Health News Review

All over the country in May, hospitals are offering “Free Throat Cancer Screening.” A Google search turned up dozens of results for that specific term or the related “oral, head and neck cancer screening.”

Here’s one example, promoting “Oral, Head and Neck Cancer Awareness Week, May 8-14.”

This promotion uses ominous warnings:

Can you live without your voice?

What about your jaw?

Would you miss it if you couldn’t swallow food?

Throat cancer can take all of those things away, along with your ability to eat, talk and breathe normally. These debilitating problems can be prevented, but you have to catch cancer early.

Some promotions – such as this one – use celebrity pitches such as “If it happened to Michael Douglas, it can happen to you.”

Here’s one that states, “A 10-minute, painless screening could save your life.”

But where’s the evidence for that?

The Memorial Sloan-Kettering Cancer Center in New York states on its website:

Currently, there are no screening methods that have been proven to increase survival rates for head and neck squamous cell carcinomas. A screening physical examination of the neck, oropharynx (the middle section of the throat that includes the soft palate, the base of the tongue, and the tonsils), and the mouth has been widely adopted as part of a routine dental examination. However, there is no evidence that this intervention reduces mortality from oral cancer. It is likely that in the coming decades this routine screening will allow earlier identification of oral cancer, when it is in a less advanced form, but this has yet to be proven in clinical studies.

There are no head and neck squamous cell carcinoma screening guidelines from the American Cancer Society, the National Comprehensive Cancer Network (NCCN), or the National Cancer Institute. And, at present, there are no known tests of blood or saliva proven to be effective for detection of head and neck squamous cell carcinomas.

In an email, American Cancer Society chief medical officer Dr. Otis Brawley wrote:

“We do not have any screening guideline on head and neck cancer screening. I am less concerned about simple visual and physical examination than say blood tests or x-ray screening tests in other diseases.”

But if you look at some of the web promotions of these screenings, you’ll see that most never mention what KIND of screening would be done. I think that’s important information for people to know. Brawley continued:

“I do think patients should not be given some false reassurance that a regular screening examination for head and neck cancer is known to save lives. There is no study that I am aware of to support that.

Rather than opportunistic screening, I would prefer that we encourage a head and neck exam be done when people go to the dentist and that we teach and encourage internists and family practice doctors to do it during routine physical examinations. Many MD’s are not comfortable with mouth pathology but are comfortable with palpation about the neck and throat.

We desperately do need to stress that people who notice a neck or throat mass get it evaluated and those who have a sore throat for more than a few days get is checked. This frequently does not happen and people frequently present with 8-month histories of a sore throat or change in voice.”

That sounds like reasonable advice.

We think these screening promotions would be better if they addressed:

• exactly what was going to be screened (there’s a lot of anatomy in the combined oral-throat-head-neck region) and how;

• is there any evidence that such screening saves lives?

• are there any American Cancer Society or US Preventive Services Task Force guidelines on such screening? (You just read Brawley’s answer. The USPSTF states that “the evidence is insufficient to recommend for or against routinely screening adults for oral cancer.”)

Readers of this blog know that we often comment on apparently well-intentioned but misleading or incomplete public messages about various screening tests.

It’s interesting that in a recent survey of users of our site, screening issues came up just twice – out of hundreds of responses.

One wrote: “tiring of the almost complete focus on screening.”

The other wrote: “I find the posts on ‘pre-disease’ and disease screening extremely important. I wish more people would pay attention to the issue of screening programs with no evidence to support a reduction in mortality.”

