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11/8/2014
1
Screening Methods forEarly Oral Cancer
M. Boyd Gillespie, M.D., M.Sc.
UCSF Head & Neck Cancer CourseSan Francisco, CANovember 8, 2014
Disclosures� Paid consultant & Research Support on sleep
apnea devices (Inspire Medical; Olympus; Surgical Specialties)� Paid consultant on head and neck surgical
devices (Medtronic)� I am no expert in this field!
Oral Cavity• Subsites
– Lips– Buccal mucosa– Upper and lower
Gums/alveolus– Floor of mouth– Oral tongue– Hard palate– Retromolar trigone
Oral Cavity Cancer• Epidemiology
– 30% of all HN Cancers (<3% of all cancer)– 95% Squamous Cell Cancer– Low 5 year survival rate (53%)
• Advanced stage (T3/4) at presentation• Nodes at presentation (40%)• Distant metastasis (10%)
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Oral Cavity Cancer• Incidence
– Classically males over 45 years old– Male : Female ratio
• 6:1 in 1950• 2:1 in 1987
– Frequency by site• Lip >oral tongue >FOM >gingiva > RMT >palate
Oral Cavity Cancer• Risk Factors
– Tobacco– Alcohol abuse– HPV status (10-25% of cases*)– Oral Health/ peridontal disease– Inflammatory Disorders– Mechanical irritation– Family History
• Genetic predisposition• Metabolic changes
– Socioeconomic Status*Galbiatti et. al. Braz j otorhinolaryngol. 79:2(2013)
Oral Cavity Cancer• Pathology
– Severe dysplasia– CIS– Invasive SCCA
• Thickness– <4mm have 11% risk of nodal metastasis– >4mm have >25% risk of nodal metastasis
SEER 1992-2004
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Incidence of Oral vs OP Cancer in the US
Oropharynx
Oral Cavity
HN Cancer Incidence US. CDC
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Advancedoral cancerIn SC.
Areas of Highest Oral Cancer MortalityWarnakulasuriya S. Oral Oncology 2009; 45: 309-316.
Top Web SearchsSxRank Order
ASCOOral/OP
Am Ca Soc ClevelandClinic
NCI Wiki
Top Sx Mouth or lip sore
Sore in mouth
Sore throat Sore throat Sore throat
2nd Red or white patch
Pain in mouth
Swallowing Pain behind breastbone
Swallowing
3rd Lump in HN Lump in cheek
Weight Loss Cough Weight loss
4th Sore throat Red or white patch
Voice change
TroubleSwallowing
Voice change
5th Hoarseness Sore throat
Ear pain Weight loss Ear pain
Neck Mass
3rd 12th 7th 7th with mouth/ throat
7th
Sore Throat
4th 5th 1st 1st 1st
Early DiagnosisOral Cavity
T1 or T2Visible lesion first symptomRequires trained eye<50% at presentationSolid cure rate (80% 2-year)Single modalityTissue Sparing
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Late DiagnosisOral Cavity
T3 or T4> 50% of cases at presentationLow cure rate (50% 2-year)Multi-modalityNon-tissue sparing
Oral Cavity CaStage Related
Late stage oral cancer is a devastating disease� 63 year old retired RN presents with recurrent
oral tongue cancer 1 year after surgery and chemoradiation for high risk features. She is a lifetime never smoker.
� Her only current chance for cure (30% 5- year survival) is total glossectomy. It is likely that she may never swallow or speak again.
� What would you do?
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Reasons for oral cancer screening:� Known high risk exposures
(poor oral care; tobacco; marijuana; alcohol; Betel nut)
� Oral lesion precede symptoms� Early stage disease easier to treat (single
modality)� Early stage disease has better survival
Limitations to oral cancer screening:� Lack of expert examiners to identify
suspicious lesions (both in US and developingworld).
� Lack of expertise to diagnosis cancer in agiven suspicious lesion.What to biopsy?How to biopsy?How to interpret pathology from biopsy?
Challenge for the Expert.� When to biopsy?� Where to biopsy?
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Question: What is the best adjuvant oral cancer case-finding method for untrained caregiver?
Head Neck 2014; Epub ahead of print.
Inclusion criteria:� Limited to modern era (1994-present)� Sample size of at least 10� Compare screening technique to gold standard
of oral biopsy� English language publication
Bewildering Number of Options for Oral Cancer Screening
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Oral Examination by Trained Provider
Oral Examination by Trained Provider
Accuracy 78%
Toluidine Blue
Vashisht N, et al. JCDR 2014; 8: ZC35-38.
Advantages� Readily available� Inexpensive� Retention in abnormal cells
allows staining of non-visibleareas.
Disadvantages� Requires biopsy� Local anesthesia
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Toluidine Blue
Accuracy 67%
CytologyAdvantages� Topical anesthesia only� Minimal trauma� Fast� Sample a large area
Disadvantages� Must be sent for analysis� Must have cytopath expert� Expensive� Inflammation can yield
inconclusive results
Cytology
Accuracy 89%
Light Wave Screening Methods
Advantages� Not invasive� Screen large regions of tissue
Disadvantages� Expensive equipment
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Laser-Induced Autofluorescence
Accuracy 96%
Diffuse Reflectance Spectroscopy
Accuracy 97%
ConclusionsSpectroscopy (Least Studied) > Standard Cytologic techniques =Proprietary Cytologic techniques (OralCDx) >>Conventional Oral Exam (Expert) >> Vital Staining
ConclusionsFuture Technological Advances in Oral Cancer Screening
Smartphones Folding Microscope