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The
Preface
Welcome by Sir David Carter
Sir David Carter, the Vice-President of the Royal Society of Edinburgh, welcomed the delegates to the meeting. He intimated that the RSE was very pleased to be associated with the programme of meetings on oral health. Sir David commented that he had alwasy been aware of what a significant problem oral cancer posed, but the days programme brought back to him the stark reality of the morbidity and mortality that this disease causes. There is a particular problem in Scotland so it was fitting that a meeting was being held in Edinburgh to discuss this disease. Oral cancer now accounts for 2-3% of all cancers in the UK and has an even higher incidence elsewhere in the world. There is also the frustration of late presentation of disease that is clearly, in part, preventable and is certainly eminently treatable if one could achieve early diagnosis and effective team work. The Royal Society of Edinburgh was very pleased that the event was multi-professional since establishing communication and effective team working were key purposes of the meeting. Sir David concluded his welcome by wishing the delegates an informative, stimulating and productive day.
The
Meeting Proceedings
The A to Z of Oral Cancer : An Holistic Route Oral Health Workshop Friday 25 January 2002
Edited by Jeremy Bagg, T Wallace MacFarlane, Mary McCann and David Soutar
2003 The Royal Society of Edinburgh. ISBN 0 902198 63 7
CONTENTS
INTRODUCTION TO THE WORKSHOP Professor David Wray ..................................................................................................... 5 SESSION 1: Epidemiology, Diagnosis and Current Treatment .......................................... 7 Epidemiology The Extent of the Problem Mr David Soutar ........................................................................................................... 7 Presentation and Diagnosis The Clinicians View Professor Michael Lewis ............................................................................................... 9 Current Treatment of Oral Cancer An Overview ....................................................... 10 Mr Jeremy McMahon Patients Pathways Co-ordinating Care .................................................................... 14 Mrs Rosemary Kelly SESSION 2: NOVEL TREATMENTS AND SCREENING ........................................................... 17 Novel and Experimental Treatments Mr Ian Ganly .............................................................................................................. 17 Screening for Cancer Dr Vikki Entwistle ......................................................................................................... 21 SESSION 3: FOLLOW-UP AND REHABILITATION ................................................................ 25 The Patients Perspective Mr Michael Walton ..................................................................................................... 25 The Speech Therapists Role Mrs Mary Jackson ....................................................................................................... 27 Palliative Care for Head and Neck Cancer Dr Hugh MacDougall .................................................................................................. 29 Restorative Dentistry in Head and Neck Oncology Mr Arshad Ali............................................................................................................... 31 SUMMARY OF CONCLUSIONS ........................................................................................ 35 SUMMARY OF MAIN ISSUES RAISED IN THE WORKSHOPS ................................................. 37 ACKNOWLEDGEMENTS .................................................................................................. 39
Epidemiology The Extent of the Problem__________ Mr David Soutar, Consultant in Plastic Surgery, Canniesburn Hospital, Glasgow Within the United Kingdom, there are about three and a half thousand new registrations of oral cancer per year. The overall survival rate at the present time is somewhere in the region of 50% (Fig. 1). Oral cancer has a very high death to registration index, which means that it is a bad cancer, similar to melanoma and cervix and almost as bad as breast disease. There are two different kinds of oral cancer, those based on premalignancy and those that arise de novo from what looks like normal oral epithelium. The premalignant lesions are usually superficial, slow growing, multifocal, some regress by changing the diet or by use of retinoids and other substances, they very rarely metastasise and they require non-radical treatment. So there is a spectrum of oral cancer in which those based on premalignancy tend to be less aggressive than the ones that arise de novo. The latter are rapidly growing, often deeply penetrating into bone, with a short time scale, often arising from a single focus, they show no regression whatsoever, they metastisise and they require radical treatment. These are the problem cases. Interpreting the statistics is made more difficult by the staging of oral cancer. Staging is determined by the TNM system, T being the tumour size, N being the nodal status and M being distant metastasis. The terms stage 1, stage 2, stage 3 and stage 4 disease are used. T1 is less than 2 cm and T2 is 2-4cm, but the size itself is not important the significant cut-off is when there is involvement of nodes. Spread to regional nodes indicates stage 3 and stage 4 disease. The prognosis depends on the stage of the disease. Stage 1 disease (T1N0) does reasonably well, whereas patients with stage 4 disease do very badly. Thus, when comparing mortality statistics between one country or another, or one set or another, particular attention must be paid to the staging of the disease. In addition, oral cancer is not a single entity, since some sites in the mouth have a better prognosis than others. Thus, lip cancer has a higher 5-year survival than any other site. Conversely, tongue cancers do particularly badly, with stage 2 disease