Comments

Brian Hill posted on May 1, 2011 at 2:41 pm

As a stage 4 survivor of an oral cancer, that had metastasized to my neck bilaterally when I finally noticed symptoms that took me to an ENT, who also dismissed my symptoms and put me on useless antibiotics, I think I can speak with some value to this.
I had a painless lesion clearly visible on my right tonsil when someone who knew what to look for finally did diagnose it. That lesion, the size of a dime, didn’t come up overnight. If a dentist, or any other person who was routinely in my mouth had been screening me, they would have found it much earlier in the disease process. I think that I certainly would have significantly reduced collateral treatment related morbidity if someone had been screening me for sure. I can’t swallow without aspirating liquids, I have carotid artery blockage from radiation induced scar tissue, I have xerostomia that is acute and causing oral issues, let alone QOL issues, I can’t move the right side of my face (radiation nerve damage), I could go on but you get the point. Don’t get me wrong, I am more than pleased to be on this side of the grass and live with compromises. But treatment was hell on earth and the prognosis poor causing my family and me significant emotional turmoil.
I think even a cursory glance at the SEER numbers shows without a doubt, stage one OSSC patients live more often and stage four patients die at greater rates. How do you get to be a stage one patient with a disease that is insidiously asymptomatic to the patient? A professional that knows the signs and symptoms, screens you opportunistically. Unfortunately in oral cancer that happens far too infrequently. Most patients are found as late stage 3 and 4 killer diseases 2/3rds of the time, not at early stages. They have symptoms and lesions that my gardener could tell you is cancer. That isn’t because the precancerous lesions or symptoms are hard to see or find, it is because historically, NO ONE WAS LOOKING. That no one has spent the time and significant money to prove the obvious in a peer reviewed published paper is no surprise, IT IS SELF EVIDENT in the SEER database and elsewhere. Ask any head and neck oncologist that is up to his elbows in someone’s blood everyday trying to save them. I will take their opinion over a bureaucrat any day.
I’m not suggesting that everyone get some invasive screening procedure for this disease. But a simple visual and tactile screening, combined with a proper patient history looking for risk factors can accomplish much. It is quick, painless, and inexpensive if costing anything at all, when you are already at the dental practitioners office. Too bad that most general MD’s know so little about it that the wouldn’t recognize a dangerous oral condition if their life depended on it, and the amount of training they get for it in their education is pathetically little. So for now we can’t look to general medicine to help us.
What turned oral cancer’s sister disease (cervical SCC) around from a major killer in the US, to one that is now very low in death rates? Opportunistic screening annually. (There are other examples but this one is really obvious.) The disease was being finally being found as precancerous dysplasia, and very early stage disease, and the death rate in the 1950′s dropped dramatically when women bought into and got annual cervical screenings. No new “cure” no new pharma solution, SCREENING. The same opportunity exists for oral cancers, which is most often the same cancer (SCC) which often produces the very same precancerous and early lesions to be found in the mouth that are found on the cervix. Of course that would only be effective if anyone were looking, which only started happening recently when a push by a small disease specific oral cancer non-profit started making noise about the opportunity.
We have treatments for oral cancers that work and are getting better. Radiation now as IMRT which spares some of the anatomical sites that cause quality of life issues, is highly successful when combined with long established chemo regimes. Surgery for early stage disease is highly effective, but too often is a salvage tool when late stage disease is discovered. We even have had successes with new monoclonal antibodies that are interrupting cellular functions like EGFR being used. The issue with all this is they are lifesavers WHEN EARLY STAGE DISEASE IS BEING TREATED. And you can’t get there without screening. There is an opportunity to reduce the death rate from 47% at five years, by just finding the disease earlier. Are there obstacles to this? You bet. Thinking like this that is being expressed in this article. Public awareness that the disease even exists is low, professional (dental in particular) involvement in early discovery is almost absent. And don’t try and sell the public that professional involvement is low because early discovery isn’t an effective tool or the early stages hard to find – that just isn’t true. It is more about lack of education, and profit motive than you might think. If a dental professional finds something suspect, in a simple 5 minute visual and tactile exam an oral cancer, does he get a billable procedure out of it? NO. It gets farmed out to medicine. For a group of professionals that are independent businessmen as much as doctors, this is an unfortunate component of the issue. A NIH/NIDCR peer reviewed article years ago (Horowitz et. al.) clearly showed that the dental community was disengaged and poorly educated in the subject. In 2012 all dental schools will have to have early detection/screening for oral cancer as a mandatory curriculum component. Are they dong this because it is not effective?
The part that states from MSKCC web site that the dental community has widely accepted screening as part of their responsibilities, and that they actually do it, is highly inaccurate. They are only recently being pushed into the oral cancer world, and not that many (in spite of what the ADA thinks their members are doing) actually are engaged in opportunistic screening. There are papers from NIDCR that document this. Too many think the high risk group are still older men who used tobacco most of their lives, and only taking a look at them. Unfortunately, that is not the fastest growing segment of the OC population, young non smokers with HPV16 etiology are, but most dentists are not keeping up with this new emerging independent risk group, nor screening 20 and 30 somethings for oral cancer, that get it from a sexually transmitted virus. Positive change is taking place in dentistry, but it is far too soon to determine with so recent a move, on a small part of the dental community’s part, whether or not they will fully embrace it the way GYN’s did for cervical, if they will be doing really informed screenings, or a decade or more from now if they make a difference. So I think it is unfair to use a quote that has no basis in actual reality, but is an unsubstantiated opinion to make your point, though I personally wish it were true that dentistry were that engaged.
Then there is ACS. An organization that for decades completely ignored oral cancer (and other small incidence cancers). I have an opinion why, but it might be construed as an inappropriate attack on them, so I will leave it out. But suffice it to say an opinion from an organization that has not helped the oral cancer paradigm in any significant way is of little interest to me and as a source of meaningful information, it is of limited value.
If you wish to really look at this issue I would have dug deeper. I would have asked some questions as to why there is no data that early discovery in these cancers doesn’t exist. Most of the articles that state a lack of evidence of efficacy for OC screening also state clearly that there were not a lot of published studies to draw from. They then make the leap to – It must not be effective. Bias abounds. PUBLISHED evidence based data is certainly thin, though a landmark study in Lancet a few years ago with 10 years of data and 170,000 participants showed OC screening highly effective. Doesn’t Lancet rank as one of the high standard peer reviewed journals? That efficacy of OC screening has not been published heavily does not mean that your position is correct. It means that no one has, in this environment of cutbacks in funding, and harsh competition for money to do any kind of research, wanted to spend the money on something that the SEER numbers and the clinical treating doctors at any major CCC will tell you is self evident. (Let alone for a disease that unlike the big cancers only impact about 37k people in the US every year.) Early staging equals survival. That you have a disease that is largely asymptomatic to the layperson in early stages, means that you have to have a professional looking for it to get an early find. Screening through a non-invasive means, is a component of better survival rates and reduction in treatment related morbidity.

