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1. Oral Cancer: To Screen or Not to
Screen ? [That is the Question]
Dr. A. Ross Kerr
Dr. Joel Epstein
ark3@nyu.edu
jepstein@coh.com

2. What is screening?
• Screening is defined as the application of a simple and cost-
effective test to a large population of patients who are
asymptomatic and apparently free of disease in order to identify
those who may have disease.

3. Organized Population Screening (with oversight)
(general population or selective groups)
Versus
Opportunistic Screening (“case finding”)
(no oversight)

4. Definition of Oral Cancer

5. What about oral potentially malignant disorders? (OMPDs)
• Global prevalence of OPMDs
approx 1-5%
• PMDs are >3x more prevalent in
men.
• If not already OSCC at baseline,
malignant transformation rate
<2%/year
Van de Waal, Oral Oncology 2009 45:317-23
Napier SS, J Oral Pathol Med 2008
Petti S. Oral Oncology 2003 39:770–780

6. Lingen et al 2011 (Oral Diseases)
Severity? Progression vs Regression?, Indolent vs Aggressive ?
Natural history of oral cavity cancer
Often preceded by “precursor” lesions, a small fraction
of which undergo malignant transformation.
How to identify those precursor lesions that transform?

7. Natural history of HPV+ oropharyngeal cancer
Rarely preceded by “precursor” lesions
The Big Black
Box
Oral
HPV
Infection
eg HPV16+
Oropharyngeal
Cancer

8. “Oral cancer screening”
means we are screening for:
Oral cavity cancer/OPMDs?
and
Oropharyngeal cancer (HPV+)?

9. Key Question 1: Is “Oral Cancer” an important enough health
problem?
Key Question 2: How should “Oral Cancer” be screened for
and what are the performance characteristics of the screening
evaluation as a means of identifying “Oral Cancer”?
Key Question 3: Does screening for “Oral Cancer” reduce
morbidity or mortality?
Key Question 4: What is the cost effectiveness of “Oral
Cancer” screening?

10. Key Question 1: Is “Oral Cancer” an important enough health problem?
www.braschlerfischer.com
Higher Burden of Disease Lower Burden of Disease
VS
Same Morbidity?

11. DeLacure
Estimated 51,540 new
oral cavity and pharynx
cancer cases will be
diagnosed and > 10,000
will die in the US in 2018
(11.2/100,000 incidence
2.5/100,000 mortality)
8th leading site in men
2.9% of all cancers

12. Overall: 64%

13. Key Question 2a: How should “Oral Cancer” be screened for?

14. Screening Test?
Conventional
Oral
Exam

15. Light-based adjuncts: autofluorescence/reflectance?
VELScope OralID
Identafi
Vizilite
Bio/Screen
Vizilite Pro
Microlux
Orascoptic
Goccles

16. Salivary Diagnostics?
CD44/total protein HPV 16

17. checkyourmouth.org
Self-Examination?

18. Key Question 2b: What are the performance characteristics of the screening
evaluation as a means of identifying “Oral Cancer”?
Higher prevalence >10%: high Se, lower Sp
Lower prevalence <10%: lower Se, high Sp
Positive screen=white patch, red patch, ulcer
In general population COE good for detecting “absence” of disease.
Similar in performance to performance for breast and cervical cancer.
Walsh T et al Cochrane Collaboration 2013

19. Is it an OPMD? Depends on Level of Training

21. Key Question 3: Does screening for “Oral Cancer” reduce morbidity or
mortality?
Oral Oncology 1997
Holmes et al J Oral Max Surg 2003
“Downstaging”

