It has been widely reported that John ‘The Voice’ Farnham had part of his jaw removed on Tuesday in marathon surgery for cancer of the mouth.
The family is yet to confirm these details – but removal of the jaw in part or total isn’t uncommon when treating oral cancer.
It’s complex surgery, as is the recovery period, which can be gruelling and life long.
Oral cancer isn’t talked about as often as breast or bowel cancer, but it’s a relatively common cancer – with about two people a day being diagnosed.
It can affect everyone from young adult to people in their twilight years.
What is oral cancer?
Cancer of the mouth is more properly known as oral cancer.
There are seven main sites where it can emerge: The lips, the tongue, inner lining of the cheek, the gums, floor of the mouth, the hard and soft palate, and the sockets of your upper teeth.
Seeing your dentist every six months for a clean and a check-up is probably the best way to catch a cancer in its early stages. It’s a dentist who will most likely see a tumour and refer you to a specialist.
According to a 2018 review by the Royal Melbourne Hospital, the vast majority of oral cavity cancers (90 per cent) are squamous cell carcinomas.
Other types of oral cavity cancers include salivary gland malignancies (very rare), sarcomas, malignant odontogenic tumours (in tissues that are capable of forming teeth), melanoma and lymphoma.
Taken together, these comprise less than 10 per cent of oral cavity cancers.
What’s the survival rate?
According to the Australian Dental Association, oral cancer ‘‘is an aggressive disease with a survival rate of only 50 per cent over five years’’.
This is due to multiple factors:
- It can often go undetected until the cancer is advanced
- It often does not cause the patient to experience any symptoms until advanced
- It is caused by a variety of lifestyle risks, many of which are a part of the everyday lives of many Australians.
Lifestyle risks for oral cancer include smoking (cigarettes, vaping, cannabis), drinking too much alcohol, poor diet, sun exposure – and oral sex, which can expose you to the Human Papilloma Virus (HPV). The virus affects males and females.
Other risk factors for squamous cell carcinoma development in the mouth include growing older, family history, being male, having a history of cancer therapy, and long-term immuno-suppression.
Symptoms of oral cancer
Changes to watch for include:
- A sore on your lip or mouth that won’t heal
- A mass or growth anywhere in your mouth
- Bleeding from your mouth
- Loose teeth
- Pain or difficulty swallowing
- Trouble wearing dentures
- A lump in your neck
- An earache that won’t go away
- Dramatic weight loss
- Lower lip, face, neck, or chin numbness
- White or red patches in, or on, your mouth or lips
- A sore throat
- Jaw pain or stiffness
- Tongue pain.
Treatments
The early stages of oral cancer usually involve surgery to remove the tumour and cancerous lymph nodes.
If caught early, surgery may be all that is required.
Treatment for advanced stages of oral cancer will usually involve a combination of chemotherapy and radiation therapy.
Good nutrition is important to recovery. Because of the pain of recovery, patients are at risk of unhealthy weight loss that can undermine recovery.
A nutritionist can help plan meals that are gentle on the mouth and throat.
Keeping your mouth clean during treatment is also crucial.
Some treatment can be radical
It has been widely reported that John Farnham underwent a mandibulectomy – also called mandibular resection – where part of the jaw was removed.
This occurs when a tumour is very close or attached to the bone.
A mandibulectomy is most common for mouth cancers that begin in the lower gums or the floor of the mouth.
The procedure usually takes between four and six hours – with reconstruction taking another six hours.
Farnham’s surgery reportedly involved 26 surgeons and went for nearly 12 hours.
A surgeon explains
Associate Professor Ardalan Ebrahimi is a specialist head and neck surgeon based in Canberra.
After completing advanced fellowship training at the Sydney Head and Neck Cancer Institute in Royal Prince Alfred Hospital, Sydney, he undertook a Mayo Clinic Fellowship in the US.
His expertise includes transoral robotic surgery (TORS) for throat cancer, reconstructive surgery for patients with facial paralysis and microvascular reconstructive surgery in the head and neck
An interview with Dr Ebrahimi follows:
When does a mandibulectomy become necessary?
