Cancer, Speaking of Tongues

MD Anderson Cancer Center
Date: 08/08/2011


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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas, M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today, our guest is Dr. Ann Gillenwater. She's professor of Head and Neck Surgery here at M.D. Anderson and we're going to talk about tongue cancer. So Dr. Gillenwater, tongue cancer is kind of one of those cancers that's kind of lumped into what we call oral cancer?

Dr. Ann Gillenwater: That's correct. It is the most common site of cancer in the oral cavity is in the tongue.

Lisa Garvin: How rare is it? We have talked earlier about it. It's fairly rare in Western world but much more common in the Eastern hemisphere.

Dr. Ann Gillenwater: Oral cancer in the United States, incidence is only about 30,000 per year and accounts probably about 7,000 deaths per year in the United States. But in other parts of the world, particularly Southeast Asia, India, Pakistan as well as Taiwan and Thailand, there are very high incidences of oral cancer. It is the number one cancer in men in India and it's the number three cancer in women in India.

Lisa Garvin: And that's due to certain lifestyle choices, is that correct?

Dr. Ann Gillenwater: We think that it has a large part to play. The use of both tobacco products as well as a stimulant called betel or areca nut.

Lisa Garvin: Now, about oral cancer, what are the risk factors here in the Western hemisphere? I would assume that smoking would be high in the list or smokeless tobacco?

Dr. Ann Gillenwater: Right, tobacco is the number one risk factor for oral cancer in the United States. Usually, that cigarette smokes--cigarette smoking but it can also be a smokeless tobacco, snuff, or cigars can also increase your risk. And then alcohol use is the second higher risk factor.

Lisa Garvin: So it's purely a lifestyle cancer that would thus be preventable in many cases I would assume?

Dr. Ann Gillenwater: In many cases, but there is also an increasing percentage of patients who do not have any of our known risk factors for oral cancer. This is a group particularly in young white females who are developing oral cancer and we don't know their risk factors.

Lisa Garvin: So there's no known genetic mutation or inherited syndrome or anything that we know of now?

Dr. Ann Gillenwater: In general most people who present with oral cancer do not have a genetic syndrome or a strong family history. However, there are patients who do have a strong family history and there is an inherited syndrome called Fanconi's anemia which has a very high rate of oral cancer development, particularly in young people.

Lisa Garvin: I would think since it's in the mouth and we use our mouth most of the day, is this something that we can catch early? Are the symptoms obvious?

Dr. Ann Gillenwater: Many times there are no symptoms, in other words, the patient doesn't feel any pain. They're not bleeding, there's no big mass initially but if they were to look into their mouth and inspect it or have their dentist inspect it when they go for their routine cleaning, many times, precancerous or potentially malignant lesions could be detected. The most common of those is oral leukoplakia which is basically just a white spot in the mouth. There's also something called oral erythroplakia which means red spot. And anytime you see ulcer, an area that doesn't heal, a lump that is new or changing, these are potential signs of oral cancer. And areas of sore gums that bleed, that don't improve after a good dental cleaning or antibiotics or reasonable amount of time should also be evaluated further for oral cancer.

Lisa Garvin: It sounds like dentists are kind of the front line in identifying oral cancers?

Dr. Ann Gillenwater: Dentists are definitely the front line and they have a tremendous opportunity to inspect people for oral cancer when they come in for their dental evaluations and dental cleanings. Unfortunately, many people don't go in regularly to see their dentist. And the other front line would be the primary care physicians, the family doctors and the internist who examine patients as well.

Lisa Garvin: How often is it caught in early stages?

Dr. Ann Gillenwater: That's a tough question. Most cases of oral cancer, even in the United States, are still presenting with advanced stage and this can be due to a variety of factors, you know, one is that people don't request medical attention or dental attention when they find something in their mouth. Another is that sometimes the clinicians are not confident enough to make the diagnosis by clinical examination alone. It's much more common to have a benign abnormality in the oral cavity than it is to have a cancer and so often dentists or physicians don't recognize the early forms of cancer.

Lisa Garvin: Where is the most common site? I think you said the tongue is the most common site within the oral cavity.

Dr. Ann Gillenwater: In the United States the tongue and the floor of the mouth area is the most common. In India, for instance, we call it--it's called the gingivobuccal sulcus or basically it's the cheek is the more common.

Lisa Garvin: Which is where they would have the betel, I guess, they would lodge it in their cheek.

Dr. Ann Gillenwater: Right, exactly.

Lisa Garvin: So, how--I'm assuming that surgery would be the front line treatment. How do you treat oral cancers?

Dr. Ann Gillenwater: Although there is some controversy, most people including our group at M.D. Anderson agree that surgery should be the front line treatment for oral cancer. Sometimes in advanced cases we need to do radiation therapy as well and we're also looking into the role of chemotherapy in oral cancer.

