An Approach to Solving the Problem of Oral Cancer

Copyright 1998 Journal of the California Dental Association.

A few weeks ago, the California division of the American Cancer Society released its annual publication "California Cancer Facts and Figures." This document again graphically displays the fact that neither incidence nor death rates from oral and pharyngeal cancer are appreciably declining. This fact is mirrored in national statistics as well. In California, 3,315 new cases of oral/pharyngeal cancer will occur -- an average of more than nine per day. It is predicted that 935 people will die the terrible death of this disease -- almost 20 per week. Oral/pharyngeal cancer continues to rank in the top 10 in incidence among all cancer types and sites.

As bad as the above may be, a worse statistic is to be found in the fact that at the time of initial diagnosis, a larger percentage of oral cancer patients have metastases to regional nodes than do patients with cancers of the breast, prostate or colon. In my mind, these data suggest that dentistry is failing in its responsibility to detect and diagnose oral/pharyngeal cancer early.

Why blame dentistry and not give medicine a share of the guilt? Dr. Larry Meskin said it well in an editorial in the Journal of the American Dental Association (128:1494-7, 1997) titled "Do It or Lose It." In that piece, Dr. Meskin made the argument that oral (and pharyngeal) cancer is "dentistry's disease." He is absolutely correct. No one knows more about the mouth than dentists. No one can examine it better than we can. No licensed dentist in this state has any reason or excuse to say that he or she does not know how to perform a complete oral cancer detection examination. Continuing education courses on the subject abound. At least one is offered at every CDA Scientific Session. Local dental societies and study groups have ready access to experienced speakers.

The principal risk factors for oral cancer -- tobacco use and alcohol abuse -- are well-known in the profession. Textbooks and monographs, even the Internet, provide access to information and photos of leukoplakia, specked leukoplakia and erythroplakia, the three most common clinical lesions associated with the disease.

If we know so much about this devastating cancer and have the opportunity to detect it early and to save lives, why are we failing?

There are several reasons -- not justifications -- that come to mind. First, patients may not present for dental care. Studies have shown that the highest risk patients for oral cancer have associated medical problems that take them to their physicians' offices four to five times more frequently than they elect or need to visit the dentist. So, is the solution to try to teach physicians to perform oral examinations and detect the cancers? My experience says emphatically, NO.

Another reason may be that dentists are still not routinely performing a complete oral cancer screening as part of their routine patient examination. For example, a 1993 study that examined oral cancer screening procedures among physicians and dentists reported that although dentists felt better prepared than physicians to identify oral lesions, only 14 percent of dentists performed all aspects of the intraoral examination.

Another reason is that patients know little about oral cancer and, thus, don't know enough to ask for an examination or to inquire if one has been done. In a 1990 study assessing U.S. adults' knowledge of risk factors and signs of oral cancer, tobacco use was the only risk factor most adults identified, and only 25 percent could name even one sign of oral cancer. And remember, even the signs expounded by the American Cancer Society are not those of early disease. Overall, the U.S. adult population is uninformed about oral cancer; and this is not improved by our profession, which is doing too little to educate them about risk factors, prevention, and means of early detection. Even if you do routinely perform an oral cancer screening examination, do you take the time to tell the patient what you are doing and why?

Is it going to take a public relations disaster -- such as would occur if a major public figure was to be diagnosed with advanced oral cancer that his or her dentist failed to detect -- to sound the clarion call for action? Do we need another AIDS-type black eye?

It seems to me that what is needed to address the problems of an uneducated public and to motivate more in our profession to do the job they are trained to do is a major national public education program on the subject of oral cancer.

The first question would be can it work. As an example of how it might work, I cite the example of cancer of the uterine cervix. Fifty years ago, that disease was a major killer of women. When Dr. George Papanicolaou and others discovered that a simple cytologic smear (Pap test) of cervical surface cells was an excellent early diagnostic tool, one would have thought the problem was ready for solution. It wasn't. Physicians resisted this "new" method. It was different and revolutionary, and they weren't ready to be convinced that it was useful. There was a myriad of reasons, but the bottom line was that the test was not widely adopted. Women's groups, the American Cancer Society, and others launched a public relations effort directed at the county's women. Women began to demand the test, and it wasn't too long before the Pap smear became a standard of care in women's health. As a result, cervical cancer has ceased to be a major killer of women.

The parallel with oral cancer is obvious. The questions are who should develop such a campaign and who should pay for it. I believe the American Dental Association ought to develop and sustain an annual oral cancer awareness month just like they do for children's dental health. I recently proposed the idea to the ADA leadership and was turned down, ostensibly for financial reasons. The American Cancer Society won't do it: it can't afford it, and oral cancer is not one of its primary focus activities. The federal government shouldn't do it; the problems would be too great. Individual states could launch programs, but they would duplicate each other and be cost-inefficient.

Coalitions of state dental associations working with ADA and in concert with organizations such as the Academy of General Dentistry, dental specialty groups, and large organizations such as Oral Health America could come together and agree to take on this challenge. Could come together? MUST come together, or oral cancer will remain a black mark on dentistry's otherwise phenomenal record of solving its health issues.

Author/Raymond J. Melrose, DDS, is professor and chairman in the Department of Oral and Maxillofacial Pathology at the USC School of Dentistry. He is immediate past president of the American Academy of Oral and Maxillofacial Pathology.