The National Cancer Control Programme (NCCP) has ranked Oral cancer as the commonest cancer among men accounting for 15.8 percent of all male cancers islandwide, with an average of seven new cases per day. What causes this easily preventable cancer and how can it be prevented?
The Sunday Observer spoke to Consultant in Community Dentistry, NCCP, Dr Udaya Usgodaarachchi, for his views on the subject.
Excerpts
Q: Oral cancer prevalence has spiked in recent years. Although a common cancer not many of our readers know what it is. Tell us what oral cancer is. Is it the same as mouth cancer?
A: Cancer is caused when there is an uncontrolled and uncoordinated growth of the tissues in any site of the body. When this occurs in either lip, tongue, palate, gums or inner side of the cheek we call it mouth cancer or oral cancer.
Q: The National Cancer Control Programme (NCCP) of Sri Lanka reportedly ranked cancer as the leading cause of death some years ago but that the number of fatalities has declined drastically since then. Is this correct?
A: There are about 7,300 oral cancer patients are in the society. That leads to 35.2 oral cancer patients per 100,000 population. According to the latest data, about 2,700 new oral cancer patients are detected per year leading to an average of detecting 7 new cases per day. There are approximately 2-3 oral and pharyngeal cancers deaths occur per day.
Q: According to information, Oral cancer (OCA) accounts for 9.8% of all cancers in Sri Lanka and most commonly occurs in middle-aged and older people. It is the commonest cancer among men, and accounts for 15.8% of all male cancers compared to 4.1% among females. Your comments?
A: Oral cancer prevalence and incidence figures may vary with years. However, over the years, it is the most common cancer among males and in females, it is within the first 10 cancers. Males have a higher incidence than females. According to latest data, about 2,100 males and 600 females are detected with oral cancer per year.
Q: Why?
A: Oral cancers are highly associated with risk behaviours such as the use of tobacco, areca-nut and alcohol. These risk behaviour are higher among males. Therefore, they are more prone to get oral cancers. It is observed that oral cancers are more common among certain occupational groups such as farmers, drivers, fishermen, security personnel, gem miners and construction and estate workers due to their addiction to above mentioned risk behavior and poor socio-cultural practices.
Q: Age wise who are more likely to be the victims?
A: Oral cancer usually develops after 10-15 years of exposure to risk factors. Therefore, oral cancer is common among middle age and older - people over 35 years of age.
Q: Covid 19 victims who smoke. Are they more vulnerable?
A: Smokers are at a higher risk of developing respiratory symptoms of Covid-19 due to already compromised lung condition. Similarly, chewing tobacco (e.g. betel chewing) poses a risk for spreading the infection due to frequent spitting and sharing of quid ingredients with others.
Q: Are there different types of oral cancer? If so, what are they?
A: More than 90% of the cancers in the mouth are originated from the lining (squamous cells) of the oral cavity. They are called as Squamous cell carcinoma. The balance comprises of cancers originating from salivary glands and adjoining bones and adjoining structures of the oral cavity.
Q: Main causes for oral cancer in Sri Lanka?
A: According to current knowledge, three main risk factors for oral cancer has been identified. They are the use of tobacco in any form (smoking and/or chewing), chewing areca-nut and drinking alcohol.
While tobacco smoking is mainly associated with lung cancer, tobacco can cause oral cancer. The most important factor is tobacco-chewing. .
Q: So which section of the population are really at risk?
A: People who are practising these habits at a higher frequency and for a longer period of time are at increased risk of getting oral cancers. Also, if anyone is practicing more than one risk behaviour at a time, (for example chewing betel and consuming alcohol together) has a higher risk of getting oral cancer.
Q: Any other related causes?
A: Ongoing infections of the oral cavity such as Human Papilloma Virus, poor nutritional status with poor oral hygiene are other predisposing factors of oral cancer. In white people, oral cancer of the lip is common due to excessive exposure to sun (UV radiation). This is rare among Sri Lankans due to the natural protection of having a pigmented skin.
Q: Can one get oral cancer without having smoked or chewed betel by simply inhaling second-had smoke?
A: The evidence of occurrence of oral cancer due to second-had smoking is very rare.
Q: Paan (betel leaf and betel nut quid) used with or without tobacco has been positively associated with oral cancer. This product is now freely available in Sri Lanka although it is illegal and many young men mostly and those engaged in long distance driving where you need to be awake and don’t have time to eat or drink. What are the adverse effects on the body by ingesting this product?
A: Carcinogenic substances in these products can change the protective mechanism of the mouth surface that leads to changes in the cellular structure of the oral tissues which later can progress into oral cancer. Moreover, these products contain substances which cause addictions leading to increase consumption with time. Once addicted, withdrawal signs/symptoms will occur upon attempting to quit.
