Is diagnostic delay related to advanced-stage oral cancer? A meta-analysis

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.

Oral Squamous Cell Carcinoma: Features and Medico-Legal Implications of Diagnostic Omission

Early diagnosis of oncologic pathologies has a crucial role to determine patient's prognosis and therapeutic path. Nonetheless, clinical errors and omissions that can occur during diagnostic, as well as detection of preneoplastic or neoplastic condition, may result in devasting consequences both for patients in terms of health and for professionals in terms of medico-legal responsibility. This study is aimed at examining in depth, through the presentation of a specific clinical case, the medico-legal aspects inherent to the diagnosis of oral cancer, analyzing the preventive, interceptive, and diagnostic strategies, the legal implications of clinical evaluation errors and diagnostic omission, and the type of medical damage produced and professional liability. The medico-legal landscape surrounding oral squamous cell carcinoma is multifaceted and characterized by diagnostic challenges, treatment complexities, and legal considerations. Health-care providers must remain vigilant in navigating these complexities to ensure optimal patient care while mitigating legal risks. By prioritizing high-quality medical records, fostering transparent communication with patients, and implementing preventive strategies, health-care institutions can strive to minimize the incidence of litigation and uphold standards of ethical practice in oral carcinoma cases. Additionally, continued research and education in forensic and legal medicine are essential in informing evidence-based practices and promoting patient safety in this evolving field.

Quality-of-Life Outcomes in Oral Cancer Patients Reconstructed With Double Free Flaps: A Preoperative and Postoperative Assessment

PURPOSE

This study aimed to evaluate quality of life (QOL) in patients with locally advanced oral cancer who underwent surgical resection followed by simultaneous double free flap reconstruction.

METHODS

Institutional database was reviewed from 2015 to 2021 and prospectively collected University of Washington Quality of Life data that were extracted for patients who met the inclusion criteria. Mean, composite, and best percentage scores were computed. Wilcoxon signed rank test was used to analyze differences between groups.

RESULTS

Thirteen patients completed the assessment, all of them being male with a mean follow-up of 2.2 ± 1.2 years. Most common double free flap combination was fibula osteoseptocutaneous flap and anterolateral thigh flap (n = 11). Improvement in pain ( P = 0.01) domain score with decline in speech ( P = 0.01) and taste ( P = 0.02) was noted along with an overall decline in QOL ( P = 0.001) after cancer diagnosis. A decrease in physical function was seen postoperatively. Chewing and saliva were the most cited postoperative patient-reported domain affecting QOL.

CONCLUSIONS

In double free flap reconstructed patients, in the postoperative phase, pain scores improved, whereas speech and taste scores declined. The overall health-related QOL declined compared with before cancer diagnosis.

Improving detection of oral lesions: Eye tracking insights from a randomized controlled trial comparing standardized to conventional approach

BACKGROUND

Early detection of oral cancer (OC) or its precursors is the most effective measure to improve outcome. The reasons for missing them on conventional oral examination (COE) or possible countermeasures are still unclear.

METHODS

In this randomized controlled trial, we investigated the effects of standardized oral examination (SOE) compared to COE. 49 dentists, specialists, and dental students wearing an eye tracker had to detect 10 simulated oral lesions drawn into a volunteer's oral cavity.

RESULTS

SOE had a higher detection rate at 85.4% sensitivity compared to 78.8% in the control (p = 0.017) due to higher completeness (p < 0.001). Detection rate correlated with examination duration (p = 0.002).

CONCLUSIONS

A standardized approach can improve systematics and thereby detection rates in oral examinations. It should take at least 5 min. Perceptual and cognitive errors and improper technique cause oral lesions to be missed. Its wide implementation could be an additional strategy to enhance early detection of OC.

Differential Expression of MicroRNA MiR-145 and MiR-155 Downstream Targets in Oral Cancers Exhibiting Limited Chemotherapy Resistance

New evidence has suggested that non-coding microRNAs play a significant role in mediating and modulating chemotherapy resistance, particularly among oral cancers. One recent study found that the upregulation of miR-145 and the downregulation of miR-155 strongly correlated with a limited chemotherapy resistance to Cisplatin, 5-Fluorouracil, and Paclitaxel, although the mechanism(s) responsible for these observations remain unidentified. Using commercially available cell lines of oral squamous cell carcinoma, RNA was isolated, converted into cDNA, and subsequently screened for the expression of downstream targets of miR-145 and miR-155 using qPCR. These results demonstrated the upregulation of miR-21, miR-125, miR-133, miR-365, miR-720, and miR-1246, as well as the downregulation of miR-140, miR-152, miR-218, miR-221, and miR-224. This screening also confirmed the differential expression and regulation of mir-145 and miR-155 among the cell lines with limited chemotherapy resistance (SCC15). In addition, several downstream targets of these specific microRNAs were upregulated by all oral cancer cell lines, such as MBTD1 and FSCN1, or downregulated in all cell lines, such as CLCN3, FLI-1, MRTFB, DAB, SRGAP1, and ABHD17C. However, three miR-145 downstream targets were identified in the least chemotherapy-resistant cells, exhibiting the differential upregulation of KCNA4 and SRGAP2, as well as the downregulation of FAM135A, with this expression pattern not detected in any of the other oral cancer cell lines. These data strongly support that the differential regulation of these three downstream targets may be related to the chemosensitivity of this oral cancer cell line. The potential involvement of these targets must be further investigated to determine how and whether mechanisms of these cellular pathways may be involved in the observed lack of chemotherapy resistance. These data may be important to design targets or treatments to reduce chemotherapy resistance and improve patient treatment outcomes.

Oral cancer: Current status and public health perspectives

Despite advances in surgical and oncological treatments, the incidence and five-year survival rates (~50 percent) of oral cancers (OC) have not improved over the last decades and remain a major public health problem. Seventy percent are still diagnosed at a late stage (T3 or T4), with an average delay in diagnosis of two to five months. As the cure and survival of patients are directly related to the development stage of the tumor at the time of diagnosis, the objective of this work was to analyze all the determinants related to oral cancer and to propose new clinical approaches for diagnosis and screening. A proposal for new models of screening, training, and concrete action to improve public awareness of the major global problem of OC is made. The strengths and weaknesses of OC screening studies need to be objectively understood to effectively guide and energize testing in primary care settings, with the prospect of using new and emerging technologies that can help improve the discriminatory accuracy of case detection. Most national organizations have not, to date, recommended population-based mass screening, due to a lack of sufficient scientific evidence of associated mortality reduction. Where health care resources are high, opportunistic individual screening is recommended, although the low diagnostic capacity of front-line clinicians is alarming.

How Much Do We Know about Oral Cancer?-An Online Survey

INTRODUCTION

Oral cancer (OC) is a disease with a high mortality rate due to its late recognition. Since the oral cavity is easily accessible for visual inspection, enabling early diagnosis, the education of healthcare workers about preventive oral examinations is critical. This research aimed to assess the level of participants' OC knowledge, as well as to raise awareness about this diagnosis.

MATERIALS AND METHODS

The research was conducted as an online survey among students of dental medicine, students of medicine, doctors of dental medicine and doctors of medicine. The questionnaire was designed solely for the purpose of this study and consisted of 29 questions. The first part of the questionnaire consisted of general questions about the participants, whereas the questions in the second part addressed their knowledge and attitudes towards OC.

