is different from other parts of the world.

The present study examines data for the three most common cancer sites in males (lung, oropharynx and oral cavity), collected by the Bhopal Population-Based Cancer Registry during the years 1986–1992.

The cancer cases were coded by four-digit International Classification of Diseases for Oncology (ICD-O) code.9 The cancer sites included under oropharynx were posterior third of tongue (141.0 and 141.6), soft palate (145.3), uvula (145.4), oropharynx (146.0–146.9), nasopharynx (147.0–147.9), and hypopharynx (148.0–149.0). The cancer sites included under oral cavity were lip (140.0–140.9), anterior two-thirds of tongue (141.1–141.5), gingivum (143.0–143.9), floor of mouth (144.0–144.9), cheek mucosa (145.0–145.2), hard-palate and retromolar area (145.5–145.9). A total of 260 controls were randomly sampled from a total of about 2500 males surveyed for tobacco habits in the Bhopal population. This tobacco survey was based on random samples from the voter list of the Bhopal municipal corporation area. The survey was conducted by the Bhopal cancer registry during 1989–1992. The controls were not matched for age with the cases, however, they were age-stratified and then randomly selected to follow the age distribution of cases.

The cases and controls were interviewed according to a precoded questionnaire. The subjects were asked about identification particulars, socioeconomic parameters, tobacco habits, and clinical history. The interview was conducted by three qualified social workers of the Cancer Registry staff. The cases for which detailed information about smoking or chewing history were not available were excluded from the study. Cases registered from death certificates were excluded. Similarly, the tongue not otherwise specified cases (141.9) were not included in the analysis. After exclusion, a total of 163 lung, 247 oropharyngeal and 148 oral cavity cancer cases were available for the analysis.

The data collected were compiled and quality checks were carried out. Age-adjusted odds ratio (OR) and 95% CI for the sites under study according to religion, educational status, smoking and chewing habits were estimated using unconditional multiple logistic regression models. The models were compared using the differences in deviance and in degrees of freedom. The result of variable of interest with and without confounding variable was tabulated. The effect of interaction between variable of interest and confounder were also obtained to understand the validity of adjustment. The dummy variable and linear dose-response model was compared for testing the extent to which the linear trend adequately explains the variation between the dose level.10 The population attributable risk and attributable risk of individuals exposed to exposure of interest were also estimated. For model fitting, the statistical program GLIM was used.11

 presents the distribution of socio-demographic, smoking and chewing habits for lung, oropharyngeal and oral cavity cancer cases and controls. Most of the cases and controls were Hindu. Of the controls, 51.5% never had formal education, while 53.4% of lung, 64% of oropharyngeal and 70.9% of oral cavity cancer cases had never attended the school. The habit of smoking and tobacco chewing was more common among cases than the controls.

The multiplicative interaction between bidi and cigarette smoking was significant at the 5% level: the risk of bidi and cigarette smoking combined was observed to be 24.1 and 6.2 for lung and oropharyngeal cancer, respectively, in comparison to non-smokers of bidi and cigarettes. The risk of developing lung cancer (11.6/7.7 = 1.5) and oropharyngeal cancer (7.9/4.1 = 1.9) was higher for bidi smokers in comparison to cigarette smokers

The risk of lung and oropharyngeal cancer increased approximately more than four and three times, respectively, within three levels of grouping done for duration of smoking of bidi/cigarettes. The risk of getting oral cavity cancer was 4.3 for those who had smoked for >30 years compared to non-smokers. The risk of >500 cumulative years of tobacco smoked compared to non-smokers was 67.6 for lung cancer, 23.0 for oropharyngeal cancer and 6.0 for oral cavity cancer. The lung cancer risk according to histological types among smokers compared to non-smokers shows that the risk is higher for squamous cell carcinoma. The OR estimates for small cell and oat cell carcinoma were based on small numbers and no convergence was obtained for this type. The risk among smokers by histological types was not estimated for oropharyngeal and oral cavity cancer as only one case of adenocarcinoma was reported for oropharyngeal cancer while for the oral cavity only squamous cell carcinomas were reported during the study period.