The mandible is the bottom jaw bone. If the oral cancer is directly next to the jaw bone or invading the jaw bone, we perform a mandibulectomy.
This can be combined with removal of other parts of the mouth, such as the tongue or the lining inside the cheek (buccal area), depending on the location and extent of the cancer.
Mandibulectomies can be partial or involve a complete segment of bone.
In either case, a reconstruction is required with a free flap, which involves taking tissue from elsewhere in the body with its blood supply to rebuild the area with missing tissue, and then performing microsurgery to give it a blood supply.
With marginal mandibulectomies, the reconstruction is usually a soft-tissue free flap to reline the mouth, typically from the forearm and sometimes from the thigh.
In the case of segmental mandibulectomies, bone reconstruction is required for the jaw to maintain the normal facial contour and keep the teeth aligned. T
ypically, we use a fibula free flap with a bone from the leg, along with some skin and muscle.
How common is it?
It’s not uncommon for patients with oral cancer.
What is the range of recovery time?
It depends how you define recovery: Typically, patients are in hospital for 10 to 14 days, but it can be longer if there are complications.
Early after surgery most patients have a tracheostomy tube to ensure they have a safe way to breathe in spite of any swelling or bleeding in the mouth or throat.
This typically is removed within a week of surgery.
As they can’t eat for at least a week after surgery, patients also have a feeding tube to allow healing and for swelling to settle down.
In terms of energy levels, speech, swallowing, swelling, appearance, etc, a lot of recovery happens in the first six to 12 weeks, but many patients continue to improve for several years.
It’s very individualised for each patient, but the recovery takes time.
What are some of the complications of recovery?
There are many risks in the early post-operative period, such as infection, bleeding, and loss of the free flap blood supply among others.
In terms of long-term potential impact, many patients have excellent outcomes over time, depending on the extent of surgery. For example, was some of the tongue also removed?
And with further treatments such as radiotherapy, there is potential for permanent changes to the way you look, ability to eat and swallow and possibly speech.
The teeth are also removed in the section of jaw bone that is removed and dental rehabilitation can be complex in these patients. Most will not be able to have a simple denture made.
Dental rehabilitation would typically require surgery to place dental implants, and then a special denture needs to be made to fit the implants.
This requires additional procedures, potentially significant costs and some risk, so many patients unfortunately never get new teeth.
How is the surgery performed?
In terms of access, it’s usually a combination of surgery through the mouth and an incision in the neck.
Occasionally the skin of the chin and lip needs to be split for access.
It’s said that 26 surgeons were involved in Farnham’s surgery. Is such a large team common with this sort of surgery?
Typically there will be two surgical teams with a consultant surgeon in charge of each team. This can depend on local expertise and skill sets.
Usually there will be one surgeon in charge of the cancer operation and the second team is in charge of the reconstruction.
While the cancer surgery team is working on the ‘top end’, the reconstructive team prepares the free flap (for reconstruction) in the arm or leg, which takes several hours.
This means when the cancer surgery is finished, the reconstructive team can disconnect the blood supply to the flap and take it to the mouth to begin reconstruction.
This part of the surgery we call ‘ischaemic time’ because the flap has no blood supply, so time is of the essence to rebuild the jaw with the bone and titanium plates and re-vascularise (have it work with its own blood supply) the flap with microsurgery.
When possible, if we are performing bone reconstruction for the mandible, we use computerised planning with models and surgical guides to improve the precision of the reconstruction and save time during surgery.
Unfortunately, many of the companies that provide this service don’t have quick enough turnaround times to provide this service for cancer patients.
What other procedures are performed at the same time, if any?
In terms of the cancer in the mouth, it depends on the extent of adjacent tissues involved. For example, patients may also need some of the cheek lining, tongue or even skin removed with the jaw.
Usually there’s a neck dissection where lymph glands are removed from the neck.
Is oral cancer becoming more common?
Overall, it’s less common given smoking rates have reduced in the past few decades.
However, we are seeing more of the subset of patients who have never smoked or drunk alcohol, some of who are very young.
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