Is it an oral cancer exam or screening?

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by Nancy W. Burkhart, BSDH, EDD

Much discussion has occurred regarding the recent article that was published by Consumer Reports in the March 2013 issue on "Save Your Life/Cancer screening is oversold/Know the tests to get and those to skip." The article purported that these screening tests may not be worthwhile for the patient and suggests that the tests are greatly oversold by practitioners to the public. One of the screenings to avoid was titled "The Oral Cancer Exam," and the authors suggested that only high-risk patients be screened through a chairside visual exam. The meaning of exam vs. screening is very different. The text below was from the Consumer Reports article and states that there are eight tests that should be avoided. One of the tests is the oral cancer exam and their definition is stated below:

What 's involved: A visual exam of the mouth by a dentist or other health-care provider.
Who needs it: Most people don't need the test unless they are at high risk, because the cancer is relatively uncommon.
Risk factors: Smoking, chewing tobacco, excessive alcohol consumption, HPV infection, and weakened immunity from medication, disease, or certain other causes.

A publication was used and referred to within the Consumer Reports article from The United States Preventative Task Force (USPTF), April 2013. The report from the USPSTF concludes on the basis of "evidence-based research" that there is no evidence regarding morbidity and mortality rates regarding oral cancer screenings. There is lack of research in this area to support it at this time. The USPSTF evaluated the following questions:

Does screening for oral cancer reduce morbidity or mortality?

USPSTF comment: "Results were reported that evidence was found from a study conducted in India and showed that cancer in screened populations were found at a much earlier stage with a greater 5-year survival rate. No such acceptable studies were reported in the United States that met "evidenced-based" standards. In the subgroup of patients who were screened and used tobacco and alcohol, the 5-year survival rate was lower that the control group."

Screening, of course, is very different in comparison to a chairside oral cancer exam in a dental office.

What are the performance characteristics of the screening oral examination as a means of identifying oral cancer or potentially malignant disorders (PMDs) for oral cancer?

USPSTF comment: The recommendation from the USPTF was based on the fact that there were no peer-reviewed studies showing that oral cancer screenings (not chairside oral exams) has any impact on long-term mortality/morbidity out comes.

The studies cited and the article in Consumer Reports are based on "mass screenings" and "in home evaluations by dental and non-dental screeners," ultimately resulting in oral cancer exams being listed as one of the tests to avoid!

Consumer Reports stated within the article that "the message that you have nothing to lose and everything to gain from being screened for cancer -- that is, to be tested for a cancer before you have any symptoms of it -- simply isn't true."

This statement is misleading on its own. The lack of value for in-office, chairside oral exams was further intensified by some dental organizations reporting the misinformation in other widely-read dental publications. The task force (USPTF) did recognize the value of early stage cancer detection through dental exams, but was unable to document a mortality benefit by "evidenced-based" publications. This appears to be in line with Rethman, et al. 2010 and the ADA findings related to the value of a visual/tactile exam in early stage cancer detection. The ADA appointed a task force, Rethman, et al. 2010, and they did not promote the use of adjuncts over carefully conducted oral chair-side screenings. The value of early oral cancer detection exams was very clear in their article.

According to SEER data, as of January 1, 2010, approximately 275,193 men and women alive had a history of cancer of the oral cavity and pharynx. The stage at diagnosis and the survival rate of a localized cancer is 82.7% compared to distant metastasis of 36.3%. (SEER, accessed May 10, 2013).

Oral cancer may utilize additional testing with adjunct devices that may be needed not only in order to support the detection of an early cancerous lesion but also to assist the patient and the dental professional in making key decisions related to suspicious tissue. Although the decision to have a biopsy (considered the gold standard) may occur, there are also instances in which additional tests may promote further reassurance that the lesion may not warrant a biopsy at the dental appointment. The clinician may decide to monitor the lesion based on all accumulated information.

The Oral Cancer Foundation. www.oralcancer.org

Dr. Jeffrey Starke was quoted in the article as saying, "Doctors and patients don't understand numbers." This statement is probably accurate for the most part in that statistics may be difficult to understand without a statistics background, but patients also pay particular attention to what they read in reputable publications. Consumer Reports is such a publication and widely read by the public.

