Delay in diagnosis and its effect on outcome in head and neck cancer

Oral and maxillofacial surgery and dental health education in undergraduate medicine: a systematic review

Undergraduates in medicine should receive a basic education to ensure understanding of dental concepts, including oral cancer, basic dental health advice, and oral and maxillofacial surgery (OMFS). This review aims to explore the exposure of OMFS and dental education in the UK medical undergraduate curriculum and follows PRISMA protocols. Four databases were used to search for literature: MEDLINE, EMBASE, SCOPUS, and Google Scholar. A three-tier reviewer panel was used to appropriately evaluate data. The Medical Education Research Quality Instrument (MERSQI) was used to assess research quality amongst the included literature. A total of 14 papers were included for review. Surveys assessing medical students' perceptions of OMFS education indicate a need for improvement of the speciality in undergraduate medicine. Mean exposure of graduating medical students to OMFS was 22% (95%CI 11 to 29%). Knowledge of relevant anatomy, physiology, and OMFS-related data was very poor across all surveys. Likewise, oral cancer teaching appears to have room for improvement, only 7% (95%CI 4.1 to 10.3%) of final year medical students can identify oral cancer and less than 20% felt confident in oral assessment and diagnosis. This appears to transfer over into postgraduate medicine where only a mean of 22% of general practitioners can correctly diagnose oral cancer. The results of this review indicate that OMFS and oral cancer are not well covered in the medical curriculum. Doctors require a basic understanding of the OMFS speciality for appropriate referrals and clinical management. Furthermore, the ability of doctors to correctly deal with oral medical problems should be improved to optimise patient outcomes.

Clinicopathological Characteristics, Prognostic Factors, and Treatment Outcomes of Patients with Oral Tongue Squamous Cell Carcinoma Treated with Glossectomy: A Tertiary Oncology Center Experience

Oral tongue squamous cell cancer (OTSCC) is one of the most prevalent cancers worldwide and incidence increases with age. An alarming increase in the incidence of OTSCC in the younger age group. This study aimed to explore clinical and histopathological characteristics, survival, and other post-surgical outcomes in patients with OTSCC treated with glossectomy through the Department of Otolaryngology-Head & Neck Surgery at the Ministry of National Guard Health Affairs (MNGHA) within our study period. This is a retrospective study carried out through the collection and analysis of data from medical charts of 56 patients with oral tongue cancer who were treated by glossectomy. Treatment was initiated from January 2010 to December 2021. Patient characteristics, tumor characteristics, treatment modality, failure patterns, and survival rates were collected and analyzed. At diagnosis, 62.5% were tobacco smokers, 46.8% had poor dental hygiene, and 76.8% had ulcerative lesions. Furthermore, 33 cases presented with early-stage clinical disease and 23 cases with advanced stage. The median follow-up was 54 months, 28 patients (50%) were free for 3-5 years. Patients who were free on 5-year follow-up had a significantly higher percentage of negative lymphovascular and perineural invasion (p < 0.05). Additionally, 12 patients (21.4%) had developed recurrence. Mortality in all cases was 30.3, but mortality-related cancer was 19.6%. Locoregional failure remains the main cause of treatment failure in resectable OTSCC. Pathological T-stage, N-stage, LVI, PNI, ECE, and LNR are all considered strong prognostic factors.

Delay in the Diagnosis of Patients With Head and Neck Cancer: Impact of Different Patient- and Healthcare Provider-Related Factors

Background In our setup, head and neck cancer (HNC) is the most common, and patients frequently present at an advanced stage, which results in dismal outcomes. Delays on the part of the patient (such as resistance to seeking treatment) or the provider (such as misdiagnosis or an extended wait period for consultation) may be the cause of a late presentation. The presentation stage may vary depending on several factors, including age, gender, smoking status, job status, and education. Objectives The study aims to identify factors that lead to advanced-stage presentations of HNCs and to determine the delays brought on by patient- or healthcare provider-related factors and how these factors affect HNC disease staging among biopsy-proven HNC patients. Materials and methods Participants in the study were those who initially presented with a biopsy-verified HNC at the cancer clinic of the department of otolaryngology-head and neck surgery at Pakistan Institute of Medical Sciences (PIMS), Islamabad. Patients answered questions on their first symptom presentation, past healthcare professional visits, and intervals between visits on a Cancer Symptom Interval Measure (C-SIM) questionnaire. For every patient, clinical and demographic information was gathered. TNM staging was completed. The test of significance was applied where applicable. Results Age, gender, education level, and smoking status had no bearing on the presentation stage. Patients without jobs present at a statistically significant higher stage (p = 0.038). The most prevalent histological form of HNC was squamous cell carcinoma 79 (82.29%), with the oral cavity and larynx being the most common sites of the disease 30 (31.25%) and 29 (30.21%) respectively. Patients took an average of 5.28 ± 9.12 months from the onset of symptoms to their first appointment with a healthcare provider. Prior to diagnosis, the majority of patients saw three or more healthcare providers (range: 1-8). The duration from the initial visit to a healthcare provider to the initiation of treatment was 3.06 ± 5.88 months. Based on the stage at presentation, there were no discernible variations in the times to presentation (p>0.05). Conclusion Significant delays and high stage of presentation are caused by unemployment. The majority of the delay was caused by the patient's tardiness in seeing a medical practitioner, yet the presentation stage was not greatly impacted by this delay.

Causes and impact of delays during the COVID-19 pandemic on head and neck cancer diagnosis

BACKGROUND

The causes for delays during the COVID19 pandemic and their impact on head and neck cancer (HNC) diagnosis and staging are not well described.

METHODS

Two cohorts were defined a priori for review and analysis-a Pre-Pandemic cohort (June 1 to December 31, 2019) and a Pandemic cohort (June 1 to December 31, 2020). Delays were categorized as COVID-19 related or not, and as clinician, patient, or policy related.

RESULTS

A total of 638 HNC patients were identified including 327 in the Pre-Pandemic Cohort and 311 in the Pandemic Cohort. Patients in the Pandemic cohort had more N2-N3 category (41% vs. 33%, p = 0.03), T3-T4 category (63% vs. 50%, p = 0.002), and stage III-IV (71% vs. 58%, p < 0.001) disease. Several intervals in the diagnosis to treatment pathway were significantly longer in the pandemic cohort as compared to the Pre-Pandemic cohort. Among the pandemic cohort, 146 (47%) experienced a delay, with 112 related to the COVID-19 pandemic; 80 (71%) were clinician related, 15 (13%) were patient related, and 17 (15%) were policy related.

CONCLUSIONS

Patients in the Pandemic cohort had higher stage disease at diagnosis and longer intervals along the diagnostic pathway, with COVID-19 related clinician factors being the most common cause of delay.

Impact of the COVID-19 pandemic on stage and incidence of head and neck cancer: A rapid review and meta-analysis

OBJECTIVES

This rapid review aims to evaluate the impact of the COVID-19 pandemic on incidence of head and neck cancer (HNC) and stage distribution at diagnosis.

DESIGN

Rapid review and meta-analysis.

PARTICIPANTS

Comparative data for new HNC patients between a pre-pandemic cohort (before March 2020) and a pandemic cohort (after March 2020 during the lockdown period).

MAIN OUTCOMES MEASURED

Data on tumour stage, incidence, referral pathway (number of new patient referrals), or workload levels (number of HNC treatments). Data on stage were summarised as odds ratios (OR) with 95% confidence intervals (CI), and data related to changes in numbers of diagnoses, referrals, and workload levels were summarised as a narrative synthesis.

RESULTS

A total of 31 reports were included in this review. Individually 16 out of 23 studies did not show a significant impact on stage relative to the pre-pandemic period. However, the meta-analysis revealed that patients diagnosed with HNC during the pandemic were 16% more likely to have nodal involvement (OR = 1.16; 95% CI 1.00-1.35), 17% more likely to have a late overall stage (OR = 1.17; 95% CI 1.01-1.36), and 32% more likely to present with advanced tumour extent (T3 and T4 stage) (OR = 1.32; 95% CI 1.08-1.62). Data on incidence was extremely limited and not currently sufficient to assess trends in burden of disease.

CONCLUSIONS

This review indicates that during the COVID-19 pandemic, there was upstaging of HNC at diagnosis, suggesting the provision of care to HNC patients was significantly affected.

A descriptive study on diagnostic timelines, and factors influencing delayed diagnosis among adult head and neck cancer patients at Uganda cancer institute

BACKGROUND

Many patients with head and neck cancer (HNC) often present with advanced disease. This may result from delay in deciding to seek care, delay in reaching the healthcare facility and or delay in accessing care in the healthcare facility. We therefore set out to determine the time to definitive diagnosis and factors associated with delayed diagnosis among patients with HNC at the Uganda Cancer Institute (UCI).

METHODS

A cross-sectional study was conducted at UCI, patients with HNC were recruited. An interviewer administered questionnaire was used to collect data on sociodemographic factors and clinical characteristics, including timelines in months, from symptom onset to deciding to seek care, to reaching the health care facility and to definitive diagnosis. Multivariate Poisson regression analysis was used to calculate odds ratios (ORs) for the factors of association with delayed diagnosis.

