Screening programmes for the early detection and prevention of oral cancer

Challenges in the Early Diagnosis of Oral Cancer, Evidence Gaps and Strategies for Improvement: A Scoping Review of Systematic Reviews

Simple Summary

Oral cancer presents a worldwide incidence of 377,713 new cases and 177,757 deaths per year (GLOBOCAN, IARC, WHO). Oral squamous cell carcinoma (OSCC) accounts for approximately 90% of oral malignancies and has a 5-year mortality rate close to 50%. We aim to better understand, based on the evidence, and to discuss in depth, the reasons for the diagnostic delay of oral cancer by reviewing systematic reviews and meta-analyses. We also aim to, identify gaps in evidence, recommend future lines of research that should be implemented, and formulate strategies for improvement.

Abstract

Oral cancer is a growing problem, accounting for 377,713 worldwide new cases per year, and 177,757 deaths annually and representing a 5-year mortality rate close to 50%, which is a considerable mortality that has not decreased substantially in the last 40 years. The main cause of this high mortality is related to the diagnosis of a high percentage of oral cancers in advanced stages (stages III and IV) in which treatment is complex, mutilating or disabling, and ineffective. The essential cause of a cancer diagnosis at a late stage is the delay in diagnosis, therefore, the achievement of the objective of improving the prognosis of oral cancer involves reducing the delay in its diagnosis. The reasons for the delay in the diagnosis of oral cancer are complex and involve several actors and circumstances—patients, health care providers, and health services. In this paper, we present the results of a scoping review of systematic reviews on the diagnostic delay in oral cancer with the aim to better understand, based on the evidence, and discuss in depth, the reasons for this fact, and to identify evidence gaps and formulate strategies for improvement.

Effectiveness of Interventions to Improve Oral Cancer Knowledge: a Systematic Review

Oral cancer is prone to late-stage diagnosis, and subsequent low five-year survival rates. A small number of interventions or campaigns designed to enhance knowledge of risk factors and symptoms associated with oral cancer have been attempted in the UK, US, and some other countries. The purpose of this systematic review is to assess the effectiveness of interventions designed to improve oral cancer knowledge. We searched five databases to identify randomized controlled trials (RCTs) and non-randomized/quasi-experimental (NR/QE) studies targeting the general population or high-risk groups (tobacco users or alcohol consumers), aged ≥15 years, and reporting the outcomes of individual and/or community level interventions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. Adhering to PRISMA guidelines, 27 (eight RCTs and 19 NR/QE studies) of the 551 studies identified from the five databases met the inclusion criteria. All RCTs and nine NR/QE studies used either printed materials, health education sessions, multimedia aids, or some combinations of these tools. The other ten NR/QE studies were community-based and used mass media campaigns to increase oral cancer awareness. Overall, the majority of studies significantly improved oral cancer knowledge; however, heterogeneity in study design and variation in measurement tools made it difficult to compare outcomes. Findings suggest that individual and/or community level interventions are generally effective in increasing knowledge of oral cancer risk factors, signs and symptoms, and/or its early diagnosis and prevention strategies among the general population or high-risk groups. However, the long-term benefits of these interventions are understudied.

EPIDEMIOLOGICAL SITUATION OF PRE-CANCER DISEASES OF THE ORAL MUCOUS IN UKRAINE

OBJECTIVE

The aim: To conduct a prospective clinical study to assess the prevalence, structure, risk factors and features of clinical manifestations of precancerous diseases of oral mucosa and red lip in Kyiv residents and to analyze opportunities to improve the quality of their primary diagnosis.

PATIENTS AND METHODS

Materials and methods: The examination of 423 patients with precancerous diseases of oral mucosa and red lip included clarification of the main complaints and anamnesis of the disease, objective assessment of the state of oral mucosa and red border of the lips according to visual, stomatoscopic, luminescent analysis, cyto-, histological studies.

RESULTS

Results: Attention is drawn to the prevalence among precancerous diseases of patients with leukoplakia - 41.37% and lichen planus - 44.21%. The levels of detection of precancerous diseases of the oral mucosa due to the current and preliminary history for individual nosological forms are almost identical, which indicates the reliability of the above indicators.

CONCLUSION

Conclusions: Promotion between the people about timely dental treatment for precancerous diseases of the oral mocosa and the use of radical technologies in their treatment will not only increase the effectiveness of treatment, but significantly limit the malignancy of these diseases.

Brazilian Oral health teams in primary care and oral cancer: Results of a national evaluation

Oral cancer is one of the most prevalent cancers in Brazil. An understanding of how public policies are implemented to address this problem can contribute to the construction of solutions. The "Programa de Melhoria do Acesso e da Qualidade" (PMAQ-AB and PMAQ-CEO) at the level of primary and secondary care are evaluations that also collect data on prevention and monitoring strategies for oral cancer. This study aimed to analyze the results of the incorporation of oral health teams to evaluate the strategies adopted by Brazil regarding the impact on the diagnosis of oral cancer. Of the 17,202 family health teams evaluated, 72.10% had oral health teams (OHT). Considering the strategies for prevention, screening, campaign, and follow-up of suspected cases, 72.27% of the campaign teams and 59.09% of the teams who accompanied suspected cases had OHT. In secondary care, more than 65% of the teams in the Southeast and South regions registered cases of oral cancer, and the referral network was more represented. The inclusion of OHT had a positive impact on campaign actions, follow-up, referral to specialists, and registration of suspected cases throughout Brazil.

Global, regional, and national burden and quality of care index (QCI) of lip and oral cavity cancer: a systematic analysis of the Global Burden of Disease Study 1990-2017

BACKGROUND

To measure the quality of care for lip and oral cavity cancer worldwide using the data from the Global Burden of Disease (GBD) Study 2017.

METHODS

After devising four main indices of quality of care for lip and oral cavity cancer using GBD 2017 study's measures, including prevalence, incidence, years of life lost, years lived with disability, and disability-adjusted life years, we utilised principal component analysis (PCA) to determine a component that bears the most proportion of info among the others. This component of the PCA was considered as the Quality-of-Care Index (QCI) for lip and oral cavity cancer. The QCI score was then reported in both men and women worldwide and different countries based on the socio-demographic index (SDI) and World Bank classifications.

RESULTS

Between 1990 and 2017, care quality continuously increased globally (from 53.7 to 59.6). In 1990, QCI was higher for men (53.5 for men compared with 50.8 for women), and in 2017 QCI increased for both men and women, albeit a slightly higher rise for women (57.2 for men compared with 59.9 for women). During the same period, age-standardised QCI for lip and oral cavity cancer increased in all regions (classified by SDI and World Bank). Globally, the highest QCI scores were observed in the elderly age group, whereas the least were in the adult age group. Five countries with the least amount of QCIs were all African. In contrast, North American countries, West European countries and Australia had the highest indices.

CONCLUSION

The quality of care for lip and oral cavity cancer showed a rise from 1990 to 2017, a promising outcome that supports patient-oriented and preventive treatment policies previously advised in the literature. However, not all countries enjoyed such an increase in the QCI to the same extent. This alarming finding could imply a necessary need for better access to high-quality treatments for lip and oral cavity cancer, especially in central African countries and Afghanistan. More policies with a preventive approach and paying more heed to the early diagnosis, broad insurance coverage, and effective screening programs are recommended worldwide. More focus should also be given to the adulthood age group as they had the least QCI scores globally.