having a 5-year survival rate of only 40% and advanced disease only 30%. The two important risk factors are tobacco (smoking, chewing or snuff) and alcohol. Alcohol and tobacco act synergistically. Thus, an individual who smokes 40 cigarettes a day and drinks 50 units of alcohol a week has a very high incidence of oral cancer. Alcohol itself is not carcinogenic but it may be that it irritates or somehow affects the protective cellular lining of the oral cavity to allow access of co-carcinogens like tobacco. It may also be the case that people whose livers have failed are less able to detoxify carcinogens. There are other recognised risk factors, such as deprivation and diets poor in fruit and vegetables. Anaemia is associated with oral cancer, as are certain vitamin deficiencies, particularly vitamins A, C and E. Candidal infections have an important role to play. The role of viral infections is unclear. Nasopharyngeal cancer is strongly linked to Epstein-Barr virus and some evidence supports human papilloma virus as being implicated in oral cancer. Lip cancer has a totally different aetiology from other forms of oral cancer. In the early 1900s lip cancer was associated with clay pipe smoking, but it is now sun exposure that is the major risk factor. Many would like to see lip cancer taken out of oral cancer and classified with skin cancer, because its aetiology is the same and many of the factors underlying lip cancer are the same as those related to skin squamous cell carcinoma. In Scotland, deprivation is a major player in the incidence of oral cancer. This may be related to tobacco and alcohol use, dietary
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Figure 2. Age-specific incidence rates of oral cancer for Scotland for 1986-1995
Source: ISD Scotland: Scottish Cancer Intelligence Unit. Cancer Registration Statistics Scotland 1986-95
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Figure 4. Leukoplakia
One of the major problems of oral cancer is late presentation. Mis-diagnosis may occur, for example confusion between cancer of the lip and a cold sore. The history is important in diagnosis. Thus, a cold sore is painful temporarily and relatively superficial whilst cancer of the lip is painless, persistent and indurated. The middle third of the lateral margin of the tongue and the floor of mouth are the most frequent sites for oral cancer. Unfortunately, unlike conditions such as aphthous ulceration which are painful, oral cancer is often painless. Because there is no pain, certainly until the cancer is quite advanced, people do not seek help. Thus, in contrast to extraoral lip lesions, intra-oral cancers are rarely detected whilst small. Small is beautiful small is a key message in relation to diagnosis and management of oral cancer. Unfortunately, most oral cancers present large, often with varied clinical appearances.
lesions are preceded by a leukoplakia an adherent white patch which cannot be diagnosed as any other disease process (Fig. 4). A more sinister lesion is erythroplakia (Fig. 5) - a red patch of the oral mucosa which cannot be diagnosed clinically as another disease. However, it is important to remember that the majority of these premalignant lesions do not progress. In the UK, 2 - 3% of white patches and 3 - 5% of red patches progress to oral cancer. Unfortunately, it is not possible to determine which of these lesions will progress therefore all patients with premalignant signs need to be kept under observation. Tissue biopsy is the only way to diagnose oral cancer. The biopsy specimen should be put on a piece of card or filter paper and placed into formalin. A biopsy specimen shrinks by 30% and will distort if not supported with card. The better the quality of specimen provided to the pathologist, the more
Figure 5. Erythroplakia
Current Treatment of Oral Cancer An Overview__________ Mr Jeremy McMahon, Consultant Oral and Maxillofacial Surgeon, Monklands Hospital, Airdrie
INTRODUCTION
The treatment goal in the management of the majority of patients who present with oral cancer is, self-evidently, to achieve cure. It is, however, worth reflecting on why we emphasise cure and how we measure the outcomes of treatment. Until recently success, or otherwise, of treatment was measured primarily in terms of disease specific survival at 5 years and this remains an important measure in clinical governance terms as well as in trials comparing alternative treatment strategies. However, it is also important to consider overall survival in analysing treatment success, and a discrepancy between the two survival curves is a consistent finding (Fig. 6). A small proportion of this discrepancy may be related to adverse effects of treatment, eg. the patient who chronically aspirates after a resection which involves the pharyngeal wall. The majority of the discrepancy is, however, accounted for by co-morbidity. Recognition of this results in a clearer understanding of treatment aims and a realisation that gauging efficacy of therapy solely in terms of survival curves is too narrow a view. A patient unlikely to survive more than 18-24 months because of a co-morbid condition may still undergo treatment with curative intent. The best way to give the majority of patients with oral cancer an improved quality of life is to achieve a cure. Oral cancer which persists or recurs leads to a progressive decline in quality of life and often a distressing death. Pain, impairment of basic and essential functions such as speech and swallowing, and significant disfigurement are all very real consequences of the disease. However, such adverse outcomes may also be adverse results of curative treatment. Circumstances arise whereby the functional impact of curative treatment is so high that a patient will choose a treatment strategy less likely to achieve locoregional control, or even cure,
Figure 6. Overall and disease specific survival curves for a series of patients presenting with metastatic SCC to the neck from an unknown primary source, demonstrating a lower overall survival compared with disease specific survival.
