This document discusses oral cancer from an international perspective. It notes that oral cancer rates and outcomes vary significantly between countries due to differences in etiological factors, socioeconomic conditions, awareness, expertise, resources and prevention strategies. While survival rates have improved in developed countries through early detection and treatment, survival remains poor in developing nations where most cases are diagnosed at advanced stages. Reducing tobacco use through education and lifestyle changes could help lower oral cancer rates globally.

1. The International Federation
of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2012
Oral Cancer
Jatin P. Shah

2. Oral Cancer
6th
Most Common Cancer
Worldwide
2012

3. Oral Cancer International Perspective
• Geographic variance
• Incidence
• Etiologic factors
• Site prevalence
• Stage distribution
• Socio-economic factors
• Awareness – education
• Expertise/technology
• Resource allocation
• Outcomes
• Economic impact
2012
• Prevention strategies

4. 2012

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7. 2012

8. Oral Cancer
Better understanding of the biology
of oral cancer, particularly with
relation to local progression and
metastatic spread.
2012

9. Oral Cancer
There is increasing emphasis
on preservation or restoration
of form and function to
improve the quality of life.
2012

10. Treatment Goals for Cancer of
the Oral Cavity
• Cure of cancer
• Preservation or restoration of form
and function
• Avoid or minimize sequelae of
treatment
2012
• Prevent second primary cancers

11. Oral Cancer
Factors Affecting Choice of
Therapy
• Tumor factors
• Patient factors
• Provider/Physician factors
2012

12. Oral Cancer Tumor Factors
• Site
• Size (T stage)
• Location
• Multiplicity
• Proximity to bone
• Histology, grade, depth of invasion, tumor type
• Status of cervical lymph nodes
• Previous treatment
2012

13. Ca. Oral Cavity - Site Distribution
Tongue Floor of Mouth Cheek Gum
2012
Retromolar Trigone Lip Hard Palate

14. Ca. Oral Cavity
5 yr. Survival by Stage
T1 T2 T3 T4
Stage I Stage II Stage III Stage IV
N0
N1 (75-95%) (65-85%)
(45-65%)
N2
N3 (10-35%)
2012 M1

15. 2012

16. Ca. Oral Cavity Histological
Distribution
Squamous Carcinoma
92% Minor Salivary Ca.
Melanoma
Lymphoma
Sarcoma
2012

17. Impact of Tumor Thickness
2 - 9 mm > 9 mm
< 2 mm
13 3 46 17 65 35
% with Lymph Node Mets. % Dead of Disease
2012

18. Oral Cancer Patient Factors
• Age • Acceptance
• General medical • Tolerance
condition • Compliance
• Life style • Socioeconomic
• Dental hygiene considerations
• Occupation • Time constraints
2012

19. Oral Cancer Physician/Provider
Factors
• Expertise
• Surgery • Rehabilitation
• Radiotherapy • Support services
• Chemotherapy • Resource allocation
• Dental – prosthetic • Third party payer
constraints
2012

20. Oral Cancer Treatment
Alternatives
• Surgery
• Radiotherapy
• Chemotherapy
• Combined modalities
2012

21. Choice of Surgery vs. Radiotherapy
Survival with single modality treatment
90 Choice of Treatment
80 depends upon:
70
60
50
40 • Site • Competence
30 • Location • Convenience
20 • Stage • Cost
10 • Histology • Compliance
0
• Node Status • Complications
I I II I
Stage I
I V
2012

22. Oral Cancer Choice of
Treatment
• Stage I & II single modality
treatment is effective and
preferable
• Stage III & IV multimodal
therapy is essential
2012

23. Oral Cancer Surgical
Approaches
• Per oral
• Pull through
• Lower cheek flap
• Upper cheek flap
• Visor flap
2012
• Mandibulotomy

24. Surgical
approaches
to the oral
cavity
2012

25. Oral Cancer
Surgical approach depends on:
• Tumor size
• Tumor site
• Tumor location
• Proximity to mandible or maxilla
• Need for neck dissection
• Need for reconstructive surgery
2012

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28. Management of the Mandible
• Mechanism of tumor invasion
• Mandible sparing approaches
2012

29. Mandible Invasion by Oral Cancer
Dentate Mandible
Marginal
mandibulectomy
feasible for invasion
of the alveolar
process or minimal
cortical erosion.
2012

30. Mandible Invasion by Oral Cancer
Edentulous
Mandible
Marginal
mandibulectomy
feasible for minimal
erosion of the
alveolar process.
2012

31. Mandibulectomy Indications
• Gross invasion by tumor
• Proximity to tumor
• Access to oral cavity?
2012

32. Segmental Mandibulectomy
Indications
• Gross invasion by oral cancer
• Primary bone tumor
• Metastatic tumor
• Inferior alveolar nerve invasion
2012

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49. Mandible Sparing Approaches
• Marginal mandibulectomy
• Mandibulotomy
2012

50. Mandible Sparing Indications
• For margins around tumor
• Approximation by tumor
• Cortical erosion
2012

51. Marginal Mandibulectomy
Contraindications
• Gross tumor invasion
• Massive soft tissue disease
• Radiated, edentulous mandible
2012

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60. Paramedian Mandibulotomy
Advantages
• Wide exposure
• Preserves hyomandibular
complex
• No denervation of skin
• No devascularization
• Easy fixation
2012
• Out of radiation portals

