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Oral Cavity Cancer – 2016

UPDATED OCTOBER 2016

1. GENERAL INFORMATION

1.1 What is the disease and how is it treated?

What is oral cavity cancer?
Oral cavity cancer (OCC) is a rare type of malignant tumour that starts anywhere in the mouth (oral cavity): lips, gums, inside lining of the cheeks and lips (buccal mucosa), front two thirds of the tongue’s surface, floor of the mouth (under the tongue), roof of the mouth (hard palate), area behind wisdom teeth.

How does oral cavity cancer manifest?
The first signs of oral cavity cancer are lesions of the mucosa (they can be white, red, red and white, or white plaques) or non-healing ulcerations.
Common symptoms of locally advanced oral cancers are: mucosal growth; pain in the ear; bad smell from the mouth; difficulty speaking, opening the mouth, chewing; difficulty and pain with swallowing; bleeding; weight loss; neck swelling.

What are the causes of oral cavity cancer?
The dominant risk factors are: tobacco use and alcohol abuse, which are strongly synergistic, chewing tobacco and other tobacco uses, such as oral snuff.
Other important risk factors are genetic mutations and diet.

Is this a frequent type of cancer?
OCC is a rare cancer: about 3.5 cases every 100,000 people in Europe, with a higher occurrence among males. This rate increases in the oldest age group of patients (65 and older). OCC is very rare in children, adolescents, and young adults.

How is it diagnosed?
Oral lesions may be incidentally noticed by the patients themselves, or may become apparent on visual inspection of the oral cavity by general dental or medical practitioners. Initial presentation may be as white, red, or speckled areas of mucosa or non-healing ulceration.
As the tumour advances in stage, patients may report pain to the ear, bleeding, and bad smell from the mouth.

How is it treated?
Surgery is the initial treatment of choice. Its principal aim is complete resection, to prevent recurrence of the tumour. Radiation, with or without chemotherapy, is often reserved for post-operative adjuvant treatment.

2. ORAL CAVITY CANCER: WHAT IS IT, HOW DOES IT OCCUR, HOW IS IT DIAGNOSED

2.1 What is oral cavity cancer?

OCC is a rare type of malignant tumour originating within the epithelium lining the oral cavity.
More than 90% of cancers of the oral cavity are squamous cell carcinomas (SCC), also called squamous cell cancers. These cancers start in squamous cells, which are flat cells that form the outer layer of the epithelium. In the earliest form of SCC, the cancer cells are present only in this outer layer. Invasive squamous cell carcinomas occur when the cancer cells have grown into deeper layers of the oral cavity.
Verrucous carcinoma is an unusual type of squamous cell carcinoma that makes up less than 2%-12% of all oral cancers. It is a slow-growing cancer that rarely spreads to other parts of the body, but it can grow very deeply into surrounding tissues.

2.1.1 Preneoplastic lesions

The presence in the mouth of white patches (leukoplakia) or red areas that bleed easily (erythroplakia) may be harmless, but if not treated they can develop into a cancer. Taking a sample from these areas (biopsy) allows doctors to ascertain the presence of abnormal cells (dysplasia).
About 5 out of 100 people (5%) diagnosed with leukoplakia show cancerous or precancerous conditions. The situation is different for erythroplakia: about half (50%) of these red lesions can turn into a cancer.
Removing the dysplasia strongly reduces the risk of developing a mouth cancer.

2.1.2 Disease stats

Frequency
OCC is a rare cancer traditionally more widespread in South-Central Asia, although in recent years a rise has been seen in Western Countries.
For the period 2000-2007, 3.5 persons out of 100,000 were diagnosed with an OCC every year (incidence) in Europe, with the lowest rate in the UK and Ireland (3.4) and the highest in Southern European countries (4.7).
Most of the patients are older than 65 years (6.3). OCC is very rare in children, adolescents, and young adults (<25 years of age): 0.2 new cases per year every 1,000,000 persons (RARECAREnet project).

Gender
In Europe, for the period 2000-2007, age-adjusted incidence for oral cavity cancers was higher in men than in women (5.0 vs.1.2 per 100,000/year).

Geographical distribution
The occurrence of the disease varies markedly worldwide: it is very high in populations from South-Central Asia (10 per 100,000/year) and Melanesia (23) in males (GLOBOCAN).
Europe is among the regions with the highest incidence, along with North America, Australia, and New Zealand.
Incidence rate (per 100,000/year) is lowest in the UK and Ireland (3.4) and highest in Central and Southern European countries (4.2 and 4.7, respectively) (RARECAREnet project).

