Introduction

How confident are you about assessing patients' risk of developing oral cancer and picking up cancerous lesions, especially early malignancy? Do you know what to do if you see something unusual? Have you ever had any CPD on improving oral cancer early detection? What actions do you take to identify and manage patient risks of developing oral cancer and promote prevention? Given rising trends in oral cancer, these issues are a priority for all members of the dental team responsible for chair-side patient care. This is reflected by the recent decision by the GDC to add oral cancer detection as a recommended CPD topic before completion of its CPD review.1 This decisive action followed lobbying from within and beyond the profession, which included strong representation by Cancer Research UK and underlines the seriousness of this issue.

Oral cancer – the increasing problem

Oral cancer (OC), including oropharyngeal cancer and cancer of the lips (ICD 10 C00-C06, C09-C10 and C12-C14) is one of the few oral diseases encountered by the dental team that can result in significant morbidity and premature mortality.

The age standardised incidence of OC in Great Britain has steadily increased over the last 20 years with a 66% increase between 1988-90 and 2007-09.* Over the next 20 years OC rates are projected to increase by around 1% per year unless decisive public health action is taken.2,3 Of all UK cancers, only melanoma, a skin cancer that may also be recognised by the dental team, is increasing more rapidly.3

It has recently been predicted that by 2030 there will be 9,200 cases of OC in the UK per year compared to 6,240 in 2009 and 3,030 in 1984.2,3 OC affects both sexes with a male:female ratio of 19:10 in 2009.2 The dental team can expect to encounter OC more frequently in the future than in the past or currently.

The brief case overviews illustrate some of the key issues (Table 1 and Figs 1,2,3,4,5,6). Regrettably, delayed OC diagnosis has resulted in GDC Fitness to Practice hearings. Although as a clinician you may only pick up a few cases of OC in your working life, you want to be ready to do so with confidence and in a timely and professional manner.

Table 1 Brief case overviews of OC presentations for six patients. Each illustrates different points, how presentations vary and can be unexpected
Figure 1
figure 1

Clinical presentations of OC linked to the six cases described in Table 1.

Figure 2
figure 2

Clinical presentations of OC linked to the six cases described in Table 1.

Figure 3
figure 3

Clinical presentations of OC linked to the six cases described in Table 1.

Figure 4
figure 4

Clinical presentations of OC linked to the six cases described in Table 1.

Figure 5
figure 5

Clinical presentations of OC linked to the six cases described in Table 1.

Figure 6
figure 6

Clinical presentations of OC linked to the six cases described in Table 1.

Identifying the patient at risk and acting on this

OC is multi-factorial in origin. Recognised risk factors are tobacco, alcohol and areca nut use, infection with human papillomavirus (HPV) and for the external lips, sunlight exposure.4,5,6,7 OC rates are currently highest in areas of social deprivation, partially reflecting higher levels of tobacco use. However, it is important to remember that OC occurs in adults from all backgrounds across our society and not all adults present with the common risk factors. The dental team can expect to care for adult patients at risk of OC, irrespective of where they practice.

Recognition of the social and behavioural risk factors for OC brings the responsibility of acting on these and promoting the health benefits of modifying behaviour with documentation in the clinical records. Multi-disciplinary working is often indicated, for example, with respect to tobacco cessation or changing alcohol use. The dental team are well-placed to promote accurate information about OC risk factors, not only with respect to their impact on oral health, but also general health.

Many GDC registrants will be aware of key issues related to risk factors for OC including those described in Delivering better health8 and similar resources.9,10,11 However, familiarity with other risk factors including HPV may be less complete. Engaging patients effectively in understanding risk factors for OC empowers patients to take responsibility for their own health, including seeking early professional advice if new lesions develop.

The need for early referral of suspicious lesions

A diagnosis of OC and the associated impact of management have enormous implications on day-to-day activities of living such as eating, drinking, speaking, socialising and working. Furthermore, OC five-year survival rates have shown very limited improvement over the last 20 years.12 This contrasts with other cancers where significant improvements in survival have been achieved over the same time period.12 Just over half the patients diagnosed with tongue or oropharyngeal cancer can expect to be alive after five years.12 However, the majority of OCs are potentially curable if diagnosed early.

Systematic examination of the oral soft tissues is a long established practice within oral healthcare. The importance of this is emphasised by the rise in HPV-associated oropharyngeal cancer that typically occurs at sites that are not easily observed by either the clinician or patient. In England, oral health assessment of patients in the current 'pilots' for a new dental contract, includes an assessment of risk and soft tissue examination – the algorithm will advise on the patient's risk denoted by a 'RAG rating' (red, amber and green) and the appropriate action to be taken. The recommended actions are in line with the evidence base for prevention.8,9

Oral cancer is managed within head and neck cancer multi-disciplinary teams in selected centres. Mechanisms for rapid referral of suspected head and neck cancer to these teams through the 'two-week wait' pathway are well established. Within these guidelines, description is given of the clinical situations that should trigger such a referral.13 However, there is evidence that only a quarter of all OCs are diagnosed via this route.14 It is the responsibility of the referring clinician to be aware of local care pathways and evaluate whether the patient's situation warrants rapid referral. These decisions need to be fully informed and will be influenced by not only lesion assessment, but also of the patient's circumstances and concerns. In cases of uncertainty, it is best to err on the side of caution and refer via the fast-track system, while being mindful of the need to use this route responsibly and the impact of any referral on a patient and the NHS. Irrespective of the referral route chosen, it is important to do this in partnership with the patient and provide a clear and realistic explanation as to the purpose of the referral and address their concerns appropriately.

Review your practice and identify your professional development needs

Key issues around OC early detection and the importance of promoting prevention have been highlighted. A wide range of CPD opportunities already exist via employers, commissioners, professional associations, postgraduate deaneries and commercial CPD providers to help you keep up-to-date. All GDC registrants responsible for chair-side patient care have an opportunity, and responsibility, to make a difference. This includes identifying and addressing risk factors as well as identifying and managing referral of possible or frank malignancy in a timely and professional manner.