Carcinoma Skin Cancer Symptoms

[man is seated in dental chair with paperdrape over his torso up to his neck.] [nurse:] how was your trip? [mr.jensen:] oh, wonderful. [nurse:] did your wife enjoy it? [mr. jensen:] very much. [nurse:] oh, that's good. excuse me, now mr. jensen, and dr. kwapis will be right in. [mr. jensen:] thank you. [dentist:] well, mr. jensen, how are you today? [mr. jensen:] fine, doctor, how are you?

[dentist:] i'll get this up just a littlebit. that's better. that's good. now, let's check your, this again, mr. jensen. [narrator:] the mouth is the most easily examined of all body openings, yet there is a tendency for dentists to focus on the teeth and gingiva and for physicians to look through the mouth to observe the throat. systematic examination of the oral cavity is too often neglected. twice each year, with every regular patient, the dentist has an opportunity to search for early cancer. [dentist examines mr. jensen's mouth.]

[dentist:] now close together. now open wide, please. hmm, the biopsy site seems to have healed nicely. [dentist pulls back patient's lower lip to examine the area.] [mr. jensen:] that sounds encouraging. dr.toleman suggested that white spot be removed. [dentist:] dr. toleman is a first-rate specialist and i'd certainly follow his advice. what did he say about the pipe smoking? [mr. jensen:] he suggests i discontinue. [dentist:] well, this would aggravate yourproblem. [mr. jensen:] yeah, i know but it would behard to do.

[dentist inserts patient's lower denture.] [dentist:] now, close together. [narrator:] many dentists perform a checkupfor oral cancer routinely on all patients. although relatively uncommon, representingonly one cancer in 30, oral cancer so often is a killer that persistent search is required. except for the lip, the five-year survival rate is less than 40 percent, [people are in a waiting room, and a graphis displayed atop that image.] but when treatment takes place before the cancer has spread, survival is several times as high as when lymph nodes are involved.

absence of spreaddepends on very early detection. in one study of tongue cancer, 40 percent had metastasized within three months after the first symptoms were noticed. [another graph is displayed over patientsin waiting area.] after 12 months, 90 percent had metastasized. [dr. nathaniel h. rowe, dds:] oral canceris largely a disease of men, who outnumber the women affected by about three to one. this may be due to men's greaterexposure to various etiologic factors such as sunlight, tobacco, alcohol.

[an older man with a cancer of the mouth isshown.] all of these factors manifest their cancerous effect increasingly with advancing age. squamous cell carcinomas, sometimes called epidermoid carcinomas, account for about eight out of ten oral cancers. together with cancers reported merely as carcinoma, they make up more than 90 percent of the total. non-ulcerated soft tissue cancers usually arise from major or minor salivary glands. these comprise about seven percent of all oral cancers. sarcomas and lymphomas, while rare, are particularly noteworthy because they occur in younger patients. [a young blond boy is shown, then a close-up of a tongue with white patches.]

squamous cell carcinoma does not appear to originate in a single cell, but in an area of epithelium which undergoes cancerous change at many points. these foci then coalesce to produce a single tumor. local growth is followed by invasion of underlying tissue, which often spreadsmuch farther than the clinical evidence would suggest. in the wake of invasion comes metastasis,initially to the lymph nodes of the neck. in one study, some 40 percent of oral cancers already involved lymph nodes by the time they were diagnosed. [the neck and chin of a patient are shown,with a hand palpating the neck area.]

neglect and further growth means eventual death by strangulation, starvation, or hemorrhage. [dr. rowe:] cancer in different oral sitespresents different problems. the lower lip is by far the most frequent site. however, lip cancer develops where it is likely to be seen early. and the five-year survival rate is high; at least 70 percent. in contrast, cancers of the tongue and of the floor of the mouth are seldom detected in an early stage. [a diseased tongue is manipulated.] and they cause more deaths than any other oral cancers.

at present, the five-year survival rate forintra-oral cancer is only about 30 percent. this carcinoma with its abrupt border, induration, ulceration, and a history of duration and growth would hardly be missed by any practitioner,but this is not early cancer. improved survival will come onlywhen cancer is detected before these classical signs appear, before it looks like cancer. [a woman is seated in a dental chair, andthe dental hygienist approaches her.] [nurse:] i'll take the kleenex, mrs. nagle. [dentist:] before i examine your teeth, mrs.nagle, i'd like to ask you some questions. have you ever had bleeding gums?