Survival
Among European adults diagnosed during 2000-2007, 71 out of 100 (71%) were alive one year after diagnosis, 48% after three years, and 41% after five years.
There has been a moderate improvement in European survival figures since the end of the 1990s. Survival at five years was better in women (51%) than in men (38%), and in patients younger than 65 (44%) than in older ones (34%).

2.2 Risk factors

Some people are at higher risk of developing certain diseases because of different risk factors.
Although some people who have oral cavity cancer have several risk factors for developing the disease, it is impossible to know for sure how much these factors contributed to causing the cancer.

Tobacco
Tobacco use is the most well-recognized independent risk factor in the development of oral cancer: chronic exposure to the multitude of carcinogens present in tobacco products leads to genomic mutations in the mucosa of the oral cavity. This also explains why most people with OCC are tobacco users (generally cigarette smokers, but even tobacco chewers or snuff users). The risk of effectively developing these cancers depends on how much and how long tobacco has been smoked or chewed.

Alcohol
Alcohol is an independent risk factor for oral cancer. A strong dose-effect has been demonstrated: heavy alcohol use, more than 50g/day (a 13% bottle of wine contains 78 g of alcohol) leads to a 5-fold increased risk of OCC, while no lower threshold has been identified. Certain forms of alcohol, in particular spirits and fortified wine, seem to have an increased ability to induce mucosal instability.

Tobacco AND alcohol
People who make use of tobacco and alcohol are at very high risk of developing oral cavity cancers. The reason is that oral mucosa becomes more permeable after contact with alcohol, leading to a greater penetration of tobacco carcinogens. Actually, tobacco and alcohol consumed together are among the strongest risk factors for OCCs.

Diet
Several studies have found that a diet low in fruits and vegetables is linked with an increased risk of OCC. Coherently, a protective effect for the Mediterranean diet and a diet rich in antioxidants and vitamins has been demonstrated (WCRF/AICR 2007).

Genetic
Common genomic alterations seen in oral cancer include mutations to p53, EGFR, and p16 genes. Among genetic disorders, Fanconi anaemia and dyskeratosis congenita increase the risk of OCC.

2.3 What are the symptoms of oral cavity cancer?

In addition to very common symptoms, such as a (not always painful) sore in the mouth that does not heal and/or pain or discomfort in the mouth that does not go away, other possible signs include:

  • white or red patches in the mouth (gums, tongue, tonsil, lining of the mouth);
  • trouble in chewing or swallowing;
  • voice changes;
  • a lump in the neck;
  • weight loss;
  • constant bad breath (halitosis);
  • numbness in the mouth;
  • loss of teeth for no apparent reason;

These signs and symptoms can be caused by reasons other than cancer. But having any of them strongly suggest you see a doctor or dentist.

2.4 Diagnosis

2.4.1 How is the disease identified as an OCC?

Oral lesions may be incidentally noticed by the patients themselves, or may become apparent on visual inspection of the oral cavity by general dental or medical practitioners. Initial presentation may be as white, red, or speckled areas of mucosa or non-healing ulceration. Presentation will also depend on the anatomical site of the tumour. For example, tumours occurring around dental sockets may present with the loss of a tooth. As the tumour advances in stage, patients may report pain to the ear, bleeding, and bad smell from the mouth.

2.4.1.1 Clinical examination

First, doctors will ask about general health and symptoms, carefully examine the mouth, and then they may examine the lymph nodes located in the neck and armpits. GPs may then prescribe tests or directly refer patients to a specialist (usually a head and neck surgeon).

2.4.1.2 Instrumental exams

A first series of tests (biopsy, fine needle aspiration) is aimed to detect the presence of cancer. Further tests, such as ultrasound scans, CT scans, MRI scans, and FDG-PET, can help make the diagnosis clearer by finding the size of the cancer and checking whether it has spread.

Biopsy
A biopsy, the taking of a sample of tissue from the affected area, helps to make a definite diagnosis. Biopsy is usually performed under local anaesthesia, although the anatomical position, or the patient’s condition, may require general anaesthesia. The small pieces of tissue taken from the suspected tumour are then sent to a pathologist to ascertain the presence of cancer and, if cancer is present, to determine what types of cells constitute the tumour. If there is a lump in the neck, samples of tissue may be taken using fine-needle aspiration (FNA).

