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References

Cancer Research UK. Cancer Research UK. Melanoma skin cancer statistics. (Accessed 27 August 2017)
Main B, Felstead A, Hughes C, Thomas S. A guide to skin cancer of the face for the dental team. Dent Update. 2014; 44:111-118
Steel BJ. Skin cancer – an overview for dentists. Br Dent J. 2014; 216:575-581
British Association of Dermatologists. (Accessed 27 August 2017)

Head and neck skin cancers and where to find them − A quality improvement project

From Volume 45, Issue 11, December 2018 | Pages 1057-1062

Authors

Neil V Shah

BDS(Bris), MFDS RCS(Ed)

Oral and Maxillofacial Surgery SHO, Prince Charles Hospital

Articles by Neil V Shah

Daniel Ashworth

FDS, FRCS(OMFS)

Consultant in Oral and Maxillofacial Surgery, Prince Charles Hospital

Articles by Daniel Ashworth

Nick Moran

BDS Wales, FDS RCS(Eng), FFD RCS(Ire)

Consultant Oral Surgeon, Prince Charles Hospital, Gurnos Road, Merthyr Tydfil, CF47 9DT

Articles by Nick Moran

Anjani Holmes

BDS(Hons) (Lond), MFDS RCS(Eng)

Specialty Doctor in Oral and Maxillofacial Surgery, Cwm Taf University Health Board, Wales, UK

Articles by Anjani Holmes

Abstract

Abstract: This article is a summary of a three-stage quality improvement project aimed to raise awareness and provide basic knowledge for the early identification and appropriate referral of suspicious skin lesions. The results of this project may indicate that not enough attention is given to these lesions in undergraduate teaching, thus indicating the requirement for change. This article aims to raise awareness of the increasing prevalence of skin cancers whilst providing information of the basic signs, symptoms and clinical features for clinicians to look out for during their examination and consultation.

CPD/Clinical Relevance: Dental surgeons are in a prime position to aid in the identification and referral of suspicious skin lesions due to exposure to the head and neck area on a regular basis.

Article

As reported by Cancer Research UK, there were an estimated 132,000 new cases of non-melanoma skin cancer and 15,400 new cases of melanoma skin cancer in the UK in 2014. The incident rates of melanomas have increased by 45% over the last decade, making it the fifth most common cancer in the UK.1 The first author's experience in the first few days working as a Maxillofacial SHO were a truly eye-opening experience into the world of skin cancers. Prior to this, the terms ‘Basal Cell Carcinoma’ and ‘Squamous Cell Carcinoma’ were words on a slide when learning about Head and Neck/Oral Cancer. It quickly became apparent that dentists are in a prime position to aid in the identification and referral of suspicious lesions on the head and neck due to the exposure to the area on a regular basis. These thoughts prompted further research and reading as to whether there had been any literature aimed at dentists to increase the awareness. The only relevant information which could be found in the Wiley Online Library were articles written by Main et al in 2014 and Steel in 2014, both of which provided an in depth insight into the epidemiology, clinical features and management of all types of skin cancers, as well as indicating to readers the main areas of incidence on the head and neck.2, 3 The development of this project primarily arose from the curiosity as to whether the awareness of skin cancer is being taught to undergraduates, or whether the exposure and knowledge of these conditions only occurs to those postgraduates who take a maxillofacial post.

Initial survey

Due to the lack of baseline research on dentists' knowledge of skin cancers, the project began as a survey with the aim to ascertain the current level of knowledge and recognition of skin cancers by dental graduates. As a pilot, it was realistic and achievable to target postgraduates in Wales owing to the ease of accessibility via study days and the scheme Training Programme Directors (TPDs). After reaching out to the various TPDs in Wales, who were running Foundation and Dental Core Training schemes, a total sample size of 97 postgraduates had been acquired. A two-sided A4 questionnaire was designed (Figure 1); the first side asked relevant questions and the second side had a range of six clinical photographs and a list of possible diagnoses which the participants could use multiple times or not at all. The paper questionnaires were posted to the TPDs along with pre-paid envelopes for their return on completion.

Figure 1. The pilot questionnaire designed to ascertain the base knowledge and recognition of skin cancers by dental graduates.

Results

A total of 87 questionnaires were returned; 47 Foundation Dentists (FDs), 21 Dental Core Trainees (DCTs) and 19 postgraduates on 2-year longitudinal schemes. This gave a response rate of 89.7% with all participants graduating between 2012 and 2016. For all the questionnaires returned, the results were analysed twice; postgraduate level (FD, DCT, 2-year longitudinal) (Figure 2) and university from which the dentist graduated. The conclusions of the pilot were as follows:

  • 55.3% of FDs have never seen a skin cancer, do not screen their patients for skin cancer and 85.1% have never referred a patient for a suspected skin cancer.
  • 57.1% of DCTs have seen a skin cancer, 95.2% screen their patients but 66.6% have never referred any for suspicious lesions.
  • 57.9% of postgraduates on the longitudinal schemes have seen skin cancer lesions but do not screen their patients for them and subsequently have never referred any suspicious lesions.
  • Although inconclusive, it would seem that all universities from which the postgraduates graduated did not include skin cancers as part of the undergraduate curriculum.
  • Twenty-four percent of FDs chose the correct picture diagnosis compared to 42% and 46.5% of DCTs and longitudinal postgraduates, respectively. This showed that postgraduates who had worked within a hospital environment after graduation scored higher with the picture diagnosis section than FDs, which is highlighted in Figure 2.
    • Figure 2. An example of the results tables created to analyse the responses of the first questionnaire. This figure shows the responses given by the three groups of postgraduates. 46.8% and 42.9% of FDs and DCTs thought this was a fibro-epithelial polyp, respectively. The responses to the correct answer, BCC, is shown by the bar in red.

