Maxillofacial Oncology at the University of Minnesota: Treating the Epidemic of Oral Cancer

Maxillofacial Oncology at the University of Minnesota: Treating the Epidemic of Oral Cancer

Jill Sink, D.D.S.,* and Deepak Kademani, D.M.D., M.D., FACS**:

ABSTRACT

Introduction. Oral cancer may present with a variety of signsand symptoms including pain, dysphagia, non-healing ulcers, redand white lesions, and indurated masses. Historically, oral cancerhas been associated with the male population, particularly thosewho use tobacco and alcohol. Recently, there has been a dramaticincrease in oral cancer rates seen in the population aged 40 yearsand younger. This increase has not been associated with thetraditional risk factors for oral cancer and is likely linked to etiologicfactors that remain still undefined. The proliferation of oral canceris also mirrored by an increase in oropharyngeal malignancies suchas base of tongue and tonsil cancer, although the increase in thissubset of patients appears to be clearly associated with HumanPapillomavirus (HPV).1

Methods. We present a summary of all oral malignanciestreated at the University of Minnesota Oral and MaxillofacialSurgery Division from 2008 through early 2011.

Results. Since July of 2008, the Oral and MaxillofacialSurgery Department at the University of Minnesota has beenreferred a total of 69 cases of head and neck malignant tumors, ofwhich 58 were primarily managed with surgery. A broad rangeof head and neck cancers were seen, with the most common beingoral squamous cell carcinoma (OSCC), which accounted for 81% of patients treated by oncologic tumor resection. The tongue was the most common site of occurrence of OSCC with 33% of cases. There was an even distribution between genders. Traditional treatment modalities included surgical resection of primary tumors including neck dissection, when indicated, with postoperative adjuvant therapies being reserved for advanced stage tumors or high-risk pathologic features for recurrence. At the conclusion of the study period in January, 2011, 83% of patients treated surgicallyfor OSCC were living disease free, 4% had recurrent tumors not amenable to resection, 6% of patients had died from other causes, and 6% had succumbed to OSCC, resulting in a disease-specific survival rate of 93% with an overall survival rate of 87%.

Conclusions. Oral cancer continues to be diagnosed with advanced stage disease in 50% of patients. Dental practitioners play a significant role in the early detection and diagnosis of oral cavity cancer. It is incumbent upon dental practitioners to be aware of the early signs and symptoms of oral cancer and to make prompt referral to head and neck cancer specialists when indicated. Diligent and frequent examination, particularly in patients with risk factors, will greatly improve survival rates and minimize the complexity and morbidity of oncologic treatment when patients are diagnosedwith earlier stage disease. 




Introduction

In 2010 it was estimated that 36,540 people would be diagnosed with oral and pharyngeal cancer and that 7,880 would die from the disease.2 The mean age at diagnosis of oral cancer is 62 years, and the current five-year survival rates are 83% when the disease is localized, 55% when metastasis to regional lymph nodes has occurred, and 32% with distant spread of disease.2 Unfortunately, the majority of patients present with advanced stage disease. At present, there are limited methods for early detection, which occurs in only approximately one third of cases.3 Most often, the signs and symptoms of early oral cancer are non-specific and often present as pain,bleeding, loosening of teeth, difficult in articulation of speech, dysphagia, odynophagia, otalgia, motor and sensory nerve disturbances, masses, and cervical lymphadenopathy3 (Table I). Commonly, early stage tumors have few or limited symptoms that develop with advancing disease and have a wide range of clinical presentation. Most often, asymptomatic patients are detected during a routine dentalexamination.4





Risk Factors
Research has shown that an increased risk for oral cancer is associated with alcohol consumption, tobacco use, and low socio-economic status.5 It is well established that the use of tobacco products and alcoholic beverages contributes to an increased risk of developing oral cancer.6,7 As many as two-thirds of oral cancer cases may be attributed to tobacco use and alcohol consumption. Additionally, the combination of tobacco and alcohol creates a multiplicative effect on the risk of developing oral cancer.8 This, in part, is due to increased mucosal permeability, with alcohol consumption heightening the carcinogenic effects of tobacco.7 
Although still an uncommon occurrence, an alarming trend is the recent increase in oral cancer seen in the young adult population. A 2008 study found a four-fold increase in oral cancer cases in the population aged 40 years and younger since the 1970s.9  Llewellyn examined oral cancer in the population of patients aged 45 years and younger and found that risk factors for the younger population appear to be similar to those of older adults.10 However, the specific etiology for this increase is yet undefined, but may be related to the increasing incidence of HPV As has been shown in oropharyngeal carcinoma.1 Additionally, the incidence of oropharyngeal cancer has increased in the United States in those aged 20-44 years.11 This may be due in part to HPV, particularly HPV-16, which has been linked to a 2.2 times increased risk for developing oropharyngeal carcinoma.12 