RESULTS

The surveyed population comprised of 140 dental students, 105 medical students, 159 doctors of dental medicine and 100 medical doctors. The level of knowledge about OC among the participants is not yet satisfactory. The group of dental medicine students scored highest, while medical doctors showed the weakest knowledge.

CONCLUSION

Additional education about OC for doctors of dental medicine and medical doctors is needed. This step will improve prevention and increase chances for early detection.

The duration of intervals on the oral cancer care pathway and implications for survival: a systematic review and meta-analysis

Introduction

Previous studies measuring intervals on the oral cancer care pathway have been heterogenous, showing mixed results with regard to patient outcomes. The aims of this research were (1) to calculate pooled meta-analytic estimates for the duration of the patient, diagnostic and treatment intervals in oral cancer, considering the income level of the country, and (2) to review the evidence on the relationship of these three intervals with tumor stage at diagnosis and survival.

Materials and methods

We conducted a systematic review with meta-analysis following PRISMA 2020 guidelines (pre-registered protocol CRD42020200752). Following the Aarhus statement, studies were eligible if they reported data on the length of the patient (first symptom to first presentation to a healthcare professional), diagnostic (first presentation to diagnosis), or treatment (diagnosis to start of treatment) intervals in adult patients diagnosed with primary oral cancer. The risk of bias was assessed with the Aarhus checklist.

Results

Twenty-eight studies reporting on 30,845 patients met the inclusion criteria. The pooled median duration of the patient interval was 47 days (95% CI = 31-73), k = 18, of the diagnosis interval 35 days (95% CI = 21-38), k = 11, and of the treatment interval 30 days (95% CI = 23-53), k = 19. In lower-income countries, the patient and treatment intervals were significantly longer, and longer patient intervals were related to later stage at diagnosis. In studies with a lower risk of bias from high-income countries, longer treatment intervals were associated with lower survival rates.

Conclusion

Interval duration on the oral cancer care pathway is influenced by the socio-economic context and may have implications for patient outcomes.

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.

Early Diagnosis of Oral Cancer: A Complex Polyhedral Problem with a Difficult Solution

Oral and oropharyngeal cancers are a growing problem, accounting for 377,713 and 98,412 new cases per year all over the world and 177,757 and 48,143 deaths annually, respectively. Despite the substantial improvement in diagnostic procedures and treatment techniques in recent years, the mortality rate has not decreased substantially in the last 40 years, which is still close to 50% of cases. The major cause responsible for this high mortality is associated with the high percentage of oral cancers diagnosed in advanced stages (stages III and IV) where the treatment harbors poor efficacy, resulting in challenges, mutilations, or disability. The main reason for cancer to be diagnosed at an advanced stage is a diagnostic delay, so it is critical to reduce this delay in order to improve the prognosis of patients suffering from oral cancer. The causes of oral cancer diagnostic delay are complex and concern patients, healthcare professionals, and healthcare services. In this manuscript, oral cancer diagnostic delay is critically reviewed based on current evidence, as well as their major causes, main problems, and potential improvement strategies.

Incidence and outcomes of delayed presentation and surgery in peritoneal surface malignancies

Background

Peritoneal surface malignancies (PSM) present insidiously and often pose diagnostic challenges. There is a paucity of literature quantifying the frequency and extent of therapeutic delays in PSM and its impact on oncological outcomes.

Methods

A review of a prospectively maintained registry of PSM patients undergoing Cytoreductive Surgery and Hyperthermic Intra-peritoneal Chemotherapy (CRS-HIPEC) was conducted. Causes for treatment delays were identified. We evaluate the impact of delayed presentation and treatment delays on oncological outcomes using Cox proportional hazards models.

Results

319 patients underwent CRS-HIPEC over a 6-years duration. 58 patients were eventually included in this study. Mean duration between symptom onset and CRS-HIPEC was 186.0 ± 37.1 days (range 18-1494 days) and mean duration of between patient-reported symptom onset and initial presentation was 56.7 ± 16.8 days. Delayed presentation (> 60 days between symptom onset and presentation) was seen in 20.7% (n=12) of patients and 50.0% (n=29) experienced a significant treatment delay of > 90 days between 1^st presentation and CRS-HIPEC. Common causes for treatment delays were healthcare provider-related i.e. delayed or inappropriate referrals (43.1%) and delayed presentation to care (31.0%). Delayed presentation was a significantly associated with poorer disease free survival (DFS) (HR 4.67, 95% CI 1.11-19.69, p=0.036).

Conclusion

Delayed presentation and treatment delays are common and may have an impact on oncological outcomes. There is an urgent need to improve patient education and streamline healthcare delivery processes in the management of PSM.

Neighborhood Socioeconomic Status and Racial and Ethnic Survival Disparities in Oral Cavity and Laryngeal Cancer

BACKGROUND

Oral cavity cancer (OCC) and laryngeal cancer are among the most common cancers worldwide. This study investigated survival in non-Hispanic (NH) Black, NH White, Asian, and Hispanic patients with OCC and laryngeal cancer of low, intermediate, and high neighborhood socioeconomic status (nSES).

METHODS

We used data from the SEER 18 Census Tract-level SES and Rurality Database of the National Cancer Institute to create cohorts of OCC and laryngeal cancer patients from 2013 to 2018. Univariate survival analysis was performed with Kaplan-Meier curves and log-rank P values by nSES and then the cross-classification of race, ethnicity, and nSES. We used Cox proportional hazards regression model for multivariable analysis.

RESULTS

Higher nSES was associated with better OCC survival for NH White, NH Black, and Asian patients, and better laryngeal cancer survival for NH White, NH Black, Hispanic, and Asian patients. In the multivariable analyses of both OCC and laryngeal cancer survival, NH Black patients had worse survival than NH White patients in the high nSES tertile. NH Black patients with OCC were at higher risk of death than NH White patients at all nSES levels. Conversely, Asian patients with laryngeal cancer demonstrated better survival than other races within the high nSES.

CONCLUSIONS

Overall survival differs between racial and ethnic groups of similar nSESs. These health disparities in patients with OCC and laryngeal cancer reflect broader inequities in the cancer control continuum.

IMPACT

The cross-classification of race, ethnicity, and nSES revealed disparities in the 5-year overall survival of patients with OCC and laryngeal cancer and highlights the importance of intersectionality in the discussion of health equity.

Using Intervention Mapping to Develop ISAC, a Comprehensive Intervention for Early Detection and Prevention of Oral Cancer in Saudi Arabia

Oral cancer forms a major public health issue. In Saudi Arabia, Jazan region has the highest rate of oral cancer; > 35% of total cases. Furthermore, dentists' engagement in oral cancer screening and patient education in Jazan region is limited. This paper aimed to describe the process used to develop a comprehensive oral cancer (OC) practice intervention to be implemented in dental clinics. The intervention was informed by the six steps of intervention mapping (IM). Steps 1-3 included mixed methods approach of reviewing relevant existing literature, focus group discussions, observations, one-on-one interviews, and questionnaires utilizing the community participatory approach. Step 4 used information form steps 1-3 to develop the intervention components and its associated tools to facilitate its delivery. Steps 5 and 6 specified the prospective plans for implementation and evaluation. ISAC is the developed intervention that comprises the following: Informing dental patients about performing routine OC screenings, Screenings for OC, Advising patients, and Connecting patients to the required services. ISAC practical applications were clustered into two components: (a) didactical session covering aspects related to OC practices and introducing ISAC and (b) practical session that included a step-by-step modeling of the intervention. Using IM facilitated the systematic planning of the ISAC intervention that covers the main issues revealed by the need's assessments. Working towards developing the ISAC required extensive work in assessing dental public health issues in a specific context with limited data - and this constituted a great challenge. The development of the ISAC was a lesson that casts light on the advantages of engaging multidisciplinary expertise to tackle serious public health issue like OC.

