Oral Cavity Cancer

The oral cavity includes the following:

• The front two thirds of the tongue.
• The gingiva (gums).
• The buccal mucosa (the lining of the inside of the cheeks).
• The floor (bottom) of the mouth under the tongue.
• The hard palate (the roof of the mouth).
• The retromolar trigone (the small area behind the wisdom teeth).

Most lip and oral cavity cancers start in squamous cells, the thin, flat cells that line the lips and oral cavity. These are called squamous cell carcinomas. Cancer cells may spread into deeper tissue as the cancer grows. Squamous cell carcinoma usually develops in areas of leukoplakia (white patches of cells that do not rub off).

 Video (Dr. Stan Wasbin, Your Cancer Today's Medical Director, gives an overview of oral cancer.) 

Tobacco and alcohol use can affect the risk of developing lip and oral cavity cancer.

Risk factors for lip and oral cavity cancer include the following:

• Using tobacco products.
• Heavy alcohol use.
• Being exposed to sunlight.
• Being male.
• Being infected with human papillomavirus (HPV).

Possible signs of lip and oral cavity cancer include a sore or lump on the lips or in the mouth.

These and other symptoms may be caused by lip and oral cavity cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

• A sore on the lip or in the mouth that does not heal.
• A lump or thickening on the lips or gums or in the mouth.
• A white or red patch on the gums, tongue, tonsils, or lining of the mouth.
• Bleeding, pain, or numbness in the lip or mouth.
• Change in voice.
• Loose teeth or dentures that no longer fit well.
• Trouble chewing or swallowing or moving the tongue or jaw.
• Swelling of jaw.
• Sore throat or feeling that something is caught in the throat.

Lip and oral cavity cancer may not have any symptoms and is sometimes found during a regular dental exam.

Tests that examine the mouth and throat are used to detect (find), diagnose, and stage lip and oral cavity cancer.

The following tests and procedures may be used:

• Physical exam of the lips and oral cavity: An exam to check the lips and oral cavity for abnormal areas. The doctor or dentist will feel the entire inside of the mouth with a gloved finger and examine the oral cavity with a small long-handled mirror and lights. This will include checking the insides of the cheeks and lips; the gums; the roof and floor of the mouth; and the top, bottom, and sides of the tongue. The neck will be felt for swollen lymph nodes. A history of the patient’s health habits and past illnesses and medical and dental treatments will also be taken.
• Endoscopy: A procedure to look at organs and tissues inside the body to check for abnormal areas. An endoscope (a thin, lighted tube) is inserted through an incision (cut) in the skin or opening in the body, such as the mouth. Tissue samples and lymph nodes may be taken for biopsy.
• X-rays of the head, neck, and chest: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist. If leukoplakia is found, cells taken from the patches are also checked under the microscope for signs of cancer.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• Exfoliative cytology: A procedure to collect cells from the lip or oral cavity. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the lips, tongue, mouth, or throat. The cells are viewed under a microscope to find out if they are abnormal.
• Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and x-rays are taken. This procedure is also called an upper GI series.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

Certain factors affect prognosis (chance of recovery) and treatment options.

Prognosis (chance of recovery) depends on the following:

• The stage of the cancer.
• Where the tumor is in the lip or oral cavity.
• Whether the cancer has spread to blood vessels.

For patients who smoke, the chance of recovery is better if they stop smoking before beginning radiation therapy.

Treatment options depend on the following:

• The stage of the cancer.
• The size of the tumor and where it is in the lip or oral cavity.
• Whether the patient's appearance and ability to talk and eat can stay the same.
• The patient's age and general health.

Patients who have had lip and oral cavity cancer have an increased risk of developing a second cancer in the head or neck. Frequent and careful follow-up is important. Clinical trials are studying the use of retinoid drugs to reduce the risk of a second head and neck cancer.

Stages of Lip and Oral Cavity Cancer

• After lip and oral cavity cancer has been diagnosed, tests are done to find out if cancer cells have spread within the lip and oral cavity or to other parts of the body.
• The following stages are used for lip and oral cavity cancer:
  • Stage 0 (Carcinoma in Situ)
  • Stage I
  • Stage II
  • Stage III
  • Stage IV

After lip and oral cavity cancer has been diagnosed, tests are done to find out if cancer cells have spread within the lip and oral cavity or to other parts of the body.

The process used to find out if cancer has spread within the lip and oral cavity or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The results of the tests used to diagnose lip and oral cavity cancer are also used to stage the disease. (See the General Information section.)

The following stages are used for lip and oral cavity cancer:

Stage 0 (Carcinoma in Situ)

In stage 0, cancer is found only in the layer of cells lining the lips and oral cavity. Stage 0 cancer is also called carcinoma in situ.

Stage I

In stage I, the tumor is 2 centimeters or smaller and cancer has not spread to the lymph nodes.

Stage II

In stage II, the tumor is larger than 2 centimeters but not larger than 4 centimeters and cancer has not spread to the lymph nodes.

Stage III

In stage III, the tumor:

• may be any size and has spread to a single lymph node that is 3 centimeters or smaller, on the same side of the neck as the cancer; or
• is larger than 4 centimeters.

