Lack of evidence for oral cancer screening by physicians
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- Published: Wednesday, 19 February 2014 07:55
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There is insufficient evidence to recommend for or against oral cancer screening in asymptomatic adults age 18 years or older by primary care physicians, according to a study published in the Annals of Internal Medicine (November 25, 2013). The researchers also did not find direct evidence of whether screening reduces morbidity or mortality among the general or high-risk U.S. population.
The U.S. Preventive Services Task Force (USPSTF) noted in its recommendation that its study focused on oral cavity screenings performed by primary care providers, not dental providers or otolaryngologists. It reiterates the group's 2004 recommendation, which also found insufficient evidence to recommend for or against screening. Some 90% of all cases of oral cancers are classified as squamous cell carcinoma. There will be an estimated 41,380 new cases and 7,890 deaths from cancer of the oral cavity and pharynx in 2013, according to the U.S. Centers for Disease Control and Prevention (CDC). At the time of diagnosis, more than 50% of people with oral cancer have regional or distant metastases.
Nearly three-quarters of all oral and pharyngeal cancer cases occur in men, making it the eighth most common cancer in men in the U.S. It's the 14th most common cancer in women. Risk factors include tobacco and alcohol use, male sex, older age, the use of betel quid, ultraviolet light exposure, infection with Candida or bacterial flora, and a compromised immune system, according to the authors. Oral cavity cancer is predominantly caused by tobacco and alcohol use. Up to 75% of oral cancers are attributable to tobacco and alcohol use, but sexually transmitted oral human papillomavirus (HPV) infection (HPV16) has recently been recognized as an increasingly important risk factor for oropharyngeal cancer, the researchers noted.
The overall prevalence of oral HPV is estimated to be 6.9% in U.S. adults ages 14 to 69 years. However, HPV prevalence can be as high as 20% for people who have more than 20 lifetime sexual partners or use tobacco. The prevalence of type-specific HPV16 is estimated at 1% in adults ages 14 to 69 years (an estimated 2.13 million infected individuals). HPV16 is associated with approximately 85% to 95% of HPV-positive oropharyngeal cancer cases, the authors noted. More than half of all patients with oral and pharyngeal cancer have regional or distant metastases at the time of diagnosis. Relative five-year survival is 82.4% for localized disease, 55.5% for regional lymph node spread, and 33.2% for distant metastases, studies show. Patients with HPV-positive oropharyngeal cancer are diagnosed an average five years younger and have improved survival compared with patients with HPV-negative oral cancer, according to the researchers. In a 2008 survey of U.S. adults, 29.4% of adults age 18 years or older reported ever having an oral cancer examination in which a doctor, dentist, or other health professional pulled on their tongue or palpated their neck, the researchers found. Adults who are most at risk for oral cancer (current smokers age 40 or older) are less likely to have ever had an oral cancer examination compared with former smokers or adults who have never smoked.
Two UK studies looked at oral examinations performed by general dentists among older adults (age 40 years or older) at increased risk because of alcohol and tobacco use and a mixed sample with unknown risk factors. The dental examination in the high-risk sample (n = 2,027) showed a sensitivity of 74%, a specificity of 99%, and a PPV of 67%, while the study of patients with unknown risk factors found a sensitivity of 71%, a specificity of 99%, and a PPV of 86%.
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