Chapter 26: Cancer and Oral Care of Patients With Cancer
What are the four most common causes of cancer among men?
What are the four most common causes of cancer among women?
How has the death rate from cancer changed over the past ten years?
The death rate from all cancers combined has decreased slightly in the past 10 years.
What is the fundamental characteristic of cancer?
Uncontrolled growth of aberrant neoplastic cells.
How do cancerous cells kill cause damage?
By destructive invasion of tissues.
(...) cells arise from cells that have genetic alterations that cause cells to lose their ability to regulate DNA synthesis and the cell cycle.
Cellular abnormalities of malignancy result in three common features. What are they?
- uncontrolled proliferation
- ability to recruit blood vessels
- ability to spread
How many somatic mutations are needed to transform a normal cell into a malignant cell?
At least three to six.
(...) tissue is characterized by atypical cell proliferation, nuclear enlargement, failure of maturation, and differentiation short of malignancy.
Cytogenetic studies of various leukemias established four cardinal attributes of genetic change in cancer. WHat are they?
- Specific or nonrandom chromosomal changes may characterize individual cancer types.
- Tumor genomes are genetically unstable and subject to continuing change.
- All cells in a given tumor trace back to a single progenitor cell and therefore are clonal.
- Tumor progression often is associated with additional “selected” chromosomal changes.
Chromosomal changes in cancer are of many types. What are the six most common types?
Malignant tumors lack cell cycle control and replicate rapidly. After how many cell doublings are tumors usually clinically detectable?
(...) is a distinct form of cancerous spread that occurs when malignant cells enter blood or lymphatic vessels and travel to distant sites.
At what age should women start annual breast cancer screening with mammograms if they wish to do so?
40 to 44 years
At what age should women get mammograms every year?
45 to 54 years
At what age can women switch to mammograms every 2 years if they wish to do so?
55 years and older
Starting at age 50 years, both men and women should follow one of seven testing plans for colorectal cancer. What are they?
- flexible sigmoidoscopy every 5 years
- colonoscopy every 10 years or
- double-contrast barium enema every 5 years
- CT colonography every 5 years
- yearly fecal occult blood test
- yearly fecal immunochemical test
- stool DNA test (sDNA) every 3 years
*The first four tests can detect both cancer and polyps; the following three mostly just detect cancer.
At what age should women start cervical cancer testing?
At what age should women have a Pap test done every 3 years?
21 and 29 years
At what age should women have a Pap test plus an HPV test (called “co-testing”) done every 5 years?
30 and 65 years
At what age should women stop cervical cancer testing if they have had regular results for the past 10 years?
The ACS does not recommend tests to check for lung cancer in people who are at average risk, but screening might be right if a patient meet three criteria. What are they?
- 55 to 74 years
- in good health
- 30 pack-year smoking history and is still smoking or has quit within the past 15 years
A pack-year is the number of (...) multiplied by the (...).
- cigarette packs smoked each day
- number of years a person has smoked
At what age should men talk to a health care provider about the pros and cons of testing for prostate cancer?
What test should be performed if a man decides to be tested for prostate cancer?
prostate-specific antigen (PSA)
Most cancers are assigned a stage (I, II, III, or IV) by the medical team on the basis of the (...) and (...).
- size of the tumor
- how far it has spread
Generally speaking, how is each stage (I, II, III, or IV) of cancer characterized based on how far it has spread?
- localized and confined to the origin
- regional, affecting nearby structures
- extends beyond the regional site
- widely disseminated
The TNM system is a detailed and specific staging system developed for particular cancers. What does TNM stand for?
What are are the possible scores for TNM scores for stage 0 cancer?
What are are the possible scores for TNM scores for stage I cancer?
What are are the possible scores for TNM scores for stage II cancer?
What are are the possible scores for TNM scores for stage III cancer?
- T1, T2 or T3
*Note that either T3 or N1 makes it stage
What are are the possible scores for TNM scores for stage IVA cancer?
