Oral Cavity and Oropharyngeal Cancer

The main causes of oral and oropharyngeal cancer are:

• Tobacco use
• Alcohol use

Other causes may include the following:

• A diet low in fruits and vegetables
• Human papillomavirus (HPV) infection
• Excessive sun exposure which, like elsewhere on the body, can cause cancer on the lip

The following are the most common symptoms.

• A lip or mouth sore that does not heal
• A white or red patch on the gums, tongue, or lining of mouth
• A lump on the lip or in the mouth or throat
• Unusual bleeding, pain, or numbness in the mouth area
• Swelling of the jaw or neck
• Pain in the ear
• Change in voice
• A chronic sore throat
• Feeling as if something is caught in the throat
• Pain or difficulty in swallowing or chewing
• Cough

The symptoms of oral and oropharyngeal cancer may resemble other disorders or medical problems. Always consult your health care provider for a diagnosis.

Tumors can develop anywhere in the oral cavity and oropharynx (or the back of the mouth where it connects with the throat). Some tumors are benign (non-cancerous), some may be precancerous (a condition that may become cancerous), while others may be cancerous.

What are benign tumors?

Many forms of benign (non-cancerous) tumors can appear in the oral cavity or oropharynx including:

Condyloma acuminatum (also known as genital warts) - A small, moist, pink or red growth that grows alone or in cauliflower-like clusters

Eosinophilic granuloma - A benign tumor which most often affects children and adolescents and is usually found in a bone or the lungs

Fibroma - A benign tumor consisting of fibrous connective tissues

Keratoacanthoma - A flesh-colored, fast-growing bump on the skin with a keratin plug in the center (keratin, is the main component of the external layer of skin, hair, and nails)

Leiomyoma - A tumor of the smooth muscle, often found in the esophagus, small intestine, uterus, or stomach

Lipoma - A tumor made up of mature fat cells

Neurofibroma - A fibrous tumor consisting of nerve tissue

Odontogenic tumors - Tumors in the jaw that start in the tooth-forming tissues

Osteochondroma - A tumor made up of bone and cartilage

Papilloma - A tumor that resembles a wart, growing on the epithelium (the cells that form the skin and mucous membranes)

Pyogenic granuloma - A small, round bump that often has an ulcerated surface

Rhabdomyoma - A striated-muscle tumor that may appear on the tongue, pharynx, uterus, vagina, or heart

Schwannoma - A single tumor that grows in the neurilemma (Schwann's sheath) of nerves

Verruciform xanthoma - Wart-shaped tumors

What oral conditions may be precancerous?

Two conditions in the mouth — leukoplakia and erythroplakia —can be precursors to cancer. Often caused by smoking or chewing tobacco, these (initially) benign conditions can occur anywhere in the mouth. Only a biopsy can determine whether precancerous cells (dysplasia) or cancer cells are present in a leukoplakia or erythroplakia.

• Leukoplakia. A condition characterized by a whitish patch that develops inside the mouth or throat.
• Erythroplakia. A condition characterized by a red, raised patch that develops inside the mouth.

Treatment for leukoplakias or erythroplakias may include use of retinoids, medications that are related to vitamin A, to eliminate, reduce, and/or prevent dysplasia from forming.

What are malignant tumors?

Although there are several types of malignant oral and oropharyngeal cancers, more than 90 percent of all diagnosed oral and oropharyngeal cancers are squamous cell carcinoma.

Squamous cell carcinoma - Also known as squamous cell cancer, this type of cancer originates in the squamous cell layer in the lining of the oral cavity and oropharynx. In the early stages, this cancer is present only in the lining layer of cells (called carcinoma in situ). When the cancer spreads beyond the lining, it is called invasive squamous cell cancer.

Verrucous carcinoma - Although also considered a type of squamous cell carcinoma, this low-grade cancer rarely metastasizes (spreads to distant sites). Comprising less than five percent of all diagnosed oral cancers, verrucous carcinoma can spread deeply into surrounding tissue, requiring surgical removal with a wide margin of surrounding tissue.

