Oral and Oropharyngeal Cancer Prevention, Screening, Treatment, and Survivorship Recommendations
By Kathleen Sacharian, MSN, CRNP, and Patricia Friend, PhD, APRN-CNS, AOCNS®, AGN-BC
Approximately 53,000 cases of oral and oropharyngeal cancer are diagnosed (https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/key-statistics.html) in the United States each year. Men are twice as likely to develop the disease, and it typically affects people older than 55.
Prevention and Screening
Dental or healthcare providers should complete regular oral cancer examinations to improve early detection, especially in high-risk individuals (e.g., history of oral cavity precancerous lesions, smoking, heavy alcohol use). Human papillomavirus (HPV) infection, specifically the high-risk HPV 16 strain, is a known cause of squamous cell cancers of the oropharynx, associated (https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf) with as many as 70% of all new diagnoses and often seen in younger patients.
Symptoms include a painless lump or swelling in the mouth or neck, sore throat, dysphagia, or painful swallowing. The cancers are more likely to occur in the tongue, tonsils, oropharynx, and floor of the mouth. Staging depends on the extent of disease, as well as the p16 biomarker (https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/key-statistics.html).
HPV 16–positive tumors overexpress p16, a surrogate biomarker for HPV positivity with clear prognostic value. All newly diagnosed oropharyngeal squamous cell carcinomas should be tested for p16 expression via immunohistochemistry (https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf). HPV-related biomarkers may also be used to monitor patients because detection of HPV after treatment completion may indicate (https://doi.org/10.1016/j.oraloncology.2018.05.015) persistent disease or early local recurrence.
Both single and combination treatment modalities are used, depending on stage and location of the disease. In oral cancers, initial therapy is typically surgery, followed by radiation or combination radiation and systemic therapy. Oropharyngeal cancers are usually treated in combination. Metastatic disease is typically treated with chemotherapy or targeted therapy, and immunotherapy may be considered. Radiation is sometimes used palliatively. Clinical trials (https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/key-statistics.html) should be considered.
Side Effects and Management
Acute side effects can cause significant morbidity and impairments, including mucositis, xerostomia, anorexia, and malnutrition. Management is supportive care with pain control, dental care, and speech and swallowing evaluation. Preventing malnutrition is important, and patients may need to be supported temporarily using enteral nutrition with tube feedings. Good oral hygiene (https://www.ons.org/pep/mucositis) will help to reduce side effects and improve symptoms. Because the toxicities are dose limiting, patients may need treatment reductions or delays, which can influence response.
Acute, late, and long-term side effects can interfere with quality of life and basic physiologic needs. Trismus, xerostomia, oral or dental complications, and dysphagia or stricture can last for months or years following treatment. Trismus, or scarring and reduced contraction of the jaw muscles that make it difficult to open the mouth, is typically seen at least six months post-radiation.
Ongoing assessment is important for survivors at each follow-up visit. Survivors need frequent dentist evaluation to manage cancer- and treatment-induced dental sequela (https://doi.org/10.1188/17.CJON.629-632). Dental care may be financially difficult for patients who are un- or underinsured, so nurses have a critical responsibility to consider and advocate for access to dental care throughout treatment and long-term follow-up (https://doi.org/10.1188/18.CJON.523-528). Education should include healthy lifestyle recommendations, such as avoiding alcohol and tobacco.
For more information, view the ACS Head and Neck Cancer Survivorship Care Guidelines (http://doi.org/10.3322/caac.21343).