RESULTS

We recruited 160 HNC patients, and 134 patients were analyzed. The median age was 49.5 years (IQR 26.5), 70% (94 of 134) were male, 48% (69 of 134) had below secondary school education, 49% (65 of 134) had a household income < 54 USD. 56% (76 of 134) were sole bread winners, 67% (89 of 134) had good access road condition to the nearest health unit and 70% (91 of 134) presented with tumor stage 4. Median time from onset of symptoms to definitive diagnosis was 8.1 months (IQR 15.1) and 65% (87 of 134) of patients had delayed diagnosis. Good access roads (aOR: 0.26, p = 0.006), secondary school education (aOR: 0.17, p = 0.038), and household income > 136 USD (aOR: 0.27, p = 0.043) were associated with lower odds of delayed diagnosis. Being the sole bread winner (aOR: 2.15, p = 0.050) increased the odds of delayed diagnosis.

CONCLUSION

Most of HNC patients (65%) at UCI had delayed diagnosis. A national care pathway for individuals with suspected HNC should be established and consider rotation of Ear, Nose and Throat surgeons to underserved regions, to mitigate diagnostic delay.

A Preliminary Study on Early Detection of Oral Cancer with Opportunistic Screening: Insights from Dental Surgeons in Sri Lanka

In Sri Lanka, opportunistic screening is encouraged as a cost-effective tool to bring down the prevalence of oral cancer, which is the most common cancer among males. The objectives of the study were to determine the practices, attitudes, and level of competency of dental surgeons regarding the early detection of oral cancer and oral potentially malignant disorders (OPMDs) through opportunistic screening. A prospective study was conducted online via a Google form using a pretested, self-administered questionnaire of 22 close-ended questions and 3 open-ended questions. Out of the 137 dental surgeons who responded, 88% (121/137) of the participants believed that screening high-risk target groups would be more effective in the early detection of oral cancer rather than opportunistic screening. Only 64% (88/137) of the participants frequently check for oral cancer and OPMDs when patients visit for dental treatment. Participants recalled an average of 34 patients (4628/137) with clinically suspicious lesions being diagnosed during examination at general dental practice during the past year, and 98% (134/137) of the participants believed that they should receive additional training in order to identify and diagnose clinically suspicious oral OPMDs and oral cancer. Opportunistic screening in general dental practice as an oral-cancer prevention strategy is appreciable, but due emphasis should be given to other prevention strategies such as population screening and screening high-risk target groups. The level of confidence of general dental practitioners in the early detection of oral cancer has to be raised in order to achieve higher standards in oral cancer prevention through opportunistic screening.

Association Between Antibiotic Prescribing and Time to Diagnosis of Head and Neck Cancer

Importance

Diagnostic delay can negatively affect patient outcomes in head and neck cancer (HNC). Neck mass and other symptoms of undiagnosed HNC may be treated with antibiotics, delaying diagnosis and treatment, despite current clinical practice guidelines.

Objective

To investigate temporal trends, associated factors, and time from symptom onset to antibiotic prescribing before an HNC diagnosis.

Design, Setting, and Participants

A retrospective cohort study was conducted using data obtained from a deidentified electronic health records data set from January 1, 2011, to December 31, 2018. Patients with HNC enrolled in the data set for at least 1 year before diagnosis date determined by either 1 inpatient encounter or first of 2 outpatient encounters within 6 months were included. Data analysis was conducted from May 1 to November 9, 2022.

Exposure

Antibiotic prescription within 3 months before HNC diagnosis date.

Main Outcomes and Measures

The primary outcome was days from the first documented symptom to HNC diagnosis.

Results

The cohort included 7811 patients with HNC (4151 [53.1%] men, mean [SD] age, 60.2 [15.8] years). At least 1 antibiotic was prescribed for 1219 patients (15.6%) within 3 months before HNC diagnosis. This represented an increase over the 8.9% prescribing rate during the baseline period 12 to 9 months before diagnosis. The rate of antibiotic prescribing within 3 months before diagnosis did not change significantly over time (quarterly percent change, 0.49%; 95% CI, -3.06% to 4.16%). Patients receiving an antibiotic prescription within 3 months of an HNC diagnosis had a 21.1% longer time between symptom onset and HNC diagnoses (adjusted rate ratio [ARR], 1.21; 95% CI, 1.14-1.29). Compared with diagnosis by otolaryngologists, primary care/internal medicine physicians were most likely to prescribe antibiotics for patients who were diagnosed with a presenting symptom (adjusted prevalence ratio, 1.60; 95% CI, 1.27-2.02). In patients presenting with neck mass/swelling, those presenting with other symptoms were more likely to have longer intervals from symptom onset to diagnosis (ARR, 1.31; 95% CI, 1.08-1.59).

Conclusions and Relevance

The findings of this cohort study suggest there is an increased rate of antibiotic prescription in the 3 months before HNC diagnosis, which is associated with an increased time to diagnosis. These findings identify an area for improvement in HNC care and guidelines.

Expression of Epsin3 and its interaction with Notch signalling in oral epithelial dysplasia and oral squamous cell carcinoma

BACKGROUND

Most oral squamous cell carcinoma patients present with late-stage disease. Early detection of the disease is considered to be the most effective way of improving patient outcomes. Several biomarkers have been identified as indicators of oral cancer development and progression; however, none have been translated into clinical practice. In this study, we have investigated the role of Epsin3, an endocytic adaptor protein, and Notch1, a transmembrane signalling protein, in oral carcinogenesis with a view to explore their potential as biomarkers.

METHODS

Oral cancer cell lines and a normal oral keratinocyte cell line were used together with tissue samples of normal oral mucosa (n = 21), oral epithelial dysplasia (n = 74) and early stage (Stages I and II) oral squamous cell carcinoma (n = 31). Immunocytochemical staining, immunoblotting and real-time quantitative polymerase chain reaction (PCR) were performed to assess protein as well as gene expression levels.

RESULTS

The expression levels of Epsin3 and Notch1 mRNA and protein are variable across different oral squamous cell carcinoma derived cell lines. Epsin3 was upregulated in oral epithelial dysplasia and oral squamous cell carcinoma tissues compared with normal epithelium. Overexpression of Epsin3 resulted in a significant reduction of Notch1 expression in oral squamous cell carcinoma. Notch1 was generally downregulated in the dysplasia and oral squamous cell carcinoma samples.

CONCLUSION

Epsin3 is upregulated in oral epithelial dysplasia and oral squamous cell carcinoma and has the potential to be used as a biomarker for oral epithelial dysplasia. Notch signalling is downregulated in oral squamous cell carcinoma, possibly through an Epsin3-induced de-activation pathway.

Interventions for the treatment of oral cavity and oropharyngeal cancers: surgical treatment

BACKGROUND

Surgery is a common treatment option in oral cavity cancer (and less frequently in oropharyngeal cancer) to remove the primary tumour and sometimes neck lymph nodes. People with early-stage disease may undergo surgery alone or surgery plus radiotherapy, chemotherapy, immunotherapy/biotherapy, or a combination of these. Timing and extent of surgery varies. This is the third update of a review originally published in 2007.

OBJECTIVES

To evaluate the relative benefits and harms of different surgical treatment modalities for oral cavity and oropharyngeal cancers.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 9 February 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared two or more surgical treatment modalities, or surgery versus other treatment modalities, for primary tumours of the oral cavity or oropharynx.