The readiness of dentists to use the autofluorescence method

Background. Head and neck squamous cell carcinoma are the sixth most common cancer in prevalence rate. Early diagnosis significantly reduces morbidity and mortality. Autofluorescence facilitates diagnosis the disease at the early stages, but it depends on the doctor’s skill in interpreting images. The aim of the study: to analyze the results of reading autofluorescence images of the oral mucosa by dentists.Materials and methods. The results of reading 10 autofluorescence images of potentially malignant diseases of the oral mucosa and 10 images of benign lesions and conditions were evaluated. The study involved 308 dentists. The assessment of the ability to recognize autofluorescence images was carried out with respect to gender, age, length of service, qualification category, academic degree, position of the head of the department.Results. On the average, dentists correctly differentiated the results of visualization of potentially malignant diseases of the oral mucosa in 3.85 ± 2.47 cases, benign lesions together with other benign conditions – in 4.56 ± 2.47 cases. Images of benign lesions and conditions were identified by dentists better than images of potentially malignant diseases of the oral mucosa (t = –17.0; p < 0.001). There is a direct correlation between the correct differentiation of visualization of potentially malignant diseases of the oral mucosa with the correct interpretation of benign lesions and conditions (r = 0.956; p < 0.001). The interpretation of potentially malignant diseases of the oral mucosa is not related to gender (t = –1.62; p = 0.306), work experience (r = –0.002; p = 0.977), department head (t = –0.11; p = 0.910), qualification category (t = –0.50; p = 0.574), academic degree (t = –0.34; p = 0.731).Conclusion. Dentists cannot recognize diseases of the oral mucosa well in autofluorescence images. The recognition skill is not related to general professional development.

Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions

BACKGROUND

Squamous cell carcinoma is the most common form of malignancy of the oral cavity, and is often proceeded by oral potentially malignant disorders (OPMD). Early detection of oral cavity squamous cell carcinoma (oral cancer) can improve survival rates. The current diagnostic standard of surgical biopsy with histology is painful for patients and involves a delay in order to process the tissue and render a histological diagnosis; other diagnostic tests are available that are less invasive and some are able to provide immediate results. This is an update of a Cochrane Review first published in 2015.

OBJECTIVES

Primary objective: to estimate the diagnostic accuracy of index tests for the detection of oral cancer and OPMD, in people presenting with clinically evident suspicious and innocuous lesions.

SECONDARY OBJECTIVE

to estimate the relative accuracy of the different index tests.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: MEDLINE Ovid (1946 to 20 October 2020), and Embase Ovid (1980 to 20 October 2020). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were also searched for ongoing trials to 20 October 2020. No restrictions were placed on the language or date of publication when searching the electronic databases. We conducted citation searches, and screened reference lists of included studies for additional references.

SELECTION CRITERIA

We selected studies that reported the diagnostic test accuracy of the following index tests when used as an adjunct to conventional oral examination in detecting OPMD or oral cavity squamous cell carcinoma: vital staining (a dye to stain oral mucosa tissues), oral cytology, light-based detection and oral spectroscopy, blood or saliva analysis (which test for the presence of biomarkers in blood or saliva).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors, independently and in duplicate. Studies were assessed for methodological quality using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Meta-analysis was used to combine the results of studies for each index test using the bivariate approach to estimate the expected values of sensitivity and specificity.

MAIN RESULTS

This update included 63 studies (79 datasets) published between 1980 and 2020 evaluating 7942 lesions for the quantitative meta-analysis. These studies evaluated the diagnostic accuracy of conventional oral examination with: vital staining (22 datasets), oral cytology (24 datasets), light-based detection or oral spectroscopy (24 datasets). Nine datasets assessed two combined index tests. There were no eligible diagnostic accuracy studies evaluating blood or salivary sample analysis. Two studies were classed as being at low risk of bias across all domains, and 33 studies were at low concern for applicability across the three domains, where patient selection, the index test, and the reference standard used were generalisable across the population attending secondary care. The summary estimates obtained from the meta-analysis were: - vital staining: sensitivity 0.86 (95% confidence interval (CI) 0.79 to 0.90) specificity 0.68 (95% CI 0.58 to 0.77), 20 studies, sensitivity low-certainty evidence, specificity very low-certainty evidence; - oral cytology: sensitivity 0.90 (95% CI 0.82 to 0.94) specificity 0.94 (95% CI 0.88 to 0.97), 20 studies, sensitivity moderate-certainty evidence, specificity moderate-certainty evidence; - light-based: sensitivity 0.87 (95% CI 0.78 to 0.93) specificity 0.50 (95% CI 0.32 to 0.68), 23 studies, sensitivity low-certainty evidence, specificity very low-certainty evidence; and - combined tests: sensitivity 0.78 (95% CI 0.45 to 0.94) specificity 0.71 (95% CI 0.53 to 0.84), 9 studies, sensitivity very low-certainty evidence, specificity very low-certainty evidence.

AUTHORS' CONCLUSIONS

At present none of the adjunctive tests can be recommended as a replacement for the currently used standard of a surgical biopsy and histological assessment. Given the relatively high values of the summary estimates of sensitivity and specificity for oral cytology, this would appear to offer the most potential. Combined adjunctive tests involving cytology warrant further investigation. Potentially eligible studies of blood and salivary biomarkers were excluded from the review as they were of a case-control design and therefore ineligible. In the absence of substantial improvement in the tests evaluated in this updated review, further research into biomarkers may be warranted.

MicroRNA as a Novel Biomarker in the Diagnosis of Head and Neck Cancer

Head and neck squamous cell carcinoma is the sixth most common cancer worldwide, with 890,000 new cases and 450,000 deaths in 2018, and although the survival statistics for some patient groups are improving, there is still an urgent need to find a fast and reliable biomarker that allows early diagnosis. This niche can be filled by microRNA, small single-stranded non-coding RNA molecules, which are expressed in response to specific events in the body. This article presents the potential use of microRNAs in the diagnosis of HNSCC, compares the advances in this field to other diseases, especially other cancers, and discusses the detailed use of miRNA as a biomarker in profiling and predicting the treatment outcome with radiotherapy and immunotherapy. Potential problems and difficulties related to the development of this promising technology, and areas on which future research should be focused in order to overcome these difficulties, were also indicated.

Application of a non-invasive oral brushing procedure based on bisulfite sequencing of a 13-gene panel to study high-risk OSCC patients

BACKGROUND

A non-invasive sampling procedure for the early detection of Oral Squamous Cell Carcinoma (OSCC) based on DNA methylation analysis of a panel of 13 genes was applied in 4 different OSCC risk-group of patients. Aim of the study is to evaluate the between-group differences and the variables related to the methylation profile of each group.

METHODS

Oral brushing samples were collected from 54 healthy subjects, 31 Oral Leukoplakia (OL) patients, 18 Oral Lichen Planus (OLP) patients and 26 patients previously treated for OSCC. Each sample was considered positive or negative in relation to a predefined cut-off value.

RESULTS

None of the samples from 54 healthy subjects were positive, whereas 22/31 OL, 3/18 OLP and 8/26 surgically treated OSCC samples showed positive values with respect to the cut-off. In OL patients, dysplasia was the only variable significantly related to positive values: 10/10 OLs with high-grade dysplasia were positive with respect to 12/21 OLs without dysplasia (Chi 6.039, p< 0.05).

CONCLUSION

DNA methylation analysis in epithelial cells collected by oral brushing seems to be a promising genetic method to distinguish lesions at high risk of developing OSCC. Larger population studies and an adequate follow-up period are necessary to confirm these preliminary data.

Oral cancer: a major and growing public health problem towards a national policy of prevention and early detection in Tunisia

Oral cancer is a growing public health problem, it is increasing worldwide since it is the sixth most common cancer overall. The highest rates of oral cancer occur in the most disadvantaged sections of the population. Early detection and screening have been shown to be effective in reducing mortality and morbidity caused by oral cancers. To ensure early detection of oral cancer measures such as mass screening or screening of high-risk group population; reducing the delay from patients´ side by creating awareness about signs and symptoms of oral cancer. Today, no national population-based screening programs for oral cancer have been implemented yet. The objectives of this project are to evaluate and educate Tunisian Dentists as well as health professionals to perform oral screening and early detection of suspicious oral lesions in order to reduce morbidity and mortality associated with oral cancer.

Risk-Based Selection of Individuals for Oral Cancer Screening

PURPOSE

We evaluated proof of principle for resource-efficient, risk-based screening through reanalysis of the Kerala Oral Cancer Screening Trial.

