Head & Neck

Oral Cancer

Oral cancer can develop in any part of the mouth, including the lips, gums, roof and floor of the mouth, tongue, and the inside lining of the cheeks and lips (see figure below). Tumors that grow in the mouth can be benign (noncancerous) or malignant (cancerous), or they can start out benign and later develop into cancer. Most cancers that develop in the mouth form from squamous cells, the thin cells that line the mouth and throat.

Diagnosing Oral Cancer

Symptoms that may point to oral cancer include a white or red patch on the gums, the tongue or the lining of the mouth; a swelling of the jaw that causes dentures to fit poorly or become uncomfortable; and unusual bleeding or pain in the mouth. However, these symptoms can sometimes go unnoticed, which may make it difficult to diagnose oral cancer at an early stage. When oral cancer is suspected, diagnostic tests will be done to determine whether cancer is actually present.

Staging

Once oral cancer is diagnosed, your doctor will use the TNM (tumor, node, metastasis) system to stage the disease and determine its extent, where it is located, and whether it has metastasized (spread) to nearby tissues or to other parts of your body. Your physical exam, diagnostic tests and a pathology report help your doctor decide the stage of your cancer and develop a treatment plan.

Treatment Options

Standard treatment options for oral cancer include surgery, radiation therapy and chemotherapy. Advances in cancer research have led to new options, such as immunotherapy. Your doctor will consider many factors when exploring treatment options, including the stage of disease, the location and size of the tumor, and your overall health status. Your doctor will also focus on preserving as much normal function as possible. Treatment options also depend on whether the oral cancer is primary or recurrent. You should talk to your health care team about the goal of treatment — whether the goal is to cure the cancer or to keep the cancer under control and relieve symptoms. Understanding the goal, as well as the benefits and risks of each option, will help you become better informed for making shared treatment decisions with your doctor.

Surgery

Surgery is done to remove early-stage tumors, such as small cancers of the lip and cancers of the floor of the mouth, front of the tongue, inside of the cheek, gums and hard palate. Larger tumors or tumors that have spread to nearby tissues, including lymph nodes in the neck, may also be treated with surgery. After surgery, reconstructive surgery may be recommended to repair damaged areas of the mouth and improve the ability to eat and speak (see Reconstructive Surgery).

Radiation Therapy

Radiation therapy is usually recommended after surgery if the risk of cancer recurrence is high or if the cancer has spread to lymph nodes in the neck or other parts of the body. Known as external-beam radiation therapy (EBRT), this type of treatment is given from a machine that aims high-energy beams of radiation, usually X-rays or gamma rays, at specific points of the body. EBRT is usually given for about six weeks, once a day for 15 to 30 minutes, five days a week. Radiation therapy, with or without chemotherapy, may be used to treat oral cancers that are very large or in patients who have medical conditions that make surgery too dangerous.

Chemotherapy

Chemotherapy drugs kill cells that divide quickly, such as cancer cells. Given alone or as a combination of two or more drugs, chemotherapy is a systemic therapy which travels throughout the body through the bloodstream, killing cancer cells or stopping them from growing and spreading. It is sometimes used to treat metastatic oral cancer and may be given after surgery to reduce the risk of cancer recurrence. Chemotherapy can be used with radiation therapy, a combination known as chemoradiation therapy. With this combination treatment, the chemotherapy drug used helps make the cancer cells more sensitive to the radiation, allowing the radiation to kill more of them.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow and kill cancer cells. With this treatment approach, substances – made either by the body or in a laboratory – are used to identify cancer cells as a threat and target them for destruction. Immunotherapy may be an option for oral cancers that have stopped responding to chemotherapy. Immunotherapy for head and neck cancers involves the use of drugs known as immune checkpoint inhibitors. These inhibitors may be given with or without chemotherapy. Immunotherapy may be an option for recurrent or metastatic oral cancer, but it is not typically used as a first-line treatment.

Targeted Therapy

Targeted therapy drugs work by targeting specific proteins and genes that help cancer cells grow. Some of these drugs target the epidermal growth factor receptor (EGFR), a protein on the surface of cancer cells that helps them grow and divide. The drugs block EGFR and stop it from working, which can help slow or stop cancer growth. Targeted therapy may be given alone or in combination with chemotherapy for oral cancer that has spread to another part of the body.

Other types of immunotherapy and targeted therapy are being evaluated in clinical trials. Ask your doctor or another member of your health care team if participation in a clinical trial is an option for you.

TNM classification for oral cancer

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
Tis Carcinoma in situ.
T1 Tumor ≤ (not more than) 2 cm, ≤ (not more than) 5 mm depth of invasion (DOI). DOI is depth of invasion and not tumor thickness.
T2 Tumor ≤ (not more than) 2 cm, DOI > (more than) 5 mm and ≤ (not more than) 10 mm;
or tumor > (more than) 2 cm but ≤ (not more than) 4 cm, and ≤ (not more than) 10 mm DOI. DOI is depth of invasion and not tumor thickness.
T3 Tumor > (more than) 4 cm;
or any tumor > (more than) 10 mm DOI. DOI is depth of invasion and not tumor thickness.
T4 Moderately advanced or very advanced local disease.
  T4a Moderately advanced local disease.
(lip) Tumor invades through cortical bone or involves the inferior alveolar nerve, floor of mouth, or skin of face (i.e., chin or nose).
(oral cavity) Tumor invades adjacent structures only (e.g. through cortical bone of the mandible [lower jawbone] or maxilla [upper jawbone], or involves the maxillary sinus or skin of the face).
  T4b Very advanced local disease.
Tumor invades masticator space (located on either side of the face around the jawbones), pterygoid plates, or skull base and/or encases the internal carotid artery.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in a single ipsilateral (on the same side) lymph node, 3 cm or smaller in greatest dimension and ENE*(-).
N2 Metastasis in a single ipsilateral (on the same side) lymph node, 3 cm or smaller in greatest dimension and ENE*(+);
or larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-);
or in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension, ENE(-).
  N2a Metastasis in single ipsilateral (on the same side) node 3 cm or smaller in greatest dimension and ENE*(+);
or a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-).
  N2b Metastasis in multiple ipsilateral (on the same side) nodes, none larger than 6 cm in greatest dimension and ENE*(-).
  N2c Metastasis in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE*(-).
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-);
or metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node 3 cm or smaller and ENE(+).
  N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-).
  N3b Metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node 3 cm or smaller and ENE(+).
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.
*Extranodal extension (ENE) refers to cancer cells that have spread beyond the lymph node into surrounding tissues.

Staging Oral Cancer

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3
T1, T2, T3
N0
N1
M0
M0
IVA T4a
T1, T2, T3, T4a
N0, N1
N2
M0
M0
IVB Any T
T4b
N3
Any N
M0
M0
IVC Any T Any N M1

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science+Business Media.

 

Additional Resources

 

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