• 8/10/2003
  • Brian Hill
  • Dental Abstracts Magazine,. Mosbey Publishing

This month’s issue of Dental Abstracts, from Mosbey Publishing, features an editorial regarding the need for additional efforts on the part of the US dental community in the early detection of oral cancers written by OCF founder Brian Hill. The Spanish language version of the magazine also carries the editorial outside the US. “ I was surprised but pleased that a US dental magazine would invite me to write a piece on the foundation’s perspectives related to the late diagnosis of oral cancer here in the US,” says Hill. “I believe this is largely a result of Dr. Larry Meskin becoming the editor of this journal. Dr. Meskin has a long history as an advocate for oral cancer screening within the dentist community. Hill has long believed that more could be done by American dentists to discover these lesions in their earliest, highly curable stages. The content of the editorial follows.

Dental Lifesavers?

An oxymoron? Perhaps not. We know that dentists and hygienists are not thought of by the public, and do not think of themselves, as people who engage in the saving of lives. After all, they are not ER doctors. But when either of these dental professionals finds an oral cancer in the course of their examinations, especially if at an early stage one or two, they have undoubtedly saved a life. The Oral Cancer Foundation has begun a Dental Lifesavers Program, designed to raise the visibility, awareness, and recognition of these individuals who, through two simple acts, educating themselves about oral cancers, and taking the time to screen their patient population for oral cancer, actually save lives. Those who are publicly recognized in this program in news stories, invariably say they were just doing their job. But to the patients who nominated them to be recognized, and to the foundation, they are heroes. By incorporating a program of cancer screening into their practice of dentistry and dental hygiene, they significantly contribute to reducing the death rate and the morbidity of this disease. They help engrain in the public’s mind, that a visit to the dentist is not just about cosmetics, hygiene, a crown or filling. When oral cancer screenings are part of a complete dental examination, it is also about saving a life. Their effort reflects the highest standards of dental practice and a commitment to providing the optimum in quality care to patients. It’s a great news story, and certainly helps elevate the dental community in the public’s eye.

But what is the real story here? With over 30,000 individuals being diagnosed with oral cancer each year, you would think that the early discovery of this disease by members of the dental community wouldn’t be that extraordinary, and certainly not newsworthy. After all, oral cancers, and even the precursor tissue changes that lead up to a malignancy, are visible to the naked eye, making them an easy target for early detection. Its discovery does not require any special tests, or high-tech equipment. Oral cancer is not hidden in a region of the body which requires an invasive procedure that might complicate the patient’s willingness to be screened, or make the disease difficult to find. When all this is considered, it would seem that a dental teams discovery and diagnosis story would be a commonplace event. While all that would seem logical, sadly, it is not the case. Most oral cancers are not found in their early stages by the dental profession.

We know that in all cancers, the greatest progress we have made in reducing death rates, has come through early detection. The PAP smear for cervical cancer, the digital exam and PSA test for prostate cancer, the mammogram and self-exam for breast cancers, have all contributed to reductions in the death rate from these diseases. The American public is very aware that these tests are annual necessities, and that concept is well engrained in the public’s mind. Compare these examples with oral cancer, where public awareness is low, and screening for it seems below most people’s radar, including that of the dental profession. Because its early detection happens too infrequently, oral cancer maintains its high ranking as a killer. It is most commonly diagnosed when it is a stage three or four disease. At these stages, it is not hard to detect, and I would argue that my gardener could diagnose it once it is the size of quarter. If oral cancer is detected early, survival rates are in the 80-90% range. Late stage detection yields less than a 20% survival rate. Overall, only 50% of those diagnosed this year will survive five years. Given these current statistics, it is clear that early detection is not routinely taking place.

Oral cancer holds an undeserved high ranking as a killer. More than cervical cancer, melanoma, Hodgkin’s disease, and others you hear much more about, it takes the life of someone every hour, of every day, of every month, of every year. It has maintained this high ranking for decades, with no significant improvement in the death rate. Given its ease of detection, the real story here is… How can this be?