METHODS

The cluster-randomized trial included three triennial rounds of visual inspection (seven clusters, n = 96,516) versus standard of care (six clusters, n = 95,354) and up to 9 years of follow-up. We developed a Cox regression-based risk prediction model for oral cancer incidence. Using this risk prediction model to adjust for the oral cancer risk imbalance between arms, through intention-to-treat (ITT) analyses that accounted for cluster randomization, we calculated the relative (hazard ratios [HRs]) and absolute (rate differences [RDs]) screening efficacy on oral cancer mortality and compared screening efficiency across risk thresholds.

RESULTS

Oral cancer mortality was reduced by 27% in the screening versus control arms (HR = 0.73; 95% CI, 0.54 to 0.98), including a 29% reduction in ever-tobacco and/or ever-alcohol users (HR = 0.71; 95% CI, 0.51 to 0.99). This relative efficacy was similar across oral cancer risk quartiles (P interaction = .59); consequently, the absolute efficacy increased with increasing model-predicted risk-overall trial: RD in the lowest risk quartile (Q1) = 0.5/100,000 versus 13.4/100,000 in the highest quartile (Q4), P trend = .059 and ever-tobacco and/or ever-alcohol users: Q1 RD = 1.0/100,000 versus Q4 = 22.5/100,000; P trend = .026. In a population akin to the Kerala trial, screening of 100% of individuals would provide 27.1% oral cancer mortality reduction at number needed to screen (NNS) = 2,043. Restriction of screening to ever-tobacco and/or ever-alcohol users with no additional risk stratification would substantially enhance efficiency (43.4% screened for 23.3% oral cancer mortality reduction at NNS = 1,029), whereas risk prediction model-based screening of 50% of ever-tobacco and/or ever-alcohol users at highest risk would further enhance efficiency with little loss in program sensitivity (21.7% screened for 19.7% oral cancer mortality reduction at NNS = 610).

CONCLUSION

In the Kerala trial, the efficacy of oral cancer screening was greatest in individuals at highest oral cancer risk. These results provide proof of principle that risk-based oral cancer screening could substantially enhance the efficiency of screening programs.

Outcomes of the National Head and Neck Cancer Awareness and Screening Campaign in Oman

Objectives

The prognosis of head and neck cancer (HNC) depends substantially on disease stage at the time of diagnosis. Unfortunately, the majority of HNC patients present at relatively late stages. In Oman, a national screening campaign was conducted to increase public awareness of HNC and encourage early detection. This study aimed to report the outcomes of that campaign.

Methods

The campaign took the form of biannual events conducted at a tertiary care centre and in public malls in Muscat, Oman from April 2015 to July 2019. Data were collected from participants using the Head and Neck Cancer Alliance screening form. Otolaryngologists and oral maxillofacial surgeons performed a thorough physical evaluation of the head and neck region.

Results

Of the 1,500 individuals visiting the hospital and malls during the campaign events, a total of 509 agreed to undergo screening (response rate: 33.9%). Of these, 12.8% had positive screening results and 5.9% required further evaluation. However, none of the cases with suspicious findings were found to be malignant after a thorough evaluation. Overall, 16.9% of the participants were aware of the early signs of HNC; in addition, 5.5% knew how to perform an oral self-examination.

Conclusion

Screening is a simple and safe method for the prevention and early detection of HNC. Mass screening and public awareness programmes may help to reduce the burden of this disease in Oman.

Feasibility of opportunistic screening for oral cancers in a dental outpatient department of a secondary care hospital in Northern India

Background:

Oral cancer is one of the most common forms of cancer in India. Majority of the patients are diagnosed at advanced stages, resulting in poor outcomes. Most of the oral cancers are preceded by visible lesions known as potentially malignant disorders (PMDs), which are amenable to early detection by screening. Oral visual examination is an established method of screening, and dentists have a unique opportunity to screen patients who come for various dental morbidities. Opportunistic screening is being recommended as a measure of cancer control. This study was conducted to assess the feasibility of opportunistic screening in a public health facility.

Methods:

Patients coming to the dental outpatient department (OPD) of a secondary care hospital were screened for oral cancer or PMD by a trained dental surgeon by visual inspection of the oral cavity. In-depth interviews were conducted with the dental surgeon and officer-in-charge of dental OPD to identify barriers and facilitators for screening. A feasibility model was used to assess the acceptability, implementation, practicality, and integration of opportunistic screening.

Results:

All patients attending dental OPD underwent screening. PMDs were detected in 0.5% of the new OPD attendees. Leukoplakia was found to be the most common lesion. Biopsy for suspected lesions was not conducted. The shortage of support staff was identified as a barrier to documenting risk factors. There was a lack of follow-up and referral linkages.

Conclusion:

Opportunistic screening for oral cancers is feasible at a secondary care public health care facility. However, a well-developed system for follow-up and linkage with referral sites is required.

Reproducibility of tissue autofluorescence for screening potentially malignant disorders

Introduction: Direct tissue autofluorescence (AF) visualization devices such as VELscope® are gaining interest to improve early detection of oral potentially malignant disorders (OPMD) and cancers. The main objective of this study was to assess inter-observer reproducibility of incandescent light (IL) and AF observations for OPMD and cancer. Materials and methods: High risk patients (exposed to alcohol or tobacco) were screened by two independent operators with a conventional oral examination (IL) followed by AF examination. The primary endpoint was the inter-observer agreement on the decision to biopsy assessed by kappa coefficients.Accuracy of IL and AF were estimated by the relative true positive rate (RTPR, increase of sensitivity), relative false positive rate (RFPR, loss of specificity) and their ratio. Results: 179 patients were included. 833 lesions were identified after IL and AF. Indication for biopsy was retrieved for 41 patients (61 lesions). Inter-observer agreement on the indications for biopsy was 93.3% after IL (Kappa coefficient 0.88 [0.80, 0.97]) and 96.1% after IL and AF (Kappa coefficient 0.78 [0.66, 0.90]). RTPR was 1.2, RFPR was 1 and their ratio was 1.2. Conclusion: IL and AF examination has shown good inter-observer reproducibility. Adjunction of AF allowed diagnosing more leukoplakia without dysplasia.

Squamous cell carcinoma of the head and neck - screening in patients who misuse alcohol and tobacco in Switzerland: a prospective pilot study

Squamous cell carcinoma (SCC) of the head and neck is the sixth most common cancer worldwide. It is preceded by early asymptomatic lesions which, if identified early enough and removed, would prevent malignant transformation or avoid delaying diagnosis to advanced stages. Our aim was to evaluate the feasibility of a screening programme for SCC of the head and neck in a group of high-risk patients, and to investigate their addiction profile. Patients admitted to an inpatient alcohol addiction centre (n=101) were prospectively enrolled and asked to fill in a questionnaire about their use of tobacco and alcohol, and the presence of warning symptoms for SCC of the head and neck from 23 June 2014 to 21 January2016. Participants in the study had a physical examination by an alcohol addiction physician followed by a full examination of the head and neck by an otorhinolaryngologist to rule out premalignant or malignant lesions of the upper aerodigestive tract. Of the 101 patients, 62 (60%) had at least one warning symptom. Alcohol addiction physicians identified leukoplakia in six (6%) and erythroplakia in two. No pre-malignant or malignant lesions were confirmed on examination by the otolaryngologist. We were unable to draw conclusions about the cost-effectiveness or the yield of the screening programme. Despite our negative findings, we may need further investigation to clarify the relevance of such a programme on health-related outcome given the high compliance rate and minimal delay that was achieved by taking advantage of an in-patient alcohol rehabilitation centre.

