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No More Stories with Sad Endings by Drs. Parul Dua Makkar and Sanjukta Mohanta

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Categories: Oral Pathology, Pharmacology, and Cariology;
No More Stories with Sad Endings 

Regular screenings for oral cancer can help prevent deaths like Dr. Manu Dua's

by Drs. Parul Dua Makkar and Sanjukta Mohanta

This is a story that doesn’t end well. It starts with a 32-year-old dentist from Calgary, Dr. Manu Dua, noticing something on the side of his tongue. He sends a photo of it (Fig. 1) to his sister, Dr. Parul Dua Makkar, a dentist in New York, and asks, “Didi [which means “older sister” in Hindi], should I be worried about this?” She urges him to get a biopsy but he shrugs it off, thinking it’s not serious. “It can’t be cancer; I’m too young,” he says. Less than two years later, Parul is sharing stories about her baby brother with family and friends—at his funeral. (Manu died of oral cancer in March at age 34.)

Oral Cancer Screening
Fig. 1

This story has an ending that didn’t have to happen. With an earlier diagnosis and proper treatment, Manu would be sharing his story of surviving cancer instead of his sister talking about his death. By learning from his story, we can change the ending for others.

This is a story about oral cancer. This is the story of what we can do to create happier endings.

Symptoms of oral cancer4, 6
  • Pain in tongue or jaw
  • White or red lesion
  • A lesion that does not heal after two weeks
  • Lump or thickening
  • Sore throat
  • Difficulty moving tongue or jaw
  • Difficulty chewing or swallowing
  • Change in voice
  • Earache on one side
  • Numbness
  • Feeling like something is caught in throat
  • Wartlike masses

Oral cancer screening

A happier ending starts with detecting oral cancer early. Screening should be done on every patient regularly.1 A study of oral cancer patients showed that 70% who had regular dental visits were diagnosed at the earlier stages (1 and 2), compared with only 40% who did not attend regularly.2 The Canadian Cancer Society notes that oral cancer is in the “high preventability” category, which means that at least 50% could be prevented or there are screening programs that can detect treatable precancerous lesions.3 Oral health care professionals are key to improving the prognosis of oral cancer through early detection.

Adjunctive aids to detect oral cancer such as staining, fluorescence, brush biopsy and salivary testing can help with detection; however, the visual and tactile intraoral and extraoral examination is the bedrock of oral cancer screening. Review the steps in performing an intraoral and extraoral assessment by reading the Oral Cancer Screening pamphlet created by The Canadian Dental Hygienists Association.4

Often, oral cancer is diagnosed at a later stage, making the prognosis worse.5 Usually, the patient is unaware of the cancer in its early development, so it’s up to us to detect oral cancer early.

Symptoms and diagnosis

Oral cancer risk factors16, 17
  • Tobacco use
  • Alcohol use
  • Betel quid use
  • Gender (males are more at risk)
  • Sunlight exposure (for lip cancer)
  • Increased age
  • Previous cancer
  • Family history of oral cancer
  • Poor nutrition (diet low in fruits and vegetables)
  • Human papillomavirus
  • Weakened immune system
  • Genetic syndromes: Fanconi anemia and dyskeratosis congenita
  • Poor oral health
  • Lichen planus
  • Graft-versus-host disease
Drinking very hot beverages and chronic irritation may be risk factors but have not been proven to be.
When Manu told Parul about the lesion, it had already been there for a month. It started off as a sore, then an ulcer formed, then the pain intensified. He had some of the symptoms of oral cancer—see box on this page—but said to his sister, “If it was cancer, it wouldn’t hurt like this.” Parul responded, “You know that if a lesion doesn’t heal after two weeks, it’s suspicious.” Manu went to an oral surgeon who thought it was erosive lichen planus and gave him prednisone. The steroid didn’t work. The lesion got bigger. The pain worsened, involving earaches and constant jaw pain, and it was difficult for Manu to eat and talk. Now, he and the oral surgeon were worried. The lesion was biopsied and the diagnosis was devastating: Stage 2 squamous cell carcinoma of his tongue.

Squamous cell carcinoma is the most common oral cancer, representing 90% of oral cancer types.6 About 40% of intraoral cancer occurs in the floor of the mouth or the lateral and ventral surfaces of the tongue.7 Manu’s lesion was in one of the high-risk zones, the lateral border of the left side of his tongue.

