Maxim Bukhbinder reviews the promising abilities of emerging cutting-edge technology that could minimize the prevalence of oral cancer worldwide.
Maxim Bukhbinder
Abstract
In this essay, the facets of oral cancer are discussed, followed by an in-depth examination of the risk factors, diagnosis, and treatment of oral cancer. Oral cancer is a deadly disease that has taken the lives of countless individuals, some of whom have died without truly understanding the cause. Since this cancer is highly treatable in its early stages, it is strongly recommended and supported by the facts and figures presented throughout this essay that all individuals, whether or not they have partaken in any potential risk factors, attend an oral cancer screening and a potential follow-up biopsy with their dental provider. After examining extensive research, I was able to understand that there was an elevated understanding of the nature of this crisis. With specific attention to Southeast Asia but applicable worldwide, it is clear that a paucity of modern screening technology and a lack of urgency on behalf of both the patient and the medical professional cause higher rates of late oral cancer detection, which is inevitably often directly associated with high mortality rates. To this end, I pose the question: how can biannual oral cancer screenings affect the rate of oral cancer diagnosis worldwide? Answering this question could prompt further action within the medical community, as
“The material examined within this paper points to a clear, salient fact - that oral cancer screenings could potentially save countless lives due to their efficiency.”
Introduction
In this extensive extended essay, I pose the question: how can biannual oral cancer screenings affect the rate of oral cancer diagnosis worldwide? This question is of particular significance, because the diagnosis of oral cancer in its early stages is crucial to the swift treatment and extraction of cancerous or potentially cancerous cell growths in the oral cavity and esophagus. Such a cancer is extremely common, and I believe that it may genuinely decrease in rates across the world if screening with proper equipment is implemented and acknowledged by both patients and doctors worldwide. With my further discussion focusing on the effects of tobacco use and other external influences affecting the rate of oral cancer in Southeast Asia, asking this question is especially crucial - as such equipment is scarcely seen implemented in these regions. For example, in the small city of Taungoo in Myanmar, the population sits at about 242,000. In a contained study conducted in the Taungoo district hospital, 784 cancer patients that attended the hospital were observed for relative ratios of cancer types within their body. Of these, 20% had oral cancer, which was 95% localized in the squamous cells of the oral cavity. This localized scenario is a great indication that such a cancer is prevalent in areas where the chewing of betel quid and tobacco consumption may have a direct correlation to cancer rates. I have personal experience with cancer in my family. One of my grandfathers passed away from colon cancer, the other from kidney cancer, and my grandmother is currently undergoing chemotherapy for lymphoma cancer. I have witnessed the harrowing effects of cancer with my very own eyes, and I am passionate to share any form of resolution to assist in the reduction of cancer worldwide. Cancer is much more than a disease, and it affects more people than the patient with the malady. Oral cancer rates, with the implementation of screening technology through a sustained and organized worldwide effort, can be dramatically reduced due to the cutting-edge technology of early stage detection. For the remainder of my essay, I will preface the facts required to understand the many complicated facets of oral cancer, as well as provide a historical insight to contextualize how such a revolutionary technological development can serve to reduce oral cancer fatality rates in Southeast Asia and across the globe.
Oral Cancer, Facets
Oral cancer is one of only two cancers that is visibly detectable on a patient. The first of such cancers is skin cancer, which can be seen as a deformity or discoloration on the surface of the skin. Similarly, oral cancer can be detected as a deformity on the interior of the esophagus and at any area within the oral cavity, including the gingiva, buccal mucosa, the hard palate, and the retromolar trigone. The flat, thin cells that line the inside of the lips and oral cavity, called squamous cells, are generally where this cancer originates. When a squamous cell carcinoma forms, it has a distinct appearance resembling flat patches or ulcers, and with skin cancer, discoloration - specifically visible as a leukoplakia, an abnormal white tissue that forms on mucous membranes in the oral cavity. These specific aspects regarding the nature of this malady warrant a consideration for the possibility of detection of this cancer at any point in its development. Cancer, as it is defined generally, is a disease that forms when abnormal cells rapidly multiply in specific parts of the body, forming a malignant growth or tumor in said area of the patient's body. To this end, it is evidently valuable to reference the multiple stages of this cancer’s development. In stage 0, also labeled carcinoma in situ, is when abnormal cells are identified within the mouth/throat bodily area, which may potentially become cancerous. In stage 1, the cancer has formed, with a relatively small tumor invading the oral cavity. At stage 2, the tumor invades the oral cavity nearly twice as deeply. Stage 3 oral cancer sees the tumor grow and spread to one lymph node, which is detrimental to the immune function of this structure, therefore the cancer becomes metastatic as it travels throughout the body. In stage 4A, the tumor spreads to multiple locations within the oral cavity as well as to several lymph nodes, which is amplified in stages 4B and 4C, where the cancer spreads to muscles, bones, lungs, and the liver.
