Cancer of the mouth

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Overview

Cancer of the mouth
Cancer of the mouth
Mouth cancer, also known as oral cancer, is where a tumour develops in the lining of the mouth. It may be on the surface of the tongue, the inside of the cheeks, the roof of the mouth (palate), the lips or gums.

Tumours can also develop in the glands that produce saliva, the tonsils at the back of the mouth, and the part of the throat connecting your mouth to your windpipe (pharynx). However, these are less common.

Symptoms of mouth cancer

The symptoms of mouth cancer include:

  • mouth ulcers that are painful and don't heal within several weeks
  • unexplained, persistent lumps in the mouth or the neck that do not go away
  • unexplained loose teeth, or sockets that do not heal after extractions
  • unexplained, persistent numbness or an odd feeling on the lip or tongue
  • sometimes, white or red patches on the lining of the mouth or tongue. These can be early signs of cancer, so they should also be checked
  • changes in speech, such as a lisp

See a GP or dentist if these symptoms do not get better within 3 weeks, particularly if you drink or smoke.

Types of mouth cancer

Mouth cancer is categorised by the type of cell the cancer (carcinoma) starts to grow in.

Squamous cell carcinoma is the most common type of mouth cancer, accounting for 9 out of 10 cases.

Squamous cells are found in many areas of the body, including the inside of the mouth and in the skin.

Less common types of mouth cancer include:

  • adenocarcinoma, which is cancers that develop inside the salivary glands
  • sarcoma, which grows from abnormalities in bone, cartilage, muscle or other tissue
  • oral malignant melanoma, where cancer starts in the cells that produce skin pigment or colour (melanocytes). These appear as very dark, mottled swellings that often bleed
  • lymphoma, which grows from cells usually found in lymph glands, but they can also grow in the mouth

What causes mouth cancer?

Things that increase your risk of developing mouth cancer include:

Who's affected by mouth cancer?

Mouth cancer is the 6th most common cancer in the world, but it's much less common in the UK.

Around 8,300 people are diagnosed with mouth cancer each year in the UK, which is about 1 in every 50 cancers diagnosed.

More than 2 in 3 cases of mouth cancer develop in adults over the age of 55. Only 1 in 8 (12.5%) happen in people younger than 50.

Men are more likely to get mouth cancer than women. This may be because, on average, men tend to drink more alcohol than women.

Mouth cancer can develop in younger adults. HPV infection is thought to be linked with the most mouth cancers that happen in younger people.

Treating mouth cancer

There are 3 main treatment options for mouth cancer:

  • surgery to remove the cancerous cells, along with a tiny bit of the surrounding normal tissue or cells to ensure the cancer is completely removed
  • radiotherapy – where beams of radiation are directed at the  cancerous cells
  • chemotherapy – where powerful medicines are used to kill cancerous cells

These treatments are often used in combination. For example, surgery may be followed by a course of radiotherapy to help prevent the cancer returning.

As well as trying to cure mouth cancer, treatment will focus on important functions of the mouth, such as breathing, speaking and eating. Maintaining the appearance of your mouth will also be a high priority.

Complications of mouth cancer

Mouth cancer and its treatment can cause complications. It can affect the appearance of your mouth and cause problems with speaking and swallowing (dysphagia).

Dysphagia can be a serious problem. If small pieces of food enter your airways when you try to swallow and the food becomes lodged in your lungs, it could lead to a chest infection, known as aspiration pneumonia.

Preventing mouth cancer

The 3 most effective ways of preventing mouth cancer from happening, or stopping it from coming back after successful treatment, are:

The NHS recommends you drink no more than 14 units of alcohol a week. If you drink as much as 14 units a week, it's best to spread it evenly over 3 or more days.

It's also important that you have regular dental check-ups. A dentist can often spot the early stages of mouth cancer.

Find a dentist near you

Outlook

The outlook for mouth cancer can vary depending on which part of the mouth is affected and whether it has spread from your mouth into surrounding tissue. The outlook is better for mouth cancer that affects the lip, tongue or oral cavity.

If mouth cancer is diagnosed early, a complete cure is often possible in up to 9 in 10 cases using surgery alone.

If the cancer is larger, there's still a good chance of a cure, but surgery should be followed by radiotherapy or a combination of radiotherapy and chemotherapy.