DATA COLLECTION AND ANALYSIS

Our primary outcomes were overall survival, disease-free survival, locoregional recurrence, and recurrence; and our secondary outcomes were adverse effects of treatment, quality of life, direct and indirect costs to patients and health services, and participant satisfaction. We used standard Cochrane methods. We reported survival data as hazard ratios (HRs). For overall survival, we reported the HR of mortality, and for disease-free survival, we reported the combined HR of new disease, progression, and mortality; therefore, HRs below 1 indicated improvement in these outcomes. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We identified four new trials, bringing the total number of included trials to 15 (2820 participants randomised, 2583 participants analysed). For objective outcomes, we assessed four trials at high risk of bias, three at low risk, and eight at unclear risk. The trials evaluated nine comparisons; none compared different surgical approaches for excision of the primary tumour. Five trials evaluated elective neck dissection (ND) versus therapeutic (delayed) ND in people with oral cavity cancer and clinically negative neck nodes. Elective ND compared with therapeutic ND probably improves overall survival (HR 0.64, 95% confidence interval (CI) 0.50 to 0.83; I2 = 0%; 4 trials, 883 participants; moderate certainty) and disease-free survival (HR 0.56, 95% CI 0.45 to 0.70; I2 = 12%; 5 trials, 954 participants; moderate certainty), and probably reduces locoregional recurrence (HR 0.58, 95% CI 0.43 to 0.78; I2 = 0%; 4 trials, 458 participants; moderate certainty) and recurrence (RR 0.58, 95% CI 0.48 to 0.70; I2 = 0%; 3 trials, 633 participants; moderate certainty). Elective ND is probably associated with more adverse events (risk ratio (RR) 1.31, 95% CI 1.11 to 1.54; I2 = 0%; 2 trials, 746 participants; moderate certainty). Two trials evaluated elective radical ND versus elective selective ND in people with oral cavity cancer, but we were unable to pool the data as the trials used different surgical procedures. Neither study found evidence of a difference in overall survival (pooled measure not estimable; very low certainty). We are unsure if there is a difference in effect on disease-free survival (HR 0.57, 95% CI 0.29 to 1.11; 1 trial, 104 participants; very low certainty) or recurrence (RR 1.21, 95% CI 0.63 to 2.33; 1 trial, 143 participants; very low certainty). There may be no difference between the interventions in terms of adverse events (1 trial, 148 participants; low certainty). Two trials evaluated superselective ND versus selective ND, but we were unable to use the data. One trial evaluated supraomohyoid ND versus modified radical ND in 332 participants. We were unable to use any of the primary outcome data. The evidence on adverse events was very uncertain, with more complications, pain, and poorer shoulder function in the modified radical ND group. One trial evaluated sentinel node biopsy versus elective ND in 279 participants. There may be little or no difference between the interventions in overall survival (HR 1.00, 95% CI 0.90 to 1.11; low certainty), disease-free survival (HR 0.98, 95% CI 0.90 to 1.07; low certainty), or locoregional recurrence (HR 1.04, 95% CI 0.91 to 1.19; low certainty). The trial provided no usable data for recurrence, and reported no adverse events (very low certainty). One trial evaluated positron emission tomography-computed tomography (PET-CT) following chemoradiotherapy (with ND only if no or incomplete response) versus planned ND (before or after chemoradiotherapy) in 564 participants. There is probably no difference between the interventions in overall survival (HR 0.92, 95% CI 0.65 to 1.31; moderate certainty) or locoregional recurrence (HR 1.00, 95% CI 0.94 to 1.06; moderate certainty). One trial evaluated surgery plus radiotherapy versus radiotherapy alone and provided very low-certainty evidence of better overall survival in the surgery plus radiotherapy group (HR 0.24, 95% CI 0.10 to 0.59; 35 participants). The data were unreliable because the trial stopped early and had multiple protocol violations. In terms of adverse events, subcutaneous fibrosis was more frequent in the surgery plus radiotherapy group, but there were no differences in other adverse events (very low certainty). One trial evaluated surgery versus radiotherapy alone for oropharyngeal cancer in 68 participants. There may be little or no difference between the interventions for overall survival (HR 0.83, 95% CI 0.09 to 7.46; low certainty) or disease-free survival (HR 1.07, 95% CI 0.27 to 4.22; low certainty). For adverse events, there were too many outcomes to draw reliable conclusions. One trial evaluated surgery plus adjuvant radiotherapy versus chemotherapy. We were unable to use the data for any of the outcomes reported (very low certainty).

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence based on five trials that elective neck dissection of clinically negative neck nodes at the time of removal of the primary oral cavity tumour is superior to therapeutic neck dissection, with increased survival and disease-free survival, and reduced locoregional recurrence. There was moderate-certainty evidence from one trial of no difference between positron emission tomography (PET-CT) following chemoradiotherapy versus planned neck dissection in terms of overall survival or locoregional recurrence. The evidence for each of the other seven comparisons came from only one or two studies and was assessed as low or very low-certainty.

A new method for oral cancer biomarkers detection with a non-invasive cyto-salivary sampling and rapid-highly sensitive ELISA immunoassay: a pilot study in humans

Introduction

Oral squamous cell carcinoma (OSCC) accounts for approximately 90% of oral malignancies and has a 5-year mortality rate close to 50%. A consistent part (70%) of all oral cancers is diagnosed at an advanced stage since available screening techniques are ineffective. Therefore, it would be urgent to improve them. The diagnostic gold standard is tissue biopsy with histological and immunohistochemical assessment. This method presents some limitations. Biopsy is invasive and the histopathological evaluation is semi-quantitative, and the absolute abundance of the target cannot be reliably determined. In addition, tissue is highly processed and may lead to loss of information of the natural state. The search for classical and new clinical biomarkers on fragments of tissue/cells collected with a cytobrush is a highly hopeful technique for early detection and diagnosis of OSCC, because of its non-invasive sampling and easy collection method.

Methods

Here we analyzed cytobrush biopsies samples collected from the oral cavity of 15 patients with already diagnosed OSCC by applying an innovative high-sensitivity ELISA technique, in order to verify if this approach may provide useful information for detection, diagnosis, and prognosis of OSCC. To this end, we selected six biomarkers, already used in clinical practice for the diagnosis of OSCC (EGFR, Ki67, p53) or selected based on recent scientific and clinical data which indicate their presence or over-expression in cells undergoing transformation and their role as possible molecular targets in immunecheckpoints blockade therapies (PD-L1, HLA-E, B7-H6).

Results

The selected tumor biomarkers were highly expressed in the tumor core, while were virtually negative in healthy tissue collected from the same patients. These differences were highly statistically significant and consistent with those obtained using the gold standard test clearly indicating that the proposed approach, i.e. analysis of biomarkers by a custom ELISA technique, is strongly reliable.

Discussion

These preliminary data suggest that this non-invasive rapid phenotyping technique could be useful as a screening tool for phenotyping oral lesions and support clinical practice by precise indications on the characteristics of the lesion, also with a view to the application of new anti-tumor treatments, such as immunotherapy, aimed at OSCC patients.

Compliance with Specialist Referral for Increased Cancer Risk in Low-Resource Settings: In-Person vs. Telehealth Options

Efforts are underway to improve the accuracy of non-specialist screening for oral cancer (OC) risk, yet better screening will only translate into improved outcomes if at-risk individuals comply with specialist referral. Most individuals from low-resource, minority, and underserved (LRMU) populations fail to complete a specialist referral for OC risk. The goal was to evaluate the impact of a novel approach on specialist referral compliance in individuals with a positive OC risk screening outcome. A total of 60 LRMU subjects who had screened positive for increased OC risk were recruited and given the choice of referral for an in-person (20 subjects) or a telehealth (40 subjects) specialist visit. Referral compliance was tracked weekly over 6 months. Compliance was 30% in the in-person group, and 83% in the telehealth group. Approximately 83-85% of subjects from both groups who had complied with the first specialist referral complied with a second follow-up in-person specialist visit. Overall, 72.5% of subjects who had chosen a remote first specialist visit had entered into the continuum of care by the study end, vs. 25% of individuals in the in-person specialist group. A two-step approach that uses telehealth to overcome barriers may improve specialist referral compliance in LRMU individuals with increased OC risk.

Salivary-Based Cell-Free Mitochondrial DNA Level Is an Independent Prognostic Biomarker for Patients with Head and Neck Squamous Cell Carcinoma

Changes in the copy numbers of cell-free nuclear DNA (cf-nDNA) and cell-free mitochondrial DNA (cf-mtDNA) have shown promising diagnostic utilities among patients with head and neck squamous cell carcinoma (HNSCC). Considering the absence of objective prognostic tools for HNSCC surveillance, this study aimed to assess the utility of saliva-based cf-nDNA and cf-mtDNA in predicting the overall survival of patients with HNSCC. The study included ninety-four patients with a confirmed HNSCC diagnosis with a mean follow-up time of 32.04 months (±19.1). A saliva-based liquid biopsy was collected from each patient. A multiplex quantitative PCR was used to determine the absolute number of cf-nDNA and cf-mtDNA. The Kaplan-Meier estimator and Cox proportional hazards regression models were used to assess overall survival. The absolute copy numbers of cf-nDNA and cf-mtDNA were statistically significantly higher among the deceased patients than among the censored ones (p < 0.05). Individuals with elevated levels of cf-nDNA or cf-mtDNA were associated with a significantly poorer overall survival (p ≤ 0.05). A univariate analysis showed that only the absolute copy number of cf-mtDNA was the sole predictor of overall survival. However, the multivariate analysis showed that all the absolute copy numbers of cf-nDNA, the absolute copy numbers of cf-mtDNA, and the stage of HNSCC were predictors of overall survival. Our study confirms that saliva is a reliable and non-invasive source of data that can be used to predict the overall survival of patients with HNSCC, where cf-mtDNA levels act as the sole predictor.

Insight on nano drug delivery systems with targeted therapy in treatment of oral cancer

Oral cancer is a type of cancer that develops in the mouth and is one of the deadliest malignancies in the world. Currently surgical, radiation therapy, and chemotherapy are most common treatments. Better treatment and early detection strategies are required. Chemotherapeutic drugs fail frequently due to toxicity and poor tumor targeting. There are high chances of failure of chemotherapeutic drugs due to toxicity. Active, passive, and immunity-targeting techniques are devised for tumor-specific activity. Nanotechnology-based drug delivery systems are the best available solution and important for precise targeting. Nanoparticles, liposomes, exosomes, and cyclodextrins are nano-based carriers for drug delivery. Nanotechnology is being used to develop new techniques such as intratumoral injections, microbubble mediated ultrasonic therapy, phototherapies, and site-specific delivery. This systematic review delves into the details of such targeted and nano-based drug delivery systems in order to improve patient health and survival rates in oral cancer.

Assessing the role of ultrasound for the evaluation of adult neck masses

Objectives

The American Academy of Otolaryngology clinical practice guidelines recommend cross-sectional imaging or fine needle aspiration for any neck mass in an adult that persists beyond 2 weeks that is not convincingly related to a bacterial infection. We aimed to assess the role of ultrasound in the evaluation and management of neck masses.

