Do you have a sore or a blister that never seems to heal? Did or does a rough white, discoloured patch of skin on your lips? Or maybe even a reddish lesion, with or without swelling.
If you answered yes to any of the previous questions, this should be a warning that not everything is quite right with your oral health, as these are common presentations of lip cancer. But what exactly is this condition?
Lip cancer is a type of oral cancer that affects the upper and lower lips, depending on the circumstances.¹
Though oral cancer can affect all areas of the mouth and throat, the lips are one of the most common sites affected by malignant tumours: they are by far the most common head and neck cancerous tumour.2
Risk factors like alcohol consumption, smoking, betel nut chewing, immunosuppressed, and sun exposure can lead to the development of this type of cancer, known scientifically as oral squamous cell carcinoma (OSCC).¹
The prognosis is usually good, with up to 92 % of patients being cured after five years if diagnosed initially.¹
What causes a person to develop lip cancer?
Squamous cell carcinoma is the most common type of mouth and lip cancer. It happens when the cells that line the oral mucosa and lips, the squamous epithelial cells, start proliferating( rapid increase) excessively.¹
Abnormalities in cells occur when cells are damaged through exposure to carcinogens (substances or environmental factors that can cause cancer), leading to a process called dysplasia: though not cancerous, dysplasia can lead to cancer.¹
Cells of abnormal shape, size, pigmentation, or function (like producing keratin when they should not do so), as well as abnormal proliferation (mitosis), are signs of dysplasia. Depending on how frequently these factors are obtained in a biopsy sample, we can grade cell dysplasia ( increasing abnormal cells produced) as mild, moderate, or severe.³
The more severe it is, the greater the risk of malignant transformation: once cells start proliferating (increasing), these abnormal cells are carcinoma in situ (a cancerous lesion in formation); once they start invading surrounding tissue, there is no other name for it: cancer.³
A common cause of lip cancer is sun exposure.4 Australia has a record of having the highest rate due to greater solar exposure all year around: UV radiation damages the squamous cells, leading to actinic cheilitis, a premalignant condition that causes chronic inflammation of the lips.5
It most frequently affects the lower lip due to its prominence in most people, and the affected lip may assume different aspects: either white when there’s hyperkeratosis (excess production of keratin), red (when there’s erosion of the epithelium due to ulcers and inflammation), or a mixture of both.5
Chronic actinic cheilitis will usually manifest as white or grey in colour, with a cracked, dry, and rough aspect to the lips.5
This condition is popularly known as farmer’s lip or sailor’s lip, as both occupations require long hours of exposure to the sun and are unprotected. However, any career that is outdoors can produce similar occurrences.5
Older males from birth with fair complexions are the most affected, especially if they spend a lot of time outdoors: it is also important to note that skin cancer is another disease associated with UV radiation exposure, making preventative measures even more imperative.5
But what does it mean to say actinic cheilitis is a premalignant condition?
A premalignant or precancerous condition or lesion that gives an opportunity to increase developing mouth cancer.6
Besides actinic cheilitis, other conditions parallel to precancerous are oral leukoplakia(white plaques located in the oral cavity), oral erythroplakia (targets the mucus membrane in the mouth), oral submucous fibrosis, oral lichen planus (a chronic condition affecting the mucus membrane), among many others.6
Having a premalignant condition does not equal having cancer or the certainty of having cancer someday; it means that the patient is potentially more at risk of developing a malignant tumour.
Therefore, the patients need to be evaluated periodically by a dentist ( dentists are experts who can look for oral-type cancer to diagnose any changes in behaviour or appearance of a lesion as to catch a potential malignant transformation as early as possible.
Lip cancer has one of the best prognoses if detected early, as almost 66 to 85 % chance for cure as an early diagnosis makes all the difference.¹
Other conditions that have been associated with an increased risk of mouth cancer are xeroderma( a dry skin condition following lip cancer, pigmentosum (a type of xeroderma that changes to severe skin pigments) and Fanconi’s anaemia (a rare genetics disorder to bone marrow failure and other organs).6
A recent study in the United Kingdom shows that patients from 1999 to 2016 evaluated the risk of oral cancer in patients who have used hydrochlorothiazide medication (HCTZ).
The study found cumulative use of this medication has significantly increased the risk of developing mouth cancer and advised dentists to pay special attention to patients who make use of HCTZ whenever they present with oral lesions.7
What signs and symptoms to look for lip cancer?
