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Killing Us Softly

This year, oral cancer will strike nearly 50,000 Americans, half of whom  will die within five years. Its mortality rate has remained stubbornly high —  so why isn’t the disease higher on the public radar? And what steps can dentists take to help arrest the damage of this persistent scourge?

By Jerilyn Forsythe

WE’RE ALL FAMILIAR with the AIDS Memorial Quilt. Charity 5K runs to raise awareness of a panoply of diseases are as common as daffodils come springtime. In their efforts to draw attention to breast cancer (and accrue some positive PR besides), Major League Baseball and the National Football League periodically outfit their players in more pink than you’d find in an entire flotilla of Mary Kay Cadillacs.

Even by the variegated standards of cancer awareness, though, oral cancer gets short shrift. Pay a visit to StandUp2Cancer.org, home of the prominent national nonprofit, and you’ll need the search skills of Dr. David Livingstone to track down a section dedicated to oral cancer.

Everyone has experienced the way a routine canker sore can make the most quotidian activity fiendishly painful. Oral cancer — of which those seemingly innocuous cankers are sometimes a first sign — kills some 10,000 Americans a year. Where are its memorial bedspread, its Ad Council public-service announcements, its professional-sports tie-ins?

Its low profile is perhaps a function of the fact that the causes of oral cancer are already widely known and largely preventable. Oral cancer spurred by excessive alcohol and tobacco use has long made up the lion’s share of cases in the United States. Yet even as the number of American tobacco users has waned substantially in recent decades — truly one of the great public-health achievements in the country’s history — a lesser-known culprit is changing the demographic profile of oral cancer, specifically oropharyngeal cancer, or those of the throat and back of the mouth: A strain of human papillomavirus (a sexually transmitted virus) known as HPV16 is responsible for the increasing prevalence of oral cancer in nonsmoking men and women. This new cohort also skews younger than the typical victim of oral cancer, who is a man at least 50 years of age.

Indeed, “the fastest-growing segment of the oral and oropharyngeal cancer population are otherwise healthy nonsmokers in the 25–50 age range,” according to the Oral Cancer Foundation, a nonprofit organization founded in 1999 and based in Newport Beach, California. About a fifth of new oral-cancer cases can be linked to HPV, and together, tobacco and HPV16 account for virtually all new diagnoses.

Unprotected oral sex is responsible for many HPV transmissions. (Though a jump in causation from this practice might stem in part from people’s increased willingness to admit the behavior to their physician.) Actor Michael Douglas caused a stir in 2013 when he said the years he spent drinking and smoking to excess were not the cause of his Stage 4 oral cancer. “Without wanting to get too specific,” he told London’s Guardian newspaper that June, “this particular cancer is caused by HPV, which actually comes about from cunnilingus.”

ORAL CANCER WILL strike nearly 50,000 Americans this year. Its fiveyear mortality rate hovers around 60 percent — a figure that has remained persistently high for a decade, and a much dimmer outlook than that of better-known ailments such as Hodgkin’s lymphoma and prostate cancer. “It’s an ongoing area of frustration for physicians, who despite our best efforts are not always getting ahead of the disease as much as we might like to,” says Dr. Julie A. Goddard, an otolaryngologist and professor at the University of Colorado School of Medicine. Even though otolaryngology — which focuses on the ear, nose and throat — is a cornerstone of oral-cancer research and treatment, the American Academy of Otolaryngology estimates that about half the people who are seeing a doctor for the first time for the disease already have an advanced case.

Early diagnosis and treatment are essential to successfully combat any cancer, as oncologists go blue in the face from saying. Screenings are therefore imperative. According to a 2014 report by Dr. Nelson Rhodus, a professor at the University of Minnesota School of Dentistry and a leading expert in the field, “If all cases of oral cancer were diagnosed and treated as early as localized tumors, almost 80 percent of patients would survive five years.”

Researchers seeking inspiration for early-detection methods might take note of the Papanicolaou test — more commonly known as the Pap smear, a test women now undergo routinely. It wasn’t “invented” until the 1940s, but it has since become a staple of women’s health, credited with decreasing cervical-cancer incidence by more than 50 percent in the U.S. over the past several decades. “A Pap smear is considered an industry standard,” Dr. Rhodus says. “We don’t have that for oral cancer.”

What we do have, of course, is a widespread semiannual oral examination: the regular dental checkup. You and your hygiene team examine a patient’s mouth for abnormalities during a cleaning. Yet oral lesions and sores — the No. 1 tipoff for potential malignancies — are so common in their benign form that it’s often hard to determine just how worried to be. “Part of the problem for dentists is that they don’t always know when or if [a lesion] is serious enough to address,” Dr. Rhodus says. “They think it’s simply a spot or a canker sore. There’s not really a good protocol for the next step — meaning, when to say ‘You need to get a biopsy.’ ”

Perhaps you have screening and biopsy tools on hand in your practice; perhaps you don’t. The hard truth is that for many of us, screening for oral cancer isn’t the most pressing concern. For all the frightening numbers bandied about, after all, oral cancer will occur in roughly one of every 1,000 people. LEDs and brush kits to help assess abnormalities are fine as far as they go, but their effectiveness is hardly foolproof; none has ever been formally endorsed by the American Dental Association.