Gary Schwitzer posted on May 2, 2011 at 11:02 am

Brian,
Thanks for your note.
Please allow me to remind you and our readers of something – and to clarify, if necessary:
There is nothing in the original post that states that people shouldn’t choose to be screened. Not a word.
We put this into the context of “apparently well-intentioned but misleading or incomplete public messages about various screening tests.”
In fact, the piece ends with some suggestions of how the promotions could have been improved. So the post didn’t even call for an end to such promotion. It just offered constructive suggestions about how to improve them.

Brian Hill posted on May 2, 2011 at 12:28 pm

Thank you for your reply and posting my rather long comment. We are the organization that put on the annual oral cancer awareness events in April (approximately 2,000 sites and events in one month nationally) and not the head and neck cancer organization (H&N cancers are in actuality 85% oral cancers) ones you are referring to in May though your links.
The Oral Cancer Foundation like many cancer non-profits walks a line between doing something that will actually bring the death rate down, and not doing things which alarm people, or subject them to unnecessary or invasive procedures. The first problem that we have in a world of lots of things that will bite you including numerous other cancers, is to get the public’s attention. This is a PR issue and not a medical one. OCF’s trademark headline has historically been “Is a killer hiding right under your nose”? It creates enough curiosity for someone to read further, and we speak to the issue of lack of symptoms that a layperson might recognize, and the need for a professional screening. If we can’t get their attention through a headline, the message may get passed by. So at some level I get why this other organization has done it the way they have, but I agree with you that anything that creates worry (rather than awareness) or sensationalizes the situation, is not the best path to raising the public awareness that is needed. I also freely admit that no screening test, be it the simple visual and tactile one we recommend once a year, or a CT scan, is 100% effective. I won’t bore you with the details of positive and negative predictive value, but we believe that the vast majority of what we are concerned with can be found at early stages through this non invasive methodology. Oral cancer screening of all the things that you get screened for has to be the least invasive, and most inexpensive one out there. You don’t even have to take your clothes off.
But I just wanted to state clearly that the absence of the evidence of benefit, which your article did address, is not equal to lack of benefit. It is scientifically equal to the lack of evidence.
OCF runs the world’s largest oral cancer support group with over 7500 members. It is open for anyone to read on our website. One of the dominant issues that you will find in reading it, is the high percentage of people there who didn’t know something was going south until it was too late, or who were misdiagnosed (or not diagnosed at all) by someone in general medicine, (think Michael Douglas here) and consequently because of a lack of professional involvement or knowledge, they were a late stage, lower chance of survival, patient. This equals a national death rate that, as a percentage, kills at higher rates than cancers you hear about every day. One person in the US dies of oral cancer every hour of the day, 24/7/365. It is not that treatments do not work. It is about this issue of late diagnosis. We have to turn that late diagnosis issue around in some manner.
The most likely group to do that are the people that we have in our mouths as a matter of routine -dentists and hygienists through the process of the early discovery of suspect/abnormal (undiagnosed) tissues, that they then refer further up the food chain for biopsy and gold standard diagnosis.
I thank you for your generosity in giving me a forum to talk about this, and if anyone wants to know more about the disease, the risk factors, the early signs and symptoms, I ask them to visit our 25 million hit per month web site at http://www.oralcancer.org. OCF was chosen the best small cancer non-profit in the US recently by a fine NP rating service GreatNonProfits. I would like to take credit for that, but in actuality it is the fine board of distinguished doctors that keep us focused on what the science says, and working within those confines.