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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
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.
| Setting | Approach | Guideline |
|---|---|---|
| Screening in high-risk populations | Visual oral examination by trained health workers for tobacco and alcohol users (Kerala trial); treatment of leukoplakia and management of oral submucous fibrosis. | not mapped |
| Resectable disease | Wide excision with marginal or segmental mandibulectomy as needed, elective or therapeutic neck dissection (Tata Memorial trial), and free-flap reconstruction. | NCCN Category 1 (elective neck dissection) |
| Borderline resectable (masticator space involvement) | Induction docetaxel-cisplatin-fluorouracil to shrink technically unresectable tumours, then surgery in responders (Tata Memorial practice); chemoradiation otherwise. | not mapped |
| After surgery | Postoperative radiotherapy for advanced stage, perineural invasion or nodes; cisplatin chemoradiation for extranodal extension or positive margins. | NCCN Category 1 |
| Palliative and recurrent disease | Oral metronomic methotrexate with celecoxib; low-dose nivolumab added where affordable; metronomic tablets with paclitaxel-carboplatin (METRO PLUS); pembrolizumab where available. | not mapped |
| Prevention | Smokeless tobacco and areca nut cessation, gutka bans, and oral screening in high-risk people. | not mapped |