Risk factors

Although there are several risk factors for oral cancer (see box on facing page), the only one that applied to Manu was his gender. It is thought that males are at higher risk because of poor lifestyle habits, but Manu was young, a nonsmoker, had no medical conditions, played sports, ate a well-balanced diet, did not use tobacco, only had the occasional drink and had no family history of oral cancer.

Human papillomavirus (HPV) is a risk factor for oropharyngeal cancers—those at the base of the tongue, tonsils and back of the throat. According to the CDC, HPV is the cause of 70% of oropharyngeal cancers in the United States.8 In Canada, intraoral cancer rates increased by 3.4% between 2003 and 2013, largely because of increases in HPV infection.9 It is not known if Manu had HPV, because he was not tested. But it is known that the HPV vaccine protects against HPV type 16, which is the type most commonly associated with oropharyngeal cancer.10

As you can see, people with no risk factors can still get cancer; cancer can affect anyone. Improving oral cancer awareness, advising patients to decrease risk factors of oral cancer, encouraging the HPV vaccine, recognizing signs and symptoms of oral cancer, and ensuring patients get a prompt diagnosis and referral for treatment are all ways dentists can prevent oral cancer and increase survival rates.

Treatment

Treatment for Stage 1 and 2 squamous cell carcinoma of the tongue involves surgical removal of the tumor and any affected lymph nodes. If the surgery does not remove all the cancer or there is a high chance for recurrence, radiation or chemoradiation may also be performed. If surgery cannot be performed (usually because of medical reasons), radiation is done instead.11

In August 2019, a team of specialists performed an eight-hour procedure on Manu that included a glossectomy (removal of the left side of his tongue) and removal of the lymph nodes on the left side of his neck. To reconstruct his tongue, the team transplanted a flap from his left arm and the radial artery from his left hand; they then removed skin from his left thigh to cover the wound on his hand. Manu also had a tracheostomy to ensure his breathing was not disturbed by postoperative swelling.

His recovery was arduous, involving nearly dying from a severe facial infection and learning how to speak, swallow and eat, and use his left hand again. With his strong will, Manu was back at his dental practice two months after surgery.12

Prognosis

According to the Canadian Cancer Society, the five-year survival rate of Stage 1 or 2 tongue cancer is 78%. The prognosis for squamous cell carcinoma is poorer if any of the following are present: a higher stage; a thicker tumor; cancerous cells found in the tumor margin; and spread to nerves, blood vessels and/or lymph nodes.13

A study on 117 South Korean patients with oral squamous cell carcinoma of the tongue showed that those under the age of 40 had higher rates of metastases and worse prognosis compared with those over the age of 40. The authors of the study suggested a more aggressive treatment plan for younger patients due to the higher risk of recurrence.14

Manu had Stage 2 tongue cancer and he was under 40. He had surgery without chemotherapy or radiation, hoping the cancer was completely removed; unfortunately, a cancerous lymph node was left behind.

Recurrence

Eight months after his surgery, just before the pandemic was declared, Manu went to his dentist for a restoration. Afterward, the left side of his neck swelled up—the same side where he’d had his cancer surgery. He called his ENT immediately for a CT scan and biopsy. The CT scan showed a small, ground glass opaque lesion in the left side of his chest. The biopsy was positive for recurrence. Again, Manu and his family were devastated—the cancer was back.15

Manu had another surgery to remove more lymph nodes and he had 33 treatments of chemotherapy and radiation over seven weeks, finishing in July 2020.15 Four months later, CT scans showed the lesion in the chest had quadrupled in size. Manu was coughing and had difficulty breathing. He had fluid in his lungs, which was drained multiple times, and a chest tube was placed. The cancer was in his lung lining, and doctors deemed it inoperable. There were several metastases, the furthest being in his pelvic bone. He had more chemotherapy and immunotherapy but the cancer was extremely aggressive and Manu endured tremendous pain.

Finally, his body had enough. He had a pulmonary embolism and, two days later, went into organ failure. His family was told to say goodbye. Parul frantically tried to see Manu one last time, but she was stuck across the border because of COVID-19 regulations. Over the phone, she tearfully told her younger brother, “You can let go now.” Soon afterward, in a Calgary hospice, with his parents by his side, Manu passed away from oral cancer.

What we can do?

