Additional considerations for treatment
For early oral cavity cancers, the depth of invasion correlates with the risk of nodal metastasis. [4]. Therefore, superficially invasive cancers may require only resection of the primary only. A meta-analysis evaluating published literature suggests that lesions over 4mm depth of invasion may benefit from staging neck dissection. [5]
The NCCN guidelines suggest that primary radiation therapy can be used in select circumstances for the treatment of early stage oral cavity cancers. While radiation alone for oral cavity cancers can be an effective modality for treatment of these cancers, the reported literature is not robust and primary surgical management is recommended. The toxicity of radiation to the oral cavity is substantial, and generally considered greater than that of surgery.
Very advanced oral cavity cancers that involve most of the tongue present a unique challenge. Although these cancers can be curable with surgery and adjuvant therapy, total glossectomy is a high morbidity procedure with permanent effects on speech and swallowing. In some cases, a concomitant total laryngectomy may also be needed because of intractable aspiration. Non-surgical treatment with chemotherapy and radiation therapy may be the best overall treatment strategy for these patients. In these cases, an individualized treatment plan with a multidisciplinary team is needed. The risks/benefits of surgical and non-surgical modalities need to be weighed against patient expectations and quality of life. These cases are some of the most challenging oral cancer cases to manage.
Followup
Routine follow up is crucial helpful for surveillance of possible recurrence or the development of a second primary malignancy. In general, follow up is recommended every 3-4 months for the first 2 years, and every 6 months until five years, and then yearly after 5 years. While most recurrences usually occur in the first two years, [6], five years is generally accepted as the milestone to define cure.
The follow up visit usually includes a complete interval history and complete head and neck exam. Endoscopic evaluation is recommended to evaluate hard to visualize areas like the posterior tongue, as well as to survey for potential second primary cancers. The risk of a second primary head and neck cancer in patients with a history of tobacco use is roughly 2% per year (need ref), hence the need for continued close observation.
For survival by stage, please see the section on epidemiology.
In addition to survival quality of life (QOL) following treatment is also important. Post treatment dysphagia can be severe and potentially permanent. Taste is often affected, especially following the use of radiation. Significant swallowing difficulties with poor control of secretions may result in aspiration, which may necessitate tracheostomy. Gastrostomy tube feeding may be needed in the short term until swallowing improves. After neck dissection, temporary shoulder dysfunction may proceed to permanent disability without therapy. These functional concerns are addressed in the post-treatment period by speech language pathologists, nutritionists, or occupational/physical therapy, coordinated by the head and neck surgeon. The AHNS strongly supports a multidisciplinary team approach to the evaluation and followup of head and neck cancer patients.
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