Methods

A retrospective chart review was performed of adult patients evaluated in the Otolaryngology clinic at a single institution from December 2014 to December 2015 for a visible or palpable neck mass persistent beyond 2 weeks who had an ultrasound exam as part of their initial workup. Patients with a history of head and neck malignancy or those presenting wtih primary salivary or thyroid gland lesions were excluded. Sonographic features, demographics, imaging, and biopsy results were recorded.

Results

Of the 56 patients who met inclusion criteria, 36 (64.3%) received FNA or biopsy, of which 18 (50%) demonstrated malignant pathology. Twenty patients (35.7%) demonstrated benign features on ultrasound and did not undergo tissue sampling. Two of these 20 patients underwent subsequent cross-sectional imaging. Eight of these 20 patients were followed with serial ultrasound with an average of 3 exams over 14.7 months. The remaining 12 patients had spontaneous resolution of their adenopathy. None of these 20 patients was subsequently diagnosed with malignancy.

Conclusion

In this study, approximately one third of patients presenting with a visible or palpable neck mass were able to safely avoid cross-sectional imaging and/or tissue sampling when ultrasound demonstrated features consistent with benign pathology. Our results suggest that ultrasound can play a useful role in the initial evaluation and management of adults presenting with a neck mass.

Level of Evidence

IV.

Novel Approach to Improving Specialist Access in Underserved Populations with Suspicious Oral Lesions

Late detection and specialist referral result in poor oral cancer outcomes globally. High-risk LRMU populations usually do not have access to oral medicine specialists, a specialty of dentistry, whose expertise includes the identification, treatment, and management of oral cancers. To overcome this access barrier, there is an urgent need for novel, low-cost tele-health approaches to expand specialist access to low-resource, remote and underserved individuals. The goal of this study was to compare the diagnostic accuracy of remote versus in-person specialist visits using a novel, low-cost telehealth platform consisting of a smartphone-based, remote intraoral camera and custom software application. A total of 189 subjects with suspicious oral lesions requiring biopsy (per the standard of care) were recruited and consented. Each subject was examined, and risk factors were recorded twice: once by an on-site specialist, and again by an offsite specialist. A novel, low-cost, smartphone-based intraoral camera paired with a custom software application were utilized to perform synchronous remote video/still imaging and risk factor assessment by the off-site specialist. Biopsies were performed at a later date following specialist recommendations. The study's results indicated that on-site specialist diagnosis showed high sensitivity (94%) and moderate specificity (72%) when compared to histological diagnosis, which did not significantly differ from the accuracy of remote specialist telediagnosis (sensitivity: 95%; specificity: 84%). These preliminary findings suggest that remote specialist visits utilizing a novel, low-cost, smartphone-based telehealth tool may improve specialist access for low-resource, remote and underserved individuals with suspicious oral lesions.

Difference in clinical presentation and their significance in oral squamous cell carcinoma: A retrospective analysis

BACKGROUND

Oral squamous cell carcinoma (OSCC) remains the most common cancer among Indian men. OSCC involving the tongue and bucco alveolar complex (BAC) behaves differently. Nevertheless, the differences in clinical features and symptoms between the two subsites and their relation to pathology remain largely unexplored.

STUDY DESIGN

The study compared various clinical parameters and pathological factors between tongue cancer patients and patients with BAC cancer.

RESULTS

Among 474 patients, 232 had tongue cancer and 242 had BAC cancer. Except for the ulcer, 30% of patients with OSCC were asymptomatic at presentation. Compared to tongue cancers, lesions confined to BAC present at an advanced stage (P = 0.006). Multivariate analysis showed that dysphagia in tongue cancer (P = 0.020) and external swelling or lesion in BAC cancers (P = 0.002) were significant predictors of an advanced stage of the disease. On histopathology, perineural invasion (PNI) was significantly associated with tongue (P = 0.008) compared to BAC cancers (P = 0.015). Cancers of the tongue with pain and referred otalgia had a significantly higher depth of invasion (DOI), compared to those without pain (DOI - no pain 6.9 mm, pain 9.9 mm, and referred otalgia 11.4 mm).

CONCLUSIONS

Patients with OSCC present late and in an advanced stage of the disease. Among tongue cancers, clinical history of pain was significantly associated with DOI and PNI, the significance of which needs to be prospectively analyzed. Clinical history in OSCC can be used as predicting factor for an advanced pathological stage of the disease. It also had an influence on various pathological characters, which is subsite specific.

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

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.

Dentists Behavioral Factors Influencing Early Detection of Oral Cancer: Direct Clinical Observational Study

This study aimed to investigate the possible factors affecting dentists' behavior relating to performing oral cancer examinations as part of routine clinical examination. A total of 95 direct clinical observation sessions-utilizing an instrument consisting of 19 evidence-based observational criteria for oral cancer examinations-were observed by four calibrated dentists. Thirty-two final-year students, 32 interns, and 31 faculty members of Jazan Dental School were examined between April 9 and May 4, 2017. A descriptive analysis was conducted to investigate the frequencies/percentages of the performed observing criteria by all examiners. ANOVA and Tukey tests were carried out to investigate the difference between the examiner groups. A total number of 32 patients participated in the study, whereby each patient was examined by three different examiners from each group, as well as by the attending observer/s. Fewer than 50% of the examiners performed the clinical steps necessary for an oral cancer examination-for example, taking into account past medical history, as well as extra and intra-oral examinations. More than 90% of the examiners examined hard tissue, whereas fewer than 30% of them educated their patients about possible risk factors. A significant difference between examiner groups was found in favor of faculty members. A gap between knowledge and actual practice of oral cancer examinations was evident: majority of participants failed to perform the necessary steps for an oral cancer examination. Previous experience and confidence in performing oral cancer examination are possible explanations for the dentist's behavior toward oral cancer examination.

Oral brush biopsy using liquid-based cytology is a reliable tool for oral cancer screening: A cost-utility analysis: Oral brush biopsy for oral cancer screening

Background

This study aimed to assess the diagnostic utility and associated cost of oral liquid‐based brush cytology (OLBC) in the diagnosis of oral cancer and oral potentially malignant disorders (OPMDs).

Methods

A total of 284 patients with oral mucosal lesions were included. OLBC samples were collected from all patients immediately before undergoing surgical biopsies. A liquid‐based cytology slide was prepared from each OLBC sample for cytological evaluation using the modified 2014 Bethesda cytology system. The results and the cost were compared with the histopathological outcomes.

Results

The level of agreement between the two approaches was very good (weighted kappa = 0.824). The accuracy of OLBC in differentiating between the different diagnostic groups was 91.69%, whereas the associated sensitivity and specificity were 79.23% and 94.81%, respectively. The estimated cost of each OLBC sample was at least 26% less than the cost of a single biopsy and more than 42% less in cases of multiple biopsied lesions.

Conclusions

The proposed modifications of the Bethesda system can be adopted as a standardized system for oral cytological assessment. Our findings support OLBC as a reliable adjunct to surgical biopsy in the diagnosis of OPMDs. This tool has potential for oral cancer–finding and surveillance programs.

Oral brush liquid‐based cytology is a reliable adjunct to surgical biopsy in the diagnosis of oral potentially malignant disorders. It has potential for oral cancer‐finding and surveillance programs.

Oral cancer analysis in a Brazilian city: interval between diagnosis and treatment

In Brazil, there are 15,500 incident cases of oral cancer (OC) yearly, and early diagnosis is the main factor for a better prognosis. The objective of this study was to analyze the interval between the first symptoms, diagnosis, and treatment commencement in patients with malignant neoplasms in the oral cavity, lips, and oropharynx diagnosed between 2012-2018. Epidemiological data, duration, history of lesion, biopsy, and diagnosis were obtained from the medical records of these patients, who were then contacted via phone and interviewed about their oncological treatment. The results were analyzed and expressed as mean, median, and SD. Of 184 patients, most were men, white, 50-69 years old, smokers, and alcoholics. The longest interval was between the first symptoms and first evaluation (a mean of 275 days). The interval between the first appointment and the result of the biopsy was shorter (13 days). Among the 85 patients interviewed, the interval between the diagnosis, the first appointment at the oncological clinic and treatment commencement was 55 days (mean) for patients using private-sector health care, and 96 days (mean) for patients using public health care. The interval was twice as long in the public health system compared with the private sector, which highlights the inequality of access to health care in Brazil. Delay in seeking health care after the appearance of the first symptoms remains a major problem.

Effectiveness of "OralDETECT": a Repetitive Test-enhanced, Corrective Feedback Method Competency Assessment Tool for Early Detection of Oral Cancer

Early diagnosis of oral cancer results in less aggressive treatment and improves the quality of life and overall 5-year survival rate. Well-trained dental professionals can play a crucial role in the early detection of oral cancers. The present study aims to determine the effectiveness of the training program "OralDETECT", a spaced repetitive, test-enhanced learning tool with a corrective feedback mechanism for early detection of oral cancer. Thirty-two dentists and 259 dental students from three Malaysian dental schools were involved in this study. All participants were trained and calibrated to recognize oral potentially malignant disorders (OPMD) and oral cancer using "OralDETECT", which is comprised of a series of pre-test, lecture, post-tests and review sessions. The percentage of correct answers (scores) for each test given by the participants was calculated and analysed using a paired t test. It was found that the overall percentage of diagnostic accuracy for both dental professionals and student groups increased to above 80% from the pre-tests to the final post-tests. There was a significant improvement in overall scores between the pre-tests and all three post-tests for the dental professional groups and the student groups. The diagnostic accuracy for individual OPMD and lesions suspicious of oral cancer also increased to above 80% for both groups. The results of our study demonstrate that the "OralDETECT" is an efficient and effective competency tool which can be used to train dental professionals and students for the early detection of OPMD and oral cancer.