[mrs. nagle:] no. [dentist:] have you ever had any sores, ulcers,or swellings that haven't healed promptly? [narrator:] taking a history of oral conditionsis the first step in a routine examination. equipment for examination: a mouth mirror,gauze sponge, good illumination, and a high degree of concern about cancer. a systematic examination sequence is essential. the dentist looks for any asymmetry or swelling and for changes in skin color or texture. [the dentist turns mrs. nagle's head and begins to examine her.] by watching for neck masses, salivary gland tumors, thyroid enlargement, and skin cancer,he may reap a bonus in case-finding.

he searches the lips for an area of induration, elevation, or other surface irregularity. [the patient's lip is pulled and manipulated.] removing dentures will reveal lesions, which may otherwise be obscured. drying the mucosa aids visualizing variations in color and texture. he palpates the buccal mucosa to note any lump, fixation, or induration. the gingiva... [the dentist examines and palpates the gums.] the palate... [the dentist checks the roof of the patient's mouth.]

the tongue. grasping the tongue with a sponge aids him in examining the obscure posterior lateral borders of the tongue and tonsillar pillars where the likelihood of finding an early cancer is greatest. using a mouth mirror as tongue depressor makes obscure areas more visible. [dentist:] say ah, please. [mrs. nagle:] ahhh. [narrator:] this drops the tongue and raises the soft palate and uvula, revealing the tonsils, fosses, and post-pharyngeal wall. checking for swelling or lumps, he palpates the salivary glands.

palpation practiced routinely extends the dentist's perceptive senses; gives him educated fingertips. he palpates the neck too, and the cervical lymph nodes which drain the oral region. sometimes an enlarged lymphnode may be the first sign detected, before the primary lesion has become apparent. when infection is not the obvious cause, enlarged lymph nodes suggest cancer until proven otherwise. [dentist:] now let me examine your teeth. [narrator:] people tend to be unaware of early oral cancer because it is usually painless and presents no handicap. the dentist's greatest opportunity for salvage lies with his regular patients

in finding the early lesions thatone might not suspect of being cancer. [a patient's tongue is explored with a narrow tongue depressor.] this velvety red area on the tongue is cancer. any change in color or texture like this should arouse suspicion. this whitish area on the palate lies adjacent to a carcinoma, but this equally suspicious milk-white raised lesion is not cancer. biopsy is essential to differentiate benign from malignant. any lesion which persists shouldbe biopsied. this one proved benign. early carcinoma of the lip may resemble common lesions such as cigarette burn, senile elastosis,

or chronic cracking and fissuring. the history of duration may help to determine how it should be regarded. this one is cancer. here one cannot observe the highlights, which are visible on nearby tissues. any roughened or atrophic mucosa with altered translucency may be cancer. [examples of mouth conditions both benignand malignant are shown.] this tiny ulcer could easily be mistaken for denture injury. it proved to be a small squamous cell carcinoma. this lesion with its papillary, warty surfaceis verrucous carcinoma.

this lesion also is non-ulcerated. being small in size and located posterior to the denture-bearing area, it might easily have been overlooked. diffuse in its distribution, this cancer mimicked infectious disease. [the mouth is probed to demonstrate the areas and lesions described.] whether ulcerated or not, any undiagnosed lesion of more than ten days duration should be biopsied. watchful waiting while treating only the symptoms may prove fatal to the patient. in short, anything unusual may be cancer.

any increase in size, any color difference, any persistent ache or pain, any erosion. any change. the future of the person who does have cancer lies largely in the hands of the first practitioner who has the opportunity to initiate action. because time is so critical, often meaning the difference between life and death, the dentist should refer the patientto a specialist who is skilled in the management of cancer to assure the best possible treatment. [dentist:] mrs. huff, would you get dr. walkeron the phone, please?

[nurse:] yes, doctor. [dentist:] mrs. harn, you have a small spoton your palate that needs special examination. it may require a small sample to be removedfor microscopic study. i'd like to have you see a dr. walker tomorrow. could you arrange that, please? [mrs. harn:] i guess so, but does it haveto be so soon? [dentist:] well, usually such conditions areminor, but there is a possibility that it could need quick attention and we really needto find out. [nurse:] i have dr. walker on the phone, sir.

[dentist:] thank you, mrs. huff. thank you.hello? dr. walker? this is dr. osterkamp speaking. i have a patient here with a lesion of thepalate i'd like you to check. her name is mrs. willis harn. could you possibly see her tomorrow? at 2:30? [male student:] why doesn't he just take abiopsy specimen himself? he's qualified. [dr. howe stands at a lectern in a classroom.] [dr. howe:] yes, he is, but what about that? when might a dentist take the biopsy himself and when might he refer it? [mr. richter:] well, if he feels that it isa cancer, he should send his patient right to the specialist who will treat him. thenthe lesion won't get any unnecessary handling.

