Q&A: Mr Paul Stimpson
Q&A - 1ST DECEMBER 2017
Mr Paul Stimpson, consultant ENT surgeon and head and neck specialist at The London Clinic, on cancers of the mouth
What does ‘mouth cancer’ encompass?
When we say mouth cancer, the implication is cancers of the mouth, the whole upper airway and throat: tongue, cheeks, lips and the floor of the mouth, as well as the salivary glands, neck, and further back in the throat, so the tonsils and the voice box.
How common are they?
As a whole, it is probably the fourth most common cancer we see in males in the UK and it is increasing in incidence—particularly oral and oropharynx cancer, which are the bits at the back of the mouth where the tonsils are.
Why do you think that is?
Although it’s not absolutely clear, we think it’s probably lifestyle-related, so due to smoking, alcohol, and poor diet. We know that all those things have an impact. Although rates of smoking have reduced in the UK, we are seeing the delayed effect of past smoking habits. Also, compared with 30 to 40 years ago, there’s been a huge increase in alcohol intake and diet is generally poorer. People are also living longer. All those things together mean we are seeing more of these sorts of tumours.
Who is most likely to get mouth cancer?
It’s much more common in men, particularly those in later life. Smoking and alcohol is generally more common among those of a lower socio-economic background, and we do see large numbers within that group. But, over recent years, we’ve seen an association with virally mediated disease—namely, the human papillomavirus virus (commonly known as HPV). Although we can’t blame that virus for the increase in cases, we’ve seen more of it as the incidence has gone up, for all types of mouth cancer. We think it’s possibly sexually transmitted. People’s sexual habits have changed—people practice oral sex more now than they used to, and there’s more of a risk of transfer of a virus between people because of that. Lots of people have the virus but only a few will develop cancer as a result, we don’t quite understand the relationship yet. The interesting thing about virus patients is, they don’t fit the usual demographic—they’re often younger professionals, non-smokers and non-drinkers. There’s a lot of research being done to look at how we can change treatments based on that knowledge.
What are the common symptoms of mouth cancer?
A red or white patch in the mouth or on the tongue that doesn’t go after about three weeks or so; an ulcer on the cheek, mouth, or tongue that’s not going away, getting bigger, or affecting your swallowing or voice; new and persistent pain or bleeding in the mouth or throat; a lump within the mouth or neck that’s not getting better—that’s at the top of the list of things to go and get checked out.
How do you check for mouth cancers?
First we take a full history. Do they drink? Do they smoke or chew tobacco? If they’re a smoker, do they use a pipe? That will increase their likelihood of developing mouth cancer more than cigarettes, as will cigars, as the smoke is in the mouth for longer. Then we ask about their general health—if they have lots of other problems, such as having had a heart attack, a stroke or if they are diabetic, that’s going to change the treatment options. After that, we have a good look. It usually involves an examination of the mouth using a good light, feeling the mouth and tongue and throat with our fingers, then we might use an endoscope to have a look at the whole lot including the voice box, to see if there’s anything abnormal. If there’s concern, they’ll be referred for imaging—often an ultrasound, but it may be an MRI or CT scan of the neck and chest. After that, we will take a small biopsy and based on that, we can decide what to do next and put it into a treatment plan.
What are the treatment options?
Surgery is the mainstay for this sort of cancer, and it can range from a small removal of the tumour through the mouth under local anaesthetic, right the way up to the biggest operations, which might involve removing large amounts of the tongue and throat, as well as tissue from the neck, then having to reconstruct that with a flap of tissue from elsewhere. These can be very long procedures of up to 12 hours. After surgery, the patient might require radiotherapy and possibly chemotherapy, depending on what the tumour looks like—if it has very aggressive features or has spread locally, it might be used to try to stop it coming back.
Obviously, it’s a very functionally sensitive area, so the patient will need a lot of support from speech therapists and dieticians. Then they go on to a very strict follow-up protocol, so they’re seen very regularly for at least five years. Unfortunately, there is a risk of further disease. Relapse is not common—most patients do well; they’re treated, and the cancer goes away—and disease recurrence at the site of the initial tumour is unusual, but it can appear in other places such as the lungs, the abdomen or the liver. We monitor patients so we can pick anything up as and when it happens.
How effective is treatment?
Early detection is very important. For patients with early stage cancers or small tumours that we can remove easily, the prognosis is good, with an 80 to 90 per cent survival rate for five years plus. For the later stage diseases and bigger tumours that have spread to the lymph nodes or the neck, it’s probably half that figure and if it’s spread elsewhere, even lower. While the life of a patient with cancer may not be a lot longer than it used to be, their quality of life and function is a lot better. You can keep a patient alive by doing huge operations, but if they have a miserable life, there’s no real benefit to that. But our ability to give people that quality of life and enable them to function in the way they want to is improving.
What’s facilitating that improvement?
There have been improvements in minimally invasive surgical treatments, robotic surgery is now available and new instruments allow us to be more accurate in terms of what we remove. We’ve also got really good quality imaging now, so before an operation we know exactly where the tumour is likely to be, and what structures we can and can’t preserve. Reconstructive techniques are always developing, which help minimise the effects of treatment on a patient. Radiotherapy techniques have improved—it’s a lot less damaging to local structures than it used to be, because it’s more accurate.
Looking to the future, there are ongoing trials to do with immunotherapy and biological therapies. There’s a national project going on called the 100,000 Genome Project, which will hopefully provide some genomic analysis—if we find recurring genes that are always present in particular cancer types, then we could do genetic testing as part of risk analysis, to see whether a person is likely to develop something and offer counsel.
What will have the biggest impact?
Improved public awareness and education, which is why things like Mouth Cancer Action Month are very important. People need to know what to look for and what symptoms they should be worried about, and have an understanding of high risk behaviours. We’ll save a lot more patients by cutting down on smoking and alcohol, improving diets and getting people to go to their dentist regularly, than we will developing state-of-the-art surgical techniques or robotics systems. We need to address the root of the cause: public health. But that won’t happen overnight.