This is a story of a dentist whose life ended too soon. This is a story meant to be shared, so no more stories end like this. What can we learn from the tragic ending of one of our colleagues? We can learn that oral cancer can happen to anyone, even one of us. We can learn that early diagnosis is the key to prevention and can save lives. We can talk to our patients about decreasing the risk factors like smoking and alcohol, and to be aware of any unusual lesions or symptoms in and around the mouth. We can do thorough oral cancer screenings on every patient, not just the ones with risk factors or symptoms. We can raise oral cancer awareness, promote self-exams and encourage the HPV vaccine.

Manu’s death is a harsh reminder and lesson for all of us as health professionals. We are more than cavity hunters. We are at the forefront of overall health care for our patients. We need to educate and advocate for our patients and ourselves. This is a story that shows the important role of dentists in preventing and decreasing oral cancer. This is a story that needs a new ending—and it starts with us.

[Editor’s note: Look for Dr. Manu Dua’s book, Life Interrupted: Dr. Dua’s Survival Guide, on Amazon. Proceeds benefit the Oral Cancer Foundation.]

References
1. Versaci, M.B. (2019, October 1). “ADA expands policy on oral cancer detection to include oropharyngeal cancer,” ADA.com
2. Musa, Z., Johnston, K., Peacock, S., Rosin, M., & Elwood, M. (2008). “Point of Care: Why Should Dentists Screen for Oral Cancer?” Journal of the Canadian Dental Association, 74(3), 243–244.
3. Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics 2019. Toronto, ON: Canadian Cancer Society; 2019. Available at: cancer.ca/Canadian-Cancer- Statistics-2019-EN
4. The Canadian Dental Hygienists Association. (2015). Oral Cancer Screening. Ottawa, Ontario.
5. Oral Cancer Foundation. (n.d.). Oral Cancer Facts.
6. Cancer Treatment Centers of America. (2021, May 17). Types of Oral Cancer: Common, Rare and More Varieties. Oral Cancer Types. cancercenter.com
7. Schiff, B.A., Merck Manuals website (2021, January). Oral Squamous Cell Carcinoma—Ear, Nose, and Throat Disorders. Oral Squamous Cell Carcinoma.
8. Centers for Disease Control and Prevention website cdc.gov (2020, September 3). “HPV and Oropharyngeal Cancer.”
9. Cancer Care Ontario website cancercareontario.com (2020, December 3). “New cases of intraoral cancers increasing after decades of decline.”
10. Castillo, A., Osorio, J. C., Fernández, A., Méndez, F., Alarcón, L., Arturo, G., Herrero, R., & Bravo, L. E. (2019). “Effect of vaccination against oral HPV-16 infection in high school students in the city of Cali, Colombia.” Papillomavirus Research, 7, 112–117.
11. American Cancer Society website, cancer.org (2021, March 23). Oral Cavity (Mouth) Cancer Treatment Options, by Stage. Treatment Options for Oral Cavity and Oropharyngeal Cancer by Stage.
12. Dua, M. “Doctor, Heal Thyself.” Dentaltown magazine (November 2019).
13. Canadian Cancer Society website, cancer.ca. “Survival statistics for oral cancer.”
14. Jeon, J. H., Kim, M. G., Park, J. Y., Lee, J. H., Kim, M. J., Myoung, H., & Choi, S. W. (2017). “Analysis of the outcome of young age tongue squamous cell carcinoma.” Maxillofacial plastic and reconstructive surgery, 39(1), 41.
15. Dua, M. “Leaving Dentistry: This Way Out.” Dentaltown magazine (March 2021).
16. Canadian Cancer Society website, cancer.ca. “Risk factors for oral cancer.”
17. Cancer.Net. (2021, February). “Oral and Oropharyngeal Cancer—Risk Factors and Prevention.”

Author Bio
Parul Dua Makkar Dr. Parul Dua Makkar graduated from the University of Oklahoma College of Dentistry with a DDS in 2003, then worked in private practice in Calgary. In 2006, she moved to New York and did one-year general practice residency at Staten Island University Hospital. Makkar currently has a private practice in Long Island, New York, where she lives with her husband and two sons. Email: parul_dua@yahoo.com.


Sanjukta Mohanta Dr. Sanjukta Mohanta is a general dentist practicing in a publicly funded dental clinic in Brampton, Ontario. She graduated from the University of Toronto Faculty of Dentistry in 1999. She volunteers with the Canadian Dental Association, the Ontario Dental Association and the Halton-Peel Dental Association. Email: sanjuktamohanta@hotmail.com, Instagram: @drsanjmohanta.
 

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