In a few days, cancer researchers from across the world will put the spotlight on a health issue which needs urgent attention, namely Oral Cancer. While Sri Lanka has forged ahead in all other health indices, recent reports have revealed that our country has one of the highest incidence of oral cancer despite the many preventive efforts by Health officials.
The Sunday Observer spoke to the with Senior Registrar in Community Dentistry, Health Promotion Bureau Ministry of Health, Dr N.A.R. Nanayakkara to find out why oral cancer continues to be a troubling issue in Sri Lanka, how it is caused, and how the soaring numbers can be reduced.
Excerpts.
Q: The global cancer community on February 4, will focus attention on Oral Cancer which according to recent evidence has seen a sharp rise both globally and ;ocally. As many of our readers still have only a limited knowledge about oral cancer, could you tell us what it is?
A. Oral cancers refer to cancers that develop in the oral cavity and related areas such as tongue, lips, and gums and even to the back of the throat.
Q: How common is it in Sri Lanka?
A. According to the World Cancer Research Fund International, Sri Lanka had the 8th overall rate of mouth and oral cancers in 2020. In Sri Lanka oral cancer is the most common cancer among males. On an average, six new oral cancer cases are diagnosed per day with an average of 3 oral cancer deaths per day (NCCP Cancer fact sheet 2020 Sri Lanka).
Q: Are there different types of oral cancer?
A. Yes. Most common oral cancer is the Squamous cell carcinoma. Other than those Adenocyctic carcinomas, Lymphomas, Mucosal melanomas and even sarcomas can be found in the oral cavity.
Q: Squamous cell carcinoma is said to be the most common type of mouth cancer accounting for 9 out of 10 cases. What are they?
A. About 80 percent - 90 percent of all oral cancers are caused by squamous cells. Squamous cells are flat cells that are found in tissues that form the surface of the skin digestive tract including oral mucosa, lining of respiratory tract, and lining of hollow organs. Squamous cell carcinomas can develop in any part of the oral cavity.
Q: Who are at high risk of oral cancer? Is there an age limit?
A. In Southeast Asia, South Asia, and certain other areas of the world, many people chew betel quid, which is made up of areca nut (betel nut), spices, lime, and other ingredients. Many people in these areas also chew gutka, a mixture of betel quid and tobacco. People who chew betel quid or gutka have an increased risk of cancer of the mouth as it contains chemicals that increase the carcinogenic effect.
Unfortunately it is mostly people in the prime of their lives who develop this as many of them like bus drivers and trishaw drivers done long distance driving and have little time for eating or drinking, chew on these betel quid to appease their hunger pangs and keep them in their mouth for a long time without spitting it out. At the same time due to these commercially prepared areca-nut products age limits of oral cancers have shifted towards much younger age.
Q: Tobacco and Alcohol use are the two main risk factors that cause oral cancer. Do you agree?
A. Yes, Tobacco (whether smoked or smokeless) and alcohol are two main risk factors. Other risk factors that contribute to developing oral cancer are chewing areca, Human Papilloma Virus, genetic factors, poor oral hygiene, and frequent trauma to oral mucosa. This means an injury to the oral mucosa which can result from physical, chemical, or thermal trauma; sharp edges of the teeth, ill-fitting dentures also contribute to developing oral cancers. Drinking alcohol increases the risk of developing oral cancers and those heavy drinkers have a higher risk than light drinkers, the risk increasing according to the dose (frequency and amount.) (Oropharyngeal cancers are mainly associated with Human Papilloma virus)
Q: According to new studies, people who drink and smoke heavily together are at a higher risk (about 30 times higher ) than those who don’t smoke or drink. True or false?
A. True. Smoking and drinking alcohol together multiplies the risk of these cancers, As for how many times it increases the level depends on the methodology that is applied to calculate this risk.
Q: Chewing on tobacco- is this a contributory cause?
A. Definitely yes. Smoking tobacco or chewing tobacco has been proven and identified as a risk factor for Oral cancer. Tobacco, areca-nut contain carcinogenic chemicals, and lime increases the carcinogenic process.
Q: The hot weather we are now experiencing has led to us being exposed to bright sunlight, Could this lead to lip cancer caused by excessive ultraviolet rays especially by those working outdoors? Is there any significant increase in persons with lip cancer now?
A. No. There isn’t such evidence.
Q: What about the genetic factor? How significant and relevant is it in the case of oral cancer?
A. There is genetic contribution for cancers in general. But at the moment there aren’t enough facilities to obtain such information in treating cancer patients in Sri Lanka
Q: Malnutrition - WHO and UNICEF recently disclosed that Sri Lanka had one of the highest rates of child malnutrition in South Asia. In what way is malnutrition in children linked to their declining oral health?
