Oral Cavity Cancer. Oral Cavity. Disclosures. Screening Methods for Early Oral Cancer
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1 Screening Methods for Early Oral Cancer M. Boyd Gillespie, M.D., M.Sc. UCSF Head & Neck Cancer Course San Francisco, CA November 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 Oral Cavity Cancer Subsites Lips Buccal mucosa Upper and lower Gums/alveolus Floor of mouth Oral tongue Hard palate Retromolar trigone 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%) 1
2 Incidence Oral Cavity Cancer Classically males over 45 years old Male : Female ratio 6:1 in :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) Pathology Severe dysplasia CIS Invasive SCCA Oral Cavity Cancer Thickness <4mm have 11% risk of nodal metastasis >4mm have >25% risk of nodal metastasis SEER
3 Incidence of Oral vs OP Cancer in the US Oropharynx Oral Cavity HN Cancer Incidence US. CDC 3
4 Advanced oral cancer In SC. Areas of Highest Oral Cancer Mortality Warnakulasuriya S. Oral Oncology 2009; 45: Sx Rank Order Top Sx 2nd ASCO Oral/OP Mouth or lip sore Red or white patch Top Web Searchs Am Ca Soc Sore in mouth Pain in mouth 3rd Lump in HN Lump in cheek 4th Sore throat Red or white patch 5th Hoarseness Sore throat Neck Mass Sore Throat Cleveland Clinic NCI Wiki Sore throat Sore throat Sore throat Swallowing Pain behind breastbone Swallowing Weight Loss Cough Weight loss Voice change Trouble Swallowing Voice change Ear pain Weight loss Ear pain 3rd 12th 7th 7 th with mouth/ throat 4th 5th 1st 1 st 1st 7 th Oral Cavity Early Diagnosis T1 or T2 Visible lesion first symptom Requires trained eye <50% at presentation Solid cure rate (80% 2-year) Single modality Tissue Sparing 4
5 Oral Cavity Late Diagnosis Oral Cavity Ca Stage Related T3 or T4 > 50% of cases at presentation Low cure rate (50% 2-year) Multi-modality Non-tissue sparing 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? 5
6 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 developing world). Lack of expertise to diagnosis cancer in a given suspicious lesion. What to biopsy? How to biopsy? How to interpret pathology from biopsy? Challenge for the Expert. When to biopsy? Where to biopsy? 6
7 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 7
8 Oral Examination by Trained Provider Oral Examination by Trained Provider Toluidine Blue Advantages Readily available Inexpensive Retention in abnormal cells allows staining of non-visible areas. Disadvantages Requires biopsy Local anesthesia Accuracy 78% Vashisht N, et al. JCDR 2014; 8: ZC
9 Toluidine Blue Cytology Advantages 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 Accuracy 67% Cytology Light Wave Screening Methods Advantages Not invasive Screen large regions of tissue Disadvantages Expensive equipment Accuracy 89% 9
10 Laser-Induced Autofluorescence Diffuse Reflectance Spectroscopy Accuracy 96% Accuracy 97% Conclusions Spectroscopy (Least Studied) > Standard Cytologic techniques = Proprietary Cytologic techniques (OralCDx) >> Conventional Oral Exam (Expert) >> Vital Staining Conclusions Future Technological Advances in Oral Cancer Screening Smartphones Folding Microscope 10
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