Lisa Garvin: I guess you have to be so careful in the head and neck region because there are so many critical structures there. How do you do the surgery? Is it--do you take out the tongue? Do you just take out the cancerous areas or how do you approach in--What is the surgical approach?

Dr. Ann Gillenwater: It all depends on where the tumor is and also how advanced it is. I think one of the key points when doing any type of treatment for cancers in the oral cavity or the rest of the head and neck is it's important to remember the function. Not only do you have to take the cancer out, you also have to maintain as much normal function as you can. In the oral cavity, the big issues are being able to talk and being able to swallow. And then the third very important component is the cosmetic result because unlike some cancers in the other parts of the body we can't hide the oral cavity under a shirt or a pair of trousers so cosmetic reconstruction is also very important.

Lisa Garvin: If you had a fairly large tumor on your tongue, can you, do you have to take the whole organ out or you can do like tongue-sparing surgery?

Dr. Ann Gillenwater: Yes, of course. Well, really what you try to do is to take out the cancer with the cuff of normal tissue around it and then we use the pathologist work very closely with us to make sure that we have all the tumor out. And then whatever is left can be--sometimes if you catch the cancers early then there's enough of the tongue left that there's very little deficit and people are able to talk and swallow and have no scars on their face. It's hard to know they even had a cancer.

Lisa Garvin: Are you doing intraoperative MRI or how are you--You say, you know, you're trying to get that perfect margin where you're getting all the cancer and leaving as much healthy tissue as possible. Are you doing the MRIs during surgery or how do you handle that?

Dr. Ann Gillenwater: We don't use MRI or CT-scan in the operation. It's mostly visual examination and palpation.

Lisa Garvin: What is the typical age for an oral cancer patient? We talked about men being more likely. Is it something that's later in life or do we see it across the age spectrum?

Dr. Ann Gillenwater: The traditional presentation of oral cancer was in elderly males usually 60 and older with a strong history of tobacco and alcohol use. That epidemiology is actually changing and there's an incidence of younger patients who have less risk factors.

Lisa Garvin: So what sorts of research is being done with radiation therapy either as an adjuvant therapy or front line therapy for oral cancer?

Dr. Ann Gillenwater: There's been a lot of research going on looking at optimal dosage of radiation therapy as well as the type of delivery method. One of the newer innovations was something we call IMRT or Image Modulated Radiation Therapy. And the beauty of this technique is that you're able to focus the rays of the radiation right to the tumor areas and to spare the normal tissues such as the jaw bone and the saliva glands. And so there's been a lot of good research going on in this manner. There's also some work on proton therapy for radiation therapy.

Lisa Garvin: What about new chemotherapeutic agents?

Dr. Ann Gillenwater: That's been very exciting because it's been over the last three decades that any chemotherapy at all has been used for head and neck cancer. Now it has become the third leg in our multidisciplinary tool to treat and manage patients. We use chemotherapy as an adjuvant for radiation therapy. We use it as an induction treatment prior to surgery. And we're even starting to look into types of chemotherapy to prevent a patient from developing cancer and we call that chemoprevention.

Lisa Garvin: Is the prognosis improving for tongue and oral cancer patients?

Dr. Ann Gillenwater: If you look at the entire spectrum of patients coming in, the survival rates are the same as they have been over the last 2, 3 or 4 decades. So there's not really been an increase in survival. There's been a dramatic increase in the quality of life and the functional outcome for the patients who do get the cancer. And there's been a shift in the manner of death of patients who develop cancer. So in previous years, 30 years ago, patients would mostly die of their local disease which frankly is not a good way to die. With the improvements in surgery and radiation therapy, we've had much better success at controlling the disease in the oral cavity as well as neck but patients are now developing additional cancers after they survived their first cancer or they can develop distant metastasis, in other words, spread to the lungs or the liver. And so the overall survival has not really changed but the manner of survival has.

Lisa Garvin: Now, that totally make sense and quality of life has improved which is you know.

Dr. Ann Gillenwater: I think quality of life has improved drastically.

Lisa Garvin: What would be your take home message in closing to people because like I said it sounds like it's a cancer that if you're paying attention you could probably catch early. So what would be your message to people about that?

Dr. Ann Gillenwater: Yes, I am a strong advocate for early detection. If we can catch the cancers at their early stage before they have a chance to metastasize then the survival is in the 90 percentile. Unfortunately, most patients do present with advanced disease when their survival rates are usually less than 15 percent. So I think early detection is the key. I think we need to improve education of people into the early signs and symptoms of oral cancer. And I also like to improve the ability of the first responders, the people in the front line to diagnose and recognize these cancers at their earlier stages.

Lisa Garvin: Great. Thank you very much. If you have questions about anything you've heard today on Cancer Newsline, contact Ask M.D. Anderson at 1-877-MDA-6789 or online [background music] at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.

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