2_risk factors.ppt

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Module 2:

Risk Factors and

Prevention



Major Risk Factors for

Oral Cancer are:

Tobacco use

Alcohol use

Age over 40



Additional Risk Factors Linked

To Oral Cancer Include:

Exposure to UV radiation

Human Papilloma Virus (HPV)

Nutritional deficiencies

Oral lichen planus

Immuno-supression

Syphilis

Marijuana use

Chronic irritation

Chronic candidiasis



Tobacco UseThe risk of oral cancer increases with the

amount of tobacco used and the

duration of the habit. All tobacco types are associated with oral

cancer, for example:

-cigarettes -cigars -pipes

-quid -snuff -chew



Tobacco Risks

90% of patients with oral cancer use tobacco

Smokers have 6 times greater risk of developing

oral cancer than nonsmokers.

Tobacco users who regularly use alcohol are at

greatest risk



Tobacco and Cancer Recurrence

According to the ACS (2004):

37% of patients who smoke after a first oral

cancer will develop another in the

oropharyngeal area.

Chances are that only 6% of these patients will

develop another cancer if they stop smoking

Illinois Department of Public Health (IDPH) Toll

Free Tobacco Quit Line is 1-866-QUIT-YES or

1-800-784-8937



Statistics Of The Adult

Population Who Smoke

DO NOT0%

20%

40%

60%

80%

SMOKE

DISTRIBUTION OF THE ADULT

POPULATION BY GENDER

WOMEN

MEN

Men

Women

DISTRIBUTION OF ADULT

POPULATION

Do Not

77%

Smoke

23%

Smoke

Do Not

The percentage ofwomen who smoke hasincreased 300% in thelast 50 years.

Male to female ratio in 1950was 6 to 1; today the ratio is2 to 1.



Current* Cigarette Smoking Prevalence(%), by Gender and Race/Ethnicity, High

School Students, US, 1991-2001

*Smoked cigarettes on one or more of the 30 days preceding the survey.

Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, National Center for

Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2002.

28

35

31

13

16

3230

11

14

23

40

37

12

28

33

4040

17

32

36

28

34

39 38

22

32

18

33

2726

0

10

20

30

40

50

White, non-

Hispanic Female

White, non-

Hispanic Male

African

American, non-

Hispanic Female

African

American, non-

Hispanic Male

Hispanic Female Hispanic Male

P r e v a l e n c e

( % )

1991 1995 1997 1999 2001





Cigars Not A Safer Alternative

Cigar smoking has increased among young and middle-aged

white men (18-44) (higher than average incomes and

education.)

CDC reports cigar use among adolescents is higher than

smokeless tobacco.

Risk of laryngeal, oral or esophageal cancer is 4-10 times

higher than non smokers.

Cigar smokers who inhale deeply are 6 times more likely todie from oral cancer and 39 times more likely to die from

laryngeal cancer (ACS, 2004).



Alcohol And Oral Cancer 75 – 80% of all patients with oral cancer drink

alcohol frequently

Alcohol may act as a solvent and allow

carcinogens from tobacco to more easily enter

oral tissues

Alcohol produces acetaldehyde as a by-

product, which is an animal carcinogen (NIDCR,

2004)

A combination of both alcohol and

tobacco provides the greatest risk of

oral cancer.



Tobacco And Alcohol:

Deadly Combination

It is estimated that

tobacco smoking and

alcohol drinking

combined account for

approximately ¾ of all

oral and pharyngeal

cancers in the U.S.

