​​SINGAPORE: Mr Jesse Pangelinan saw a “perfect red circle” on his left inner cheek one day in August last year when he was brushing his teeth.

He suspected it could be a sign of oral cancer. But instead of seeing a doctor, he decided to self-medicate.

The ulcer, which was indeed a sign of oral cancer, eventually grew so big that surgery to remove it has left him without parts of his lip and his cheek.

At the time, the 32-year-old was apart from his wife who was in Singapore and hid the problem from her. Mr Pangelinan was in the Northern Mariana Islands, a part of the United States where he would travel frequently to for his job as a lecturer in a community college.

In January this year, when the Singapore permanent resident was still in the Marianas where he was born, he went for a free oral cancer screening and a biopsy confirmed that he had the disease. Oral cancer is common there as betel nut leaf chewing – one of the risk factors for the illness – is prevalent there, said Mr Pangelinan who had the habit growing up.

It became harder for Mr Pangelinan to hide the problem – the tumour had grown so large that it could be seen when he was talking.

“Whenever I talk, you can start to see like it was kind of growing already. You can see there’s something in my mouth,” he said.

Although she could not see him physically, his wife, a Singaporean, noticed the growth over a video call.

“My mouth was already starting to droop because the tumour had already grown … My wife thought I had a stroke,” he said.

He could not fully close his mouth and was “constantly drooling”.

“I always had to have something with me to wipe up the pus, and it was bleeding too … it was so nasty,” he said.

Mr Pangelinan came to Singapore in February this year to seek treatment at the National Cancer Centre Singapore (NCCS). By then, his disease had reached an advanced stage – the growth had pierced the skin of his face and was protruding out of it.

An operation to remove the tumour was successful, but parts of his cheek and lips had to be removed, along with the teeth on the left side of his mouth where the tumour was.

While that has left a permanent scar on his face, Mr Pangelinan is able to speak and eat normally, although he can only take in smaller portions at a time as he is unable to open his mouth as wide as before.

Seeking treatment for oral cancer late can lead to issues with swallowing and speech, said Professor Gopal Iyer, a head and neck cancer surgeon.

As the tumour progresses, the portions of the tongue or other parts of the oral cavity that need to be removed become more “extensive”, said Prof Iyer, who is head of the department of head and neck surgery at Singapore General Hospital and NCCS.

  • How to do a self-check of your mouth
    Roof of mouth: Tilt your head back to inspect the hard palate and soft palate.
  • Lips: Look and feel inside your lips.
  • Tonsil area: Examine your tonsil area at the back of your mouth.
  • Cheeks: Look and feel inside your cheeks.
  • Tongue: Stick out your tongue and look at the top and under surface.
  • Floor of mouth: Inspect this area by lifting your tongue up.
  • Upper and lower jaw: Inspect your upper and lower jaw.

The survival rate also drops in later stages of oral cancer, which is the most common head and neck cancer the centre sees, said Dr Iyer, who is also Mr Pangelinan’s doctor.

Among those who seek treatment early, the survival rate is “upwards of” 85 to 90 per cent. However, among those who present late, this rate drops to 40 per cent, he said.

The cancer progresses fast as well. “(In) two to three months you can go from Stage 2 to Stage 4,” said Dr Iyer.

Oral cancer patients make up an average of 100 patients out of about 800 new head and neck cancer patients annually at NCCS.

This underscores the importance of people checking their mouths for early signs and symptoms, said Dr Iyer.

“The oral cavity is so easy to examine, it's not something that needs anything beyond really good lighting, a mirror and awareness.

“There's a disproportion between how easy it is to identify and diagnosis, versus those patients that do present late … we want to break that cycle.”

People should look out for things like ulcers that do not heal within two weeks, red or white patches that “you cannot brush away”, and lumps with some blood, he said. Other signs to look out for are difficulty swallowing and soreness at a particular site, he added.

“It's important to talk about this because we do see an increasing trend in oral cancers in younger patients,” Dr Iyer said.

Oral cancer patients in Singapore used to be mostly in their 60s and 70s, but more are now in their 50s and 60s. Dr Iyer said NCCS sees some patients in their 20s and 30s – and even teens – although these cases are rare.

“We see a much younger group of non-smokers, non-drinkers having oral cancers. The reasons are unknown,” he said.

Risk factors for oral cancer include tobacco use, which includes smoking, second-hand smoking and chewing tobacco, excessive alcohol use and trauma to the mouth caused by sharp teeth or bad dentures.

Dr Iyer said that dentists are the “best port of call” when patients are in doubt as they are trained to pick up signs of oral cancer.

Dr Chelsia Sim, senior consultant in oral and maxillofacial surgery at the National Dental Centre Singapore, said that dentists are trained to examine the oral mucosa and teeth.

“We are familiar with the normal structures in the oral cavity and hence can pick up on abnormalities which can be pre-cancerous changes,” she said.

Dentists look out for white or red patches as well as persistent ulcers or sores in the mouth that do not heal after two to three weeks, she said.

“We also check for swellings, lumps or bumps inside the mouth, either on the gums, tongue, lips, floor of mouth or the roof of the mouth,” she said.

She echoed Dr Iyer’s view on the importance of checking the mouth for symptoms regularly for early detection of any pre-cancerous lesions.

“People should perform self-checks to look for any irregularities and if they notice any changes in their mouth or find any of the above symptoms, they should see their dentist immediately to get a thorough oral examination,” she said.

However, given that sometimes symptoms may be hard to spot or too small to see, she suggested seeing a doctor at least once a year for an oral examination.

Dr Sim said that a lack of awareness can delay the diagnosis of oral cancer as most of the pre-cancerous symptoms are painless.

“When they start to notice these changes when it becomes painful, it is highly likely that the cancer has spread deep and this will impact the outcome of treatment,” she said.

For Mr Pangelinan, it was only after his surgery that reality sank in. “It hit me – it hit me I'm never going to be the same again.”

His advice for others is to seek treatment early.

“Please don't wait, man. Just go, it's easy,” he said.