22. KERALA STUDY
INDIA
TRIVANDRUM CITY
Kerala
Indian Ocean
Bay of Bengal
Vakkom
Kadakavoor
Kizhuvilam
Azhoor
Mangalapura
m
Andoorkonam
Pothencod
e
Kazhakutta
m
Sreekariyam
Attipra
Kadinamkula
m
Chirayinkil
Anjuthengu
Intervention Clusters
Control Clusters
TRIVANDRUM CITY
Arabian
Sea
Courtesy of Kannan Ranganathan
13 clusters
Intervention: 96,516 screened
Control: 95,356
4 rounds of screening (‘98, ‘02, ‘04. ‘09)

23. Kerala study – after 15 years (1996 - 2010)
Sankaranarayanan et al, Oral Oncology, 2013. 49:314-321
Summary:
“….our findings support the routine use of oral visual screening to
reduce oral cancer mortality among the high-risk group and may be
cost-effective………..
…..We recommend that dentists and general practitioners perform a
careful visual oral examination in tobacco or alcohol users during
routine clinical interactions …”
Opportunistic screening in high-risk groups
may work
…but not for the for the overall population

24. Taiwan Screening Program (2004-2009)
4,234,393 high-risk patients screened (1-3 times)
follow-up 4.5 years
Chuang et al, Cancer, 2017. 123: 1597-609
60.4%
53.5%
Screened group showed 26% reduction in mortality

25. What is the Cost Burden of Oral/Pharyngeal
Cancers?
• Commercial Insurance Database
(under 65 years of age)
• Medicare Database
(over 65 years of age)
• Health & Productivity Management Database
(absenteeism, short-term disability)
= 3,236 cases
= 1,763 cases
= 237 cases
Key Question 4: What is the cost effectiveness of “Oral Cancer” screening?
Courtesy of Jed Jacobson

26. What is the Cost Burden of
Oral/Pharyngeal Cancers?
Average Direct Medical
Cost of Cancer
= $84,153*
Average Short-Term
Disability Costs
= $ 8,338
Total = $92,491
* The most expensive cancer to treat in the US – Jacobson, JJ, et al.: The cost
burden of oral, oral pharyngeal, and salivary gland cancers in three groups:
commercial insurance, Medicare, and Medicaid, Head & Neck Oncology 2012, 4:15.

27. Cost of Treating Early vs.
Advanced Oral Cancer
$0
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
(P<0.001)
Commercial
(P<0.001)
Medicare
(P<0.132)
Medicaid
Single Modality
Multimodal
$49,745
$133,603
$35,932
$77,860
$54,804
$99,666

28. Methods: Simulation using a decision analysis model on hypothetical populations in
various primary care settings
Conclusions: Opportunistic high-risk screening, particularly in general dental practice,
may be cost-effective. This screening may more effectively be targeted to younger age
groups, particularly 40–60 year olds.
Further study is needed on malignant transformation rates of oral potentially malignant
lesions and to determine the outcome of treatment of oral potentially malignant lesions.
Speight PM, Palmer S, Moles DR, Downer MC, Smith DH, Henriksson M, et al . The
cost-effectiveness of screening for oral cancer in primary care. Health Technol Assess
2006;10 (14).

29. The USPSTF concludes that the current evidence is
insufficient to assess the balance of benefits and harms
of screening for oral cancer in asymptomatic adults.
www.uspreventiveservicestaskforce.org/uspstf/uspsoral.htm

31. 28 year old female with no risk factors: OSCC

33. Oral Cancer: To Screen or Not to Screen ?
[That is the Question]
YES to opportunistic screening of all patients by oral
healthcare providers
We need better screening tests to identify cancer and
OPMDs with high risk for malignant transformation

34. HPV Vaccines
• Gardasil (HPV 16,18, 6,11)
• vs cervical, vaginal, vulvar
cancer (2006)
• vs genital warts in
men/women (2009)
• vs anal cancer in
men/women (2011)
• Cervarix (HPV 16/18)
• vs cervical cancers
(2009)
• Gardisil 9
• New nonavalent vaccine
• Covers HPV 6, 11, 16, 18,
31, 33, 45, 52, and 58
• There needs to be a bigger
push to vaccinate boys