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News Bulletin : ADA News Bulletin July 2011
14 July 2011 In recent years, dentists have seen the introduction of devices which promote oral cancer screening, raising interest in this disease and its early detection. However, it is still the conventional oral soft tissue examination (visual and palpation) which constitutes the gold standard screening study for oral cancer and pre-cancer.1 An interesting question arises. Is there any evidence that oral cancer screening works? In other words, is there any evidence that oral cancer screening is associated with decreased oral cancer mortality and morbidity and, very importantly, does it work in the dental practice setting? While oral cancer screening is often trivialized, it is in fact a complex topic and largely unexplored. It is well known that, when a patient is diagnosed with oral squamous cell carcinoma (SCC), the patient’s prognosis depends on a number of factors including tumour site, size, depth of invasion and presence or absence of nodal metastases.2-4 Advanced disease is associated with poor prognosis (Fig 1).2,3 Despite the many advances in treatment of oral SCC, survival remains poor, with early detection and diagnosis appearing paramount.5,6 Unfortunately, it is a sad fact that most oral cancer patients are diagnosed at advanced disease stage. 7,8 Why is this the case, given that the oral cavity is so easily accessible and therefore examinable by the doctor, dentist and patient themselves? Dental Health Week 2011 Oral cancer screening committee report Diagnostic delay is defined as the period from the onset of signs and/or symptoms to the final diagnosis of oral cancer and it is often subdivided into patient and professional delay.9 Patient delay refers to the time period from the onset of signs and/or symptoms to that patient’s first visit to a health professional.9 Professional delay in turn refers to the time period from the patient’s first professional visit to the point in time when correct diagnosis is made.9 While professional delay is at times to blame for diagnostic delay, it appears that patient delay is the far greater problem, with as many as one- third of oral cancer patients delaying seeking treatment for three or more months, after noticing a problem.9,10 Unfortunately, reasons for this delay are not well understood. Lack of public knowledge of the signs and symptoms of oral cancer appears to be in part to blame, although the concept of ‘silent disease’, i.e., initial symptoms not reliably predicting early disease has also been proposed. 10-15 IS ORAL CAnCER SCREEnInG THE MAGIC SOLUTIOn In light of the above, is oral cancer screening the magic solution? Screening is defined as the search for disease in either a person who does not have symptoms or a person who does not recognise the symptoms as being related to the particular disease. 16 According to the latest Cochrane review on the subject, insufficient evidence exists to recommend inclusion or exclusion of screening for oral cancer using a visual examination in the general population. 17 This conclusion is mainly attributed to very limited research in the area, with only one randomised controlled trial meeting the review’s inclusion criteria.18 Results of this Indian study favour oral cancer screening in the high risk population (users of tobacco, alcohol or both) but not in the general population.18 While at present little evidence exists to support implementation of a national oral cancer screening program, authors of the Cochrane Review go on to say that, as an alternative for a national screening program, regular opportunistic screening by visual examination applied by qualified health care providers for a high risk group might be effective in achieving an improved outcome.18 There is another argument that can potentially be made against a national oral cancer screening program. When one considers the low compliance with cancer screening programs, specifically oral cancer, together with disease of low prevalence, the end result is a very low detection rate and therefore perhaps not worth the resource investment required. 19,20 Is oral cancer screening in the dental office (opportunistic screening) a more logical approach? Dentists, in this regard, are well placed amongst the health care professionals, as they often appear to be the first clinicians consulted regarding symptoms of oral cancer and are in fact more likely to identify oral SCC’s correctly. 21 Accepting that oral cancer screening may be effective when it is applied to the high risk population, the question then becomes – are dentists seeing the high risk patients, i.e., individuals over 40, males, those consuming alcohol, smoking and consuming a poor diet; how many of those patients are being seen; and how often (Fig 2)?22 While data in this area are conflicting, most studies suggest that dentists are not seeing the high risk individuals regularly, raising questions about the effectiveness of oral cancer screening in this environment. 22-26 Fig 1. Patient with advanced oral squamous cell carcinoma.
ADA News Bulletin June 2011
ADA News Bulletin August 2011