Stage IV

Stage IV is divided into stages IVA, IVB, and IVC as follows:

• In stage IVA, the tumor:
  • has spread to nearby tissues in the lip and oral cavity; or
  • is any size and may have spread to nearby tissues in the lip and oral cavity. Cancer has spread to 1 or more lymph nodes on one or both sides of the neck, and the involved lymph nodes are 6 centimeters or smaller.
• In stage IVB, the tumor:
  • may be any size and has spread to one or more lymph nodes that are larger than 6 centimeters; or
  • has spread to the muscles or bones in the oral cavity, or to the base of the skull and/or the carotid artery. Cancer may have spread to one or more lymph nodes on one or both sides of the neck.
• In stage IVC, the tumor has spread beyond the lip and oral cavity to other parts of the body. The tumor may be any size and may have spread to the lymph nodes.

Recurrent Lip and Oral Cavity Cancer 

Recurrent lip and oral cavity cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the lip or mouth or in other parts of the body.

Treatment Option Overview

• There are different types of treatment for patients with lip and oral cavity cancer.
• Patients with lip and oral cavity cancer should have their treatment planned by a team of doctors who are expert in treating head and neck cancer.
• Two types of standard treatment are used:
  • Surgery
  • Radiation therapy
• New types of treatment are being tested in clinical trials. These include the following:
  • Chemotherapy
  • Hyperfractionated radiation therapy
  • Hyperthermia therapy

There are different types of treatment for patients with lip and oral cavity cancer.

Different types of treatment are available for patients with lip and oral cavity cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country.  Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Patients with lip and oral cavity cancer should have their treatment planned by a team of doctors who are expert in treating head and neck cancer.

Treatment will be overseen by a medical oncologist, a doctor who specializes in treating people with cancer. Because the lips and oral cavity are important for breathing, eating, and talking, patients may need special help adjusting to the side effects of the cancer and its treatment. The medical oncologist may refer the patient to other health professionals with special training in the treatment of patients with head and neck cancer. These include the following:

• Head and neck surgeon.
• Radiation oncologist.
• Dentist.
• Speech therapist.
• Dietitian.
• Psychologist.
• Rehabilitation specialist.
• Plastic surgeon.

Two types of standard treatment are used:

Surgery

Surgery (removing the cancer in an operation) is a common treatment for all stages of lip and oral cavity cancer. Surgery may include the following:

• Wide local excision: Removal of the cancer and some of the healthy tissue around it. If cancer has spread into bone, surgery may include removal of the involved bone tissue.
• Neck dissection: Removal of lymph nodes and other tissues in the neck. This is done when cancer may have spread from the lip and oral cavity.
• Plastic surgery: An operation that restores or improves the appearance of parts of the body. Dental implants, a skin graft, or other plastic surgery may be needed to repair parts of the mouth, throat, or neck after removal of large tumors.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to increase the chances of a cure, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

For patients who smoke, radiation therapy works better when smoking is stopped before beginning treatment. It is also important for patients to have a dental exam before radiation therapy begins, so that existing problems can be treated.

New types of treatment are being tested in clinical trials. These include the following:

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Hyperfractionated radiation therapy

Hyperfractionated radiation therapy is radiation treatment in which each day's total dose of radiation is divided into two or more smaller doses, usually given hours apart, instead of giving it all at once. This is also called superfractionated radiation therapy.

Hyperthermia therapy

Hyperthermia therapy is a treatment in which body tissue is heated above normal temperature to damage and kill cancer cells or to make cancer cells more sensitive to the effects of radiation and certain anticancer drugs.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied.

 Video (Dr. Kenneth Hilsen has an in-depth discussion about screening and treatments for oral cancer.) 

Treatment Options by Stage

Stage I Lip and Oral Cavity Cancer
Stage II Lip and Oral Cavity Cancer
Stage III Lip and Oral Cavity Cancer
Stage IV Lip and Oral Cavity Cancer

Stage I Lip and Oral Cavity Cancer

Treatment of stage I lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity.

Lip

If cancer is in the lip, treatment may include the following:

• Surgery (wide local excision).
• Internal radiation therapy with or without external radiation therapy.

Front of the tongue

If cancer is in the front of the tongue, treatment may include the following:

• Surgery (wide local excision).
• Internal radiation therapy with or without external radiation therapy.
• Radiation therapy to lymph nodes in the neck.

Buccal mucosa

If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

• Surgery (wide local excision) for tumors smaller than 1 centimeter, with or without internal and/or external radiation therapy.
• Surgery (wide local excision with skin graft) or radiation therapy for larger tumors.

Floor of the mouth

If cancer is in the floor (bottom) of the mouth, treatment may include the following:

• Surgery (wide local excision) for tumors smaller than ½ centimeter.
• Surgery (wide local excision) or radiation therapy for larger tumors.

Lower gingiva

If cancer is in the lower gingiva (gums), treatment may include the following:

• Surgery (wide local excision, which may include removing part of the jawbone, and skin graft).
• Radiation therapy with or without surgery.

