The multistep progression of areca nut-induced oral cancer: a mechanistic roadmap from pathogenesis to precision therapy

Areca nut is classified as a Group 1 carcinogen by the International Agency for Research on Cancer. It is a widely consumed psychoactive substance with profound cultural roots in regions including Hunan, Hainan, and Taiwan of China. Its key bioactive components include alkaloids (e.g. arecoline and arecaidine) and areca nut-specific nitrosamines, that induce DNA damage, reactive oxygen species bursts, and chronic inflammation in oral tissues. Coupled with mechanical trauma from chewing, these insults drive the malignant progression of oral submucous fibrosis to oral cavity carcinomas. This review systematically outlines the pathological progression from normal oral mucosa to invasive oral cavity carcinomas, highlighting two core mediators of oral submucous fibrosis carcinogenesis: immune microenvironment reprogramming and oncogenic signaling activation. Furthermore, this review elaborates the molecular mechanisms of areca nut-induced oral cancer, providing a theoretical foundation for biomarker discovery and the development of novel therapeutic strategies. It also provides actionable guidance for reducing the incidence of areca nut-related oral cavity carcinomas and improving patient prognosis.