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Guideline for the Early Detection of Oral Cancer in British Columbia 2008
At the request of the College of Dental Surgeons of British Columbia, this guideline has been written by a
working group of the BC Oral Cancer Prevention Program, which is a multidisciplinary team composed of
clinicians and scientists from the BC Cancer Agency.
This guideline is intended to provide guidance about the appropriate use of oral cancer screening techniques
and to help dentists make informed decisions about screening for oral cancer in practice. It should be used to
facilitate clinical decision-making.
Due to the importance of ongoing research related to oral cancer screening, this guideline will be updated
on a regular basis with multidisciplinary input.
MARCH 2008
Clinical Practice guidelines
))orca bc oral cancer prevention program
• Oralcancerisacommoncancerofglobalconcern.It
isknowntobeadevastatingdiseaseoftremendous
consequencetotheindividual,tofamilyandtosociety.
• Thisyear3,200peoplewillbediagnosedwithoralor
pharyngealcancerinCanada.Ofthese,itisestimated
thatabout2,700(84percent)couldpotentiallybe
detectedbyadentist.1
• Thefive-yearsurvivalrateisapproximately62percent.
• Earlydetectionhasthepotentialtosignificantly
reduceoralcancerdeathsandmorbidity.
• Knownriskfactorsincludetobaccoandalcohol
consumption,togetherresponsibleforabout
75percentoforalcancersindevelopedcountries.
• Mostoralpremalignantlesionsandcancers
shouldbedetectableatthetimeofacomprehensive
oralexamination.
• Theselesionsoftenpresentasawhitepatchor,less
frequently,aredpatch.Progressionfrompremalignant
lesionstocancerusuallyoccursoveryears.
ReCoMMendAtions
Theserecommendationsareintendedforuseinadultpatients.Theydonotapplytoindividualswithapersonalhistoryoforalcancersincethesepatientsrequirespecializedcare.
• Itistheexpectationthatahead,neckandoralsofttissueexaminationiscompletedonallpatientsatthetimeofthenewpatientexaminationandatgeneraldentalrecall.
• Werecommendastandardizedstep-by-stepapproachtooralcancerscreeningandtotheevaluationofanymucosallesionsuspectedtobepremalignantormalignant.
• Onthebasisofpresentevidenceandthepotentialforbenefit,itisrecommendedthatsystematicoralcancerscreeningbeoffered.Atpresent,ourconsensusrecommendationistoofferthisannuallytoallindividualsfromage40.
• Adjunctivescreeningtools(seeNo.3)maybe of added value and could be considered inconjunctionwiththeannualoralcancerscreeningexaminationoratthetimeofidentificationofanysuspiciouslesion.
• Theuseoftheseadjunctivescreeningtools
requiresappropriatetrainingandexperience.
APPRoACH
oral Cancer screening and Mucosal
Lesion Assessment
1. Patient History 2
The first step in screening for oral cancer is the completion of a patient history, which should include review of:
Generalhealthhistoryincludingalistofcurrent•
medicationsandmedicationallergies
Oralhabitsandlifestyle,withparticularreferenceto•
quantity, frequency and duration of tobacco use and
alcoholconsumption
Symptomsoforalpainordiscomfort.•
2. Visual screening examination 3
Extraoral examination:
Inspecttheheadandneckregionforasymmetry,•
tendernessorswelling.
Palpatethesubmandibular,neckandsupraclavicular•
regionsforlymphnodes,payingparticularattentionto
size,number,tendernessandmobility.
Inspectandpalpatethelipsandperioraltissuesfor•
abnormalities.
Intraoral examination:
Systematicallyinspectandpalpatealloralsofttissues,•
payingparticularattentiontothehigh-risksitesforthe
developmentoforalcancerincludingthelateraland
ventralaspectsofthetongue,floorofmouthandthesoft
palatecomplex.
2 ClinicalPracticeGuidelinesMarch2008
3Guideline for the Early Detection of Oral Cancer in British Columbia 2008
Lesion inspection: 4
Evaluatethespecificcharacteristicsofeachlesionwith•
particularattentiontosize,colour,textureandoutline.