The impact of lag time to cancer diagnosis and treatment on clinical outcomes prior to the COVID-19 pandemic: A scoping review of systematic reviews and meta-analyses

Background

The COVID-19 pandemic has disrupted cancer care, raising concerns regarding the impact of wait time, or 'lag time', on clinical outcomes. We aimed to contextualize pandemic-related lag times by mapping pre-pandemic evidence from systematic reviews and/or meta-analyses on the association between lag time to cancer diagnosis and treatment with mortality- and morbidity-related outcomes.

Methods

We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library of Systematic Reviews for reviews published prior to the pandemic (1 January 2010-31 December 2019). We extracted data on methodological characteristics, lag time interval start and endpoints, qualitative findings from systematic reviews, and pooled risk estimates of mortality- (i.e., overall survival) and morbidity- (i.e., local regional control) related outcomes from meta-analyses. We categorized lag times according to milestones across the cancer care continuum and summarized outcomes by cancer site and lag time interval.

Results

We identified 9032 records through database searches, of which 29 were eligible. We classified 33 unique types of lag time intervals across 10 cancer sites, of which breast, colorectal, head and neck, and ovarian cancers were investigated most. Two systematic reviews investigating lag time to diagnosis reported different findings regarding survival outcomes among paediatric patients with Ewing's sarcomas or central nervous system tumours. Comparable risk estimates of mortality were found for lag time intervals from surgery to adjuvant chemotherapy for breast, colorectal, and ovarian cancers. Risk estimates of pathologic complete response indicated an optimal time window of 7-8 weeks for neoadjuvant chemotherapy completion prior to surgery for rectal cancers. In comparing methods across meta-analyses on the same cancer sites, lag times, and outcomes, we identified critical variations in lag time research design.

Conclusions

Our review highlighted measured associations between lag time and cancer-related outcomes and identified the need for a standardized methodological approach in areas such as lag time definitions and accounting for the waiting-time paradox. Prioritization of lag time research is integral for revised cancer care guidelines under pandemic contingency and assessing the pandemic's long-term effect on patients with cancer.

Funding

The present work was supported by the Canadian Institutes of Health Research (CIHR-COVID-19 Rapid Research Funding opportunity, VR5-172666 grant to Eduardo L. Franco). Parker Tope, Eliya Farah, and Rami Ali each received an MSc. stipend from the Gerald Bronfman Department of Oncology, McGill University.

Current advances in noninvasive methods for the diagnosis of oral squamous cell carcinoma: a review

Oral squamous cell carcinoma (OSCC), one of the most common types of cancers worldwide, is diagnosed mainly through tissue biopsy. However, owing to the tumor heterogeneity and other drawbacks, such as the invasiveness of the biopsy procedure and high cost and limited usefulness of longitudinal surveillance, there has been a focus on adopting more rapid, economical, and noninvasive screening methods. Examples of these include liquid biopsy, optical detection systems, oral brush cytology, microfluidic detection, and artificial intelligence auxiliary diagnosis, which have their own strengths and weaknesses. Extensive research is being performed on various liquid biopsy biomarkers, including novel microbiome components, noncoding RNAs, extracellular vesicles, and circulating tumor DNA. The majority of these elements have demonstrated encouraging clinical outcomes in early OSCC detection. This review summarizes the screening methods for OSCC with a focus on providing new guiding strategies for the diagnosis of the disease.

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.

Lip and Oral Cavity Cancer Burden and Related Risk Factors in China: Estimates and Forecasts from 1990 to 2049

Lip and oral cavity cancer is a common malignancy faced by many developing countries, and the disease burden is high in China. This study explored this cancer burden and its risk factors using data from China in the GBD 2019, along with predicting the incidence trends in 2020-2049. Data on age-standardized rates (ASR), incidence, death and disability-adjusted life years (DALY), by sex, age and risk factors were collected from the Institute for Health Metrics and Evaluation (IHME). Joinpoint regression and Age-Period-Cohort (APC) models were selected to analyze the epidemic trend of this cancer in China, and descriptive analysis was used for the time trend and age distribution of risk factors. The Bayesian APC model was selected to foresee the incidence trend in 2020-2049. This cancer burden was found to be in an upward trend in China in 1990-2019. The upward trend was more pronounced among men than among women. These cancer deaths and DALYs are overwhelmingly attributable to smoking and drinking. On APC analysis, the younger generation in China demonstrated a lower cancer risk. In 2049, the incidence of this cancer is projected to be 3.99/100,000, 6.07/100,000, 7.37/100,000, 10.49/100,000, 14.82/100,000, 19.19/100,000, 20.71/100,000, 23.64/100,000, 16.42/100,000 and 9.91/100,000 among those aged 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, 85-89, 85-89 and over 95 years, respectively. Disease control policies and early screening should focus on men and the elderly and target different risk factors.

Disparities in Oral Cancer Stage at Presentation in a High HIV Prevalence Setting In Sub-Saharan Africa

PURPOSE

Oral cancer is the sixth most common cancer worldwide and is the seventh most common in Botswana. Lack of improvement in oral cancer survival despite the availability of multiple treatment options may be due to the high prevalence of advanced stage at presentation. We identified risk factors for presenting with oral cancer at an advanced stage to facilitate interventions to reduce mortality from oral cancers.

METHODS

A retrospective cohort analysis was conducted among individuals with biopsy-confirmed oral cancer at Princess Marina Hospital in Gaborone, Botswana, between 2010 and 2020. Data collected included age at diagnosis, sex, place of residence, HIV status, oral cancer stage, and oral subsite. Multivariable analyses were controlled for age, sex, district of residence, and oral subsite.

RESULTS

Of the 218 records analyzed, 79% were male, 58% were HIV-positive, the median age was 56 years (interquartile range: 47-63), and 67% presented with advanced-stage disease. Cancers from hidden oral sites were more likely to present at an advanced stage with an adjusted odds ratio (OR) of 2.98 (95% CI, 1.29 to 6.89; P = .01). Residence in socioeconomically disadvantaged districts was associated with higher likelihood (OR, 2.36; 95% CI, 1.28 to 4.39; P = .01) of advanced stage presentation compared with other districts. HIV infection was not associated with risk of advanced lesion presentation (OR, 1; 95% CI, 0.61 to 1.61; P = .97).

CONCLUSION

Hidden oral cancer sites and residence in districts with limited access to care were risk factors for advanced oral cancer at the time of diagnosis in Botswana. These findings support a need to increase efforts to improve access to care and increase oral cancer awareness to decrease the burden of advanced oral cancer.