Oral cancer chairside exams seem to have fallen into this realm of worthless tests when one reads the Consumer Reports article. The article states that the fad of "screening parties" is not appropriate, and the decision to have a screening test should be weighted by the doctor and the patient and the tests should not be promoted for everybody across the board. I think that most people would agree with that statement.

Roger Chou, MD, is quoted as saying, "Truth is, sometimes the choice to screen or not is a close call." The article also makes the point that many tests have become sensitive enough that even small "cancer-like" lesions are found, but that the philosophy of how cancer behaves has also changed. All cancers are not alike.

In the Consumer Reports article, three tests were reported to be very worthwhile: breast, colon, and cervical. However, eight were not seen as beneficial such as bladder, lung, skin, prostate, ovarian, pancreatic, testicular, as well as oral cancer exams.

In the case of oral cancer, the article does not mention screening tests such as the staining procedures that evaluate abnormal cells. In fact, the article actually targets the basic oral cancer exam that we all learned in dental/dental hygiene school, encompassing a visual and tactile exam. With patients reading this article, many will wonder why they are paying any extra expense for any "screening exams" related to the mouth and question why they may even be needed. The patient may perceive the time spent as wasted time with little to no value. The standard dental visit does include a yearly oral cancer exam. Mass screenings should be the more appropriate term that should have been used by Consumer Reports and not yearly oral cancer exams?

It is thought by many that the body has a miraculous ability to target cancer cells and that the body may clear them on its own. Dr. Virginia Moyer, chairwomen of the U.S. Preventative Services Task Force, is quoted as saying that "lots and lots of cells in our body turn cancerous and then disappear; others look like cancer and then disappear." Research on the human papilloma virus falls into this category as well. Testing for this particular virus has fallen into this realm and is a dilemma for the dental community. The article alludes to the fact that, with all of this said, early cancers may be initially treated when they may dissipate on their own and also finding these early cancers may subject patients to unnecessary radiation, infection and surgery. There is also the psychological trauma that is suffered by the patient when they are not given a clean bill of health or told that they have a possible malignancy or pre-malignancy.

The article states that the exam is only needed for high-risk individuals such as those using tobacco, alcohol, and those with disease states such as HIV+ patients. In the past few years, much research and publications have focused on the human papilloma virus. When referring to the typical HPV+ cancer patient, the demographics may be a nonsmoker, nondrinker, a younger individual, white male, higher socio-economic status, who develops palatine and lingual tonsil cancer that is poorly differentiated. An increase of older white males has been documented as well and the number of life-time sexual partners a patient may have had, as these appear to be factors in these cases. One fact that is not known, in older individuals, is whether the virus stays dormant from an earlier exposure to reappear at a later date. The association with Epstein Barr virus is also being investigated. With all this said, there may be no way to accurately identify a "high-risk patient."

So, based on the suggestions presented in Consumer Reports, who warrants an oral exam?

A complete dental exam includes palpation with a thorough visual exam of the posterior pharyngeal areas of the mouth. A visual exam encompasses more than just detecting an obvious ulcer, a break in the tissue or some change that has occurred. The mouth has been termed "the window to the rest of the body" by many practitioners and used as a "whole body" health indicator for centuries. Practitioners of Chinese medicine evaluate the tongue immediately during any exam as standard protocol. The tongue and nails give the practitioner of Chinese medicine a good indication of any disease process occurring in the body. Even the best physicians do not retract the tongue and view all aspects of the mouth within a complete exam during a physical. The tongue is a high-risk area, and cancers linked to the human papilloma virus (HPV) are known to occur at the base of the tongue and within the tonsillar crypts --specifically, HPV 16.

Although the clinician cannot peer deeply into the crypts of a tonsil, there is swelling and asymmetrical tonsillar enlargement that occurs as the cancer progresses that may be present during palpation. The visual and tactile component of the oral exam is very crucial in finding an early stage cancer, and, the base of the tongue is within our view. The light source that is used in the dental office is superior to a pen light and to many of the other light sources used by other health-care workers in mass screening situations or in-home evaluations.