Lip cancer usually presents as white (leukoplakia), red (erythroplakia) plaques, or mixed white and red (erythroplakia) in the lining of the mouth that sores and persists for more than two weeks.¹
It may or may not present with pain or discomfort, though red lesions are usually associated with pain and can appear crusty.¹
Lips that appear chronically dry, rough and crackled to the touch can also point to actinic cheilitis or early-stage oral cancer.5
Invasion of nearby structures can have series of signs and symptoms as well as tooth mobility, ear pain, sensory changes and even difficulty opening the mouth (trismus).2
In a later stage, the cancer cells can spread locally to the lymph nodes of the neck, causing a hard, painless mass to appear on one or both sides of the neck.¹
This type of cancer usually spreads in locations involving the neck lymph nodes, though distant metastasis is possible.
Management and treatment for lip cancer
Lip cancer has a good prognosis if diagnosed early: the 5-year survival rate falls between 60 to 90%.¹ However, at a late stage, this survival rate drops to 50%.
An official guideline for the United Kingdom to treat lip cancer has been developed and endorsed by the speciality associations involved in the care and treatment of head and neck cancer.2 The following treatment options are
- Surgery remains the first and best option, with complete removal of the tumour with clear margins.2 Complete removal of neck lymph nodes, though elective, should be presented as an option to the patient: it diminishes the risk of recurrence and local spreading of the tumour2
- If it is not possible to completely remove the tumour or with clear margins, adjuvant radiotherapy can be considered.¹¹ Tumours that can’t be removed can also benefit from radiotherapy ( radiotherapy is an X-ray that kills the remaining cancer)2
- Metastatic tumours, if present, should be removed surgically if possible or receive an association of radiotherapy and chemotherapy2
- Surgical reconstruction of the lip for cosmetic and functional purposes can be performed.2
Clinically, any sore, ulcer, or mouth lesion that persists for more than two weeks is automatically suspected to be oral cancer and should be investigated.³ The National Cancer Institute lists a few tools that can be used to diagnose oral cancer:
- Physical examination: Assessing the mouth and throat for oropharyngeal cancer signs. A medical doctor or a dentist to look for potential lesions and assess their virulence factors, region, and extension.8 Lymph nodes of the head and neck should also be examined.8
- Patient’s history: it can point to risk factors that contribute to the hypothesis, such as whether or not they smoke and or drink alcohol, whether they chew betel quid (traditional practices that involve betel nuts enveloped with palm leaf, chewing can give red/black discolouration teeth and causing ulcers and trigger oral cancer) or not, frequency of unprotected sun exposure, or a history of immunosuppression (such as being an HIV-positive patient or having received organ transplantation)6
- CT scan and MRI: Image exams are useful to assess the extension of advanced lesions and their relation to deep tissues and structures, as well as lymph node involvement8
- Biopsy: It is essential to do a biopsy of the lesion to confirm the biopsy hypothesis. A pathologist will examine the sample under the microscope and determine if there is dysplasia (and if so, how severe) and infiltration into surrounding tissue, as well as identify what kind of cancer (or other disease) it is
Other exams might be performed, like a PET scan or a bone scan to identify any potential distant metastasis if cancer is confirmed.8
When it comes to oral cancer, a few risk factors can be strongly associated with it:
- Smoking or chewing tobacco: tobacco is one of the most known carcinogens; it damages the DNA of cells beyond repair and can increase chances of developing mouth cancer anywhere from 3 to 7 times compared to a non-smoker9
- Alcohol consumption: alcohol can be metabolised locally and transformed into acetaldehyde, which is a carcinogen, damaging mouth cells; besides, it is known as a tobacco’s carcinogen effect, further increasing the risk of developing cancer when both drinking and smoking⁴
- Chewing betel nut (also known as betel quid or areca nut): this tradition to aid with digestion from Southeast Asian South Indians and Sri Lanka contributes to an increased risk of oral cancer through irritation of the oral mucosa caused by the nut10
- Viral exposure: infection by a few types of the Human Papillomavirus (HPV), especially HPV-16 and HPV-18, has been linked to oral and laryngeal cancer, as well as cervical cancer1
- Immunosuppression: patients who have been under immunosuppression therapy (for HIV or organ transplantation) or who have developed graft versus host disease are more at risk of developing oral cancer6
- Sun exposure: the massive risk factor for lip cancer is sun exposure; UV radiation damages DNA and causes dysplasia of the tissue.1 People of older age and lighter skin are at extensive damage of developing actinic cheilitis over the years, which is a premalignant lesion, as well as those who live in tropical regions5
How can I prevent lip cancer?