(ACS, 2004)

http://www.google.com/imgres?imgurl=http://news.bbc.co.uk/olmedia/1705000/images/_1708257_young_drinking_smoking150.jpg&imgrefurl=http://news.bbc.co.uk/1/hi/health/1708257.stm&h=180&w=150&sz=13&tbnid=Dh086ih3fwQJ:&tbnh=96&tbnw=80&start=3&prev=/images%3Fq%3Dpeople%2Bdrinking%2Balcohol%2Bfiletype:jpg%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DG



Age And Oral Cancer

95% of oral cancers occur in individuals over age40, and the average age of diagnosis is in the 60s

Because 1/3 of the U.S. population is now over

age 45, oral cancer will be a significant problem inupcoming years

Changes in biochemical and biophysical

processing occur in aging cells

Chemicals, viruses, hormones, nutrients, and

physical irritants further affect aging cells, and may

contribute to the development of oral cancer

Silverman, 1999



Race And Genetics Link unclear

African-Americans have higher rates than other groups

Genetic factors may be at work

Differences in lifestyles and habits also have an impact

Differences in

access to care,

tendency to seek medical and dental care, and

education levels most likely contribute to higher ratesof later diagnosis of oral cancer (Silverman, 1999)

Mutation of the p53 gene under investigation (damage tocell’s DNA, growth and division)



Gender And Oral Cancer

Oral cancer occurs more than twice as often in

males

The ratio of male to female cases was 6:1 in1950; today is about 2:1

One reason for the reduced ratio is theenormous increase during the past 50 years in

females who smoke



Gender And Oral Cancer

The lifespan of women is

longer and may contribute

to the increase in oral

cancer among women

The number of women

over age 65 exceeds thatof men by nearly half

http://www.google.com/imgres?imgurl=http://www.delawaresecc.org/images/posters/1024x768/Elderly%2520Woman%25201024.jpg&imgrefurl=http://www.delawaresecc.org/heartfelt_images_thumbnails.htm&h=768&w=614&sz=87&tbnid=bcGb6bXNmDYJ:&tbnh=140&tbnw=112&start=2&prev=/images%3Fq%3Delderly%2Bwoman%2Bfiletype:jpg%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DG



Ultraviolet Light

& Lip Cancer UV exposure contributes to lip cancer

Fair skinned individuals at higher risk

30% of lip cancers occur in those with prolonged exposure

to sunlight

Lip cancer decreasing due to lip balm w/ sun screen

Lip cancer is also seen in pipe smokers at the site where the

pipe stem is held

Lip cancers readily seen

More likely to be diagnosed at earlier, treatable stage

http://www.google.com/imgres?imgurl=http://www.medicinechest.co.uk/images/sun_mansun.jpg&imgrefurl=http://www.medicinechest.co.uk/editorials/the_sun3.htm&h=221&w=150&sz=6&tbnid=uh-ANy82zA0J:&tbnh=101&tbnw=69&start=43&prev=/images%3Fq%3Dsun%2Bexposure%2Bfiletype:jpg%26start%3D40%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DN



Diet And Oral Cancer

Nutritional deficiencies implicated as riskfactor

Diet low in fruits & vegetables implicated in

cancers of mouth, larynx, and esophagus

Diet low in vitamin A has been linked to oralcancer in some studies

Iron deficiency associated with Plummer-

Vinson syndrome causes an elevated risk forsquamous cell carcinoma of the esophagus,

oropharynx and posterior mouth (Regezi &

Scuiba, 1999).

http://www.google.com/imgres?imgurl=http://www.stopfloridatorture.com/piecesofmyheart/F-FRUITS%2520AND%2520VEGETABLES.jpg&imgrefurl=http://www.stopfloridatorture.com/piecesofmyheart/&h=677&w=470&sz=80&tbnid=m61t8Ps6Pg4J:&tbnh=136&tbnw=95&start=5&prev=/images%3Fq%3Dfruits%2Band%2Bvegetables%2Bfiletype:jpg%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DG



Viruses

Human papilloma virus (HPV) and herpes simplex(HSV) may play a role in oral cancer development

2/3rds of oral cancers have HPV DNA in their cells

DNA from Epstein-Barr, cytomegalovirus, herpes

simplex, and HVP detected in oral cancer

biopsies (NIDCR, 2004)

Viruses contribute to the oral cancer

transformation in the presence of other

contributing factors



Oral Lichen Planus

Wickham striae, or interconnecting white lines,

are common in reticular lichen planus.