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Incidence
Mortality 25 20 15 10 5 0
5 Most deprived
Deprivation quintile
Figure 7. ISD data demonstrating increased incidence and mortality from head and neck cancer with social deprivation.
Figure 8. Cause-specific survival by health board Incidence, unadjusted survival at 5 years and adjusted hazard ratio (with 95% CI) compared to Scotland (with 95% CI): patients diagnosed 1991-951
Survival analyses Health Board2 Argyll & Clyde Ayrshire & Arran Borders Dumfries& Galloway Fife Forth Valley Grampian Greater Glasgow Highland Lanarkshire Lothian Tayside Scotland5 Incidence rates3 16.1 13.3 11.6 10.8 13.8 13.8 13.8 20.1 14.5 14.3 15.2 12.9 15.2 No. included in analysis 347 259 76 97 250 186 349 889 153 366 565 273 3874 Unadjusted survival 56.9 64.0 68.7 62.0 56.0 56.7 64.0 54.6 61.6 55.8 52.7 49.4 56.7 Adjusted hazard ratio4 1.00 0.79 0.69 0.82 1.08 1.06 0.81 1.04 0.86 0.98 1.17 1.20 1.00 95% CI Lower 0.85 0.65 0.46 0.58 0.89 0.85 0.68 0.94 0.65 0.84 1.04 1.01 Upper 1.18 0.97 1.05 1.15 1.30 1.32 0.97 1.16 1.12 1.15 1.32 1.43 -
The hazard ratio is the ratio of the rate of death in a health board to the rate in Scotland as a whole. Health boards with higher survival usually have lower hazard ratios. However this is not always the case because the hazard ratios have been adjusted for difference in age, sex and deprivation category between health boards. See the ISD publication Trends in Cancer Survival in Scotland 1971-1995 for further information
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have 5 years follow-up 2 Mainland health boards only 3 Age-standardised incidence rates per 100 000 person-years at risk (European standard population) 4 Adjusted for age and 1991 Census Carstairs deprivation category 5 Figures for Scotland include Orkney, Shetland and Western Isles Source: ISD publication Trends in Cancer Survival in Scotland 1971-1995
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periosteal lymphatics. Advances in our understanding of the mechanisms of tumour nodal metastasis, and the nodal echelons at risk in the neck, have led to mandiblesparing procedures and structure-preserving neck dissections respectively. Current investigation evaluating the efficacy of sentinel lymph node biopsy may lead to a further reduction in the morbidity for many patients at high risk of occult nodal metastasis. The use of access procedures to approach otherwise difficult areas has led to sparing of uninvolved structures whilst facilitating complete and controlled tumour resection. Reconstructive surgical techniques have made enormous strides over three decades. Mandibular reconstruction with free tissue transfer means that it is possible to maintain form and function for the large majority of patients requiring a jaw resection for direct invasion. The replacement of missing lining with local, pedicled, and particularly free flaps, means that oro-cutaneous fistula formation is an uncommon postoperative event, substantially decreasing duration of hospital stay. The replacement of resected oral lining means that secondary loss of function, particularly residual tongue, due to tethering is minimised. This optimises postoperative speech, mastication, and swallowing. Effective methods of reconstituting both the hard and soft palate partition are now widely utilised. Prosthodontic solutions remain the preferred option for some low level maxillary defects however. For early stage disease (T1N0, T2N0), radiotherapy with surgery for salvage is generally regarded as being equally efficacious, with surgery as the primary treatment modality, utilising post-operative radiotherapy where there are adverse pathological features. However, direct comparisons with randomised trials are lacking. The primary treatment modality is chosen on the basis of relative treatment associated morbidity, patient co-morbidity, logistics, and protocols designed to prevent relapse of disease in regional lymph nodes. Recently reported evidence from the West of Scotland demonstrates improved outcomes when treatment planning is protocol based, and this is probably the most important factor in treatment selection. Radiotherapy may be delivered in the form of external beams of particles (photons and electrons) generated by linear accelerators (teletherapy), or in the form of radioactive implants (interstitial or brachytherapy).