Particularattentiontopredominantlywhite,redand
white,ulceratedand/orinduratedlesionsisindicated.
Documentation:
Atthetimeofinitialassessmentandateachre-evaluation•
appointment,itisrecommendedthatanimageofany
clinicallyvisiblelesionbeobtainedandalesiontracking
sheetbecompleted.Thisdocumentisavailableat
www.orcanet.ca
3. optional screening Adjuncts
Adjunctivevisualtoolscanenhancecontrastbetween•
theclinicallesionandtheadjacentnormaloraltissue.
TechniquescurrentlyusedbytheBCOralCancer
PreventionProgramaffiliatedclinicsincludetoluidine
bluestaininganddirectfluorescencevisualization.
Mucosalchangesstainingpositivelywiththeapplication
oftoluidineblueorshowinglossoffluorescenceoccur
inpremalignantormalignantconditionsbutarenot
restrictedtoonlythesechanges.
Althoughthesetechniquesarenotdiagnosticalone,they•
may enhance lesion characteristics, identify satellite lesion
sitesandassistinbiopsysiteselection.Thesetechniques
arecomplementarytoandnotareplacementforthe
comprehensivehistoryandconventionalvisualand
manualhead,neckandoralexamination.Goodclinical
judgmentremainsindicatedinallcircumstances.
º Toluidine Blue Staining Toluidinebluehasalonghistoryofuseasavitalstain
toidentifyoralcancers.Researchconductedatthe
BCCancerAgencyhasshownthatbiopsy-provenoral
premalignantlesionsthatstainpositivelyaresixtimes
more likely to become oral cancers than those that do
not.Thisfindingsupportsaroleforthisvitalstainin
identificationofhigh-riskorallesions.5
º Direct Fluorescence Visualization Newtechnologiesareemerging,suchastheintraoral
applicationofdirectfluorescencevisualization.The
technologyutilizesahand-helddevicethatemitsa
coneofbluelightthat,whendirectedintothemouth,
excitesvariousmoleculeswithinmucosalcells,causing
themtoabsorbthelightenergyandre-emititasvisible
fluorescence.Healthyoraltissueemitsapalegreen
fluorescencewhilealteredtissues,whichattenuatethe
passageoflight,appeardarkbrowntoblack(loss
offluorescence).6,7,8
4. diagnostic Biopsy
• Ifasuspiciousmucosallesionpersistsformorethan
threeweeksfollowingremovalofidentifiedlocal
irritantssuchastrauma,infectionorinflammation,
diagnosticbiopsyisrequired.Alternatively,referralto
aBCOralCancerPreventionProgramaffiliatedreferral
clinicorcommunity-basedpractitionerwithexpertise
intheevaluationandmanagementofpremalignantor
potentiallymalignantconditionsisrecommended.
• Tissuebiopsyremainsthegoldstandardfordiagnosing
anoralpremalignantlesionororalcancer.Acarefully
selected,performedandinterpretedbiopsyiscriticalin
renderinganaccuratediagnosis.9
• Ifbiopsy-provendysplasiaisidentified,anoralrisk
assessmentisrecommendedtodetermineappropriate
management.Thismayrangefromlong-termmonitoring
tomedicalorsurgicaltherapy.
4 ClinicalPracticeGuidelinesMarch2008
ReCoMMended RefeRRAL PAtHwAy in BRitisH CoLuMBiA
suspicious oral Lesion
no dysplasia Low Grade dysplasia(MildorModerate)
High Grade dysplasiaor Above
(Severe,CISorSCC)
(persistentthreeweeksafterelimination ofpossiblelocalirritants)
Biopsy
BCOralBiopsyService*
Community Clinics
Risk Assessment Clinics
VancouverGeneralHospital•UBCSpecialtyClinic•ExperiencedCommunityPractitioner•
BC Cancer Agency Centre
Vancouver Centre•Fraser Valley Centre•
Ifabiopsyreveals: no dysplasia
Continuedmonitoringincommunitypractice isrecommended.