A. Children fed with starchy sweetened food as their main meal or given a snack, high in carbs, oil and salt instead of a proper nutritious meal run the risk of developing dental caries, besides adverse effects on their general health and immune systems. .
Q: The current economic crisis has affected all Sri Lankans in different ways. In what way has this crisis affected the oral health of our people in general? For example, it has been reported that many people are now switching from toothpastes with fluoride to tooth powders as they are cheaper. How harmful are these substitutes on their teeth?
A. Tooth powder doesn’t contain fluoride which is essential for dental health and can damage dental hard tissues as it causes tooth wear.
Q: Could you briefly summarise what you consider as the main causes of oral diseases ?
A. Ingestion of too many sweetened foods that stick on the teeth, poor nutrition, improper tooth brushing, not using fluoridated toothpaste. In addition, unhealthy lifestyle habits such as smoking, betel quid chewing, using alcohol, and poor oral hygiene, combination of untreated dental caries, poor gingival (gum) health like bleeding, swollen gums, deposits of calculus, are all risk factors for oral diseases in general.
Q: As school children are among the most-vulnerable to oral diseases, some of the most common oral diseases found among school children.
A. Dental caries, Malocclusion (condition) and Dental trauma - injury
Q: What are the first signs to look out for?
A. In Periodontal disease, look out for reddish, swollen or bleeding gums. For Caries white or brown patch on gum margin of tooth surface.
Q: Is a painful tooth also an indication?
A. At the initial stage no pain is experienced in both conditions. In advanced stage tooth pain is a symptom of dental caries
Q: Any other symptoms of oral cancer?
A. As mentioned earlier, at the initial stage no pain associated with oral cancers. But oral potentially malignant disorders (OPMDs) can be developed which can be identified at initial stage e.g. burning sensation or reduction in mouth opening
Q: What are the first signs to look out for?
A. It can be a red lesion, white lesion or mixed red and white lesion, condition like burning sensation in the mouth, and reduced mouth opening
Q: Can ill-fitting dentures also lead to oral cancer? If so, how?
A. Ill-fitting dentures cause frequent trauma to oral mucosa with the traumatic surfaces easily absorbing harmful chemicals to the body.
Q: According to new studies infection with certain types of Human papillomavirus (HPV) -can cause some forms of cancer, including cancers of the penis, cervix, vulva, vagina, anus, mouth, and throat, Who are most at risk of this?
A. Oropharyngeal cancers show male predominance and appearance in the 5-6th decade of life.
Q: The global cancer community this year commemorates World Cancer Day, on February 4, with the slogan “Close the care gap”. What are these gaps?
A. One third of cancers can be preventable while 1/3 of cancers can be successfully treated. But this is not happening in the real situation due to multiple reasons, and at different points in the cancer journey from primordial prevention to palliative care.
Q: You mentioned Primordial Care. What does it involve? At what stage of development of the disease is it required?
A. Primordial care is care given before you develop the risk factors . This means that in order to prevent developing the risk factors, it is necessary that we initiate a process of primodial prevention.
Q: So what happens to those who have already developed risk factors?
A. Once you have developed the risk factors the only way to prevent getting the disease is by discontinuing the risk behaviour.
Q: Can you cure the disease? How?
A. To cure the disease it should be diagnosed at an early stage and the patient should quit all the risk behaviour and adhere to medical advice.
Q: How do you deal with an oral cancer patient who has reached an advanced stage of the disease?
A. For those with serious complications of the disease, we offer them rehabilitation care to make their life comfortable, for example help in managing airway and naso-gastric feeding and palliative care for example spiritual help, for patients’ to end his/her life in a more comfortable manner. This spiritual care is given to patients’ caregivers too.
Q: Gaps in the delivery of optimal care for oral cancer patients in Sri Lanka- how would you like to see them filled?
A. One of the main causes is late presentation or not presenting at the early stage of the disease . This reluctance to get examined at an early stage as well as other factors involving risky behaviors like betel quid chewing, smoking and alcohol intake as well betel quid chewing is a socio-culturally accepted behaviour in Sri Lanka. To overcome and close this gap we need to increase awareness through media and health sector programs, increase early identification by opportunistic and high risk screening.
Q: Do you have a message for the public, especially those currently indulging or about to indulge in risky behavioral habits leading to oral cancer.?
A. Your health is your responsibility. Before you indulge in unhealthy habits keep in mind the following advice: A healthy diet, good oral and sexual hygiene, and awareness of the signs and symptoms of the disease are important.