Evaluation of the prevalence of metachronous second primary malignancies in hypopharyngeal carcinoma and their effect on outcomes

Background

To investigate the clinical characteristics of metachronous second primary malignancies (Met‐SPMs) and its impact on prognosis in hypopharyngeal carcinoma (HPC).

Methods

We reviewed 593 newly diagnosed HPC patients without invasive synchronous SPMs (Syn‐SPMs) who were treated in our cancer center between 2009 and 2019. According to the status during follow‐up, patients were classified into three groups: (a) without SPMs (No‐SPMs, n = 440), (b) with tumors in situ in the esophagus or stomach (Tis, n = 80), or (c) with Met‐SPMs (n = 73).

Results

The median follow‐up time for entire cohort (n = 593) was 66.7 months. Met‐SPMs were present in 12.3% of the cohort (73/593). The predominant site of SPMs was esophagus, followed by lung, oral cavity, thyroid, stomach, and oropharynx. In Met‐SPMs group, both index tumor and SPMs were the main causes of death. Tis group exhibited comparable 5‐year overall survival (OS) and disease‐specific survival (DSS) with that of No‐SPMs group. The Met‐SPMs group had similar 5‐year OS rate and better 5‐year DSS rate of 47.3% versus 43.6% (odds ratio [OR], 0.931; 95% confidence interval [CI], 0.681–1.274, p = 0.657) and 66.3% vs. 46.2% (OR, 0.600; 95% CI, 0.402–0.896, p = 0.012), respectively, compared with the No‐SPMs group.

Conclusion

The overall incidence of Met‐SPMs in HPC was 12.3%. The occurrence of Met‐SPMs does not jeopardize the survival outcome of HPC. Routine surveillance of Met‐SPMs was requisite for patients with HPC.

Professional delays in referral of patients with mouth cancer: six case histories

Professional delay is an important delay in referral of patients with suspected mouth cancer. Missing the possibility of cancer might not only result in worse outcomes in respect to function and survival, but also have medicolegal implications. The aim of this article was to review a consecutive cohort of patients over a two-year period with mouth cancer diagnosis and identify those with professional delay and illustrate the main types of presentations using short case histories. The multi-disciplinary team records were used to identify case notes of a two-year (2019 and 2020) consecutive cohort of patients diagnosed with mouth cancer, including referrals from primary and secondary care. Professional delay was considered if red flag symptoms were not referred within two weeks or if there was initial misdiagnosis. In total, 246 patients with mouth cancer were discussed with the multi-disciplinary team: 35 had delay in referral or misdiagnosis of mouth cancer. Six common scenarios were identified: 1) sudden onset paraesthesia; 2) dental abscess; 3) temporomandibular joint dysfunction syndrome (TMJD) and abscess; 4) TMJD; 5) trauma/facial fracture; and 6) non-healing socket following dental extraction. To conclude, it can be difficult to accurately diagnose mouth cancer in primary dental and medical care and an index of suspicion is essential in order to minimise the possibility of professional delay.

Oral and maxillofacial cancer: A 35-year retrospective analysis at a referral dental hospital in Saudi Arabia

Objectives

As rates of oral and maxillofacial cancer (OMFC) continue to rise, the role of dentists in early detection and prevention has become increasingly important. The present study examined the frequency and pattern of OMFC cases diagnosed at a referral dental hospital.

Methods

A retrospective analysis of all primary malignant neoplasms of the oral and maxillofacial area diagnosed at the Histopathology Laboratory of the Dental University Hospital, Medical City, King Saud University, Saudi Arabia from 1984 to 2020 was performed.

Results

A total of 242 patients had histologically diagnosed primary malignant neoplasms of the oral and maxillofacial area, accounting approximately 3.7% of the archives. The mean age of patients was 48.87 years, and the male-to-female ratio was 1.5:1. The most prevalent malignant neoplasm was squamous cell carcinoma (SCC) (58.3%), followed by mucoepidermoid carcinoma (11.6%). The tongue and gingiva were the most prevalent malignancy sites, accounting for 19.8% and 18.2% of the cases, respectively. The prevalence of SCC in patients over 50 years old (68.4%) was highly significantly greater than that in younger subjects (31.5%) (P < 0.0005). SCC was also more common in males (66.7%) than in females (33.3%) (P = 0.026).

Conclusion

OMFC primarily affecting the tongue and gingiva was the predominant in older male patients. SCC was the most frequent type of OMFC and was significantly associated with age older than 50 years. This study provides baseline data on the frequency of OMFC cases diagnosed for the first time by dental practitioners and warrants the need for increasing OMFC awareness among these clinicians.

Interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy

BACKGROUND

Oral cavity and oropharyngeal cancers are the most common cancers arising in the head and neck. Treatment of oral cavity cancer is generally surgery followed by radiotherapy, whereas oropharyngeal cancers, which are more likely to be advanced at the time of diagnosis, are managed with radiotherapy or chemoradiation. Surgery for oral cancers can be disfiguring and both surgery and radiotherapy have significant functional side effects. The development of new chemotherapy agents, new combinations of agents and changes in the relative timing of surgery, radiotherapy, and chemotherapy treatments may potentially bring about increases in both survival and quality of life for this group of patients. This review updates one last published in 2011.

OBJECTIVES

To determine whether chemotherapy, in addition to radiotherapy and/or surgery for oral cavity and oropharyngeal squamous cell carcinoma results in improved overall survival, improved disease-free survival and/or improved locoregional control, when incorporated as either induction therapy given prior to locoregional treatment (i.e. radiotherapy or surgery), concurrent with radiotherapy or in the adjuvant (i.e. after locoregional treatment with radiotherapy or surgery) setting.

SEARCH METHODS

An information specialist searched 4 bibliographic databases up to 15 September 2021 and used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where more than 50% of participants had primary tumours in the oral cavity or oropharynx, and that evaluated the addition of chemotherapy to other treatments such as radiotherapy and/or surgery, or compared two or more chemotherapy regimens or modes of administration.

DATA COLLECTION AND ANALYSIS

For this update, we assessed the new included trials for their risk of bias and at least two authors extracted data from them. Our primary outcome was overall survival (time to death from any cause). Secondary outcomes were disease-free survival (time to disease recurrence or death from any cause) and locoregional control (response to primary treatment). We contacted trial authors for additional information or clarification when necessary.

MAIN RESULTS

We included 100 studies with 18,813 participants. None of the included trials were at low risk of bias.  For induction chemotherapy, we reported the results for contemporary regimens that will be of interest to clinicians and people being treated for oral cavity and oropharyngeal cancers. Overall, there is insufficient evidence to clearly demonstrate a survival benefit from induction chemotherapy with platinum plus 5-fluorouracil prior to radiotherapy (hazard ratio (HR) for death 0.85, 95% confidence interval (CI) 0.70 to 1.04, P = 0.11; 7427 participants, 5 studies; moderate-certainty evidence), prior to surgery (HR for death 1.06, 95% CI 0.71 to 1.60, P = 0.77; 198 participants, 1 study; low-certainty evidence) or prior to concurrent chemoradiation (CRT) with cisplatin (HR for death 0.71, 95% CI 0.37 to 1.35, P = 0.30; 389 participants, 2 studies; low-certainty evidence). There is insufficient evidence to support the use of an induction chemotherapy regimen with cisplatin plus 5-fluorouracil plus docetaxel prior to CRT with cisplatin (HR for death 1.08, 95% CI 0.80 to 1.44, P = 0.63; 760 participants, 3 studies; low-certainty evidence).  There is insufficient evidence to support the use of adjuvant chemotherapy over observation only following surgery (HR for death 0.95, 95% CI 0.73 to 1.22, P = 0.67; 353 participants, 5 studies; moderate-certainty evidence). Among studies that compared post-surgical adjuvant CRT, as compared to post-surgical RT, adjuvant CRT showed a survival benefit (HR 0.84, 95% CI 0.72 to 0.98, P = 0.03; 1097 participants, 4 studies; moderate-certainty evidence). Primary treatment with CRT, as compared to radiotherapy alone,  was associated with a reduction in the risk of death (HR for death 0.74, 95% CI 0.67 to 0.83, P < 0.00001; 2852 participants, 24 studies; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The results of this review demonstrate that chemotherapy in the curative-intent treatment of oral cavity and oropharyngeal cancers only seems to be of benefit when used in specific circumstances together with locoregional treatment. The  evidence does not show a clear survival benefit from the use of induction chemotherapy prior to radiotherapy, surgery or CRT. Adjuvant CRT reduces the risk of death by 16%, as compared to radiotherapy alone. Concurrent chemoradiation as compared to radiation alone is associated with a greater than 20% improvement in overall survival; however, additional research is required to inform how the specific chemotherapy regimen may influence this benefit.

