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.)
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.”
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.
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.