Artificial intelligence for oral and maxillo-facial surgery: A narrative review

Artificial Intelligence (AI) is a set of technologies that simulate human cognition in order to address a specific problem. The improvement in computing speed, the exponential production and the routine collection of data have led to the rapid development of AI in the health sector. In this review, we propose to provide surgeons with the essential technical elements to help them understand the possibilities offered by AI and to review the current applications of AI for oral and maxillofacial surgery (OMFS). The review of the literature reveals a real research boom of AI in all fields in OMFS. The algorithms used are related to machine learning, with a strong representation of the convolutional neural networks specific to deep learning. The complex architecture of these networks gives them the capacity to extract and process the elementary characteristics of an image, and they are therefore particularly used for diagnostic purposes on medical imagery or facial photography. We identified representative articles dealing with AI algorithms providing assistance in diagnosis, therapeutic decision, preoperative planning, or prediction and evaluation of the outcomes. Thanks to their learning, classification, prediction and detection capabilities, AI algorithms complement human skills while limiting their imperfections. However, these algorithms should be subject to rigorous clinical evaluation, and ethical reflection on data protection should be systematically conducted.

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.

The Current Landscape of Oral Squamous Cell Carcinoma: A Comprehensive Analysis from ClinicalTrials.gov

Objective

A better understanding of the current characteristics of clinical trials in oral squamous cell carcinoma (OSCC) is important to improve trial design and identify neglected areas of research. The objective is to summarize the current characteristics and publication status of OSCC trials registered on ClinicalTrials.gov.

Methods

The ClinicalTrials.gov database was searched on November 9, 2020, for trials containing the term “oral squamous cell carcinoma”. We assessed the characteristics of the included trials and searched the publication status of the primary completed trials by using PubMed and Google Scholar.

Results

Our search identified 325 studies for analysis, including 279 interventional (85.8%) and 46 observational (14.2%) studies. Interventional studies were mostly single-group (50.9%), single-center (57.0%), non-randomized (59.1%), open-label (81.4%), and early-phase (70.6%) trials. The vast majority of the studies (82.8%) focused on the treatment of OSCC. Chemotherapy (36.8%) was the most common treatment, followed by targeted therapy (15.2%) and immunotherapy (15.2%). Furthermore, 58.9% of the primary completed interventional studies were published by January 8, 2021, and the median time to publication was 48.0 months. Studies registered before this study began (HR = 1.69, 95% CI = 1.02–2.80, P = .040) and in phases 1/2 or 2 (HR = 2.10, 95% CI = 1.09–4.06, P = .026) were associated with an improved likelihood of publication.

Conclusions

OSCC clinical trials usually have small sample size and are open-label and non-randomized studies. Advanced OSCC and immunotherapy-oriented therapy are becoming the focus of current trials. Researchers should perform standardized registration and publish their results in a timely manner.

Salivary Metabolomics for Oral Squamous Cell Carcinoma Diagnosis: A Systematic Review

Oral squamous cell carcinoma (OSCC) is the most common type of oral cancer in which the consumption of tobacco and alcohol is considered to be the main aetiological factor. Salivary metabolome profiling could identify novel biochemical pathways involved in the pathogenesis of various diseases. This systematic review was designed to answer the question “Are salivary metabolites reliable for the diagnosis of oral squamous cell carcinoma?”. Following the inclusion and exclusion criteria, nineteen studies were included (according to PRISMA statement guidelines). In all included studies, the diagnostic material was unstimulated whole saliva, whose metabolome changes were determined by different spectroscopic methods. At the metabolic level, OSCC patients differed significantly not only from healthy subjects but also from patients with oral leukoplakia, lichen planus or other oral potentially malignant disorders. Among the detected salivary metabolites, there were the indicators of the impaired metabolic pathways, such as choline metabolism, amino acid pathways, polyamine metabolism, urea cycle, creatine metabolism, glycolysis or glycerolipid metabolism. In conclusion, saliva contains many potential metabolites, which can be used reliably to early diagnose and monitor staging in patients with OSCC. However, further investigations are necessary to confirm these findings and to identify new salivary metabolic biomarkers.

Cytology-based Cancer Surgery of the Head and Neck (CyCaS-HN): a prospective, randomized, controlled clinical trial

Purpose

Liquid-based cytology (LBC) is routinely used in gynecology but is rarely applied in head and neck oncology though many suspicious lesions are easily accessible. While several studies have evaluated the potential use of LBC for early detection and molecular characterization of head and neck squamous cell carcinomas (HNSCCs), no study investigated its potential role in surgical management and therapy planning so far.

Methods

Twenty-five patients with cT1-2 squamous cell carcinomas of the oral cavity and oropharynx were prospectively enrolled in this study and were randomized to two treatment arms: in the control arm, a diagnostic panendoscopy with incisional biopsy was followed by a second operation with transoral tumor resection ± neck dissection and tracheostomy. In the intervention arm, patients underwent LBC diagnostics and in case of a positive result received one single operation with panendoscopy and incisional biopsy for confirmation of LBC result by rapid section histology followed by transoral tumor resection ± neck dissection and tracheostomy in the same session.

Results

Time between clinical diagnosis and definitive surgical treatment was significantly shorter in the intervention group compared with the control group (p < 0.0001). Additionally, time of hospitalization (p < 0.0001) and cumulative operation time (p = 0.062) were shorter in the intervention group. No significant differences in overall, progression-free, and disease-specific survival were observed.

Conclusion

Cytology-based cancer surgery is a promising therapeutic strategy that can potentially be considered for a well-defined group of early-stage HNSCC patients and help to avoid repetitive general anesthesia, shorten the diagnosis-to-treatment interval and spare operation as well as hospitalization time.

The Effect of an Informative Video upon Anxiety and Stress in Patients Requiring an Oral Biopsy: A Randomized Controlled Study

OBJECTIVE

The use of multimedia tools improves patient understanding of surgical procedures, reduces anxiety and increases satisfaction. The present study evaluates the impact of an audiovisual intervention (video) upon anxiety and stress in patients requiring an oral biopsy.

MATERIAL AND METHODS

A prospective randomized clinical trial was carried out in patients requiring an oral biopsy. The control group (n = 60) received verbal standard information while the experimental group (n = 60) received information in the form of a video. The following data were recorded: gender, age, educational level and hemodynamic parameters (blood pressure, heart rate and blood oxygen saturation). The following questionnaires were used to assess anxiety and stress before and after the biopsy procedure: Corah's Modified Dental Anxiety Scale (MDAS), the State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The final study sample consisted of 120 patients, of which 65.8% were women and 34.2% men, with a mean age of 40.5 ± 15.3 years. At the end of the study, the experimental group presented a significantly lower MDAS score than the control group (p = 0.041). The STAI score also showed a significant decrease with respect to the control group at the end of the study (p = 0.012). There were no statistically significant changes in the hemodynamic parameters in either group.

CONCLUSIONS

The video constituted a useful and easy tool for reducing anxiety among patients requiring an oral biopsy.

Comparison of transepithelial cytology and histopathology in the diagnosis of potentially malignant and malignant lesions of the oral mucosa

Background/Aim: The objective of the study was to compare cytological diagnoses using transepithelial cytology (oral brush biopsy) with histopathological diagnoses obtained by incisional biopsy in patients with benign lesions, oral potentially malignant disorders and oral squamous cell carcinoma. Material and Methods: The study included 57 patients. Brush biopsy was performed after local anaesthesia administration using the cervical brush. It was immediately followed by an incisional biopsy. Modified Bethesda System was used for cytological analysis and correlated with histopathological diagnoses according to intraepithelial neoplasia. Results: Good agreement was shown between cytological and histopathological diagnosis (kappa = 0.791). The sensitivity of the study was 92.85%, specificity 100%, positive predictive value (PPV) was 100% and negative predictive value (NPV) 93.54%. Conclusions: Oral brush biopsy, which allows the collection of epithelial cells of all layers can provide fast, precise and efficient cytological results which are in good agreement with the 'gold standard'-incisional biopsy followed by histopathology.