- N0 or N1
- any T
*Note that either T4 or N2 makes it stage IVA.
What are are the possible scores for TNM scores for stage IVB cancer?
- any T
*Note that N3 makes it stage IVB.
What are are the possible scores for TNM scores for stage IVC cancer?
- any T
- any N
*Note that M1 makes it stage IVC.
What changes in the cytoplasm are considered diagnostic criteria for malignancy? (2)
- scant cytoplasm
- increased nucleus to cytoplasm ratio
What changes in the nucleus are considered diagnostic criteria for malignancy? (7)
- variation in size
- irregular membrane
- irregular chromatin
- prominent nucleoli
- mitotic figures
What changes in cellular relationships are considered diagnostic criteria for malignancy? (3)
- variation in cell size and shape
- abnormal stratification
- decreased cohesiveness
Treatment strategies for cancer are based on eliminating fast multiplying cancer cells without killing the host. What are the three basic modalities?
- irradiation (beam or implants)
Radiation therapy kills cells by damaging (...) needed for cancer cell replication.
Chemotherapeutic agents are most effective against rapidly growing tumors by adversely affecting the (...) or (...) of cancerous cells.
- DNA synthesis
- protein synthesis
How does the number of chemotherapeutic agents used effect their efficacy?
Tumoricidal efficacy is gained with use of these various agents in combination.
High-dose multidrug protocols are used in hospital settings to induce myelosuppression for patients with leukemia, lymphoma, and breast cancer. What is a major concern during the myelosuppressive period?
(...) is the most common type of cancer in the United States, with 98% of cases occurring in women.
The incidence of breast cancer increases with age. What are three risk factors for breast cancer?
- early menarche
- late menopause
All breast cancers are the result of somatic genetic abnormalities. What genes are most commonly mutated in breast cancer cells?
BRCA1 and BRCA2
Cancer in one breast decreases the risk for cancer development in the other. True or false?
False: cancer in one breast increases the risk for cancer development in the other.
Most breast cancers are infiltrating (...) carcinomas; a smaller percentage are infiltrating (...) carcinomas.
What are the three most common sites for metastasis of breast cancer?
Lumpectomy is preferred over radical mastectomy what the lumor is less that (...) cm in size.
Hormone therapy (tamoxifen) is recommended when invasive carcinoma exceeds (...) cm in diameter or axillary lymph nodes are positive.
What three chemotherapeutic drugs are commonly used to treat breast cancer?
Since the widespread use of (...), the incidence of cervical cancer has decreased dramatically.
Papanicolaou (Pap) smears
(...), which are epitheliotropic sexually transmitted DNA viruses, are the major etiologic agent of cervical carcinogenesis.
human papillomaviruses (HPV)
HPV dysregulates the cell cycle and tumor suppressor genes (TP53 and pRb) through overexpression of viral early genes (...) and (...).
E6 and E7
Which four strains of HPV are classified as "high-risk" types, associated with the majority of cancer cases?
What are three factors that increase the risk of cervical cancer besides viral infection?
- chronic cigarette smoking
- multiple sexual partners
Cervical cancer typically has a long asymptomatic period before the disease becomes clinically evident. True or false?
True: the earliest preinvasive changes are diagnosed by Pap smear along with HPV testing.
If neoplastic cells penetrate the underlying basement membrane of the uterine cervix, widespread dissemination can occur. What site of metastasis can lead to ureteral obstruction and azotemia?
The 5-year survival rate for cervical cancer is relatively high but drops below 50% when the cancer extends to and beyond the (...).
(...) is the most common malignancy of the gastrointestinal tract and overall the fourth most common cancer of persons living in the United States.
The vast majority of colorectal cancers are what type of carcinoma?
Inherited predisposition and environmental factors contribute to development of colorectal cancers. Which three chromosomes are contributory?
- chromosome 5 (adenomatous polyposis)
- chromosome 17 (TP53 gene)
- chromosome 18 (DCC gene)
An initiating and probably obligatory event is the oncogenic activation of the adhesion protein (...).
