Screening for the disease during an era of personalized care
BY Dennis M. Abbott, DDS
There is a movement that is quietly taking place in health care. Like any movement that ultimately gives rise to change, the shift is subtle and still unnoticed by many.
But as dental professionals pause next month to draw attention to the horrors of oral, head, and neck cancer (OHNC), it is important to realize how this trend is affecting and will continue to affect the way we search for and manage this disease. The revolutionary concept is known as personalized or individualized health care.
Beyond the Standard of Care
Treatment of disease has, up to now, been founded upon the concept of standard of care (i.e., the best course of prevention or treatment for the general population). In oral cancer, for example, let's say a suspicious lesion is found and a biopsy performed. The pathologist reports a diagnosis of poorly differentiated invasive squamous cell carcinoma of the base of the tongue. Without even meeting the patient, most oncologists could begin to devise a treatment plan that would likely include surgery, followed by radiation therapy given to a cumulative dose in excess of 60 grays, and even perhaps a concomitant or subsequent regimen of chemotherapy with a drug such as Erbitux or Cisplatin.
View related articles
But what if this patient's tumor is not affected by the chemotherapy chosen by the medical oncologist, and the cytotoxic drugs make the patient even more ill without providing any benefit? That is where the practice of individualized medicine can make a huge difference. Readily available technology allows an individual's tumor cells to be grown in vitro from biopsy cells and exposed to various chemotherapeutic agents. The oncologist can then develop an in vivo plan utilizing only drugs effective against the tumor, avoiding the trial-and-error process in the patient.
This is but one example. Most of this personalized approach to health care revolves around the genetic uniqueness of the individual and his or her susceptibility and responsiveness to disease. Since the completion of the Human Genome Project in 2003, researchers have discovered more than 1,800 disease genes; there are currently more than 2,000 genetic tests for human conditions.
Now, you might be saying to yourself, "That all seems really interesting, but that's medicine. It doesn't really affect me. I'm just a dentist, or hygienist." That, my friend, is where you are wrong. First, as a health care professional, it does affect you; and you're not just a dentist or just a hygienist. You are a mouth expert and the leading voice of authority in your community when it comes to teeth, gums, and oral health.
Advocating for the early detection of OHNC in your neighboring medical community and the public at large can open an array of yet unseen doors for you and your practice in the expanding universe of personalized health care. And so, with the onset of April, when we focus on an awareness of OHNC, let's look at how personalized health care already influences the manner in which we confront this disease.
OHNC is still the sixth most prominent cancer in the United States today - in 2015, one person will die every hour, each day from oral cancer. One of those could be your spouse or partner, family member, friend, coworker, or patient. How can personalized health care help us, as dental professionals, make a difference in this statistic?
Patient as Partner
As we move into an era of more individualized care, the general population has an increased desire to be involved in every aspect of their care. Gone are the days when the doctor's orders are obeyed without question. Patients now expect to be informed of treatment risks, benefits, and alternatives in real time. We expect to be well informed because we all want the best for our loved ones and ourselves, and that desire runs no deeper than our health. Fortunately, more patients are realizing that Benjamin Franklin was probably right when he said, "An ounce of prevention is worth a pound of cure." More and more patients are turning to wellness plans as investments in themselves.
Whereas many women will routinely elect a Pap smear or mammogram each year to look for cervical or breast cancers, few will think to include a thorough head and neck examination to look for early signs of head and neck cancer as part of their wellness plan. Similarly, a physician may order a prostate-specific antigen (PSA) test or a colonoscopy to check for abnormalities in a man's prostate or colon, but his dentist does not offer an oral cancer screening to look for its early signs.
Some patients, unfortunately, have never been informed about the need for such an examination. Others are aware of the process, but fail to see the importance of such an exam because they feel they are not at risk. In a world of personalized care, education becomes increasingly important to the engagement of the patient as a partner in his or her well-being, and that education includes information about the signs and risks of OHNC and the benefits and availability of thorough head and neck examinations.