Circular RNAs as a Diagnostic Biomarker in Oral Squamous Cell Carcinoma: A Meta-Analysis

PURPOSE

Studies have found a positive correlation between various cancers and circular RNAs (circRNAs), which are newly discovered noncoding RNAs. However, limited scientific evidence is available to prove the clinical value of circRNAs in the presentation of oral squamous cell carcinoma (OSCC). This study aimed to comprehensively explore the potential of circRNAs as diagnostic indexes of OSCC.

METHODS

Online databases were systematically searched to identify published literature on the discovery of circRNAs in OSCC. Data were acquired from each reviewed study and collated to create a 2 × 2 eventuality table. Hierarchical analysis of the literature was conducted for the type of cancer, year of publication, and the sample size of each study. The diagnostic accuracy was calculated using indexes such as the pooled sensitivity and specificity and critically assessed using the Quality Assessment for Studies of Diagnostic Accuracy 2.

RESULTS

This meta-analysis included findings of 6 studies on 335 patients diagnosed with OSCC. These 6 studies examined 7 circRNAs, 5 in tissues and 2 in the saliva of patients with OSCC. When used as a diagnostic tool for OSCC, circRNAs manifested a sensitivity level of 0.72 (95% confidence interval: 0.67 to 0.76) and a degree of specificity of 0.81 (95% confidence interval: 0.76 to 0.85), with a general projected probability rate of 3.82 (95% confidence interval: 2.98 to 4.91) being positive and 0.35 (95% confidence interval: 0.29 to 0.41) being negative. The combined probability rate was 11.07 (95% confidence interval: 7.64 to 16.04), comprising a total of 0.76 (95% confidence interval: 0.72 to 0.79) of the region under the curve. A higher diagnostic value was found for salivary circRNAs (diagnostic odds ratio = 17.52; 95% CI: 10.11 to 30.35) than for tissue circRNAs (diagnostic odds ratio = 8.47; 95% CI: 5.6 to 12.83). This indicated that circRNAs showed a good discrimination ability as biomarkers of OSCC.

CONCLUSIONS

circRNAs showed high accuracy in the diagnosis of OSCC and could be used as prospective biomarkers to facilitate the diagnostic process.

Early diagnosis of oral squamous cell carcinoma may ensure better prognosis: A case series

Oral squamous cell carcinoma is an extremely malignant tumour: in order to reduce mortality and morbidity, early diagnosis and treatment is the clinician's best weapon.

Pilot Model for Community Based Oral Cancer Screening Program: Outcome from 4 Northeastern Provinces in Thailand

Management of advanced-stage oral cancer adds a great burden to individuals and health care systems. Community-based oral cancer screening can be beneficial in early detection and treatment. In this study, a novel oral cancer screening program was conducted utilizing an existing network of health care personnel, facilities, and digital database management for efficient coverage of a large population. The screening program considered 392,396 individuals aged ≥40 from four northeastern provinces in Thailand. Three levels of screening were performed: S1 by village healthcare volunteers to identify risk groups, S2 by dental auxiliaries to visually identify abnormal oral lesions, and S3 by dentists for final diagnosis and management. A total of 349,318 individuals were interviewed for S1, and 192,688 were identified as a risk group. For S2, 88,201 individuals appeared, and 2969 were further referred. Out of 1779 individuals who appeared for S3, oral potentially malignant disorders (OPMDs) were identified in 544, non-OPMDs in 1047, doubtful lesions in 52, and no results in 136 individuals. Final treatment was carried out in 704 individuals that included biopsies of 504 lesions, exhibiting 25 cancerous lesions and 298 OPMDs. This study is so far one of the largest oral cancer screening programs conducted in Thailand and showed effective implementation of community-based oral cancer screening.

Impact of delay in diagnosis and treatment-initiation on disease stage and survival in oral cavity cancer: a systematic review

AIM/OBJECTIVES

This study aimed to systematically review the literature on the impact of delay in diagnosis and treatment of oral cavity cancer.

METHODS

PubMed and Embase were systematically searched for articles reporting impact of delay in diagnosis and treatment on cancer-stage and survival of oral cavity cancer. Studies comprising at least ten patients, and published since the year 2000, were included.

RESULTS

Sixteen studies (n = 45,001, range: 62-18,677 per study, 83% men), from Australia, Asia, Europe, North America and South America, met the inclusion criteria. Eleven studies (n = 1,460) examined delay in diagnosis, while five studies (n = 43,541) reported delay in treatment. Eight of the eleven studies, examining delay in diagnosis (n = 1,220), analyzed the correlation between delay in diagnosis and tumor stage at diagnosis. Three studies found a significant correlation between patient delay and advanced stage at diagnosis (p < 0.05), whereas three other studies did not. The studies reporting a significant correlation were from Asian countries, whereas the three studies that did not find a correlation were from other continents. Studies reporting on professional delay and total diagnostic delay, generally, did not find a significant correlation with advanced cancer at diagnosis. Time to treatment (TTI), defined as time from diagnosis to treatment, was found significantly correlated with survival in three studies (p < 0.01, p < 0.001, p < 0.05), and nonsignificant in two studies.

CONCLUSION

A significant correlation between patient delay and advanced stage cancer was reported in Asian studies only, while professional delay and total diagnostic delay were generally found to be non-correlated with advanced stage cancer at diagnosis. TTI was in some studies reported to be correlated with poorer outcome, while other studies did not report a correlation. One study presented that there was no clear advantage in overall survival (OS) for patients treated within 30 days, compared to patients treated between 30 and 44 days.

Oral cancer histopathological subtypes in association with risk factors: a 5-year retrospective study

Background: Oral cancer is a worldwide public health problem, being the sixth most common neoplasm. The high mortality rate of this type of cancer is due to a delayed diagnosis, a fast evolution and metastasis, no primary symptomatology, the multitude of risk factors and the lack of awareness among the population concerning oral malignancy. Aim: The aim of this 5-year retrospective study was to evaluate the incidence of oral cancer patients in the Clinic of Maxillo-Facial Surgery, Emergency County Hospital, Timişoara, Romania and quantify the histopathological (HP) subtypes, localization, age, gender, tumor staging and differentiation, positive loco-regional lymph nodes and risk factors. Patients, Materials and Methods: A number of 129 patients diagnosed with oral cancer were included in the study and their medical records were analyzed. A statistical analysis was performed that included the variables gender, age, tumor staging, differentiation grade, HP subtype, lymph nodes, localization, and risk factors. Results: Our results outlined a high prevalence of oral cancer among males (65.9%), squamous cell carcinoma (SCC) being the most common HP subtype. Tumor staging revealed the fact that the majority of were T3 and T4 tumors with dissemination in the loco-regional lymph nodes. In 52% of the cases, tobacco was identified as a risk factor, and the association of tobacco and alcohol was present in 28.3% of the cases. Conclusions: The early diagnosis is crucial for the improvement of oral cancer survival rate. The oral cavity is permanently exposed to carcinogenic substances that associated with other risk factors have an influence upon the incidence of oral malignancies.

Salivary NUS1 and RCN1 Levels as Biomarkers for Oral Squamous Cell Carcinoma Diagnosis

BACKGROUND/AIM

Oral cancer may become advanced because of delay in diagnosis. In order to promote oral cancer screening, simple and highly reliable screening methods that can be implemented at general dental clinics are required. Herein we investigated differential salivary gene expression between oral squamous cell carcinoma (OSCC) patients and healthy volunteers (HV) to identify new biomarkers for OSCC detection.

MATERIALS AND METHODS

Candidate genes were selected by microarrays, nuclear undecaprenyl pyrophosphate synthase 1 (NUS1) and reticulocalbin 1 (RCN1) were selected for further investigation. We used real-time quantitative reverse transcription PCR (qRT-PCR) to determine NUS1 and RCN1 expression levels in saliva and tissues.

RESULTS

qRT-PCR analysis of clinical samples revealed that OSCC patients had significantly higher expression of salivary NUS1 and RCN1 than HV.

CONCLUSION

A combination of NUS1 and RCN1 accurately distinguished patients from controls, and this combination can be implemented as a screening test for OSCC.

Clinicopathological Risk Factors for Contralateral Lymph Node Metastases in Intraoral Squamous Cell Carcinoma: A Study of 331 Cases

The current study aimed to examine the effects of clinicopathological factors, including the region, midline involvement, T classification, histological grade, and differentiation of the tumor on the rate of contralateral lymph node metastasis for oral squamous cell carcinoma and to assess their effects on survival rates. A total of 331 patients with intraoral squamous cell carcinomas were included. The influence of tumor location, T status, midline involvement, tumor grading, and the infiltration depth of the tumor on the pattern of metastasis was evaluated. Additionally, the effect of contralateral metastases on the prognosis was examined. Metastases of the contralateral side occurred most frequently in squamous cell carcinomas of the palate and floor of the mouth. Furthermore, tumors with a high T status resulted in significantly higher rates of contralateral metastases. Similarly, the midline involvement, tumor grading, existing ipsilateral metastases, and the infiltration depth of the tumor had a highly significant influence on the development of lymph node metastases on the opposite side. Oral squamous cell carcinomas require a patient-specific decision. There is an ongoing need for further prospective studies to confirm the validity of the prognostic factors described herein.

