Oral Cancer: Confronting the Enemy

The Human Toll

Rick Bender is sometimes called "the man without a face," a description he feels suitably describes his appearance. After 14 years of using spit (or smokeless) tobacco, he was diagnosed with oral cancer and underwent surgery that resulted in the loss of part of his tongue, half his jaw, and partial use of his right arm. Rick Bender is evidence of the damage oral cancer can do to a face, a person, a life.

Oral or pharyngeal cancer will be diagnosed in an estimated 34,000 Americans this year, and will cause more than 8,000 deaths. The disease kills one person every hour -  more people than cervical cancer, Hodgkin's disease, or malignant melanoma. When the definition of oral cancer is expanded to include laryngeal cancer, which shares risk factors with oral cancer, the number of cases in the United States, per year, climbs to 41,000 and the number of deaths to 12,500. Oral cancer is the sixth most common cancer worldwide and the third most common in developing nations.

Some might say the old adage, "the cure is worse than the disease," applies to existing treatments for oral and pharyngeal cancers. Victims of oral cancer not only deal with the debilitating side-effects of radiation and chemotherapy but with the very visible evidence of surgery. Surgery to treat oral cancer is often extensive and disfiguring and may involve removing parts of the face, tongue, cheek, or lip, causing changes in appearance that can be especially difficult to live with in a society that values physical beauty. Chemotherapy and radiation to the head and neck cause their own problems: jaw pain, mouth sores, and salivary glands that cease to function, resulting in difficulty chewing, swallowing, and talking. Recovering the ability to speak clearly and adjusting to new oral prostheses are additional challenges.

As with any cancer, the threat of death is an overriding fear. Most disturbing about oral and pharyngeal cancer is the survival rate. In the United States it is approximately 50 percent, a statistic that has not changed appreciably over the past 20 years. Oral cancer is unusual in that it carries a high risk of second primary tumors. Patients who survive a first cancer of the oral cavity have up to a 20-fold increased risk of developing a second primary oral cancer. The heightened risk can last 5-10 years, sometimes longer. Until researchers learn more about this phenomenon, second primary tumors will remain a specter faced by all oral cancer patients.

Additionally, oral cancer, like many diseases, continues to take a disproportionate toll on minorities. Incidence peaks in African Americans 10 years earlier than in the general population, in whom the disease is usually diagnosed between ages 65-74. The difference in survival rates between whites and African Americans is staggering 55 percent of whites survive five or more years, while only 34 percent of African Americans live that long. African American males suffer the highest incidence and lowest survival rates of any group. Oral cancer is the fourth most common cancer among African American men in the United States.

What We Know...About How Cancer Develops

We've known for a long time that cancer cells, unlike normal cells, multiply uncontrollably, ignoring the usual signals to stop. We also know that cancer cells can metastasize — migrate from their original site and set up shop in another part of the body, where they continue to multiply unchecked.

But over the past two decades cancer research has uncovered much more. We now know that all neoplastic transformations (cancers) result from mutations, or changes, in genes that control cell growth and behavior. These genes normally restrict cell proliferation and direct the cell to repair DNA damage, or failing that, to self-destruct, a process called apoptosis, or cell 'suicide.' The mutated genes free the cell from these controls, allowing it to divide continuously and to pass on the mutation(s) to its progeny.

What causes these mutations? Many factors come together to cause each type of cancer. Genetic mistakes can be inherited or they can be acquired as a result of exposure to chemicals, radiation, or viruses. Random mistakes also occur each day in the course of duplicating the three billion units in our DNA during cell division. No one mutation is enough to make a cell cancerous. Multiple genetic changes, in specific classes of genes, are needed to transform a normal cell into a neoplastic cell that grows out of control. A small percentage of people inherit a susceptibility for certain types of cancer, putting all their body's cells one step closer to the disease.

What We Know...About Oral Cancer

Scientists now understand that oral cancers, which are included in the category of head and neck cancers, result from a multistep process of accumulated genetic mutations caused by many factors. Tobacco and alcohol use, diet, viruses, and a possible genetic susceptibility may all work together in various combinations to cause these cancers.

Using tobacco, including cigarettes, pipes, cigars, and spit tobacco-is a well-established risk factor for oral cancer, as it is for some other cancers. Tobacco in any form contains carcinogens and nicotine, an addictive chemical that can keep the user hooked. A popular betel quid-spit tobacco mixture, used throughout India, has been implicated in the high rate of oral cancer in that part of the world.

Excessive alcohol consumption can also increase a person's chance of developing oral cancer. One theory suggests that alcohol generates metabolites, or byproducts of metabolism, that are carcinogenic to humans; the major metabolite of ethanol is acetaldehyde, a recognized animal carcinogen. Alcohol also might "grease the wheels" for tobacco by acting as a solvent and making it easier for carcinogenic agents to penetrate the oral tissues.

Rick Bender-
In his own words
 

Rick Bender appeared in a videotape titled "Dangerous Game," produced by the National Institute of Dental and Craniofacial Research, the National Cancer Institute, and the Centers for Disease Control and Prevention. In addition to Rick, the videotape featured major league baseball players and trainers who talked about the dangers of using spit tobacco, also called smokeless tobacco. The video was distributed to major and minor league baseball teams, and was made available to high schools as part of a package that includes pamphlets for students and a teachers' guide.

"The ulcer grew to about the size of a dime shortly after the first of the year there in '89. I then pretty much resolved to myself that, 'hey, Rick you've got cancer.'