FNA
A thin, hollow needle is inserted into the mass for sampling of cells to be examined. This may be performed with or without ultrasound guidance.

Ultrasound scan
Sound waves are used to take a picture of internal parts of the body; this method can be used during FNA and biopsy. The scan is painless.

Computerized Tomography (CT) scan
A machine takes a series of X-rays of the body from different angles, then a computer will put them together, returning a very detailed, three-dimensional picture of the inside of the part of the body being scanned. A head-and-neck CT makes it possible to establish the size of the cancer and any enlarged lymph nodes in the neck. A chest and abdominal CT may reveal if cancer has spread outside the oral cavity. The scan is painless.

Magnetic Resonance Imaging (MRI) scan
Magnetic waves are used to produce images of the internal organs of the body. This method is particularly suitable when dealing with soft tissues, such as those of the mouth. The exam is painless.

FluoroDeoxyGlucose-Positron Emission Tomography (FDG-PET)
This imaging technique produces a three-dimensional image of functional processes in the body. It detects the radioactive signals emitted by a tracer introduced into the body. In this case FDG, an analogue of glucose, is used in order to reveal areas with a higher than normal metabolic activity (detectable as an increase in glucose consumption by the cells), a sign of the presence of cancer cells. This technique is useful in detecting distant metastases.

2.4.2 Do these tests involve any risks for patients?

Generally, all of these exams are well tolerated. Biopsy may require the use of local or general anaesthesia. CT and MRI scans may require the injection of a dye (or contrast medium) in order to obtain clearer images. FDG-PET always uses dyes. Anaesthesia and contrast media could give rise to side effects.

3. HOW IS ORAL CAVITY CANCER TREATED?

3.1 General information

The three main tools to treat OCC are surgery, radiation therapy, and chemotherapy. For this reason, someone with a cancer of the oral cavity may also meet a specialist from radiation oncology as well as a medical oncologist. In some cases of advanced cancers of the oral cavity, a specialist in reconstructive surgery may also become involved to assist with specialized reconstruction, should it be required.
In general, first-line therapy based on stage (see cancer stages below) requires either surgery or radiation therapy, or a combination of surgery, radiation therapy, and chemotherapy or even the concurrent use of the three therapies.
Whatever treatment strategy is employed, an attempt should be made to minimize functional morbidity – difficulty in swallowing, speaking, and breathing, and disfigurement.
All patients should undergo pre-treatment dental assessment in order to minimize the adverse effects of radiation: dental caries, infection, and demineralization of the teeth.
Further preventive measures include: oral hygiene, education, use of topical fluoride treatment during and after radiotherapy, monitoring and treating oral candidiasis. Irradiated patients need regular dental check-ups at least twice a year.
Part of the pre-treatment assessment should also include the involvement of dieticians to screen for correctable nutritional deficiencies. Patients who at the time of diagnosis have swallowing and speech dysfunctions, or are suspected to develop them during therapy, should be referred to a speech and swallowing therapist.

3.2 Surgery

Surgery is the most common primary treatment option for OCC. Its principal aim is complete resection to prevent the recurrence of the tumour. The size of the surgery resection needed depends on the size and depth of the cancer, but also on whether there is a risk that the cancer has spread into lymph nodes of the mouth and neck.
Relations with neighbouring bone structures involve the need to sacrifice, in part or in whole, bone formations near the tumour. However, in specialist centres, a substitution with grafts or autogenous transplants or other compatible materials can be planned. A wide choice of options among different reconstruction procedures is possible.

3.2.1 What differentiates surgical procedures?

The choice of the type of surgery depends on different factors, related both to the disease (e.g., cancer stage and grade – see below –, whether it has spread, i.e., metastases), and to the patient (general health, age, comorbidities). Patient’s willingness is another key factor to be taken into account.

Early disease
For some very early stage cancers, laser surgery (under local or general anaesthesia) may be used. Laser surgery uses a very thin beam of light to cut away the cancer cells.
But most of the operations for OCC are major surgeries, involving the use of general anaesthesia.
When no signs of metastasis are present (early disease), the aim of surgery is to remove the tumour with an adequate margin (at least 1cm) of healthy surrounding tissue, in order to be sure that all the cancer cells have been removed. The majority of these tumours can be removed through the oral aperture. However, this may not be possible in cases of tumours involving the throat.
Sometimes it may be necessary to remove part of the tongue (hemiglossectomy); in such cases, a reconstructive intervention will be required (see below).