Advances in surgery, radiotherapy and chemotherapy have resulted in much improved cure rates.

Overall, around 6 in 10 people with mouth cancer will live for at least 5 years after their diagnosis, and many will live much longer without the cancer returning.

Head and neck cancers

Mouth cancer is a type of cancer that comes under the umbrella term, "cancers of the head and neck".

Other types of head and neck cancer include:

Symptoms

Mouth cancer can develop in most parts of the mouth, including the lips, gums and occasionally the throat.

The most common symptoms of mouth cancer are:

  • sore mouth ulcers that do not heal within several weeks
  • unexplained, persistent lumps in the mouth that do not go away
  • unexplained, persistent lumps in the lymph glands in the neck that do not go away

Other symptoms may include:

  • pain or difficulty when swallowing (dysphagia)
  • changes in your voice or speech problems
  • unexplained weight loss
  • bleeding or numbness in the mouth
  • 1 or more teet, that become loose for no obvious reason, or a tooth socket that does not heal after a tooth is removed (extraction)
  • difficulty moving your jaw
  • red or white patches on the lining of your mouth. These are common and are rarely a sign of cancer, but they can sometimes turn into cancer, so it's worth seeing a doctor if you have them 

When to seek medical advice

Many of the symptoms listed above can be caused by less serious conditions, such as an infection.

However, it's strongly recommended that you see a GP or dentist if any of the symptoms have lasted longer than 3 weeks. It's particularly important to seek medical advice if you drink or smoke regularly.

Dental check-ups

Mouth cancer often does not cause any noticeable symptoms during its initial stage.

This is why it's important to have regular dental check-ups, particularly if you smoke, drink heavily, chew tobacco or chew betel nut (a type of nut commonly consumed in Asia). Your dentist may be able to detect mouth cancer during an examination.

You should have a dental check-up at least once every year. More frequent check-ups may be recommended if you have a history of tooth decay or gum disease.

Who can get it

The leading causes of mouth cancer in the UK are tobacco and alcohol.

Both tobacco and alcohol are carcinogenic, which means they contain chemicals that can damage the DNA in cells and lead to cancer.

If you drink alcohol or you smoke, this increases your risk of mouth cancer. If you both smoke and drink alcohol, this further increases your risk.

It's not known exactly what triggers the DNA changes that lead to mouth cancer, or why only a small number of people develop it.

Other risk factors

Other risk factors for mouth cancer may include:

  • chewing tobacco or other smokeless tobacco products
  • chewing betel nuts with or without added tobacco
  • an unhealthy diet
  • the human papilloma virus (HPV)

Smokeless tobacco

Smokeless tobacco products include:

  • chewing tobacco
  • snuff – powdered tobacco designed to be snorted

Smokeless tobacco products are not harmless and may increase your risk of mouth cancer, as well as other cancers, such as liver cancer, pancreatic cancer and oesophageal cancer.

Betel nuts

Betel nuts are mildly addictive seeds from the betel palm tree. They're widely used in many southeast Asian ethnic communities, such as people of Indian, Pakistani, Bangladeshi and Sri Lankan origin.

Betel nuts have a stimulant effect similar to coffee. They also have a carcinogenic effect, which can increase the risk of mouth cancer. This risk is increased by chewing betel nuts with added tobacco, as many people in south Asia do.

Because of the tradition of using betel nuts, rates of mouth cancer are much higher in people from the Indian, Pakistani, Bangladeshi and Sri Lankan community than in the British population at large.

Diet

There's evidence that an unhealthy diet can increase your risk of getting some types of mouth cancer.

Eating a healthy, balanced diet that includes plenty of fruit and vegetables is thought to reduce your risk of developing mouth cancer.

Human papilloma virus (HPV)

The human papilloma virus (HPV) is a family of viruses that affect the skin and moist membranes inside the body, such as those in the cervix, anus, mouth and throat.

You can get an HPV infection by having sexual contact with a person who's already infected. You do not have to have penetrative sex, just skin-to-skin contact.

There's evidence that in rare cases, certain types of HPV can cause abnormal tissue growth inside the mouth, triggering mouth cancer.

Oral hygiene

As cancer is sometimes associated with long-standing wounds, there's a small chance that jagged, broken teeth, which cause persistent ulcers or wounds on the tongue, can increase the chance of mouth cancer developing there.

