The dental community is up in arms over a recent Consumer Reports article that claims oral cancer screening is one of several medical tests that are overrecommended and unnecessary for all but high-risk patients.
The article, which appears in the March 2013 issue, concluded that “most people shouldn’t waste their time” on most diagnostic tests, including chairside visual screenings for oral cancer.
“Most people don’t need the test unless they are at high risk, because the cancer is relatively uncommon,” Consumer Reports wrote.
But the ADA and the Oral Cancer Foundation vehemently disagree with the magazine’s conclusions, asserting that visual screening can result in earlier diagnosis of oral cancer and other oral diseases.
The Consumer Reports article recommends only three cancer tests — cervical, colon, and breast — as worthwhile, and includes oral cancer screening among “eight to avoid” tests: ovarian, pancreatic, testicular, prostate, bladder, lung, oral cavity, and skin cancer.
The magazine said its ratings were based mainly on reviews from the U.S. Preventive Services Task Force.
Early diagnosis critical
According to Consumer Reports, the medical community has “systematically exaggerated” the benefits of screening while downplaying the harms, such as unnecessary radiation and biopsies.
The ADA quickly registered its disappointment with the recommendations and sent a letter — co-signed by the American Academy of Oral & Maxillofacial Pathology — to the editors of Consumer Reports, noting that noninvasive visual and tactile oral cancer screenings are typically included in oral exams and can result in earlier diagnosis of oral cancer and other oral diseases.
Brian Hill, executive director of the Oral Cancer Foundation who had stage IV bilateral cervical lymph node metastases when his oropharyngeal cancer was discovered, also took issue with the magazine’s recommendations.
“I disagree categorically,” he told DrBicuspid.com. “It isn’t an invasive exam, there’s no radiation (no long-term exposure issue), it is painless, it’s usually free, and you’re already sitting in the dentist chair. Why would you not get it?”
The problem is there’s no good screening mechanism to identify the high-risk group, he added.
“Obviously, tobacco users and those who consume high levels of alcohol have been the historic high-risk group. But with HPV [human papillomavirus] 16 becoming the fastest-growing segment of the oral cancer population, we have a new problem: we cannot sort the group of people with persistent viral infections from the general population today,” Hill said, noting that many people with HPV infections don’t know they have it as there are no outward, obvious signs or symptoms.
Some 99% of those with HPV infections clear the virus through normal immune response (within two years if you use the cervical cancer model), and only 1% will develop oral cancer, he added.
“To use the logic that oral cancer does not occur frequently enough to warrant getting the screening is myopic,” he stated. “One American dies every hour of every day of the year from oral cancer. That is not something to ignore. We can no longer realize who is high- or low-risk.
The American Cancer Society also endorses oral screenings and recommends that “doctors examine the mouth and throat as part of a routine cancer-related checkup” in its policy guidelines.
False positives and biopsies
John Santa, MD, MPH, director of the Consumer Reports Ratings Center, acknowledged that the magazine struggled with including oral cancer screening among the tests that were not recommended.
“I think this is more of an issue with doctors than dentists,” he told DrBicuspid.com. “While it’s laudable that all these organizations recommend oral cancer screening, I would ask them to produce evidence that shows it saves lives.”
In addition, Dr. Santa noted, cancer screenings can produce false positives, resulting in unnecessary biopsies, and data from the U.S. Preventive Services Task Force and Cochrane Review research did not support routine oral cancer screening.
In fact, a recent study in the Journal of the American Dental Association found that clinical oral exams have a poor overall performance as diagnostic methods for predicting dysplasia and oral squamous cell carcinoma. But a 2010 report by a panel convened by the ADA Council on Scientific Affairs endorsed routine visual and tactile examinations in all patients during dental appointments (JADA, May 2010, Vol. 141:5, pp. 509-520).
Also, oral oncologists are reporting seeing more young people who don’t have the usual risk factors such as smoking or drinking but are developing oral cancer.
Close to 42,000 Americans will be diagnosed with oral or pharyngeal cancer, and it kills more than 8,000 patients annually, according to the Oral Cancer Foundation, which notes the mortality rate for oral cancer is higher than that of cancers such as cervical cancer or Hodgkin’s lymphoma.
*This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.