Minor salivary gland cancers - The lining of the oral cavity and oropharynx contains numerous salivary glands. Sometimes cancer will originate in a salivary gland. Treatment depends on the type and location of the salivary gland cancer, as well as the extent of spreading. According to the ACS, salivary gland cancers are rare.

Although heredity also plays a factor, certain lifestyle habits and health conditions can increase a person's risk for developing oral and oropharyngeal cancers. A risk factor is anything that may increase a person's chance of developing a disease. It may be an activity--such as smoking or diet, family history, or many other things.

Although these factors can increase a person's risk, they do not necessarily cause the disease. Some people with one or more risk factors never develop the disease, while others develop disease and have no known risk factors. But, knowing your risk factors to any disease can help to guide you into the appropriate actions, including changing behaviors and being clinically monitored for the disease.

Tobacco use - The majority of patients with oral and oropharyngeal cancers use tobacco in one form or another. Tobacco can damage cells in the lining of the oral cavity and oropharynx causing abnormal cells to grow more rapidly to repair the damage. According to the ACS, it is suspected that the DNA-damaging chemicals in tobacco are linked to the increased risk of oral and oropharyngeal cancers.

Alcohol use - The majority of patients with oral and oropharyngeal cancers use alcohol frequently. When paired with tobacco use, patients increase their risk of developing oral and oropharyngeal cancers even more.

Sunlight - Prolonged exposure to ultraviolet radiation from the sun can cause skin cancer. People who are outdoors for an extended period of time increase their risk of lip cancer, as well.

Chronic irritation - Chronic irritation to the lining of the mouth, due to poorly fitting dentures or other reasons, may increase a person's risk for oral cancer.

Lack of fruits and vegetables in diet - Research has suggested that fruits and vegetables, which contain antioxidants that can "trap" harmful molecules, can decrease the risk for oral and oropharyngeal cancers (and other cancers). It is speculated that persons with a low intake of these types of foods are at an increased risk for (oral and oropharyngeal) cancer.

Human papillomavirus (HPV) infection - HPV usually causes warts and has been linked to cervical, vaginal, and penile cancers. HPV also increases the risk for cancers of the oral cavity and oropharynx.

Males - Oral and oropharyngeal cancers are twice as common in men then in women, partly because men are more likely to use tobacco and alcohol.

In addition to a complete medical history and physical examination, diagnostic procedures for oral cancers of the oral cavity and oropharynx may include one or more of the following:

• Biopsy. A procedure in which tissue samples are removed (with a needle or during surgery) for examination under a microscope to determine if cancer or other abnormal cells are present.
• Computed tomography (CT-scan). A noninvasive procedure that takes horizontal, or axial, images of the brain or other internal organs to detect any abnormalities that may not show up on an ordinary X-ray.
• Ultrasonography. A diagnostic imaging technique that uses high-frequency sound waves to create an image of the internal organs.
• Magnetic resonance imaging (MRI). A noninvasive procedure that produces 2-dimensional view of an internal organ or structure, especially the brain and spinal cord. If additional imaging is needed, your doctor may order a PET scan, which can determine where your cancer started.
• Barium swallow. Because cancer of the esophagus may occur with oral cancer, your doctor may order this test, often called an upper GI series, to look for cancer of the esophagus. You will drink a chalky solution while X-rays are taken.
• Endoscopy. A small fiber optic scope can be used to examine the oropharynx and oral cavity. The scope can also be used to obtain biopsies.

Once a diagnosis is made, the cancer will be staged (to determine the extent of the disease) before a treatment plan is established.