An Immeasurable Toll
This April, I would encourage you to educate yourself, your team, and your patients about OHNC. The simple truth is that the majority of OHNC is still discovered at a late stage when the cancer has already spread to the lymphatic or circulatory systems. Patients must know that when these cancers are discovered at an advanced stage, the chance of surviving at least five years beyond the diagnosis drops significantly. In fact, with a late-stage diagnosis, only slightly more than half of patients will be alive in five years. In contrast, when oral and head and neck cancers are found at an early stage, the chance for at least a five-year survival improves to 80-90%.
And while most of us who have been in dentistry for any length of time are familiar with these statistics, we sometimes fail to realize that it is not just survival that must be considered, but also the toll that OHNC treatment takes on the quality of life of the patient and their family. Early detection may reduce the amount and severity of treatment, treatment-related complications, stress and anxiety, and overall cost of care. When oral and head and neck cancer is discovered at an advanced stage, these factors are exacerbated, and treatment often includes surgery that can leave facial and neck deformities and radiation therapy so intense that it may forever compromise routine daily functions such as swallowing, tasting, and speaking.
Common Signs and Symptoms of Oral, Head, and Neck Cancer
• An ulcer or mouth sore that does not heal within two weeks
• Difficulty or pain in swallowing
• Feeling of something caught in the throat
• Persistent sore throat or hoarse voice
• Swelling or lump in the mouth
• A painless lump on the outside of the neck or in the cheek
• An earache on one side that persists for more than a few days
• Pain when chewing
• Numbness in the mouth or lips
Patients should understand that oral and head and neck cancers don't just happen to older men who have a history of smoking and drinking alcohol. Teach them about the risk associated with human papillomavirus (HPV) infection and how the demographics of the oral and head and neck cancer have changed. Information about oral cancer can be disseminated in a variety of ways in the practice: a written handout or flyer, oral communication between the doctor or hygienist and the patient, and video loops or other media available in the office. Write a blog. Post information on Twitter or whatever social media outlet your practice uses. Become the expert. The point is that education does not have to take up a considerable amount of time to be effective.
As you educate, be sure to discuss the disease risk factors. Patients should understand that some choices they make may increase their likelihood for developing OHNC. Lifestyle choices such as smoking, using smokeless tobacco products, and heavy consumption of alcohol increase the risk of oral cancer. Unfortunately, many who will be diagnosed this year will have no history of either tobacco use or drinking alcohol. Many of the cancers discovered in the tonsillar and throat regions, for example, will be attributed to cellular changes brought about by an infection from human papillomavirus (HPV), the most common sexually transmitted virus and infection in the United States.
It is believed that as many as 80% of Americans have been infected with HPV at some point in their lives, but almost 99% are able to clear the virus through normal function of the immune system, and many will never know they were infected.
Patients should know that HPV is transmitted through contact with the genitals, most commonly through vaginal, anal, or oral sex. Like many other sexually transmitted diseases, the risk of HPV infection is directly related to a person's number of sexual partners. Having sex with a person who has had multiple sexual partners also increases the risk of HPV infection. It should also be understood that HPV might lie dormant in some individuals for weeks, months, or even years.
While this may sound like an odd point, we must remember that our patients are more than just mouths and teeth - when emotions and personalities come into play, it is important to point out that a diagnosis of HPV-related head and neck cancer need not be grounds for divorce based on infidelity. The original infection may have occurred years, even decades, prior to the cancer diagnosis.
Examinations and Education
Still, even with a clearer understanding of the risks associated with oral and head and neck cancers, approximately 7% of cases diagnosed this year will not fall into any known risk category. The incidence of disease in these individuals is attributed to genetic predisposition or not yet understood environmental factors, and strongly indicates that all people should receive a thorough head and neck examination as part of a wellness plan.