In the absence of hard evidence, then, we do what we’ve always done: conduct a visual test and send anyone with something sufficiently suspicious to an oral pathologist for a biopsy. Dr. Robert O. Greer, an oral pathologist in Denver, regards dentists as the first line of defense against oral cancer. “[They] have the best opportunity to examine [the oral cavity],” he says, “and they’re also the most exquisitely trained in examining and diagnosing that area.”

Another big problem blocks the path from screening to biopsy to diagnosis: The whole cycle is contingent on a patient visiting his or her dentist in the first place. High
risk individuals — heavy smokers and drinkers in particular — might not have access to regular dental appointments, or might simply forego them altogether. “If we see a mouth that is neglected,” Dr. Goddard says, “it often means other things are being neglected as well.”

“Oral cancer is an ongoing area of great frustration for physicians.”

THE GOOD NEWS is that some products currently in development might soon make a biopsy far easier to conduct. Dr. Rhodus and his team at the University of Minnesota are working on a diagnostic test that hunts for special biomarkers in saliva, which Dr. Rhodus says is designed to get around a dentist’s dilemma of whether to recommend a biopsy. He hopes to get the test into dental practices and even general health clinics within two years. It currently works solely for cancer of the oral cavity; it can’t yet detect back-of-mouth cancers caused by HPV because the two leave different biomarkers.

Dr. Rhodus’s ultimate goal: an easy-to-use oral cancer screen that functions almost like a home pregnancy test. “What I would ideally like to see is a home test where you spit in a tube,” he says. “If it turns blue, you know you’re OK, and if it turns a different color, you’ll need to see a doctor ASAP. And it’d be only about $25 a test.”

Early detection, naturally, is key. Most Stage 1 or Stage 2 oral-cancer diagnoses, in addition to having an 85 percent five-year rate of remission or cure, are amenable to minor surgery.

Early detection, naturally, is key. Most Stage 1 or Stage 2 oral-cancer diagnoses, in addition to having an 85 percent five-year rate of remission or cure, are amenable to minor surgery, according to a report by Dr. Rhodus published earlier this year in the journal Northwest Dentistry. Stage 3 and Stage 4 cancers “have a much higher mortality rate and are usually treated with combination therapy — irradiation and surgery,” he wrote.

Oral-cancer patients who face more-traditional treatment are usually in for the typical unappetizing smorgasbord: hair loss, nausea, fatigue and painful sores in the mouth. Radiation’s long-term effects can include injury to the salivary glands, a change in tooth development, swelling of targeted areas and scarring. Late-stage surgery — which often entails removing part of the tongue, throat or jaw — is perhaps the most debilitating measure of all. Brian Hill, founder of the Oral Cancer Foundation, a Vietnam veteran and a survivor of the disease, knows this firsthand. “If you find oral cancer late, you’ll get radiated and poisoned to the max,” says Hill, whose salivary glands no longer function. “Your quality of life could be crap from then on. It’s not survival like other cancers. You live with serious consequences.”

If dentists want to start improving the lamentable numbers associated with oral cancer, it might be time after all to work on the equivalent of the AIDS quilt or the NFL’s pink shoes and wristbands: a campaign, both individual and collective, to raise public awareness. Decades of advertisements, studies, Surgeon General warnings, journalistic exposés and social opprobrium regarding tobacco’s harmful effects on the body have been astonishingly effective — yet 16 percent of Americans still smoke. Vaping is a better option, but “e-cigarettes, while not quite as toxic, have been shown to contain these carcinogens as well,” Dr. Rhodus wrote in Northwest Dentistry. Moreover, the federal Centers for Disease Control and Prevention found in 2014 that just 62 percent of American adults between ages 18 and 64 had seen a dentist in the previous 12 months, and the percentage for oral cancer’s highest-risk population — those over 65 — was exactly the same.

Dentists’ tireless efforts to inform their patients about the connection between oral health and wholebody wellness will just have to become, well, even more tireless — “getting people to understand that negligence of the mouth has bigger ramifications than just ‘My teeth aren’t as pretty as I want them to be,’ ” says the University of Colorado’s Dr. Goddard. Patients, especially those at high risk, need to know that they can — and should — ask their dentist for a special screening.

Some initiatives are starting to bear fruit. In its inaugural tally of the 32 Most Influential People in Dentistry (Winter 2017), Incisal Edge named actress Gwyneth Paltrow No. 26. Her father, Bruce, died of oral cancer at age 58 in 2002, and under the auspices of the Oral Cancer Foundation, his family later established the Bruce Paltrow Oral Cancer Fund, which raises and disburses money primarily to inner-city and rural neighborhoods and towns, where both incidence of and mortality rates for the disease are far higher still than they are nationwide.

You need not be a movie star to make a difference. Dr. Rhodus urges dentists to be continually proactive by asking their patients about recent changes in their mouth or any other concerns about their oral health that might not be readily apparent. Even small actions like these can help our profession start combating this stealthy killer — the first stitch in the commemorative oral-cancer duvet of the future, say. “Patients need to understand that seeing a dentist regularly is not just about the teeth,” Dr. Goddard says. “It’s often where first detection for oral cancer comes in.”

JERILYN FORSYTHE is a writer and editor in Denver. She last wrote for Incisal Edge about the American Dental Association’s 2016 conference there