Implementation of Technology and Historical Context
Recently, technology has been more and more prevalent in the medical community, and with
great reason. Chemiluminescent light source systems, usually present in dermatological offices for skin cancer identification, have been finding their way into dental offices more and more recently - now implemented for oral cancer screenings.
Additionally, fluorescent imaging techniques have been the sole reason for over 274,000 cases of oral cancer reported nationwide, as the capturing and analyzing of fluorescent images reduces the subjectivity that may exist when performing a screening. The average patient has a dental visit and check-up biannually, and during this time, there is an opportunity for an oral cancer screening. Such screenings take a few minutes, which is a revolutionary aspect of screening equipment in contemporary medical science. In The Emperor of All Maladies by Siddhartha Mukherjee, a cancer physician and researcher, Mukherjee references a 1963 screening trial for breast cancer, where a machine the “size of a full-grown bull” was utilized to produce images that would have to be frothed in toxic chemicals in a dark room. This is a drastic change from the modern-day screening, which can be done in a matter of moments with handheld technology that is in no way harmful to the patient or the doctor qualified to be performing such a screening. Additionally, screening has had to overcome many hurdles in its past. In a 1995-1999 study, additionally referenced in The Emperor of All Maladies, the primary hurdle was that of over-diagnosis and under-diagnosis. The low quality of procedure at this time due to the technological availability and advancement thresholds warranted a possibility to either not detect, or falsely detect a cancerous growth in a patient. Such a mistake can be detrimental to the further treatment of a patient, therefore placing a life at risk due to a faulty system. If a patient is under-diagnosed, they may not be aware of a cancer, and with the confirmation of the cancer’s inexistence, they may fully mentally ignore it until it is too late for them to treat it. Conversely, if they are over-diagnosed, a patient may receive treatment for a cancer that they do not have, therefore causing side effects that would unnecessarily place the life of a patient at risk. To this end, modern day technology has granted patients and doctors alike with the introduction of the biopsy. A biopsy is essentially a confirmation tool for medical professionals. If a screening is done and a cancerous growth is found, a dental professional will perform a biopsy on the patient with a harmless laser method, which will take a sample of the suspectedly cancerous tissue, before sending it off to a laboratory for further tests to confirm the validity of the biopsy. This revolutionary technique, paired with the readily and easily accessible screening at a relatively affordable cost, is a drastic historical progression that has the potential to save millions of lives. As Mukherjee stated in The Emperor of All Maladies, “survival rates seem to increase … because of a screening test.” However, some doctors still have personal reasons for not conducting such screenings. According to the American Academy for Oral Systemic Health, doctors may prefer not to complete oral cancer screenings for various rationales, ranging from not wanting to instill fear in a patient by “using the ‘C’ word” to fearing an “overzealous diagnosis” label by an ENT or oral surgeon. In essence, this begs the question as to why this technology is not implemented worldwide - but there is no clear answer. In nations and regions where oral cancers are most prevalent, specifically Myanmar and other Southeast Asian regions, such screenings are only performed in hospitals and medical facilities with large concentrations of cancer patients, and even oftentimes only during studies performed by external organizations seeking to collect data on cancer rates in such countries. Realistically, the supplementation of these devices to medical professionals across these regions would only prompt the immediate usage of them - as dental workers and medical facilities who treat oral cancer patients will readily have access to a technological marvel that eliminates a grueling aspect of the cancer process - the primary identification of the cancerous growth.
Southeast Asia and Oral Cancer
With any disease, inclusive of oral cancer, there are several risk factors that may lead to an ultimate causation. Some factors are simply not within one’s control or the patient may have limited control considering the circumstances necessary to achieve such a state. According to the Oral Cancer Foundation, these factors include, but are not limited to, HPV16 viral infection, age, race, ethnicity, economics, recurrence, and gender. However, some variables, which are arguably more crucial to the outcome of a patient’s condition, are able to be controlled. Such variables include, but once again are not limited to tobacco usage, alcohol consumption, betel nut and bedis, sun exposure, and low intake of fruits and vegetables. One particular area where one may perhaps draw a connection between controllable risk factors and the rate of oral cancer is Southeast Asia.
