Building a model for early detection
Using patient demographics, behavioural factors and clinical factors to calculate an individual’s cancer risk
Head and neck (and within this oral) cancer is a disease of high mortality and high morbidity when detected at later stages. If detected at early stages, however, patients can face a much better prognosis.
Early detection leads to better patient outcomes. For example, surgical treatment alone is often less destructive than when combined with adjuvant radiotherapy treatment which is often indicated at advanced stages. Whilst early detection is essential, efforts to prevent future cases developing in the first place are also key (e.g. through behavioural intervention) This led me to develop a model to help dentists, GPs and other secondary care professionals to detect cancer early and to help shape cancer prevention in the future.
Inequality and access backlogs
Head and neck cancer incidence is increasing in Scotland, as reported by the BDA.1 There are many different factors at play which are influencing this increase in cases. There are clinical factors, such as the growing incidence of HPV-positive oropharyngeal cancer but also underlying socioeconomic inequalities that will only be worsened by the cost-of-living crisis. People living in more deprived communities (who typically may need treatment more urgently) are struggling the most to access and pay for care. Deprivation cannot be understated or overlooked.
Dentists and healthcare professionals cannot detect cancer in patients if they can’t get appointments, however. Both medical and dental primary care services have suffered from massive backlogs as a result of the pandemic. For example, at a vaccine clinic, I came across what I suspect may have been head and neck cancer in an elderly patient who had been struggling to get a GP appointment, presenting with a persistent hoarseness and throat pain of well over a year and reporting a history of heavy smoking. I ended up contacting the patient in question’s GP. I don’t suppose I’ll ever know the outcome for that patient, but I really hope my suspicion was wrong. This story typifies some of the challenges we, as clinicians, face as we deal with the damaging effects of the pandemic and chronic underfunding of the health service.
Specialising in cancer
After completing years one to three of my BDS degree, I began my intercalated year studying Public Health just as the pandemic hit. After my first year, a unique opportunity with the TRACC (to Train and Retain Academic Cancer Clinicians) Programme presented itself. TRACC is a novel, exciting clinical academic training programme which is jointly run by the Universities of Edinburgh and Glasgow and funded by Cancer Research UK.
It is an unusual PhD – the programme takes place immediately after an intercalated degree before a student resumes their MBChB or BDS course. The programme aims to arm future clinicians with research techniques and experience, afforded by a fully funded and supported PhD. Students will then finish their clinical degree in dentistry or medicine and be qualified academically, as well as clinically. I am the first dental student in this programme, hopefully paving the way for others to take up this opportunity in the future.
Creating a risk prevention tool
The final tool I’m developing as part of the TRACC programme will aim to use patient demographics, behavioural factors, and clinical factors (obtainable from routine patient histories, notes or even a waiting room questionnaire) to calculate an individual’s cancer risk for a clinician. This could have scope for early detection, for example – the prompting of referrals. Crucially, such a model has major scope for prevention, the long-term value of which cannot be understated. The tool could promote changes in recall times and link in with preventative behavioural change pathways. Research has found brief motivational interventions (supported by risk assessment) in the clinical settings have potential for behavioural change.2 Thus, a clinical risk model could prove a massive aid in such interventions, a calculation or quantification of risk offering a “teachable moment” for at-risk patients. Examples of the factors considered for inclusion include:
Sex: Men are more predisposed, being 2-3 times more likely to develop HNC
Age: As we age, the probability of developing many types of cancer increases. Exposure to carcinogens or conversely protective agents is important to consider. Most patients present between their 5th and 7th decade of life
Socioeconomic status: Deprivation is a huge factor – area-based deprivation and personal social and economic circumstances greatly affect individual access to care but also the ability to interact with local services.
Alcohol: Clinicians are always conscious of the effects of alcohol increasing cancer risk in patients
Smoking: Tobacco smoking is a major risk factor, acting synergistically with alcohol to promote carcinogenesis. We should also be mindful of other chewable tobacco products such as Betel Quid. Individual risk can be greatly mitigated if a patient quits smoking – in fact individual risk after 20 years of smoking cessation is on par with that or a never smoker.
HPV: HPV infection can promote carcinogenesis and is a big driver in the increase of oropharyngeal cancer rates. It will take years for the full protective effect of the HPV vaccination programme to be fully realised
Clinical Factors: Persistent hoarseness, red or white patches, stridor, unexplained weight loss, neck lumps.
Alongside the BDA oral cancer toolkit available to dental teams3 and cancer recognition CPD4 providing advice on how to complete an examination of the mouth, oropharynx, and neck for reportable lesions, I want the model to support and equip practitioners to help open a dialogue and start those (sometimes difficult) conversations with patients on behavioural change.
Looking ahead
Head and neck cancers present a major challenge to our healthcare systems, but I believe there is hope. A dual strategy is required, where we improve public awareness and equip clinicians to detect and manage cancers as early and promptly as possible.
There have been great strides in awareness of breast cancer and colon cancer, for example, with high-profile voices speaking out. Despite being the eighth most common type diagnosed, head and neck cancer sometimes goes ‘forgotten’ in the public sphere. Awareness is shockingly low, and we must work harder to reach marginalised people in deprived areas.
From seeing cutting-edge robotic surgery cases to presenting at an international conference in Heidelberg, Germany, my PhD has taken me to new settings in healthcare and beyond. I cannot thank the TRACC programme and my supervisors David Conway, Alex McMahon, Alistair Ross and Gareth Inman enough for the opportunities as well as Jenny Montgomery and the QEUH ENT department for their support. I’d also like to express my thanks to Cancer Research UK for their funding of this project.
Dental school is a great starting point to get dentists out there in the field, but research and academic training are also vital for the future, especially in areas such as cancer prevention. I would wholeheartedly encourage dental students and dentists to grab opportunities with both hands and try new things. The more experience you can gain, the better.
References
- BDA.org – Oral Cancer in Scotland
- Mathur, S., Conway, D., Macpherson, L. et al. Systematic overview of systematic reviews and clinical guidelines: assessment and prevention of behavioural risk factors associated with oral cancer to inform dental professionals in primary care dental practices. Evid Based Dent (2022).
- Doctors.net.uk – Oral Cancer Toolkit 2015
- BDA and Cancer Research UK Oral Cancer Recognition Toolkit CPD
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