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THE JOURNEY
Although it is no holiday, I would like to relate our patients pathway to todays more conventional journey a package holiday. Many professionals can be likened to those who help to make the journey possible during the book-in, check-in, in-flight and ground support all the way to the destination. In order to deliver seamless care we want to get the traveller to the point of departure without unnecessary delays. So at prediagnosis or the booking-in, we want rapid access. Do we offer the local bus service which calls in to every village square, or do we go Inter-city? Has our traveller got the necessary documents? For treatment planning we need to know that the patient is fit to make the journey, so we are the insurance company. If he cannot fly, then we need to arrange an alternative route with the travel agent. But what kind of service does our travel brochure offer? Is it a small outfit which offers limited options, but good personal service, or is it a bigger company, where service is spread more thinly, and where even a short journey needs a big team. In a combined regional oral cancer unit, there must be co-ordination; the bed coordinator, transport co-ordinator, just to start, and there are numerous other co-ordinators along the different stages of the journey. With so many different units involved there must be good communication between ground control and the flight-deck.
Quality of life questionnaires are often complicated and time-consuming to administer successfully. Simply asking your patient What do you want to do that you can no longer do? may quickly give some measure of what is important to his / her quality of life. For example, how often do dentures figure in quality of life questionnaires? And yet, how many of us hear these recurring questions, When will I get my dentures? or Of course, Ill be able to eat, once I get my dentures. How can we guide patients along the pathway to ensure optimum quality of life? Patient pathways are fashionable at the moment, but the care of the oral cancer patient is so individualised and involves so many different disciplines that to design a standardised care pathway is incredibly difficult. What kind of journey is it for the oral cancer sufferer? It is often a one-way ticket, with no turning round. It is usually to a life that will never be the same again, and a successful life depends on how adaptable the traveller proves to be. It is a challenge. In bygone days, it was often a journey without support - dependent on luck, a frontiersman perhaps - dependent on a watering hole, with hopefully no Indians along the way. Perhaps nowadays, it is more like climbing a mountain; for some an afternoon up Ben Lomond, but for others it is more like Mount Everest. Although there may be some support from base camp the hardest stretch must be done alone or perhaps with one close companion - then there is always the descent.
THE TRAVELLERS
The patient journey may be illustrated by some case histories. The question posed is whether their journey was first class or economy class in terms of support. Happy Harry is 75 and he has an early cancer. He is generally well in himself but he is the sole carer for a disabled wife. There are no other family members and he is edentulous. Bingo Betty has multifocal oral dysplasia and she needs yet another small excision. She smokes and takes social alcohol, enjoys her socialising and would not dream of facing the world without her teeth.