In such a region, the long term effects of heavy smoking are especially prevalent, as oral cancer rates warrant a particular attention to Southeast Asian lifestyles and directly catalyze oral cancer rates across Southeast Asian countries. In a study conducted by GATS (the Global Adult Tobacco Survey) in 2013, three Southeast Asian countries- India, Bangladesh, and Thailand- were surveyed extensively and the findings were then analyzed in order to find any trends or patterns across the region. To ensure the full-proofness of their survey, the GATS established a baseline for what a heavy smoker is. The definition was clarified as an individual who is a current daily smoker that, despite knowing the dangers and associated risks that come alongside smoking, continue to smoke from their first moments in the day to their last, and have no intention to quit. This restrictive surveying process yielded a surprisingly high figure: there were “31.3 million hardcore smokers in the three Asian countries.” Notably, this figure constituted for 100% of the hardcore smoking population in this region, but only “18.3-29.7% of daily smokers,” which underscores a clear, immediate cause for concern in Southeast Asia and across the world. However, to draw a line from hardcore smoking to its consequences, one must establish the consequences first. According to the Nepal Journal of Epidemiology published by the International Nepal Epidemiological Association, oral cancer “is the most common type of cancer in South Asian Countries like India … and Bangladesh and contributes nearly one-fourth of all new cases of cancer.” This massive quantity of new oral cancer cases in this region is not a coincidence.
One reason for this occurrence is the lack of specialized equipment meant for the detection and treatment of oral cancer in Southeast Asia. The Department of Otorhinolaryngology at Khon Kaen University in Thailand states that there is an “urgent need to prioritize resources to put in place structured programs” that would result in lower rates of oral cancer in Southeast Asia. These resources range across the spectrum of the oral cancer world, from early diagnosis technology such as chemiluminescent light systems to other later treatment equipment that accompanies chemotherapy treatment for cancer patients. In 2004, the U.S Preventive Services Task Force (USPSTF) published an official statement regarding the importance of oral cancer screenings, stating that “Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx” when they are with a patient that consents to such an examination. Whilst this is a U.S. based organization, such advice can be applied worldwide, and especially so in countries that exhibit an abnormally large ratio of smoking and oral cancer rates. However, despite the underscored risk and recommendations of treatment and detection, most dental workers in such regions simply do not conduct these tests for their patients. The otolaryngologists in Khon Kaen University further argue that it is “evident that data collection in many of the SEA [Southeast Asian] countries is very much … supported through external regional and/or international collaborations.” This factor is representative of the utter scarcity of care towards the diagnosis and treatment of cancer, as the very countries that struggle the most with oral cancer take little to no initiative in relieving such a major issue that has the potential to harm vast chunks of their populations. When viewing the high mortality rate through the lens of the lack of attention that oral cancer receives in such regions, it would not be unreasonable to draw a connection between smoking trends and cancer rates. Smoking is not specific to Southeast Asia, however, and is a destructive habit that has invaded the lives of countless individuals across the world. In that sense, it is even more imperative that dental professionals push the use of oral cancer screening equipment.
The Patient’s Responsibility
Whilst it is important that the clinical professional conduct the screening, it is equally the responsibility of the patient to attend and actively acknowledge the screening. Oral cancer screening is virtually risk-free, and relatively inexpensive. With prices as low as six U.S dollars , the screening is a small price to pay for one’s health. However, the same official statement released by the U.S Preventive Services Task Force mentioning the responsibility of the dentist to ensure the oral health of the patient also argues that community-based screenings are cost ineffective. However, another study published just a year later in 2005 in India “reported a significant reduction in mortality” when male patients were screened for oral cancer, 24.6 per 100,000 compared to that being 42.9 per 100,000 within the population that was part of their study. This is a staple demonstration of how an individual’s environmental pressures or location may influence their physical health, as there was ultimately insufficient data to support that screenings were cost-effective in the U.S in comparison to India. However, there has been no controlled, long-term study of the effectiveness and cost-effectiveness of oral cancer screenings in the United States since the aforementioned study in 2004. Since 2004, there have been countless revolutionary and relatively inexpensive new technologies, such as chemiluminescent light, that certainly may change the perspective of the U.S Protective Services Task Force, which could further prompt a call to action from the executives of the medical community. Additionally, technology that was able to accurately diagnose patients existed in the U.S well before the USPSTF published their report. This technology is called OralCDx, and was extensively studied in 1999
by a group of American researchers who deemed it to be “a highly accurate method of detecting oral precancerous and cancerous lesions”. Therefore, it is evident that an outdated report on an ill-developed technology should not entirely dictate the decision of a patient to sign up for a screening. It is, in fact, the contrary - as there are plenty of affordable screening options that may be covered by a
patient’s insurance. However, some patients may choose not to attend a screening due to the fear of the machine legitimately detecting a cancerous growth in their oral cavity. To this end, it is even more urgent that one who is afraid of the consequences must conduct a screening - as it has been shown time and time again that an early detection creates a far smoother treatment process for the cancer in a patient.
