Deciding on a Treatment Plan

Before starting treatment, your doctor will make sure that the following steps are completed.

Pre-treatment evaluation

  • A full history and physical examination, including a complete head and neck exam (mirror and/or fibreoptic examination if needed)
  • An evaluation by the members of a head and neck cancer team
  • A biopsy to confirm a diagnosis of cancer
  • Imaging of the lungs to check for spread, if needed
  • Imaging of the primary tumour and the neck with CT and/or MRI
  • A dental evaluation, with or without jaw X-rays, when necessary
  • Pre-treatment medical clearance and optimisation of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on a number of factors.

Depending on whether the cancer has spread or not, there are three general therapeutic options to consider:

  • Surgical removal (with or without reconstruction)
  • Radiation (a few different types)
  • Medications (chemotherapy and biologic medications)

Surgery is the recommended treatment when possible in almost all cases of oral cancer. Also, if a positive margin (rim of tissue around the tumour that should be normal tissue but has cancer cells in it) is found after removal of the cancer, all efforts should be made to resect and get to negative margins (rim of normal tissue around the tumour).

Except for the lip, the treatment recommendations for oral cancers do not really vary by sub-site, though there are certain subtle differences for lip cancer. The surgery your doctor recommends does vary depending on the location of the cancer as well as the stage. You should have an extensive discussion with your care team about different surgeries that might be required for your cancer.

Also, the reconstruction that your doctor recommends will change depending on what is removed.

Below are the recommended treatment options for lip cancer, depending on your T and N stages.

T1-2, N0 For cancers in this category, the treatment options are:

Surgical removal of the cancer (preferred treatment)

Surgical removal of the cancer with or without a sentinel lymph node biopsy may also be performed. A neck dissection may also be performed depending on the results of the biopsy.

The treatments above should then be followed by either no additional treatment, radiation alone, surgery again, or chemotherapy with radiation, depending on what is found in initial surgery.

Radiation alone as primary treatment is also an option. This may be followed by either no additional treatment or surgery/reconstructions, depending if there is left over disease from the initial radiation.

T3, T4a, N0 or

Any T, N1-3

The preferred initial treatment is surgical removal of the cancer of the lip, along with possible same-sided or both-sided neck dissection, depending on several factors including the clinical N stage and/or certain features of the tumour itself. For cancers of the upper lip or commissure, your doctor might discuss the need to remove lymph nodes around the parotid gland.

If a neck dissection is done, and there are no cancerous lymph nodes, then you need close follow-up.

If a neck dissection is done, and there is one cancerous lymph node (without any adverse features), then radiation can be considered.

If there are multiple positive nodes, or invasion into/around nerves, vessels or lymphatics, then chemotherapy with radiation (preferred), additional surgery, or radiation alone are reasonable options after performing a neck dissection.

However, if there is any evidence of spread of cancer outside of the lymph node, or if on the lip there is a positive margin that cannot be removed, then radiation alone or chemotherapy with radiation is recommended.

Other options for the initial treatment of lip cancer in this category is to either give definitive radiation or chemotherapy with radiation. Then surgical removal of the cancer or a neck dissection should be performed only if there is evidence of residual cancer in the neck or the lip. In some instances, when the expertise is available, implanting radiation may be considered in addition to external beam radiation.

T4b, any N or

Unresectable neck disease

In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.