Q: Pre-cancerous lesions- could they be treated easily?
A: There is no ‘pre-cancerous’ lesions. The term is not correct. There are lesions that have a potential to develop into oral cancer. Therefore, they are called as Oral Potentially Malignant Disorders (OPMD). (Only a certain portion of them will transform into oral cancer). If OPMD are detected at early stages, they can be treated easily by risk modifications and by simple medical and surgical interventions. It is also important to monitor these lesions with regular follow-up visits for a long period of time to detect early signs of malignant transformations.
Q: As Oral cancer develops in different parts of the mouth, what are the commonest sites found among Sri Lankans?
A: In Sri Lanka, the common sites are inner-side of the Cheek (Buccal Mucosa), tongue and floor of the mouth. Throat cancer is not considered as oral cancer due to differences in aetiological factors.
Q: What about cancer of the Jaw? Is this common here?
A: Cancers originating from the jaw is not common. But, cancer originating in other parts such as cheek can spread into jaw involving jaw bones.
Q: Who is able to diagnose oral cancer and how is it diagnosed?
A: Oral cancer can be tentatively diagnosed by any dental surgeon or medical officer by clinical examination of the oral cavity. But, the definitive diagnosis is done by an expert such as an Oral and Maxillo-facial Surgeon or an Onco-surgeon based on clinical findings and biopsy-based pathological report given by the pathologist.
Q: Treatment- when a patient presents early symptoms what is the initial treatment given?
A: Usually when a patient with an oral lesion comes to a health care institution, a thorough history is taken to identify the causative factors of the lesion. Once the risk factors are identified, counselling is done to help the patient to quit risk behaviour. Following oral hygiene improvement, a small piece of the lesion (biopsy) is sent to a pathologist to confirm the diagnosis. Then, depending on the pathological diagnosis, and the clinical presentation the cancer will be managed. The method of treatment may vary from surgery, radiotherapy chemotherapy or combination therapy. Usually, the first line of treatment for early-stage lesion is surgery or radiotherapy.
Q: If the cancer advances what is the treatment available?
A: For late-stage oral cancers, surgery, radiotherapy, chemotherapy or combined therapy is performed followed up with reconstructive care to compensate for lost tissues. Palliative care is also needed for terminal cases. It is important to note that treatment for late-stage cancers results in functional impairment and disabilities.
This will give rise to poor quality of life of the patients and ultimately poor survival rates. Moreover, as these are treatment are expensive and time consuming, for both health sector as well as to patients, it causes an enormous burden to the society. Therefore, the importance of prevention and early detection remains the key strategy in the management of oral cancer.
Q: As the focal point of information and also overall supervision of all cancer prevention programmes island wide, the NCCP plays a vital role. What are the intervention you have put in place in recent years to reduce oral cancer?
A: In addition to already available interventions, the following new interventions are introduced:
Strengthening public awareness programmes with the inclusion of the hazards of recent smokeless tobacco preparations and chewable arecanut preparations. In order to facilitate the easy access to oral cancer detection, steps have been taken to expand the oral cancer screening services up to all primary health care institutions such as dental clinics and healthy lifestyle centres (HLC). Also, strengthening oral cancer screening services for marginalised high-risk groups are done by the revision of existing criteria.
Q: What are the gaps you see that need to be filled in delivering optimal care for detecting, treating and rehabilitating oral cancer patients?
A: Oral cancer is easily preventable by abstaining of habits and easily detectable by routine dental examinations. However, due to various reasons like low knowledge, misbeliefs and cultural acceptance, people still chew betel with tobacco and areca-nut, predisposing them to a higher risk of developing oral cancer.
Moreover, the utilization of existing oral health services is still poor because routine dental screening is not an accepted practice among Sri Lankan population and a majority seek treatment when they have problems. Due to this reason, most oral cancer patients seek treatment when oral cancer developed into a symptomatic late-stages.
Therefore, collective multi-sectoral support is required to overcome these issues. Since the media is a powerful tool in terms of changing behaviours of the population, more support is needed from media in terms of from discouraging these habits as well as encouraging routine dental screening of the public.
Q: Your message to our readers out there especially young persons who are increasingly being exposed to Oral cancer without realizing the long-lasting health impacts on them?
A: Do not get misled by indirect advertising and bogus claims. Do not get addicted to any form of tobacco, arecanut and alcohol products. No matter what they claim, these products are harmful and give no benefit. By quitting tobacco and areca-nut products it will not only improve your health but you will be better off economically as well.
If you are already practising risk habits, stop immediately and get your mouth checked by a dental surgeon to exclude any warning signs of oral cancer. It is also very important that you have to develop habits of self-mouth examination at least once a month and have a routine dental examination at least once a year.