Detecting oral cancers and improving outcomes through collaboration in primary care

In support of Mouth Cancer Action Month, Gavin Wilson, Clinical Fellow in Dentistry, blogs about collaboration in primary care and improving outcomes for oral cancer patients. This blog has been co-produced in partnership with the National Clinical Advisors for Oral Health and General Practice at CQC.

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Oral cancer is the sixth most common cancer worldwide and November is Mouth Cancer Action Month. Primary care dentists and GPs both have roles to play in diagnosing the disease, and collaboration between the professions can lead to better outcomes for patients.

It is key that all primary care practitioners are aware of the signs and symptoms to look for and know when and where to refer when necessary. Effective collaboration between all groups of practitioners will optimise care. For GPs, that means helping to give advice and information to patients and support them so that they can receive the appropriate dental assessment and necessary dental care before their radiotherapy. General dental practitioners (GDPs) should also communicate with and notify GPs when referring a patient through the suspected cancer pathway.

Approximately 8,300 cases of oral cancer are diagnosed each year in the UK (1 in 50 cancer diagnoses) with approximately 2,300 people dying from the disease. Around half of all oral cancers are at an advanced stage when they are diagnosed. Early diagnosis of oral cancer is important for many reasons:

1. Early diagnosis leads to better survival. A patient with an early cancer has a 90% chance of being cured. Patients who present late with advanced disease have less than a 25% chance of being cured.

2. Early diagnosis leads to a better quality of life. Patients who have early disease can often be treated with a simple operation to remove their cancer. Patients with more advanced disease often need more disfiguring surgery that has a much greater impact on their ability to speak and swallow. They are also more likely to need radiotherapy treatment that is associated with a lifelong decrease in quality of life.

3. Early diagnosis saves the NHS money. Treating a patient with advanced cancer is three times more expensive than treating a patient with early cancer.

Presentation

Oral cancer is not common, therefore most primary care dentists or GPs will not see cases regularly. Therefore, it is vital that doctors, dentists, nurses, therapists and hygienists maintain a high level of awareness for any new symptoms or lesions in a patient’s mouth. Providers should consider how they accommodate appropriate examination of the oral cavity in the context of COVID-19.

There are several signs and symptoms that are often associated with oral cancer to be aware of, including ulcers (present for three weeks or more and usually unilateral), white patches (leukoplakia), red patches (erythroplakia), speckled red and white patches (erythroleukoplakia), lumps on lip or in oral cavity (not typical of simple mucocele or polyps), lumps in the neck, and unexplained pain or bleeding.

Where does oral cancer occur?

Oral cancer can occur anywhere in the mouth, but there are a few areas where it is more common, including:

· Lateral tongue (the sides of the tongue)

· Ventral tongue (the under-surface of the tongue)

· The floor of the mouth.

· Retromolar region around the site of the lower wisdom teeth.

Risk factors

While oral cancer is twice as common in men than in women, it is important to remember that anyone can get oral cancer. Several risk factors are strongly associated with oral cancer:

· Smoking or chewing tobacco is associated with around a third of all cases of oral cancer and drinking alcohol is associated with around a quarter of cases. The risk for people who drink alcohol and also smoke is many times greater than for people who only smoke or only drink.

· Using betel nut, paan or betel quid is an important risk factor for oral cancer in the UK. It is common in parts of Asia, where it is responsible for making oral cancer the commonest form of cancer.

· Age, socio-economic deprivation and Human Papilloma Virus are all also risk factors.

Patient management following cancer treatment

Patients who have had radiotherapy to the head and neck are at high risk of a number of complications. The short and long-term sequelae of oral cancer treatment can have significant consequences for patients’ oral health. These patients may have dry mouth, oral mucositis, infection (oral thrush), pain, altered taste and increased caries rates.

There may be a need for GPs to prescribe, usually as advised by a member of the patient’s multidisciplinary team. Dentists can only prescribe, through the NHS, medications listed on the Dental Practitioners’ Formulary. Some patients may not have a relationship with a dental practice, and where appropriate, GPs should support their oral health by prescribing to support their treatment plan, including saliva substitutes, analgesics or pain relief, high fluoride toothpaste, mouthwash and nutritional supplements.

Key actions for primary care practitioners

GPs and dentists have played key roles in supporting the rest of the health and social care system during the pandemic. We have seen the hard work across both sectors to ensure people continue to receive the services they need, in a safe and effective way. That includes the impressive work done to quickly innovate and develop new models of care to meet people’s needs and keep them safe. This Mouth Cancer Action Month, there are some key actions that we ask you to bear in mind:

· Maintaining a high index of suspicion in any patient with unexplained mouth symptoms or lesions.

· Detecting and onward referral through the two-week suspected cancer pathway for those with a persistent unexplained neck lump or oral ulceration (present for more than three weeks).

· Detecting and urgent referral to a GDP (where one is available) for patients with a lump on the lip or in the oral cavity, or a red or white patch. If no GDP is available, you should make an urgent referral to secondary care.

· Referring to a GDP for dental assessment before starting oral cancer treatment.

· Giving smoking and alcohol cessation advice at every opportunity.

· Giving sexual health advice in relation to human papilloma virus (HPV).

· Encouraging regular checks and dental attendance in all patients with above-mentioned risk factors.

· Having clearly defined referral processes and improved communication, and facilitating better access to a general dental practitioner for patients with suspected oral cancer, including patients receiving residential care and those with barriers to access.

· Validating your referral by following up with the patient — ensuring they have been assessed and managed within the two-week timescale.

Thanks to A. McKechnie, University of Leeds, for his contributions.

Resources:

NICE Guideline 2015. Suspected Cancer: Recognition and Referral

BDA/CRUK Oral Cancer Recognition Toolkit

National Cancer Institute

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