The motivation for examining the carcinogenic effects of tobacco smoking and chewing in this population was that smoking habits differ in India and in this region from other parts of the world. The habit of bidi smoking and ‘zarda’, a form of tobacco chewing, is peculiar to this region. Case ascertainment in the present study is based on Cancer Registry data and thus entailed high-quality diagnostic confirmation. The controls were randomly selected from a tobacco survey conducted in the same population. Although the controls were not selected concurrently with the cases, it seems unlikely that this will alter the risk estimates as the period of survey (1989–1992) was almost same as the recruitment of cases (1986–1992) for the study. Further, no anti-tobacco activities were organized during the study period to alter the prevalence of tobacco habits in this population.

Religion and educational status were not observed to be risk factors in the present study. A study of the association of religion and smoking habits with lung cancer likewise did not observe any excess risk for different religion.5 Both bidis and cigarettes were found to be independently associated with increased risk of lung and oropharynx cancer. Two previous studies on the risk of lung cancer among bidi smokers have shown conflicting results. Notani and Sanghavi,4 taking hospital controls, found a relative risk of 2.6, while Jussawalla and Jain,5 taking community controls, found a relative risk of 19.3 in comparison to non-smokers. Similar to the present study increased risk for oropharyngeal cancer among bidi smokers was observed in a previous study.6

The observed OR for bidi and cigarette smoking combined (OR = 24.1 for lung and OR = 6.2 for oropharynx) in comparison to non-smokers of both was much lower than expected, indicating that either mode of action is not multiplicative or those smoking both bidis and cigarettes are light smokers of each.

Chewing tobacco contains a high level of TSNA.13 Of these, for NNK and its reduction product 4-(methyal(nitrosoamino)-1-1(3-pyridyl)-1-butanol) (NNAL) the major target organ is the lung, especially the peripheral part of the lung. This is independent of the route of admission, whether these procarcinogens are applied topically to the skin, taken orally or by intraperitoneal injection.16,17 These experimental studies suggest that tobacco chewing may also enhance the risk of lung cancer. The present study, however, did not observe any increased risk of tobacco chewing for lung cancer. The increased risk for oral cavity cancer among tobacco chewers is in accordance to that observed by other workers.7,8,18 These risk estimates in the present study could not be adjusted for the use of alcohol as history of alcohol use was not taken in the Cancer Registry proforma. However, this does not seem to alter the risk of tobacco chewing to a great extent. In India the prevalence of alcohol consumption particularly relative to tobacco chewing is low. Studies from India have not observed excess risk for oral cancer among alcohol users.

 Of action of tobacco quid chewing and smoking may not be multiplicative. It further indicated a decline in risk of chewing of tobacco with increased amount of tobacco smoked, this may be because heavy smokers chew less than light smokers.

In India cross-sectional surveys have shown that the percentage of people who chew betel quid without tobacco is small. In the present study also, based on small numbers, elevated risk was observed for oral cavity cancer among chewers not using tobacco, a finding similar to another study from south India.8

Tobacco consumption has decreased in many developed countries while in most developing countries it is still increasing. This may largely be due to the fact that relatively fewer studies have been reported from developing countries, including India, on the risk of cancer at different cancer sites due to the use of various forms of tobacco.19 In the present study it was estimated that the population attributable risk per cent (PARP) for smoking was quite high for lung (82.7%) and oropharyngeal cancer (71.6%). Similarly, the PARP was found to be 66.1% for tobacco chewers for development of oral cavity cancer. The attributable risk among smokers was observed to be 92% and 85% for lung and oropharyngeal cancer, respectively. The attributable risk for those who chewed tobacco was 84.4% for development of oral cavity cancer. This suggests that the high percentage of lung, oropharyngeal and oral cavity cancers in Bhopal could be prevented if tobacco habits were not started. Intervention studies encouraging quitting tobacco use have much relevance in Bhopal as in this population lungs are already damaged to some extent due to exposure to methyl isocynate gas as a result of the chemical disaster in December 1984. Even if gas exposure proves to be carcinogenic in future, by preventing the use of tobacco, a large number of cancer cases could be prevented.

The authors would like to thank the staff of the Bhopal Cancer Registry. The helpful advice of Dr Matti Hakama and Dr Suvi Virtanen is gratefully acknowledged. The Bhopal Cancer Registry is a part of and funded by National Cancer Registry Programme of Indian Council of Medical Research.

