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Oral Cancer: Early Detection and Prevention MiniMedical School Dr. Harry Goodman, Professor Universi

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Title: Oral Cancer: Early Detection and Prevention MiniMedical School Dr. Harry Goodman, Professor Universi


1
Oral CancerEarly Detection and
Prevention Mini-Medical School Dr. Harry
Goodman, ProfessorUniversity of Maryland Dental
SchoolBaltimore, MDSeptember 21, 2005
2
Oral Cancer Outline
  • Overview and risk factors
  • Epidemiology
  • Review of Maryland and US oral cancer data
  • Disparities in incidence and mortality
  • State prevention initiatives
  • Oral pathology
  • Signs and symptoms
  • Diagnostic tools
  • Treatment
  • Oral cancer examination

3
Oral Cancer
  • The forgotten disease
  • Lower priority cancer to healthcare providers and
    the public
  • Little attention paid to healthcare providers and
    public
  • Know and how taught
  • Attitudes and beliefs
  • Behaviors and practices
  • No improvement in 5-year survival rates
  • Lower for African-Americans

4
Oral Cancer
  • Incidence and mortality preventable
  • Known high risk factors
  • Identifiable clinical features
  • Easily performed and inexpensive screening
    intervention
  • Effective non-deforming treatment for early
    lesions

5
The Problem
6
The Face of Oral Cancer
7
Oral CancerFacts
  • Comprise about 3 of all cancers in the United
    States
  • More common than
  • Leukemia
  • Hodgkins disease
  • Cancer of the brain, liver, bone, thyroid gland,
    stomach, ovary or cervix

8
Oral Cancer Estimated New Cases and Deaths, CDC,
2003
9
Oral CancerMaryland
  • Maryland ranks seventh in mortality rates
  • Maryland ranks sixth in mortality rate among
    males
  • 3rd highest mortality rate in the US for African
    American males
  • 5-year survival rate in Maryland for African
    Americans is 33 (whites - 55)
  • this has actually decreased
  • Nearly a 20 higher death rate from oral cancer
    in Maryland than the US
  • Ries et. al. SEER Cancer Statistics review,
    1973-1996

10
Risk Factors
  • Tobacco
  • Cigarettes
  • Cigars
  • Snuff
  • Spit tobacco
  • Pipes
  • Alcohol
  • More than 25 of oral cancers not due to tobacco
    and/or alcohol
  • Sunlight lip cancer
  • Lack of fruits and vegetables
  • Viruses e.g., Human papilloma virus

11
Spit Tobacco
  • Snuff and chewing tobacco
  • 28 carcinogens
  • Has nicotine formaldehyde
  • Addictive
  • 7.6 million users age 12 and older
  • Men 10 X more likely than women
  • Increased risk for oral cancer, heart disease,
    and diabetes
  • Causes leukoplakia
  • Often reversible upon cessation

12
Oral CancerMost Common Oral Cavity Sites
  • Ventrolateral aspect of the tongue - 30
  • Increased 60 over past 30 years in adults
    YOUNGER than 40
  • Schantz, Yu Arch Otolaryngol Head Neck
    Surgery, 2002, 268-274
  • Human Papilloma Virus??
  • Lips - 17
  • Floor of the mouth - 14

13
Oral Cancer Epidemiology
14
Oral CancerEpidemiology
  • Individuals 45 years of age and over 90 percent
  • Males higher than females
  • Account for 3.1 of all cancers in men
  • 10th most common cancer for all U.S. males
  • Tongue cancer increasing in males lt40 years old
  • 1.6 of all cancers in females
  • 14th most common cancer among all U.S. females
  • Male to female ratio has decreased from 61 in
    1950 to 1.81
  • Incidence in women has increased from 15 to 33
    of all cancers diagnosed in last 45 years

15
Oral CancerEpidemiology U.S.
  • Occur more frequently in African-Americans than
    Caucasians
  • 4th most common cancer in African-American males
  • Oral cancer mortality rates are also high for
    African-Americans
  • Nearly twice the mortality rate of Caucasians in
    1998.
  • Oral cancer is the 7th leading cause of cancer
    death in African American men

16
MD Oral Cancer Incidence Rates by Race and
Gender(1992-1998 per 100,000 population)
(MD Cancer Registry 2003)
17
MD and US Oral Cancer Mortality Rates (1992-1998
per 100,000 population)
  • (MD Cancer Registry 2003)

18
MD and US Oral Cancer Mortality Rates by
Race(1992-1998 per 100,000 population)
  • (MD Cancer Registry 2003)

19
Oral Cancer5-Year Survival Rates
  • 5-year oral cancer survival rate - 53
  • One of the lowest of any of the major cancer
    sites
  • Little improvement over the past 30 years
  • 5-year survival rate for early stage oral cancer
    82
  • Advanced stage cancer 23
  • U.S. African Americans have disproportionately
    lower 5-year survival rates for oral cancer than
    Caucasians (35 versus 59)