What are four risk factors for development of colorectal cancer?
- ulcerative colitis (most important)
- high-fat diet (40% of total calories)
- low dietary fiber intake
- smoking cigarettes (20+ years)
What are two protective factors against development of colorectal cancer?
- NSAID use
- folate supplementation
Colonic adenomas (polyps) have malignant potential; however, fewer than 5% develop into carcinomas. What disease is an important exception to this rule?
Colorectal cancer often is not diagnosed until age 40 years and increases in incidence after age 50 years. What are the major signs and symptoms of colorectal cancer? (3)
- rectal bleeding
- abdominal pain
- change in bowel habits (constipation)
(...) is the preferred approach for evaluating a patient for colorectal cancer.
(...) is the cause of 14% of cancer cases and is the leading cause of cancer deaths in the United States.
Overall, more than 85% of cases are related to (...) with a dose-dependent effect.
In 60% of human lung cancers, the (...) tumor suppressor gene is mutated.
What is the mechanistic link between smoking tobacco and mutations in the TP53 tumor suppressor gene?
Evidence suggests that aromatic hydrocarbons of tobacco smoke form adducts within the TP53 gene.
Histologically, lung cancers are divided into two groups. What are they?
- non–small cell lung cancers (80%)
- small cell lung cancers (20%)
Histologically,non–small cell lung cancers are divided into three types. What are they?
- large cell undifferentiated (10%)
- squamous cell carcinoma (30%)
- adenocarcinoma (40%)
Lung cancer is a clinically silent disease until late in its course. True or false?
True; tumors that grow locally can produce a cough or change the nature of a chronic cough or manifest as dyspnea on exertion.
Stage I and stage II non–small cell lung cancers are treated by (...).
(...) is used for advanced non–small cell lung cancers and when patients with stage I or II disease refuse or are medically unfit for surgery.
(...) is used in combination with radiotherapy for stage III and stage IV non–small cell lung cancers.
What are five chemotheuraputic drugs used in the treatment of lung cancer?
*Usually two or three agents are used.
(...) is the mainstay treatment for small cell lung cancer.
The current 5-year survival rate for all stages of lung cancer is just (...)%.
(...) is the second most common cancer, the most common cancer of men in the United States, and the second leading cause of cancer deaths among men.
The vast majority of prostate cancers are what type of carcinoma?
Cancer of the prostate produces few signs and symptoms until late in the course of the disease. What is the common symptom of prostate cancer?
urinary problems (hesitancy, decreased force, etc.)
Screening procedures are paramount to the successful management of prostate cancer. What are three screening methods?
- digital rectal examination (DRE)
- prostate-specific antigen (PSA)
- endorectal ultrasound imaging
The upper normal level for the PSA is (...) ng/mL.
Transrectal ultrasound-guided needle biopsy of the prostrate is recommended in patients with what four findings?
- PSA > 10 ng/mL without a DRE
- PSA > 4 ng/mL (even if DRE is negative)
- positive DRE (even if PSA < 4 ng/mL)
- PSA that has increased from 1 year to the next by 0.75 ng/mL or more (PSA velocity).
Radionuclide scanning is recommended for men diagnosed with prostate cancer with a PSA greater than (...) ng/mL to determine the extent of the disease.
Of the three primary types of skin cancer, (...) is the most common type followed by (...) and (...).
- basal cell carcinoma
- squamous cell cacinoma
Mutation plus inactivation of the human “patched” gene located in chromosome (...) is probably required for the development of basal cell carcinoma.
Four types of basal cell carcinomas are recognized. What are they?
- sclerosing (morpheaform)
Classically, the (...) basal cell carcinoma is a pearly papule with telangiectasias, a rolled waxy border, and a central ulceration (“rodent ulcer”).
Basal cell carcinomas are readily removed with cryotherapy and surgical excision. Contemporary therapy results in greater than a (...)% cure rate.
