The document discusses several studies conducted on screening for oral cancer in India and Taiwan. The Kerala, India study was a cluster-randomized controlled trial that screened over 35,000 individuals aged 15+ using oral visual examination by trained health workers. It found a 38% reduction in oral cancer incidence and 81% reduction in mortality among those screened 4 times over 15 years. The Taiwan study was a nationwide screening program of over 4 million smokers/betel nut chewers screened biennially by dentists/physicians. It reported a 17% reduction in oral cancer incidence and 26% reduction in mortality after screening from 2004-2012. Both studies demonstrated that screening by oral visual examination can help reduce oral cancer rates.

1. NATIONAL INSTITUTE OF CANCER PREVENTION &
RESEARCH
SCREENING FOR ORAL CANCER IN INDIA - IACSS ‘17
Prof. Ravi Mehrotra
MD, FRCPath, DPhil
ICMR -NICPR
Dept. of Health Research, Govt. Of India
ravi.mehrotra@gov.in

2. SCREENING
WHO definition:
Screening is the identification of unrecognized disease or defects by means of tests,
examinations, or other procedures that can be applied rapidly.
Screening is a strategy to detect a disease in an individual who does not have any signs
or symptoms.
2

3. India has one third of oral cancer cases in the world .
Oral cancer accounts for around 30% of all cancers in India.
Oral cancers in India (Globocan, 2012)
New cases: 77,003
Deaths: 52,067
In general, more men suffer and die from oral cancer than women
3
• Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial.
Lancet 2005;365:1927–33
•Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11[Internet]Lyon,
France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 6th August 2014

4. PIONEER STUDIES
The studies were conducted in rural areas of Ernakulum District, Kerala, Bhavnagar
District of Gujarat and Srikakulam District, Andhra Pradesh.
A total of 36000 tobacco users were screened, Oral Visual Examination (OVE) was done
and followed up for 10 years.
Intervention was given using personal and mass media communication.
These results established an almost complete association between tobacco use, oral
cancer and precancer.
4•Gupta PC, Mehta FS, Pindborg JJ. Aghi MB, Bhonsle RB, Daftary DK, Muti PR, Shah HT, Sinor PN. Intervention study for
primary prevention of oral cancer among 36000 Indian tobacco users. The Lancet. May 31, 1986.

5. There was a decrease in the incidence of leukoplakia and palatal changes associated with
smoking in those who stopped the tobacco habit.
These studies have examined the feasibility of training the basic health workers to
examine the mouth for early detection of early cancerous and precancerous lesions.
5
•Gupta PC, Mehta FS, Pindborg JJ. Aghi MB, Bhonsle RB, Daftary DK, Muti PR, Shah HT, Sinor PN. Intervention study for
primary prevention of oral cancer among 36000 Indian tobacco users. The Lancet. May 31, 1986.

6. ERNAKULUM TRIAL
Primary prevention trial in Ernakulum District, Kerala was a 10 year follow up study, with
the intervention cohort of 12212 tobacco users aged 15 years and over.
House to house survey was done with a team of dentist, interviewer and local help, the study
participants were visited once a year.
OVE was done, photographs were taken during each visit.
This study reported that among the intervention group there was a decrease in the tobacco
use with decrease in the incidence of leukoplakia
6
•Gupta PC, Mehta FS, Pindborg JJ, Bhonsle RB, Muti PR, Daftary DK, Aghi MB. Primary prevention trial of oral cancer in
India: a 10 year follow up study. J Oral Pathol Med. 1992; 21:433-9.

7. TRIVANDRUM TRIAL
Cluster-Randomised Controlled Trial, 15-year follow-up of 35
year old individuals.
13 clusters were selected, 7 clusters in the intervention arm
with 96,517 subjects and 6 clusters to the control arm with
95,356 subjects.
Intervention arm received four rounds of oral visual
inspection by trained health workers at 3-year intervals, and the
control arm received routine care during 1996–2005 and one
round of visual screening during 2006–2009.
7
• Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial.
Lancet 2005;365:1927–33.
•Sankaranarayanan R, Ramadas K, Thara S. Long term effect of visual screening on oral cancer incidence and mortality in randomized trial in Kerala, India.
Oral Oncol. 2013 Apr;49(4):314-21.

8. ▰House to house interview was done by health workers.
▰Data on demographic details was done by face to face interview, OVE was
done.
▰Control were screened only during 2006-2008.
▰All screen-positive subjects were referred to a weekly clinic in the study project
office where dentists and oncologists, biopsy was done to confirm.
8
• Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet
2005;365:1927–33.
•Sankaranarayanan R, Ramadas K, Thara S. Long term effect of visual screening on oral cancer incidence and mortality in randomized trial in Kerala, India.
Oral Oncol. 2013 Apr;49(4):314-21.