Times to Diagnosis, Staging, and Treatment of Head and Neck Cancer Before and During COVID-19

Objective

The coronavirus disease 2019 (COVID-19) pandemic has reduced the demand for, and supply of, head and neck cancer services. This study compares the times to diagnosis, staging, and treatment of head and neck cancers before and during the COVID-19 pandemic.

Study Design

Retrospective cohort study.

Setting

Tertiary academic medical center in New York City (NYC).

Methods

The times to diagnosis, staging, and treatment of head and neck cancer for patients presenting to the clinics of 4 head and neck oncology surgeons with newly diagnosed head and neck cancers were compared between pre–COVID-19 and COVID-19 periods.

Results

Sixty-eight patients in the pre–COVID-19 period and 26 patients in the COVID-19 period presented with newly diagnosed head and neck cancer. Patients in the COVID-19 group had a significantly longer time to diagnosis than the pre–COVID-19 group after adjustment for age and cancer diagnosis (P = .02; hazard ratio [HR], 0.54; 95% CI, 0.32-0.92). Patients in the pre–COVID-19 and COVID-19 groups had no statistically significant differences in time to staging (P > .9; HR, 1.01; 95% CI, 0.58-1.74) or time to treatment (P = .12; HR, 1.55; 95% CI, 0.89-2.72).

Conclusion

This study found that time to diagnosis for head and neck cancers was delayed during a COVID-19 period compared to a pre–COVID-19 period. However, there was no evidence of delays in time to staging and time to treatment during the COVID-19 period. Our results prompt further investigations into the factors contributing to diagnostic delays but provide reassurance that despite COVID-19, patients were receiving timely staging and treatment for head and neck cancers.

[Timeframe for initiating oral cancer treatment in Brazil since approval of new legislation in 2012: time trend, 2013-2019]

The study aimed to investigate whether the maximum delay (60 days) for initiating oral cancer treatment following diagnosis, as provided in Federal Law n. 12,732/2012, was achieved in Brazil from 2013 to 2019 and to describe the trend in the number of cases that initiated treatment within this timeframe. A time series was performed with treatment data (N = 37,417) from the Oncology Dashboard of the Brazilian Health Informatics Department (DATASUS) database, according to the patient's region of residence. Analysis of trend used Prais-Winsten regression. In 2018 and 2019, we observed higher percentages of treatments within 60 days, and especially within 30 days. In 2019, 61.5% of treatments began within 60 days, with the highest proportions in the South (71.3%), Southeast (60.1%), and Central-west (59.1%) regions of Brazil. The time trend for the category from 0-60 days was upward in the North of Brazil, with 15.7% annual percent change (APC), and was stationary in the other four major geographic regions of Brazil. The time trend for 0-30 days was only upward in the North and Northeast, with APCs of 29.75% and 20.56%, respectively. In conclusion, since 2018 there were more cases that initiated oral cancer treatment within the stipulated timeframe, as provided in Law n. 12,732/2012 (up to 60 days), with regional differences and a stationary trend in most regions and in Brazil as a whole. Partial achievement of the target, the predominance of a stationary trend, and regional inequalities indicate the need to continue monitoring time-to-treatment for oral cancer in Brazil and to intensify efforts to guarantee timely healthcare.

Perceptions and Practices of General Practitioners towards Oral Cancer and Emerging Risk Factors among Indian Immigrants in Australia: A Qualitative Study

BACKGROUND

In Australia, Indian immigrants are one of the fastest-growing communities. Since oral cancer is widespread in India, the indulgence of Indians in customs of areca (betel) nut use in Australia may be linked to the recent rise in oral cancer cases. Since GPs (general practitioners) are primary healthcare providers, it is pivotal to ensure the oral cancer awareness of GPs. This study aimed to explore oral cancer risk-related knowledge, beliefs, and clinical practices of GPs in Australia.

METHODS

Fourteen semi-structured interviews were conducted with GPs practicing across New South Wales and Victoria. Purposive and snowball sampling were used for recruitment. Data were analysed through a directed content analysis approach.

RESULTS

All GPs were knowledgeable of major oral cancer causative factors including tobacco and alcohol, but some had limited understanding about the risks associated with areca nut preparations. Positive attitudes were evident, with all participants acknowledging the importance of oral cancer risk assessment. Most GPs recalled not performing oral cancer routine check-ups.

CONCLUSION

GPs presented good oral cancer knowledge except for emerging risk factors such as areca nut use. Varied beliefs and inconsistent clinical practices relating to oral cancer screening is concerning. Accessible oral cancer training around emerging risk factors may benefit GPs.

Mutations in p53 Gene Exons in a Sample from the South of Spain in Oral Cancer

Background

Cancer is a genetic disease caused by mutations in DNA and epigenetic alterations that control gene expression. The majority of epidermoid carcinomas develop within the fields of epithelial genetic alterations. The mechanisms underlying tumorigenesis of epidermoid carcinoma are as yet unknown; therefore, precise identification of the risk factors is needed. Aim: The main aim of this study is to analyse and identify the emergence of the mutations described in the literature of the p53 gene with regard to the emergence of cancer in a sample of dysplastic and cancerous lesions in oral cavity mucosa in the population of the south of Spain, in order to determine the presence of said mutations and the percentage of them in our population.

Material and Methods

A cross-sectional study was carried out, with a sample size of 22 patients with potentially malignant oral lesions ancillary to biopsy. All were patients, of both sexes, over 18 years of age from the Virgen del Rocío University Hospital with potentially malignant lesions in oral mucosa ancillary to biopsy (leukoplakias, erythroplasias or leukoerythopkias). An anatomopathological study was performed on all the samples and the lesions were divided into three types: low-grade dysplasia, high-grade dysplasia and squamous cell carcinoma. In respect of the genome study process, a complete search or scan for mutations in exons 5, 6, 8 and 9 of the p 53 gene was carried out, given that in the IARC database we observed that the 5 and 6 as well as the 8 and 9 exon sizes can be scanned completely in this way, since they have amplificon sizes of 476 and 445 base pairs respectively.

Results

In the scan for the complete exons 5, 6, 8 and 9 only a single result of interest was found to be described. In patient NBI 57 a change was observed in the TAT triplet by ATT of EXON 6, the change being of the T nucleotide by the A and in both directions both in Forward and Reverse. The exact location in the NCBI is GR Ch 37 p13 on chromosome 17, EXON 6 of the P53 gene and the change is in the C.613 T>A nucleotide; NM_000546.

Conclusions

On reviewing this genetic variant in different scientific databases, such as ENSEMBL among others, in at least 6 different biocomputing tools it is described as a pathogen, therefore we can conclude that it is a pathogenic mutation for this case in particular. The rest of the mutations described in the literature on exons 5, 6, 8 and 9 of the p53 gene have not been found in our sample.