(...) is a malignant neoplasm arising from melanocytes.
Melanoma occurs primarily in skin but can occur at any site where (...) are found, including the oral cavity.
(...) exposure is the major etiologic factor of melanoma.
Clinical features of melanoma are characterized by the mnemonic ABCDE. What does this stand for?
- irregular border
- color variegation
- diameter (>6 mm)
Oral cancer includes a variety of malignant neoplasms that occur within the oral cavity. More than 90% of cases are attributed to (...) carcinoma.
squamous cell carcinoma (SCC)
What type of cancer presents as a slightly raised lesion with rolled waxy border and central ulceration on sun-exposed surface?
basal cell carcinoma
What type of cancer presents as a nonhealing white, red-white carcinoma lesion; ulcer; or fungating mass on the lateral tongue, floor of the mouth, or lip?
squamous cell carcinoma
What type of cancer presents as purple plaques or nodules of the palate, gingiva, or face?
What type of cancer presents as brown or black enlarging plaque on skin or palate (satellite lesions)?
What type of cancer presents as dome-shaped swelling with carcinoma central ulceration of palate, retromolar region, or lytic osseous lesion?
What type of cancer presents as gingival enlargement, and bleeding, skin pallor, small hemorrhages of the skin and mucous membranes, and bruising?
What type of cancer presents as enlarged, nonpainful lymph nodes, palatal or pharyngeal swellings, retromolar ulcerations?
What three types of cancers can present as lytic osseous metastases in the mandible?
What are six risk factors for the development of oral SCC?
- exposure to carcinogens (80%)
- UV light exposure (10%)
- immunodeficiency (10%)
- HPV infection (30%)
- Plummer-Vinson syndrome
- vitamin A deficiency
What areca nut chewed in Southeast Asian is associated with oral SCC?
The most common deletion in smoking tobacco–related oral SCCs occurs in p53 of chromosome (...).
Overexpression of (...) and activation of the ras and c-myc oncogenes play contributory roles in oral SCC.
epidermal growth factor receptor (EGFR)
Oral SCC is variable in appearance. White lesions that cannot be scraped off and are clinically nonspecific, called (...), are potential precursor lesions.
Nonspecific red lesions involving the oral mucosa (erythroplakia), although less common than white lesions, are malignant in more than (...)% of cases.
Advanced oral lesions are more often ulcerated with raised margins and induration. What are the four highest risk sites?
- floor of the mouth
- lateral (posterior) tongue
- ventral (anterior) tongue
- soft palate
*These areas are less keratinized and more susceptible to carcinogens.
Oral SCC spreads by local infiltration into surrounding tissues or metastasis to regional lymph nodes through lymphatic channels. What are the four first-station drainage nodes?
Oral SCC spreads by local infiltration into surrounding tissues or metastasis to regional lymph nodes through lymphatic channels. What are the four second-stage nodes?
- upper posterior cervical
- lower posterior cervical
Distant metastasis of oral SCC is rare, but can occur. What three sites are most commonly affected?
How does the location of an oral lesion affect the probability that it will metastasize?
Lesions in posterior sites tend to metastasize earlier than carcinomas located in anterior oral sites.
How does the arch in which an oral lesion is located affect the probability that it will metastasize?
Lesions in the maxillary region have a greater tendency to metastasize than do those in the mandibular region.
Oral cancer can lead to death in six ways. What are they?
- local obstruction
- infiltration into major vessels
- secondary infections
- impaired function of other organs
- general wasting
- complications of therapy
Most early oral SCCs are amenable to surgery, but stage III or IV cancers are usually treated with combination therapy. What are the three methods of irradiation used in the treatment of oral SC?
The tumoricidal dose of external-beam radiation ranges from (...) to (...) centigrays (cGy), given in separate doses of (...) to (...) cGy over (...) to (...) weeks.
- 5000 to 7000 cGy
- 150 to 200 cGy
- 6 to 7 weeks
(...) is a method of external-beam radiation that uses slightly lower daily doses and is delivered twice a day.
