Oral Cancer Screening: A Necessary Part of Any Exam

Oral cavity cancer is actually the number-one cancer in India, with buccal mucosa being the most common site, likely due to the widespread use of chewing tobacco mixed with the carcinogenic betel nut. One of the few studies examining the effect of oral cancer screenings was completed recently in India by Sankaranarayanan et al. (Sankaranarayanan R et al., for the Trivandrum Oral Cancer Screening Study Group. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet 2005;365:1927-33). Tobacco users in the intervention group who had undergone screening had a reduced mortality from oral cancer compared with the control group. But can we apply these findings to the United States? The incidence of oral cavity cancer in India is four to six times higher than in the United States, making a screening program in India more likely to detect a patient with a lesion. There are other factors that may have led to the success of Dr. Sankaranarayanan’s intervention. This study involved recruiting patients by going door to door. How would we get these patients to present for screening? Furthermore, the breakdown analysis found that only high-risk patients (with a history of tobacco use and drinking) should be screened. If we try to apply that in this country, we will be missing the 10% to 20% of patients with oral cavity cancer and perhaps a higher percentage of patients who have oropharyngeal cancer without a smoking or drinking history. And with the increasing prevalence of HPV-associated disease, particularly with oropharyngeal disease, this may lead to a significant number of people who are at risk but not screened due to lack of tobacco use.

The Importance of Screening

At the University of Illinois at Chicago, 76% of our patients have advanced-stage disease, well over the Surveillance, Epidemiology, and End Results (SEER) database average for all sites. Some may consider this to be university bias. Regardless, I consider this to be unacceptable. During my first few months as an attending physician, I noticed that patients were coming in with bulky disease that perhaps might have been visible earlier, and some of these patients were followed by other doctors for their comorbid conditions. In fact, the vast majority of patients with advanced stage disease have seen a doctor for some other complaint in the past year.

With this in mind, I have started a more systematic teaching of medical students about the oral examination and how to do an oral screening. I emphasize performing a complete oral exam, but the real take-home point (at least in is country) is to learn to examine the lateral tongue. The lateral tongue is the most common place for Americans to develop oral cancer, yet it is rarely examined in a general exam. I emphasize in my lecture and in clinic that adding the command, Stick out your tongue, move it to one side, move it to the other side will allow examination of the lateral tongue in less than 15 seconds and will likely result in improved early detection. Because of the increase in HPV-associated oropharyngeal cancers, I have recently started emphasizing visual inspection of the tonsils as well as palpation of the base of tongue and tonsils. I also teach self-exam to my patients who have cancer or are high risk due to smoking or drinking.