Ifabiopsyreveals: low grade dysplasia (mildormoderatedysplasia)
Referraltoariskassessmentclinicor experiencedcommunitypractitionerisrecommended.
Ifabiopsyreveals: high grade dysplasia (severedysplasia,carcinomain-situ or squamouscellcarcinoma)
ReferraltoaBCCancerAgencyaffiliatedclinicisstronglyrecommended.
*TheBCOralCancerPreventionProgramiscloselyaffiliatedwiththeBCOral
BiopsyService.Treatmentand/orreferraldecisionsarebasedontheclinical
presentationandpathologyresults.
5Guideline for the Early Detection of Oral Cancer in British Columbia 2008
LeVeL of eVidenCe
Thereisamplescientificevidencetoshowthepotential
benefitsoforalcancerscreening.Visualinspectionissimple
andrisk-free,andcanidentifyoralpremalignantlesions
andearly-stagecancers.Theadditionofmethodssuchas
toluidinebluestaining,directfluorescencevisualization,
andawiderangeofdevelopingprocedures,addsto
thatpotential.
Thestandardofscientificevidencerequiredtoprove
thatscreeningisbeneficialtothepatientisextremely
demanding.Theidealistohaveevidencefromaprospective
randomizedtrialtoshowthatsubjectswhoareoffered
screeninghaveareductionindeaths,ascomparedto
comparisonsubjectsnotofferedscreening.Astudyto
showthisneedstobeextremelylarge,withlongfollow-
up.Screeningforbreastcancerbymammographyandfor
colorectalcancerbyfaecaloccultbloodtestingaretheonly
cancerscreeningproceduresforthegeneralpopulation
supportedbythisidealbestevidence.
Oralcancerisalessfrequentproblemthanbreastor
colorectalcancerindevelopedcountries,andnosuchlarge-
scaleprospectivestudieshavebeendone.Astudystarted
nowtoassesstheuseofthenewertechnologiesinoral
cancerscreeningwouldtakemanyyearstoproduce
mortalityresults.
However,evidenceofbenefitmayalsobeobtainedbythe
demonstrationthat,withscreening,cancerisdetectedatan
earlierstagewithbetterclinicalresults,orfromobservational
studiescomparingscreenedandunscreenedsubjectsor
populations.Themostlong-establishedcancerscreening
program,forcervicalcancerbyPapsmears,isnotsupported
byrandomizedtrials,butissupportedbyconsistentevidence
fromtheseweakertypesofstudydesign.
Fororalcancerscreening,thereisinfactrandomizedtrial
evidenceofbenefit,butinadifferentenvironment.An
ambitiousrandomizedtrialofvisualscreeningfororal
cancerinIndiainvolvedmorethan95,000peoplebeing
offeredoralvisualinspectionbycommunityhealthworkers,
withasimilarnumberofpeoplenotofferedscreening,and
upto12yearsmonitoringofmortalityresults.Asmightbe
expected,clinicalfollow-upwasnoteasy:only63percent
ofpeoplefoundwithlesionshadtherecommendedfurther
assessment.Despitethis,comparedtothecontrolgroup,
deathsfromoralcancerwerereducedby21percentinthe
groupofferedscreening,whichwasnotstatisticallysignificant,
butinusersoftobaccooralcoholthereductionwas34
percent,whichwasstatisticallysignificant.10
Nosuchextensivetrialsoforalcancerscreeningin
developedcountrieshavebeenperformed.Anextensive
review11includesseveralstudiesofvisualinspection,not
assessingmortalityreduction,butassessingacceptance
ofscreening,yieldofabnormalities,shifttowardsearlier
stagecancers,andsurvivaldataforthepatientswith
cancerdetected.Thisreviewconcludedthatwhilethere
wasnostrongdirectevidenceofbenefit,onthebasisof
theavailabledataintheUnitedKingdomcontext,high-
riskopportunisticscreeningbyageneraldentalmedical
practitionermightbecost-effective.11
Theclinicalrecommendationspresentedherefordental
practiceinCanadaaddressopportunisticscreening,that
is,screeninginthecontextofaclinicalassessmentlinked
toroutinecare,andgiveinformationaboutsubjectswho
maybeathigherrisk.Weacceptthatthereisnodefinitive
scientificevidenceofultimatebenefitoforalcancer
screeningdirectlyrelevanttotheCanadiancontext,asno
suchstudyhasbeendone,buttheresultsoftheIndian
trialandothersourcesofevidenceareencouraging.We
encouragedentiststotakepartinfurtherresearchand
evaluationstudieswheretheyhavetheopportunity.
