Early Detection

Early Detection: Downstaging for Oral Cancer

Implementation requires several steps similar to cervical cancer:

A health education program to raise awareness of oral cancer, its links to tobacco use, and its curability when diagnosed early.
Users of tobacco are taught to examine their own mouths with a mirror and that of their friends in a "look a friend in the mouth" program to detect premalignant lesions.
Primary health care workers are trained to examine the mouth to identify premalignant lesions, and how to do case finding and to refer patients for diagnosis and treatment.
Again, a link is established between identification of an abnormality and a referral system for diagnosis, treatment and follow-up. The infrastructure for timely and effective surgical treatment must be accessible and in place. In most countries this maybe at regional or district hospitals.
An information system is needed to monitor and evaluate the program.

As with cervical cancer, so with oral cancer in that the natural history of the disease is long and determines the target age group where screening is likely to be the most cost-effective. With the onset of the tobacco habit at about age 12, one begins to see leukoplakia, erythroplakia and submucous fibrosis between ages 18 and 35 where less than 8% of cancers are found. Examination in this age range is unlikely to find many cancers. But carcinoma in situ begins about age 35 through to age 45, when invasive cancer is seen through to death at age 50. More than 92% of cancers are seen in the 35 to 45 year range where examinations will be the most cost-effective.

Similar indicators are used to monitor and evaluate oral downstaging programs (WHO,1995). For example:

Process Measures
More than 80% of those smoking and chewing tobacco are educated about oral cancer and how to examine their mouths.
More than 80% of primary health workers are educated and trained in visual examination of the oral cavity.

Impact Measures:
Over 80% of those smoking or chewing tobacco in the target 35-45 year group are examined at least once.

Outcome Measures
Short Term: More than one-third of oral cancers are discovered by examination
Medium Term There is more than a third reduction in cases presenting with advanced disease (stage II and beyond).
Long Term: There is more than a third reduction in the mortality of oral cancer.

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