Treatment
Once there is clinical suspicion of oral cancer, the gold standard for diagnosis is a tissue biopsy. When histologic diagnosis of OSCC is confirmed, the patient should undergo a standardized staging evaluation (Table II). All subsequent treatment is predicated on a patient’s stage. Early stage OSCC is primarily managed with surgical resection of the primary tumor and management of the neck when tumors and patients are amenable to surgery. The principal goal is to obtain wide tumor-free margins.3 Adjuvant postoperative radiotherapy for advanced stage disease is recommended with high risk pathologic features, such as close or positive surgical margins, perineural invasion, angiolymphatic invasion, cervical metastasis, or extracapsular spread. Since the oral cavity is residence to many vital functions, including mastication, swallowing, and speech, surgical resection of tumors often negatively affects lives of patients.3 Therefore, immediate reconstruction of the surgical defect created during tumor resection is beneficial in maintaining quality of life and optimizing the functional outcomes from treatment (Figure 1). 
University of Minnesota Experience
Since 2008, the University of Minnesota Oral and Maxillofacial Surgery Department has been referred 69 cases of oral and oropharyngeal cancer. The majority of patient referrals come from the local and regional dental community in Minnesota and neighboring states. Of the 69 patients, 58 were treated surgically, seven received radiotherapy or combined chemoradiotherapy for primary oropharyngeal tumors, and four patients with advanced stage disease declined treatment. A wide histologic variety of oral cavity tumors were seen, with OSCC accounting for 57 cases, 47 of which were treated surgically. Other varieties include osteogenic and salivary gland malignancies (Table III).
Of all the head and neck malignancies treated by surgical resection, squamous cell carcinoma was the diagnosis in 81% of patients. The average age at diagnosis was 64 years, with an age range from 25 to 89 years. An even distribution was seen between males and females. The most common sites affected were the tongue (33%), mandibular gingiva (23%), and retromolar trigone and floor of mouth, each accounting for 11% (Figure 2). Thirty-nine percent of patients presented with stage one disease; stages two and three each occupied 19% of the study population, and 23% of patients presented with stage four disease (Figure 3). Risk factors in the patient population included tobacco use among 63% diagnosed, alcohol consumption in 72% of patients, and a combination of alcohol and tobacco use in 54% of patients diagnosed with OSCC. Patients were treated by a variety of modalities, with the mainstay being surgical tumor resection. Twenty-seven patients were treated by surgical means including neck dissection. Primary treatment with radiation only or chemoradiotherapy without surgery has been reserved for inoperable tumors of the oral cavity, or as primary management of oropharyngeal tumors in order to optimize organ preservation. 
At present, 83% of the OSCC patients treated by surgical measures are living cancer-free, 4% with recurrent unresectable tumors are alive, 6% have died from oral cancer, and 6% have died from non-oncologic causes. The disease specific survival rate was 93%, with an overall survival rate of 87%. The patients who are free of disease are composed of 49% who were diagnosed with stage I disease, 18% with stage II, 18% with stage III, and 15% with stage IV disease at diagnosis. Of those who have died from OSCC, all were diagnosed with advanced stage disease (Figure 4).    





Role of Oral and Maxillofacial Surgeons in Head and Neck Cancer
Oral and maxillofacial surgery residency-training programs provide education in the diagnosis, management, and treatment of oral cancer. However, there are few programs nationally that are able to offer comprehensive surgical care of these patients. Since the mid-1980’s there have been formal fellowship programs for oral and maxillofacial surgeons to specialize in oncologic head and neck surgery.
Treatment of oral cancer cannot be accomplished without individualized interdisciplinary collaboration to improve cure rate and enhance quality of life of patients. Coordination of treatment among the surgical, medical, and dental disciplines involved in the care of the head and neck cancer patient is essential to optimize treatment outcomes and survival rates. This team approach provides a medium that allows for efficient clinical care of patients and increased opportunities for treatment and research. 
It is critically important for dental practitioners to have a heightened awareness of oral cavity cancers or clinically suspicious lesions (Figure 5). It is often general dental practitioners, dental specialists, and community oral and maxillofacial surgeons who make the initial diagnosis of oral cancer. It is the responsibility of the entire dental community to be diligent with providing oral cancer screenings, biopsies, and expeditious referral to practitioners with expertise in the management of these tumors. 
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*Dr. Sink is an intern in oral and maxillofacial surgery at the Veterans Affairs Medical Center, Minneapolis, Minnesota.
*Dr. Kademani is associate professor, oral and maxillofacial surgery, University of Minnesota School of Dentistry, Minneapolis, Minnesota. Email is kadem001@umn.edu.