    Discussion

    The response rate of 89.7% proved that targeting postgraduate dentists in Wales via their study days with paper questionnaires was a success. However, on reflection, the diagnosis list for the pictures was too specific and, it was agreed, more emphasis needed to be made on identifying sinister features, broad classification and appropriate referral. The results obtained provided a sufficient incentive for an intervention.

    Intervention

    Given the findings and points of discussion which arose from the service review, there was a desire to create an intervention which was simple and logical, similar to that of the British Association of Dermatologists (BAD) guidance which was aimed at the general public.4 The broad classifications and easy-to-digest information was attractive and became the cornerstone of our intervention which was in the form of a poster (Figure 3) and short informative video. This video can be found on YouTube at the following URL: https://www.youtube.com/watch?v=939jjLX9UJM or alternatively by searching ‘Head and Neck Skin Cancer Wales’ on YouTube and it is the first channel available with an account picture of the number 4. All participants were given a copy of the poster and TPDs were provided with a hyperlink to the video with the hope that it would be shown to the postgraduates at their next study day.

    Figure 3. The poster designed as part of the intervention based on information provided by the BAD.

    Audit of pilot study following intervention

    The third stage of this project was to ascertain the effect of the interventions mentioned above on the dental postgraduate level of knowledge of skin cancers. This was achieved by approaching the same sample of postgraduates from the pilot study with another questionnaire, allowing direct comparisons to be made. The questionnaires were designed in a similar format to the pilot questionnaires. However, contrary to the first study, the diagnosis list for the pictures was based on the BAD broad classification of lesions falling under ‘Melanoma’, ‘Non-melanoma’ or ‘Non-cancerous’ (Figure 4).

    Figure 4. The second questionnaire which was designed to assess the effectiveness of the intervention.

    Results

    A total of 75 questionnaires were returned; 47 Foundation Dentists (FDs), 13 Dental Core Trainees (DCTs) and 15 postgraduates on the longitudinal schemes. This gave a response rate of 77.3%, with all participants graduating between 2012 and 2016. The questionnaires were analysed in the same manner as for the initial cycle (Figures 5 and 6). The conclusions of the audit were as follows:

  • The overall compliance of viewing the informative video was poor, with 63.8% of FDs having not seen it.
  • Of participants, 96.3% read the poster and found the intervention useful, however, 55.3% of FDs were still not confident in assessing skin cancers.
  • An average of 72.9% of FDs, 86.5% of DCTs and 88.3% of postgraduates on the longitudinal schemes chose the correct diagnosis for the pictures, an example of which can be seen in Figures 5 and 6.
    • Figure 5. An example of the results tables created to analyse the responses of the second questionnaire by the three groups of postgraduates. 53.2% and 84.6% of FDs and DCTs correctly thought that this was a non-melanoma lesion, respectively.
    Figure 6. Another example of the impact of the intervention, shown here with the responses to a picture diagnosis question on the second questionnaire. 89.4% and 92.3% of FDs and DCTs, respectively, correctly identified this as a melanoma lesion.

    The conclusions from the audit appear to show a successful intervention.

    Discussion

    Although the intervention appeared to have been effective, 55.3% of FDs were still not confident in assessing suspicious skin lesions. Confidence will grow only if this intervention is repeated at regular intervals. The feedback from participants who either did not find the intervention useful or did not feel confident were all based around the requirement for more exposure to clinical cases and a greater number of clinical photographs to supplement the information provided.

    It became apparent that postgraduates who had hospital experience after graduating had a greater exposure to skin cancers and therefore felt more comfortable screening their patients. By altering the diagnoses to the broad classification outlined by the BAD, the hope is that clinicians will have an in depth knowledge of skin cancers and, accordingly, have the confidence to refer to secondary care. With this framework, the end goal will be for all dentists to feel confident in assessing skin lesions without the requirement to spend a year in a hospital placement.

    Recommendations

    Our goal is for the skill and knowledge to screen patients for head and neck skin cancers to be something that is taught to undergraduates in their early clinical years. It can easily be incorporated when teaching the steps to take for a thorough extra-oral exam, which will add around two minutes to the examination duration. If instilled at this early stage, then the hope will be for the skill to become second nature by the time the students graduate. Hopefully, this article can become the trigger to encourage universities to push this initiative to become a part of the core curriculum.

    Whilst the universities are being targeted, it is important to repeat this project every year with the aim to expand to all postgraduate schemes in England, Scotland and Northern Ireland and eventually all general dental practitioners. In order to achieve this goal, the authors have worked closely with the Welsh Deanery to develop an elearning module which will issue all users who successfully complete the module with a one hour verifiable eCPD certificate. It has been designed to incorporate the preliminary questions, ensure that the video is mandatory, includes an interactive section and, finally, a picture quiz which requires satisfactory completion. This module is in the final stages of development and will go live on the Welsh Deanery website in the next few months. In the meantime, the authors would encourage readers to take two minutes to watch the informative video and share it on social media. By raising awareness, dentists could have a key role to play in the early identification of cancerous lesions on the head and neck which will hopefully lead to favourable outcomes.

    Within our Trust a direct referral to dermatology is an existing and successful pathway. However, the key message and recommendation going forward from this project is to increase awareness and give dentists the confidence to refer any suspicious lesions. In some cases, this may be to a local dermatology unit, a maxillofacial department or, at the very least, the patient's general medical practitioner.