Key words:Oral cancer, p53, Mutations, Exon.

Impact of the Presenting Symptom on Time Intervals and Diagnostic Routes of Patients with Symptomatic Oral Cancer

This investigation was aimed at determining the time intervals from the presenting symptoms until the beginning of oral cancer treatment and their relative contribution to the total time, and to assess the impact of the presenting symptom on diagnostic timelines and patient referral routes. A cross-sectional, ambispective study was designed to investigate symptomatic incident cases. The Aarhus statement was used as a conceptual framework. Strategies for minimizing potential recall biases were implemented. A sample of 181 patients was recruited (power: 99.5%; α = 0.05). The patient interval reached 58.2 days (95% CI, 40.3-76.2), which accounted for 74% of the whole prereferral interval and for more than one third of the total time interval. The presenting symptom (trigger for consultation) influenced both the number of primary care consultations and the length of time to diagnosis. General dental practitioners generated longer intervals to diagnosis (p < 0.005) and needed more consultations before referring a patient (RR = 0.76; 95% CI, 0.61-0.93), than general medical practitioners. The current study identifies the patient as the main target for interventions to improve awareness and reinforces the need for increased alertness amongst healthcare professionals about presenting symptoms of oral cancer and to diminish the number of prereferral consultations in order to optimize the primary care interval.

Identification of Possible Salivary Metabolic Biomarkers and Altered Metabolic Pathways in South American Patients Diagnosed with Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) represents 90% of oral malignant neoplasms. The search for specific biomarkers for OSCC is a very active field of research contributing to establishing early diagnostic methods and unraveling underlying pathogenic mechanisms. In this work we investigated the salivary metabolites and the metabolic pathways of OSCC aiming find possible biomarkers. Salivary metabolites samples from 27 OSCC patients and 41 control individuals were compared through a gas chromatography coupled to a mass spectrometer (GC-MS) technique. Our results allowed identification of pathways of the malate-aspartate shuttle, the beta-alanine metabolism, and the Warburg effect. The possible salivary biomarkers were identified using the area under receiver-operating curve (AUC) criterion. Twenty-four metabolites were identified with AUC > 0.8. Using the threshold of AUC = 0.9 we find malic acid, maltose, protocatechuic acid, lactose, 2-ketoadipic, and catechol metabolites expressed. We notice that this is the first report of salivary metabolome in South American oral cancer patients, to the best of our knowledge. Our findings regarding these metabolic changes are important in discovering salivary biomarkers of OSCC patients. However, additional work needs to be performed considering larger populations to validate our results.

Circulating free DNA as a marker of response to chemoradiation in locally advanced head and neck squamous cell carcinoma

Context

Liquid biopsy has moved from bench to bedside as a non-invasive biomarker for early diagnosis and monitoring treatment response.

Objective

This study investigated the role of circulating free DNA (cfDNA) as a diagnostic marker in locally advanced head and neck squamous cell carcinoma (HNSCC) and in monitoring response to chemoradiation therapy.

Materials and Methods

Serum was collected from treatment naïve, histopathologically diagnosed tumors in 24 HNSCC cases and 16 normal controls. CfDNA levels were quantified using β globin gene amplification.

Results

The cfDNA level was significantly elevated in HNSCC (992.67 ± 657.43 ng/mL) as compared to healthy controls (60.65 ± 30.42 ng/mL, P = <0.001). The levels of cfDNA did not significantly correlate with TNM stage, lymph node involvement and grade. In responders, percentage decrease in cfDNA levels was 9.57% and 29.66%, whereas in nonresponders percentage increase was 13.28% and 24.52% at the end of three months of follow-up.

Conclusion

Our study adds to the evidence that cfDNA levels are significantly higher in HNSCC cases and provides some evidence that levels increase with tumor progression. CfDNA may be a promising prospective non-invasive marker to predict response in patients undergoing chemo-radiotherapy.

Assessment of apoptotic index in various grades of oral epithelial dysplasia: A cross-sectional study

Context

: Oral cancer is a major health problem worldwide. In cancer, the equilibrium between cell proliferation and apoptosis is disturbed. The defect in the apoptotic pathway allows cells to proliferate with genetic abnormalities. Thus, the apoptotic index (AI) can be used to assess the significance of apoptosis as a proliferative marker in oral epithelial dysplasia.

Aims

To assess the apoptotic index in various grades of epithelial dysplasia.

Objectives

1) To calculate the apoptotic index in various grades of oral epithelial dysplasia, 2) To compare the apoptotic index between various grades of oral epithelial dysplasia, 3) To predict the biologic behavior of oral epithelial dysplasia based on an apoptotic index.

Settings and Design

Cross-sectional tissue analyzing study.

Methods and Materials

This study constituted 30 cases, previously diagnosed with various grades of oral epithelial dysplasia (OED). AI was calculated as the number of apoptotic bodies/cells expressed as a percentage of the total number of cells counted in each case.

Statistical Analysis Used

Statistical analysis was carried out using ANOVA test.

Results

A statistically significant difference was observed between mild dysplasia and severe dysplasia where P = 0.002. The mean AI was increased progressively with increasing grades of OED.

Conclusions

This study demonstrated the clinical significance of apoptosis in assessing disease progression in Oral Potentially Malignant Disorder (OPMD) which may be used as a prognostic indicator in OED. This would, in turn, help in knowing the prognosis of the disease and to develop targeted drug therapy.

Using the Exploratory Sequential Mixed Methods Design to Investigate Dental Patients' Perceptions and Needs Concerning Oral Cancer Information, Examination, Prevention and Behavior

Objectives: The objective of this study was to investigate dental patients’ behavior, thoughts, opinions and needs for oral cancer information, and dentists’ behavior regarding prevention and examination of oral cancer. Materials and Methods: This study utilized an exploratory sequential mixed methods design. Semi-structured interviews with open-ended questions were conducted for forty dental patients of both sexes. Based on the qualitative analysis, a structured questionnaire was developed and distributed among the participants. Data were analyzed for 315 participants to quantify their thoughts, needs, behavior and behavior expected from dentists regarding oral cancer. Frequency, percentages and cumulative percentages were calculated. Results: This study reveals that patients’ oral cancer knowledge levels were adequate, but most reported that their dentist had never examined them for oral cancer. Additionally, the participants had never performed self-examinations for oral cancer, nor were they aware of the possibility of doing so. Participants showed a preference for being examined and educated by their dentist about oral cancer and believed it would help early detection. Conclusions: The study participants are aware of oral cancer and its risk factors. The practice of oral cancer examinations and patient education of its risk factors by dental practitioners is limited. Patients feel a need for more attention to be paid to oral cancer examinations, preventive measures and targeted information on oral cancer risk factors.

Bioinformatics analysis reveals that ANXA1 and SPINK5 are novel tumor suppressor genes in patients with oral squamous cell carcinoma

BACKGROUND

Oral squamous cell carcinoma (OSCC) is a solid tumor of squamous epithelial origin. Currently, surgery is still the main treatment for OSCC, with radiotherapy and chemotherapy as important adjuvant treatments. However, the problem of poor prognosis of OSCC patients still exists in clinical practice. To explore further potential biomarkers or treatment targets in OSCC patients, this study used a high-throughput gene expression database to study the potential molecular mechanisms of OSCC carcinogenesis.