Therecommendationthatoralcancerscreeningshouldbe
offeredinthecontextofroutinedentalcareisjustified
bythesimplicityoftheprocedureandtheminimalrisks
involved,comparedtothepotentialbenefits.
6 ClinicalPracticeGuidelinesMarch2008
selected References
1. Canadian Cancer Society, National Cancer Institute of
Canada. Canadian Cancer Statistics 2007. pp 1-112. 2007.
Toronto, Canadian Cancer Society.
2. Laronde DM, Hislop TG, Elwood JM, Rosin MP. Oral
cancer: Just the facts. Journal of the Canadian Dental
Association 2008; 74(3). In press.
3. Poh CF, Williams PM, Zhang L, Rosin MP. Heads up! –
a call for dentists to screen for oral cancer. Journal of the
Canadian Dental Association 2006; 72(5):413-6.
4. Williams PM, Poh CF, Ng S, Hovan AJ. Evaluating a
suspicious oral mucosal lesion. Journal of the Canadian
Dental Association 2008; 74(3). In press.
5. Zhang L, Williams PM, Poh CF, Laronde DM, Epstein JB,
Durham JS, and others. Toluidine blue staining identifies
high-risk primary oral premalignant lesions with poor
outcome. Cancer Research 2005; 65(17):8017-21.
6. Lane PM, Gilhuly T, Whitehead PD, Zeng H, Poh CF, Ng
S and others. Simple device for the direct visualization of
oral-cavity tissue fluorescence. Journal of Biomedical Optics
2006; 11(2):024006.
7. Poh CF, Ng SP, Williams PM, Zhang L, Laronde DM, Lane
P and others. Direct fluorescence visualization of clinically
occult high-risk oral premalignant disease using a simple
hand-held device. Head and Neck 2007; 29(1): 71-76.
8. Poh CF, Zhang L, Anderson DW, Durham JS, Williams PM,
Priddy RW and others. Fluorescence visualization detection
of field alterations in tumor margins of oral cancer patients.
Clinical Cancer Research 2006; 12(22):6716-6722.
9. Poh CF, Ng S, Berean K, Williams PM, Rosin MP, Zhang L.
Biopsy and histopathalogic diagnosis of oral premalignant
lesions. Journal of the Canadian Dental Association 2008;
74(3). In press.
10. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R,
Thara S, Mathew B and others. Effect of screening on oral
cancer mortality in Kerala, India: a cluster-randomised
controlled trial. The Lancet 2005; 365(9475):1927-1933.
11. Speight PM, Palmer S, Moles DR, Downer MC, Smith DH,
Henriksson M and others. The cost-effectiveness of screening
for oral cancer in primary care. Health Technology Assessment
2006; 10(14).
Glossary of terms
erythema: Rednessoftheoralmucosathatsuggests
epithelialinflammation,thinnessandirregularity.
erythroplakia:Awell-definedred,velvetyorgranularlesion
oftheoralmucosa.
Homogenous:Adescriptivetermforamucosallesionthat
isuniforminappearance.
indurated:Anabnormallyfirmorhardportionoftissue
withrespecttothesurroundingsimilartissue.Atermoften
usedtodescribethefeeloflocallyinvasivemalignanttissue
onpalpation.