Critical review of clinical practice guidelines for evaluation of neck mass in adults

Objective

Several clinical practice guidelines have been produced and disseminated for the evaluation of a neck mass. However, to date, the quality and methodologic rigor of these clinical practice guidelines have not been appraised. Therefore, this study set out to identify and assess the methodologic quality of national and international guidelines for the evaluation and management of neck masses in adults.

Methods

We conducted a comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources until September 2020. The quality of these guidelines was assessed by four reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered acceptable quality if they scored >60%, and Intraclass Correlation Coefficients (ICC) were calculated to assess agreement among the appraisers.

Results

Seven guidelines were assessed for evaluation. Among these, only the American Academy of Otolaryngology (AAO), Cancer Care Manitoba (CCMB), and the American Society of Clinical Oncology (ASCO) achieved an overall rating of “high”. The remaining four guidelines achieved ratings of either “average” or “low”. The “Scope and Purpose” domain achieved the highest mean score (94.4% ± 5.0%), and lowest was “Applicability” (51.5% ± 29.2%). ICC analysis showed substantial to very good agreement across all domains (0.75–0.98).

Conclusion

These findings highlight the variability in methodologic quality of guidelines for the evaluation and management of adult neck mass. The results from this analysis highlight the need to improve guidelines development process for this topic and may guide the selection and use of these guidelines in clinical practice.

Perioperative mortality of head and neck cancers

Background

Head and neck cancers are aggressive cancers, most clinical studies focused on the prognosis of patients with head and neck cancer. However, perioperative mortality was rarely mentioned.

Methods

A retrospective analysis was performed using all head and neck cancer patients admitting in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital, Central South University from January 2010 to December 2019. The analysis of overall survival and progression-free survival were performed using the Kaplan–Meier method, and cross tabulation with chi-squared testing was applied to analyze the difference in parameters between groups.

Results

From January 2010 to December 2019, a total of 6576 patients with head and neck cancers were admitted to our department and 7 died in the hospital, all of whom were middle-aged and elderly patients including 6 males and 1 female. The perioperative mortality rate (POMR) was about 1‰. The causes of death included acute heart failure, rupture of large blood vessels in the neck, hypoxic ischemic encephalopathy due to asphyxia, respiratory failure and cardiopulmonary arrest.

Conclusion

Preoperative radiotherapy, previous chemotherapy, hypertension, diabetes, advanced clinical stage and postoperative infection are risk factors for perioperative mortality of head and neck cancer.

A cause-specific Cox model for second primary tumors in patients with head and neck cancer: A RONCDOC study

Background

The aim of this study was to identify risk factors for the development of second primary tumors (SPTs) in the head and neck region, lungs, and esophagus in patients with head and neck cancer.

Methods

We collected data from 1581 patients. A cause‐specific Cox model for the development of an SPT was fitted, accounting for the competing risks residual/recurrent tumor and mortality.

Results

Of all patients, 246 (15.6%) developed SPTs. Analysis showed that tobacco and alcohol use, comorbidity, and the oral cavity subsite were risk factors for SPTs. The C‐index, the discriminative accuracy, of the model for SPT was 0.65 (95% confidence interval, 0.61–0.68).

Conclusions

Our results show that there is potential to identify patients who have an increased risk to develop an SPT. This might increase their survival chances and quality of life. More research is needed to provide head and neck clinicians with definitive recommendations.

Salivary CCL20 Level as a Biomarker for Oral Squamous Cell Carcinoma

BACKGROUND/AIM

This study investigated the utility of C-C motif chemokine ligand 20 (CCL20) expression in saliva as a biomarker for oral squamous cell carcinoma (OSCC) and also examined the associated microbiome.

MATERIALS AND METHODS

The study group included patients with OSCC or oral potentially malignant disorder (OPMD), and healthy volunteers (HVs). microarray and qRT-PCR were used to compare salivary CCL20 expression levels among groups. Data on CCL20 levels in oral cancer tissues and normal tissues were retrieved from a public database and examined. Furthermore, next-generation sequencing was used to investigate the salivary microbiome.

RESULTS

A significant increase in the expression level of CCL20 was observed in both OSCC tissues and saliva from patients with oral cancer. Fusobacterium was identified as the predominant bacteria in OSCC and correlated with CCL20 expression level. OSCC screening based on salivary CCL20 expression enabled successful differentiation between patients with OSCC and HVs.

CONCLUSION

CCL20 expression may be a useful biomarker for OSCC.

Trends in mortality rates for oral and oropharyngeal cancer in Spain, 1979-2018

OBJECTIVE

To analyse mortality rate trends in Spain for oral cavity and oropharyngeal cancer (OCOPC) from 1979 to 2018, evaluating differences between oral cavity cancer (OCC) and oropharyngeal cancer (OPC).

MATERIALS AND METHODS

Death certificates and mid-year population data were collected from the Spanish National Statistics Institute. Age-standardized mortality rates were calculated using the direct method. Joinpoint regressions were used to identify significant changes in mortality trends. Independent effects of age, period and cohort (APC) were estimated.

RESULTS

A total of 52,057 deaths were registered from OCOPC, 38,988 from OCC and 13,069 from OPC between 1979 and 2018. While OCC mortality rates declined, OCOPC rates increased slightly and OPC significantly. OCC and OPC mortality reached their highest values between 1979 and 1992, when OCC rates began to decrease in males and OPC levelled off until 2018. Lip cancer suffered the highest drop. APC models showed a mortality increase in males and females from 40 to 45 and 50 to 55 years of age, respectively.

CONCLUSIONS

Favourable OCC mortality trends was plausibly influenced by decreased tobacco/alcohol consumption, while OPC rise was probably associated with increased human papillomavirus infection. The importance of closely monitoring these cancers by age group, sex and location, and continuing with preventive measures against known risk factors, is highlighted.

Oral Cancer and Precancer: A Narrative Review on the Relevance of Early Diagnosis

Oral cancer (OC) is an uncommon malignancy in Western countries, being one of the most common cancers in some high-risk areas of the world. It is a largely preventable cancer, since most of the different risk factors identified, such as tobacco use, alcohol consumption, and betel nut chewing, are behaviors that increase the likelihood of the disease. Given its high mortality, early diagnosis is of utmost importance. Prevention and the anticipation of diagnosis begin with identification of potentially malignant lesions of the oral mucosa and with local conditions promoting chronic inflammation. Therefore, every lesion must be recognized promptly and treated adequately. The clinical recognition and evaluation of oral mucosal lesions can detect up to 99% of oral cancers/premalignancies. As stated by the World Health Organization, any suspicious lesion that does not subside within two weeks from detection and removal of local causes of irritation must be biopsied. Surgical biopsy remains the gold standard for diagnosis of oral cancer. Adjunctive tools have been developed and studied to help clinicians in the diagnostic pathway, such as toluidine blue vital staining and autofluorescence imaging. In the near future other methods, i.e., identification of salivary markers of progression may help in reducing mortality due to oral cancer.

Artificial intelligence in dentistry: Harnessing big data to predict oral cancer survival

BACKGROUND

Oral cancer is the sixth most prevalent cancer worldwide. Public knowledge in oral cancer risk factors and survival is limited.

AIM

To come up with machine learning (ML) algorithms to predict the length of survival for individuals diagnosed with oral cancer, and to explore the most important factors that were responsible for shortening or lengthening oral cancer survival.

METHODS

We used the Surveillance, Epidemiology, and End Results database from the years 1975 to 2016 that consisted of a total of 257880 cases and 94 variables. Four ML techniques in the area of artificial intelligence were applied for model training and validation. Model accuracy was evaluated using mean absolute error (MAE), mean squared error (MSE), root mean squared error (RMSE), R² and adjusted R².

RESULTS

The most important factors predictive of oral cancer survival time were age at diagnosis, primary cancer site, tumor size and year of diagnosis. Year of diagnosis referred to the year when the tumor was first diagnosed, implying that individuals with tumors that were diagnosed in the modern era tend to have longer survival than those diagnosed in the past. The extreme gradient boosting ML algorithms showed the best performance, with the MAE equaled to 13.55, MSE 486.55 and RMSE 22.06.

CONCLUSION

Using artificial intelligence, we developed a tool that can be used for oral cancer survival prediction and for medical-decision making. The finding relating to the year of diagnosis represented an important new discovery in the literature. The results of this study have implications for cancer prevention and education for the public.

Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis

BACKGROUND

Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival.

OBJECTIVES

The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care.

METHODS

Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored.

RESULTS

Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools.

DECISION MODEL

In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters.

SURVEY

Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals).

LIMITATIONS

There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates.

CONCLUSION

The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness.

FUTURE WORK

Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068373 and CRD42017068375.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.

Delay in diagnosis of patients with head-and-neck cancer in Canada: impact of patient and provider delay

Background

Head-and-neck cancers (hncs) often present at an advanced stage, leading to poor outcomes. Late presentation might be attributable to patient delays (reluctance to seek treatment, for instance) or provider delays (misdiagnosis, prolonged wait time for consultation, for example). The objective of the present study was to examine the length and cause of such delays in a Canadian universal health care setting.

Methods

Patients presenting for the first time to the hnc multidisciplinary team (mdt) with a biopsy-proven hnc were recruited to this study. Patients completed a survey querying initial symptom presentation, their previous medical appointments, and length of time between appointments. Clinical and demographic data were collected for all patients.

