Cancer Research UK : Oral Cancer prevention

Oral Cancer prevention

Primary prevention

At least three-quarters of oral cancers could be prevented by the elimination of tobacco smoking and a reduction in alcohol consumption. The removal of these two risk factors also reduces the risk of second tumours in people with oral cancer. Smoking cessation is associated with a rapid reduction in the risk of oral cancers, with a 50% reduction in risk within 3 to 5 years.1 Ten years after smoking cessation, the risk for ex-smokers approaches that for life-long non-smokers. Protection against solar irradiation would further reduce the incidence of lip cancers.

In India and Sri Lanka efforts are being made to reduce the prevalence of the traditional habit of betel quid chewing.2 The greatest cost-benefit is gained by educating children not to take up the chewing habit.3 A recent study has shown that tobacco chewing in Indian men is the strongest risk factor for oral cancer while tobacco smoking is the main risk factor for developing pharyngeal and oesophageal tumours.4 In developing countries especially, dietary supplementation may help to reduce the risk of oral cancer. In the UK, knowledge about the risks of betel chewing and the symptoms of oral cancer seems to be lacking in the high-risk south Asian populations.5,6 More research is needed into effective interventions for populations who use betel quid with or without tobacco.7

Patient delay has been cited as the main reason for late presentation and it seems probable that in both high-risk groups and the general population, neither the symptoms of oral cancer nor the main risk factors are well understood.8-10 With rising incidence rates, in younger age groups whose expectation of cancer is low, public education is urgently needed.11 One award-winning example is the West of Scotland Mouth Cancer Awareness Project and later this year Cancer Research UK will launch its own mouth cancer awareness initiative with funding from the Department of Health.12

Secondary prevention: screening

Treatment of early stage oral cancers achieves higher survival rates with less attendant morbidity but at present far too many patients present with late stage disease. Therefore screening for premalignant or early stage oral cancers is worthy of consideration. However, in 1993 the UK Working Group on Screening for Oral Cancer and Precancer concluded that there was insufficient evidence to support population screening.13 Problems include the relative rarity of the disease, a lack of knowledge of the natural history of the disease, disagreement over disease management and the lack of evidence on the efficacy of different screening methods. 14-16 An alternative strategy would be to encourage opportunistic screening of high-risk groups attending primary care services.17 The educational needs of primary carers including dentists must be addressed and there is still the difficulty of reaching high risk groups. 18,19

Future

Despite the overall fall in incidence and mortality rates for oral cancer in the last century, there is no place for complacency especially as recent trends report some significant increases among young and middle-aged men. Studies have reported an alarming lack of awareness about oral cancer, its symptoms and causes and this needs to be addressed by further public education, possibly targeted at high risk groups.

Survival rates have risen slightly over the last twenty years but could be further improved by earlier detection and more effective treatments. Advances in surgical techniques have helped to reduce disfigurement and functional impairment. Over the next few years as the new government service guidelines come into practice, patients should benefit. A nationwide audit is ongoing with the aim of improving the data for head and neck patients so that the impact of new services can be measured and areas of concern can be addressed.20

The debate on screening is ongoing but better still would be the primary prevention of at least three quarters of cases through the elimination of tobacco consumption and the moderation of alcohol-intake.

More research is needed into the natural history of the disease, particularly which precancerous lesions will progress over time and how the risk factors interplay in the development of premalignant conditions and their carcinogenic transformation. At the molecular level there is a need to develop tumour markers so that treatment can be tailored to the individual patient.

References for oral cancer prevention

Samet, J.M., The health benefits of smoking cessation. Med Clin North Am, 1992. 76(2): p. 399-414.
Pindborg, J.J., D.K. Daftary, and P. Gupta, Public Health Aspects of Oral cancer: Implications for cancer prevention in the Community. Oral cancer: Detection of patients and lesions at risk, ed. Johnson N W. 1991: Cambridge University Press.
Stjernsward, J., Cost-benefit in Sri Lanka, (pers. comm)
Znaor, A., et al., Independent and combined effects of tobacco smoking, chewing and alcohol drinking on the risk of oral, pharyngeal and esophageal cancers in Indian men. Int J Cancer, 2003. 105(5): p. 681-6.
Ahmed, S., A. Rahman, and S. Hull, Use of betel quid and cigarettes among Bangladeshi patients in an inner-city practice: prevalence and knowledge of health effects. Br J Gen Pract, 1997. 47(420): p. 431-4.
Shetty, K.V. and N.W. Johnson, Knowledge, attitudes and beliefs of adult South Asians living in London regarding risk factors and signs for oral cancer. Community Dent Health, 1999. 16(4): p. 227-31.
West, R., A. McNeill, and M. Raw, Smokeless tobacco cessation guidelines for health professionals in England. Br Dent J, 2004. 196(10): p. 611-8.
Scully, C., et al., Sources and patterns of referrals of oral cancer: role of general practitioners. Br Med J (Clin Res Ed), 1986. 293(6547): p. 599-601.
Warnakulasuriya, K.A., C.K. Harris, and D.M. Scarrot, An Alarming lack of public awareness towards oral cancer. Br Dent J, 1999(187): p. 319-322.
Sanderson, R.J. and J.A. Ironside, Squamous cell carcinomas of the head and neck. Bmj, 2002. 325(7368): p. 822-7.
Llewellyn, C.D., N.W. Johnson, and S. Warnakulasuriya, Factors associated with delay in presentation among younger patients with oral cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2004. 97(6): p. 707-13.
NHS Scotland. West of Scotland Mouth Cancer Awareness Project. Accessed 2005;
Speight, P.M., M.C. Downer, and J. Zakrzewska, Screening for oral cancer and precancer. A report of the UK Working Group on Screening for Oral cancer and precancer. Community Dent Health (suppl), 1993(10): p. 1-89.
Cox, G., A. Alcock, and R. Corbridge, Biopsy under local anaesthetic is inadequate (letter). BMJ, 1999(319): p. 706-707.
Rodrigues, V.C., S.M. Moss, and H. Tuomainen, Oral cancer in the UK: to screen or not to screen.Oral Oncol, 1998. 34(6): p. 454-65.
Kujan, O., et al., Evaluation of screening strategies for improving oral cancer mortality: a cochrane systematic review. J Dent Educ, 2005. 69(2): p. 255-65.
Zakrzewska, J., I. Hindle, and P.M. Speight, Practical considerations for the establishment of an oral screening programme. Community Dent Health, 1993(10): p. 79-85.
British Dental Association, BDA Occasional paper No. 6 Opportunistic Oral Cancer Screening. April 2000.
Warnakulasuriya, K.A. and N.W. Johnson, Dentists and oral cancer prevention in the UK: opinions, attitudes and practices to screening for mucosal lesions and to counselling patients on tobacco and alcohol use: baseline data from 1991. Oral Dis, 1999. 5(1): p. 10-4.
British Association of Head and Neck Oncologists. DAHNO.

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Oral Cancer prevention

Primary prevention

Secondary prevention: screening

Future

References for oral cancer prevention

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