Oral Cancer Knowledge, Attitude, and Practice of Dentists in the State of Qatar

Objectives: The aim of this study was to assess existing knowledge on oral cancer (OC), attitude toward OC examination, and clinical practice among dentists practicing in the governmental health sector in the State of Qatar, including the influence of personal characteristics. Materials and Methods: All 271 dentists practicing in Primary Health Care Centers (PHCC) and the Hamad Medical Corporation (HMC) were invited to participate in this cross-sectional study. Of these, 177 completed a self-administered, 48-item questionnaire. Based on the responses, knowledge of the risk factors for and clinical presentation of OC was categorized as high, medium, or low, and then further separated into satisfactory (medium/high) and unsatisfactory (low). Information on attitudes toward OC examination and clinical practice was also taken from the questionnaire. Results: The mean score for knowledge of the clinical presentation of OC was 7.59 (standard deviation [SD] = 2.40) out of 14. The mean score for knowledge of the risk factors for OC was 8.96 (SD = 2.31) out of 16. Dentists with ≤10 years of experience were more likely to have satisfactory knowledge of OC compared to dentists with >15 years of experience. Attending a continuous professional development (CPD) course on OC showed a trend with satisfactory clinical knowledge, although it was not statistically significant. Conclusion: This study identified gaps in dentists’ knowledge of OC; dentists demonstrated unsatisfactory knowledge of the clinical presentation of and risk factors for OC. The findings highlighted the need for educational interventions on OC, which are essential to improving health care outcomes and delivery of care.

Implementation of a targeted HPV educational program in a population with HIV

Patients living with human immunodeficiency virus (PLWH) are at higher risk of developing human papillomavirus (HPV)-associated malignancies. This prospective, longitudinal study evaluated the baseline knowledge of PLWH regarding HPV infection and its association with head neck cancer, and it aimed to determine whether a focused educational session could promote both short- and long-term knowledge acquisition in this population. Twenty-seven subjects participated in an interactive educational session and completed pre-test and immediate and delayed (4-month) post-test questionnaires. When compared to their pre-test answers, subjects demonstrated significant improvements in all 28 questions immediately following education. Knowledge preservation was demonstrated 4 months after initial evaluation, with subjects performing significantly better than their pre-test scores in 24 of the original 28 questions. These results suggest that short, focused, educational programs for PLWH may promote a better understanding of HPV's association with human immunodeficiency virus (HIV) and HPV risk factors, methods of transmission, and prevention.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Diagnostic Pathway of Oral Cavity Cancer in an Integrated Health Care System

CONTEXT

Survival for patients with oral cavity squamous cell carcinoma (OCSCC) has remained relatively stagnant despite advances in treatment. Few studies have examined why advanced-stage disease is diagnosed in 40% of patients with OCSCC nationally.

OBJECTIVE

To characterize the diagnostic pathway of OCSCC in an integrated health care system.

DESIGN

Retrospective study of patients with OCSCC (2007-2010).

MAIN OUTCOME MEASURES

Referral patterns and demographic, clinical, and tumor characteristics associated with time to diagnosis (diagnostic interval).

RESULTS

Of 247 patients, 167 (68%) had early-stage (I/II) disease, 86 (35%) were referred by dentists, and 70 (28%) had a history of premalignancy. The median time (interquartile range) from symptom onset to care sought from a primary care physician (patient interval), from primary care physician to otolaryngologist, and from otolaryngologist to diagnosis was 8.6 (4.0-25.8), 1.0 (0.6-3.1), 0.0 (0.0-3.0) weeks, respectively. These intervals did not differ by demographic characteristics, clinical factors, or tumor stage. Prolonged diagnostic intervals were observed among patients with premalignant lesions.

CONCLUSION

The patient interval was the largest component of the total diagnostic interval. The subsequent professional workup proceeded relatively efficiently. Prolonged diagnostic interval in patients with premalignant lesions may reflect the natural history of malignant transformation rather than a delay in diagnosis. However, nearly one-fourth of these cases were diagnosed at an advanced stage; closer surveillance may represent an opportunity for diagnosis at an earlier stage. Surveillance for premalignant lesions and facilitating referrals from dentists may expedite the diagnosis and treatment of OCSCC. Further investigation is warranted.

Oral Cancer Screening among Smokers and Nonsmokers

Aims and Objectives:

The aim of visual systematic screening is early identification of oral cancer (OC) precursor lesion. OC mortality improves when cancer is identified at early stages. This is important in patients whose lifestyle choices render them at higher risk of developing OC. This study described the prevalence of OC screening among smokers and nonsmokers in Kuwait and ascertained demographic predictors.

Materials and Methods:

This cross-sectional study utilized a self-administered online survey in English and Arabic through Survey Monkey^® and disseminated using the social networking app “WhatsApp.” The survey included 21 questions on demographics, smoking status, and knowledge of OC. Screening questions were adopted from the Maryland Cancer Screening and Risk Behavior Survey. Data were analyzed using the computer software “Statistical Package for Social Sciences, SPSS version 24.0” (IBM Corp, Armonk, NY, USA).

Results:

The study included 404 Kuwaiti respondents, 311 (77%) nonsmokers and 93 (23%) smokers. Prevalence of OC screening was 7.2, 7.7% among nonsmokers and 5.4% in smokers. Only 36.6% were aware of OC, with more nonsmokers (38.9%) than smokers (29%). Logistic regression revealed twice more males likely to go for screening than females and with the likelihood of those being in the age group of 25–44 years four times more (P < 0.012) than other age groups.

Conclusion:

There was low prevalence of screening and poor awareness of OC among sampled. Increased efforts are needed by health professionals to spread awareness and improve knowledge on OC and demand the inclusion of screening during their routine and opportunistic oral examinations.

Prevalence of oral cancer, oral potentially malignant disorders and other oral mucosal lesions in Cambodia

OBJECTIVES

To obtain data on the prevalence of oral mucosal lesions (OMLs) among Cambodians, and to assess the relationship between known risk habits of oral diseases with prevalence of oral potentially malignant disorders (OPMDs).

DESIGN

This was a population-based, cross-sectional study whereby subjects were adults aged 18 years old and above. A workshop on the identification of OML was held to train and calibrate dental officers prior to data collection in the field. Sociodemographic and risk habits data were collected via face-to-face interview, whilst presence of OML and clinical details of lesions such as type and site were collected following clinical oral examination by the examiners. Data analysis was carried out using the Statistical Package for Social Science (SPSS) version 12.0. The association between risk habits and risk of OPMD was explored using logistic regression analysis.

RESULTS

A total of 1634 subjects were recruited. Prevalence of OML for this population was 54.1%. Linea alba was the most common lesion seen (28.7%). This study showed an overall OPMD prevalence of 5.6%. The most common type of OPMD was leukoplakia (64.8%), followed by lichen planus (30.8%). Subjects who only smoked were found to have an increased risk for OPMD of almost four-fold (RR 3.74, 95%CI 1.89-7.41). The highest risk was found for betel quid chewers, where the increased risk observed was more than six times (RR 6.75, 95%CI 3.32-13.72). Alcohol consumption on its own did not seem to confer an increased risk for OPMD, however when practiced concurrently with smoking, a significant risk of more than five times was noted (RR 5.69 95%CI 3.14-10.29).

CONCLUSION

The prevalence of OML was 54.1%, with linea alba being the most commonly occurring lesion. Smoking, alcohol consumption and betel quid chewing were found to be associated with the prevalence of OPMD, which was 5.6%.