METHODS

The GEO database related to OSCC was searched and analyzed using GEO2R. Oncomine and the Human Protein Atlas were used to evaluate the expression level of differentially-expressed genes (DEGs). The cBioPortal dataset was used to analyze the mutations of the potential DEGs and patient survival.

RESULTS

Three GEO datasets, GSE146483, GSE138206, and GSE148944, were downloaded and 7 DEGs were found in common in OSCC tissues. Using Oncomine and the Human Protein Atlas, ANXA1, IL1RN, and SPINK5 were decreased in cancer tissues, while protein levels of APOE and IFI35 were increased accordingly. Interestingly, low levels of ANXA1 and SPINKS were associated with the TNM stage of OSCC patients. No mutations in DEGs were found in OSCC patients, based on the cBioPortal dataset. Survival analysis indicated OSCC patients with high MSR1 had poor overall survival (OS), while low expression of CXCR4, ANXA1, IL1RN, and SPINK5 also predicted poor OS in OSCC patients.

CONCLUSIONS

Our findings uncovered 7 potential biomarkers of OSCC patients, with ANXA1 and SPINK5 serving as potential tumor suppressor genes in OSCC.

Disease Profile and Oncologic Outcomes After Delayed Diagnosis of Human Papillomavirus-Associated Oropharyngeal Cancer

OBJECTIVE

Diagnostic delay in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV(+)OPSCC) is common due to nonspecific symptoms. We aim to describe the disease burden and oncologic outcomes of patients with HPV(+)OPSCC diagnosed >12 months after symptom onset.

STUDY DESIGN

This is a retrospective cohort study of HPV(+)OPSCC patients receiving intent-to-cure treatment (including surgery ± adjuvant therapy or primary chemoradiation).

SETTING

2006-2016, tertiary care center.

METHODS

Tumor stage was compared between patients with and without delayed diagnosis using χ² tests. Kaplan-Meier survival analysis with univariate and multivariable Cox regressions were used to determine the effect of diagnostic delay on oncologic outcomes.

RESULTS

In total, 664 patients were included. Compared to patients diagnosed <12 months from symptom onset (n = 601), those diagnosed at >12 months (n = 63) were more likely to have T4 disease and higher overall American Joint Committee on Cancer (AJCC) clinical stage at presentation (P < .01 for both). At 5 years, rates of overall survival, cancer-specific survival, progression-free survival, and distant metastases-free survival in the delayed diagnosis cohort were 80%, 90%, 80%, and 89%, respectively. A >12-month delay in diagnosis did not significantly impact overall survival (adjusted hazard ratio [aHR], 1.16; 95% CI, 0.58-2.31), cancer-specific survival (aHR, 0.83; 95% CI, 0.29-2.39), progression-free survival (aHR, 1.15; 95% CI, 0.56-2.37), or distant metastases-free survival (aHR, 1.00; 95% CI, 0.42-2.40) after adjusting for age, sex, and clinical AJCC stage (P > .05 for all).

CONCLUSIONS

Delayed diagnosis of HPV(+)OPSCC is associated with greater burden of disease at presentation, but oncologic outcomes remain favorable across treatment modalities. When appropriate, intent-to-cure therapy should be pursued despite diagnostic delay.

LEVEL OF EVIDENCE

Level III.

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.

The interval since first symptoms until diagnosis of squamous cell carcinoma in the head and neck region is still a problem in southern Brazil

Background

The aim was to examine the interval since first symptoms until final diagnosis of squamous cell carcinoma (SCC) in the head and neck region in southern Brazil.

Material and Methods

The individuals were prospectively selected and underwent anamnesis, physical examination and interview in the first medical consultation at a Cancer Hospital from south of Brazil.

Results

From 488 patients who underwent clinical examination, 105 were included in the study with diagnosis of SCC. Patients average interval from first symptoms to final diagnosis was 152 days (median 86; max:1105; min: 1), the average professional interval was 108 days (median: 97; max:525; min: 1) , and the average total period interval was 258 days (median: 186; max:1177; min: 45). Factors statistically associated with patient and diagnosis itinerary intervals were smoking and poorly adapted dentures and distance from home to hospital, respectively.

Conclusions

The identification of the itinerary characteristics of this specific population may reflect in more effective public policies, such as primary and secondary prevention programs, aiming to increase the survival of oncological patient. Furthermore, the knowledge of the variables that influence the late diagnosis minimizes patient's journey in search of care to cancer centers through health programs.

Key words:Head and neck cancer, time interval, time to diagnosis, diagnosis delay, squamous cell carcinoma.

Countermeasure and opportunistic screening systems for oral cancer

OBJECTIVES

Tokyo Dental College started oral cancer screening in cooperation with a local dental association in 1992. Reveal the usefulness of Countermeasure and Opportunistic Screening Systems for Oral Cancer. The actual results of countermeasure and opportunistic oral cancer screening systems are reported.

MATERIALS AND METHODS

Countermeasure screening for the public was performed in each region, and opportunistic screening was performed in a general dental clinic of a cooperating physician.

RESULTS

In countermeasure screening, 19,721 persons were checked from 1992 to 2018; the gender ratio was 1:3. The close examination rate was 4.45%. The detection rates of oral cancer and oral potentially malignant disorders were 0.13% and 1.85%, respectively. In opportunistic screening, 29,912 persons were checked from 2006 to 2018; the gender ratio was 2:3. The close examination rate was 2.33%. The detection rates of oral cancer and oral potentially malignant disorders were 0.08% and 2.15%, respectively. The close examination rate was significantly lower in opportunistic screening than in countermeasure screening. The oral cancer detection rates and the positive predictive value for cancer were equivalent. In addition, the detection rate of oral potentially malignant disorders was significantly higher in opportunistic screening than in countermeasure screening.

CONCLUSION

Oral cancer detection rates were equivalent between countermeasure and opportunistic screenings, and opportunistic screening were more effective on number of participants and the close examination rate, and the detection rate of oral potentially malignant disorders.

Knowledge, attitudes and practices of general medical practitioners in developed countries regarding oral cancer: an integrative review

BACKGROUND

Oral cancer is a public health concern and is widespread in developing countries, particularly in South Asia. However, oral cancer cases are also rising in developed nations due to various factors, including smoking, viruses and increased migration from South Asia. In this context, the role of general medical practitioners (GPs) in identifying oral cancer is becoming increasingly important and, while some studies have explored their perspective about oral cancer, a synthesis of these results has not been undertaken.

OBJECTIVE

The objective of this integrative review is to synthesize existing evidence regarding oral cancer-related knowledge, attitudes and practices of GPs in developed countries.

METHODS

Four electronic databases were searched to identify studies focussing on the objective of this review. The inclusion criteria were: peer-reviewed English language publications; studies conducted in developed countries involving GPs; explored at least one study outcome (knowledge/attitudes/practices). No restrictions were placed on the publication date.

RESULTS

A total of 21 studies involving 3409 GPs were reviewed. Most studies revealed limited knowledge of GPs about emerging risk factors, such as betel nut chewing (0.8-50%). Significant variation (7-70%) was evident in routine oral examination practices of GPs. Most GPs felt unsure about diagnosing oral cancer and many (38-94%) raised the need for further education. No study explored the specific relevance of GPs' practices concerning South Asian immigrants.