The overall 5-year survival rate for oral and pharyngeal SCC has been virtually unchanged since 1980 at (...)%.
Lesions clinically suspicious for cancer and those that fail to heal within (...) days despite alleviating measures should be biopsied
Dental treatment planning for a patient with cancer begins with the establishment of the diagnosis. What are the three stages of treatment planning for cancer?
- pretreatment evaluation and preparation
- oral health care during cancer therapy
- posttreatment management of the patient
The risk for a second oral cancer in smokers whose habits remained unchanged is about (...)%, compared with (...)% for those who quit.
A pretreatment oral evaluation is recommended for all cancer patients before the initiation of cancer therapy. What are four goals of the pretreatment evaluation?
- rule out oral disease
- provide a baseline
- detect metastatic lesions
- minimize oral discomfort
What are five indications for tooth extraction prior to head and neck irradiation or chemotherapy?
- pocket depths ≥6 mm
- periapical inflammation
- nonrestorable, nonfunctional tooth
- lack of interest in saving tooth/teeth
- inflammatory osseous disease
All tooth extractions should be performed at least (...) week(s) before initiation of radiation therapy, and at least (...) days before initiation of chemotherapy of the maxilla, and or (...) days in the mandible.
- 2 weeks (ideally 3 weeks)
- 5 days
- 7 days
Symptomatic nonvital teeth should be endodontically treated at least (...) week(s) before initiation of head and neck radiation or chemotherapy.
If a patient is going to undergo radiation in a couple weeks and needs the following:
- tooth extraction
- restorative care
- periodontal care
- endodontic care
Which should be prioritized?
Treatment of infections, extractions, periodontal care, and irritations should be prioritized before treatment of carious teeth, root canal therapy, and restorations.
Tooth scaling and prophylaxis should be provided before initiation of cancer therapy to reduce the risk of oral complications such as (...) and (...).
Radiation therapy induces cell necrosis, microvascular damage, and parenchymal and stromal damage by the production of (...) from oxygen.
Production of oxygen free radicals from ionizing radiation is one of the leading causes of cell damage. What type of cells are most susceptible to radiation?
Cells that undergo rapid turnover.
(...), inflammation of the oral mucosa, results from the direct cytotoxic effects of radiation or antineoplastic agents on rapidly dividing oral epithelium.
Mucositis develops most often between days (...) and (...) after chemotherapy, when the effects of the drugs produce an extremely low WBC count (nadir).
days 7 to 14
Mucositis generally subsides (...) to (...) weeks after the completion of treatment.
1 to 2 weeks
If the major salivary glands have been irradiated, (...) comes after the initial onset of mucositis.
What are nine methods of managing mucositis at home?
- bland mouth rinse (salt and soda water)
- topical anesthetics and/or antihistamines
- antimicrobial rinses such as chlorhexidine
- antiinflammatory agents
- adequate hydration
- diet of soft, nonriitating foods
- oral lubricants and lip balms
- humidified air
- avoidance of alcohol and tobacco
During radiation therapy and chemotherapy, patients are prone to secondary infections. What organism is most frequently implicated in opportunistic infections of the oral cavity?
Candidiasis manifests clinically in four different forms. What are they?
- angular cheilosis
During cancer therapy, the most common form of candidiasis is (...), which produces white plaques that when scraped off leave behind tiny hemorrhages.
A slightly less prevalent form of candidiasis is the (...), atrophic form, which manifests as a red patch accompanied by a burning sensation
The least common form of candidiasis is (...), which manifests as a thick, white plaque that cannot be scraped off, commonly in patients with hyposalivation.
Candidiasis is best managed with topical oral antifungal agents. What are the two most commonly used?
- nystatin (suspension, four to five times daily)
- clotrimazole (lozenges, 10 mg five times a day)
Systemic therapy is warranted if patients develop severe oral fungal infections or fungal septicemia. What three drugs are most commonly used?