It's therefore very important to do everything you can to keep your mouth and teeth healthy.

How mouth cancer spreads

There are 2 ways mouth cancer can spread:

  • directly, by spreading to nearby tissue, such as surrounding skin or to the back of the jaw
  • through the lymphatic system, which is the network of vessels and glands found throughout your body which produces special cells that are needed by your immune system to fight infection

Mouth cancer that spreads to another part of the body is known as metastatic oral cancer, which are often called secondaries.

The lymph glands in the neck are usually the first place where mouth cancer forms secondaries.

Diagnosis

If you have symptoms of mouth cancer, a GP or dentist will do a physical examination and ask about your symptoms.

Early detection can boost your chance of survival from 50% to 90%. This is why you should report any symptoms to your dentist or doctor if they do not get better after 3 weeks.

If mouth cancer is suspected, you'll be referred to hospital for further tests or to speak to a specialist oral and maxillofacial surgeon.

Biopsy

A small sample of affected tissue will need to be removed to check for the presence of cancerous cells. This is known as a biopsy.

The main methods used to carry out a biopsy in cases of suspected mouth cancer are:

  • an incision or punch biopsy
  • a fine needle aspiration with cytology
  • a nasendoscopy
  • a panendoscopy

The samples taken during a biopsy are examined under a microscope by a specialist doctor (pathologist).

The pathologist then sends a report to the surgeon to tell them whether it's cancer and, if it is, what type and what grade it is.

Incision and punch biopsy

An incision biopsy is usually done using local anaesthesic if the affected area is easily accessible, such as on your tongue or the inside of your cheek.

After the area has been numbed, the surgeon will cut away a small section of affected tissue.

The wound is sometimes closed with dissolvable stitches. The procedure is not painful, but the affected area may feel sore afterwards.

A punch biopsy is where an even smaller piece of tissue is removed and no stitching is used.

Fine needle aspiration cytology

A fine needle aspiration cytology (FNAC) may be used if you have a swelling in your neck that's thought to be a secondary from the mouth cancer.

It's usually done at the same time as an ultrasound scan of the neck.

FNA is like having a blood test. A very small needle is used to draw out a small sample of cells and fluid from the lump so it can be checked for cancer.

The procedure is very quick and the discomfort felt is the same as with a blood test.

Nasendoscopy

A nasendoscope is a long, thin, flexible tube with a camera and a light at one end. It's guided through the nose and into the throat.

It's usually used if the suspected cancer is inside your nose, throat (pharynx) or voice box (larynx).

A nasendoscopy takes about 30 seconds. Local anaesthetic may be sprayed into your nose and throat first, to reduce any discomfort.

Occasionally, tissue may be taken using a telescopic punch biopsy.

Panendoscopy

A panendoscopy is similar to a nasendoscopy, but uses a larger tube (scope) which give better access. You will be given a general anaesthetic before the procedure because the scope would be too uncomfortable if you were awake. 

A pandendoscopy can also be used to remove small tumours.

Further tests

If the biopsy confirms that you have mouth cancer, you'll need further tests to check what stage it's reached before any treatment is planned.

These tests usually involve having scans to check whether the cancer has spread into tissues next to the primary cancer, such as the jaw or skin, as well as scans to check for spread into the lymph glands in your neck.

It's rare for mouth cancer to spread further than these glands, but you'll also have scans to check the rest of your body.

Tests you may have include:

Your X-rays and scans will be looked at by a specialist doctor called a radiologist. They'll write a report which plays a major part in making decisions about staging.

After these tests have been done, it should be possible to determine the stage and grade of your cancer.

Staging and grading

Staging is a measure of how far the cancer has spread. The TNM system of staging is used for staging mouth cancer:

  • T relates to the size of the tumour (also called the primary cancer) in the mouth; T1 is the smallest and T4 is the largest or most deeply invasive
  • N is used to show whether there are secondaries (metastases) in the neck lymph glands; N0 means none have been found during examination or on scans, and N1, N2 and N3 indicate the extent of neck secondaries
  • M refers to whether there are secondaries elsewhere in the body

Grading describes how aggressive the cancer is and how fast it's likely to spread in future.

