Management of the head and neck in locally advanced oral cancers
Dr Kaustubh Patel - HCG Cancer Centre, Ahmedabad, India
As you know, advanced oral cancers are the main issues in India. We have a lot of oral cancers and we have to manage them by day-to-day in our day-to-day practice.
How are they managed and assessed?
Basically advanced oral cancers are T3 and T4 advanced oral cancers and they can present with N0, N1/2 or N3 nodes in the neck. These N3 nodes can be operable nodes, maybe inoperable nodes. So we go ahead with clinical examinations, of course the biopsies and all of those things, but with that we have special imagings and this imaging includes CT scan MRI, not only that but PET-CT and PET-MR. These are the things which will tell us what status, clinical status, the patient is in and based on that we’ll be planning our treatment modalities. Basically T3, T4 oral cancers are treated by surgery so some kind of neck dissection is always warranted and it all depends on your clinical examination and imaging whether the patient is in N0, 1, 2,3, whether he is operable or not. So depending on that we’ll take our operative decisions.
How have the treatments been developed?
We operate about 200 patients in a month and most of them are oral cancers. We have two senior head and neck surgeons in our team and then we have four or five other people and the fellows. We analyse and keep track of our patients. Then, based on those retrospective analyses, we come to a conclusion that what should be the best way to manage. Of course there are clinical guidelines, like NCCN and AJCC and all other literature and data support based on that we can have. But the most important thing at our place is a multidisciplinary team. So we have medical oncologists, radiation oncologists, surgical oncologists, pathologists, radiologists and jointly we decide the line of management for that patient.
What are the main causes for these cancers?
In India the commonest cancer is oral cancer in males if we consider the entire epidemiology. It’s because of the tobacco chewing and betel nut and areca nut. So these are the risk factors in our country which cause oral cancer and it is not the smoke tobacco it’s the chewing tobacco which causes oral cancer. That’s very rampant in our country so that’s the reason we get a lot of patients now compared to Western, American and European, counterparts of oral cancer. They get more tongue and fewer mouth cancers but in my country the major chunk of our oral cancer patients are buccal mucosa and buccal alveolar sulcus cancers. So that’s the major difference between the group of patients coming to us compared to the Western world.
What preventative measures do you have in place?
Oral cancer is the best model for prevention because you know why it is produced, most of the time it is because of tobacco. Oral cavity can be examined very easily; examination of oral cavity in a mirror is inexpensive. So the patient who is chewing tobacco can just examine his mouth and there are definite precancerous lesions like leukoplakias and erythroplakias. So if you teach the community that these are the risk lesions which can convert into cancer and if they can come in time after seeing their oral cavity having leukoplakias or erythroplakias you can prevent these cancers or else at least you can detect them early. The problem is awareness.
What support do you have in regards to government?
There are NGOs which are trying hard; there are healthcare systems and healthcare organisations which are trying hard. Government is supporting but not to an extent which the healthcare workers would expect them to, say like chewing tobacco can be banned. But because of the political reasons it’s not being done there.
Do you have a take home message for doctors watching?
The best preventable cancer in the world is oral cancer and it can be easily prevented if you have good awareness and if you can convince the population in the right way and more so convince the policy makers.