Oral Cancer Screening: More Critical than Ever
Oral Cancer Screening: More Critical than Ever
There are no races or ribbons for oral cancer. Even so, every day in the United States approximately 100 people are diagnosed with oral cancer, and every hour another person succumbs to the disease.
Despite an 80% to 90% survival rate when detected early, most oral cancers are found as late-stage malignancies, accounting for a 5-year mortality rate of about 45% to 57%,1 as well as high treatment-related morbidity among survivors. Oral cancer is often detected only after it has metastasized, making prognosis significantly worse than for those with localized disease.
The HPV Connection
Historically, tobacco and alcohol use have been the primary risk factors for oral cancer. Recently, another etiology? and obstacle to early detection?has emerged in the form of human papillomavirus 16 (HPV 16), the same virus responsible for most cervical cancers.
The impact of HPV exposure is borne out by growing incidence rates; 2010 marked the 5th year in a row in which there has been an increase in the rate of occurrence of oral cancers, and a jump of more than 11% was seen in 2007 alone.1 HPV not only contributes to disease incidence, but also frequently does so in the oropharynx, tonsils, and base of the tongue, where malignancies don?t produce early warning signs.
This new reality, which has manifested as the largest new incidence of oral cancer in individuals under age 40 with no traditional risk factors, is caused by the upsurge in oral sex (especially among teens and young adults). Dental professionals should screen patients previously viewed at low risk, especially women and girls as young as 15. Dentists and hygienists also need to be prepared to broach the subject with these patients and their parents, and to consider items in a patient?s history?such as the use of birth control?as reasons to screen.
Visual Exam Basics
While oral cancer screening has long been considered the standard of care, late-stage diagnosis remains the rule, in large part because of poor public awareness coupled with the lack of a national program for opportunistic screenings. Both the dentist and hygienist should perform a visual screening during every exam as well as during recare appointment for high-risk patients.
The need for such screening as a routine part of the comprehensive dental exam is underscored by the insidious nature of the disease, which, in its early stages, can thrive without pain or other symptoms. Patients who survive an initial occurrence are at up to 20 times greater risk of developing a second cancer?a risk that can last for 5 to 10 years after the first occurrence.
For this reason, screening should be approached as a team effort, with the hygienist viewed as critical in the discovery, surveillance, and management of mucosal abnormalities, including oral cancers.
While anything that looks whitish should be investigated, lesions can range from whitish to ulcerated and red. Most benign lesions tend to resolve within about 10 days, any lesions present for longer than 10 days should be examined via biopsy. After treatment of a potentially malignant lesion, patients return for ongoing surveillance and case management.
Beyond the Visual Exam
The publicized cases of oral cancer in Michael Douglas and Roger Ebert have created public awareness. The HPV link also has heightened awareness, and more patients are broaching the subject with their dentists.
More and more patients expect the best in oral cancer screening technology. Even so, some fearful patients may resist screening. They should be reassured that the ?flip-side? of the low 5-year oral cancer survival rates is the 85% to 90% cure rate when diagnosed early.
A number of modalities enhance the efficiency and effectiveness of visual exams while rendering the findings more accurate and predictable. Comprehensive exams should incorporate the use of an adjunctive device for the earliest possible detection of abnormalities.
Designed to help identify, evaluate, monitor, and mark suspicious lesions that may be difficult to see, the ViziLite Plus with TBlue Advantage uses an acidic-type rinse to stimulate oral receptors, along with a proprietary light stick to illuminate potential precancerous lesions.
VELscope emits a safe but high-energy blue light that excites tissues. As the they return to normal, the tissues emit the absorbed energy in the form of various fluorescent patterns. Typically, healthy tissues fluoresce green and abnormal tissues appear dark. VELscope also enables the attachment of a digital camera, so the dentist can photograph lesions to send to the head and neck surgeon or other specialist.
Identafi 3000 is similar to VELscope but includes a mirror attachment for visualization further back into the oral cavity. A secondary light shows the amount of vascularization.
While most dentists are doing visual screenings, only a few are incorporating a screening device. Some cite cost as a consideration? especially if reimbursement is an issue?believing the incidence isn?t sufficiently high to justify the investment. Others are reluctant to incorporate what they view as a push for high technology when they?ve ?always done just fine using visual exams.?
The addition of light, as with such devices, is especially critical because of the varied appearance of cancerous and precancerous lesions. With the aid of a screening device, a lesion in need of further investigation will be seen as dark regardless of its outward appearance.
When it comes to cost, some investigation should be enough to reassure practitioners that such devices are within their means. ViziLite?s disposable light stick technology costs roughly $20 per use and, with a reasonable mark-up, can be affordable without a considerable upfront investment. VELscope and Identafi require more of an initial investment (approximately $2000 to $3500), but the $1/patient cost makes this investment feasible, and well within what most patients are willing to pay for what is truly life-saving technology.
Ron Kaminer, DDS is a graduate of the New York State School of Dental Medicine at Buffalo. He subsequently completed a 2-year postgraduate Advanced Dentistry residency at Northshore Hospital on Long Island. Dr. Kaminer is a noted author, lecturer, and teacher on topics such as laser, minimally invasive, and high-tech. He was recently awarded the Mastership from the World Clinical Laser Institute. Dr. Kaminer maintains a teaching appointment at Peninsula Hospital in Queens, where he trains postgraduate residents in advanced pediatric and cosmetic education. Dr. Kaminer brings to both his practices, in Hewlett and Oceanside, NY, a comprehensive state-of-the-art level of care to all his patients.