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70. Trans Oral Robotic Surgery
(TORS)
Advantages Dis advantages
• Evolving role of the • Robotic arms are not
Robot designed for Oral
• Avoids mandibulotomy surgery
• Faster recovery • Learning curve is
• Less bleeding steep
• Takes more time
• Less pain
• Equally good • Expensive
resection ?? • Outcomes data not
available
2012

71. Oral Cancer
Head and Neck Service, MSKCC
• Total no. of patients on database: 953
• Excluded patients: 358
– Previous treatment elsewhere: 275
– Incomplete information: 21
– Lip cancer: 29
– Carcinoma in situ: 9
– Unresectable dis. Or distant meta: 14
– Radiotherapy alone: 10
2012 • Total 595 patients treated with surgery

72. 1.0 Survival
0.9
77%
0.8 DSS
0.7
68%
RFS
0.6 68%
OS
0.5
Proportion
Surviving
0.4
0.3
0.2 DSS – OS = 9%
0.1
0.0
0 12 24 36 48 60 72 84 96 108 120
2012
Follow-up Interval in Months

73. Disease-Specific Survival – T Status
Univariate
• Clinical T stage 1.0
94%
0.9 T1
• Clinical N stage 76%
0.8 T2
• Clinical overall stage 0.7 66%
T3
0.6 58%
Surviving
T4
• Pathologic T stage
0.5
• Pathologic N stage 0.4
0.3
• Pathologic overall stage
0.2
• Tumor grade 0.1 P<0.0001
0.0
• Surgical margins 0 12 24 36 48 60 72 84 96 108 120
• Depth of invasion Months
2012

74. Disease-Specific Survival – N Status
Univariate
• Clinical T stage 1.0
0.9 84%
N0
• Clinical N stage 0.8
• Clinical overall stage 0.7
58%
N1
0.6
Surviving
• Pathologic T stage 0.5 46%
N2, 3
• Pathologic N stage 0.4
0.3
• Pathologic overall stage 0.2
• Tumor grade 0.1 P<0.0001
0.0
• Surgical margins 0 12 24 36 48 60 72 84 96 108 120
• Depth of invasion Months
2012

75. Disease-Specific Survival – Stage
Univariate
1.0
94%
• Clinical T stage 0.9
I
80%
II
• Clinical N stage 0.8
66%
0.7 III
• Clinical overall stage 0.6 58%
Surviving
IV
• Pathologic T stage 0.5
0.4
• Pathologic N stage 0.3
• Pathologic overall stage 0.2
P<0.0001
0.1
• Tumor grade
0.0
• Surgical margins 0 12 24 36 48 60 72 84 96 108 120
Months
• Depth of invasion
2012

76. Disease-Specific Survival - Margins
Univariate
1.0
• Clinical T stage
0.9 82%
Negative.
• Clinical N stage 0.8
0.7
• Clinical overall stage 57%
Positive.
0.6
Surviving
• Pathologic T stage 0.5
0.4
• Pathologic N stage
0.3
• Pathologic overall stage 0.2
P<0.0001
• Tumor grade 0.1
0.0
• Surgical margins 0 12 24 36 48 60 72 84 96 108 120
Months
• Depth of invasion
2012

77. Conclusion
• Changing distribution of primary tumor:
– Oral tongue 48% of all oral ca: The highest
reported from our institute
• Improved Outcome: 5-year overall survival
– 1960~1964: 48%
– 1979~1983: 57%
– 1986~1995: 68%
• Significant predictors:
– Disease-specific survival: surgical margins and
2012
pathologic N stage

78. Summary
Changing Trends in Outcome
5-year Overall Survival
80% 68%
57%
60% 48%
40%
20%
0%
60~64 79~83 86~95
2012
N=494 N=398 N=595
Stage III/IV 53% 36% 37%

79. Oral Cancer
Improvement in results is seen due
to:
• Early identification and treatment
of nodal metastases
• Employment of adjuvant therapy
2012

80. Oral Cancer
Improvement in quality of life
is seen due to
• Contemporary surgical techniques
• Preservation or reconstruction of
mandible and soft tissues
• Osseointegrated implants
2012

81. Age Adjusted Death Rates for Oral
Cancer per 100,000 Population
Country
China 0.52 0.33
USA 1.5 0.69
UK 1.63 0.74
Australia 1.79 0.78
Italy 2.7 0.62
Spain 3.3 0.59
Brazil 3.4 1
France 4.1 0.73
India 7.62 4.43
2012 Hungary 10.27 1.4
Melanesia 21.69 13.81

82. Advanced Carcinoma of the Oral Cavity
Survival Outcomes
60% 59%
47%
50%
Percent Survival
40% 33%
27% 27%
30%
20%
10% 12%
10%
0%
MSKCC, 2002 * India, 2000 ** Brazil, 2002 * Taiwan, 1999*
(n=595) (n=1505) (n=364) (n=703)
Stage III Stage IV
* Represents overall survival
** Represents relative survival
2012
MSKCC: Unpublished data
India: Yeole BB et al. Cancer 89: 437-44, 2000
Brazil: Unpublished data Carvalho A, Kowalski L et al.
Taiwan: Chen YK et al. Oral Oncol 35: 173-79, 1999.

83. Oral Cancer International Perspective
The most progress in the field
can be achieved by employing
prevention strategies -
Developed Countries Developing Countries
• Awareness/education • Awareness/education
• Lifestyle changes • Lifestyle changes
– Cessation of tobacco – Cessation of tobacco
in all forms and alcohol in all forms and alcohol
• Chemoprevention trials • Mass screening strategies
2012