The 3 grades of mouth cancer are:

  • low grade – the slowest
  • moderate grade
  • high grade – the most aggressive

Staging and grading will help determine whether you have:

  • early mouth cancer, which is usually curable with an operation
  • intermediate mouth cancer, which still has a high chance of a cure, but will almost certainly need a more complex operation and radiotherapy
  • advanced mouth cancer, which has a lower chance of a cure and will need all 3 treatments (surgery, radiotherapy and chemotherapy)

Staging and grading cancer will help your multidisciplinary care team decide how you should be treated.

Find out more from Cancer Research UK about staging and grading of mouth cancer.

Treatment

If mouth cancer is found early, surgery may be used, which has a high chance of curing the cancer so it does not come back.

That's why you should report any changes in your mouth to a dentist and doctor if they do not get better after 3 weeks.

For advanced mouth cancer, you'll need treatment with surgery, radiotherapy and medicine over a period of at least 4 months.

Your treatment team

Mouth cancer may affect structures in the body that are important for breathing, eating, swallowing and speaking. It may also affect your appearance.

As well as being treated by a surgeon and a doctor who specialises in cancer (clinical oncologists), you may also see a dietitian, speech therapist, and a dentist.

You'll also usually have the support of a nurse who specialises in head and neck cancer (clinical nurse specialist).

Being diagnosed with cancer can cause stress and anxiety for you and your family. In some hospitals, a psychologist will be available to provide support if you need them.

If problems with swallowing temporarily make it difficult for you to get the nutrition you need by mouth, you may need to have a tube inserted through your nose and passed down into your stomach (nasogastric tube).

If the problem is likely to be long-term, a doctor who specialises in stomach and bowel conditions (gastroenterologist) or a radiologist will insert a tube directly into your stomach (gastrostomy).

Your treatment plan

Your treatment for mouth cancer will depend on:

  • the type and size of the cancer
  • the grade and stage of the cancer (how far it's spread)
  • your general health

If the cancer has not spread beyond the mouth or the part of your throat at the back of your mouth (oropharynx) a complete cure may be possible using surgery alone.

If the cancer is large or has spread to your neck, a combination of surgery, radiotherapy and chemotherapy may be needed.

Your doctors will make recommendations about your treatment with the help and advice of all your care team, but the final decision will be yours.

Before going to hospital to discuss your treatment, you may find it useful to write a list of questions to ask the specialist.

For example, you may want to find out about the advantages and disadvantages of a particular treatment.

Before treatment begins

Radiotherapy makes the teeth more sensitive and vulnerable to infection, so you'll be given a full dental examination and any necessary dental work will be done before treatment begins.

If you smoke or drink, stopping will increase the chances of your treatment being successful.

Your GP and specialist nurse can give you advice and support to help you quit smoking and cut down on alcohol.

Surgery

The aim of surgery for mouth cancer is to remove any affected tissue while minimising damage to the rest of the mouth.

If the cancer is advanced, it may be necessary to remove part of your mouth lining and, in some cases, facial skin. This can be replaced using skin taken from elsewhere on your body, such as your forearm or chest (a skin graft).

If your tongue is affected, part of it will have to be removed, called a partial glossectomy. 

The tongue may be left to heal on its own – this usually takes 3 to 4 weeks – or it may need to be reconstructed using grafted tissue.

If the cancer has invaded deep into your jawbone, the affected part of the jaw will need to be removed. 

Surgeons now use a complex technology called 3D printing to plan the reconstruction so that the replacement bone matches the removed bone almost exactly.

The grafted bone is kept alive by carefully joining tiny arteries and veins under a microscope (microvascular surgery). This increases the length of the operation.

The bone and muscle used for this replacement is usually taken from the lower leg, hip or shoulder blade. Dental implants can often be put into the new bone so that dental bridges can be made to replace lost teeth.

Occasionally, other bones, such as cheekbones, may have to be removed to get rid of the cancer completely.

These can be replaced with bone from other parts of your body, or a specialist dentist can make an extensive denture called an obturator, which holds the cheek out from the inside to give a relatively normal appearance.

During surgery, your surgeon may also remove lymph nodes near the site of the initial tumour. This is often done as a preventative measure in case they contain a small number of cancerous cells that cannot be detected on any scans.

The thought of having reconstructive facial surgery can be worrying. Your surgeon should explain the operation to you in detail and answer any questions you have.

You may also find it helpful to talk to other people who've had the same operation.