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she still socialise? Will she be able to go out of the house? Will she become depressed? A study in the early 1990s by Espie showed that at least one third of oral cancer patients suffer from significant depression. Eleven years on, are we any more skilled in identifying this fact and doing something about it? Pretty Penny has a good chance of cure but she needs psychological support now. Will she be lucky and have access to a counsellor now or will she be one of the thousands of cancer patients who have to draw lots for consultations with psychologists? Will she have support from a member of the MacMillan or a Marie Curie home care team now, or does she live ten miles further down the road where reduced resources mean that the waiting time is six weeks just for a home visit? Will she routinely have ongoing services with a speech therapist so that she can return to work with confidence? Anxious Alan is doing his best and is keen to get back to his computer course. He wants to co-operate with everyone who tries to help him. He has been given sufficient understanding of the proposed treatment. He would like to give up smoking, but no one has actually told him to stop, so he feels like a lost cause. Who will advise on smoking cessation? During treatment, either radiotherapy or chemotherapy, he may have to fend for himself in a hostel. Who will recognise his need for continued support from a dietitian during treatment? Will there be one available to him? He needs help with re-housing, but he feels that he was treated like low-life by the housing officials because is an alcoholic. Who will he confide in? Who will liaise with his social worker or key worker? Aimless Alex has had numerous problems. Several co-morbid conditions were discovered. He has had endless complications including DTs and respiratory infections to name a few. He has received care from every member of the in-house team and from other specialities during all stages of treatment. He especially needs the social work department to find him suitable accommodation so that he can be discharged from hospital, but despite all of this support he still blames everyone else, not least the doctor who did this to him. He can now no longer eat his favourite pie and chips nor manipulate the scrap metal. He is noncompliant and fails to keep appointments. Eventually he is lost to follow-up until he presents to A & E with advanced recurrence.
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Novel and Experimental Treatments__________ Mr Ian Ganly, Specialist Registrar in Otolaryngology, Royal Alexandra Hospital, Paisley One of the main causes of treatment failure in oral cancer is local and regional recurrence, due to minimal residual disease. This is due to inadequate or incomplete surgical resection. The second cause of failure, which is becoming more important, is distant metastatic disease. This is due to clinically and radiologically undetectable micro-metastases. Patients successfully go through surgery and radiotherapy, then six months to one year later present with clinically evident metastatic disease. The third cause of treatment failure is the development of second primaries of the aero-digestive tract. It is estimated that two thirds of patients with oral cancer present with stage 3 or stage 4 disease, i.e. advanced disease. In these patients, the incidence of loco-regional recurrence after treatment is 50% and the incidence of developing distant metastases is 25%. The incidence of recurrence and metastases is directly related to the number of positive neck nodes. The present treatment for recurrence is very poor. Reirradiating patients is seldom possible because the patients have had the full dose of radiation therapy. Brachytherapy is possible for patients with recurrent tongue tumours but results are less good than for primary tumours. Chemotherapy is also of limited benefit. For distant metastatic disease, chemotherapy is usually the only treatment of choice. In both recurrence and distant metastases, the overall response to chemotherapy is only 35%. Rarely is such treatment curative and the duration of response is 6-9 months. In essence, once there is recurrence or distant metastases, the prognosis for patients is extremely poor. The possible clinical situations where novel therapies might be useful are as follows. First, novel therapies could play a role in the treatment of loco-regional recurrence by intra-tumoral injection or by systemic therapy. Secondly, distant metastases, once they have occurred, could be treated by systemic therapy. Thirdly, the prevention of loco-regional recurrence could be undertaken at the time of surgery by treating minimal residual disease, possibly by injecting surgical resection beds to mop up residual cells. Fourthly, it may be possible to prevent distant disease that cannot be detected clinically or radiologically, again by giving systemic therapy. Lastly, there is the treatment of premalignant lesions such as leukoplakia. The types of novel therapies that will be considered are gene therapy, viral oncolytic therapies and antibody therapy. Gene therapy is the transfer of foreign DNA into cells to produce a therapeutic effect. There are three different ways in which DNA or genes can be transferred into cells chemical, physical and viral. DNA can be incorporated into a chemical transporter such as a liposome, enabling transfer across the cell membrane. An example of physical transfer of DNA is to apply an electric current to the tumour cells, which temporarily liquefies the cell membrane, allowing DNA to transfer across. This method is called electroporation, and electroporation guns are now available that can be used to deliver injections to patients. The third and currently most important method is by using viral vectors, such as adenoviruses. These vectors have had a significant amount of their genetic machinery removed from them, which makes them non-replicating. The gene of interest is inserted into these viral vectors and the virus then carries the gene into the cells. There are two ways of doing this. The first is in vivo, where the virus containing the DNA is injected directly into the patient. Alternatively, it can be undertaken ex vivo, by taking cells out of a patient, injecting the virus into the cells and
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this phase one study, the researchers were able to inject up to 1011 virus particles into the patients without producing any toxic side effects. In a phase 2 trial with 101 patients, they were able to produce seven complete responses, ten partial responses and twenty-nine stable diseases. The work has now progressed to a phase 3 trial, the first gene therapy trial in cancer that has reached phase 3.
