Oral Cancer Stages
A cancer’s stage refers to how large the primary tumor is and how far the cancer has spread in the patient’s body. Knowing the stage helps the care team understand the disease and develop an appropriate treatment plan. It also impacts the patient’s prognosis, or chance for a successful treatment.
TNM stages
The TNM staging system is used for most cancers.
TNM staging describes cancer based on three main factors:
- The size of the primary tumor (T) and whether it has invaded nearby tissues.
- The cancer’s spread to nearby lymph nodes (N).
- Whether the cancer has metastasized (M), or spread, to distant parts of the body.
Each TNM factor is assigned a number that reflects the extent of the cancer. Tumors (T) are scored between 1-4, nodes (N) 1-3, and metastasis (M) 0-1.
After all diagnostic and staging procedures are performed, your doctor should know the TNM stage of your cancer and be able to explain how this stage impacts your treatment and prognosis.
0 to IV stages
Often, TNM staging can be simplified into stages four stages (I-IV). For some cancers, there is also a stage 0. Larger numbers mean the cancer is more advanced and is generally more difficult to treat.
- Stage 0 reflects the presence of abnormal cells that have not spread to tissue that is immediately nearby. Stage 0 is considered precancerous, though it could become cancer in the future. This stage is also called “in-situ,” which means “in its original place.” Not all cancers have a stage 0.
- Stage I cancers are typically small and confined to the area where they began.
- Stage II and Stage III cancers have spread to nearby tissue and/or lymph nodes.
- Stage IV cancer has spread to distant areas of the body. This is also called metastatic cancer. Stage IV cancer often cannot be cured, but frequently can be managed like a chronic disease.
Oral cancer 0-IV stages
Source: National Cancer Institute
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the lining of the lips and oral cavity. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Stage I
In stage I, cancer has formed. The tumor is 2 centimeters or smaller and the deepest point of tumor invasion is 5 millimeters or less.
Stage II
In stage II, the tumor:
- is 2 centimeters or smaller and the deepest point of tumor invasion is greater than 5 millimeters; or
- is larger than 2 centimeters but not larger than 4 centimeters and the deepest point of tumor invasion is 10 millimeters or less.
Stage III
In stage III, the tumor:
- is larger than 2 centimeters but not larger than 4 centimeters and the deepest point of tumor invasion is greater than 10 millimeters; or
- is larger than 4 centimeters and the deepest point of tumor invasion is 10 millimeters or less; or
- has spread to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the primary tumor.
Stage IV
Stage IV is divided into stages IVA, IVB, and IVC.
In stage IVA, the tumor:
- is larger than 4 centimeters and the deepest point of tumor invasion is greater than 10 millimeters; or cancer has spread to the outer surface of the upper or lower jawbone, into the maxillary sinus, or to the skin of the face. The cancer may have spread to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the primary tumor; or
- is any size or cancer has spread to the outer surface of the upper or lower jawbone, into the maxillary sinus, or to the skin of the face. Cancer has spread:
- to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the primary tumor, and cancer has spread through the outside covering of the lymph node into nearby connective tissue; or
- to one lymph node that is larger than 3 centimeters but not larger than 6 centimeters, on the same side of the neck as the primary tumor; or
- to multiple lymph nodes that are not larger than 6 centimeters, on the same side of the neck as the primary tumor; or
- to multiple lymph nodes that are not larger than 6 centimeters, on the opposite side of the neck as the primary tumor or on both sides of the neck.
In stage IVB, the tumor:
- has spread to one lymph node that is larger than 6 centimeters; or
- has spread to one lymph node that is larger than 3 centimeters, on the same side of the neck as the primary tumor, and cancer has spread through the outside covering of the lymph node into nearby connective tissue; or
- has spread to one lymph node of any size on the opposite side of the neck as the primary tumor, and cancer has spread through the outside covering of the lymph node into nearby connective tissue; or
- has spread to multiple lymph nodes anywhere in the neck, and cancer has spread through the outside covering of any lymph node into nearby connective tissue; or
- has spread further into the muscles or bones needed for chewing, or to the part of the sphenoid bone behind the upper jaw, and/or to the carotid artery near the base of the skull. Cancer may have also spread to one or more lymph nodes of any size, anywhere in the neck.
In stage IVC, the tumor has spread beyond the lip or oral cavity to other parts of the body, such as the lung, liver, or bone.
