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M. Williams and J. Bethea British Dental Journal 2011; 210: E9

Editor's summary

A previous paper in this Journal by Dr Williams and co-author identified that dental access centres attract significant numbers of patients with risk factors for oral cancer.1 After demonstrating the potential for these centres to play a role in oral cancer prevention, the present study follows up by looking at the effectiveness of a simple preventive campaign.

The results are a little disappointing, in that the posters and leaflets displayed in the access centre were read by less than half of the patients who attended during the study period, and even after reading the information the oral cancer knowledge of the high risk patients interviewed was poor. However, the findings are still valuable: dental access centres have been identified as venues where hard-to-reach patients at high risk of oral cancer may be targeted with preventive advice; it is therefore important to make sure that any advice is provided in such a way as to make it effective. By following up their initial work, the authors clearly show that a more sophisticated method of communication is needed in order to successfully reach this group of patients.

What such a method would look like remains to be seen. In his commentary on this paper, Professor McGurk suggests that simply providing information to patients is always likely to be ineffective, no matter what the format; the authors, on the other hand, suggest that social marketing techniques might have more success. Whatever the ultimate answer (which may well turn out to be a combination of methods), the most important thing is that this research is being carried out and these questions asked.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 210 issue 6.

Rowena Milan, Managing Editor

Author questions and answers

1. Why did you undertake this research?

This research follows an earlier study, which demonstrated that a significant proportion of patients attending the Dental Access Centre in Nottingham had lifestyle habits that predisposed to the development of oral cancer. In order to be effective in the primary prevention of oral cancer, information would need to be presented in an appropriate format to this cohort of patients known to be difficult to influence. This is important because, by their very nature, dental access centres attract patients who are unlikely to have regular dental examinations. The patient visit to the access centre may represent one of only few opportunities to receive targeted health information. The purpose of this research was to determine whether patient awareness of tobacco and alcohol consumption as risk factors for oral cancer could be raised by information delivered in a simple written format.

2. What would you like to do next in this area to follow on from this work?

Accepting what appears to be the rather disappointing outcome of a poster and leaflet campaign, the natural progression would be to look at other ways of delivering advice about risk factors associated with oral cancer to high-risk patients attending access centres. Social marketing techniques may be more effective. Further qualitative research that would consider not only the efficacy but also the practicalities of more sophisticated approaches, ideally in a number of access centres, is envisaged.

Commentary

This article has sought to identify, then inform a group of patients at risk of developing mouth cancer. The informed patient should then alter lifestyle factors to reduce the risk of disease or present early in the disease process. Screening by regular inspection is not cost-effective, so current strategy has shifted to the at-risk group.

One would expect education to hold the key to success. It is the basis of most preventive programmes! The authors identified a group at risk of cancer; but perhaps occurring 20 years hence. They were unsuccessful in educating them away from the risk of disease. In the last 40 years, cancer has gone from being a taboo topic to one freely discussed in society. This alone should have promoted early recognition, but my experience (>1,000 cases of mouth cancer evaluated 1960-2010) shows the ratio of early (stage I and II) to advanced (stage III and IV) disease has remained static (≈50:50) for 50 years. A Scottish television campaign increased attendance for oral checks but the effect was transient. Information provision on its own is ineffective.

It is difficult to see how to take this subject forward (in some countries dramatic pictures are used to try shock smokers out of buying cigarettes). At present there seem to be two options. One is to shift emphasis away from changing social mores to more short-term objectives and concentrate on better strategies to facilitate early symptom recognition both for patient and physician. However, physicians only encounter a mouth cancer patient once every 63,000 consultations. How can one train to be alert for such odds? The other option is to invest nationally in developing molecular tests that will allow screening of the population. There is the prospect that a cancer signature may be held in salivary samples. The at-risk population seldom attend their doctors or dentists but patients must take responsibility for their health and those that do not attend for screening should be responsible for a percentage of treatment costs.