In addition to this, intraoral cameras can enlarge, document, and focus on a selected tissue area of interest. It has been well-documented that a person who has a cancer detected in stage 1 is much more likely to survive a cancer than someone in a late stage diagnosis. (SEER, 2013). We do know that oral cancer does not dissipate once identified and because of the rich source of blood supply in the mouth, may progress rapidly.

The public reads material in "reader-friendly" type publications such as Consumer Reports, and they base their decision to seek dental care including oral cancer exams on the material set forth by such publications. It is indeed detrimental that oral cancer exams were presented in such a way to devalue their importance in early cancer detection. The oral cancer exam performed using visual and tactile evaluation may be the only element, in most cases, that is considered useful in detecting an early stage oral cancer (Rethman, et al.2010).

The analyses set forth by the USPTF was based on data from a large study, conducted in another country, utilizing both dental and non-dental screeners, in-home evaluations with non-standard light sources. Even out of the USPTF study, a conclusion was drawn that there was a benefit to early stage oral cancer detection and mortality, but it was not determined that early cancer detection was significant based on peer-reviewed studies.

Because oral cancer numbers are small and a considerable number of patients do not have a regular dentist anyway, screenings will never find enough early oral cancers to make a statistical difference in the overall outcome in the United States. I think that this is where evidence-based data has gone awry and has been misinterpreted. If oral cancer happens to you, it is 100 percent. Oral cancer is life-changing, affecting speaking, eating, and often disfiguring for the person, as well as affecting the person psychologically. The article in Consumer Reports does not mean that early cancer detection does not save lives because we know it does just that. Early stage recognition means less surgery, less radiation, less chemotherapy, and a better prognosis for the individual.

Dr. John Wright, Regents Professor and chair of diagnostic sciences at Texas A & M University Baylor College of Dentistry said, "I would suggest asking those patients whose lives have been saved if it was worth the time for their dentist to find their early oral cancer and if they really care that saving their life didn't change the national figures for the prognosis of oral cancer. Some would argue that screening a large segment of the population, say at a health fair, can't be justified because of the exceedingly low numbers of cancers that would be found, and I could agree with that statement. Performing an oral cancer exam is not screening. It is not only the right thing to do, it is the expected standard of care. Individual patients unequivocally and profoundly benefit from that effort."

Oral cancer exams save lives. The value of exams is magnified when an early stage cancer is identified. These standard exams are noninvasive. Early cancers are found in patients who receive dental exams on a regular basis, and the dental exam does not take a lot of time during an appointment. In general, dental exams are a good indicator of many disease processes and the total health of an individual. So, why wouldn't you perform an oral cancer exam?

As always, ask good questions, and always listen to your patients.RDH

References

Gillison ML, Broutian T, Pickard RK, Tong ZY, Xiao W, Kahle L, et al. Prevalence of oral HPV infection in the United States, 2009–2010. JAMA: 2012;307(7):693-703. PMID: 22282321

Olson CM, Burda BU, Beil T, Whitlock EP. Screening for Oral Cancer: A Targeted Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 102. AHRQ Publication No. 13-05186-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; April 2013.

Rethman MP, Carpenter W, Cohen EEW, Epstein J, et al. Evidenced-Based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 2010;141;509-520.

http://seer.cancer.gov/statfacts/html/oralcav.html#survival, accessed May 10, 2013.

http://www.cdc.gov/cancer/hpv/statistics/, accessed May 10, 2013.

http://www.dentalcare.com/en-US/dental-education/continuing-education/ce337/ce337.aspx

The Oral Cancer Exam, https://www.mededportal.org/publication/7768

NANCY W. BURKHART, BSDH, EdD, is an adjunct associate professor in the department of periodontics, Baylor College of Dentistry and the Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (http://bcdwp.web.tamhsc.edu/iolpdallas/) and coauthor of General and Oral Pathology for the Dental Hygienist. She was a 2006 Crest/ADHA award winner. She is a 2012 Mentor of Distinction through Philips Oral Healthcare and PennWell Corp. Her website for seminars on mucosal diseases, oral cancer, and oral pathology topics is www.nancywburkhart.com.