A Guide to Oral Cancer

Last month I attended the Oral Cancer Conference in London. Here is a summary of what I learnt from the day.

Oral cancer screening is one of the four domains of oral health that dental professionals need to be aware of. I feel that there isn't a lot of public knowledge about this type of cancer in comparison to others such as breast or lung cancer, despite there being around 9000 new cases each year. 

Worryingly, oral cancer is increasing in incidence in younger people and there is a widening gap between lower socio-economic groups compared to groups which are less deprived. This is probably down to social differences, namely the use of tobacco and alcohol. Other factors can also be implicated such as the Human Papilloma Virus (HPV), sunlight exposure and poor diet e.g. low in fruit, so low in antioxidants. 

22% of adults smoke in the UK - still a large proportion but nothing compared to the 70% of men who smoked in the 1960s! Practising in East London has also made me aware of other forms of tobacco which are popular in some ethnic groups such as Paan or Khat. 

Smoking together with alcohol multiplies the risk of the development of oral cancer. Do we all ask our patients if they drink and how much they drink? 

What is a unit of alcohol?

This is the amount that is equivalent to 10ml of pure ethanol, which corresponds to roughly:

25ml shot of spirit (of 40% alcohol)
Half a 175ml of wine (12.5% alcohol)
Half a pint of lager (4% alcohol)

Department of Health Guidelines:

Men should not regularly drink more than 3-4 units a day
Women should not regularly drink more than 2-3 units a day
Pregnant women are recommended to avoid alcohol

Oral cancer screening is a GDC core competency, so if you suspect an oral cancer what do you do?

Urgent Referrals

Look up the guidelines and protocols for your local area hospital but it usually looks like this:
  • Fax or send the referral via a secure email account ASAP
  • If this is not possible, send a letter urgently but also give your local team a phone call
  • Use the word CANCER if you suspect as this will fast track the referral
  • Other things to include should be medical history, risk factors, signs and neck lumps
Delay in referral can affect the outcome for these patients and hospitals have to see these urgent referrals within 2 weeks.
If there is late detection in the cancer, the 5 year survival rate is 51%, but if it is detected early this increases to 80%

Potentially malignant conditions

  1. Leukoplakia (this is a diagnosis of exclusion which can be granular, specular, nodular, verrucous, homogenous and non-homogenous)
  2. Erythroplakia (uncommon but with a increased risk of malignancy)
  3. Oral lichen planus
  4. Submucous fibrosis
  5. Chronic hyperplastic candidosis
  6. Discoid lupus erythematosus (DLE)
  7. Iron deficiency e.g. B12 or folate

Histological classifications

  • Intraepithelial neoplasia
  • Carcinoma in Situ (this means that the dysplasia has not reached the basement membrane)
  • Dysplasia (mild, moderate, severe)
Sites that are most commonly affected by malignant lesions are the tongue and the floor of mouth.

Management of dysplasias

  1. Excision by laser or surgical 
  2. Prevention measures i.e. decrease smoking and alcohol intake. 50% of leukoplakias can disappear if the patient stops smoking
  3. Increase antioxidant intake 
  4. Regular reviews 

The management of oral cancer is multi-disciplinary, with treatment managed by ENT and Maxfax sugeons, oncologists, radiologists, dentists, speech and language therapists and dieticians. 
The later the diagnosis of the oral cancer, the more likely that treatment will need to be more radical, have a poorer prognosis and ultimately, decrease the quality of life for that patient. 

Not only will large resections change the life of that patient, adjunctive radio or chemotherapy also have severe side effects. Whilst plastics can now to wonders in terms of facial reconstruction, the functional implications of having a large portion of their mouth resected can be debilitating.

The take home message from the conference was on early diagnosis! You should be performing oral cancer checks for all your patients at EVERY appointment, and if there is anything suspicious send on urgently. These referral centres would rather see something innocent every now and then rather than run the risk of late presentations of poor prognosis.

Thanks to all the speakers from the day. Do you have any thoughts or experiences of seeing oral cancer in practice? Leave your comments in the section below!

Why not take a look at my other Clinical Guide posts?

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