Currently, head and neck cancers are most commonly diagnosed at an advanced stage of the disease, with approximately two-thirds of cases diagnosed at Stage III and IV. The goal of awareness is to increase the potential for stage regression with diagnosis at Stage I/II from Stage III/IV.
In addition to awareness of oral cancer and other malignant diseases that can present in the head and neck, changes in risk factors have changed the presentation of potential cancers.
For example, rates of oropharyngeal cancers have been increasing. The vast majority of these cancers are due to the human papilloma virus (HPV), making them sexually transmitted infections that can lead to cancer. HPV cancers have different etiology and response to current treatment.
Other cancers that can present in the head and neck include salivary gland cancers, thyroid cancer, lymphoma, leukemia, and metastatic disease from other sites.
Working with Patients
Dental workers have the opportunity and the need to obtain a full medical, dental, and social history of each patient. Symptoms associated with head and neck cancer can be minimal but may increase over time due to progression of the condition.
The medical history should include oral product use, tobacco use, alcohol use, and prior cancers. Current discussion also includes the importance of obtaining a sexual history.
Important symptoms may include a mass in the neck, which first may be found by the patient, that’s detectable during a head and neck examination; discomfort such as mild or moderate pain; a lesion in the mouth; a sore throat; difficulty swallowing; limited movement of the jaw or tongue; a change in speech; oral bleeding; and weight loss.
Lymph nodes in the head and neck should be assessed in all patients. Oral and throat lesions may be detected during a visual exam and/or upon palpation. Many oral cancers may have potentially detectable precursor lesions, but this is not common in the oropharynx. A thorough history and head, neck, and oral examination are critical.
Oral cancer awareness also provides the opportunity to discuss with patients behaviors that increase the risk of cancer such as tobacco use, alcohol abuse, and infection by HPV, as well as prevention, including immunization.
Obtaining an appropriate history and providing a head, neck, and oral examination during routine dental visits is described as “opportunistic” screening, but actually represents “case finding.” The challenge in screening (identifying disease in patients not seeking care for that condition) for rare or uncommon conditions is a challenge for all cancers, including oral and oropharyngeal.
Screening outcomes may be better in high-risk populations such as heavy tobacco and alcohol users and at clinics for mucosal disease with patients with prior upper aero-digestive tract cancers including oral cancers. In these settings, the screening of asymptomatic or minimally symptomatic cases may be more productive.
The Dentist’s Responsibility
Dental responsibility covers the entire cancer continuum from detection to diagnosis, as well as management of oral complications during and following cancer treatment where complications may continue for the life of the patient. These individuals are at higher risk since they have a risk of recurrent cancer and a higher risk of new cancers, and they must be more carefully evaluated at ongoing dental visits.
Furthermore, prior cancer therapy may lead to elevated risk of dental disease, and treatment options may be limited by prior cancer therapy. Therefore, cancer survivors have increased oral and dental needs and may have more complex conditions to manage. In these settings, knowledge to be able to institute prevention for oral and dental disease and for early detection of cancer or dental disease is important.
April provides opportunities to inform the public, patients, and professionals about the detection and prevention of head and neck cancers. Dentistry has had an exemplary public health record, so let’s continue it in oral, head, and neck cancer. Have a good month!
Joel B. Epstein, DMD, MSD, Diplomate American Board of Oral Medicine, is Professor, Department of Surgery, Cedars-Sinai Medical Center, and a Collaborative member of the Samuel Oschin Comprehnsive Cancer Institute at Cedars-Sinai. He is consulting staff in the Division of Otolaryngology and Head and Neck Surgery at the City of Hope National Medical Center. He maintains a referral oral medicine practice and is conducting a number of funded clinical studies in the practice. He has published extensively in the area of oncology, infectious disease, facial pain, and general areas of oral medicine, with more than 700 contributions to the literature. He also serves as editor and reviewer on a number of leading journals related to oral medicine and oral oncology. He can be reached at firstname.lastname@example.org.