How do I ensure I don’t miss an oral cancer?
The early detection of oral cancer has now become a recommended topic by the General Dental Council for Continuing Professional Development. This is, in part, due to an increasing number of patients who are claiming (rightly or wrongly) that their dentist failed to diagnose their mouth cancer and, as such, are suing them for negligence.
One recent example considered in the High Court in England earlier this year, cleared the dentist, but not before his being accused of failing to identify the cancer on her gum at an early stage.
What can we do to help minimise such an event?
In America, the top reasons why a patient pursues a case of negligence against a dentist in respect of oral cancer are:
- Failure to make an early diagnosis
- Failure to refer to a specialist
- Claiming damages for the consequences of a failure to detect the cancer at an early stage
- A perception by the patient that the dentist had not taken their concerns seriously.
Key questions to consider when assessing the malignant potential of an oral lesion
1. What Risk Factors are present?
While the number of cigarettes consumed within the UK has dropped profoundly over the last 25 years or so (from a staggering 102 billion in 1990), the reduction in the number of smokers has not been as dramatic. Approximately 25 per cent of the population in Scotland still smoke.
Although novel approaches to certain groups have had some success (e.g. “Give it up for baby” – a smoking cessation intervention for pregnant women in Scotland, organised by Paul Ballard and NHS Tayside) there is still a long way to go. Clinicians should be actively involved in raising awareness of the potential detrimental effects of smoking on oral health and giving smoking cessation advice.
A key question to ask the patient with a clinically suspicious lesion is: “Do you smoke?” At least 75 per cent of oral cancers are associated with tobacco use.
With the increase in cost, many people are turning to hand-rolled cigarettes because they are cheaper, but they may lack an effective filter. Key additional questions include recording type of tobacco use, number of years they have smoked and daily quantity consumed.
As with tobacco, it is worth asking about their use of alcohol, as this is an important risk factor for oral cancer, particularly when combined with tobacco use. The Government and indeed all the Royal Colleges, support the guidance as regard low risk drinking.
For men this is considered as no more than four units in a day or 2ı units in a week (for women it is no more than three units in a day and ı4 units in a week) with at least two days free of alcohol.
Obtaining a reliable alcohol history isn’t always easy, partly because many patients don’t know the alcohol unit content of what they drink, but also because we are often economical with the truth. Studies have shown that in the UK there is a 40 per cent underestimation of what people claim they drink, when compared with actual alcohol sales.
We have gathered data regarding drinking habits and understanding of alcohol guidelines over several years during our annual Mouth Cancer Awareness Week campaigns at the University of Dundee. There is a tendency for students to underestimate the number of units of alcohol in a pint of beer. When this is combined with the frequency that they admit to binge drinking (defined as at least six units in any one session for women, and at least eight units for men), then many students would appear to be drinking at a level that would trigger a brief alcohol intervention.
The development of an appropriate intervention for dental practice is currently being explored (Shepherd S, et al Current practices and intention to provide alcohol-related health advice in primary dental care, British Dental Journal 211:322-3 2011 doi:10.1038/sj.bdj.2011.822).
2. What is the colour?
(‘Red is a mean mean colour’)
While I’m sure Steve Harley didn’t have oral cancer in mind when he wrote that song, it seems peculiarly apposite. Red is a far more significant colour when it comes to early manifestation of oral cancer.
Yet leukoplakia is often considered the most frequent precancerous lesion. By focusing on the white element, the issue of any surrounding erythema may be lost. Although much is made of the white patch, its malignant transformation rate is probably less than 5 per cent, whereas that of the erythroplakia is at least 80 per cent (far more significant).
Having said that, the most significant leukoplakias are those that are large and non homogenous. Far more important and more frequently associated with asymptomatic early oral cancer are the so called speckled leukoplakias (erythroleukoplakia).
3. What does the early oral cancer look like?
The early asymptomatic cancer presents in a far more subtle way than many of the textbooks might suggest. The identification of an oral cancer that has raised, rolled hard edges surrounding an area of ulceration that is oozing blood is an advanced lesion that hopefully no one would miss.
Unfortunately, by the time it has that appearance, such an advanced lesion has had plenty of opportunity to either invade surrounding tissues (such as bone) or metastasise to local, regional or distant lymph nodes.
Our attention as clinicians should be to focus on raising our index of suspicion. High risk sites in the UK are the so-called non-keratinising sites such as ventral tongue and floor of mouth. However, the routine screening and recording in the notes of the entire oral mucosa should be mandatory. Not only to help detect an early lesion, but also to help protect yourself from any claims of negligence that you failed to detect the cancer at an early stage.
Such a task that takes minimal time, requires no fancy expensive equipment, but yet could make such a difference to the patient’s prognosis (if a cancer is there), is ignored at our peril. (The use of dyes or techniques based upon fluorescence or cytology are still being evaluated or have not proved to have the sensitivity or specificity to become adopted as routine tests).
The recent high profile case in which the patient attempted to sue the dentist for negligence in failing to detect the oral cancer at an early stage was exonerated. He was greatly helped by the accuracy of his record keeping and screening of the mucosa.
The early detection of an oral cancer, can quite literally save that patient’s life. In helping to raise your index of suspicion when assessing the malignant potential of an oral lesion you should consider:
- What risk factors are present? (NB tobacco and alcohol)
- What is its colour? (NB red)
- How long has it been present? (It should have healed in two to three weeks)
- Is it painful? (Pain is a relatively late manifestation, hence a non painful ulcer should arouse
Remember, the early lesion is often asymptomatic (no pain, no ulceration, no bleeding).
Remember too that a patient is never too young to get oral cancer. One in 10 cases now arise in those below the age of 45 years. (See the Ben Walton Trust http://www.benwaltontrust.org)
For those who wish to get involved in raising awareness of oral cancer, for example during Mouth Cancer Awareness Week in November each year, then see the link to How you too can raise awareness of mouth cancer http://www.benwaltontrust.org/pdf/mouth_cancer_awareness_booklet.pdf
About the author
Prof Ogden is professor of oral surgery at the University of Dundee. His main research themes are aetiology (in particular alcohol) and early detection of oral cancer.
On the GDC’s specialist list for both oral surgery and oral medicine, he is currently president of the Association of British Academic Oral & Maxillofacial Surgeons (ABAOMS).
Prof Ogden is a former chair of the Special Advisory Committee for Oral Surgery, responsible for writing the curriculum for specialty training in oral surgery. He is also on the Medical Advisory Panel for Drinkaware and is now a vice dean (Dental Faculty) of the Royal College of Physicians and Surgeons of Glasgow.