Preventing and Controlling Oral and Pharyngeal Cancer Recommendations from a National Strategic Planning Conference
In August 1996, CDC convened a national conference to develop strategies for preventing and controlling oral and pharyngeal cancer in the United States. The conference, which was cosponsored by the National Institute of Dental Research of the National Institutes of Health and the American Dental Association, included 125 experts in oral and pharyngeal cancer prevention, treatment, and research; both the private and public sectors were represented. Participants at the conference developed recommendations concerning advocacy, collaboration, and coalition building; public health policy; public education; professional education and practice; and data collection, evaluation, and research.
A follow-up meeting consisting of selected participants of the 1996 conference was held in September 1997. During this meeting, changes that had occurred in the political and scientific arenas since the 1996 conference were considered, and 10 recommended strategies from the conference were selected for priority implementation. These 10 strategies were to a) establish a mechanism to implement and monitor the recommended strategies developed during the conference; b) urge oral health professionals to become more actively involved in community health; c) require instruction in preventing and controlling tobacco and alcohol use at all levels of training in dental, medical, nursing, and other related health-care disciplines; d) encourage Medicaid, Medicare, traditional insurance plans, and managed-care entities to consider making oral cancer examinations an integral part of comprehensive physical and oral examinations; e) designate federal funding for a national program of oral cancer prevention, early detection, and control; f) after assessing local needs, develop, implement, and evaluate statewide models to educate all relevant groups; g) develop and conduct a national promotional campaign to raise public awareness of oral cancer and its link to tobacco use and heavy alcohol consumption; h) develop health-care curricula that require competency in prevention, diagnosis, and multidisciplinary management of oral and pharyngeal cancer; i) sponsor and promote continuing education for health-care professionals on the multidisciplinary management of all phases of oral cancer and its sequelae; and j) strengthen organizational approaches to reducing oral cancer by developing organized cooperative and collaborative arrangements, funding formal centers, and involving commercial firms.
CDC will use these recommended strategies to develop programs to reduce the burden of oral and pharyngeal cancer in the United States. Through the Oral Cancer Roundtable, a group of conference and meeting participants, CDC will communicate to interested agencies, organizations, and state health departments ways in which they can implement elements of the national plan. The Roundtable will help CDC track the efforts and progress of these groups.
During the past decade, federal health agencies have focused on reducing the incidence of oral and pharyngeal cancer and increasing the 5-year survival rate from these cancers in the United States. Beginning with a consortium of health agencies in 1992 (and including a strategic planning conference in 1996 and a follow-up meeting in 1997), CDC has been involved in concerted efforts to establish a national plan for preventing and controlling these cancers. This report presents recommended strategies for action from the 1996 conference and a list of priority recommendations from the 1997 meeting. These recommendations will enable CDC to develop a coordinated national plan to reduce morbidity and mortality from oral and pharyngeal cancer in the United States.
ORAL AND PHARYNGEAL CANCER
Oral cancer (i.e., cancer of the lip, tongue, floor of the mouth, palate, gingiva and alveolar mucosa, buccal mucosa, or oropharynx) * accounts for 2%-4% of cancers diagnosed annually in the United States; approximately two thirds occur in the oral cavity, and the remainder occurs in the oropharynx (1). In 1998, this diagnosis will be made in an estimated 30,300 Americans; approximately 8,000 deaths (5,200 males and 2,800 females) are expected in this year (2). Ninety-five percent of cases of oral cancer occur among persons aged greater than 40 years, and the average age at diagnosis is 60 years (3). In 1950, the male-to-female ratio of oral cancer incidence was approximately 6:1; by 1997, it was approximately 2:1. The changing ratio is likely the result of the increase in smoking among women in the past three decades (3). In addition, cancer is an age-related disease, and in the United States, the number of women aged greater than 65 years now exceeds the number of men aged greater than 65 years by almost 50% (3). During 1990-1994, the annual incidence rate among black males in the United States was 1.6 times higher than the rate among white males (20.1 versus 12.9 new cases per 100,000) and the annual mortality rate among black males was 2.5 times higher (7.6 versus 3.1 deaths per 100,000); the annual incidence rate among black females was slightly higher than that among white females (5.6 versus 4.9 new cases per 100,000), as was the annual mortality rate (1.8 versus 1.2 deaths per 100,000) (4). Despite agressive combinations of surgery, radiation therapy, and chemotherapy, the 5-year survival rate for oral cancer is poor (blacks: 35%; whites: 55%) (1,5).
Tobacco smoking (i.e., cigarette, pipe, or cigar smoking), particularly when combined with heavy alcohol consumption (i.e., greater than or equal to 30 drinks per week), has been identified as the primary risk factor for approximately 75% of oral cancers in the United States (6). The use of tobacco in other forms (i.e., snuff and chew) has also been identified as a risk factor (7-9), as have certain other lifestyle and environmental factors (e.g., diet and occupational exposure to sunlight) (10).
Approximately 90% of oral cancer lesions are squamous cell carcinomas. Persons who have oral cancer often develop multiple primary lesions (i.e., field cancerization), and they develop second primary tumors at a rate of approximately 4% annually (11). Persons having primary oral cancer are more likely to develop a second primary cancer of the aerodigestive tract (i.e., oral cavity, pharynx, esophagus, larynx, and lungs) (12,13). The initally diagnosed disease accounts for one half of the deaths caused by oral cancer; one fourth of these deaths are due to a second primary cancer, and the remaining one fourth are attributable to other illnesses (13).
