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; 15(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

Suite500–1765West8thAve.

Vancouver,B.C.V6J5C6

Tel:604736-3621or800663-9169

Fax:604734-9448or866734-9448

Email:postmaster@cdsbc.org

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.

to Provide feedbackTheEarlyDetectionofOralCancerWorkingGroup

encouragesyourfeedback.Ifyouwishtoprovide

feedback, need further information or have

difficultyapplyingthisguideline,pleaseemailusat

guidelinefeedback@cdsbc.org orcontactususing

theinformationbelow.