Mouth cancer – What is it to Me and You?

All dental clinicians are expected to be able to recognise abnormalities or changes in the orofacial tissues that may suggest the presence of mouth cancer and, if present, arrange appropriate further assessment. In this respect, we all share the same duty to our patients, both in primary and secondary care, to undertake a regular and an effective soft tissue examination. Size matters with regard to mouth cancer since the single most important factor in improving the 5-year survival is detection of the tumour at less than 2 cm in diameter, before metastatic spread to the lymph nodes in the neck. A mucosal abnormality that is 2 cm in diameter is the equivalent size of one of your fingernails. Squamous cell carcinoma in the mouth is a surface event, representing epithelial growth that is out of control with invasion of underlying tissues. All dental professionals should be able to detect a change in the lining of the mouth that is the size of a fingernail, either visually or by palpation.

What is mouth cancer to me as a specialist in oral medicine? My daily work includes the management of individuals referred from dental or medical primary care with mucosal disorders affecting the mouth, including urgent suspected cancer (USC). Clear and informative communication is an essential aspect of the referral process. In this respect, I have been actively discouraging the use of the word ‘lesion’ not only in referrals, but also in the patient's clinical notes. The term ‘lesion’ derives from the Latin word, laesio, meaning injury or damage and, as such, in the clinical context is completely meaningless. I believe that it is essential to use descriptive words, such as red patch, ulcer or swelling, combined with other clinical findings.¹ As a generalisation, an abnormality of the orofacial tissues that is firm to palpation tends to represent neoplasia, while one that is not, is usually due to an inflammatory process (Figure 1). In addition, pain is associated with inflammation rather than malignancy. As such, when I am reading the information included in a referral, a sentence that includes, ‘a single persistent painless ulcer that is firm to palpation’ would raise more concern than, ‘multiple recurrent painful ulcers that are soft to touch.’ Use of descriptors, rather than ‘lesion’, is extremely helpful when vetting non-USC referrals as either urgent or routine. From personal experience, on occasions, the descriptive information provided in a routine referral may result in it being re-graded for an appointment at the dedicated USC clinic. Therefore, I urge you to drop the word ‘lesion’. The importance of this is demonstrated by the conversion rate of only 6% in USC clinics in the UK, which equates to six cases of mouth cancer being diagnosed per 100 USC referrals. We need to improve the quality of referrals.

During the 6 months prior to 23^rd March 2020, we received approximately 12 USC referrals per week. However, following the introduction of lockdown, the number of referrals per week gradually fell, and was zero by the week beginning 6th April 2020.² Although referrals are now increasing, there has undoubtedly been an adverse impact on patients who, owing to the delay, are now presenting with tumours at a more advanced stage that require more complex treatment and, ultimately, will have a poorer 5-year survival. A further impact of COVID, which will add additional delay to definitive surgical treatment, is the requirement for a 2-week period of self-isolation prior to admission to the hospital, which is now 72 hours prior to surgery, to ensure a negative result for coronavirus. Not only is this delaying treatment, but it has a significant psychological impact on the patient who is just accepting a diagnosis of cancer and substantial treatment.

In addition to detection of mouth cancer, all dental professionals should actively promote knowledge about mouth cancer, in particular the clinical signs and symptoms along with advice on the avoidance of recognized risk factors. The positive benefit of a brief intervention with regard to tobacco habits and alcohol consumption represents a great opportunity for dental primary care.

So, that is what mouth cancer means to me. How about you? Hopefully, if you are working in primary care, you will be engaged in a range of activity during the mouth cancer action month of November. At this time, you also need to reassure patients that a dental practice is a safe environment to visit and they should contact you if they have a concern.