A white area in your mouth that is flat, painless and smooth may indicate the presence of leukoplakia. Usually, these are white patches in your mouth that do not rub off, unlike white areas due to a fungal infection like thrush. The causes of leukoplakia are not completely understood but can be related to tobacco use (including smokeless tobacco), irritation from teeth and, in some countries, the practice of chewing betel nuts. Doctors consider leukoplakia to be a form of precancer, although the actual percentage of these areas becoming cancer is around 5 percent to 20 percent. All areas of leukoplakia should be biopsied to establish a diagnosis and to rule out a malignancy. Treatments include cessation of tobacco products, repair of any teeth that may be contributing to the problem, and oral rinses with low concentrations of steroids to reduce the inflammation. Hairy leukoplakia, which is associated with HIV and other conditions that impair your immune system, is not considered a premalignancy and is not associated with your condition. Q2. My mom was treated over the past year for squamous cell carcinoma of the tongue. The disease was stage IV. Her doctors have said that they did successfully treat the cancer. The chemoradiation therapy eliminated the primary tumor and eliminated cancer in the lymph node. I am still scared though. I read articles, and all of them have said the survival rates for this stage of oropharyngeal cancer is not very good at all. What can I do to ease my fears some? The chemo doctor told us that somehow the chemotherapy did not cause her white blood cell count to drop at all, and in fact it actually increased a bit to help fight the cancer. All of this is very confusing to me — her doctors saying they got it all and that she has a good prognosis, and the Internet articles saying that stage IV oropharyngeal cancer does not have a good survival rate at all. So please, if you can, give me some suggestions to help ease my fear and anxiety. Cancer is a scary diagnosis, and I’m not sure there is anything that I or anyone else can say that will completely make your fears go away. But the first rule of cancer treatment is that a patient’s prognosis is always better when there has been a good response to treatment. That seems like a no-brainer, but patients (and sometimes doctors) can lose sight of this. Staging for cancer is very important, and it has an impact on prognosis and treatment plans. One use of cancer staging is so that medical professionals can communicate rapidly and accurately between each other. However, it was never intended as something a patient should be focused upon. Also, survival rates are based on data from many different patients lumped or averaged together. Two patients with the same staging may not, in fact, have the same burden of disease. So, when it comes to prognosis and long-term survival, one patient with stage IV cancer may not be the same as another patient at the same stage. If your mother has had a good response to chemoradiation and there is currently no evidence of cancer, I would take that as a good sign. And careful surveillance from this point on will detect any potential recurrences early, and early detection is a key to long-term survival. Fighting cancer is a long battle, and I encourage my patients and their families to celebrate every victory that comes their way. Q3. My fiancé is undergoing radiation/chemo treatments for stage I cancer on the base of the tongue. He lost saliva, taste and had difficulty swallowing, all early on into the treatments. How long after the treatments are over will saliva, swallowing ease and taste return? And will they ever be at the same level, or will they be forever compromised? I can’t find those answers anywhere. Radiation therapy can affect healthy tissue as well as cancer cells. In the mouth, salivary glands as well as taste buds on the tongue can be affected by radiation. The result can be a reduction or complete loss of saliva (xerostomia), loss of taste buds and difficulty swallowing (dysphagia). With newer intensity modulated radiation therapy (IMRT), a computer uses a CT scan to model a three-dimensional treatment plan that can reduce radiation doses to salivary glands and other important areas. In chemo-radiation therapy, the chemotherapy makes the cancer cells more sensitive to the effects of radiation. While this makes it easier to kill cancer cells, other healthy cells can also be affected, leading to increased incidence of mucositis. Mucositis is often described as like a very bad sunburn inside your mouth and throat. This can lead to difficulty swallowing as well as loss of taste and dry mouth. Fortunately, most salivary function should return if the glands were spared during radiation therapy. Taste buds will also return, although many patients complain of a reduction in ability to taste things or having things taste strange (dysguesia). Dysphagia can be avoided by swallow exercises during treatment that prevents scarring of muscles used in swallowing. With radiation therapy, the total dosage as well as type of radiation therapy given will determine the types and duration of complications. Ask your head and neck surgeon or radiation oncologist for details. Q4. I have a white sore on the side of my tongue that was barely there and is now worse. I went to the doctor when it was barely there, and she diagnosed it as a canker sore / fever blister. I have been using a regular mouthwash, but it doesn’t seem to be working. Should I be concerned