CONCLUSION

This review suggests the need for educational programs to enhance GPs' knowledge regarding oral cancer. Further research exploring oral cancer-related practices of GPs caring for South Asian immigrants is warranted.

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.

People would rather see a physician than a dentist when experiencing a long-standing oral ulceration. A population-based study in Spain

BACKGROUND

Primary care physicians have been reported to be the first choice for patients with oral ulcerations. This study investigates the health-seeking behaviour of lay public in Galicia (North-western Spain) if experiencing a long-standing oral ulceration.

MATERIAL AND METHODS

Cross-sectional population-based survey of randomly selected respondents conducted from March 1, 2015 to 30 June 2016.

RESULTS

A total of 5,727 pedestrians entered the study (response rate: 53%), mostly in the 45-64 age group (30.2%; n=1,728), 47.7% of them (n=2,729) were males. Most participants (42.1%; n=2,411) reported to visit their dentist once a year and had secondary or compulsory education as their highest educational achievement (28.18%, n=1,614; 28%, n=1,600 respectively). When questioned what they would do if they had a wound/ulceration lasting longer than 3 weeks, most participants answered they would go to see their primary care physician (62.8%; n=3,597) and less than one quarter of the sample (23.8%; n=1,371) would seek consultation with their dentist.

CONCLUSIONS

General Galician population would seek professional consultation about a long-standing oral ulceration, relying mostly on primary care physicians. Those neglecting these lesions are elderly, less-schooled people and unaware of oral cancer.

Modeling and processing up-to-dateness of patient information in probabilistic therapy decision support

OBJECTIVES

Probabilistic modeling of a patient's situation with the goal of providing calculated therapy recommendations can improve the decision making of interdisciplinary teams. Relevant information entities and direct causal dependencies, as well as uncertainty, must be formally described. Possible therapy options, tailored to the patient, can be inferred from the clinical data using these descriptions. However, there are several avoidable factors of uncertainty influencing the accuracy of the inference. For instance, inaccuracy may emerge from outdated information. In general, probabilistic models, e.g. Bayesian Networks can depict the causality and relations of individual information entities, but in general cannot evaluate individual entities concerning their up-to-dateness. The goal of the work at hand is to model diagnostic up-to-dateness, which can reasonably adjust the influence of outdated diagnostic information to improve the inference results of clinical decision models.

METHODS AND MATERIALS

We analyzed 68 laryngeal cancer cases and modeled the state of up-to-dateness of different diagnostic modalities. All cases were used for cross-validation. 55 cases were used to train the model, 13 for testing. Each diagnostic procedure involved in the decision making process of these cases was associated with a specific threshold for the time the information is considered up-to-date, i.e. reliable. Based on this threshold, outdated findings could be identified and their impact on probabilistic calculations could be reduced. We applied the model for reducing the weight of outdated patient data in the computation of TNM stagings for the 13 test cases and compared the results to the manually derived TNM stagings in the patient files.

RESULTS

With the implementation of these weights in the laryngeal cancer model, we increased the accuracy of the TNM calculation from 0.61 (8 out of 13 cases correct) to 0.76 (10 out of 13 cases correct).

CONCLUSION

Decision delay may cause specific patient data to be outdated. This can cause contradictory or false information and impair calculations for clinical decision support. Our approach demonstrates that the accuracy of Bayesian Network models can be improved when pre-processing the patient-specific data and evaluating their up-to-dateness with reduced weights on outdated information.

Diagnostic delay for head and neck cancer in South India: A Mixed-methods Study

Background:

Early diagnosis is an important aspect of quality of cancer care.Analysis of the diagnostic delays and the reasons for delay helps to plan strategies to improve cancer care.

Objectives:

To determine the primary, secondary, and total diagnostic delay of patients diagnosed with head and neck cancer and to explore the reasons for the delay from the patient perspective.

Methods:

Explanatory mixed method design was used. Two hundred persons with a confirmed diagnosis of head and neck cancer attending the ENT (ear, nose, throat) cancer clinic in a teaching hospital before the initiation of treatment were included in the study. The median delay and the association of the delay with the various factors were analyzed. Sixteen one-to-one interviews of patients were done to identify the reasons for the delays from the patient perspective.

Results:

Median primary, secondary, and total diagnostic delays were 30 days, 30 days, and 73 days, respectively. Statistically, primary delay was found significantly longer among ever users of smokeless tobacco and significantly longer secondary delay was found among those with age less than 60 years. The reasons for the delay were grouped in the categories (i) Symptom appraisal delay due to low perceived seriousness and (ii) health-seeking behavior delay.

Conclusions:

The diagnostic delay was considerable. Measures to enhance symptom appraisal by improving health literacy, opportunistic screening, and strengthening the referral system would decrease diagnostic delay.

Screening for oral cancer: Future prospects, research and policy development for Asia

Although the incidence of oral cavity cancer is high among low and middle income countries in Asia where the risk habits (tobacco smoking, tobacco chewing and betel quid use) are common, the benefits for introducing oral cancer screening for the whole population in these countries still remains controversial. It is disappointing, but not surprising that many of studies, without control arms, could not provide a clear answer as to whether screening is effective in reducing mortality or combating rising incidence trends. Only one Indian study that reported a randomized controlled trial (RCT) elucidated that mass screening for high risk groups could significantly reduce the cancer mortality or down-stage cancers detected by screening. Several professional organizations that considered any potential benefits of oral cancer screening remain unconvinced that the current knowledge on its natural history, available tests and interventions to treat potentially malignant disorders satisfy the desirable criteria to recommend organized screening for oral cancer. In this review we discuss advantages and disadvantages for oral cancer screening particularly with reference to high incidence countries in Asia. If screening is undertaken, we propose that it is targeted to high risk groups and to combine screening with education on risky life-styles so that overall incidence can be reduced in the future. Further research on increasing public awarenes and impact of professional education such as e-learning to reduce diagnostic delays, studies on the natural history of oral potentially malignant disorders and cancer, comprehensive tobacco and areca nut cessation programs, developing tools to identify high-risk individuals and high-risk lesions are proposed.

Orabase-Formulated Benzalkonium Chloride Effectively Suppressed Oral Potentially Malignant Disorder In Vitro and In Vivo

Oral potentially malignant disorder (OPMD) is associated with an increased risk of progression to oral cancer. Patients with dysplastic changes of the precancerous lesions have a higher malignant transformation rate than those without dysplastic changes. Radiotherapy and surgery are the traditionally preferred choices for OPMD treatment. However, side effects caused by radiotherapy and surgery may reduce the willingness of patients to accept therapy. Therefore, developing an Orabase-formulated drug, which can be non-invasively administered, may provide an alternative treatment choice. To find, verify, and develop a new anti-cancer drug cost a lot of time and money, while drug repurposing can shorten both time and cost. In this study, we utilized high-throughput screening library to identify clinical drugs, which may have new bioactivities. Herein, we report that benzalkonium chloride (BAK), an antimicrobial preservative for pharmaceutical products, significantly induced reactive oxygen species production and cell death in oral precancerous cells. Additionally, our results showed that phosphorylation of STAT3 (Tyr705) and Akt (Ser473) were involved in cell death caused by BAK in DOK cells. According to animal studies, the development of DMBA-induced oral precancerous lesions was inhibited by 2% BAK. In conclusion, Orabase-formulated BAK may be a potential treatment for OPMD in the future.