9. ▰Oral cancer incidence and mortality in the study groups. We obtained
information on the incident oral cancer cases in the study clusters from the
Trivandrum population-based cancer registry, hospital cancer registry of the
RCC and medical records departments of other hospitals treating oral cancer
patients
▰38% reduction in oral cancer incidence and 81% reduction in oral cancer
mortality in tobacco and/or alcohol users adhering to four screening rounds.
9
• Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial.
Lancet 2005;365:1927–33.
•Sankaranarayanan R, Ramadas K, Thara S. Long term effect of visual screening on oral cancer incidence and mortality in randomized trial in Kerala, India.
Oral Oncol. 2013 Apr;49(4):314-21.

10. TAIWAN STUDY
A nationwide population-based screening program was done
2004 – 2009 in Taiwan.
A total of 4,234,393 individuals aged18 years from the National
Nutrition and Health Survey in Taiwan were screened for oral
cancer.
Biennial screening program
10• Chuang SL, Su WW, Chen SL et al. Population-based screening program for reducing oral cancer mortality in 2,334,299 Taiwanese cigarette
smokers and/or betel quid chewers. Cancer. 2017 May 1;123(9):1597-1609.

11. Three main modes of detection:
Screen-detected cases - diagnosed at a prevalent or subsequent screening
Interval cancers - diagnosed within 2 years or those diagnosed beyond 2 years since the
last negative screening
Nonattendees - never participated in the screening program
Followed over time to ascertain deaths from oral cancer until the end of 2012 (4.5
years).
Excluded - oral cancer diagnosed before they were invited to the screening program.
11• Chuang SL, Su WW, Chen SL et al. Population-based screening program for reducing oral cancer mortality in 2,334,299 Taiwanese cigarette
smokers and/or betel quid chewers. Cancer. 2017 May 1;123(9):1597-1609.

12. Data Collected:
Demographic characteristics - smoking or betel quid chewing was collected through a
questionnaire by face-to-face interviews in the communities/hospitals.
Oral Visual Examination by dentist or physicians
Referral screen-positive participants with Oral Potentially Malignant (OPM) disorders or
suspected malignancy were referred to specialists in the hospitals for confirmatory pathologic
examination.
Participants who screened negative were invited to the next screening.
The survival of those who had screen-detected and clinically detected oral cancers was
monitored from the National Cancer Registry and National Death Registry
12• Chuang SL, Su WW, Chen SL et al. Population-based screening program for reducing oral cancer mortality in 2,334,299 Taiwanese cigarette
smokers and/or betel quid chewers. Cancer. 2017 May 1;123(9):1597-1609.

13. 13
KERALA, INDIA STUDY TAIWAN STUDY
Study design Cluster-Randomised Controlled Trial Population-Based Screening Program
Eligibility 35 year old individuals 18 year old with oral habits of cigarette smoking
and/or betel quid chewing
Target Healthy Individuals High-risk Individuals
Duration 1996–2010, (15 year follow up)
screening at 3 year interval 1996-2006
One round of screening during 2006–2009
2004-2009 (Biennial screening program)
Followed up to 2012 from the National Cancer
Registry and National Death Registry
Methodology
and
Data
Collected
13 clusters were selected, 7 clusters in the
intervention arm with 96,517 subjects and 6
clusters to the control arm with 95,356 subjects.
Intervention group were screened 1996-2009
Control group were screened – 2006-2008
2,334,299 – 1st screening
484,247 - 2nd screening
114,856 – 3rd screening
(control – non screened group)
Demographic characteristics ,
Oral Visual Examination of Oral Potentially
Malignant (OPM) disorders or Malignancy,
Referral of screened positives
Demographic characteristics ,
Oral Visual Examination of Oral Potentially
Malignant (OPM) disorders or Malignancy,
Referral of screened positives
Screening
was done by
Health Workers (non-medical university
Graduates)
Dentist or Physician

14. 14
KERALA, INDIA STUDY TAIWAN STUDY
Results •5586 ever screened-positive, 2336 were
diagnosed with OPM and 192 with oral
cancer
•There was a statistically significant 38%
reduction in incidence in those who had
four screens and 47% reduction and 81%
reduction in oral cancer mortality in
those who complied with three and four
screening rounds.
•18,116 (0.8%) had a positive screening at the 1st screening,
with OPM in 11,051 individuals and oral cancer in 4110
individuals.
•Total of 8033 oral cancers were diagnosed during the study
period
•17% reduction in incident oral cancer and 21% reduction in
stage III or IV oral cancer diagnoses and a 26% reduction in
oral cancer mortality
Strength •Health workers were trained and used
for screening
•Large sample size
Limitations •Small sample were randomized •No randomization
•Repeated screening rate was low
•Shorter follow-up
• Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial.
Lancet 2005;365:1927–33.
•Sankaranarayanan R, Ramadas K, Thara S. Long term effect of visual screening on oral cancer incidence and mortality in randomized trial in Kerala, India.
Oral Oncol. 2013 Apr;49(4):314-21.
• Chuang SL, Su WW, Chen SL et al. Population-based screening program for reducing oral cancer mortality in 2,334,299 Taiwanese cigarette smokers
and/or betel quid chewers. Cancer. 2017 May 1;123(9):1597-1609.