about cancer? Should I visit the doctor again? Ulcers in the mouth can be caused by a number of different things including trauma (such as bites or burns), viral and bacterial infections, cancer or other systemic illnesses. Most of these ulcers are very painful but tend to heal on their own. In general, ulcers that persist and continue to be painful after two weeks should be looked at more closely. Often, ulcers can take more than two weeks to heal fully, but the pain should get better as the ulcer starts to fill in. If your ulcer has not gotten better, or if you notice that it has grown in size or is starting to bleed, you should visit your doctor again for re-evaluation. A final word about mouthwash: most mouthwashes have a high amount of alcohol as their base, and can sometimes irritate ulcers and keep them from healing. Simple saltwater rinses can be as effective as mouthwashes. Q5. They detected a small tumor in my husband’s saliva gland. The doctor first told us that even if it was not cancerous now, that they tend to turn cancerous if not removed. The biopsy was mostly fluid, but there were some abnormal cells — not enough to be conclusive. The MRI revealed all the “characteristics” of a non-cancerous tumor. The doctor now tells us that because it shrunk and is so small, that we should wait and watch. This makes us both nervous, because of his first statements. What advice do you have? There are both major and minor salivary glands in your body. Minor salivary glands are small clusters of cells and line the roof and sides of your mouth and can number up to 250 glands. Major salivary glands are paired and include the parotid glands, found on the sides of your face in front of your ears; submandibular glands, found below your jaw; and sublingual glands, found below your tongue. In general, the larger the gland, the more likely it is that a growth in that gland is benign. For example, 80 percent of masses in the parotid gland (the largest salivary gland) are benign. In contrast, 50 percent of masses in minor salivary glands (smallest glands) are cancerous. Fine needle aspiration — where a small needle is inserted into the tumor and cells are removed for analysis — is a common method of distinguishing between benign tumors and cancers. MRIand CT scans can also help determine the size and location of the lesion. Whether or not to undergo surgery depends on many factors, including the location, size and type of tumor. For example, even a small benign tumor in the parotid gland should be removed as it will grow over time and can become more difficult to treat. In contrast, some small cysts can be watched over time if there is confidence that they can be easily evaluated. All cancerous lesions require treatment, whether it’s surgery, radiation or both. In general, these treatment decisions should be made in consultation with your doctor. If you are concerned about a specific treatment plan, my advice is to sit down with your doctor and discuss your concerns. Q6. I keep getting these little white things on my tongue that hurt like heck. They come and go. Do you have any idea what they are? I smoke and have been under a lot of stress and lack of sleep because of my youngest son dying this January. I don’t know if this would cause any of my problems. I’m worried about cancer. Thanks. The mouth harbors many bacteria and viruses that colonize but don’t always cause infections. On occasion, a break in the lining of the mouth can allow an infection to occur. Most infections are self-limiting, meaning that they go away on their own, and usually clear in one or two weeks. Viruses such as herpes simplex virus (HSV) are associated with cold sores and aphthous ulcers (canker sores) that can be very painful and persist for weeks. Some of these infections and ulcers can be associated with stress as this can reduce the immune system. If these lesions are going away on their own, they are most likely infectious in nature. But since you have other risk factors, such as smoking, I would have a thorough head and neck examination to rule out oral cancer and other possibilities. In general, lesions that do not improve or clear up in a couple of weeks should be examined by your doctor. Q7. My husband had a bilateral neck dissection recently after being treated with chemo and radiation for base of tongue squamous cell carcinoma. Now he has a lot of severe tightness in the neck, and says it feels like a “choke collar.” Radiation and chemotherapy can cause increased fibrosis or scarring of the skin and deep tissues of the neck. Neck dissection, which removes cancerous lymph nodes and oftentimes the surrounding muscles and vessels, can induce even further scarring. The end result is a very fibrotic or “woody” neck. Like your husband, many patients complain of tightness around the neck, and even a choking feeling. Fortunately, much of the initial tightness will resolve once the body has had a chance to remodel the scar tissue. This can take months, however. Physical therapy, including range of motion exercises, can help in many cases. Taking care of your skin during radiation also can help minimize scarring. Products such as Aquaphor and Silvadene (silver sulfadiazine) creams — originally designed for skin burns — can be helpful. Smoking, in addition to causing cancer, will greatly decrease your ability to heal, as the nicotine causes constriction of the small vessels of the skin and soft tissue. Learn more in the Everyday Health Oral, Head, and Neck Cancer Center.
