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 fibreoptic exam 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
  • Maybe a PET-CT for advanced cancers
  • A dental evaluation, with or without jaw X-rays, when necessary
  • Examination under anaesthesia with endoscopy if necessary
  • Nutrition, swallowing and speech therapy when necessary
  • Pre-treatment medical clearance and evaluation of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on several 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 re-resect and get to negative margins (rim of normal tissue around the tumour).

The treatment recommendations for oral cancers do not really vary by subsite, 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 oral cancer, depending on your T and N stages.

 

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

Surgical removal of the cancer, with or without neck dissection, depending on location of the tumour and how thick the tumour is (preferred treatment)

Surgical removal of the cancer with or without a sentinel lymph node biopsy. 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 surgery.

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

T3, N0 or

T1-3, N1-3 or

T4a, Any N

The initial treatment is surgical removal of the cancer with neck dissection(s). Then, either no additional treatment, radiation or chemotherapy and radiation will be recommended, depending on findings in the surgery. Certain factors that might guide what additional treatment is required will be features such as:

Positive margins (the presence of cancer cells at the edge of the resection that was performed)

Spread of cancer beyond the lymph nodes in the neck

T3 or T4 tumours based on pathologic evaluation

N2 or N3 disease in the neck lymph nodes

Cancerous lymph nodes in the lower part of the neck (Level IV), or toward the back portion of the side of the neck, behind the big neck muscle called the sternocleidomastoid (Level V)

Invasion into or around nerves

Tumour inside blood vessels

 

T4b, any N or

Unresectable neck disease or

Unfit for surgery

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