Advanced disease
In case of advanced oral cancer, the standard of care is a combined treatment with surgical resection, neck dissection, and post-operative radiotherapy, with or without chemotherapy. In addition, if the tumour is large or involves the throat, the surgeon will have to cut through the neck or the jawbone (mandibulotomy), or perform a lingual release procedure in order to reach it.

Reconstructive surgery
Surgical removal of OCC may leave an empty space, which must be reconstructed. For this purpose, different approaches are available, using:

  1. tissues from another part of the body (free flap or flap repair), to replace the removed section of the mouth;
  2. bones from another part of the body (fibular flap), to replace part of the jawbone that had to be taken away.

The reconstruction should be tailored to the patient: in addition to the missing anatomical portions, the surgeon will consider the patient’s overall health status and ability to undergo a long surgical procedure.

3.2.2 Side effects

In order to guarantee a radical removal of cancerous tissues, surgery may turn out extensive and destructive. Consequently, the operation can likely leave large defects, causing patients to have trouble swallowing, eating, and speaking.

3.3 Radiotherapy (RT)

Radiation therapy uses high-energy X-rays or particles to destroy cancer cells or slow their rate of growth.
Radiation therapy can be used in several situations:

  • if a patient’s comorbidities preclude radical surgery, then radical radiotherapy becomes the first choice of treatment;
  • it can be used after surgery (adjuvant therapy), either alone or with chemotherapy, as an additional treatment to try to kill any small deposit of cancer that may not have been removed during surgery;
  • it may be used (along with chemotherapy) to try to shrink larger tumours before surgery (neoadjuvant therapy); in some cases this makes it possible to use less radical surgery and remove less tissue.
3.3.1 Side effects

The most common side effects are skin changes like sunburn to the skin surrounding the mouth/neck, hoarseness, loss of sense of taste, redness, and pain in the mouth and throat.
RT may also cause long-lasting or permanent side effects to the salivary glands, causing a dry mouth. This can lead to problems eating and swallowing. The lack of saliva can also lead to tooth decay. People treated with radiation need to practice careful oral hygiene to help prevent these problems.

3.4 Chemotherapy

Chemotherapy implies the use of drugs capable to destroy cancerous cells. The drugs are administered by intravenous injection or taken by mouth, which allows them to enter the bloodstream and reach cancer that has spread to any organs. Chemotherapy may be used in several different situations:

  • combined with radiation therapy, it may be used instead of surgery as the main treatment for some OCCs;
  • it may be given after surgery to try to kill any small deposit of cancer cells that may have been left behind (adjuvant chemotherapy);
  • it may be used to shrink larger tumours before surgery (neoadjuvant therapy); in some cases this makes it possible to use less radical surgery and remove less tissue, which can lead to fewer serious side effects from surgery;
  • with or without radiation, it can be used to treat cancers that are too large or have spread too far to be removed by surgery; the goal is to slow the growth of the cancer as long as possible and help relieve any symptoms the cancer is causing.

Doctors prescribe chemotherapy in cycles, where each period of treatment is followed by a period of rest, so the body has time to recover. Each chemotherapy cycle typically lasts for a few weeks.

3.4.1 Chemotherapeutic drugs

The chemotherapeutic drugs that have demonstrated the highest efficacy in the treatment of OCCs are 5-fluorouracil (5-FU), cisplatin, taxane (docetaxel). Patients unfit for cisplatin may be treated with monoclonal antibodies, such as cetuximab (epidermal growth factor receptor – EGFR – inhibitor).

3.4.2 Side effects

The side effects of chemotherapy depend on the type of drugs used, their dose, and their combination. The most common are: nausea and vomit, diarrhoea and constipation, hair loss, infections, fatigue, decrease in the number of blood cells (neutropaenia, anaemia).
Chemotherapy potentiates the side effects of radiotherapy when given as concurrent treatment.

3.5 Management of the neck

Sometimes OCCs spread to the lymph nodes in the neck. In such cases, nodes should be removed (neck dissection) to prevent the continuous growth of cancerous cells. However, neck dissection can have long-term side effects and it is not suitable for all patients.
In a rather high percentage of cases (about 30%) clinical and radiological exams do not show metastases, even though they are present (occult metastases); the occurrence of occult metastases increases with the depth of the tumour. In these cases the surgeon can choose to perform an elective neck dissection in order to verify the presence of metastases.