- ketoconazole (Nizoral)
- fluconazole (Diflucan)
- itraconazole (Sporanox)
Oral bacterial infections typically appear with signs of swelling, erythema, and fever. Why might these features can be masked in patients undergoing chemotherapy?
Due to reduced inflammation caused by low WBC counts.
In immunosuppressed patients, a shift occurs in the oral flora to gram-(...) organisms.
Recurrent (...) infections often develop during chemotherapy if antivirals are not prophylactically prescribed.
herpes simplex virus (HSV)
A daily dose of at least (...) g acyclovir equivalent is needed to suppress HSV recurrences.
Cancer patients who undergo total body irradiation or high-dose chemotherapy are susceptible to (...), leading to gingival bleeding and submucosal hemorrhage.
Gingival bleeding and submucosal hemorrhage can occur as a result of minor trauma when the platelet count drops below (...) per mm3.
Many patients receiving radiation therapy experience (...) as a result of damage to the microvilli of taste cells.
Many patients receiving radiation therapy experience a diminished sense of taste. How long does it take for recovery of gustatory function to occur?
In most patients, the ability to taste returns in 3 to 4 months after completion of radiotherapy.
Neurotoxicity is a side effect of chemotherapeutic agents, particularly vincristine and vinblastine, which can produce odontogenic pain that mimics irreversible pulpitis. Where does this most commonly occur?
The pain is more frequently described in the molar region and can be bilateral.
In general, routine dental procedures can be performed if the granulocyte count is greater than (...) per mm3, the platelet count is greater than (...) per µm, and the patient feels capable of withstanding dental care.
If cancer therapy is completed, the cancer patient should be placed on an oral recall program. Usually, the patient is seen once every (...) months during the first (...) years and at least every (...) months thereafter.
- 1 to 3 months
- 2 years
- 3 to 6 months
If cancer therapy is completed, the cancer patient should be placed on an oral recall program. What are four reasons for why this is necessary?
- patients with cancer tend to develop additional lesions
- latent metastases may develop
- initial lesions may recur
- complications related to therapy can be detected and managed
Salivary gland tissue is moderately sensitive to radiation damage. Usually, a (...)% reduction in salivary flow occurs in the first week after radiation therapy.
50 to 60%
Usually, a 50% to 60% reduction in salivary flow occurs in the first week after radiation therapy. How long does it take for recovery of salivary gland function to occur?
In most cases, salivary gland function never recovers.
The manifestations of salivary hypofunction in patients having undergone radiation therapy for head and neck cancer include a severe form of caries called (...).
Several artificial salivas are available, some of which provide a modicum of symptomatic relief from oral dryness. What two cellulose derivatives are these compounded from?
Patients should avoid wearing their dentures during the first (...) months after completion of the radiotherapy because even mild trauma to the altered mucosa can result in ulcerations and possible osteonecrosis.
Implants can be placed (...) months after radiation therapy, but the procedure requires knowledge of tissue irradiation fields, degree of healing, and vascularity of the region.
12 to 18 months
(...) is a condition characterized by exposed bone that fails to heal after high-dose radiation to the jaws.
Risk for development of osteoradionecrosis is greatest in (...) sites and in patients who have received radiation doses in excess of (...) cGy to the jaw.
- posterior mandibular
- 6500 cGy
The risk for osteoradionecrosis is dose-dependent. True or false?
True: risk of osteoradionecrosis increases with increasing dose to the jaw.
Protocols to reduce the risk of osteoradionecrosis includes (...), which involves sequential daily “dives” under 2 atmospheres of oxygen pressure in a chamber.
hyperbaric oxygen therapy
Which are is more commonly affected by osteoradionecrosis?
Why is the mandible more commonly affected by osteoradionecrosis than the maxilla?
Because the limited collateral circulation results in a greater reduction in blood flow after radiotherapy.
Patients who have received neck irradiation are more likely to develop (...), which can be detected by panoramic radiography and are a risk factor for stroke.
carotid artery atheromas