Results

The average time for patients to have their first appointment at the mdt clinic was 15.1 months, consisting of 3.9 months for patients to see a health care provider (hcp) for the first time since symptom onset and 10.7 months from first hcp appointment to the mdt clinic. Patients saw an average of 3 hcps before the mdt clinic visit (range: 1-7). No significant differences in time to presentation were found based on stage at presentation or anatomic site.

Conclusions

At our tertiary care cancer centre, a patient's clinical pathway to being seen at the mdt clinic shows significant delays, particularly in the time from the first hcp visit to mdt referral. Possible methods to mitigate delay include education about hnc for patients and providers alike, and a more streamlined referral system.

Detection of Oral Dysplastic and Early Cancerous Lesions by Polarization-Sensitive Optical Coherence Tomography

Detection of oral dysplastic and early-stage cancerous lesions is difficult with the current tools. Half of oral cancers are diagnosed in a late stage. Detection of early stromal change to predict malignant transformation is a new direction in the diagnosis of early-stage oral cancer. The application of new optical tools to image stroma in vivo is under investigation, and polarization-sensitive optical coherence tomography (PS-OCT) is potentially one of those tools. This is a preliminary study to sequentially image oral stromal changes from normal, hyperplasia, and dysplasia to early-stage cancer by PS-OCT in vivo. We used 4-Nitroquinoline-1-oxide drinking water to induce dysplasia and early-stage oral cancer in 19 K14-EGFP-miR-211-GFP transgenic mice. A total of 8 normal, 12 hyperplastic, 11 dysplastic, and 4 early-stage cancerous lesions were enrolled. A new analytic process of PS-OCT imaging was proposed, called an en-face birefringence map. From the birefringence map, the sensitivity, specificity, positive predictive value, and negative predictive values to detect dysplasia and early-stage cancer were 100.00%, 95.00%, 93.75%, and 100.00%, respectively, and the kappa value of these images between two investigators was 0.942. The mean size of malignant lesions detected in this study is 1.66 ± 0.93 mm. This pilot animal study validates the use of PS-OCT to detect small and early-stage oral malignancy with high accuracy and consistency.

Mortality from oral and oropharyngeal cancer in Brazil, between 2000 and 2013: trends by sociodemographic strata

Generalized observations of temporal trends in mortality could mask consistent specific patterns. This study aims to analyze the trend of oral and oropharyngeal cancer mortality rates in Brazil, from 2000 to 2013, considering the differences by gender, anatomical site, age group and ethnicity. Data on oral and oropharyngeal cancer mortality were retrieved from the Mortality Information System. The trend of historical series mortality rates by stratum was estimated through a generalized linear regression by the Prais-Winsten method. In total, 61,190 deaths from oral and oropharyngeal cancer were recorded in the 2000-2013 period (mean of coefficients: 3.50 deaths/100 thousand inhabitants/year). The trend of mortality rates was stable for males and increasing for females (1.31%/year). A growing pattern was identified for men aged 20-29 years (2.92%/year) and brown men (20.36%/year). The increasing pattern was also identified for white women (2.70%/year) and brown women (8.24%/year). We can conclude that surveillance of this condition should consider the sociodemographic differences of the population for equitable planning of care strategies because they reflected in different trends of oral and oropharyngeal cancer mortality rates in Brazil.

Effectiveness of mouth self-examination for screening of oral premalignant/malignant diseases in tribal population of Dehradun district

Background:

Mouth self-examination (MSE) is shown as a speedy, economical, and effortless method of oral cancer detection. As previous studies were conducted in population with high literacy, the current survey was performed to explore the usefulness of MSE for finding the oral cancerous precancerous lesions in indigenous low literate population of Dehradun district.

Materials and Methods:

It is a cross-sectional survey which was done on the Buksa tribal communities in Dehradun district, India. Out of seven tehsils in the district, two were randomly selected, from which two villages were selected. Individuals belonging to Buksa tribe above the age of 18 years were gathered in commonplace. A total of 539 people who gave their consent were enrolled for study. Using a questionnaire, information regarding sociodemographic details, history of risk factors, and practice of MSE was obtained by interview method, followed by recording oral findings by a single expert. Later, performance of MSE was taught to the participants and they were asked to record the same. Descriptive analysis and Chi-square test were applied wherever applicable and significance level was kept at below 0.05.

Results:

It was observed that out of 539 participants, 220 (40.8%) practiced MSE and 319 (59.2%) have never practiced MSE. Further analysis showed that a total of 39% males and 42.7% females had MSE habits and this difference was not statistically significant (P > 0.05). In totality, the prevalence of oral lesions identified by health worker was 213 (39.5%), whereas MSE showed only prevalence rate of 69 (12.8%). MSE had low sensitivity (24.6%), whereas high specificity (87.4%) for all the lesions and most sensitive in detecting ulcers (72.7%), and highest specificity in identifying red lesions (99.2%).

Conclusion:

Even though the sensitivity of MSE for detecting oral premalignant/malignant lesions was low, specificity was very high. Frequent efforts to educate and encourage public on MSE may enhance efficacy and compliance.

Two-week rule: suspected head and neck cancer referrals from a general medical practice perspective

The two-week rule (2WR) referral system was designed to fast-track patients with suspected malignancies to secondary care services to facilitate prompt investigation and management, the ultimate goals being early detection and improved survival. Patients with symptoms of head and neck cancer primarily present to the general practitioner (GP) who has an important role in the identification of high-risk patients for prompt management. This paper reports urgent 2WR referrals from primary care to highlight difficulties in the referral process. Data were collected from three GP practices (16 GPs) in Merseyside that all used the EMIS Web system (EMIS Health). All patients who were referred on the 2WR pathway in a two-year period from January 2017 were identified (n=113). The conversion rate for malignant diagnosis was 5.5% (95% CI: 2.0 to 11.5%). Those with multiple symptoms had a higher rate of malignancy (16%, 3/19) than those with a single symptom (3%, 3/91) (p=0.06). In total, 76% of patients had had no treatment before referral. The duration of symptoms ranged from 1 - 208 weeks (median (IQR) 6 (4-12) weeks). Common benign symptoms included laryngopharyngeal reflux (n=27), thyroid lesion (n=9), and neck lymph node (n=7). The diagnosis of head and neck cancer in primary care is challenging. Initiatives to try to increase the cancer conversion rate are required, but they run the risk of missed diagnosis and increased delay. Sufficient resources are needed in secondary care to ensure the timely assessment of patients who are referred on the 2WR pathway.

Oral Cavity Cancer Outcomes in Remote, Betel Nut-Endemic Pacific Islands

BACKGROUND

Oral cavity carcinomas individually are the fifth-leading cause of overall cancer mortality in the Northern Mariana Islands, which is likely a representative statistic for many other betel-nut-endemic Pacific islands. Factors associated with survival have been minimally evaluated in this region. The purpose of this study is to further characterize oral cavity carcinoma outcomes and associated prognostic factors in the United States commonwealth of the Northern Mariana Islands (CNMI).

METHODS

A single-institution retrospective review was undertaken for 81 patients diagnosed with head and neck cancers at the CNMI's only regional hospital complex from 2005 to 2019. A subset of patients diagnosed with oral cavity carcinoma was further evaluated for survival outcomes. Cox proportional hazard regressions were performed to evaluate for variables associated with survival.

RESULTS

A majority of patients had cancer of the oral cavity (64/81, 79%). Fifty-five of these patients had sufficient data for review. The average age at the time of diagnosis was 48 and over half were diagnosed with stage IV disease (29/55, 53%). Five-year overall survival (OS) was 49.5% (95% CI, 33.3-63.7%). Factors associated with worse OS were lymph node metastases at presentation (P = .031), higher overall stage (III or IV vs I or II, P = .016), and higher T-stage (III or IV vs I or II, P = .027). Those who used betel nut were diagnosed at a significantly younger age than those who did not (47.2 vs 55.4, P = .001).

CONCLUSIONS

The head and neck cancer burden in the CNMI is dominated by betel nut related oral cavity disease that is characterized by delayed presentations in younger patients and decreased OS. Future studies are indicated to improve health literacy as well as to investigate the potential for screening programs.

Head and neck sarcomas: the first report addressing the duration of symptoms and diagnostic work up

Background: Head and neck sarcomas are rare and difficult to diagnose and manage.Aim: To describe a population of patients with head and neck sarcomas focusing on the effect of symptom duration and time to diagnosis on mortality and recurrence risk.Materials and methods: Fifty-one patients treated in our department between 1998-2013 were retrospectively included. Patient and tumour characteristics as well as dates of interest were obtained from sarcoma registries, charts and pathology records. The effect of symptom duration and time to diagnosis on mortality and risk of recurrence was tested by multivariate analysis.Results: There was a wide range in symptom duration (1-144 months, median 5) and time for diagnosis (0-234 days, median 14) without significant effect on overall mortality, disease-specific mortality or risk of recurrence. Chondrosarcomas in the larynx dominated among the patients with the longest diagnostic duration.Conclusion and significance: The diagnostic process is challenging and in some cases of extremely long duration without effect on mortality. The symptom duration and time to diagnosis in relation to mortality and risk of recurrence has not previously been described. Early biopsy, better imaging and advanced pathological techniques can hopefully speed up the diagnostic process and reduce morbidity and mortality.