Tumour cells transfected with wt p53 p53 mediated apoptosis Regression of tumour (wtp53 is dominant)
Patient
RV IL-2 Il-2 stimulates cytotoxic T cells against tumour cells
Inject s/c
G1 S Loss of cell cycle control
Thus, the genes that we would want to transfer, are those which have been lost i.e. tumour suppressor genes. This type of gene therapy is called gene replacement therapy. This has been attempted in clinical trials where the p53 transgene has been injected into patients with recurrent head and neck cancer (Fig. 10a). In 1997, at the MD Anderson Cancer Institute in America, patients with un-resectable tumours in their necks and with a non-functioning p53, had the gene injected back into the tumours. These tumour cells then started expressing the normal gene, became more like normal cells and the cells actually began to die. In
Ganciclovir injection
Ganciclovir activated by tk
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viral replication p5 55
cell lysis
abortive infection
p53
cell lysis
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potential to actually help the immune system. It now has the grand title of psychoneuroimmunology and has produced some interesting and positive results in breast cancer patients. We felt that there were certain things that happened on our pathway that really did help. We were fortunate in having, at that time, the only non-medical fully trained counsellor in Scotland working with oral cancer patients. This meant that not only did we have a translator at consultations but also we were encouraged to write things down, to ask questions and to come away with the answers to them. This allowed us to have both practical and emotional support when we needed it. We had someone to encourage us so that we could make informed decisions and come away feeling that we had done the best we could and perhaps most importantly it helped our morale. We came away sure that generally we understood the future and importantly that the team that looked after us showed us that they cared and were doing everything in their power to get the best result under poor circumstances. They ensured that they were there for us through the good and bad. We never felt excluded or abandoned, even when all their useful treatment was exhausted, and for what more can one ask? To sum up, increased public awareness, sustained professional development and rapid detection, fast track referral to a centre of excellence for diagnosing and treating oral cancer, will save lives.
change of role within the family and society. Although survival, disease-free interval and symptom-free period are the prime concern of patients, the quality of life and functional implications should be carefully considered prior to treatment. Pre-treatment contact with the patient and family enables the therapist to establish a speech profile and to discuss post-treatment outcomes. Although the exact details of the functional effects generally cannot be provided pre-operatively, the focus is on informing the patient that there are likely to be changes in speech and swallowing. The patient can be reassured that although intelligibility may be compromised, he will be able to speak.
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Palliative Care for Head and Neck Cancer___________________ Dr Hugh MacDougall, Consultant Clinical Oncologist, The Edinburgh Cancer Centre, Western General Hospital, Edinburgh What is palliative care in head and neck cancer? There is a speciality called palliative care and it is a very important one, but palliative care is a generality for all care in this field. It is often thought to be about relief of pain and suffering and, particularly, the holistic approach to death and dying espoused by the hospice movement over the last decades. As opposed to that view, there is another concept, which arose at the Christie Hospital, Manchester, in the 1930s and 40s where Ralston Patterson worked. He developed the simple but important concept of the decision as to whether to treat patients in a palliative sense or in a radical sense. He had a fairly straightforward and clear feeling that he could assess a patient. If the patient had a curable tumour they were appropriate for radical treatment with surgery or radiotherapy. If they did not have a curable tumour they were appropriate only for palliative treatment and palliative treatment was only appropriate if the patients had symptoms. In other words,
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there was a group of patients who were relatively asymptomatic who did not need to be treated. Nowadays, we think about skilled symptom control, the appropriate supportive nurse, social and pastoral support and the quote which comes from Cicely Saunders to enable the patient to live until they die. Head and neck cancer accounts for 2% of cancers in the UK, but is very common in the Third World. Both there and here, advanced disease is very common. The clinical problems reflect the anatomical importance of the structures affected. There is a critical interface of the air passages, the food passages and the vital senses. Head and neck cancers are heterogeneous anatomically and histologically and are not one subject. Palliative therapy in head and neck cancer has not been subject to systematic analysis, but the sorts of symptoms that cause problems reflect the pathophysiology. The obstructive symptoms are associated with the obstruction of the airways and food passages. Haemorrhage is
