Source: www.ada.org/news
Author: Jennifer Garvin
A panel convened by the ADA Council on Scientific Affairs explored the potential benefits and risks of screening for oral squamous cell carcinomas and the use of screening aids to detect malignant or potentially malignant oral lesions. The panel’s findings are published as the cover story in the May edition of The Journal of the American Dental Association.
“Evidence-Based Clinical Recommendations Regarding Screening for Oral Squamous Cell Carcinomas” were developed by a CSA expert panel convened in April 2009, and join similar recommendations on topical fluoride and sealants as the Association’s only evidence-based recommendations.
Though evidence-based dentistry (EBD) recommendations do not represent a standard of care, the CSA hopes practitioners will use the recommendations as a resource in their clinical decision-making process alongside a clinician’s judgment and experience in the context of a patient’s individual needs.
The panel worked with ADA Center for Evidence-Based Dentistry staff and assessed five systematic reviews and four clinical studies as a basis for developing the recommendations. They addressed whether or not screenings help reduce morbidity and mortality, and whether or not oral cancer detection devices aid in detecting potentially malignant or malignant lesions.
The panel concluded that while oral cancer screenings may detect potentially malignant and/or malignant lesions, clinicians are urged to remain alert for signs the lesions may become cancerous or early stage cancers while performing routine visual and tactile examinations in all patients, particularly those who use tobacco or consume alcohol heavily.
“What’s most important is that this (review) points to the need for more research on the natural history of squamous cell carcinomas in the mouth and the epidemiology of oral cancer,” said Dr. Michael Rethman, CSA chair. “We still don’t understand the answers to a lot of fundamental questions like the progression of the disease and whether intervention helps. It’s plausible that early diagnosis helps, but we don’t even know that,” he added.
“There’s an incredible need for more research on this topic,” he added.
For more information about the ADA’s clinical recommendations, visit http://ebd.ada.org.
To see the May issue of JADA, go to http://jada.ada.org.
Notes:
1. In developing the evidence-based clinical recommendations for oral squamous cell carcinomas, the ADA Council on Scientific Affairs considered the following four questions:
- Does screening through visual and tactile examination performed by a dentist reduce morbidity and mortality resulting from potentially malignant or malignant lesions?
- Does the use of the following adjuncts (autofluorescence, tissue reflectance and transepithelial cytology) by a dentist, in conjunction with visual and tactile examination, reduce morbidity and mortality from oral cancer to a greater extent than that experienced with visual and tactile examination alone?
- In comparison with visual and tactile examination alone, do the currently available oral cancer detection devices enhance the diagnostic properties (such as sensitivity, specificity, positive and negative predictive values) in detection of potentially malignant or malignant lesions?
- Are there specific population subgroups—defined by age, sex, ethnicity, risk factors or other characteristics—in which oral cancer screening has relatively high positive and negative predictive values, resulting in detection of potentially malignant or malignant oral lesions?
The Oral Cancer Foundation disagrees with this academic literature review which does not STRONGLY state that early discovery leads to significantly less morbidity in treated individuals, and has a positive outcome on long term survival. Note that they had to put a disclaimer at the end of their article that says; “This article does not reflect the opinions of the CDC” (their stated partner in its production). As a long-term member of the oral cancer work group at the CDC, I know that to be a fact. There is a serious disconnect in the ADA, between what the organization’s stated (on the web site) policy is, i.e. you must screen for oral cancer when you do exams, and what the ADA/EBD (ADA evidenced based internal group that produced this paper) thinks are appropriate guidelines for the behavior of dentists… which would appear to be, gee we really can’t recommend definitively, in a strong manner, for or against. When you compare this ivory tower, academics produced paper with the real world of treating oncologists, the disconnect with the real world of oral cancer becomes even more evident. There is no ambiguity in the government complied SEER (surveillance, epidemiology, and end results) numbers for oral cancer, that clearly show that stage one patients live longer and have less morbidity than stage four patients. Of course it is obvious that in order to be a stage one patient, you have to have your disease found early…. That would be through screening of course.
The realm of dentistry is (and if they are going to be schizophrenic, I guess I will have to state “should be”) early detection/discovery at stages in which survival is greatest. That means stage one disease at worst, pre cancers at best. Discovery is a by-product of screening.
This paper has contradictions in the paper itself. In one area stating that recommendations ARE for screening since it has positive benefit in reduction of morbidity and death when speaking of black populations, and in another paragraph later stating that the evidence for improvements in these areas (morbidity and long term outcomes) cannot be known. Are we to interpret this as something specific to the black population? Of course this was not their intention, but it is their outcome. I have a great deal of respect for some of the authors, but the omission of important articles, and a bias to the published evidence based perspective only, completely eliminating the clinical experience in the world of oncology, yields a document that satisfies no one and comes to conclusions that are not strongly stated, or perhaps even completely valid. For that matter they even stated that the evidence to produce the opinions and recommendations was “not robust.” This is my grand father would have said, is a “no shit” moment in time…. If there is not enough evidence to come to finite conclusions in an evidenced based document, how does it help anything or anyone, to put out a paper full of maybes? This has everything to do with the parameters for conducting the review, set up before it was done. In my opinion those parameters were flawed.
In every field, be it dental or medicine, there are some academics that live solely in the world of “evidence based peer reviewed publications.” In my opinion this is myopic at best. Please show me going back in centuries, the peer reviewed document that, without ambiguity, proves that the earth is round. IT DOES NOT EXIST. The explanation/proof for the roundness of the earth was first done through mathematics and other venues. This is not evidence based but scientific extrapolation, that is an important tool. When we were finally able to look back at the world from flight, it was self evident – ROUND! We are able to look back at our oral cancer patient populations from the treatment facilities, who will laugh this paper into obscurity. The evidence of early discovery benefit is SELF EVIDENT in the treatment world of oncology.
Now someone explain to me who is going to spend a decade at least, and hundreds of millions of dollars, to do a study that shows that screening for oral cancers finds them at earlier states, yielding earlier staging, which we know yields better end results in treatment – both in death and morbidity (damage to the patient as a result of the treatments.). NO ONE. Because we know from clinical experience that it is self evident, and if DENTISTS THAT LIVE IN ACADEMIA WOULD GO OUT INTO THE TREATMENT WORLD OF ONCOLOGY, AND GET UP TO THEIR ELBOWS IN SOMEONE’S BLOOD FOR A CHANGE, this would be as obvious to them as it is to those that deal with those patients every day. It is self evident that someone who has their tongue or jaw removed as a result of a late find and diagnosis, even if they survive the disease, has a tough road ahead of them, of unemployment, lack of ability to eat and speak, and so much more. This is the real world morbidity of treatment of late stage oral cancer. Late discovery equals late stage diagnosis, and is a major issue that dentistry needs to turn around, and is capable of doing.
The ADA has only added mud to the water by putting this paper out there, Their news release here does not fully convey the discrepancies in the thinking and conclusions of the full article, and I urge all those interested to read it in its entirety. Their news release (shown here) seems cohesive in statement, the actual EBD paper is not. OCF will not be putting space to waste to put it up but it is on the ADA site. Perpetuation and distribution of this is counter productive. The good news in all this is hardly anyone reads JADA.
To suggest that early detection’s benefits are ambiguous in anyway is a disservice, and confuses the general dental practitioner who we depend on for early discovery. The cause and the public did not need this now.