Real Time Optical Vascular Imaging: A Potential Technique for the Diagnosis of Mucosal Disease Including Early Oral Cancer

Early detection of oropharyngeal carcinoma is imperative in order to minimise morbidity and increase survival rate, but most of these patients present to the specialist with already advanced stages of malignancy, when the prognosis is relatively poor. General dental practitioners and dental care professionals have a unique opportunity during routine examination to detect any suspicious lesions. However, we continue to rely mostly on conventional examination, which is known to have limitations. There are diagnostic adjuncts available to help detect oral squamous cell carcinoma (OSCC) and oral potentially malignant disorders (OPMD), such as vital staining, brush cytology and macroscopic light-based detection techniques, discussed elsewhere in this issue. However a recent meta-analysis demonstrated that these techniques are not reliable enough as standalone diagnostics and that conventional biopsy remains the diagnostic gold standard. This article shows a new imaging technique which has the potential to detect early signs of oral cancer. This technique is based on the use of green light which allows the observation of oral microvasculature. General dental practitioners and dental care practitioners have a privileged opportunity during routine examination to detect any suspicious lesions in the head and neck region and refer when necessary to specialist care. However, they rely mostly on conventional examination, which is known to be insufficient for the detection of early signs of malignancy. There are diagnostic adjuncts available to help detect oral cancer and oral premalignant disorders, such as vital staining, brush cytology and macroscopic light-based detection techniques, but a recent meta-analysis has concluded that alone, these are not reliable enough to make a full tissue diagnosis. In the main, their value is more as a guide to indicate need for and to locate sites for conventional biopsy, which remains the diagnostic gold standard. However, biopsy also has inherent limitations such as sample handling and site errors and is associated with patient morbidity at every sampling event. The authors have developed and tested a new real-time optical vascular imaging technique (RTOVI) to observe the gingival microvasculature as a direct reporter of local tissue function and behaviour. In addition to direct imaging, the reliability of a potential image analysis method, developed for microvascular images, was assessed. The images were assessed for number of capillaries, capillary area (CA), total capillary area (TCA) and aspect ratio (AR). The mean number of capillaries found in our study (45.06 per mm2) which was higher than figures identified in previous 'same-location' oral mucosal studies (15.42 per mm2). This may reflect the wide variation between individuals and potentially improved resolution and contrast optics between studies. This small study suggests that mean values in CA, TCA and AR may be reliable parameters for thresholding normal values, for comparison between individuals and for the assessment of the microvasculature over time. This assessment of normal is essential to pave the way for further studies involving inflammatory and mitotic lesions.

Surface-enhanced Raman spectroscopy of blood serum based on gold nanoparticles for the diagnosis of the oral squamous cell carcinoma

BACKGROUND

Oral squamous cell carcinoma (OSCC) is becoming more common across the globe. The prognosis of OSCC is largely dependent on the early detection. But the routine oral cavity examination may delay the diagnosis because the early oral malignant lesions may be clinically indistinguishable from benign or inflammatory diseases. In this study, the new diagnostic method is developed by using the surface enhanced Raman spectroscopy (SERS) to detect the serum samples from the cancer patients.

METHOD

The blood serum samples were collected from the OSCC patients, MEC patients and the volunteers without OSCC or MEC. Gold nanoparticles(NPs) were then mixed in the serum samples to obtain the high quality SERS spectra. There were totally 135 spectra of OSCC, 90 spectra of mucoepidermoid carcinoma (MEC) and 145 spectra of normal control group, which were captured by SERS successfully. Compared with the normal control group, the Raman spectral differences exhibited in the spectra of OSCC and MEC groups, which were assigned to the nucleic acids, proteins and lipids. Based on these spectral differences and features, the algorithms of principal component analysis(PCA) and linear discriminant analysis (LDA) were employed to analyze and classify the Raman spectra of different groups.

RESULTS

Compared with the normal groups, the major increased peaks in the OSCC and MEC groups were assigned to the molecular structures of the nucleic acids and proteins. And these different major peaks between the OSCC and MEC groups were assigned to the special molecular structures of the carotenoids and lipids. The PCA-LDA results demonstrated that OSCC could be discriminated successfully from the normal control groups with a sensitivity of 80.7% and a specificity of 84.1%. The process of the cross validation proved the results analyzed by PCA-LDA were reliable.

CONCLUSION

The gold NPs were appropriate substances to capture the high-quality SERS spectra of the OSCC, MEC and normal serum samples. The results of this study confirm that SERS combined PCA-LDA had a giant capability to detect and diagnosis OSCC through the serum sample successfully.

Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the aetiology and risk factors for head and neck cancer and the recommended interventions appropriate for each risk factor. Recommendations • Recent evidence synthesis from National Institute for Health and Care Excellence suggests that the following brief interventions for smoking cessation work should be used: ○ Ask smokers how interested they are in quitting (R) ○ If they want to stop, refer them to an intensive support service such as National Health Service Stop Smoking Services (R) ○ If they are unwilling or unable to accept a referral, offer a stop smoking aid, e.g. pharmacotherapy. (R) • Brief interventions are effective for hazardous and harmful drinking. (R) • Specialist interventions are effective in people with alcohol dependence. (R) • Most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment. (R) • Management of leukoplakia is not informed by high-level evidence but consensus supports targeted use of biopsy and histopathological assessment. (R) • The management of biopsy proven dysplastic lesions favours: ○ advice to reduce known environmental carcinogens such as tobacco and alcohol (R) ○ surgical excision when the size of the lesions and the patient's function allows (R) ○ long-term surveillance. (R) • Fanconi anaemia patients should: ○ be followed up in a multidisciplinary specialist Fanconi anaemia clinic (G) ○ have quarterly screening for head and neck squamous cell carcinoma and an aggressive biopsy policy (G) ○ receive prophylactic vaccination against high risk human papilloma virus (G) ○ receive treatment for head and neck squamous cell carcinoma with surgery alone where possible. (G).

Efficacy of light based detection systems for early detection of oral cancer and oral potentially malignant disorders: Systematic review

Background

Earlier detection of oral squamous cell carcinoma (OSCC) and oral potentially malignant disorders (OPMD) is essential for dental professionals to improve patient survival rates. The aim of this systematic review is to to evaluate the effectiveness of devices that utilise the principles of chemiluminescence and tissue autofluorescence as adjuncts in the detection of OSCC and OPMD.

Material and Methods

The electronic retrieval systems and databases searched for relevant articles were PubMed [MEDLINE] and Science direct. The search was for limited articles published in English or with an English abstract and articles published during the period from January 2005 to April 2014. Clinical trials utilized ViziLite, Microlux TM/DL and Visual Enhanced Light scope (VELscope) for early detection of OPMD and OSCC.

Results

Twenty primary studies published satisfied our criteria for selection - 10 utilised chemiluminescence and 10 tissue autofluorescence. Senstivity of Vizilite for detecting OSCC nad OPMD ranged from 77.1 % to 100% and specificity was low that ranged from 0% to 27.8%.Most have shown that chemiluminescence increases the brightness and margins of oral mucosal white lesions and thus assist in identification of mucosal lesions not considered under Conventional visual examination. However, it preferentially detects leukoplakia and may fail to spot red patches. Clinical trials demonstrated that sensitivity of VELscope in detecting malignancy and OPMD ranged from 22 % to 100 % and specificity ranged from 16 % to 100%. Most studies concluded that VELscope can help the experienced clinician to find oral precursor malignant lesions. But it couldnot differentiate between dysplasia and benign inflammatory conditions.

Conclusions

Both devices are simple, non-invasive test of the oral mucosa but are suited for clinicians with sufficient experience and training. More clinical trials in future should be conducted to establish optical imaging as an efficacious adjunct tool in early diagnosis of OSCC and OPMD.

Key words:Oral cancer, early diagnosis, potentially malignant disorders, chemiluminescence, tissue autofluorescence, VELscope, ViziLite plus.

Organização dos serviços públicos de saúde bucal para diagnóstico precoce de desordens com potencial de malignização do estado do Rio de Janeiro, Brasil

Resumo Estudo sobre a organização dos serviços públicos de saúde no estado do Rio de Janeiro referente ao diagnóstico precoce de desordens com potencial de malignização (DPM). Foram utilizados os dados secundários do banco do primeiro ciclo do Programa de Melhoria do Acesso e Qualidade da Atenção Básica.Verificou-se a realização de ações nos diferentes níveis de prevenção ao câncer, a disponibilidade de serviços de apoio diagnóstico e sobre a organização da rede de atenção. Os resultados mostram que só 58,8% das equipes de saúde bucal registram e acompanham os casos suspeitos; que somente 47.1% relatam dispor de fluxos preferenciais para encaminhamento e há grande variação nos tempos de espera para confirmação do diagnóstico. Ações gerenciais locais e de apoio regional podem melhorar a organização da rede de cuidado ao câncer bucal no estado.