Leukoplakia:Awhitepatchthatcannotberubbedoffand
cannotbecharacterizedclinicallyorhistologicallyasany
otherlesion.
nodular:Adescriptivetermreferringtoagranular
surfacetexture.
speckled:Amucosallesionthathasredandwhite
componentstoit.
ulceration:Theresultoflossofepithelialintegrityinvolving
alllayersofepitheliumwithresultantexposureofthe
underlyingconnectivetissue.
Verrucous:Adescriptivetermreferringtoanirregular
mucosalsurfaceconsistingofnumerouselongatedor
“wart-like”whitesurfaceprojections.
7Guideline for the Early Detection of Oral Cancer in British Columbia 2008
the early detection of oral Cancer working Group
Membershipdr. Michele williams Co-Chair,OralMedicineLeader,BC Cancer Agency
dr. Mark elwood Epidemiologist,CommunityMedicine;VicePresident,Family&CommunityOncology,BC Cancer Agency
dr. Greg Hislop Epidemiologist,CommunityMedicine,BC Cancer Agency
dr. Calum MacAulay Physicist;Head,CancerImaging,BC Cancer Agency
dr. Catherine Poh OralPathologist,OutreachLeader,BC Cancer Agency
dr. Lewei Zhang OralPathologist;Head,DivisionofOralMedicine&Pathology,University of British Columbia
dr. Meredith Moores Community Dentist
Ms. denise Laronde DentalHygienist;PhDCandidate,Simon Fraser University
Ms. Heather MacKay Registrar,College of Dental Surgeons of BC
dr. Peter Lobb President,College of Dental Surgeons of BC
dr. Miriam Rosin Chair,TranslationalScientist;Director,BCOralCancerPreventionProgram,BC Cancer Agency
Acknowledgementsdr. simon sutcliffe President,BC Cancer Agency;Vice-Chair,Canadian Partnership Against Cancer
dr. Barry sheehan RadiationOncologist;Chair,HeadandNeckTumorGroup,BC Cancer Agency
dr. John Hay RadiationOncologist;HeadandNeckTumorGroup,BC Cancer Agency
Prof. Rick Gallagher Leader,CancerControlResearch,BC Cancer Agency
dr. stuart Peacock HealthEconomist;Director,HealthEconomics&CancerResearch,BC Cancer Agency
dr. Joan Bottorff Dean,FacultyofHealth&SocialDevelopment,University of British Columbia
dr. Allan Hovan ProvincialPracticeLeader,OralOncology,BC Cancer Agency
dr. Chris Zed AssociateDean,Strategic&ExternalAffairs,University of British Columbia; Head,DivisionofDentistry, Vancouver Hospital
dr. Andy Coldman VicePresident,PopulationOncology,BC Cancer Agency
dr. John o’Keefe Editor-in-Chief,JournaloftheCanadianDentalAssociation, Canadian Dental Association
Ms. Jocelyn Johnson ExecutiveDirector,BC Dental Association
Ms. nicole Adams Director of Communications, BC Cancer Agency
Ms. Margot white Director of Communications, College of Dental Surgeons of BC
Ms. Zarha Musa GraduateStudent,HealthCare&Epidemiology,University of British Columbia
Ms. Karissa Johnston GraduateStudent,HealthCare&Epidemiology,University of British Columbia
Participants of the oral Cancer Community screening initiatives
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Tel:604736-3621or800663-9169
Fax:604734-9448or866734-9448
Email:[email protected]
www.cdsbc.org
Clinical Practice Guidelines provide directions
for dentists and certified dental assistants in how to
meet the professional standards in specific situations.
They are developed by and for practitioners and are
designed to enhance, not replace, clinical judgement
and expertise. Guidelines describe best practices and
are not meant to be rigid or definitive in all situations.
For CDSBC, Clinical Practice Guidelines could contain
practice parameters which should be considered by all
dental practitioners in the care of their patients.
Regulatingdentistsandcertifieddentalassistantsinthepublicinterest.
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