Cheek Cancer

Some potential predisposing risk factors that increase one's chances of oral cancer are:

• Male gender, as men are twice as likely to develop oral cancers than women
• Previous history of oral cancer
• Family history of oral cancer or other cancers
• Genetic conditions

Certain known lifestyle factors that are modifiable are known to be directly linked with the development of oral cancer, including that of the inner cheek. These factors include: 

• Tobacco: Tobacco is a carcinogen that can produce cancerous changes in cells with prolonged contact and exposure. Tobacco is widely consumed by smoking cigarettes but is also used through non-smoking means.
• Smoking: Not only does smoking increase the risk of oral cancer substantially, but it also increases the risk of several other cancers including lung cancer. 
• Chewing tobacco in forms like gutka, paan, betel nut, areca nut, chalia, naswar, toombak, etc, increases the risk of oral cancer manifold. 
• Alcohol: Consumption of alcohol increases the chances of developing oral cancer and this risk is further multiplied if the habit is in conjunction with tobacco use. 
• Human Papillomavirus (HPV) infection: Human papillomavirus (HPV) infections of the mouth, commonly transmitted through sexual contact, can predispose one to oral cancer. Human papillomavirus (HPV) type 16 has been most significantly implicated in oral cancer. Human papillomavirus (HPV) vaccination, for both males and females, can help prevent it. 
• Premalignant conditions: Some lesions present in the mouth can have a high risk of transforming into cancer over time. A common example is a leukoplakia, which is a white plaque-like lesion in the mouth or upper throat that cannot be rubbed off. A red irregular lesion that persists on the tongue or floor of the mouth and cannot be attributed to another is known as erythroplakia and is also a type of premalignant lesion. 
• Chronic sun and UV-ray exposure of the face: Increased sun exposure over time, especially from a younger age, can pose a risk of cancer in the future. 
• Poor oral and dental hygiene: Cells of the mouth and oral cavity can undergo cancerous transformation due to prolonged poor hygiene and inflammation. 
• Poor nutrition: A diet high in processed grains, meats and rice can increase the risk of cancer by free-radical-induced cell damage. Foods rich in antioxidants like vitamin A, vitamin C and vitamin E like fruits and vegetables help reduce cell damage. 
• Weak immune system

Oral cancers can most commonly present as non-healing ulcers anywhere in the mouth. An oral ulcer or sore that has not healed and has persisted for more than three weeks should raise suspicion of oral cancer and should ideally be looked at by a doctor or dentist. Other signs and symptoms associated with oral cancers include, but may not be limited to:

Signs:

• A white thick patch that cannot be rubbed off (known as leukoplakia) 
• A red irregular lesion on the tongue or floor of the mouth that cannot be attributed to any other cause (known as erythroplakia)
• A lump in the throat, on the inner surface of cheeks, mouth, tongue or lips that persists
• Unusual bleeding or numbness in the oral cavity
• A lump in the neck
• Weight loss

Symptoms:

• Pain on chewing
• Pain or difficulty swallowing
• A sensation of something being stuck in the throat
• Sore throat
• A change of voice
• Voice hoarseness
• Speech or articulation problems
• Loose teeth or ill-fitting dentures
• Jaw pain or swelling
• Severe ear pain

It is advisable to visit a doctor or dentist if a non-healing ulcer or sore persists anywhere in the oral cavity for more than three weeks at a time. Signs and symptoms that may raise a suspicion of oral cancer have to be assessed by a doctor or dentist to arrive at a definitive diagnosis. The medical professional will begin by taking a thorough medical history from the patient, laying special emphasis on lifestyle habits and family history, while garnering information about the development and progression of the oral lesion. Following this, a thorough physical examination will be conducted, which will include an oral examination using tools like speculums. The oral cavity will be assessed for lumps, unexplained bleeding and suspicious lesions. The medical professional might also take a biopsy, which is a small sample of tissue, from the suspicious area to investigate further under a microscope. Investigations will be ordered to confirm the diagnosis and stage the cancer, if present, before proceeding with the available treatment options.

Following a history and examination, the medical professional will proceed to take a biopsy, or a small tissue sample, from suspicious areas in the mouth. 

