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Chapter 211 Screening for Oral Cancer

• •Particular attention should be paid to observing for patches that are either red or white. • • A high index of suspicion must be maintained for patients with a history of smoking, chronic alcohol use, and heavy exposure to sunlight. • • Atrophic or hyperplastic areas of the oral mucosa must be viewed with suspicion, particularly if they are red or white (erythroplasia or leukoplakia) and last more than 2 weeks after the cessation of smoking, drinking, and exposure to irritants. • • Referral for definitive biopsy is indicated for persistent lesions. 1. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med 2001;344:975. ( A primary-care-oriented review of the pathophysiology of squamous cell carcinoma of the skin, including the lip, with brief overview of management and outcomes. ) 2. Decker J, Goldstein JC. Risk factors in head and neck cancer. N Engl J Med 1982;306:1151. ( Reviews the epidemiology of oral malignancy, emphasizing the importance of smoking, alcohol, and poor oral hygiene. ) 3. D’Souza G, Kreimer A, Viscidi R, et al. Case-control study of human papil lomavirus and oropharyngeal cancer. N Engl J Med 2007;356:1944. ( Evidence of HPV’s role as a unique risk factor. ) 4. Forastiere A, Koch W, Trotti A, et al. Head and neck cancer. N Engl J Med 2001;345:1890. ( A comprehensive review; 117 references. ) 5. Greer RO. Oral manifestations of smokeless tobacco use. Otolaryngol Clin North Am 2011;44:31. ( An extensive review with 90 references of the conflicting evidence supporting or refuting the role smokeless tobacco plays in the development of oral cancer. ) 6. Lowry DR, Munger K. Prognostic implications of HPV in oropharyngeal cancer. N Engl J Med 2010;363:82. ( Editorial summarizing the uniqueness of this variety of oropharyngeal cancer. ) 7. Sonawane K, Suk R, Chiao EY, et al. Oral human papillomavirus infection: differences in prevalence between sexes and concordance with genital human papillomavirus infection, NHANES 2011-2014. Ann Intern Med 2017;167:714. ( Oral HPV infection higher among men than women, and especially high in those with more than 16 lifetime sexual partners, smoking more than 20 cigarettes/day, men who have sex with men, many lifetime oral sexual encounters, and men with concurrent HPV infection. ) Natural History and Responsiveness to Treatment 8. D’Cruz AK, Vaish R, Kapre N, et al.; for the Head and Neck Disease Man agement Group. Elective versus therapeutic neck dissection in node-negative oral cancer. N Engl J Med 2015;373:521. ( Elective neck dissection at the time of primary surgery gave better outcomes than did therapeutic neck dissection after nodal relapse. ) 9. Shah AY, Doherty SD, Rosen T. Actinic cheilitis: a treatment review. Int J Dermatol 2010;49:1225. ( A comprehensive review of this often overlooked precan cerous condition of the lip and the most common management modalities. ) 10. Shklar G. Oral leukoplakia. N Engl J Med 1986;315:1544. ( An editorial regarding its significance. ) 11. van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; present concepts of management. Oral Oncol 2010;46:423. ( A concise overview of the most common premalignant lesion of the oral cavity with excellent tables and a management algorithm for leukoplakia. ) Screening and Diagnostic Procedures 12. Chan KCA, Woo JKS, King A, et al. Analysis of plasma Epstein-Barr virus DAN to screen for nasopharyngeal cancer. N Engl J Med 2017;377:513. ( Evidence of efficacy for this experiment in early detection of cancer by examination of plasma for etiologic DNA; however, high false-alarm rate suggesting use best restricted to high-risk populations. ) 13. Mehanna H, Wong W-L, McConkey CC, et al.; for the PET-NECK Trial Management Group. PET-CT surveillance versus neck dissection in advanced head and neck cancer. N Engl J Med 2016;374:1444. ( Similar survival rates, but less morbidity and cost with PET-CT use. ) Recommendations 14. Rethman MP, Carpenter W, Cohen EW, et al. Evidence-based clinical rec ommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 2010;141:509. ( Includes a thorough, evidence-based review; finds no evidence that screening of normal-risk patients improves disease-specific survival, but survival improved by screening high-risk persons. ) 15. U.S. Preventive Services Task Force. Screening for oral cancer. 2004. Avail able at: www.uspreventiveservicestaskfroce.org/uspstf/uspsoral/htm. ( Finds data insufficient to recommend for or against screening of all normal-risk persons, but acknowledges the value of careful examination of persons at increased risk. ) ANNOTATED BIBLIOGRAPHY Epidemiology and Risk Factors

The initial evaluation of a suspicious lesion begins with checking for important risk factors for oral and oropharyngeal cancer (e.g., smoking, alcohol excess, orogenital sexual activity). Irritative lesions, suggested by aspirin use, jagged teeth, and poorly fitting dentures, can be confirmed by addressing them and watching for rapid healing. Mucosal ulceration that fails to heal within 1 or 2 weeks after the elimination of a presumed mechanical irritation must be biopsied. In any patient with a suspicious lesion, the use of a noxious agent such as tobacco must be eliminated at the outset. Any red or white lesion that persists for 2 weeks after initial recognition and the elimination of irritating agents requires referral for biopsy. High-risk patients—specifically those with histories of smoking and chronic alcohol use—should be referred for biopsy promptly, as should any patient with a deeply ulcerative or fungating lesion, a patient with a lesion that bleeds easily, or a patient complaining of new-onset paresthesia or tooth mobility concomitant to the development of the lesion. There is no substitute for biopsy. Exfoliative cytology and in vivo staining with toluidine blue, although sometimes suggested as noninvasive diagnostic methods, do not provide sufficient sensitivity or specificity to take the place of incisional biopsy. A brush biopsy technique for screening suspicious lesions has been widely promoted, but this technique is no substitute for definitive incisional biopsy. Any swelling beneath a normal-appearing oral mucosa must be evaluated as well. Such lesions are commonly benign and are the result of infection , bony exostosis , or mucus retention phenom ena, but they may represent neoplasms of the minor salivary glands or other submucosal structures. Because of high frequency of spread to regional lymph nodes, the question arises and debate continues as to the need for regional lymph node dissection in persons presenting with seemingly localized disease. PET-CT scanning has been found helpful in detection of more advanced disease and useful in limiting the need for lymph node dissection, but outcomes with early regional node dissection seem to be better than with wait ing until there is clinical evidence suggesting regional spread. The dream of detecting cancer early by sampling circulating blood for tumor-associated DNA has been the subject of study in nasopharyngeal cancer, where the presence of Epstein-Barr virus DNA is strongly associated with tumor presence. Screening plasma for viral DNA segments in high-risk populations shows potential for improving early diagnosis, but false-positive rates are high when such testing is applied in unselected populations. RECOMMENDATIONS (14,15) Both the American Dental Association and the U.S. Preventive Services Task Force found existing data insufficient regard ing the risks and benefits of screening normal-risk adults for oral cancer to recommend implementation. However, they did acknowledge the potential value of regular examination for detection of early disease in persons at increased risk (especially smokers and drinkers). • • Patients should be counseled on preventive measures, especially the importance of avoiding the use of tobacco products, excessive alcohol consumption, and engaging in high-risk orogenital sexual activity (see also Chapters 107 and 141). • • A thorough visual and manual examination of the lips and oral cavity should be considered for inclusion in the routine physical examination, especially in persons at increased risk due to smoking and excess alcohol consumption.

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