Oral and pharyngeal cancer: lack of prevention and early detection by health care providers.

Abstract

Worldwide, approximately 8% of all cancers in men occur in the mouth and pharynx, with a correspondŽ ing estimate for women being 4% Pindborg et al., . 1997 amounting to around 250 000 new cases in men each year and 120 000 in women. More than 90% of all oral and pharyngeal cancers occur in individuals older than 45, although there is evidence of an increasing incidence of tongue cancer in Ž . younger age groups La Vecchia et al., 1997 . Major risk factors include use of tobacco products, heavy alcohol consumption and exposure to the sun for lip cancer. According to late stages diagnosis, the 5-year survival rate is only 52%. In recent decades, in spite of advances in detection and treatment of many other malignancies, this rate has remained disapŽ pointingly low and relatively constant Greenlee et . al., 2000 . Treatment often produces dysfunction and distortions in speech, mastication, swallowing, dental health and even in the ability to interact socially. Thus, it must be considered among the most debilitating and disfiguring of all cancers. As is the case with most other malignancies, early detection of malignant and premalignant lesions and reduction of risk factors can produce a great improvement in the prognosis. Therefore, annual mouth examinations in people over 40 and the cessation of alcohol and tobacco consumption are the imperative goals of every health programme against Ž oral cancer American Cancer Society, 1992; British . Dental Association, 1998 . As many authors suggest ŽDanish Dental Association, 1990; Horowitz et al., . 1996 , dentists share an important role in secondary prevention of oral cancer. In fact, dental recalls are considered to be a great opportunity for the detection of asymptomatic early malignant neoplasm, for the differentiation of benign from precancerous conditions and for the undertaking of biopsies or referrals of patients to oral surgeons or oral medicine ENT specialists. This opportunistic screening of the oral mucosa, particularly in high-risk individuals, consists of soft tissue examination, which could be carried out as part of a 5-minute dental inspection. It is thought to decrease morbidity and mortality in the same way as other screening procedures, such as those used in respect of breast and cervical carcinomas. In the last few years other scientists have emphasized a more important role for dental practitioners, suggesting they should be responsible also for primary prevention, giving advice on smoking cessation, alcohol moderation and sun protection Ž . Macgregor, 1996; Johnson, 1997 . In spite of all these guidelines, in the past few decades no remarkable progress has occurred in improving the earlier diagnosis and prognosis of oral Ž . cancer Greenlee et al., 2000 . Most oral and pharyngeal malignancies are detected at a late stage and smoking and drinking habits still remain the major aetiological factors in the development of oral cancer, synchronous and metachronous second primary tumours of the upper aerodigestive tract. Tragically, only 14% of US adults reported having had oral Ž . cancer examinations Horowitz and Nourjah, 1996 . Surprisingly, many studies conducted to determine dentists’ attitudes and practices towards oral cancer prevention and early detection have shown contrary results. In a recent UK survey, 84% of dentists who replied claimed to provide routine oral mucosa exŽ aminations for all their patients Warnakulasuriya . and Johnson, 1999 . A similar US survey showed 81% of dentists reporting oral cancer examinations for 100% of their patients over the age of 40 and approximately 90% asking about cancer history and Ž . tobacco use Horowitz et al., 2000 . How is one to interpret these contrasting data? Worldwide, many authors report that most oral and pharyngeal carcinomas are not diagnosed until they have attained at least the T2 stage, revealing a delay of diagnosis varying from a few weeks to more than