Your care team can give you the contact details of organisations, such as Saving Faces, which offer helplines or support groups for people with mouth cancer.

Radiotherapy

Radiotherapy uses doses of radiation to kill cancerous cells.

In mouth cancer, it's usually used after surgery to prevent the cancer returning.

In throat cancer, it's often the first treatment to be given, in combination with medicine (chemoradiotherapy).

The treatment is usually given every day over the course of 6 weeks, depending on the size of the cancer and how far it's spread.

As well as killing cancerous cells, radiotherapy can also affect healthy tissue.

It has a number of side effects, including:

Any side effects will be monitored by your care team and treated where possible.

The side effects of radiotherapy can be distressing, but many of them will improve once the radiotherapy is complete.

Internal radiotherapy

Internal radiotherapy, also known as brachytherapy, can be used to treat early-stage cancers of the tongue.

It involves placing radioactive implants directly into the tumour after you've had a general anaesthetic.

The implants will be left in for 1 to 8 days, during which time the cancer cells will receive a much higher dose of radiation than the rest of your mouth.

Visits by friends and family will need to be restricted because of the radiation. Pregnant women and children will not be able to visit you.

The radioactive implants will cause your mouth to become swollen, and you'll experience some pain 5 to 10 days after the implants are removed.

Chemotherapy

Chemotherapy is sometimes used in combination with radiotherapy when the cancer is widespread, or if it's thought there's a significant risk of the cancer returning.

Chemotherapy uses powerful cancer-killing medicines, which damage the DNA of the cancerous cells, interrupting their ability to reproduce.

As well as killing cancerous cells, chemotherapy can also affect healthy tissue.

Side effects of chemotherapy are common and include:

  • tiredness (fatigue)
  • sore mouth
  • mouth ulcers
  • feeling sick 
  • being sick
  • hair loss
  • hearing and balance problems
  • kidney problems
  • numbness and tenderness of the hands and feet

These side effects usually stop once treatment has finished.

Chemotherapy also weakens your immune system and makes you more vulnerable to infection.

Immunotherapy

A type of immunotherapy medicine called a checkpoint inhibitor is used to treat mouth cancer that has spread or cannot be removed through surgery.

Immunotherapy helps your immune system find and kill cancer cells. Checkpoint inhibitors help the immune system to do this, by blocking the signals that stop white blood cells attacking cancer cells.

It's possible to have a skin reaction when taking immunotherapy. The most common reaction is a rash, while some people get itchy skin, or patches of white or paler skin.

Speak to your care team about other side effects of immunotherapy.

Cetuximab

Cetuximab is a new type of medicine, called a targeted therapy, which is sometimes used instead of standard chemotherapy to treat mouth cancer. 

It does not cause all the side effects of standard chemotherapy and is usually used in combination with radiotherapy.

Cetuximab targets proteins on the surface of cancer cells, known as epidermal growth factor receptors. These receptors help the cancer to grow. By targeting them, cetuximab prevents the cancer from spreading.

The National Institute for Health and Care Excellence (NICE) ruled that cetuximab does not represent a cost-effective treatment in most cases and has recommended it only be used in people who are:

  • in a good state of health and likely to make a good recovery if treated
  • unable to have chemotherapy for medical reasons – for example, because they have kidney disease or are pregnant

Skin reactions often happen during the first 3 weeks of treatment with cetuximab. About 8 out of 10 (80%) people who have cetuximab are affected. An acne-like rash is the most common type of skin reaction.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) may be recommended if you have mouth lesions that are close to turning into cancer, or if cancer is at a very early stage and only found on the surface of your mouth. However, its cure rate has not yet been compared with conventional treatment.

PDT can also be used to temporarily control cancer where it's been decided that further conventional treatment will not provide a cure or benefit.

PDT involves taking a medicine that makes all your skin and other tissues sensitive to the effects of light. The cancerous tissue becomes even more sensitive.

After receiving the medicine, light is directed on to the cancer using lasers. This destroys the surface of the cancer and some mouth lining next to it.

You must stay in a dark room for 7 days with no light whatsoever, including no TV and no bedside light. If you're exposed to any light at all over this period, you'll develop serious burn to your skin.

Living with

Having mouth cancer does not necessarily mean you'll have to give up work. However, you may need quite a lot of time off, and you may not be able to work in the same way you did before treatment.

