Oral (mouth) cancer

The most common site in India, closely linked to chewing tobacco. Can grow into the jaw bone and skin.

More likely to spread to the neck nodes, even when small, so the neck is treated even in early cancers.

Gum cancers often involve the jaw bone. Lip cancers are usually found early and have a good outcome.

A small piece of the ulcer or lump, taken under local anaesthesia.

MRI or CT of the face and neck shows the depth, bone involvement and neck nodes. CT chest or PET-CT checks for spread in advanced cancer.

A dental check before radiotherapy, and a dietitian review. Many patients have lost weight; a feeding tube may be advised before treatment.

Before starting chemotherapy, immunotherapy or targeted therapy, these tests check that you are fit for treatment, and give a starting point to compare with later.

Before immunotherapy, also:

Sometimes needed, depending on your treatment:

• Pregnancy test for women who could be pregnant.
• Calcium and magnesium: for example before cisplatin or bone-strengthening injections.
• Dental check-up before bone-strengthening injections (zoledronic acid or denosumab), as they can rarely affect the jaw bone.
• Hearing test before cisplatin, in some patients.
• Clotting tests (PT/INR) before a biopsy or chemoport.

Your doctor will choose the tests that apply to you. Some of them are repeated during treatment.

• The scans decide how much tissue and jaw bone must be removed, and how the defect will be rebuilt.
• Teeth and nutrition need to be ready before surgery and radiotherapy.
• Waiting a week or two for planning does not make the cancer worse; operating with a complete plan gives the best result.

Tumour up to 4 cm (and limited depth), no lymph nodes. The aim is cure.

Larger or deeper tumour, or one small lymph node on the same side.

Grown into bone, skin or deeper structures, or larger or several neck nodes. Still curable in many.

Spread to distant organs such as the lungs.

1. Surgery: removal of the tumour with a margin of normal tissue.
2. Neck dissection (removal of neck lymph nodes), even if they feel normal, because small spread is common.
3. Radiotherapy afterwards only if the report shows risk features.

Side effects: surgery

1. Surgery: removal of the tumour (sometimes with part of the jaw), neck dissection, and reconstruction with tissue from another part of the body (flap).
2. Radiotherapy after surgery for about 6 weeks, with cisplatin if margins are close or nodes show spread outside the capsule.
3. Pembrolizumab before and after surgery is a newer option for suitable patients.
4. If surgery is not possible: induction chemotherapy (docetaxel, cisplatin and 5-FU), then reassessment, or chemoradiotherapy.

Side effects: surgery · radiotherapy · chemotherapy

1. If the cancer comes back only in the head and neck: surgery or re-irradiation may still cure some patients.
2. Otherwise, depending on the PD-L1 (CPS) result: pembrolizumab alone, or pembrolizumab with chemotherapy.
3. Other options: chemotherapy with cetuximab; in India, low-dose nivolumab with metronomic chemotherapy (oral methotrexate with celecoxib) is an affordable option.
4. Palliative radiotherapy for pain or bleeding.

Side effects: immunotherapy · chemotherapy

• Swelling, and changes in speech and swallowing for some weeks; therapy helps.
• After jaw surgery with a flap: changes in appearance and chewing; dental rehabilitation can help later.
• Shoulder stiffness after neck dissection: shoulder exercises help.

• From the 2nd or 3rd week: sore mouth and throat (mucositis), painful swallowing, thick saliva and loss of taste. Pain medicines, mouthwashes and soft food help; a feeding tube is used if eating becomes difficult.
• Skin redness on the neck, like sunburn.
• Weight loss: a dietitian review is important.
• Long-term: dry mouth, tooth decay, stiffness of the jaw, neck stiffness, and an underactive thyroid (check TSH yearly).
• Most early side effects settle 4 to 8 weeks after treatment.

• Nausea and vomiting: well controlled with medicines given before and after chemotherapy.
• Low blood counts and infection risk: fever of 38°C or more needs urgent care.
• Tiredness, mouth sores, loose stools or constipation.
• Cisplatin: nausea, kidney effects, ringing in the ears or hearing loss; plenty of fluids are given.

More about chemotherapy · Side effects of your regimen

• The immune system can affect normal organs: thyroid, skin (rash, itching), bowel (loose stools), lungs (cough, breathlessness) and liver.
• These can happen months after starting, or even after stopping. Report any new symptom, even if it seems small.
• Thyroid, cortisol and liver blood tests are checked regularly.

More about immunotherapy · Side effects of your regimen

• Dental check-up before radiotherapy; unhealthy teeth may need removal first.
• After radiotherapy: soft toothbrush, fluoride toothpaste or gel daily, and regular dental visits for life.
• Tell any dentist you had radiotherapy before a tooth extraction: the jaw bone heals poorly (risk of osteoradionecrosis).
• Mouth-opening and jaw exercises every day help prevent stiffness.

• Soft, moist, high-protein food and nutritional supplements during treatment.
• Keep swallowing small sips or soft food even with a feeding tube, so the swallowing muscles stay active.
• Speech and swallowing therapy helps recovery. Nutrition and diet

• Stop all tobacco (smoking, gutka, khaini, betel quid) and alcohol completely.
• Continuing tobacco makes treatment less effective, increases side effects, and greatly increases the risk of a second cancer.
• Ask us for help; medicines and counselling make quitting easier.

• Every 1 to 3 months in the first year, then less often, for at least 5 years.
• A PET-CT or MRI about 3 months after treatment to check the response.
• Thyroid test (TSH) every year after neck radiotherapy.
• Mind and emotions

Bleeding from the mouth, throat or neck, difficulty breathing or noisy breathing, inability to swallow even liquids, or fever of 38°C or more need urgent care.

When to seek help urgently