Life-Saving Oral Cancer Exam Takes Only a Minute

NEW ORLEANS—Although a good examination for oral cancer takes less than a minute to perform, most physicians do inadequate exams or fail to screen for oral cancer at all, according to the professor and head of oral pathology at Louisiana State University School of Medicine, New Orleans.

“Since oral cancers are really just sitting there in the mouth, it is amazing that half the patients still die of this disease within 5 years. There is nothing biological about oral cancer that makes it bad; the reason patients die is a failure to detect early,” Jim C. Weir, DDS, JD, said at a cancer update, sponsored by The Ochsner Medical Foundation and the American Cancer Society.

Who Gets Oral Cancer?

About 30,000 cases of oral cancer are diagnosed in the United States each year, and about half are fatal. Since about 75% of cancers in the mouth can be seen or felt, many fatal cases could be prevented by a thorough examination, said Dr. Jim Weir, of the LSU School of Medicine

Oral cancers are usually squamous cell cancers, most often occurring in white men over age 55. Patients often wear dentures and have poor oral hygiene. About 95% of oral cancer patients use tobacco (cigarettes or smokeless tobacco), and about 75% abuse alcohol. In fact, the combination of tobacco and alcohol raises the risk 15-fold over that of nonusers.

Smokeless tobacco has a striking carcinogenic effect, exerting a 50-fold increased risk of buccal mucosa cancer in regular users. An estimated 7 million people use smokeless tobacco; 60% of males aged 12 to 17 have tried it, and up to 10% are regular users.

“If you use smokeless tobacco, it is not a matter of if you will get oral cancer, but of when,” Dr. Weir stressed. “They are not aggressive cancers, but they are big lesions, so they are almost inoperable.”

Tips for a Good Examination

A good exam has three components: external, oral, and laryngeal. In the external exam, the clinician palpates behind the ears and works toward the center of the face, concentrating around the parotid gland, the cervical lymph nodes, and thyroid, and under the mandible.

The oral exam starts with the lips. The majority of squamous cell carcinomas will occur on the lower lip and are usually the result of occupational exposure to sunlight. Cancer on the upper lip is more likely a basal cell carcinoma and can be more aggressive.

Squamous cell cancer of the lower lip often begins as a crusted swelling and, to the patient, appears to be a fever blister that does not heal and is not painful. The crusted ulcer may have raised borders and be firm on palpation. Fortunately, this cancer is very rarely more than a cosmetic problem.

The lips should also be palpated, which can reveal salivary gland tumors, mostly benign. The next step is to pull the lips out and look underneath them, and to inspect the buccal mucosa. This is where one often finds a lesion resulting from chronic exposure to smokeless tobacco or snuff. This lesion is often white, ragged, and “piled up.” It carries only a 50% five-year survival rate.

Inspection of the tongue should be thorough, since this is the second most common site for oral cancer. The lateral and ventral tongue are the most common sites for cancerous lesions, and the dorsal tongue is the most rare. Dr. Weir advised “grabbing the tongue and ‘shifting gears’ with it to make sure all surfaces are visible.”

Lesions are usually asymptomatic in the early stages. Red lesions on the tongue are more likely than white lesions to be cancerous. Up to 70% of tongue carcinomas metastasize, and up to 70% recur locally. Only 25% of patients survive cancer of the tongue.

The floor of the mouth may contain a cancerous lesion that exhibits a change in texture, which the patient will often report. In the roof of the mouth, a bright red lesion should be a cause of great concern. Again, these lesions tend to be asymptomatic until late in the course.

Cancer of the gums can be very insidious and very destructive. In a patient with dentures, lesions may be assumed to be denture-related sores; if the lesion is painful, it is usually not malignant. In the case of a gum lesion in a denture-wearing patient, the patient should be reevaluated after leaving off the dentures for several days.

Almost all oral lesions should be biopsied, except for clearly inflammatory conditions. Surgical removal, sometimes combined with irradiation, is usually the treatment of choice, he added.

“Since most of these lesions are asymptomatic, the important message,” he emphasized, “is simply to do oral exams and find these lesions early!”