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If an abnormal area has been found in the oral cavity, a biopsy is the only way to know whether it is cancer. Usually, the patient is referred to an oral surgeon or an ear, nose, and throat surgeon, who removes part or all of the lump or abnormal- looking area. A pathologist examines the tissue under a microscope to check for cancer cells.

Almost all oral cancers are squamous cell carcinomas. Squamous cells line the oral cavity.

If the pathologist finds oral cancer, the patient’s doctor needs to know the stage, or extent, of the disease in order to plan the best treatment. Staging tests and exams help the doctor find out whether the cancer has spread and what parts of the body are affected.

Staging generally includes dental x-rays and x-rays of the head and chest. The doctor may also want the patient to have a CT (or CAT) scan. A CT scan is a series of x-rays put together by a computer to form detailed pictures of areas inside the body. Ultrasonography is another way to produce pictures of areas in the body. High-frequency sound waves (ultrasound), which cannot be heard by humans, are bounced off organs and tissue. The pattern of echoes produced by the waves creates a picture called a sonogram. Sometimes the doctor asks for MRI (magnetic resonance imaging), a procedure in which pictures are created using a magnet linked to a computer. The doctor also feels the lymph nodes in the neck to check for swelling or other changes. In most cases, the patient will have a complete physical examination before treatment begins.

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Our clinics are the world’s largest cancer treatment centre using alternative medicine or Homeopathy. Almost all variants of the disease are treated here in the thousands. As there are no other forms of people getting to know about our cancer treatment successes, we have found that almost all cancer patients visiting us are doing so because they are personally aware of another patient suffering from cancer or similar life threatening disease.

This is the disease that is receiving the maximum attention of Researchers in Medicine. Literally millions of academic papers have been published on the subject and countless Billions of Dollars have been invested in research. Yet unfortunately, very little progress is being seen on the ground using conventional medicine so far.

Our experience as demonstrated in a very few randomly selected cases, is that compared to conventional therapies (normally chemo therapy or radiotherapy) they live better, longer and even have the highest chance of becoming free from the disease completely. Another factor that is important for a country like India, Africa, Latin American countries is that the cost of pursuing this form of treatment is significantly lower inspite of these distinct advantages over conventional medicine.

Another vital feature of our treatment is that our treatment can be used even when the health of the patient is too frail to be subjected to Chemo, Radiotherapy or Surgery. This is because unlike the conventional medicine treatment options our medicines do not have any side-effects at all and can be confidently used in every state of the patient’s health.

Our Approach to Treatment:

We now have standardised treatments that are specific for each type of cancer that we have found to act in most of the cases. In those minorty of the cases where the patient fails to respond to these standardised treatment procedures we need to adopt a more individualistic approach.

We have two simultaneous lines of medication. One set addresses the immediate concerns of the patient - like pains, water accumulation, nausea, Insomnia (sleeplessness) etc. The other line of medication is targeted at the main disease itself. A lot of research effort has been put into Cancer Pain management and as a result again there is a group of medicines identified by us which enables us to address the severe pains experienced by cancer patients.

The first line of treatment is aimed at improving the quality of life of the patient. The second line of treatment is for dealing with the main disease.

However, the procedures adopted are dependent on the exact symptoms of the disease

Click here to have a look at a randomly selected set of 48 successfully treated Cancer cases among the thousands that we have been treating successfully all these years.

The important thing is that most of them respond to the standardised treatment that has been created by the extensive research carried out over several decades by Dr. Parimal Banerji and his son Dr. Paramesh Banerji

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From 1995 to 2002, a case-control study on food groups and risk of cancer of the oral cavity and pharynx was conducted in Montevideo, Uruguay. Two hundred thirty cases were frequency-matched to 460 controls on age, residence, and urban/rural status. The study was restricted to men. The relationship between foods and risk of oral and pharyngeal squamous cell carcinoma was examined through: 1) individual food group analysis, 2) factor analysis, and 3) determination of empirical scores. The results were similar. Factor analysis generated 2 patterns, which were labeled as “stew” and “vegetables and fruits.” The stew pattern loaded positively on boiled meat, cooked vegetables, potato, and sweet potato. This pattern was directly associated with risk of oral and pharyngeal cancer [odds ratio (OR), 3.75; 95% confidence interval (CI), 1.99-7.06; P value for trend=0.0002]. The vegetables and fruits factor loaded positively on raw vegetables, citrus fruits, other fruits, liver, fish, and desserts. This pattern was inversely associated with risk of oropharyngeal carcinoma (OR, 0.34; 95% CI, 0.18-0.64; P value for trend=0.0008). Joint effects of high intake of risk foods and low intake of protective foods were associated with a risk of 12.0 (95% CI, 4.1-34.6). Our study confirms the important role of dietary factors in oral and pharyngeal cancer risk and suggests that the analysis of dietary patterns is a powerful tool to investigate the links between nutrition and cancer.

