EN
Tumours of the mouth and tongue are almost always found late — and not because they are hard to see. On the contrary: the changes are usually visible to the naked eye. It is simply that at an early stage they do not hurt, and where nothing hurts, nobody looks. On top of that the lining of the mouth is home to a great many harmless spots and small ulcers, and without a specialist it is impossible to tell one from another. Hence a simple rule worth remembering: any change in the mouth that has not gone within four weeks is a reason to see a doctor rather than to wait a little longer.
What people usually come with
A sore on the tongue, the cheek or the floor of the mouth that will not heal. A whitish, grey or bright red patch that does not brush away (white plaques — leukoplakia — are regarded as a precancerous change and require assessment). A lump that can be felt with the tongue. A sensation of a foreign body, pain on swallowing, a change in speech. Sometimes the first sign is not the tumour itself but an enlarged node in the neck.
According to the German registry, about 9,700 men and 4,200 women a year develop cancer of the mouth and pharynx in Germany. The main risk factors have long been known — smoking and regular consumption of alcohol, and together they act far more strongly than separately. Poor hygiene plays its part, as does constant mechanical irritation of the mucosa by a denture or by the sharp edge of a tooth. A separate and growing story is the human papillomavirus: tumours of the oropharynx associated with it have become more frequent in recent years, including in comparatively young people with no history of smoking or drinking. This is precisely why in Germany HPV vaccination is recommended for boys as well as girls at the age of 9 to 14.
How the diagnosis is established
Examination, however experienced the doctor, is not enough here: by eye one can suspect but not assert. So the first step is a biopsy, taking a piece of tissue from the suspicious area. The pathologist looks at whether malignant cells are present, how far they are altered and how far the change in the mucosa has gone.
For tumours of the oropharynx it is additionally determined in Germany whether the tumour is associated with HPV (the p16 marker and a test for the virus). This is not a formality: HPV-associated and non-associated tumours behave differently, are staged differently and are treated by different regimens — to the point that for the former the possibility of gentler regimens is now seriously discussed.
Next a map is needed: CT or MRI of the head and neck shows the borders of the tumour and the state of the lymph nodes, ultrasound of the neck completes the picture, CT of the chest excludes distant deposits, and PET-CT is added where necessary. A panendoscopy is usually performed as well — an examination under anaesthesia of the whole upper aerodigestive tract, because with these tumours a second, independent one is sometimes found. The data collected are reviewed by a tumour board: a maxillofacial or ENT surgeon, an oncologist, a radiation oncologist, a radiologist, a pathologist. The plan is born there, not in one doctor’s consulting room.
Which approaches are used
For tumours of the mouth proper the basis of treatment most often remains surgery — removal of the tumour with a margin of healthy tissue and, as a rule, an operation on the lymph nodes of the neck. Reconstruction is now done during the same operation: the defect is closed with the patient’s own tissue in order to preserve swallowing, speech and appearance. This is the main answer to the fear of “being left disfigured” — the question is discussed in advance, before the operation, and is part of the plan.
Radiotherapy may follow the operation if risks remain at the margin of the excision or in the nodes. For tumours of the oropharynx it is often the principal method as well — on its own or together with chemotherapy. In advanced disease and when a tumour returns, drug treatment is included in the regimen, among it immunotherapy — drugs that help the immune system recognise tumour cells. What exactly is chosen depends on the site and the extent of the tumour, the HPV status, age and accompanying diseases: a patient of 50 and a patient of 80 are deliberately managed differently.
A separate part of the plan, worth asking about at once, is the supportive care: dental treatment before irradiation begins, nutrition during treatment, restoration of speech and swallowing with a speech therapist, pain relief. In German certified head and neck centres this is part of the pathway rather than being left to the patient.
A second opinion
If the diagnosis has been made at home and the proposed extent of surgery seems large, or on the contrary the plan raises doubts, it is sensible to begin not with a move abroad but with a second opinion. A German specialist needs the images on a disc, the medical records and — this is essential — the biopsy slides or blocks: a local pathologist reviews them. Review of the material and re-staging sometimes change the tactics before the patient has travelled at all.
This material is for information only and does not replace a consultation with a doctor. Whether treatment is possible, what it will involve and what it will achieve can be determined only after an examination at the clinic in person.