Lesions are usually on the buccal mucosa, butthe tongue and gingiva may also be affected.

Lesions may be erosive with

pseudomembrane-covered ulcerations and

erythema.



Oral Lichen Planus

Findings from various studies indicate a riskof malignancy, particularly in the

erythematous areas of the erosive form.

Lichen planus is not presently classified as

precancerous, but further definitive studies

may prove otherwise.

A close examination of Lichen planus lesions

in patients with the disease is prudent.



Immunosupression

Persons with AIDS and those undergoing

immuno-supression for organ or bone marrow

transplantation may be at increased risk for

various oral, head, and neck malignancies

(Neville, et al. 1995)

AIDS patients usually develop Kaposi sarcoma

and lymphoma, rather than squamous cell

carcinoma (Sapp, Eversole, and Wysocki, 1997)



Chronic Irritation

Irritation may be caused by ill-fittingdentures and broken teeth or fillings

Chronic irritation does not initiate oralcancer, but it is possible it may hastensits progress

The debate as to chronic irritation as arisk factor is ongoing



Candidiasis Chronic candidiasis has been implicated as a riskfactor in oral cancer.

Certain strains of Candida Albicans produce

nitrosomines, which are carcinogenic.

Definitive studies have not proven candidiasis

infection to be a causative agent, but it may have the

potential to promote the development of oral cancer.

Candidiasis may be superimposed upon a preexisting

leukoplakia.



Relationship Between Cell Events and

Lesion Appearance

DNA

AdductsSmoking Environmental

Factors

Virus DietDNA Damage

Oral Leukoplakia [White Lesions]

Erythrop lakia [Red Lesions]

Premalignant

Oral Carcinoma Malignant

DNA Repair

DNA Content

Cell Growth

Apoptosis



State of Prevention Science

•Discontinue smoking and alcohol consumption

(health professional/patient)

•Head and neck examination (health professional)

•Medical history (health professional)

• Improve diet: fruits and vegetables (health

professional/patient)



Other Factors that Play a Role in

Prevention:

• Genetics

• Oral health

• Sexually transmitted infections



Discontinuing Smoking and

Alcohol Consumption

•Tobacco Control-

•counseling

•behavior modification

(dentist/patient/specialist)

•Referral to other health practitioners-

•Oral Medicine

•Oral Maxillofacial Pathology

•Diet-

•Nutritional counseling



Oral Cancer Examinations

Obtain annual oral cancer examinations

after age 40

Ask medical and dental providers for an

annual examination



Tobacco

Tobacco cessation should be

recommended to all patients who use

tobacco products.

The accompanying Tobacco Control

Program will provide you with tobacco

cessation techniques to use with your

patients.





Alcohol

People who drink alcohol and don’t use tobacco

are at a greater risk for oral cancer, but the

combination of the two is most deadly.

Most oral cancers could be prevented if peoplequit using tobacco in any form and quit heavy

drinking.

Quitting tobacco and limiting alcohol use sharply

reduces any risk of oral cancer, even after many

years of use.



Nutrition

Consume a diet high in fiber

Consume enough folic acid, vitamins and

minerals

Eat at least five servings of fruits and

vegetables daily

Provide nutritional supplements for

individuals unable to intake adequate

quantities of food









Alternative Cancer Treatments for Oral

Cancer Prevention and Treatment

Retinoids have been used

to:

•Prevent premalignantoral lesions

•Reduce the growth of

established oral

carcinoma

•Reduce formation of

second primary oral

cancer



•Vitamin E has been shown to:

-prevent oral premalignant lesions

-enhance the anti-oral tumor capacity of

chemotherapy and other agents

-block the cancer formation activity of

tobacco carcinogens

•Vitamin E and PAH both form complexeswhich modify Phase I and II enzyme genes

expression and expression of endocrine

factors

DNA Damage

Decreased

DNA Repair Increased

then Decreased

DNA Content

Decreased

Apoptosis

Increased

Fewer Smaller

Oral Tumors



Green Tea Effect on Smokers

Compared to Non-Smokers

Molecular and cellular effects of green

tea on oral cells from smokers: A pilot

study.Schwartz JL, Vikki B, Larios E, and

Chung FL.

