Developing a guideline for treatment of late-stage oral cavity cancer

Dr Moni Abraham Kuriakose - Mazumdar Shaw Cancer Center, Bangalore, India

We presented in a panel looking at advanced oral cavity cancer. My specific task was to cover operability or define operability in oral cavity cancer. So that’s a very important issue in oral cavity because the moment you say a patient is inoperable that means almost equated to that incurability. So that criteria is very important. I was trying to highlight which patients should be considered incurable and inoperable. I was looking at some of the issues we are facing currently in oral cavity cancer. I highlighted that it’s important that we should have a different sub-site based staging system. So every T4b tumour, so-called considered to be very advanced and inoperable, should not be the same in different sub-sites. For example, a tongue cancer is totally different from a cheek cancer. We have shown some data to show that in a cheek cancer going to the ... we can get fairly good local regional control by surgery. So that was a theme I was trying to explain.

Are there guidelines for when you should treat people?

There are guidelines but guidelines mostly exist in the early stage tumour. For advanced T4b tumours we don’t have a guideline and it’s important that we develop guidelines. So in this panel there were different discussions about giving alternative therapy like induction chemotherapy and so on. But there are data to show that that modality doesn’t work. It doesn’t work, it doesn’t mean that it is the right answer they have given. What that shows is that in most studies they lump different tumour stages together and gave chemotherapy and we got diverse results. So we need a definitive study looking at the sub-site with the particular stage and then ask the question what are the guidelines to develop. That needs to be developed.

Are there plans for such a study?

That is one of the proposals we had at the end of the meeting and that needs a collective effort, collective not just from one investigator or from one country, in a multi-centre, multinational type of trial.

Is this specifically for people presenting late?

Late stage, that’s right, yes.

What countries could be involved?

If you look at anywhere in the world almost 70% of oral cavity cancers present with advanced stages. Now, that is more pronounced in the developing countries, that is where the high prevalence of oral cavity like Brazil, India, Southeast Asia and so on. So those countries should take the lead in running those studies. At the same time to make that research meaningful to the entire world other countries also need to participate.

What’s causing these cancers?

The majority of the cancers are caused by risk factors fairly well defined. That varies from different country to country. In Brazil or India and Southeast Asia mostly by chewing tobacco; in India and Southeast Asia not only tobacco, areca nut also plays a role. So that is a primary factor for developing oral cavity cancer. In addition to that we have smoking and alcohol. Alcohol plays a less important role but smoking and chewing tobacco and areca nut are the primary factors.

What’s the take-home message?

The main thing is that not all the patients currently staged as inoperable should not be triaged towards inoperable tumour. It’s important to look at sub-site and see which tumours need to be considered triaged towards resection rather than triaging towards palliation.