It would be comforting to think that management of head and neck cancer had moved forward greatly since those days of Grant, Cleveland and Freud. Techniques may have improved, and local control rates may have advanced a little, but our decision-making often remains subjective. The decision on whether to treat is crucial in terms of the advanced care of cancer. On many occasions, such decisions are not made for good scientific or clinical reasons and there is little in the literature about this subject. We know that fewer than 40% of oral cancer patients survive in advanced disease and 50% die of local disease progression. Some of the major complaints are pain, dysphagia, airway obstruction, fungating wounds, nausea, vomiting and mucosal dryness. What are the treatment options? Multidisciplinary assessment is vital, even in the advanced cases where palliative treatment is appropriate. It is an easy decision to actively treat and a very difficult decision not to treat. It is still too common to be presented with a patient who has been told by a surgeon outside the unit that he/ she is going to be treated with a course of radiotherapy, when it is probably not in the patients best interest. That makes a decision not to treat even more problematic. In relation to interventions, pain control is becoming more sophisticated. Xerostomia, and associated candidal infections, can be managed medically. Managing speech and communication disorders is an important aspect of palliative treatment. For the treatment of swallowing disorders, the assistance of speech therapists is important. Increasing numbers of patients are being fed by gastric tubes, which is probably appropriate, but there is a little explicit thinking about whether to feed the patient or not to feed the patient. These issues need to be faced up to in terms of explicit decision-making. Radiotherapy does not have a vast role in the palliative treatment itself. Surgery may have a role in many cases in advanced cancer. Photo-dynamic therapy is said to have a role, but current data are inconclusive. On occasion, laser or cryotherapy can help to keep the patient more comfortable than no treatment. In conclusion, palliative care is a significant challenge in head and neck cancer. There are no clear-cut rules and guidelines and lack of good studies. There is, too often, dependence on the experience of clinicians and that can be systematically flawed. It remains unclear to me whether we have made progress since Grover Cleveland, Ulysses Grant and Sigmund Freud.
In relation to periodontal disease, very often after surgery there will be an altered oral anatomy, which may result in difficult access for oral hygiene. There is a reduced vascularity and an impaired capacity of the supporting tissues to re-model and repair following radiotherapy. The reduced salivary flow will also increase plaque accumulation. Osteoradionecrosis of the mandible may arise from sites of periodontal disease. Clearly, pre-treatment assessment is extremely important to try to avoid these situations arising. Another major problem in regard to restorative dentistry is trismus, which is often seen postoperatively and post radiotherapy. This may be reduced by use of jaw exercises at an early stage after treatment, using either patients fingers, tongue spatula or a trismus screw. Osteoradionecrosis can be a real problem in these cases. There are different guidelines as to when teeth should be extracted. The optimal period would be about three weeks prior to radiotherapy. Ill-fitting prostheses after radiotherapy can also cause osteoradionecrosis. In one study of osteoradionecrosis, 23 out of 78 episodes affecting the mandible required fairly radical resection. With regard to rehabilitation, one has to consider all of the functions, namely mastication, speech, swallowing, and control of saliva and respiratory secretions. In some cases there will be cosmetic disfigurement and we also have to consider the psychological rehabilitation. In relation to the maxilla (Figs. 12a-c), there are some surgical aspects which will help in the prosthodontic rehabilitation: retaining as
much of the hard palate as possible, retaining key teeth, using the palatal mucosa to cover the margins of the resection and skin grafting the cheek flap. A skin graft provides more flexibility of the cheek flap, it helps to retain the obturator and it is not as sensitive as respiratory mucosa. With regard to the mandible, there are certain factors which aid prosthodontic rehabilitation. These include mandibular continuity and retention of some teeth. Tongue function is very much better now with the modern surgical techniques involving flaps such as the radial forearm flap. Ridge and soft tissue contours are important and implants will be discussed later.
consider bone grafting. Other implants can be placed in the tuberosity, pterygoid plates and the zygomatic arch. Success rates with implants are higher in non-irradiated patients. It may be necessary to consider the use of hyperbaric oxygen in patients who have had radiotherapy to the jaws.