In one study, only 7% of those who regularly visit a dentist report having had an examination for oral cancer. If you argue that they received one and did not know it, triple the number in the study to compensate for a possible statistical error, and still less that one quarter of that study population would have received the exam. Another published study indicates that the dental community is poorly prepared to identify early cancers. In it, only 54% of dentists knew the two most common sites where oral cancer occurs. Only 36% knew that erythroplakia and leukoplakias were the two most common lesions to be associated with oral cancer. The statistic which I find the most disturbing, comes in a report from the State of Maryland Cancer Registry, which found 83% of oral cancers are diagnosed by non-dental personnel. It is probable that this number is not unique to Maryland. By the time an individual approaches an M.D. with their complaint, it is likely an enlarged neck node, this location and symptom taking their thought process away from dentistry and towards general medicine. Of course malignant nodes are infrequently the primary tumor, and being the most common metastatic location for oral cancer, it is reasonable to conclude that someone did not catch it early in the oral environment. Something is very wrong with all this.

There is a wave building in the US. It is a wave of awareness. The ADA, with the generous financial support of OralScan Laboratories, has embarked on an ambitious public awareness campaign. A free public screening effort initiated by NYU has blossomed into a multi-center consortium of universities and hospitals in the Northeast, which with the help of ABC-TV, is pushing the public awareness of oral cancer. The federal government’s national health goals for 2010 have for the first time, included objectives which are aimed exclusively at oral cancer. An Oral Cancer Foundation has been created to fill a void and a need for information, advocacy, and support. Their six-month-old web site is receiving over 775,000 hits a month. Simultaneous events like these do not occur in a vacuum. There is always a precipitating factor. In this case, that factor is the realization that five decades with no improvement in the early detection of this disease, and the subsequent high death rate, is no longer acceptable. What does this mean to dentistry and to general medicine? The status quo is about to change… with their cooperation, or without it. The only question remaining is, what role will the dental community play in this change?

At a recent meeting of the oral cancer planning committee at the Centers for Disease Control, which I attended and spoke at, this very issue was a topic of discussion. Of all the comments made by presenters there, one stuck in my mind more than the others. “If dentists do not take the initiative, it is likely they will be litigated into being more concerned about the early detection of oral cancer.” Indeed, I am aware of several cases currently in the court systems where dentists are defendants in cases of missed diagnosis involving oral cancer, or worse, treating the patient with what I can only characterize as watchful neglect. Monitoring over a protracted period as the patient’s small “non typical aphthae, or atypical herpetic lesion” blossomed over the course of a year of observation into a late stage squamous cell carcinoma. Given simple alternatives, such as the brush biopsy to determine early in the process, if a benign condition or a dangerous lesion has been encountered, and a well-established referral system, this should not occur. Certainly the majority of lesions or soft tissue abnormalities (in one study 3-5 a day) that are seen by dentists are benign, and many of these innocuous conditions mimic oral cancer. But this should not induce apathy. Any condition which has not resolved with in a 14-day period, with or without treatment, should be considered suspect and worthy of further diagnostic procedures or referral. While I normally save this observation for those in general medicine, it bears repeating here. When a patient over 40 presents with an enlarged neck node, cancer should be the first differential diagnosis. Please do not spend weeks using up your prescription pads on antibiotics.

Dentistry has a unique opportunity to catch this wave of momentum, and turn it into a positive force, reversing decades of passive neglect. Decades
I might add, that are not currently in the public’s awareness. Each opportunity that we are presented with exists for a finite moment in time. The time to capitalize on this one is right now. A dental community involved with saving lives through early detection will add prestige to its profession, build practices using the annual cancer screening as a vehicle, and serve the public good. I ask you to become an involved active partner in changing the status quo. Take a CE course and apply that refreshed knowledge in your practice, or join the Oral Cancer Foundation, and take advantage of the resources and information they provide. Get involved, and take a stand against this killer.