• Biopsy: The biopsy sample can be taken from a suspicious area in the oral cavity by the following methods:
  • Exfoliative cytology: The medical professional will take a brush, or similar instrument, and scrape some cells from the suspicious area gently onto a glass slide to view under the microscope. This can be performed in the doctor’s office itself.
  • Incisional biopsy: A numbing anaesthetic is injected in the oral cavity near the suspicious area first, before taking a small sample of tissue with a scalpel blade. If the suspicious area is situated deeper in the tissue, the procedure may be performed in an operating room. Otherwise, it can be routinely done in the doctor’s office.
  • Fine needle aspiration cytology (FNAC): If a lump or swelling in the neck is observed on examination, the doctor will proceed to take some cells from it by a needle in order to study it under a microscope.
• Histopathological investigations: The biopsy sample taken is assessed by a pathologist under a microscope to study the cells and make the final diagnosis.
• Radiological imaging investigations: After confirming the diagnosis of cancer, radiological investigations are needed to assess the extent or spread of the tumour to stage the disease. This also helps understand whether any lymph nodes or distant organs have been infiltrated by the cancer as well. Treatment options depend on this information. Imaging tools that may be used to stage the cancer include:
  • Computed Tomography (CT) scan 
  • Magnetic resonance imaging (MRI)

Once the diagnosis of inner cheek cancer has been made, and the cancer has been staged, the treatment options will depend on:

• The size of the tumour
• The location of the tumour
• The extent of spread of the tumour to neighbouring structures
• Involvement of neighbouring, or distant, lymph nodes by the tumour
• Metastasis or spread of cancer to distant tissues and organs
• The overall health of the patient
• Age of the patient

Oral cancers are highly treatable and curable when caught early. The aim of treating inner cheek and other oral cancers is to:

• Kill the cancer cells or remove the cancer cells
• Prevent the cancer from returning 
• Ease the symptoms of cancer 
• Preserve or restore the appearance and functions of the mouth

Surgery: Depending on the size, location and type of inner cheek cancer, the type of surgery varies. The aim, however, remains to remove as many of the cancer cells as possible by resecting the tumour and the surrounding marginal tissue. Sometimes, light therapy treatment, known as photodynamic therapy (PDT) is also incorporated with surgery to remove small mouth cancers.

Radiotherapy: Radiation is used to target and kill cancer cells and stop them from multiplying by high energy beams. Two types of radiation therapy can be used: 

• External radiation therapy: This is the more common type of the two used for cancer treatment. An external machine is used to focus radiation on the target tumours. 
• Internal radiation therapy: Also known as brachytherapy, this modality utilises small radioactive wires by placing them next to the cancer cells for a short period of time before removal. 

Chemotherapy: Medicines, called chemotherapy drugs, are used in addition to surgery or radiation therapy, to increase the efficacy of treatment in suitable cases. In some instances where cure is not possible, or surgery and radiation therapy not feasible, chemotherapy may be the only treatment used.

Unlike many other cancers, oral cancers can be prevented to a certain extent by modifying lifestyle habits. Steps to prevent inner cheek and other oral cancers include:

• Quitting smoking
• Abstaining from alcohol
• Not chewing or consuming any other form of tobacco and its products like gutkha, paan, betel nut, areca nut, etc. 
• Getting vaccinated against human papillomavirus (HPV) can reduce the risk of oropharyngeal cancers significantly. The HPV vaccine is advisable for both young men and women. Women are additionally protected from cervical cancer with the HPV vaccine. 
• Maintaining good oral hygiene can prevent inflammation of the mucosal membranes and cancerous changes from occurring as well.
• Following a nutritious diet rich in fresh fruits and vegetables. 
• Avoiding highly refined grains, sugar, rice and meats in your daily diet. 
• Getting any suspicious persistent non-healing ulcer or sore in the mouth looked at by a doctor or dentist as soon as possible.

When diagnosed early, inner cheek cancer has a high cure rate and a good overall prognosis for the patient. If the cancer has spread to neighbouring lymph nodes or to distant organs, the prognosis becomes worse.