3.5.1 Sentinel node biopsy

Sentinel lymph node biopsy can be an alternative to elective neck dissection. Following this technique, the surgeon identifies the first echelon nodes and then performs a biopsy. The microscopic analysis of the sample thus obtained will reveal if cancer has actually spread to nodes. The rationale is the following: if no metastases are seen in the nodes closer to the tumour, then they will non be present in more distant ones. Regularly checking these sentinel nodes will make it possible to monitor the spread of metastases.
There is increasing evidence that this is a way of more accurately predicting patients with N0 (see below) necks that are truly negative for metastatic disease.
Sentinel lymph node biopsy is an alternative to elective neck dissection in centres with expertise in this method for early (T1, T2) primary oral cavity cancers.

4. STAGES AND GRADES OF ORAL CAVITY CANCER

The stage of a tumour indicates its extension and its spread beyond its site of origin (metastases). It is important in order to choose the most appropriate treatment. The stage of a tumour may be referred to in several ways, because there are several staging systems.

4.1 TNM staging

It is the most commonly used system, where:

  • T refers to the size or position of the primary tumour (where the cancer first starts in the body);
  • N refers to which lymph nodes are affected, if any;
  • M refers to metastatic disease (when the cancer has spread to other parts of the body).
Table 1. Classification of tumours of the oral cavity by TNM system.
Stage
Characteristics
Primary tumour (T)
Tx Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour ≤2 cm in greatest dimension
T2 Tumour >2 cm but not more than 4cm in greatest dimension
T3 Tumour >4 cm in greatest dimension
T4a Moderately advanced, local disease
Lip: Tumour invades through cortical bone, inferior alveolar nerve, floor of mouth, skin of face
Oral cavity: Tumour invades adjacent structures (cortical bone into deep extrinsic muscle of the tongue, maxillary sinus, or skin of face)
T4b Very advanced, local disease: tumour invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery.
Regional lymph nodes (N)
Nx Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node >3cm but ≤ 6cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none >6cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension
N3 Metastasis in a lymph node >6 cm in greatest dimension
Distant metastasis (M)
Mx Metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

4.2 Number staging

In this system staging is identified by numbers, from 1 (small cancers that have not spread) to 4 (advanced cancers with metastases).
In order to give more detailed information about cancer size and spread, number stages may be followed by lowercase letters.

Table 2. Classification of tumours of the oral cavity by anatomic stage.
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IVa T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
IVb Any T N3 M0
T4b Any N M0
IVc Any T Any N M1

4.3 Grading

The speed at which the tumour may progress is related to the appearance of cancer cells under the microscope. These morphologic characteristics are defined by “grades”.
A low-grade cancer is made of cells that look very similar to normal cells, grow slowly, and are less likely to spread. Very abnormal cells, prone to grow quickly and spread, are typical of high-grade tumours.

Table 3. Classification of tumours of the oral cavity by histological grade.
Grade Characteristics
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

4.4 Other terms

Other terms are normally used, such as:

  • “early” or “local”: a cancer that has not spread;
  • “locally advanced”: a cancer that has begun to spread into surrounding tissues or nearby lymph nodes;
  • “local recurrence”: the cancer has come back in the same area after treatment;
  • “secondary”, “advanced”, “widespread”, “metastatic”: the cancer has spread to other parts of the body.

5. PROGNOSIS

5.1 General information

Prognosis indicates the likelihood that a treatment will be successful. It is a statistical measure obtained from different studies that observe the progress of the disease in a high number of patients. Generally, it is referred to as the percentage of survival at 5 or 10 years since the start of treatment: this indicates the percentage of patients that are still alive after 5 or 10 years since the beginning of therapy, as demonstrated in large studies.
It is important to remember that these statistics merely provide an indication: no doctor is able to predict exactly what the outcome of treatment in an individual patient will be, nor how long the patient will live, as prognosis depends on several factors related to the individual patient.
Data show an increase in survival for oral cancer over the last 30 years. This is predominantly seen in the subset of patients with tumours arising from the tongue, with survival from floor of mouth, gum, and lip cancers remaining relatively constant.

5.2 Prognostic factors for OCC

The chance of survival depends on the stage of the disease, as described in paragraph 4, at the moment of diagnosis. Increasing disease stage results in reduced overall survival: after 3 years from diagnosis, 80% of patients with early stage disease are still alive, compared to less than half of those initially diagnosed at a later stage.
The presence of cervical lymph node metastases is the single most important prognostic factor in oral cavity cancer. Five-year survival is 81% for patients without metastases and 64% for patients with intranodal metastases; if the tumour extends outside the confines of the lymph node (extra-capsular) spread, survival drops to 21%.
Another important factor, related to the presence of metastases in the neck, is tumour thickness (or depth of invasion).