If you have cancer, you're covered by the Equality Act 2010. This means your employer is not allowed to discriminate against you because of your illness, and they have a duty to make reasonable adjustments to help you cope.

Examples of adjustments include:

  • allowing you time off for medical appointments and treatment
  • being flexible about your working hours, tasks or working environment

The definition of what is reasonable depends on the situation – for example, how much it would affect your employer's business.

It will help if you give your employer as much information as possible about how much time you'll need off and when.

Talk to your human resources representative if you have one. Your union or staff association representative should also be able to give you advice.

If you're having difficulties with your employer, you may be able to receive help from your union or local Citizens Advice.

Money and financial support

You may find it difficult to cope financially if you have to stop work or work part-time because of cancer.

If you have cancer or you're caring for someone with cancer, you may be entitled to financial support such as:

  • Statutory Sick Pay from your employer, if you have a job but cannot work because of your illness
  • Employment and Support Allowance if you do not have a job and cannot work because of your illness
  • Carer's Allowance if you're caring for someone with cancer
  • other benefits if you have children living at home or a low household income

Speak to the social worker at your hospital to find out as early as possible what financial help is available to you.

Talk to others

It's not always easy to talk about cancer, either for you or your family and friends. You may sense that some people feel awkward around you or avoid you.

Being open about how you feel and what your family and friends can do to help may put them at ease. Do not feel embarrassed or awkward about telling them that you need some time to yourself, if that's what you need.

If you have questions, your GP or nurse may be able to reassure you. You may find it helpful to talk to a trained counsellor or psychologist, or someone at a specialist helpline. Your GP surgery will have information about these.

Some people find it helpful to talk to other people who have mouth cancer, either at a local support group or on an online chat room:

You can also call the Saving Faces helpline on 07792 357972 (9am to 5pm) to speak to a member of staff who will be able to put you in touch with other people who've had the same treatment as you. Alternatively, you can contact them by email: helpline@savingfaces.co.uk.

Caring for someone with mouth cancer

If you're caring for someone with mouth cancer, it's important to look after yourself and get as much help as possible. You may need a break from caring if you're feeling down and finding it difficult to cope.

You can call the Carers Direct helpline on 0300 123 1053 (Monday to Friday, 9am to 8pm and weekends, 11am to 4pm)

Complications

Mouth cancer and its treatment can cause several complications, including changes to the appearance of your mouth, difficulty swallowing (dysphagia), and speech problems.

These effects can sometimes cause emotional problems and withdrawal from normal life.

Dysphagia

If you're having problems swallowing (dysphagia), a speech and language therapist will assess your swallowing reflex using a test called a videofluoroscopy.

This test involves swallowing food and liquid that contains a special dye while a type of X-ray is taken.

The dye shows on X-ray and allows the speech therapist to see your swallowing reflex and assess whether there is a risk of food or liquid entering your lungs when you eat or drink.

If there's a risk, you may need to have a feeding tube for a short period, which will be directly connected to your stomach (gastrostomy). You'll be given exercises to help you learn how to swallow properly again.

Find out more about how dysphagia is treated.

Speech

Like swallowing, your ability to speak clearly involves a complex interaction of muscles, bones and tissue, including your tongue, teeth, lips and soft palate.

Surgery and radiotherapy can affect this process, making it difficult to pronounce certain sounds. If your speech is severely affected, you may have problems making yourself understood.

A speech and language therapist will help you improve your speech by teaching you a number of exercises that develop your range of vocal movements. They'll also teach you new ways of producing sounds.

Emotional impact

The emotional impact of living with mouth cancer can be significant. Many people experience a "roller coaster" effect.

For example, you may feel down when you're first diagnosed, but feel positive  when the cancer responds to treatment. You may then feel down again as you try to come to terms with the side effects of treatment.

These emotional changes can sometimes trigger depression. Signs that you may be depressed include feeling down or hopeless during the past month and no longer taking pleasure in the things you usually enjoy.

You should see your GP if you think you're depressed. A number of effective treatments are available for depression, including antidepressants and talking therapies, such as cognitive behavioural therapy (CBT).



The information on this page has been adapted by NHS Wales from original content supplied by NHS UK NHS website nhs.uk
Last Updated: 23/11/2022 13:58:47