The Scottish Government must take action to improve Scotland’s position on the mouth cancer league table.
November is Mouth Cancer Action Month. This is the charity campaign run by the Oral Health Foundation, which aims to raise awareness of mouth cancer and make a difference by saving thousands of lives through early detection and prevention. The British Dental Association (BDA) is also supporting the campaign by sending out information packs to GDPs and PDS clinics. The latest statistics from Cancer Research UK continue to highlight the soaring oral cancer rates across the UK. We know that Scotland is top of this particular league. It has an appalling record.
The European age standardised oral cancer rates for both men and women are significantly higher in Scotland – 16.8 per 100,000 compared with 12.4 in England and 11.9 in Northern Ireland.
What used to be termed ‘oral cancer’ is now better described as either oral cavity cancer (OCC) or oro-pharyngeal cancer (OPC) as the risk factors, treatment and outcomes from these two different diseases are different.
Each year, around 500 patients are diagnosed with OCC and nearly 350 with OPC in Scotland. Whilst the rates of OCC have seen moderate increases in recent years, rates of OPC are the fastest rising cancers in Scotland. These cancers are among the most unequally distributed – with the greatest burden in the most deprived areas. If these cancers are detected early enough, a patient’s chance of survival can increase from about 50 % to 80 %.
So what are the risk factors?
Older age, low socio-economic status, and male gender are associated with increased risk for both OCC and OPC. The main behavioural risks are tobacco and alcohol consumption, particularly those behaviours in combination. Smoking in a person who has never been an alcohol drinker doubles the risk for both cancers. Likewise drinking alcohol in a person who has never been a smoker doubles the risk. Although alcohol and smoking are independent risk factors for OCC and OPC, for smokers and drinkers the population attributable risk for both is 72%, of which 4% comes from using alcohol alone, 33% from using tobacco alone and 35% from using tobacco and alcohol together.
Other risk factors include a diet low in fresh fruit and vegetables and poor levels of oral health and dental care. Oral human papilloma virus (HPV) seems to be an important risk factor for OPC but not OCC. While we don’t fully understand the natural history of oral HPV – it is becoming clear that it is sexually transmitted.
We know that the best way to save lives for both diseases is by early detection and prevention. Prevention is the key to any successful strategy and the fundamental element for this is behaviour change. This is not just about changing our behaviour as health care professionals, but also changing the behaviour of the public, our patients and the Government.
The dentists’ role
As health care professionals we have an important role to play in prevention and early detection through identifying individuals at risk. To reduce the burden of cancer, prevention needs to be focused on explaining the benefits of smoking and alcohol cessation. Giving up smoking has an almost immediate effect with the risk reducing to normal within one-four years of quitting, whereas the benefits of reducing alcohol intake can take a longer time to fully emerge – up to 20 years.
Older men who smoke and drink alcohol and come from lower socioeconomic groups are our obvious patients to target. We can also identify potentially malignant lesions, symptoms and signs using the Scottish Referral Guidelines. Anyone with persistent/unexplained head and neck lumps for more than three weeks or ulceration/unexplained swelling of the oral mucosa persisting for more than three weeks should set the alarm bells ringing. All red or mixed red and white patches of the oral mucosa persisting for more than three weeks should likewise raise concerns. Difficulty or pain when swallowing or persistent pain in the throat for more than three weeks should also be investigated further.
Early detection of OCC or OPC reduces the treatment burden and improves the prognosis of those diagnosed with the disease, especially quality of life and survival. Unfortunately it’s also a sad fact that those at highest risk are less likely to attend our dental practices.
The latest information statistic division (ISD) statistics show that just over two-thirds of the adult population in Scotland attends a dentist regularly and this figure drops down 10% lower in areas of deprivation. This means that many are missing out on getting this vital check. The Government needs to do more to address this particular health inequality. Whilst we don’t want to have a stampede of the ‘worried well’ coming to our practices looking for reassurance, we do need to have a targeted education package for those high-risk individuals who don’t visit a dentist on a regular basis. Targeting other health care professionals such as GMPs, pharmacists, respiratory disease clinics and other agencies that come into contact with these high-risk groups is an obvious approach.
As we await the outcome of the Scottish Government’s Oral Health Plan, there is a real opportunity to introduce a properly resourced Oral Health Risk Assessment (OHRA) with the potential to reverse the upward trend in these devastating cancers. The risk assessment could incorporate a red/amber/green (RAG) scoring system for the four most common and preventable dental problems – caries, periodontal disease, tooth surface loss and mouth cancer. The last one could give each patient a specific mouth cancer ‘score.’ This would enable dentists to make an informed decision about future treatment needs for their patients and also focus the assessment on detection of the disease at an early stage. This ‘score’ would also enable patients to understand the risk of succumbing to OCC or OPC and make them appreciate the benefits of preventing future problems. This has the added advantage of encouraging our patients to take responsibility for their own oral health.
There are also health economic benefits for Government by preventing or diagnosing mouth cancer early – not least by saving lives, but also by not having to refer patients onto secondary care. Recent estimates show that the cost of treating those patients is in the region of £40,000 per patient.
The Scottish Government must take robust action now to remove Scotland from its undesirable position at the top of the mouth cancer table.