Reply to this article that was posted on the Dr. Bicuspid website article by OCF Founder Brian Hill
I put no weight on what the U.S. Preventive Services Task Force and Cochrane Review have to say about this since their determination was based on the evidence that no peer review studies have been done to show that oral cancer screening has any impact on long-term outcomes. They are actually right, but there is a caveat here.
The fact that there have been no peer-reviewed studies is only partly true. There was a landmark study, published in Lancet which is a strictly peer reviewed, respected journal, done in India by several researchers from different countries which did find significant benefit to early discovery through screening, but Cochrane disagreed with the protocol for the study which looked at tens of thousands of people offer a protracted period of time, (about a decade). The study found a huge reduction in deaths as a result of opportunistic screening. What they really did not like about the study was that the screeners were NOT DOCTORS in many of the cases. So just think of that – you have a study which shows about a 25% reduction in deaths or better, and EVEN WITH NON DOCTORS DOING MANY OF THE SCREENINGS, you have this great outcome. So they subjectively omitted it from the materials they reviewed to come to their conclusion. More so, something much more obvious. Even with the absence of a study, their conclusion is not proof of a negative, that screenings have no value, it is actually proof that THERE ARE NO STUDIES. Nothing more. Having addressed this on several occasions with groups that do these “meta analysis ” types of reviews and then draw conclusions from them, I have never gotten a satisfactory answer to this question, “Where is the study that shows that parachutes save lives?” The government (FAA) mandates that I wear one when flying aerobatics, so they obviously think it is a good thing and would save my life in a mishap, and our military pilots fly with one on every mission, so they obviously buy into the value of a parachute to save your life as well. But where is the study that proves it? One does not exist. There is plenty of anecdotal evidence, and lots of published stories of them saving lives, but no peer reviewed study or paper anywhere. If you exclude common sense, or what is self evident from your conclusion, you would have to have a statement that there is no evidence that parachutes save lives.
So if this is the case, it begs the question as to why are there no studies? The most obvious answer to this question is that no one is going to spend millions of dollars to do a study on something which is self evident. I asked this question of a H&N surgeon who is routinely up to his elbows in someone’s blood, who stated that his job would be drastically reduced if we were finding more cancers at earlier stages.
So this makes the next question pretty obvious. We know from the best database of disease rates and outcomes in the US, the SEER database (Surveillance, Epidemiology, and End Results) which is how we track incidence, causes, and outcomes in the US, that stage one oral cancer patients have better outcomes, and stage four patients have poorer outcomes. This should not surprise anyone. Stage one people have besides longer lives, far fewer treatment related morbidity issues to get to a point of no disease (NED).
The real question is HOW DO YOU GET TO BE A STAGE ONE FIND AT TIME OF DISCOVERY? There are two possible pathways to this. The first would be what OCF and many others including the ADA have always advocated for, and that is OPPORTUNISTIC screening. This is screening of an entire population or group of people, not just those with complaints or with known high risk factors like tobacco use, but everyone that your practice sees. This concept is even more important today since we no longer can, with the fast rise of HPV16 as a prime driver of oral / oropharyngeal cancers, identify easily the high risk group (outside of tobacco users) in the American population.
The second means to becoming a stage one find at time of diagnosis would be SELF DISCOVERY. This would mean that a population of people were knowledgeable enough to recognize that something is not right in their mouth, neck, etc. and take themselves to the doctor to have it explored in detail, before it got too far out of control. OCF is working on a public outreach and creating a dialog with the American public directly to raise awareness not just of the disease that too few have even heard of, but of the early warning signs and symptoms that should concern them enough that they self refer to a doctor for evaluation. These are the only two reasonable pathways to becoming a stage one find, which today happens too infrequently in our country.
So I state once again, that Consumer Reports missed this by a mile and is backpedaling to trying and justify a position that is categorically without merit. They have done a significant disservice to their readers by suggesting that just because in their opinion, 42,000 people is too small a group to be concerned with, that skipping the screening is the proper answer. Dr. Santa should meet some oral cancer patients; see their pain, their inability to speak ever again, to never eat normally, to no longer have the ability to kiss their loved ones and be facially disfigured, just some of the huge drop in quality of life issues that they live with -IF they are one of the lucky ones to be in the 57% that even survives to five years. Perhaps his attitude about screening and self defense of his finding would be less cavalier.