There are several warning signs for OHNC that you should share with your patients (see sidebar). Education about signs and symptoms can help the patient become his or her own best advocate. An informed patient who understands the risks, signs, and symptoms is more likely to self-discover concerning issues earlier and bring those to the attention of the dentist or hygienist. Similarly, the dentist and hygienist should be aware of these common symptoms as visual or tactile discovery of early stage cancer, particularly in the throat area, is often extremely difficult. Related questions should be asked at the time of the thorough head and neck examination.
Educational information should be presented in a manner that replaces fear with vigilance. In 2015, there is no shortage of information - your patients need to hear information from you. They come to you because they trust you, so who better to give them correct information on changes that could be indicative of oral and head and neck cancer? You should also impress the need to seek prompt professional attention should they experience signs or symptoms associated with oral and head and neck cancer or if they discover a suspicious area.
A head and neck examination to look for early signs of OHNC should be performed at each recall visit. Of course, an excellent examination begins with visual and tactile evaluation of the oral, head, and neck anatomy. Form a routine for the systematic evaluation of all structures and repeat it for each and every patient so that no area is left unchecked. The clinician should explain what is being done and why it is included during each part of the examination. Many clinicians find it easier to simply narrate the process, explaining each step and its purpose to the patient.
Each patient should understand without a doubt that he or she has just received a head and neck examination to look for early stages of OHNC, as well as any other anomalies that might be present in or around the mouth. This is a great time to show through actions that your practice sincerely cares about the health and well-being of the individual in your chair. Examples of a thorough head and neck examination can be found at the Oral Cancer Foundation's website (oralcancerfoundation.org/discovery-diagnosis/screening.php) or at Six Step Screening (sixstepscreening.org).
The shift toward personalized health care and continued research built on the Human Genome Project has provided new tools for dentists and hygienists to conduct the most advanced and individualized thorough head and neck examinations ever. Simple salivary tests for HPV are available, so an individual aware of his or her increased risk should undergo a head and neck examination more frequently.
There are other readily available salivary diagnostic tools that get right to the genomic core of individualized health, particularly oral cancer. A chairside test utilizing salivary mRNA markers is now on the market; it was built upon more than a decade of research from the National Cancer Institute's Early Detection Research Network. The test measures salivary transcriptome markers that have been shown to be discriminatory for oral squamous cell carcinoma, and can assess the likelihood that the individual in your chair is presenting with oral squamous cell carcinoma. The test was originally designed to provide confidence when assessing if an early stage suspicious lesion detected during the head and neck examination should be evaluated histologically through biopsy. By utilizing information regarding certain gene expression in the presence of cancer, specifically the oral squamous cell carcinoma that accounts for approximately 90% of all OHNC, the test can detect the presence of early stage squamous cell carcinoma - even carcinoma in situ - and hopefully avoid unnecessary biopsies; even better, prompt an urgent biopsy of a lesion that previously might have been approached with a wait-and-see attitude.
Knowing that a highly accurate, noninvasive, easy-to-use chairside test now exists to provide information about the presence of oral and head and neck cancer, hopefully even more dentists and hygienists will have the confidence to provide the level of care that patients are demanding as health care moves into a new era of personalization.
So, make a belated resolution for 2015 to be the year your practice finally takes a bold stand against oral cancer. Get serious about your screening. After all, it's only March. The best is yet to come! RDH
Dennis M. Abbott, DDS, is the founder and CEO of Dental Oncology Professionals (DOP), an oral medicine practice based in Dallas, Texas, dedicated to care for the unique dental and oral health needs of individuals battling cancer. Dr. Abbott holds a bachelor of arts in biology from Rice University in Houston, and is an honor graduate of Baylor College of Dentistry in Dallas. After dental school, Dr. Abbott studied immunology, microbiology, and oral medicine at the School of Dental Medicine, State University of New York at Buffalo. In addition to private practice, he is a member of the dental oncology medical staff at Baylor Charles A. Sammons Cancer Center and Baylor University Medical Center in Dallas and serves as a consultant to the national American Cancer Society in the development of oral monitoring guidelines for post-treatment cancer survivors.