20
Five-Year Relative Survival Rates Following
Diagnosis
of Oral Cancer in United States, 1974-1997
(CDC, SEER)
Percent
100
90
80
70
60
50
40
30
20
10
0
1974-76
1977-79
1980-82
1983-85
1986-88
1989-91
1992-97
Year of Diagnosis
21
Five-Year Relative Survival Rates Following
Diagnosis
by Race for Oral Cancer in United States,
1974-1997 (CDC, SEER)
Percent
100
90
80
70
60
50
40
30
20
10
0
1974-76
1977-79
1980-82
1983-85
1986-88
1989-91
1992-97
Year of Diagnosis
White
Black
22
Oral CancerStaging by Race
  • Only 19 of U.S. African Americans diagnosed at a
    local stage
  • 42 local staging for Caucasians
  • Regional staging
  • African-Americans (52)
  • Caucasians (42)
  • Distant staging
  • African-Americans (18)
  • Caucasians (8)
  • SEER Cancer Statistics review, 1975-2000
    seer.cancer.gov/csr/1975_2000/results_merged/sect_
    19_oral_cavity.pdf

23
Healthy People 2010Oral Cancer Objectives
  • Objective 21-6 Oral Cancer Staging
  • Increase proportion of oral cancers detected at
    earliest stage
  • Target 50 percent
  • Baseline 35 percent of oral cancers (stage I,
    local )
  • Objective 21-7 Oral Cancer Examinations
  • Increase the proportion of adults who, in the
    past 12 months, report having an examination for
    oral cancers
  • Target 20 percent
  • Baseline 13 percent of adults aged 40 years and
    older
  • Objective 3-6 - Oral Cancer Mortality Rate
  • Reduce the oral cancer death rate
  • Target 2.7 deaths per 100,000 population
  • Baseline 3.0 deaths per 100,000 population in
    1998 (age adjusted to the year 2000 standard
    population)

24
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25
Oral CancerEarly Detection and Diagnosis
  • Access to dental services disparity
  • Limited for those populations at highest risk
  • Poor
  • Adults
  • Older adults
  • More likely to visit a physician, family nurse
    practitioner or physicians assistant than
    dentist
  • Oral cancer examination responsibility of all
    health care practitioners

26
Maryland Health Care Providers Oral Cancer
Knowledge and Practices,1995 Summary and
Conclusions
  • Majority know tobacco and alcohol risk factors
  • Many do not adequately assess tobacco and alcohol
    use - especially past use
  • Majority do not feel adequately trained to
    provide comprehensive oral cancer exams
  • Further need for better knowledge and information
    to improve practices

27
Oral CancerPublic
  • Maryland Adults Knowledge of Oral Cancer and
    Having Oral Cancer Examinations, 1994
  • Maryland telephone survey of the public
  • - 23 correctly identified one early sign of
    oral cancer
  • - 39 did not know early signs of oral
    cancer
  • Horowitz, Moon, Goodman, Yellowitz. J Public
    Health Dent 199858(4)281-7

28
Oral Cancer ResultsMaryland Public
  • Relatively few recall ever having an oral cancer
    examination
  • 85 reported hearing about oral cancer
  • Only 28 had ever had an oral cancer exam
  • Only 24 had an oral cancer exam in the past year
  • African-Americans (14) less likely than whites
    (32) to have had an exam
  • Horowitz Moon, Goodman, Yellowitz. J Public
    Health Dent 199858(4)281-7

29
Maryland Oral Cancer Prevention Initiative
  • Statewide, prevention and education public health
    approach encompassing
  • Oral cancer education for the public
  • Education/training of dental and non-dental
    health care providers
  • Screening and referral, if needed
  • Producing targeted health educational activities
    and materials
  • Creating didactic training program for health
    care providers throughout Maryland
  • Conducting an evaluation of the program and
    assess outcomes
  • Developing a statewide public relations oral
    cancer prevention campaign

30
Oral Cancer Prevention Initiative
  • Governor proclaims June 23-29 2nd Annual Oral
    Cancer Awareness Week in Maryland
  • Eastern Shore Coalition
  • Statewide Oral Cancer Screenings
  • Public Service Announcements print, TV, radio
  • Public relations Prevent Oral Cancer campaign
  • Develop oral cancer prevention toolkit
  • Public oral cancer education and awareness
  • Training of health care providers examinations
  • Develop oral cancer minimal clinical elements,
    flowcharts, screening, referral and consent forms
  • Prevention/education oral cancer grants to 21
    counties
  • Healthcare provider trainings
  • Public education and awareness
  • Oral cancer screenings

31
Oral Cancer Awareness WeekCamden Yards Kickoff
32
Del Marva Shorebirds Ballfield Poster Campaign
33
Oral Cancer
  • Red lesions (erythroplakia)
  • White lesions (leukoplakia)
  • Red white lesions (speckled leukoplakia
    erythroplakia)
  • Lichen planus

34
Oral Cancer Type
  • Approximately 90 percent of all oral cancers are
    squamous cell carcinomas
  • Cancers of the epithelial cells
  • Remainder are salivary gland tumors and lymphomas

35
Squamous Cell Carcinomas
36
Toluidine Blue
  • Fast and easy office procedure
  • Stain suspected malignant tissue
  • When several surface abnormalities are present
  • Tissue that stains blue indicates either
    dysplasia or malignancy
  • Pending approval in U.S.