Oral cancer symptoms by stage
Oral cancers can cause many different symptoms. And, because they may develop on the tongue, lips, gums, cheek, hard palate or floor of the mouth, these symptoms vary widely.
In the earlier stages of oral cancer, we tend to see more anatomical symptoms, such as a white patch on the gums or a lesion inside the cheek. As oral cancer becomes more advanced, though, we start seeing pain and more functional symptoms, such as trouble eating, slurred speech, and loose teeth that can make chewing difficult.
Here is a guide to help you recognize some other oral cancer symptoms by stage.
Pre-cancerous and stage I oral cancer symptoms
You can take a look inside of your mouth to see what’s going on, just by using a mirror and a flashlight.
In the earliest stages of oral cancer, suspicious things to look for include:
- White patches, known as leukoplakia, which can be cancerous or pre-cancerous
- Red patches, known as erythroplakia
- Patches with a mixture of red and white, known as erythroleukoplakia
- Other changes in texture or color
- Any ulcer or sore spot that doesn’t heal, or at least improve, within two weeks
- A thickening of the buccal mucosa, or inner cheek lining
Stage II and III oral cancer symptoms
As a tumor becomes larger and deeper, it can start affecting the nerves of the head and neck. So, if you have undiagnosed oral cancer, you may start noticing numbness or a loss of sensation around the jaw, lips, tongue or mouth. Invaded nerves can also cause hypersensitivity and pain. As oral cancer progresses, it may begin affecting the muscles that control the jaw, making it harder to open and close your mouth or chew your food.
Here are some other symptoms you may notice with stage II or III oral cancer:
- Swollen salivary glands
- Swollen lymph nodes in the neck
- Pain in the mouth that won’t go away
- Slurred speech
- Dentures that no longer fit
Stage IV oral cancer symptoms
Once oral cancer is really advanced, and a tumor has spread beyond its original location, it begins to affect major nerves. So, you might start noticing larger areas of numbness or feeling significant pain.
If lymph nodes become involved as well, you could see swelling or bumps or lumps in the neck or jaw. And, if oral cancer has invaded the muscles that control the jaw or the jaw bone itself, you may also experience a condition called trismus, or “lockjaw,” which prevents you from opening your mouth very wide — or in some cases, at all.
Once an oral cancer has metastasized, additional symptoms will depend on where it has spread, such as the liver or lungs. But other stage IV symptoms of oral cancer can include:
- Loose teeth
- Swelling of the jaw bone or tongue
Other oral cancer symptoms
Pain when swallowing, hoarseness, voice changes, and an earache that won’t go away can sometimes be symptoms of oral cancer. But they’re much more common symptoms of throat cancers, also known as oropharyngeal cancers. You usually can’t see those cancers in the mouth.
Some oral cancer symptoms can also appear with both early and late-stage disease. Weight loss, for example, generally occurs in early-stage oral cancers because patients can’t move their jaws or tongue well enough to eat. But in later-stage oral cancers, weight loss occurs because patients have lost their appetite.
Bleeding in the mouth is another tricky symptom. If you’re brushing your teeth and see a little blood oozing out of a lesion mixed with saliva, that could be a sign of early-stage oral cancer. But the amount and pattern of bleeding matter. If it’s a significant amount or the bleeding doesn’t stop, that’s a really bad sign. But continuous bleeding is not usually a sign of oral cancer.
When to contact a doctor about oral cancer symptoms
Most oral cancers in the United States occur on the tongue or mouth. In other countries, especially those in Southeast Asia, where chewing betel nuts is more common, oral cancers appear more frequently on the gums and inner cheek.
But between 60,000 and 100,000 people will be diagnosed with oral cancer in the U.S. this year alone. And the number of people estimated to have suspicious lesions in their mouth is about 10 times that much.
So, talk to your doctor or ask for a referral to an oral surgeon or a head and neck specialist if you notice anything out of the ordinary, especially if it doesn’t heal or improve in a couple of weeks. Don’t put off investigating anything unusual you see inside your mouth.
Mouth cancer is prevalent even among young patients without any risk factors. And, early detection with a simple biopsy, done in clinic, allows quick and accurate diagnosis at an early stage. Cancers are much easier to treat when we catch them early. Early diagnosis might also spare patients additional therapies, such as radiation or chemotherapy.
Moran Amit, M.D., Ph.D., is a surgeon and researcher who specializes in the treatment of head and neck cancers.
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