Retromolar trigone

If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

• Surgery (wide local excision, which may include removing part of the jawbone.)
• Radiation therapy with or without surgery.

Upper gingiva or hard palate

If cancer is in the upper gingiva (gums) or the hard palate (the roof of the mouth), treatment is usually surgery (wide local excision) with or without radiation therapy.

Stage II Lip and Oral Cavity Cancer

Treatment of stage II lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity.

Lip

If cancer is in the lip, treatment may include the following:

• Surgery (wide local excision).
• External radiation therapy and/or internal radiation therapy.

Front of the tongue

If cancer is in the front of the tongue, treatment may include the following:

• Radiation therapy and/or surgery (wide local excision).
• Internal radiation therapy with surgery (neck dissection).

Buccal mucosa

If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

• Radiation therapy for tumors that are 3 centimeters or smaller.
• Surgery (wide local excision) and/or radiation therapy for larger tumors.

Floor of the mouth

If cancer is in the floor (bottom) of the mouth, treatment may include the following:

• Surgery (wide local excision).
• Radiation therapy.
• Surgery (wide local excision) followed by external radiation therapy, with or without internal radiation therapy, for large tumors.

Lower gingiva

If cancer is in the lower gingiva (gums), treatment may include the following:

• Surgery (wide local excision, which may include removing part of the jawbone, and a skin graft).
• Radiation therapy alone or after surgery.

Retromolar trigone

If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

• Surgery (wide local excision, which includes removing part of the jawbone).
• Radiation therapy with or without surgery.

Upper gingiva or hard palate

If cancer is in the upper gingiva (gums) or the hard palate (the roof of the mouth), treatment may include the following:

• Surgery (wide local excision) with or without radiation therapy.
• Radiation therapy alone.

Stage III Lip and Oral Cavity Cancer

Treatment of stage III lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity.

Lip

If cancer is in the lip, treatment may include the following:

• Surgery and external radiation therapy with or without internal radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Front of the tongue

If cancer is in the front of the tongue, treatment may include the following:

• External radiation therapy with or without internal radiation therapy.
• Surgery (wide local excision) followed by radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Buccal mucosa

If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

• Surgery (wide local excision) with or without radiation therapy.
• Radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Floor of the mouth

If cancer is in the floor (bottom) of the mouth, treatment may include the following:

• Surgery (wide local excision, which may include removing part of the jawbone, with or without neck dissection).
• External radiation therapy with or without internal radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Lower gingiva

If cancer is in the lower gingiva (gums), treatment may include the following:

• Surgery (wide local excision) with or without radiation therapy. Radiation may be given before or after surgery.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Retromolar trigone

If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

• Surgery to remove the tumor, lymph nodes, and part of the jawbone, with or without radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Upper gingiva

If cancer is in the upper gingiva (gums), treatment may include the following:

• Radiation therapy.
• Surgery (wide local excision) and radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Hard palate

If cancer is in the hard palate (the roof of the mouth), treatment may include the following:

• Radiation therapy.
• Surgery (wide local excision) with or without radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

Lymph nodes

For cancer that may have spread to lymph nodes, treatment may include the following:

• Radiation therapy and/or surgery (neck dissection).
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of hyperfractionated radiation therapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied.

Stage IV Lip and Oral Cavity Cancer

Treatment of stage IV lip and oral cavity cancer depends on where cancer is found in the lip and oral cavity.

Lip

If cancer is in the lip, treatment may include the following:

• Surgery and external radiation therapy with or without internal radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Front of the tongue

If cancer is in the front of the tongue, treatment may include the following:

• Surgery to remove the tongue and sometimes the larynx (voice box) with or without radiation therapy.
• Radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Buccal mucosa

If cancer is in the buccal mucosa (the lining of the inside of the cheeks), treatment may include the following:

• Surgery (wide local excision) and/or radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Floor of the mouth

If cancer is in the floor (bottom) of the mouth, treatment may include the following:

• Surgery before or after radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Lower gingiva

If cancer is in the lower gingiva (gums), treatment may include the following:

• Surgery and/or radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Retromolar trigone

If cancer is in the retromolar trigone (the small area behind the wisdom teeth), treatment may include the following:

• Surgery to remove the tumor, lymph nodes, and part of the jawbone, followed by radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Upper gingiva or hard palate

If cancer is in the upper gingiva (gums) or hard palate (the roof of the mouth), treatment may include the following:

• Surgery with radiation therapy.
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

Lymph nodes

For cancer that may have spread to lymph nodes, treatment may include the following:

• Radiation therapy and/or surgery (neck dissection).
• A clinical trial of chemotherapy and radiation therapy.
• A clinical trial of chemotherapy before or after surgery.
• A clinical trial of hyperfractionated radiation therapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied.

Treatment Options for Recurrent Lip and Oral Cavity Cancer 

Treatment of recurrent lip and oral cavity cancer may include the following:

• Surgery, if radiation therapy was used before.
• Surgery and/or radiation therapy, if surgery was used before.
• A clinical trial of chemotherapy with or without radiation therapy.
• A clinical trial of hyperthermia therapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied.

Source: National Cancer Institute