37
Volume2 Issue6
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S
upporting
Y
our
P
ractice
A significant change inOSCCandOPC
incidence isoccurringbecauseof adecrease
in thenumber of cases associatedwith
tobacco,whilehumanpapillomavirus (HPV)
is increasing thenumber of newcancers. Up
to20%of newcasesofOSCCandup to85%
of newcasesofOPCareassociatedwithHPV.
1,2
Theetiopathogenesisof squamous cell
carcinoma is important asHPV-associated
OSCCandOPChavehigher cure rates than
OSCCandOPCassociatedwith tobacco
andalcohol risk factors.
3
Unfortunately,
approximately2/3of lesions are identified
at anadvanced stage, thus affecting
treatment options, requiringmorecomplex
therapyand increasing themorbidityof
treatment andcost of care. Theexpectation
thatmanagement ofOPMDandearly-
stage squamous cell carcinomawill lead to
improvedoutcomeshas led to thegoal of
increasingefforts towardearlydetection.
AlthoughmostOSCCcases areexpected
tobeprecededbyOPMD, it isnot known
whetherOPCarises frompotentially
detectableprecursor lesions.
PublicHealthScreening
Theprevalenceof disease inapopulation
plays an important role inassessing theutility
of screening. Inuncommonconditions, such
asOPMDandOSCC, provingutilitypresents
achallenge. Indeed falsepositive resultsmay
addaburden to thepatient and thehealth
care system. Inoral screening, distinguishing
common inflammatory lesions fromOPMD
andOSCChasbeena keyconcernwith
current adjunctivemodalities. Other key
considerations include themethods available
for screening, thepotential riskof testing, the
cost of the test, theutilityof the results and
theconsequencesof falsepositiveand false
negativeoutcomes (
Table1).
Tounderstandoral cancer screening
better, it is instructive to review screening
for other diseases, suchasbreast, cervical,
prostate, colon, skinand lungcancer. Other
commonconditions, suchashypertension,
alsoprovideguidance. Hypertension is a
commoncondition,with knownhigh-risk
populations; screening isnon-invasive, rapid
and lowcost and, thus, recommended. In
oncology, however, dysplasticandeven
cancer cellsmay resolveand, becauseof
this, cervical Papanicolaou tests arenownot
recommended forwomenyounger than
21years.Wedonot havedataon remission
ofOPMD, OSCCandOPC. Computed
tomography scans for lungcancer havebeen
shown
4
tobeof value in screeninghigh-risk
patients (e.g., heavy tobaccousers) aged55–
74years, but arenot recommended for others
becauseof thehighcost of testing, radiation
exposureand theneed for follow-up testing
(e.g., lungbiopsy),which incurs additional
costs and risk. Controversy regardingprostate-
specificantigen testingandmammography
continues, and, hence, guidelines are reviewed
onanongoingbasis asnew information
becomes available. Theseexamples illustrate
someof the issues surrounding screening for
disease thatmust beconsidered in thecaseof
OPMD, OSCCandOPC.
Screening forOralPotentiallyMalignantEpithelialLesionsand
SquamousCellCarcinoma:
ADiscussionofBenefitandRisk
From an individual’s point of view, early diagnosis is amust; however, from the
public health view, it is ameasure of probability. These perspectives are often at
odds. Although screening for early detection of disease has been promoted formany
years, recently the practice has beenunder increasing scrutiny formany conditions.
This paper reviews the issues surrounding screening for oral potentiallymalignant
disorders (OPMD), oral squamous cell carcinoma (OSCC) and oropharyngeal
carcinoma (OPC).
JoelB.Epstein
DMD,MSD,FRCD(C),
FDSRCSE
Dr. Epstein is a consult-
ant in the division of
otolaryngology and
headandneck surgery
at theCity ofHope,
Duarte,California,
he is a collaborative
member of the Samuel
OschinComprehensive
Cancer Institute at
Cedars-SinaiMedical
Center inLosAngeles,
California, andhe
maintains a private
practice in oralmedi-
cine inVancouver.
Theauthorhasnodeclared
financial interests.
Thisarticlehasbeenpeer
reviewed.
