My mother-in-law has been diagnosed with tongue cancer. She is 79 and somewhat frail. We will go to a specialist tomorrow for further analysis of the cancer. What is the spectrum of treatments for someone of this age?

J.C.

The treatment depends on how large the cancer is and whether it has spread to lymph nodes in the neck. Without knowing the size of the tumor, I cannot give you a very specific answer as to your mother-in-law's options. However, I can certainly answer your question regarding the spectrum of treatments available for tongue cancer.

Regardless of the size of the tumor, she will almost certainly undergo a CT scan and/or an MRI to evaluate the extent of the tumor and the presence of suspicious lymph nodes in the neck.

1. Very small cancers are treated by surgical excision. If the tumor is very, very small, her doctors may then choose to "watch the neck." This means that they will see her on a monthly basis to re-examine her neck. If she develops one or more suspicious lumps, the neck will require treatment as described in the following paragraphs.
   
2. For larger tumors (and some small tumors are considered large by us), she will need neck treatment to eradicate cancer from the lymph nodes of her neck. Her options are radiation therapy and a bilateral neck dissection, an operation in which all lymph-node-bearing tissue in the neck is removed.
   
3. All tongue cancers, be they small or large, can be treated by radiation therapy. Why not just irradiate the tongue and neck at the same time? This is certainly an option, and it may be her best one if she is too frail to undergo surgery. Nevertheless, radiation therapy to the mouth is a nasty ordeal. She can look forward to mouth pain, chronic dry mouth and a decrease in her sense of taste. For small tumors, it is much easier to recover from surgery than it is to recover from radiation therapy.
   
4. If the cancer has grown so large that surgery would entail a total glossectomy (removal of the entire tongue), many physicians would instead recommend a combination of radiation and chemotherapy. If the tumor continues to grow despite combination therapy, surgery is still an option. Total glossectomy is a very maiming operation -- hence, my recommendation for combined therapy. Her ability to speak and swallow would be permanently damaged by such an operation. Also, many people have problems aspirating saliva (choking on their spit) after a total glossectomy, leading some surgeons to recommend that a laryngectomy (removal of the voice box) also be performed. Needless to say, these are major operations.
   There are operations to restore bulk to the floor of the mouth after a total glossectomy. One of the older operations is known as a PMC flap, in which a chest wall muscle is transferred to the floor of the mouth, replacing the tongue. This provided a bulky mass that was, unfortunately, without sensation and immobile. Still, it was better than nothing. More recently, head and neck surgeons have been transferring skin and muscle tissue to the floor of the mouth while trying to preserve a nerve for sensation and a nerve for muscle function. These are called "sensate free-flaps." They are better than a PMC, but still a pale imitation of the real thing.
   
5. If she is indeed very frail, and if her doctors anticipate that she has a very short life expectancy due to her other medical problems (less than one year), they may talk to her about palliative care. In other words, they would recommend the least invasive treatment possible for her tongue cancer, and would do everything possible to make her remaining time pain-free.