Social inequalities in oral cancer literacy in an adult population in a multicultural deprived area of the UK

BACKGROUND

To report the level and correlates of oral cancer literacy in a deprived area of the UK.

METHODS

This study is part of the East London Oral Health Inequality Study, which included a representative sample of adults 16-65 (n = 2343) years old living in Waltham Forest, Redbridge and Barking and Dagenham in 2009-10. This cross-sectional study adopted a multi-stage, stratified, random sampling approach. Data were collected through home visits by trained examiners and interviewers. Hierarchical logistic regression modelling was adopted.

RESULTS

Only 26.7% participants were aware that a small lesion in the mouth can develop into oral cancer, and 39.5% were aware that early treatment could prevent a lesion from developing into oral cancer. Adjusted odds ratios confirmed the social gradient in awareness that a small lesion in the mouth can develop into oral cancer, even after adjusting for age, gender and ethnicity. Inequalities in awareness that a small lesion in the mouth can develop into oral cancer were significantly attenuated after forcing education level into the equation. Interestingly, adjusting for education cancelled the difference previously observed between manual/routine and professional/managerial occupations.

CONCLUSIONS

Oral cancer literacy is poor among adults in Outer North East London, and we have identified particularly vulnerable sub-populations.

Recommendations for screening and early detection of common cancers in India

Cancers of the breast, uterine cervix, and lip or oral cavity are three of the most common malignancies in India. Together, they account for about 34% of more than 1 million individuals diagnosed with cancer in India each year. At each of these cancer sites, tumours are detectable at early stages when they are most likely to be cured with standard treatment protocols. Recognising the key role that effective early detection and screening programmes could have in reducing the cancer burden, the Indian Institute for Cytology and Preventive Oncology, in collaboration with the US National Cancer Institute Center for Global Health, held a workshop to summarise feasible options and relevant evidence for screening and early detection of common cancers in India. The evidence-based recommendations provided in this Review are intended to act as a guide for policy makers, clinicians, and public health practitioners who are developing and implementing strategies in cancer control for the three most common cancers in India.

Increasing opportunistic oral cancer screening examinations: findings from focus groups with general dentists in Puerto Rico

This study aims to identify educational and training modalities that dentists in Puerto Rico (PR) believe will increase the quality and quantity of opportunistic oral cancer screening examinations (OCS) in dental offices on the island. The study was conducted in three phases: a systematic search of relevant literature, an expert review and consensus panel, and focus groups (FG) involving PR general dentists. To increase OCS by dentists in PR, the FG participants proposed a small group, hands-on OCS training, an integrated oral cancer course, and readily available videos, photographs, and computer simulations to further demonstrate OCS performance and facilitate differential diagnosis. OCS training requirements for licensure and re-licensure, improving OCS dentist-patient communication skills, and establishment of an oral lesion referral center were also viewed favorably. In conclusion, general dentists in our FGs believed the quality and quantity of OCS in Puerto Rico can be increased through the application of specific continuing education and training modalities.

Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions

BACKGROUND

Oral squamous cell carcinoma is the most common form of malignancy of the lip and oral cavity, often being proceeded by potentially malignant disorders (PMD). Early detection can reduce the malignant transformation of PMD and can improve the survival rate for oral cancer. The current standard of scalpel biopsy with histology is painful for patients and involves a delay whilst histology is completed; other tests are available that are unobtrusive and provide immediate results.

OBJECTIVES

PRIMARY OBJECTIVE

To estimate the diagnostic accuracy of index tests for the detection of oral cancer and PMD of the lip and oral cavity, in people presenting with clinically evident lesions.

SECONDARY OBJECTIVE

To estimate the relative accuracy of the different index tests.

SEARCH METHODS

The electronic databases were searched on 30 April 2013. We searched MEDLINE (OVID) (1946 to April 2013) and four other electronic databases (the Cochrane Diagnostic Test Accuracy Studies Register, the Cochrane Oral Health Group's Trials Register, EMBASE (OVID) and MEDION (Ovid)). There were no restrictions on language in the searches of the electronic databases. We conducted citation searches and screened reference lists of included studies for additional references.

SELECTION CRITERIA

We selected studies that reported the diagnostic test accuracy of the following index tests when used as an adjunct to conventional oral examination in detecting PMD or oral squamous cell carcinoma of the lip or oral cavity: vital staining, oral cytology, light-based detection and oral spectroscopy, blood or saliva analysis (which test for the presence of biomarkers in blood or saliva).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors, independently and in duplicate. Studies were assessed for methodological quality using QUADAS-2. Meta-analysis was used to combine the results of studies for each index test using the bivariate approach to estimate the expected values of sensitivity and specificity.

MAIN RESULTS

We included 41 studies, recruiting 4002 participants, in this review. These studies evaluated the diagnostic accuracy of conventional oral examination with: vital staining (14 studies), oral cytology (13 studies), light-based detection or oral spectroscopy (13 studies). Six studies assessed two combined index tests. There were no eligible diagnostic accuracy studies evaluating blood or salivary sample analysis.The summary estimates for vital staining obtained from the meta-analysis were sensitivity of 0.84 (95% CI 0.74 to 0.90) with specificity of 0.70 (0.59 to 0.79), with 14 studies were included in the meta-analysis. For cytology, sensitivity was 0.91 (0.81 to 0.96) and specificity was 0.91 (0.81 to 0.95) with 12 studies included in the meta-analysis. For light-based detection, sensitivity was 0.91 (0.77 to 0.97) and specificity was 0.58 (0.22 to 0.87) with 11 studies included in the meta-analysis. The relative test accuracy was assessed by adding covariates to the bivariate analysis, no difference in model fit was observed.

AUTHORS' CONCLUSIONS

The overall quality of the included studies was poor. None of the adjunctive tests can be recommended as a replacement for the currently used standard of a scalpel biopsy and histological assessment. Given the relatively high values of the summary estimates of sensitivity and specificity for cytology, this would appear to offer the most potential. Combined adjunctive tests involving cytology warrant further investigation.

Cancer detection rates in a population-based, opportunistic screening model, New Delhi, India

BACKGROUND

In India, cancer accounts for 7.3% of DALY's, 14.3% of mortality with an age-standardized incident rate of 92.4/100,000 in men and 97.4/100,000 in women and yet there are no nationwide screening programs.

MATERIALS AND METHODS

We calculated age-standardized and age-truncated (30-69 years) detection rates for men and women who attended the Indian Cancer Society detection centre, New Delhi from 2011-12. All participants were registered with socio-demographic, medical, family and risk factors history questionnaires, administered clinical examinations to screen for breast, oral, gynecological and other cancers through a comprehensive physical examination and complete blood count. Patients with an abnormal clinical exam or blood result were referred to collaborating institutes for further investigations and follow-up.

RESULTS

A total of n=3503 were screened during 2011-12 (47.8% men, 51.6% women and 0.6% children <15 years) with a mean age of 47.8 yrs (±15.1 yrs); 80.5% were aged 30-69 years and 77.1% had at least a secondary education. Tobacco use was reported by 15.8%, alcohol consumption by 11.9% and family history of cancer by 9.9% of participants. Follow-up of suspicious cases yielded 45 incident cancers (51.1% in men, 48.9% in women), consisting of 55.5% head and neck (72.0% oral), 28.9% breast, 6.7% gynecological and 8.9% other cancer sites. The age-standardized detection rate for all cancer sites was 340.8/100,000 men and 329.8/100,000 women.

CONCLUSIONS

Cancer screening centres are an effective means of attracting high-risk persons in low-resource settings. Opportunistic screening is one feasible pathway to address the rising cancer burden in urban India through early detection.