Oral cancer, as with any cancer, can be staged into several different places, depending on the calamity of the cancerous growth. The American Cancer Society has a prescribed overview of the treatment options for each stage of oral cancer, and after acknowledging each, it is clear to see that as the cancer progresses into the late stages and the oral carcinoma has spread into the lymph nodes, it is incredibly difficult to treat the disease. On the other hand, when the oral cancer is within the earlier stages - including stage 0 - the treatment is fairly simple and effective. Requiring one surgery and close follow-up with a possibility of a need for chemotherapy, the treatment for early stage oral cancer is far less physically and mentally exhausting and painful, avoiding the potential of a perpetually negative toll on the well-being of the patient. In essence, the patient is responsible in equal part to the dental professional - as they are implored to make the conscious decision of attending an oral cancer screening twice a year to rule out any possibility of cancerous growth. It is integral, however, that these screenings remain a part of the patient’s biannual routine. The patient should commit themselves to attending such screenings every 6 months, and should additionally avoid any possible risk factors, including all those aforementioned. In particular, the American Cancer Society states that “continuing to smoke increases the risk that a new cancer will develop,” which has been made clear on multiple occasions. However, the fact that this specific risk factor is underscored in this medical overview presents the salient fact that smoking is truly the worst culprit of oral cancer worldwide.
Conclusion and Further Action
Oral cancer is a disease that has rapidly become synonymous as the ultimate consequence for the heavy smoker, along with lung cancer. The persistence of smoking amongst the human population throughout the immeasurably lengthy span of time that tobacco has been a deeply rooted cultural norm is perhaps the primary cause for this specific type of cancer. In fact, the Illinois Department of Public Health claimed that 90% of all oral cancer patients use tobacco products in some form. This staggering figure only serves to emphasize the importance of screenings, especially for tobacco users. According to Mukherjee in The Emperor of All Maladies, the per capita cigarette consumption in 1870 was less than one cigarette per year, but a “mere thirty years later, Americans were consuming 3.5 billion cigarettes and 6 billion cigars every year.” As this rapid incline occurred, countless corporations used this momentum to advertise smoking in a positive light. This normalization of this carcinogen-rich habit has been incredibly destructive across the world, and has seen diagnoses and mortalities far and wide. Recently, however,
“New technological breakthroughs in the dental field, like fluorescent imaging techniques and chemiluminescent light, have brought hope to the medical community.”
However, this hope must be translated into action. Dental professionals worldwide, especially in those nations where oral cancer is highly prevalent, must routinely encourage screenings and follow-up biopsies in order to reduce the harmful impact that such a cancer can have on their populations. To answer the central question posed in this paper, the collaborative effort of multiple nations in ensuring that the implementation of cutting-edge oral cancer screening technology finds its way into mainstream practice, with patients visiting their dentists biannually for such a screening, would see a dramatic decline in the rates of success of oral cancer treatment and elimination. The earlier a cancerous growth is detected, the easier it is to remove it. According to the World Health Organization’s International Agency for Research on Cancer, of the 355,000 new cases of oral cancer in 2018, 177,000 ended in death. Considering all things discussed in this paper, it is reasonable to infer that this number would significantly decrease due to an abundance of screening technology worldwide. Oral cancer is one of only two cancers to be visible to the human eye - however it is certainly crucial to note that an individual should not wait until this carcinoma is visible to act. If an individual has partook in any risk factor that could potentially increase their chances of oral cancer, it is imperative that they attend a screening and a potential biopsy, regardless of whether or not one “thinks” they have cancer. Ultimately, as the world changes and new technologies are constantly being manufactured to better shed light -literally - on diseases that were previously hidden, there is a duty presented to both the medical professional and the patient. This is the duty to attend a biannual oral cancer screening session, where, for a reasonable price, the doctor will examine one’s oral cavity for any potential cancerous growth. However, even this duty is a luxury. Some nations, such as those in Southeast Asia, are in dire need of a stronger support system in the field of oncology. Therefore, it is imperative that there be a collaborative effort amongst multiple countries to equally distribute new technologies that will aid the screening process as well as an effort to educate and encourage the common population to attend these screenings twice a year. In summation, all of the facts, figures, and statements presented throughout this paper are a call to action for people worldwide to acknowledge the dangers associated with oral cancer, and to
act upon such danger with collaboration, encouragement, and diligence.
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