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The oral cavity is a very specific place, well defined and broken down into various sites.  The reason for this is that the treatment and prognosis for each site can vary tremendously, depending on the size and extent of the tumor.  For the purposes of this discussion, I will actually include some sites that are, strictly speaking, not actually part of the oral cavity, such as the tonsil, soft palate, and base of tongue.  These are actually parts of what is called the oropharynx, or upper throat.  I do this because most people would think that any tumor you can see with the mouth open is in the mouth.  As simple an explanation as that is, it is not exactly correct from a scientific point of view.

There are a number of different cancers that can be found in the oral cavity.  The most common is one called Squamous Cell Carcinoma (cancer) and it is almost always, but not always, associated with smoking and drinking.  This is a cancer that begins in the cells of the lining of the mouth and upper respiratory and digestive tract.  We will focus on this one because it is the most common.  Another source of cancer in the mouth is the minor salivary glands that are found there just underneath the surface.  These cancers are usually what are called adenocarcinoma or some variation of adenocarcinoma and are much less common.   Finally, there are a number of other cancers of the oral vacity that are very uncommon and rare.

We will focus on Squamous Cell Cancer in the mouth and related places. For more information on oral cancer, please visit our site, www.tonguecancer.com

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The oral cavity extends from the skin-vermilion junctions of the anterior lips to the junction of the hard and soft palates above and to the line of circumvallate papillae below and is divided into the following specific areas:

•           Lip.

•           Anterior two thirds of tongue.

•           Buccal mucosa.

•           Floor of mouth.

•           Lower gingiva.

•           Retromolar trigone.

•           Upper gingiva.

•           Hard palate.

The main routes of lymph node drainage are into the first station nodes (i.e., buccinator, jugulodigastric, submandibular, and submental). Sites close to the midline often drain bilaterally. Second station nodes include the parotid, jugular, and the upper and lower posterior cervical nodes.

Early cancers (stage I and stage II) of the lip and oral cavity are highly curable by surgery or by radiation therapy, and the choice of treatment is dictated by the anticipated functional and cosmetic results of treatment and by the availability of the particular expertise required of the surgeon or radiation oncologist for the individual patient. [1] [2] [3] The presence of a positive margin or a tumor depth of more than 5 mm significantly increases the risk of local recurrence and suggests that combined modality treatment may be beneficial. [4] [5]

Advanced cancers (stage III and stage IV) of the lip and oral cavity represent a wide spectrum of challenges for the surgeon and radiation oncologist. Except for patients with small T3 lesions and no regional lymph node and no distant metastases or who have no lymph nodes larger than 2 cm, for whom treatment by radiation therapy alone or surgery alone might be appropriate, most patients with stage III or stage IV tumors are candidates for treatment by a combination of surgery and radiation therapy. [2] Furthermore, because local recurrence and/or distant metastases are common in this group of patients, they should be considered for clinical trials. Such trials evaluate the potential role of radiation modifiers or combination chemotherapy combined with surgery and/or radiation therapy.

Patients with head and neck cancers have an increased chance of developing a second primary tumor of the upper aerodigestive tract. [6] [7] A study has shown that daily treatment of these patients with moderate doses of isotretinoin (13-cis-retinoic acid) for 1 year can significantly reduce the incidence of second tumors. No survival advantage has yet been demonstrated, however, in part due to recurrence and death from the primary malignancy. Additional trials are ongoing. [8]

The rate of curability of cancers of the lip and oral cavity varies depending on the stage and specific site. Most patients present with early cancers of the lip, which are highly curable by surgery or by radiation therapy with cure rates of 90% to 1