Specific treatment for cancers of the oral cavity and oropharynx will be determined by your health care provider based on:

• Your age, overall health, and medical history
• Extent of the disease
• Your tolerance for specific medications, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference

Treatment may include:

• Surgery. Different surgery techniques are used to remove specific types of tumors, including:
  • Primary tumor resection. Removal of the entire tumor and surrounding area of tissue.
  • Maxillectomy. Removal of the tumor, including part or all of the hard palate (roof of the mouth), if bone is involved.
  • Glossectomy. Removal of the tongue.
  • Mohs' micrographic surgery. Removal of the tumor in "slices" to minimize amount of normal tissue removed (may be considered when the cancer involves the lip).
  • Laryngectomy. Removal of a large tumor of the tongue or oropharynx, which may involve removing the larynx (voice box).
  • Neck dissection. If cancer has spread to the lymph nodes in the neck, these lymph nodes may need to be removed as well.
  • Transoral Robotic Surgery (TORS), a minimally invasive procedure which improves outcomes and avoids complications in patients with oral cancers.
• Radiation therapy. Treatment that uses high-energy rays that damage cancer cells and halts the spread of cancer. Radiation therapy is very localized, aimed at only the area where the cancer is present. Radiation therapy may be administered externally with a machine, or internally with radioactive materials.
• Chemotherapy. Medications that go throughout the entire body to kill cancer cells. Chemotherapy has the ability to interfere with the cancer cell's replication. Chemotherapy may be used in combination with surgery and radiation therapy.
• Targeted therapy. Drugs that target specific cancer cells are also an option and often cause fewer side effects than chemotherapy that kills both cancerous and noncancerous cells.

Side effects of treatment for oral and oropharyngeal cancer

Side effects of treatment vary, depending on the type of treatment and the area being treated. Side effects can be temporary or permanent. The following are some of the more common side effects of treatment for cancers of the oral cavity and oropharynx:

• Swelling from surgery
• Sore mouth
• Difficulty chewing, swallowing, or talking
• Changes to appearance, temporarily or permanently
• Weight loss due to a sore mouth, which may make eating difficult
• Inability to wear dentures for a period of time

Depending on the type of treatment, other side effects may include:

• Fatigue
• Dental problems
• lowered immune system
• Nausea
• Vomiting
• Mouth sores
• Lack of appetite

Types of rehabilitation after treatment for oral and oropharyngeal cancer

Rehabilitation may vary from person to person depending on the type of treatment, and the location and extent of the cancer. Rehabilitation may include:

• Dietary counseling. Many patients recovering from surgery have difficulty eating, so it is often recommended that they eat small meals consisting of soft, moist foods.
• Reconstructive surgery. Some patients may benefit from reconstructive or plastic surgery to restore the bones or tissues of the mouth, returning a more normal appearance.
• Prosthesis. If reconstructive or plastic surgery is not an option, patients may benefit from dental or facial-part prosthesis to restore a more normal appearance. Special training may be needed to learn to use a prosthetic device.
• Speech therapy. If a patient experiences difficulty in speaking following treatment, speech therapy may help the patient relearn the process.

Careful monitoring and the involvement of an experienced otolaryngologist are important to the successful outcome for patients with ear, nose and throat disorders and conditions.

If you are having surgery or a procedure, you will likely be scheduled for a visit to the Weiner Center for Preoperative Evaluation for pre-operative information and tests.

If surgery is needed, you will be cared for in the operating room by an experienced otolaryngology surgeon. After surgery, you will recover in the post-surgical care unit where you will receive comprehensive care by an experienced medical and nursing staff.

Brigham and Women’s Faulkner Hospital provides a multidisciplinary approach to patient care by collaborating with colleagues who have extensive experience in diagnosing and treating ear, nose and throat disorders and conditions. In addition, patients have full access to Brigham and Women's Hospital’s world-renowned academic medical community, with its diverse specialists, and state-of-the-art facilities.

When surgery is necessary, our board-certified surgeons offer extensive surgical experience, performing thousands of operations per year. Our otolaryngologists are faculty members at Harvard Medical School and active researchers who continually seek causes and investigate treatments for conditions and diseases affecting the ear, nose and throat.