37
Chemiluminescent Light
  • A liquid similar to diluted vinegar is applied to
    the area of the mouth to be screened
  • Under the special light, the liquid causes
    pre-cancerous or cancerous cells to glow
  • Approved for use in the United States but not yet
    widely available

38
Brush Biopsy
  • Uses small stiff-bristled brush to collect
    mucosal epithelial cells from a suspicious site
  • Apply firm pressure with the brush to the
    suspected area
  • Brush is then rotated five to ten times until
    pinpoint bleeding occurs
  • Immediately place and fix the tissue on a slide
  • Slide is subsequently sent to a laboratory for
    computer analysis
  • Results sent back to the practitioner within a
    week

39
Biopsy
  • Provides most definitive diagnosis
  • If malignant, determines the stage and grade
  • Common oral biopsy techniques
  • Excisional
  • Remove whole lump
  • Incisional
  • Remove a portion of the lump
  • Punch
  • 3-4mm diameter cuts out cylindrical piece of
    tissue

40
Treatment
  • Multidisciplinary approach
  • Expensive
  • Can be visually deforming
  • Curative treatment modalities
  • Surgery
  • Radiation
  • Chemotherapy
  • If metastasis suspected or confirmed

41
Oral Cancer Examination
  • Can be performed by
  • Dentist
  • Dental Hygienist
  • Physician
  • Physicians Assistant
  • Family Nurse Practitioner
  • Nurse

42
Clinical Oral Cancer Exam
  • Extraoral examination observe face, head, and
    neck noting any asymmetry, color change, and
    growths
  • Conduct bilateral palpation to detect enlarged
    nodes
  • Begin perioral and intraoral soft tissue
    examination by assessing lips
  • NIH, NIDCR, March 1996

43
Clinical Oral Cancer Exam
  • With patients mouth partially open, inspect
    labial mucosa of maxillary and mandiular
    vestibules
  • Observe for changes in color, texture and any
    swelling or other abnormality
  • NIH, NIDCR, March 1996

44
Clinical Oral Cancer Exam
  • Retract the buccal mucosa on both right and left
    sides extending from the labial commissure to the
    anterior tonsillar pillar
  • Note any changes in color, pigmentation, texture,
    mobility and other abnormalities
  • NIH, NIDCR, March 1996

45
Clinical Oral Cancer Exam
  • With teeth in occlusion, assess the buccal and
    labial aspects of the gingiva and alveolar ridges
    going from maxillary right posterior to left
    posterior and then to mandibular gingiva
  • Assess palatal and lingual aspects with mouth
    open
  • With patients tongue at rest and mouth partially
    open, inspect dorsum of tongue for any
    abnormalities including pattern of the papillae
  • NIH, NIDCR, March 1996

46
Clinical Oral Cancer Exam
  • The patient should protrude tongue and with a 2x2
    gauze, the examiner should inspect from side to
    side to note any abnormalities
  • Can use a mouth mirror to inspect the right and
    lateral tongue margins
  • Should palpate tongue while in grasp
  • NIH, NIDCR, March 1996

47
Clinical Oral Cancer Exam
  • Have patient lift tongue to inspect ventral
    surface
  • With tongue still raised, inspect floor of the
    mouth for changes and abnormalities
  • NIH, NIDCR, March 1996

48
Clinical Oral Cancer Exam
  • With patients mouth open, depress base of tongue
    with mouth mirror or tongue depressor to inspect
    tonsillar and oropharyngeal areas
  • At same time, inspect hard and soft palatal areas
  • NIH, NIDCR, March 1996

49
Clinical Oral Cancer Exam
  • Perform bimanual intraoral palpation on the floor
    of the mouth
  • Also palpate
  • Tongue
  • Lips
  • Other soft tissues
  • NIH, NIDCR, March 1996

50
Oral Cancer Signs and SymptomsAmerican Cancer
Society
  • Early
  • Sore in the mouth that does not heal (most
    common)
  • White or red patch on gums, tongue, tonsil, or
    soft tissue
  • Late
  • A lump or thickening in the cheek and/or neck
  • A sore throat or a feeling that something is
    caught in the throat
  • Difficulty chewing or swallowing
  • Difficulty moving the jaw or tongue
  • Numbness of the tongue or other area of the mouth
  • Swelling of the jaw causing dentures to fit
    poorly
  • Loosening of the teeth or pain around the teeth
    or jaw
  • Voice changes
  • Weight loss

51
Oral Cancer Signs and Symptoms
  • Pain is not an early finding

52
Patient AdviceHow to Help Guard Against Oral
Cancer
  • Dont use tobacco in any form
  • Drink alcohol only in moderation
  • Avoid exposure to strong, direct sunlight
  • Have regular dental check-ups
  • Consume a diet with fruits and vegetables
  • Any white patch, lump, or scaly area that lasts
    longer than 2 weeks should be checked by a
    physician or dentist

53
Questions?
  • Thanks
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