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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