Diagnosis of early oral and oropharyngeal squamous carcinoma: obstacles and their amelioration.

These comments and observations are based on 25 years of clinical practice in oncology, and prospective research studies of oropharyngeal squamous carcinoma in high-risk populations; the review of innumerable publications related to squamous carcinoma (most of which have usually been based on retrospective analysis of data or anecdotal information) and my observations, as a clinician and a patient, of the behavior, beliefs, and practice of dental and medical clinicians. Although the oral cavity and oropharynx are as easily accessible for visualization, as is skin, and the population at high risk (development of squamous cancers of these sites has been identi®ed in a multitude of studies in the USA and Western Europe), early diagnosis has not been forthcoming with the resultant lack of increase in 5-year survival rates when compared to cancers of other sites. It is with dismay I observe that over the last 20±30 years, early diagnosis and survival rates for cancers of the breast, colon, prostate and melanoma have increased considerably, due primarily to an increase in early detection. However, survival rates for cancers of the oral cavity and oropharynx have remained constant during this period at approximately 40±50% with a small decrease in the black population. Paradoxically, even though the mucosa of the colon is internal and requires endocscopic examination for evaluation, 36% of colon cancers (US) are localized when diagnosed, identical to the number of localized oral/ oropharyngeal (O/OP) cancers diagnosed. Most of the O/OP cancers at time of diagnosis are symptomatic late-stage disease with at least 50% revealing regional cervical metastases. Survival is poor. We have an overwhelming responsibility to ameliorate this situation. I believe there are two areas of concern that are greatly responsible for this de®ciency in diagnosis. The ®rst deals with the split professional responsibility attendant to this anatomical region. Dentists who are, supposedly, in the ®rst line of defense and are responsible for the early diagnosis of these cancers have a con icted position. Their training, education, and experience in dealing with cancer as a concept and in practical terms is somewhat limited. The emphasis in their education and practice is primarily related to restoration and amelioration of dental and hard tissue problems. Although at home in the oral cavity and much more capable of performing a soft tissue examination than their physician counterparts, they re exly respond to the restoration mode. My experience as a patient, clinician, teacher and casual observer con®rms that few generalists or specialists evaluate the high-risk sites of occurrence as part of the standard dental examination. Literature disseminated by major dental organizations, government, non-pro®t, dental schools, etc., list programs and lectures in a variety of dental spheres. Cancer infrequently is listed as a topic. The physician, on the other hand, although trained to be concerned with oncology, has minimal or no training in the oral cavity. Sections of O/OP cancer and examination of this anatomical region in medical texts are woefully inadequate. Related lectures for medical students and trainees are few. A physician using a tongue blade with a pen ashlight for illumination, requesting the patient to say ``ah'', cannot possibly highlight the minimal mucosal changes which signify early asymptomatic squamous cancer. Among medical practitioners