Diseases of the mouth

Oral pathologic abnormality is common and can be potentially serious. There are many diseases of the mouth that medical personnel must be able to diagnose and initiate management. The most prevalent lesions can be categorized as infectious, inflammatory, and common benign and malignant lesions. This article discusses prevalence, cause, diagnosis, and management of lesions such as stomatitis, candidiasis, caries, oral cancers, and bony tori.

Acceptability of a Rinse Screening Test for Diagnosing Head and Neck Squamous Cell Carcinoma Among Black Americans

OBJECTIVE

Head and neck squamous cell carcinoma (HNSCC) is a debilitating and deadly disease. We evaluated an easy-to-administer and innovative rinse that assays soluble CD44 and total protein as HNSCC early detection markers. We examined whether the rinse was acceptable and whether the results would promote screening behavior.

STUDY DESIGN

This is a prospective observational study.

METHODS

Participants (N = 150) from underserved, low-income Black American backgrounds completed assessments of satisfaction, intention to repeat test, and likely screening behavior after receiving results. Descriptive statistics, t tests, and analysis of variance (ANOVA) were conducted.

RESULTS

The rinse was highly acceptable to participants and perceived to be acceptable among peers. Participants strongly agreed that they would perform the rinse as prescribed, engage in preventative behaviors if results indicated risk of cancer, and initiate treatment if they had a positive cancer finding. Employed participants slightly disliked the taste of the rinse but were more likely to schedule a follow-up appointment and engage in preventative behaviors based on the results. Those with health-care coverage (including public health insurance) reported that the test was harder to perform than those who were uninsured.

CONCLUSION

An easy-to-use rinse technique is acceptable and likely to promote screening behavior among Black Americans at risk for HNSCC. Given that many cancer screening modalities are considered unpleasant to undergo, this rinse holds promise for promoting screening behaviors and, thereby, may result in early detection of this potentially fatal disease.

LEVEL OF EVIDENCE

IV.

A chemiluminescent light system in combination with toluidine blue to assess suspicious oral lesions-clinical evaluation and review of the literature

OBJECTIVES

The aim of the study was an evaluation of an acetic acid wash and chemiluminescent light system in combination with toluidine blue in order to detect visual identified, potentially malignant lesions.

MATERIALS AND METHODS

Forty-four patients with 50 oral lesions of primary uncertain visible dignity were included. Next to a clinical examination, a screening with ViziLite® (VL) as well as toluidine blue (TB; together ViziLite® Plus (VLP)) was conducted. Histopathology served as gold standard and sensitivity (SE), specificity (SP), positive as well as negative predictive value (PPV, NPV) was calculated descriptively. Additionally, a PubMed literature search using the key words "ViziLite" and "chemiluminescence oral cancer" was conducted.

RESULTS

Histological diagnosis showed 40 lesions of reactive/inflammatory nature, moderate dysplasia (n = 3) and oral squamous cell carcinoma (OSCC n = 7). All OSCCs and one dysplasia were identified correct via clinical diagnosis (SE 90 %, SP 100 %, PPV 100 %, NPV 97.5 %). VL examination could show all malignancies with low specificity (SE 100 %, SP 30 %, PPV 26 %, NPV 100 %). TB and VLP were positive in all cases of cancer and in one case of inflammation (SE 80 %, SP 97.5 %, PPV 89 %, NPV 95 %). In the review, eight clinical trials with similar results were included.

CONCLUSIONS

The adjunct of TB to VL reduces the number of false positives without increasing the rate of false negatives.

CLINICAL RELEVANCE

Clinical evidence to justify the additional cost of the system for diagnosis of suspicious lesions is weak. However, for the potential role of VLP in detection of lesions not otherwise identified in the visual exam in general dental practice further studies are required.

Screening programmes for the early detection and prevention of oral cancer

BACKGROUND

Oral cancer is an important global healthcare problem, its incidence is increasing and late-stage presentation is common. Screening programmes have been introduced for a number of major cancers and have proved effective in their early detection. Given the high morbidity and mortality rates associated with oral cancer, there is a need to determine the effectiveness of a screening programme for this disease, either as a targeted, opportunistic or population-based measure. Evidence exists from modelled data that a visual oral examination of high-risk individuals may be a cost-effective screening strategy and the development and use of adjunctive aids and biomarkers is becoming increasingly common.

OBJECTIVES

To assess the effectiveness of current screening methods in decreasing oral cancer mortality.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 22 July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 6), MEDLINE via OVID (1946 to 22 July 2013), EMBASE via OVID (1980 to 22 July 2013) and CANCERLIT via PubMed (1950 to 22 July 2013). There were no restrictions on language in the search of the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of screening for oral cancer or potentially malignant disorders using visual examination, toluidine blue, fluorescence imaging or brush biopsy.

DATA COLLECTION AND ANALYSIS

Two review authors screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias independently and in duplicate. We used mean differences (MDs) and 95% confidence intervals (CIs) for continuous data and risk ratios (RRs) with 95% CIs for dichotomous data. Meta-analyses would have been undertaken using a random-effects model if the number of studies had exceeded a minimum of three. Study authors were contacted where possible and where deemed necessary for missing information.

MAIN RESULTS

A total of 3239 citations were identified through the searches. Only one RCT, with 15-year follow-up met the inclusion criteria (n = 13 clusters: 191,873 participants). There was no statistically significant difference in the oral cancer mortality rates for the screened group (15.4/100,000 person-years) and the control group (17.1/100,000 person-years), with a RR of 0.88 (95% CI 0.69 to 1.12). A 24% reduction in mortality was reported between the screening group (30/100,000 person-years) and the control group (39.0/100,000) for high-risk individuals who used tobacco or alcohol or both, which was statistically significant (RR 0.76; 95% CI 0.60 to 0.97). No statistically significant differences were found for incidence rates. A statistically significant reduction in the number of individuals diagnosed with stage III or worse oral cancer was found for those in the screening group (RR 0.81; 95% CI 0.70 to 0.93). No harms were reported. The study was assessed as at high risk of bias.

AUTHORS' CONCLUSIONS

There is evidence that a visual examination as part of a population-based screening programme reduces the mortality rate of oral cancer in high-risk individuals. In addition, there is a stage shift and improvement in survival rates across the population as a whole. However, the evidence is limited to one study, which has a high risk of bias and did not account for the effect of cluster randomisation in the analysis. There was no evidence to support the use of adjunctive technologies like toluidine blue, brush biopsy or fluorescence imaging as a screening tool to reduce oral cancer mortality. Further RCTs are recommended to assess the efficacy and cost-effectiveness of a visual examination as part of a population-based screening programme in low, middle and high-income countries.

Advances in optical adjunctive AIDS for visualisation and detection of oral malignant and potentially malignant lesions

Traditional methods of screening for oral potentially malignant disorders and oral malignancies involve a conventional oral examination with digital palpation. Evidence indicates that conventional examination is a poor discriminator of oral mucosal lesions. A number of optical aids have been developed to assist the clinician to detect oral mucosal abnormalities and to differentiate benign lesions from sinister pathology. This paper discusses advances in optical technologies designed for the detection of oral mucosal abnormalities. The literature regarding such devices, VELscope and Identafi, is critically analysed, and the novel use of Narrow Band Imaging within the oral cavity is also discussed. Optical aids are effective in assisting with the detection of oral mucosal abnormalities; however, further research is required to evaluate the usefulness of these devices in differentiating benign lesions from potentially malignant and malignant lesions.

Oral premalignancy: the roles of early detection and chemoprevention

Premalignancy and chemoprevention studies in head and neck cancer typically focus on the oral cavity. Avoiding or cessation of alcohol and smoking, early detection of potentially malignant disorders or cancer, and early detection of recurrent and/or second primary tumor form the basis of prevention of oral cancer. Analysis of tissue prospectively collected in evaluation of retinoids for chemoprevention trials allowed identification of molecular biomarkers of risk to develop oral cancer, loss of heterozygosity being the most validated one. Improving risk assessment and identification of new targets for chemoprevention represent the main challenges in this field.

