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Cancer of the cheek lining and gums is India's commonest cancer in men, caused by chewing tobacco and areca nut. Surgery with reconstruction is the mainstay, and trials from Tata Memorial in Mumbai have shown that removing the neck nodes up front, cheap oral chemotherapy, tiny doses of immunotherapy and visual screening by health workers all save lives at low cost.
Squamous cell carcinoma of the buccal mucosa, gingivobuccal sulcus, lower alveolus and retromolar trigone is the characteristic oral cancer of South Asia, where smokeless tobacco (gutka, khaini, mawa) and areca nut are held against the cheek for hours a day. It is often preceded by leukoplakia or by oral submucous fibrosis, the areca-nut induced stiffening of the cheek that limits mouth opening and hides tumours. The Kerala trial, reported by Sankaranarayanan in 2005, showed that visual oral examination by trained health workers cut oral cancer deaths in tobacco or alcohol users by about a third, the only randomised evidence for oral cancer screening.
Surgery is the mainstay: wide excision with marginal or segmental mandibulectomy for bone involvement, clearance of the infratemporal fossa when the masticator space is involved, neck dissection and free-flap reconstruction with anterolateral thigh or fibula flaps. The Tata Memorial trial of elective neck dissection, reported by D'Cruz in 2015 in 596 patients with early node-negative oral cancer, showed three-year overall survival of 80.0 against 67.5 percent, and Tata Memorial surgeons have redefined which tumours invading the masticator space can still be resected; induction docetaxel-cisplatin-fluorouracil is used to make borderline tumours operable. Postoperative radiotherapy or cisplatin chemoradiation follows for advanced stage, extranodal extension or positive margins.
Because most Indian patients present late and few can afford imported drugs, Tata Memorial trials have built a low-cost palliative pathway: oral methotrexate with celecoxib beat intravenous cisplatin (median survival 7.5 against 6.1 months, with fewer serious side effects); adding nivolumab at one-twentieth of the usual dose raised one-year survival from 16.3 to 43.4 percent; and METRO PLUS in Varanasi doubled median survival from 5 to 10 months by adding metronomic tablets to paclitaxel-carboplatin. Tobacco control, state bans on gutka and screening are the levers for prevention, and incidence is still rising.
India carries about a third of the world's oral cancers, and the gingivobuccal complex (the cheek lining, the gums and the sulcus between them) is the commonest site there because chewed tobacco and areca nut sit in the cheek pouch; it is the leading cancer in Indian men.
Site decides cause and behaviour: HPV drives oropharyngeal cancer, EBV drives nasopharyngeal cancer, tobacco drives oral and laryngeal cancer; all drain into the neck node levels that surgeons and radiotherapists map.
Same organ: Acinic cell carcinoma of the salivary glands, Carcinoma ex pleomorphic adenoma, Multiple endocrine neoplasia type 1 (MEN1), Multiple endocrine neoplasia type 2 (MEN2A and MEN2B), Hyperparathyroidism-jaw tumour syndrome (CDC73-related parathyroid carcinoma), Oropharyngeal cancer (tonsil and base of tongue), Laryngeal and hypopharyngeal cancer, Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma, Nasopharyngeal carcinoma, Salivary gland cancers, Papillary thyroid cancer, Follicular thyroid cancer, Medullary thyroid cancer, Anaplastic thyroid cancer, Thyroid cancer, Nasal cavity and paranasal sinus cancers (including esthesioneuroblastoma), NUT carcinoma (midline carcinoma with NUTM1 rearrangement), Parathyroid carcinoma, Multiple endocrine neoplasia syndromes (MEN1, MEN2, MEN4), HPV-positive oropharyngeal cancer, HPV-negative head and neck squamous cell carcinoma (including HPV-negative oropharyngeal cancer), Recurrent or metastatic head and neck squamous cell carcinoma, Hypopharyngeal cancer, Adenoid cystic carcinoma, Salivary duct carcinoma, Mucoepidermoid carcinoma, Oral tongue and floor of mouth cancer, Lip cancer, Locoregionally advanced nasopharyngeal carcinoma (stage III to IVA), Recurrent and metastatic nasopharyngeal carcinoma, Esthesioneuroblastoma (olfactory neuroblastoma), Sinonasal undifferentiated carcinoma (SNUC) and SWI/SNF-deficient sinonasal carcinoma
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Visual oral examination by trained health workers for tobacco and alcohol users (Kerala trial); treatment of leukoplakia and management of oral submucous fibrosis.
Wide excision with marginal or segmental mandibulectomy as needed, elective or therapeutic neck dissection (Tata Memorial trial), and free-flap reconstruction.
Induction docetaxel-cisplatin-fluorouracil to shrink technically unresectable tumours, then surgery in responders (Tata Memorial practice); chemoradiation otherwise.
Postoperative radiotherapy for advanced stage, perineural invasion or nodes; cisplatin chemoradiation for extranodal extension or positive margins.
Oral metronomic methotrexate with celecoxib; low-dose nivolumab added where affordable; metronomic tablets with paclitaxel-carboplatin (METRO PLUS); pembrolizumab where available.
Smokeless tobacco and areca nut cessation, gutka bans, and oral screening in high-risk people.
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Elective neck dissection is now the standard for early oral cancer everywhere. The trial shows what high-volume Indian centres can contribute: a definitive answer to a surgical question that had been debated for half a century and that Western centres, with far fewer oral cancers, could not resolve.
Targeted visual screening of tobacco and alcohol users is a cheap, workable way to cut oral cancer deaths in high-incidence countries, and is the basis for India's national oral cancer screening component. Its effect depends on people attending repeatedly and on treatment being available.
Cisplatin chemoradiation after surgery is standard for extranodal extension or involved margins; radiotherapy alone suffices for other adverse features.
With EORTC 22931, this trial defines who receives postoperative chemoradiation: patients with extranodal extension or positive margins, not those whose only risk factor is multiple nodes.
Query for this cancer: (TITLE:"Buccal mucosa and gingivobuccal cancer" OR ABSTRACT:"Buccal mucosa and gingivobuccal cancer" OR TITLE:"oral cancer in India" OR ABSTRACT:"oral cancer in India" OR TITLE:"Gingivobuccal complex cancer" OR ABSTRACT:"Gingivobuccal complex cancer" OR TITLE:"Cheek cancer" OR ABSTRACT:"Cheek cancer" OR TITLE:"Betel quid-associated oral cancer" OR ABSTRACT:"Betel quid-associated oral cancer" OR TITLE:"Indian oral cancer" OR ABSTRACT:"Indian oral cancer") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Buccal mucosa and gingivobuccal cancer (oral cancer in India), not a curated reading list.
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Bleeding that does not stop by itself, bleeding from more than one site, or new bruising in several places or one large area.
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
Capecitabine: take within 30 minutes after a meal. DPD deficiency (DPYD variants) causes severe toxicity: pre-treatment genotyping is recommended in Europe.
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Dose reduce or avoid for CrCl below 60 (carboplatin is the alternative).
Capecitabine: reduce to 75% for CrCl 30-50; contraindicated below 30.
See all on the product pages:CisplatinDocetaxelFluorouracil (5-FU)MethotrexateNivolumabPembrolizumab·Printable cards in the navigator
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