15. PREVENTION STRATEGIES
15
Prevention Strategies Specific Interventions
Primordial prevention Inhibit the emergence of risk factors
Primary prevention Health promotion and specific protection
Secondary prevention Early diagnosis (e.g. screening tests, and case
finding program) and adequate treatment
Tertiary prevention Disability limitation and rehabilitation

16. ▰Oral cancer may be preceded by potentially malignant disorders
that could be detected in the oral cavity due to the easy access of the
site.
▰Early detection of these potentially malignant disorders of the oral
cavity is possible during routine general health check-ups/screening
by doctors/dentists/health workers or by self-examination.
16

17. TYPES OF SCREENING
▰ Organized screening
▰ Targeted screening of risk groups
▰ Opportunistic screening
17

18. ▰The Government of
India has recently
formulated an
“Operational
Framework” for the
country’s national cancer
screening programme.
18

19. SCREENING PROCESS
19
Age of beneficiary 30 -65 years
Method of Screening Oral Visual Examination (OVE)
Frequency of screening Once in 5years
Referral of screen positive
cases
To Surgeon/Dentist/ENT
specialist/Medical officer at CHC/DH
for confirmation and biopsy.

20. Oral Cancer Screening Level-wise
20
Phasing Year wise Level Oral cancer
( men and women)
30-65 years
1st year
25% coverage
Village 93
Sub Centre x 5 465
2nd year
25% coverage
Village 93
Sub Centre 465
3rd year
30% coverage
Village 111
Sub Centre 555
Total coverage (80%) Village 297
Sub Centre 1485

21. SCREENING PROCESS
▰Awareness generation/motivation by Accredited Social Health Activist (ASHA)
▰The Auxiliary nurse midwife (ANM) and Staff Nurses would be performing
OVE
▰Medical officers/Specialists will be evaluating and treating the Positives
detected during screening
▰Data compilation and analysis will be done by data entry operators
21

22. Roles and Responsibilities for cancer screening
at different levels of healthcare
22
ANM, ASHA,
MPW (Male)
Mid-Level Worker,
Village/Sub
Centre
Staff Nurse/ANM
NCD nurse
FHW, MHW
MO
Ayush doctors, Dentists in
some states
PHC
OVE
(Wherever possible)
Sensitization & motivation
OVE
Evaluation by MO, of screen positives refd
from subcentre
Population records
Management of sub centres
Sensitization and mobilization
Evaluation of all screen- positives
Biopsy for suspected Oral lesions
Dentist, Surgeon
NCD cell staff
CHC
Evaluation of all screen- positives
Biopsy for suspected Oral lesion
Training hub
Centre to confirm cases & refer to tertiary centre
for treatment
H/P and Tt if facilities available
Dentist,Surgeon
NCD cell staff
MO i/c
Pathologist, technician
Radiologist
Support staff
DH

23. ALGORITHM FOR SCREENING OF ORAL CANCER
23
Accredited Social Health Activist (ASHA)/ Health workers collect responses from people
Fill and Issue Oral health cards/ Self Administered Questionnaire
Individuals with history of tobacco /
arecanut/ alcohol habit irrespective of age
All Individuals with known risks for cancer; Age
30 years and above
Tobacco Cessation Centers or Alcohol
Deaddiction centre at nearest Medical /
Dental college
Any abnormality on Oral Visual Examination
Screening by NCD Nurse / Auxiliary nurse midwife
(ANM) / Male Health Workers: Oral Visual
Examination
Normal findings on Oral Visual
Examination
Evaluated by the Dentist/ Surgeon/ ENT specialist / MO at PHC/
CHC/ DH sensitization and education of private dentists
Suspected Oral Cancer
Potentially Malignant
Lesions
Clinically Diagnosed
Oral Cancer
Elimination of Etiological factors
and Tobacco Cessation
(Observe for 6 weeks)
Detailed Intraoral Examination and biopsy (if
required) Histo-pathological reporting. Intervention
will be decided based on the presence of dysplasia.
CHC/ DH
Dysplastic & needs surgical interventionNon dysplastic
No change/ ProgressionRegression
Medical Management
•Reinforced counseling
•Follow up and monitoring Referral to Tertiary Cancer Care Centers / Medical Colleges
5 Year
Screening
Schedule

24. "Training of Master Trainers for cancer screening of Oral, Breast
and Cervix" from 24th - 26th October, 2016 at NICPR
24
34 master trainers (Gynecologists, dentists, surgeons, Radiotherapist, and Unani doctors) were
trained from Agartala, Hyderabad, Lucknow, Aligarh and Chennai.

25. HANDS-ON TRAINING ON CERVICAL, BREAST & ORAL CANCER
SCREENING, 14th to 16th SEPTEMBER 2016
ALL INDIA INSTITUTE OF AYURVEDA
25
32 Ayurveda doctors from various specialties were trained in oral,
breast and cervical cancer screening.

26. ICMR-NICPR Team
26

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謝謝谢谢