Molecular Nutrition and Food Research. In Press, 2004.



Background For Green Tea Study

•80 articles published showing green tea offers

protection against tumorigenesis including initiation,promotion and progression (skin, lung, liver, mammary,colon).

•Green tea contains-antioxidant, ”polyphenolics” (e.g.,epigallocatechin gallate (EGCG)).

•Studies in animals and cells point to a mechanism that

involves p53 induction of apoptosis.

•Delivery of tea polyphenols through a drink, leaves or

extract has suggested possible delivery systems to

reduce risk for oral cancer formation



0

5

10

15

20

25

30

35

w eek 0 w eek 1 w eek 2 w eek 3 w eek 4

Weeks of Treatment

% o f

C e l l s

smoker 3

smoker 2

smoker 1

0

20

40

60

80

100

week

0

week

1

week

2

week

3

week

4

Weeks of Treatment

% o f

c e l l s smoker 1

smoker 2

smoker 3

B[a]P-N2-

dG

Adducts

8-OH-dG

Adducts

40



0

10

20

30

40

w e e k 0

w e e k 1

w e e k 2

w e e k 3

w e e k 4

w e e k 0

w e e k 1

w e e k 2

w e e k 3

w e e k 4

Weeks of Treatment

%

o f C e l l s

smoker1

smoker2

smokers3

Cyclin D1 Caspase-3

0

5

10

15

20

25

30

35

40

45

w e e k

0

w e e k

1

w e e k

2

w e e k

3

w e e k

4

w e e k

0

w e e k

1

w e e k

2

w e e k

3

w e e k

4

Weeks of Treatment

% o

f C e l l s

smoker1

smoker2

smokers3

p53 DNA

(aneuploid)

Content

Cell Cycle

and

Apoptosis

Markers

Tumor

Suppressor

DNA Content



Green Tea Study Summary

•Oral cytology in conjunction with

“chemoprevention” agents can be used to

monitor specific molecular events on acontinuous basis.

•Green tea polyphenols in some smokers can

reverse the effects of exposure to tobacco

smoke

(e.g., cell proliferation is slowed and

increased apoptosis is noted).



Limit Sun Exposure

To help prevent lip cancer :

- Use lip balm containing sun screen

- Use wide-brimmed hats

- Avoid outdoor activities in midday when

ultraviolet exposure is at its peak

R t Th Si



Report These Signs or

Symptoms to Doctor or Dentist: A sore or area in the mouth that does not heal

after 2 weeks

Persistent pain in the mouth

Persistent lump or thickening in the cheek

Sore throat or feeling that something is caught

in the throat

Difficulty chewing or swallowing

Difficulty moving the jaw or tongue

Voice changes



Additional Signs and Symptoms:

Numbness in the tongue or other mouth area

Swelling in the jaw that causes dentures to fit

poorly or become uncomfortable

Loosening of the teeth or pain around the teeth

or jaw

Lump or mass in the neck Weight loss (unexplained)

Persistent bad breath



Role for the Health Professional

•Screen patients at risk

•Provide dental care to improve response to

cancer treatment

•Treat oral complications

•Provide referral to other specialists



Prevention A Key Role for the

Health Professional

•Health professionals will use oral cells to

- Screen for an array of genetic and moleculardisorders

- Assess prevention of tobacco related cancers

by various agents- Evaluate environmental carcinogens



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2_risk factors.ppt