The Royal College of Surgeons of England has produced guidelines for selecting cases suitable for osseointegrated implants. There are difficulties with funding, but one of the priorities for implants within the NHS is for patients requiring replacements of hard and soft tissues. In the main, implants have been used where conventional treatment has been unsuccessful, but where there is sufficient bone and adequate access for implant placement. Patients must also be motivated. Timing of placement is also an
The other major area for implant use is extraoral rehabilitation. Implants are used now to
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rehabilitate patients with ear, nose and eye defects (Figs. 14a-b). Before the advent of implants, adhesives were used to retain these extra-oral prostheses. National guidelines are being produced for treatment of cancers. This is under the auspices of the National Institute of Clinical
SUMMARY OF CONCLUSIONS
The mortality in Scotland for oral cancer is rising at an alarming rate The disease is not static and is changing for the worse Despite advances in medicine and science, there has been no improvement in survival across Scotland as a whole Early disease can be successfully treated but there remains a high proportion of cases presenting with advanced disease Clinical diagnosis can be difficult Routine examination of the oral cavity during physical examination should be encouraged, looking for colour changes, swelling and persistent ulceration Suspicious or persistent lesions should be biopsied There is a need for education in oral examination techniques and clinical features of oral cancer for a variety of healthcare professionals working in primary care Oral cancer patients have varying needs and require adequate support and information to ensure optimum quality of life Specialist teams are required to provide complete care for oral cancer patients
Rapid access in to the care system for diagnosis, investigation and treatment of oral cancer is required Equity of access can be provided by regionalisation of oral cancer services and by the establishment of managed clinical networks Improvements in outcomes (both survival and quality of life) can most dramatically be affected by ensuring early presentation and rapid access to dedicated head and neck cancer multi-disciplinary teams Such teams are complex involving many health care professionals involved in the diagnosis and assessment, treatment planning, rehabilitation, palliation, and communication Multidisciplinary teams require adequate resourcing Novel therapies in the treatment of oral cancer are in their infancy and are unlikely to impact on the disease for many years Increased public awareness should ensure earlier presentation Widespread use of screening programmes for oral cancer requires further investigation
Increased public awareness, sustained professional development, rapid detection, and fast track referral to a centre of excellence for diagnosing and treating oral cancer will save lives
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Delegates considered two questions. WHY IS LATE PRESENTATION OF ORAL CANCER A CONTINUING PROBLEM? PUBLIC AWARENESS Ignorance of the problem among members of the general public Patients with no recognized risk factors Lack of knowledge about potential for treatment POSSIBLE SOLUTIONS . . . Enhanced publicity, including television activity e.g. Eastenders Need to consider carefully the key messages for publicity Consider deprivation, culture and attitudes PATIENT PATHWAYS Much depends on the patients first port of call Delays within the system if the patient does not enter the correct pathway Lack of equity of service provision POSSIBLE SOLUTIONS . Service re-design with rapid access clinics fast track referral . Regionalisation of oral cancer care in specialist centres . Establishing managed clinical networks EDUCATION Lack of public knowledge and awareness Variability of facilities for examination and investigation Variable expertise among medical and dental practitioners and other healthcare professionals POSSIBLE SOLUTIONS . Increase public awareness and education . Increase funding for primary care education . Improve access for adequate examination and investigation . Develop defined patient pathways
CLINICAL DETECTION . The cohorts of patients most at risk of oral cancer are more likely to be irregular dental attenders Oral cancer is often symptomless in its early stages and diagnosis can be difficult Older patients attend for dental care less often than the young Fear and anxiety surrounding dental attendance Costs of attendance for dental examinations and treatment POSSIBLE SOLUTIONS . . . Free dental examination for patients at risk Targeted screening of patients at risk Opportunistic screening of patients undergoing clinical or dental examination
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LACK OF PUBLIC AND PROFESSIONAL AWARENESS Poor public perception of oral cancer Variable knowledge amongst health care professionals POSSIBLE SOLUTIONS . Public education campaign . Increase funding for primary care education . Encourage research, development of protocols and audit
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The
For further information, please contact: The Royal Society of Edinburgh 22-26 George Street Edinburgh, EH2 2PQ Tel 0131 240 5000 Fax 0131 240 5024 e-mail oralhealth@royalsoced.org.uk web www.royalsoced.org.uk 2003 The Royal Society of Edinburgh. ISBN 0 902198 63 7