Oral Cancer – what you need to know and how you can help

Oral Cancer – what you need toknow and how you can helpAndrew BaldwinMBChB(Hons) BDS FRCS(CSiG) FRCS(OMFS) FDSRCS FDSRCSEdConsultant Oral & Maxillofacial SurgeonPennine Acute Hospitals NHS Trust

Who am I?Consultant since 2003Lead Clinician for Head & Neck Oncology (PennineAcute Hospitals Trust, Manchester)Clinical Lecturer University of ManchesterMember Greater Manchester & Cheshire CancerNetwork Head & Neck Site Specific GroupRegional Advisor Faculty of Dental Surgery RoyalCollege Surgeons of EnglandCouncil Member British Association of Oral &Maxillofacial SurgeonsFaculty of Examiners Royal College of Surgeons ofEdinburgh

Aims/OutcomesOutline the incidence, aetiology, diagnosis andmanagement of oral cancerIndicate how oral cancer could be classed as asocial diseaseEnsure the dental team know what to look forand when to refer, and understand their role inthe continuing care of patients with oral cancerHelp to promote an understanding andimprovement in general health promotion inprimary dental careDemonstrate reconstructive techniques andmethods of dental rehabilitationDental nurse roles in oral cancer

Prognosis of Oral CancerStage of disease at time of diagnosis &treatment is single most important factoraffecting prognosisSignificant number of patients still presentat advanced stage at diagnosis

Oral Cancer15 th most common cancer in UK2% of all cancers in UK

Mouth, lip and oral cavityRegistrations– 5410 (2007); 6539 (2010)– 4097 (66%) men– 2139 (34%) womenDeaths 1851 (2007); 1985 (2010)

Oral Cancer (England)

Survival1996 – 1999– 47% men and 55% women survive oral(cavity) cancer for 5 years or more

High risk sites70% occur in sump areaOnly 30% surface area of mouth– Floor of mouth– Ventral & lateral tongue– Mandibular alveolusDifferent sites in Indian sub-continent– Buccal mucosa common

Increase in younger age groups

Oral Cancer - Sex, drugs and rock& roll?Is this a disease of lifestyle?Can it be avoided?

Risk factorsMain causes of oral cancer have longbeen knownMany cases of disease could be prevented– Often regarded as a life-style diseaseSmoking & alcohol - ~ 75% cases(Europe)Nutrition – diet deficient in fruit &vegetables - ~ 10% cases (Europe)

Tobacco & oral cancerMain predisposing factorEither smoking or chewingCurrent smokers have 3-fold increasedrisk of oral cancerDose & duration dependentTakes greater than 20 years for risk toreduce to that of non smokers

Betel quid (pan)Worldwide 200-400 million practice habitComposed of– Leaf of vine, Piper betel, areca nut, slakedlime & spicesAreca nut carcinogenic to humansRisk increases with addition of tobaccoAmong Asian communities in UK,Bangladeshis most likely to retain habit ofbetel quid chewing

AlcoholMajor risk factorRisk increases related to intake of alcoholHeavy drinkers & smokers have 38 – 56xrisk of abstainers

AlcoholUK consumption doubled since 1950’sExceeding safe limit– 1988 – 10% women; 26% men– 2002 – 18% women; 30% menHeaviest in 16 – 24 years; likely to bingedrink

Ultraviolet lightAffects lip3x more common in menMay be effect of occupation, sun-exposure& smoking

Human Papilloma VirusHPV-16 & HPV-18 (also HPV-31 & -45)Association strongest for oropharynx

HPVRisk factors:Often don’t have known risk factors eg.– Smoking, alcohol consumption or tobaccochewingAssociation between HPV related cancers:– increased number of sexual partners– increased oral sexual behaviour

Potentially malignant lesionsLeukoplakia– Up to 10% transformation over 10 years– May resolve on withdrawal of risk factorsErythroplakia– Up to 70% premalignant or malignantLichen planus– 1% transformationOral submucous fibrosis

Potentially malignant lesionsLichen planusCandidal leukoplakia

What to look for & when to referUlceration of oral mucosa > 3 weeksOral swelling > 3 weeksRed / white patch of oral mucosaHoarseness > 6 weeksDysphagia > 3 weeksUnilateral nasal obstructionUnexplained tooth mobility not associated withperiodontal diseaseUnresolving neck masses > 3 weeksCranial neuropathiesOrbital masses

Head and NeckCancer Referral Form

2 week wait referral form(suspected head and neck cancer referral)Always use this form if require urgentreferral for possible malignant, premalignantor suspicious signs/symptomsPLEASE DO NOT ABUSE THISREFERRAL PATHWAY