[dr.howe:] fine. any other ideas? [male student:] well, whenever the natureof the lesion is uncertain, it should be biopsied. patients often tend to procrastinate, so thebiopsy is best done by the dentist while the patient is still seated. [dr.howe:] good. what does this leave forexplorative cytology? mr. richter? [mr. richter:] i'd say even more than before, because if suspicion is upgraded, so are all the tests. explorative cytology should bedone when clinical judgment wouldn't indicate biopsy. [male student:] but the surface scraping test can leave a deep-seated cancer undetected, especially if it is covered with leukoplakia.

[dr. howe:] true, and cytology appears limited to finding only one type of cancer, epidermoid carcinoma. keep in mind that neither a negativecytology, nor even a negative biopsy, rules out cancer. it simply means that cancer cells were not seen in the specimen submitted. if the condition does not behave as you believe it should, it should be checked again. [dr. osterkamp sits at his desk, making a phone call.] [dr. osterkamp:] hello, dr. walker? did mrs. harn see you for the biopsy? [dr. walker]: yes, she did. i just got thereport. it shows verrucous carcinoma. fortunately, this is very amenable to surgery. we'll plan her operation in the morning. [mrs. harn wears a blue dress and is seatedon an examining table in a medical office.]

[narrator:] when biopsy confirms the presence of cancer, how is treatment determined? what are the principles that govern therapy? [john s. pratt, jr., m.d., ellis fischel statecancer hospital:] the treatment for a cancer is determined by its location, its extent,its pathological characteristics, and by knowledge of its natural history or behavior. has experience shown that a particular cancer is best treated by radiotherapy, or surgery, or by a combination of methods? if surgery is selected, the extent will be governed by the need to remove involved tissues with an adequate margin. if the surgeon doesn't remove it, the cancer will.

fortunately, early oral cancer seldom spreads beyond the lymph nodes of the neck. even when the cervical lymph nodes are involved, cure is often possible. when radiotherapy is selected, it must beequally radical and expert to eliminate cancer without excessively damaging normal tissues or the functions of organs or the patient's appearance. for some conditions, the coordinateduse of surgery and radiotherapy may be the most beneficial. this requires teamwork by the pathologist, the surgeon, and the radiologist. the prosthodontist should participate whenthe treatment will result in an intra-oral defect. when there is no indication of spread,the treatment can be less radical. when more head and neck cancers are detected early, primary lesions can be controlled with

fewer disabling operations and with a favorable prognosis for more patients. [woman lies in hospital bed after surgery.] after a cancer is treated, frequent follow-up examinations are imperative. even a small lesion may metastasize, but this spread may not be detectable for some time. [dr. howe:] moreover, the person who has hadoral cancer may develop additional primary tumors or local recurrence or metastases. [narrator:] the patient must be taught toparticipate in his follow-up by reporting anything unusual without delay and by keepinghis appointments for periodic re-examination.

[dr. howe:] mrs. harn's dentist was able toarrange early treatment because mrs. harn belongs to the 40 percent of our populationthat gets regular dental care. improved public education is one means by which we may reach the other 60 percent. true, the person who realizes there is something wrong with his mouth will very often go to a dentist, but he may take a dangerous amount of time getting around to it. in one study, the average patient with oral cancer put off seeing anyone until eight months after he noticed a lesion. when the typical patient has it checked, it is no longer early. however, the dentist can still play a role in salvage by seeing that his patient receives immediate and proper referral. he can also prepare study modelsbefore cancer treatment, so that when a prosthesis is made,

it will closely restore the patient'snormal appearance. what procedures are now in store for the cancer patient whose disease has spread beyond the primary site? many of these cases call for immediate radical surgery and neck dissection. [surgery is shown.] if the surgeon doesn't remove it, the cancer will. end results of such procedures are very gratifying, but the patient whose life is preserved may wonder for a while if it's worth it. functional impairmentand disfiguration lead to depression and hopelessness. the prosthodontist who is called in beforehandcan often provide an appliance within a week

after surgery. this will lessen the contractionof soft tissue and what it does for the patient's ability to feed himself, to swallow and tospeak, will once again give him hope. [man in dental chair attempts to speak, butwords are not clear.] [narrator:] treatment today is providing oral cancer patients with much more than just greater life expectancy. [doctor:] what this prosthesis meansto you? [man:] it means my very life, doctor. withoutthese, i might as well be dead. i can't live without them. i can't eat, drink, i can't talk. it is my life; that's what it is. [a man looks in the mirror and inserts a prosthesis,]

[narrator:] dentists can save thousands ofpatients every year, and thereby ensure for them a meaningful extension of life. [people seated around a table with drinksand food talk to one another.]