5.3 Second primary tumours

Patients with oral cancer are at increased risk for the development of a second primary tumour because of the exposure of the whole upper aerodigestive tract to the risk factors known to cause malignancies. Second primary tumours are the second leading cause of death amongst head-and-neck-cancer patients, although it should be noted that some second cancers could develop outside the head and neck.

6. WHAT TO DO AFTER TREATMENT

6.1 General information

After completing treatment, the oncologist will plan a series of subsequent visits and additional tests to:

  1. make sure that cancer does not recur (as well as provide early identification of disease recurrence or second primary tumours);
  2. monitor the effects of treatment and related side effects, which can be significant with treatments for oral cancer, including difficulties in speech, swallowing, voice, and cosmetics; these side effects need to be addressed and managed to improve patients’ specific and overall quality of life;
  3. achieve effective palliation: unfortunately, many patients develop non-curable recurrence or second primary disease and the support of both patients and carers is vital.

The planning of visits is called follow-up and it lasts for at least 5 years. If no recurrences appear during this time, it means that for the patient the risk of having a cancer is the same as the rest of the population.
It is important for a patient to immediately contact his/her oncologist in case of new symptoms or side effects, even beyond the already scheduled appointments that are part of the planned follow-up care schedule.

6.2 The follow-up of OCC

Follow-up schedules are tailored according to the nature of the disease and specific patient factors. Specialized support may come from oncologists, speech and language therapists, dieticians, specialist cancer nurses, and clinical psychologists. Further investigations, including radiology, may be required as part of baseline monitoring or the investigation of specific symptoms.
A typical follow-up regime might be as follows:
Year 1: every 1-3 months;
Year 2: every 2-3 months;
Year 3: every 4 months;
Year 4-5: every 6 months;
After 5 years: discharge or every 12 months.
Most recurrences occur within the first two years. This is also the period during which the most significant treatment-related side effects appear and it is the reason why the intervals between one follow-up visit and another in the first few years are so short.

7. WHAT TO ASK DOCTORS

General questions

• What should I do if I feel anxious and cannot sleep?
• May I phone you? What is the best time? If you are not available, may I ask for other specialists? Whom specifically?
• What leaflets, books, or websites could I read to learn more about oral cavity cancer?
• Is there a patient association I could contact?
• Do you have special advice regarding nutrition?
• Does oral cavity cancer run in families? Are my children at risk of getting oral cavity cancer?
• Do I need psychological support?

Diagnosis and exams

• What tests are you going to do?
• What are you looking for?
• Will the test show if I have cancer?
• What should I do in preparation for a CT scan or MRI?
• How long will the exam take?
• Is it painful?
• Will I be asleep?
• Should someone be with me?
• Are CT or MRI dangerous because of radiation exposure?
• Is biopsy painful? Is it performed under general or local anaesthesia?
• Is fine needle aspiration cytology performed under local anaesthesia?
• What kind of oral cavity cancer do I have? Where is it located?
• Has my cancer spread beyond the main (primary) site?
• How long will it take to confirm diagnosis?

Treatment

• Which centre in my country has the highest level of expertise in treating this disease?
• What did the tests show about the stage of my cancer?
• What type of treatment do I need?
• Is there any choice of treatments?
• Should I have any treatment before or after surgery?
• What are the risks and benefits of these treatments?
• What are the side effects?
• How long will the treatment last?
• Why do I need an operation?
• Is there any treatment I can have instead of surgery?
• What exactly will the surgeon do?
• Will the operation cure my cancer?
• What are the risks and benefits of having this operation? What are the possible complications?
• What will I look like after the operation? Will I ever get back to normal, or will I have some long-term effects?
• Is surgery performed under general or local anaesthesia? Will it be painful? What should I do before and after surgery?
• Will I be able to eat and drink normally after this operation?
• How long will it take to get over the operation?
• What are the possible side effects of chemotherapy? Will I lose my hair? Will I have nausea and vomiting?
• Will treatment reduce my pain?
• During treatment should I take special precautions or change my habits?
• Is there any behaviour I could adopt to improve my prognosis?
• What late effects could treatments have?
• What supportive therapy is suggested during the treatment?
• How will my treatment affect me?
• Will I need a special diet?
• Is there anything I should not eat?
• Will I be able to go back to work?