Initial staging of squamous cell carcinoma of the oral cavity, larynx and pharynx (excluding nasopharynx). Part I: Locoregional extension assessment: 2012 SFORL guidelines

OBJECTIVES

To set out good practice guidelines for locoregional extension assessment of squamous cell carcinoma of the head and neck (excluding nasopharynx, nasal cavities and sinuses).

MATERIALS AND METHODS

A critical multidisciplinary review of the literature on locoregional extension assessment of squamous cell carcinoma of the head and neck was conducted, applying levels of evidence in line with the French health authority's (HAS) literature analysis guide of January 2000.

CONCLUSION

Based on the levels of evidence of the selected articles and on work-group consensus, graded guidelines are set out for clinical, endoscopic and imaging locoregional extension assessment of head and neck cancer.

Factors related to late stage diagnosis of oral squamous cell carcinoma

AIMS

To identify factors related to advanced-stage diagnosis of oral cancer to disclose high-risk groups and facilitate early detection strategies.

STUDY DESIGN

An ambispective cohort study on 88 consecutive patients treated from January 1998 to December 2003.

INCLUSION CRITERIA

pathological diagnosis of OSCC (primary tumour) at any oral site and suffering from a tumour at any TNM stage. Variables considered: age, gender, smoking history, alcohol usage, tumour site, macroscopic pattern of the lesion, co-existing precancerous lesion, degree of differentiation, diagnostic delay and TNM stage.

RESULTS

A total of 88 patients (mean age 60±11.3; 65.9% males) entered the study. Most patients (54.5%) suffered no delayed diagnosis and 45.5% of the carcinomas were diagnosed at early stages (I-II). The most frequent clinical lesions were ulcers (70.5%). Most cases were well- and moderately-differentiated (91%). Univariate analyses revealed strong associations between advanced stages and moderate-poor differentiation (OR=4.2; 95%CI=1.6-10.9) or tumour site (floor of the mouth (OR=3.6; 95%CI=1.2-11.1); gingivae (OR=8.8; 95%CI=2.0-38.2); and retromolar trigone (OR=8.8; 95%CI=1.5-49.1)). Regression analysis recognised the site of the tumour and the degree of differentiation as significantly associated to high risk of late-stage diagnosis.

CONCLUSIONS

Screening programmes designed to detect asymptomatic oral cancers should be prioritized. Educational interventions on the population and on the professionals should include a sound knowledge of the disease presentation, specifically on sites like floor of the mouth, gingivae and retromolar trigone. More studies are needed in order to analyse the part of tumour biology on the extension of the disease at the time of diagnosis.

Dental attendance of oral and oropharyngeal cancer patients in a public hospital in Western Australia

BACKGROUND

Dentists have recently seen the introduction of devices which aim to facilitate early oral cancer detection, sparking interest in opportunistic oral cancer screening. However, concerns have been raised about the lack of regular dental attendance amongst high risk individuals. The purpose of this study was to obtain information pertaining to dental attendance of oral and oropharyngeal cancer patients.

METHODS

All records of patients referred to the Oral Medicine Clinic at the Oral Health Centre of Western Australia, between January 2005 and December 2009, from one major teaching hospital were examined. Information extracted included age, gender, smoking status, referral date, tumour type, tumour site, disease stage (TNM classification), and information on dental attendance. Outcomes measured included time (months) since the patient's last dental visit and information concerning regularity of dental attendance.

RESULTS

No association was found between dental attendance and gender, smoking, disease stage or age at diagnosis. Most patients had not visited a dentist in the preceding 12 months. The mean date of last dental visit was 5.6 years prior.

CONCLUSIONS

More should be done in Australia to encourage patients at high risk of oral cancer to attend the dentist and undergo annual oral soft tissue examination.

Assessment of tissue autofluorescence and reflectance for oral cavity cancer screening

OBJECTIVE

Although approved by the US Food and Drug Administration for clinical use, the utility of handheld tissue reflectance and autofluorescence devices for screening head and neck cancer patients is poorly defined. There is limited published evidence regarding the efficacy of these devices. The authors investigated the sensitivity and specificity of these modalities compared with standard examination.

STUDY DESIGN

Prospective, cross-sectional analysis.

SETTING

Tertiary care medical center.

SUBJECTS AND METHODS

Patients who were treated previously for head and neck cancer (n = 88) between 2009 and 2010 were included. Patients were screened using white light visualization (standard of care) and compared with tissue reflectance and autofluorescence visualization. Screening results were compared with biopsy or long-term follow-up.

RESULTS

Autofluorescence visualization had a specificity of 81% and a sensitivity of 50% for detecting oral cavity cancer, whereas white light visualization had a specificity of 98% and a sensitivity of 50%. Tissue reflectance visualization had low sensitivity (0%) and good specificity (86%). The power of this study was insufficient to compare the positive and negative predictive values of standard white light examination (50% and 98%, respectively) to tissue autofluorescence (11% and 97%) or reflectance (0% and 95%). In addition, stratification by previous radiation therapy found no statistically significant difference in screening results.

CONCLUSION

Standard clinical lighting has a higher specificity than tissue reflectance and autofluorescence visualization for detection of disease in patients with a history of head and neck cancer. This study does not support the added costs associated with these devices.

Clinical recommendations for oral cancer screening

SCOPE AND PURPOSE

To address the benefits and limitations of oral cancer screening and the use of adjunctive screening aids to visualise and detect potentially malignant and malignant oral lesions. Squamous cell carcinomas of the lips and cancers of the oropharynx (including the posterior one-third of the base of the tongue and the tonsils were excluded.

METHODOLOGY

A specially convened expert panel evaluated the available evidence which was derived from a systematic search of Medline and the Cochrane Library. Further details about the search are available in a supplement to the published article available on the Journal of the America Dental Association's website (http://jada.ada.org/cgi/content/full/141/5/509). Qualitative synthesis of the data was performed by the panel. Where consensus could not be reached majority voting was employed. Recommendations were reviewed by internal and external scientific experts and organisations. After review recommendations were revised where appropriate and the ADA Council on Scientific Affairs approved the final clinical recommendations.

REVIEW AND UPDATING

No information provided in article.

RECOMMENDATIONS

The key recommendations were all classified as level D being based on grade IV evidence or extrapolated from grade I, II or III evidence using a system based on Shekelle et al.(1) The main recommendations can be summarised as:1) Clinicians should remain alert for signs of potentially malignant lesions or early-stage cancers in all patients while performing routine visual and tactile examinations, particularly for patients who use tobacco or who are heavy consumers of alcohol. 2) For seemingly innocuous lesions, clinicians should follow up in seven to 14 days to confirm persistence after removing any possible cause to reduce the potential for false-positive screening results. 3) For lesions that raise suspicion of cancer or for lesions that persist after removal of a possible cause, clinicians should communicate the potential benefits and risks of early diagnosis. Considerations include the following: a) that even suspicious lesions identified during the course of a routine visual and tactile examination may represent false positives; b) that clinical confirmation (a second opinion) can be sought from a dental or medical care provider with advanced training and experience in diagnosis of oral mucosal disease so as to reduce the potential for a false positive or false negative oral cancer screening result; c) that a malignancy or non-malignancy can be confirmed only via microscopic examination that requires a surgical biopsy; d) that a decision to pursue a biopsy to confirm the presence or absence of malignancy should be made in the context of informed consent. 4) Although transepithelial cytology has validity in identifying disaggregated dysplastic cells, the panel suggests surgical biopsy for definitive diagnosis.

RESEARCH RECOMMENDATIONS

In all, 15 separate research recommendations were made ranging from determining the prevalence of potentially malignant oral mucosal lesions in the United States to whether the use of adjunctive devices improves patient education and adherence to follow-up care.