Oral Cancers and Potentially Malignant Disorders: Population-Based Interventions for Early Detection

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Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine the effectiveness of population-based interventions for early detection of oral cancers and potentially malignant disorders, either in the general population or in high-risk or symptomatic populations. Evidence was considered insufficient because only one study with relevant health-related outcomes, and limited generalizability to the U.S. population, was identified.

Intervention

Population-based interventions for early detection of oral cancers and potentially malignant disorders can take many forms, which include:
  • Educating the public about the risk factors, symptoms, and signs of oral cancer, and the value of early detection
  • Encouraging high-risk or symptomatic people to examine themselves for suspicious lesions and seek professional examination and care
  • Training health workers to detect suspicious lesions and refer patients for follow-up as needed
  • Screening people through community outreach initiatives at the workplace, home, health fairs, field clinics, or through usual source of care, and referring those with suspicious lesions for follow-up and treatment

This review does not cover screening done as part of routine dental examinations in primary care settings. The U.S. Preventive Services Task Force evaluated the effectiveness of screening asymptomatic adults for oral cancer in the primary care setting and found insufficient evidence to assess the balance of its benefits and harms.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

About The Systematic Review

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to oral health.

Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny A-M. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database of Systematic Reviews 2013;11.

The published review included 1 study (search period 1950-2013). The CPSTF finding is based on results from the published review, additional analyses of data from included studies, and expert input from team members and the CPSTF. This finding updates and replaces the 2000 Task Force finding on Population-Based Interventions for Early Detection for Oral and Pharyngeal Cancers.

Context

The updated search for evidence identified a systematic review that evaluated the accuracy of screening tests for the early detection of oral cancers and potentially malignant disorders. Findings from this review are covered comprehensively by the U.S. Preventive Services Task Force.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

One study qualified for the review.

  • A single study looking at the effectiveness of screening programs for improving oral cancer outcomes showed a 24% reduction in oral cancer mortality in high-risk individuals (those who used tobacco or alcohol or both).
  • The study also showed that the proportion of cancers diagnosed as stage III or worse were significantly lower among those participants undergoing screening (53%) compared to those who did not receive screening (65%).

Summary of Economic Evidence

An economic review of this intervention was not conducted because the CPSTF did not have enough information to determine if the intervention works.

Applicability

Applicability of this intervention across different settings and populations was not assessed because the CPSTF did not have enough information to determine if the intervention works.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help fill remaining gaps in the evidence base. (What are evidence gaps?)
  • High quality research in needed in different settings with populations that have varying cancer rates.
  • Studies are needed to evaluate the effectiveness of other forms of population-based initiatives, such as public awareness campaigns and educational interventions, with relevant health-related outcomes.
  • More research is needed on the steps that follow initial detection and diagnosis, including management of potentially malignant disorders, effective treatment strategies, potential markers that can predict the likelihood for developing into a malignancy, time frame for progression, and patients’ knowledge and compliance with referrals and follow-up.
  • Continuing research should be done to help identify those at higher risk for oral cancer, particularly as causes emerge or become more common (e.g., infection with human papillomavirus [HPV])

Study Characteristics

  • The one included study was conducted in India, where the incidence of oral cancer is greater than in the U.S.
  • The randomized controlled trial had a large sample size (n=191,873) and 15 years of follow-up data.

Analytic Framework

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Effectiveness Review

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny A-M. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database of Systematic Reviews 2013;11.

Included Studies

Effectiveness Review

Refer to the existing systematic review for a full list of included studies:

Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny A-M. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database of Systematic Reviews 2013;11.

Search Strategies

Effectiveness Review

Refer to the existing systematic review for information about the search strategy:

Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny A-M. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database of Systematic Reviews 2013;11.

Review References

Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny A-M. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database of Systematic Reviews 2013;11. Available at URL: http://summaries.cochrane.org/CD004150/ORAL_screening-programmes-for-the-early-detection-and-prevention-of-oral-cancer.

Walsh T, Liu JLY, Brocklehurst P, Glenny A-M, Lingen M, Kerr AR, Ogden G, Warnakulasuriya S, Scully C. The detection of oral cavity cancers and potentially malignant disorders in apparently healthy adults. Cochrane Database of Systematic Reviews 2013;11. Available at URL: http://summaries.cochrane.org/CD010173/ORAL_the-detection-of-oral-cavity-cancers-and-potentially-malignant-disorders-in-apparently-healthy-adults.

Considerations for Implementation

Despite the finding of insufficient evidence, the following are considerations for implementation drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • These interventions are challenged by low rates of participation and follow-up.
    • Studies evaluating the accuracy of screening methods within population-based programs found participation rates ranged from 50%-93% (Walsh et al., 2013).
  • Some evidence suggests the surgical removal of potentially malignant lesions may not remove the risk of a malignancy developing.
  • It is important to focus on prevention strategies that reduce risk of oral cancer (e.g., tobacco use and alcohol abuse prevention programs). Such programs would support the World Health Organization’s resolution to incorporate oral cancer into national cancer control programs.