Current management of oral cancerSurgery– With or without reconstructionRadiotherapy– Primary radical (+/- with chemotherapy),postoperative or palliativeChemotherapy– Primary radical (+/- with radiotherapy),downstaging prior to surgery or palliative

Surgical Treatment:Resultant DefectOften largeAnatomically complexFunctional implications

Reconstructive OptionsHow destructive will the surgery be ?What reconstructive techniques are possible ?Likely functional resultAestheticsSpeechSwallowing

Further Management AndRehabilitationSpeech & swallowing therapyPsychological and social supportFurther surgery - dental implantsRegular review - early detection ofrecurrenceTerminal care if needed

Problems with treatmentRisks of surgerySide effects of radiotherapy/chemotherapyFunction – speech & swallowingQuality of life

Primary care following treatmentEnsure good preventive measuresGood oral hygieneS&PTopical fluoride applicationHygiene around dental implantsRestorative dentistryReferral for extractions post-radiotherapy

TEAM-WORKING!PARTNERSHIP

Role of the dental nurse in oralcancerAware of the risk factorsAware of potentially malignant lesionsMonitor the mouth with the dentistEnsure awareness of the need for urgentreferral and protocols in placeEncourage active management followingcancer treatmentHealth promotion

Role of the dental nurse in oralcancer“Dental Nurses are now able to undertake oral healtheducation with the aim of being able to promote oralhealth to the public and patients. Dental Nurses with theappropriate training can now perform other duties suchas applying fluoride varnish in a programme overseen bya Consultant or Specialist in Dental Public Health, orusing plaque indices to help educate patients- both ofwhich Dental Nurses would not have dreamt would bepossible until recently. The possibilities for DentalNurses are expanding and Oral Health Education isbecoming an exciting part of the Dental Nurse role.”(The dental nurse network)

Career DevelopmentSpecific educationalor health promotionrole in primary careRole in secondarycare – OMFS deptCertificate in OralHealth

Aims of health promotionTo increase awarenessTo reduce incidence of diseaseTo reduce morbidity & mortality associatedboth with treatment and natural diseaseprogression

What strategies can we develop?Health profession educationClinical monitoring & early treatmentPatient education– Individual or communityNational campaignsMedia involvementVaccinationGene therapy & molecular pathology

Examination of mouth– 58% GDPs regularly examined for mouthcancer– GMPs examined in a response to complaint ofsorenessLack of confidence in detecting oral cancer– GMPs 85% (lack of training cited by 70%)– GDPs 63%

Perceived risk factors– Smoking (97%) & alcohol (79%)– Age (76%)– Leukoplakia – GMP (72%) GDP (79%)– Erythroplakia – GMP (22%) GDP (66%)Health promotion questions– Smoking habits - 87% GMPs 19% GDPs– Alcohol consumption - 67% GMPs 3% GDPsGMPs wished for more training– Detection 91%– Prevention 79%

Public awareness of mouth cancer2006, BDJ. 384 individuals95% heard of mouth cancer (only 56% in1999 in similar study)Tobacco & mouth cancer– 85% aware of smoking link– 80% aware of chewing link

Public awareness of mouth cancerBUT only– 20% link between alcohol & oral cancer– 30% aware of white patches as potentialproblem– those at highest risk of condition had leastknowledge & less likely to recognise earlysigns of disease

Education in the communityIf possible, feed information before habitscommenceAim at school childrenDifficulties– Peer pressure– Cooperation from establishments– What age to start?– How graphic do we make the warning?– Attitudes of parents

Sex EducationHPV is the most prevalent STD50-60% US college-aged women have HPV(only 10% have cancer-causing strains) – (2004)55% teenagers admitted to engaging in oralsexual acts60% of surveyed college students do not equateoral-genital contact with sex

The Future - VaccinationVaccine for HPV recently introduced forgirlsActs against HPV 6, 11, 16 & 18? Give to whole population for risk of HPV-16 & HPV-18 induced oral cancer?Prevents– Spread of virus– Development of disease

BMJ – January 2010

The Future - VaccinationDr Nigel Carter, chief executive British DentalHealth Foundation (July 2009)– “Mouth cancer killing more people than cervicalcancer and testicular cancer combined”– “By expanding its HPV vaccination programme toinclude boys as well as girls, the government wouldbe able to address the problem of rising HPV-relatedmouth cancer deaths in a simple, fair and effectivemanner

The Future - Molecular PathologyAs yet no absolute molecular test whichwill predict transformationStill very much in the research stages

ConclusionsIdentifiable aetiologiesLargely preventable diseaseHigh mortality & morbidityOpportunistic screening in practice possibleMedia & national campaignsDevelopment of reliable screening toolsVaccinationMolecular markersEarly hard-hitting intervention to prevent uptakeof harmful habits