We Can Do Better
How Inadequate Oral Cancer Screening Can Fail Our Patients
The latest statistics from the American Cancer Society estimate 53,000 new cases of oral cavity and pharynx cancer in the United States in 2019. All in all, it is estimated that more than 10,800 friends, neighbors, family members, and coworkers will succumb to a late stage diagnosis of oral cancer. These statistics are not very promising, and trends in new cancer cases and deaths can only be estimated because the incidence and mortality data still lag at least two to four years, due to the time it takes to analyze, qualify, organize, and then disseminate the results.
What we do know now is that our patients are dying of underdiagnosed and undertreated oral diseases. Yet, the activities necessary to change these results are unsuccessful, and as a result the numbers continue to escalate. What can we do first? To begin the process of integrating and implementing protocols in your practice, I recommend 5 important steps (listed on the next page).
What about the clinical oral exam (COE)? Is it still relevant, effective, and consistently utilized with a standard that ensures that patients will be safe and free of disease? Not in my experience. Relying on subjective, under-standardized, antiquated, and under-executed clinical oral exams is an inadequate way to prevent oral cancers.
Can you diagnose oral cancer with a clinical oral exam? The responsible answer is no, not all spots or abnormalities are cancer. There is no differential diagnosis in a palpation or visual exam. The clinical oral exam for detecting oral mucosal changes requires a thorough head and neck, intraoral and extraoral examination. The comprehensive evaluation includes a visual inspection under incandescent overhead or halogen illumination, along with manual palpation. Unfortunately, this exam does not include enough time for technology integration for screening nor prevention education for the patient. And while we do detect cancer with a COE, it's often too late. We detect it when we see asymmetry in a patient's face, jaw, or neck, or when we palpate an abnormality larger than a grain of rice, or when a patient presents with underdiagnosed symptoms. If caught earlier, this abnormality would not have penetrated the basement membrane or invaded other lymph or other tissue structures.
Abnormality detection is extremely important in gaining a definitive diagnosis from an oral pathologist, specialty group, or reputable hospital vetted for cancer diagnosis protocols. The first step is to establish a detailed protocol. Through my lectures and training programs on prevention therapy and biofilm care protocols, I have learned that everyone does not see the same, examine the same, or articulate care the same. For this reason, I have developed a synchronized training system for clinicians and patients called SOSA™, which stands for screening for oral and skin abnormalities. Its purpose is to synchronize screenings to save lives and to educate the community (including the patient) about how self-examination of all skin surfaces, including the epithelium behind the lips, is important.
The second step is to invest in whatever tools you need to meet the objectives of your office's oral abnormality screening protocol. The patient's risk factors, the clinician's expertise, and the patient's willingness to be examined all affect our ability to screen for abnormalities. The likelihood of a visual exam identifying or ruling out dysplasia, OSCC, or human papillomavirus (HPV) is at best questionable, especially for patients who do not have any recognizable or documented risk factors. Technology and documentation, as well as following up on referrals, are vital.
In conclusion, if you need better illumination, get it. If you need to practice how to palpate, come to a program. If you need to better communicate, then role play. Then practice together until the team is successful, and it becomes second nature in your daily treatment. Having defined objectives will establish a higher standard of care with your patients, and they will appreciate early detection as the first line of prevention.
Pathway to Better Screening
1. Build a matrix of adjunctive medical professionals: the oral cavity is only one aspect of patient health and wellness. If you do not already have a referral tree in your community, look at your patients' medical histories to see whom they are being treated by and introduce your services to them.
2. Be openminded and embrace new perspectives: what we learned in school may be outdated, as the availability of technology advances.
3. Be confident in your skills and communication: choose your words carefully to promote effective outcomes. Ask patients if they understand, and then listen to them.
4. Teamwork (when we train as a team we succeed as a team): we must have systems in place to build on our successes and modify inconsistencies.
5. If you do not know, do not let it go: get comfortable asking questions, sharing patients, and following up with a diverse group of clinicians, labs, specialists, and educators.
About the Author
Debbie Zafiropoulos, Preventionist
Principle, OralED Institute
West Palm Beach, Florid