More needs to be done to raise the priority of the prevention and early detection of oral cancer
The Oral Health Improvement Plan. When this was launched at the beginning of the year, it raised some questions, and some eyebrows. Though the dental profession in Scotland cautiously welcomed the plan’s overarching aims, there was significant concern about some core elements. Areas of controversy included the lack of any costings for the plan or any information about how it was to be funded; the focus on long-term prevention without any real short to medium-term solutions; and the one element that really grabbed the headlines – 24-month recall.
Fast forward to a couple of weeks ago, and I’m in a meeting room in Holyrood with dental professionals, politicians and survivors of oral cancer. We’ve been brought together by the BDA Scotland, for the launch of their Oral Cancer Action Plan. Incidences of oral cancer are increasing, and at a faster rate than any other cancer, now killing more than three times as many people in Scotland as car accidents. The three main causes of oral cancer are alcohol, HPV infections and tobacco, and data cited by the BDA shows that 90 per cent of cases could be prevented.
The same figures suggest that survival could be improved from 50 per cent to 90 per cent with early detection. Which leads to one question – does the OHIP support the prevention and early detection of oral cancer? The short answer seems to be, no. Oral cancer is mentioned only once in the entire plan, action 17, which states that the Scottish Government will ensure that the [oral cancer] clinical pathway across Scotland is safe, consistent, clear, and effective. Good. There is no doubt that the current pathway is complex, and with current figures suggesting that 40 per cent of new oral cancer cases present through GPs rather than GDPs, there is clearly a need for all primary and secondary healthcare services to have a clear, joined-up approach. However, this on its own will simply not be enough. Worse than falling short, though, is the issue that the OHIP may actually work against early detection. Yes, we’re back to that pesky 24-month recall.
BDA figures show that 97 per cent of Scottish dentists believe longer recall intervals would pose a risk for oral cancer detection. Dentistry is unique among healthcare services in that it provides a regular touchpoint for patients. The value of this for early detection cannot be underestimated. What happens when this touch point is removed? Remember those 40 per cent presenting through GPs? It would be interesting to research how much that figure might increase and, ultimately, how many cases would just not be caught because the patient didn’t think anything was wrong so didn’t go to their GP, let alone their GDP.
Surely though, patients can be educated to take on some responsibility for early detection, can’t they? In its action plan, the BDA talks about raising awareness of the early signs of suspected oral cancer. The Scottish Government certainly seems to have latched on to this. At the event, in his response to the BDA’s concerns about 24-month recall, Joe Fitzpatrick, Minister for Public Health, Sport and Wellbeing, said that the government was keen to encourage people to self-examine and learn how to spot symptoms of oral cancer. Can’t argue with that. Self-examination has certainly improved breast cancer figures. Except oral cancer is not breast cancer. Let’s make no bones about it, oral cancer diagnosis is not easy. Indeed, it is nigh on impossible, even for those who see cases every day and, in their examinations, have access to every part of a patient’s oral soft tissue, access that an individual could never achieve at home.
At the lectures on oral cancer recognition and referral at our last Scottish Dental Show, clinical slides of various oral cancer signs were shown. The lecturer asked the audience to say which they would refer as high risk. I think it is fair to say that the audience found it very difficult. Slides which everyone agreed could only be malignant proved to be benign, and slides which showed cases that looked innocuous were quite the opposite. The advice from the lecturer? If in doubt, refer. Good advice. What’s the advice to the public though? If you see anything suspicious get it checked out. But checked out by whom. The public is conditioned to go to their GPs with concerns about cancers, not their dentist, the actual expert in oral health. That 40 per cent presenting through GPs is climbing again.
Which leaves us with prevention. This is something where the public really can have an impact. Stopping smoking, eating more healthily, cutting down on alcohol, all things individuals can do themselves. Except, it’s not as simple as that. Achieving this requires not just a significant public engagement and education campaign, a few posters and leaflets won’t cut it I’m afraid, but a public health and private sector infrastructure that supports individuals to live healthier lifestyles. Minimum alcohol pricing certainly might help: the cuts to alcohol treatment and smoking cessation services won’t. And this is all before we get onto the issue of the disparity of cost between ‘healthy’ and ‘unhealthy’ food. Best not to get me started on that one.
The final mention should probably go to one significant cornerstone of oral cancer prevention – HPV vaccines. It is wonderful that the HPV vaccine is going to be administered to boys. It will really make a difference to the 29,000 12-year-old boys across Scotland destined to receive the first wave of vaccinations. It will be even more wonderful when there’s a date for it.
And just imagine how wonderful it would be if the Scottish Government agreed to a catch-up programme of vaccinations for the 140,000 older boys still at school.