EXECUTIVE SUMMARY

• The document is based on consensus among the experts and best available evidence pertaining to Indian population and is meant for practice in India.
• Evaluation of a patient with newly diagnosed buccal mucosa cancer should include essential tests: Biopsy of the primary lesion, complete blood counts, renal function tests and liver function tests, chest X-ray, dental evaluation, and ultrasonogram (USG) of the neck in patients with no clinically enlarged neck nodes. Computed tomography (CT) magnetic resonance imaging (MRI)/positron emission tomography (PET)-CT are not recommended for all patients.
• For early stage disease (I/II), single modality treatment with surgery (with or without postoperative radiotherapy (PORT) or radiotherapy (RT) (brachytherapy or external beam radiotherapy [EBRT] or in combination) is recommended.
• For locally advanced Stage (III–IV A), surgery followed by RT with or without chemotherapy, concurrent chemo-RT, altered fractionation RT schedules, induction chemotherapy, followed by surgery with or without RT are valid treatment options.
• Stage IV B/metastatic diseases are treated with intent of palliation with chemotherapy and/or RT along with best supportive care.
• Clinical examination including history and physical examination is done at each follow-up visit and no routine radiological investigation is recommended.

INCIDENCE

Carcinoma of the buccal mucosa (BMC) is the commonest cancer of the oral cavity in India. As per population based cancer registry data[1] of the National Cancer Registry Program, of the Indian Council of Medical Research, the males of Ahmedabad urban showed highest age adjusted rate (AAR) for mouth cancer (17.1) followed by Bhopal (12.5). For females however, Kamrup urban district (7.6) and East Khasi Hills of Meghalya (7.3) showed the highest AAR, followed by Bangalore (6.2). In the hospital-based cancer registry[2] report, cancer of the oral cavity is also ranked as the leading site in Mumbai in males and was within the first five leading sites in all registries in males. In the developed countries, BMC is relatively uncommon when compared to the Indian subcontinent.[3] As per the recent GLOBOCAN 2012, 77,000 new cases of oral cavity cancers are diagnosed every year in India and 52,000 die of this disease.[4] The high incidence of BMC in our country is attributable to the extensive use of tobacco in various forms and the locally advanced cancers account for about 70% of the cases at the time of presentation.

PURPOSE

Several international consensus guidelines are available for the management of oral cavity cancers, but none of them addresses BMC in particular. Therefore, formulating reliable guidelines based on western data for Indian patients is questionable given the fact that buccal mucosa tumors are quite rare in the developed countries. There is obviously an urgent need to formulate consensus statement for the management of BMC based on Indian data[5,6,7,8,9] and experience which would not only incorporate the evidence available but would also be feasible to be practiced in the hospitals of India. Oral cancer in India is different compared to the western countries. Here, it involves the gingivo buccal sulcus (the site where the tobacco quid is commonly kept by the patient). The nature of spread, biological behavior and the treatment is also different. Based on the available evidence and expert consensus opinion, we present the proposed national consensus document for management of BMC.

DIAGNOSIS

Evaluation of a patient presenting with a lesion in the buccal mucosa should be aimed at pathological confirmation and staging of the disease. Essential test, which needs to be done in all patients include: Biopsy of the primary lesion, complete blood counts, renal function tests and liver function tests, chest X-ray, USG of the neck in patients with no clinically enlarged neck nodes, dental evaluation and CT scan except in patients with early lesions and clinically USG proven no lymphadenopathy in the neck. CT scan/MRI is advisable if mandible is involved clinically and ortho-pantomogram is negative, lesion is involving the retromolar trigone, there is suspected involvement of pterygoids or pterygoid plate, lesion is extending into the upper gingivo buccal sulcus and there is suspicious involvement of para-nasal sinuses or if there is need to assess the operability of cervical lymph nodes. Evaluation under anesthesia should be done in cases where clinical examination is not feasible. 2-[18F] fluoro-2-deoxy-D-glucose PET (PET-CT) is not routinely recommended.

Extensive investigations are not recommended in cases with (intent of treatment in these cases is primarily palliation) hard and fixed N3 nodes, extensive skin involvement with or without cutaneous nodules, severe trismus not due to oral submucous fibrosis or clinical involvement of infra temporal fossa.

Staging should be done with American Joint Committee on Cancer staging manual[10] (7th edition, 2009) and patients should be assigned a TNM and a group stage (which would remain unchanged throughout).

TREATMENT PLAN

Treatment decisions are based on the stage. The aim of treatment is “curative” for patients with Stage I–IV A and “palliative” for patients with Stage IV B (locoregionally advanced disease) and IV C (metastatic disease).

RECURRENT DISEASE

For recurrent disease, if recurrence is operable and patient is RT naïve, surgery followed by PORT with or without chemotherapy or radical RT (for recurrent T1/T2) may be employed. Concurrent chemo-radiation or radiation alone is a valid option in these patients, if surgery is not medically feasible or patient is not willing for surgery.

If surgery is not feasible and patient has poor performance status the treatment should be individualized. If RT naïve, palliative RT else palliative chemotherapy may be employed along with best supportive care.

FOLLOW-UP AND REHABILITATION

Patient should be encouraged to maintain abstinence from tobacco and alcohol and maintain oral hygiene. Dental prophylaxis, shoulder exercises, jaw stretching exercises, swallowing and speech rehabilitation should be instituted as appropriate. The aim of follow-up is to assess the recurrence in primary and nodal areas, to rule out any second primary and to assess any complication due to surgery/RT. Follow-up is done every 2-3 months for first 2 years, six monthly for next 3 years and annually thereafter. Clinical examination, including history and physical examination is done at each visit and no routine radiological investigation is recommended.

Footnotes