- Avoid smoking and chewing tobacco or betel quid
- Avoid alcohol consumption or practice moderation
- Wear sun protection: sunscreen can help diminish the risk of skin cancer, but also wear lip balm with UV-ray protection to avoid lip cancer, as well as hats or caps whenever outdoors for extended periods.
- HPV vaccination: HPV plays a role in oropharyngeal cancer, and now that a vaccine exists, vaccination is the best protection.2 As it is a sexually transmitted disease, practising safe sex is a way to protect yourself against it and many other diseases.
How common is lip cancer?
It is the most common head and neck cancer.2 Its incidence is estimated to be 12 per 100,000 people in Europe, with the lower lip representing 90% of cases, the upper lip 7%, and oral commissure (mouth corners) 3% representing cases of lip cancer.2
What can I expect if I have lip cancer?
Prognosis is good: at an early stage, up to 90% of patients cleared of cancer in 5 years.1 Surgery performed under local anaesthetic and complete removal of the tumour with clear margins is enough to treat it, making it one of the simple types of cancer to treat.2 Even when radiotherapy is needed, the lips are an optimal site for radiation therapy and respond well to treatment.2
Most of the time, if the lesion is not advanced, cosmetic surgical repair is not needed. New surgical techniques like laser removal have been used recently to avoid scars and unpleasant cosmetic results.2
When should I see a doctor?
If you present with any type of ulcer, sore, or lesion that hasn’t healed or gone away in two weeks, you should seek medical advice. Other symptoms that are concerning are hard masses around the neck area, as that can point to lymph node involvement and pain.
Lip cancer is the most common head and neck cancer, and it affects those AMAB of older age and fairer skin more frequently. This type of cancer can be caused by a myriad of factors: smoking, drinking alcohol, chewing tobacco or betel quid, HPV infection, immunosuppression caused by diseases like HIV and graft versus host disease or organ transplantation, and, most frequently, sun exposure. Although lip cancer usually has a good prognosis, this disease should not be underestimated: protecting yourself against these risk factors and wearing adequate sun protection can lead to our goal of a cancer-free life.
- Howard A, Agrawal N, Gooi Z. Lip and Oral Cavity Squamous Cell Carcinoma. Hematology/Oncology Clinics of North America. 2021 Oct;35(5):895–911. Available from: https://www.sciencedirect.com/science/article/pii/S0889858821000599
- Kerawala C, Roques T, Jeannon J-P, Bisase B. Oral cavity and lip cancer: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology. 2016 May;130(S2):S83–9.
- Ridge JA, Glisson BS, Lango MN, et al. "Head and Neck Tumors" in Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach. 11 ed. 2008.
- Miranda-Filho A, Bray F. Global patterns and trends in cancers of the lip, tongue and mouth. Oral Oncology. 2020 Mar;102:104551. Available from: https://www.sciencedirect.com/science/article/pii/S1368837519304610
- Larios, G; Alevizos, A; Rigopoulos, D (15 April 2008). "Recognition and treatment of actinic cheilitis". American Family Physician. 77 (8): 1078–9.
- Yardimci G. Precancerous lesions of oral mucosa. World Journal of Clinical Cases. 2014;2(12):866.
- Carney K, Cousins M. Does hydrochlorothiazide increase the incidence of skin, lip and oral cancer in a UK population? Evidence-Based Dentistry. 2022 Mar 25;23(1):38–9.
- Lip and Oral Cavity Cancer Treatment (Adult) (PDQ®)–Patient Version - National Cancer Institute [Internet]. www.cancer.gov. 2020. Available from: https://www.cancer.gov/types/head-and-neck/patient/adult/lip-mouth-treatment-pdq
- Gandini S, Botteri E, Iodice S, Boniol M, Lowenfels AB, Maisonneuve P, et al. Tobacco smoking and cancer: A meta-analysis. International Journal of Cancer. 2007;122(1):155–64. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ijc.23033
- IARC Working Group on the Evaluation of Carcinogenic Risks to Humans (2012). "Personal habits and indoor combustions. Volume 100 E. A review of human carcinogens". IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. 100 (Pt E): 1–538.