Diagnosing cancers at an early stage is crucial to improving survival rate and reducing morbidity. At the time of diagnosis of oral cancer, 36% of persons have localized disease, 43% have regional disease, and 9% have distant disease (for 12% the disease is unstaged) (4). The 5-year survival rate for persons having oral cancer is 81% for those with localized disease, 42% for patients with regional disease, and 17% for those with distant metastases (4). During the past decade, at diagnosis stage has not changed significantly (3).
ORAL CANCER STRATEGIC PLANNING CONFERENCE Background
In 1992, a consortium of health agencies led by CDC and the National Institute of Dental Research (NIDR) of the National Institutes of Health began to establish goals, objectives, and programs to reduce oral cancer morbidity and mortality in the United States. The Oral Cancer Work Group, which was formed as part of this initiative, subsequently developed short-term and long-term goals for preventing and controlling oral cancer. A list of these goals was disseminated to interested organizations and individuals in 1993.
One of the recommendations of the Oral Cancer Work Group was to summarize the state of the science regarding oral cancer. In response, CDC commissioned nine background papers regarding the prevention, control, and treatment of the disease and addressing current knowledge, emerging trends, opportunities, and barriers to further progress. The authors, representing several specialties and expertise, drew on current literature reviews, in-depth critiques, and personal experience.
The Oral Cancer Work Group also suggested that CDC convene a conference to develop national strategies to help make oral cancer prevention and control a higher public health priority. Subsequently, CDC, in partnership with NIDR and the American Dental Association (ADA), formed a conference planning group. The planning group, along with a larger cadre of oral cancer experts, developed a draft set of strategies. This draft and the nine background papers were distributed to invited participants before the conference.
The Oral Cancer Strategic Planning Conference was held August 7-9, 1996, at the ADA headquarters in Chicago. Participants included 125 invited experts in oral cancer prevention, treatment, and research; both the private and public sectors were represented. Following brief welcoming remarks by ADA, CDC, and NIDR representatives, nationally recognized experts made presentations on the etiology of oral cancer, its epidemiology, ongoing and needed research, and clinical experience with five other cancers (i.e., leukemia and breast, cervical, lung, and prostate cancers). A survivor of oral cancer described the human impact of the disease.
Conference participants broke into five work groups: advocacy, collaboration, and coalition building; public health policy; public education; professional education and practice; and data collection, evaluation, and research. Each work group had a chairperson and co-chairperson who were preselected from the conference participants; toward the conclusion of the conference, chairpersons presented their work groups' recommended strategies to all conference participants, who provided oral and written feedback. The work groups made revisions, including comments raised during the general session.
After the conference, the recommended strategies were disseminated to all participants for final review and comments. These last comments were incorporated to produce the finalized recommended strategies to reduce oral cancer morbidity and mortality in the United States.
Recommended Strategies from Work Groups Advocacy, Collaboration, and Coalition Building
The work group on advocacy, collaboration, and coalition building (e.g., formation by the oral health community of partnerships with other health professionals and public or private organizations to facilitate increased awareness of the risk factors for oral cancer) developed three main recommended strategies.
Public Health Policy
This work group presented its recommended strategies in four categories.
Prevention and Control of Tobacco and Alcohol Use.
Professional Knowledge and Behaviors. **
Seven major strategies were recommended by the work group on public education.
Professional Education and Practice
This work group developed five recommended strategies.
In addition, the work group identified seven initiatives that would facilitate achievement of their recommended strategies: develop educational standards and standards of care for oral cancer; standardize techniques for oral cancer examination and implement them consistently; create a national speakers bureau with standardized educational materials; place an oral cancer home page on the World Wide Web; create guidelines for developing screening and detection programs; develop self-instructional materials for health professionals on a range of topics (e.g., risk factors, early detection, and counseling of high-risk patients); and identify and catalog professional education materials, determine deficits in these materials, and ensure access to the cataloged materials.
Data Collection, Evaluation, and Research
These recommended strategies would facilitate research regarding the etiology, prevention, and treatment of oral cancer and would translate research findings into effective public health action.
ORAL CANCER WORKING GROUP
The Oral Cancer Working Group, a multidisciplinary group who attended the 1996 Oral Cancer Strategic Planning Conference, met September 29-30, 1997, to identify 10 strategies from the 1996 meeting recommendations to receive immediate attention and implementation by the agencies they represented. The Oral Cancer Working Group considered political and scientific changes that had occurred after the 1996 conference (e.g., the U.S. Food and Drug Administration had been given regulatory authority over tobacco, legal cases involving tobacco had been settled in several states, national tobacco legislation had been proposed, and four comprehensive oral cancer research centers had been funded by NIDR) and selected strategies the group could effect (as opposed to strategies already under way as a result of the leadership and support of other groups). Leadership at the 1997 meeting was shared by representatives of ADA, the American Association of Dental Research, the Association of State and Territorial Dental Directors, CDC, the International Society of Oral Oncology, NIDR, and Oral Health America. The 10 priority strategies are as follows.
Advocacy, Collaboration, and Coalition Building
Public Health Policy
Professional Education and Practice
Data Collection, Evaluation, and Research
At the 1997 follow-up meeting, the Oral Cancer Working Group created a smaller group known as the Oral Cancer Roundtable. Members of the Roundtable will communicate among themselves to discuss implemention of the priority recommendations and the recommendations from the 1996 conference and to share information on progress made. Through the Roundtable, CDC will communicate to interested agencies, organizations, and state health departmets ways in which they can implement elements of the national plan. The Roundtable will help CDC track the efforts and progress of these groups.
National efforts to reduce morbidity and mortality associated with oral cancer must focus on two areas: primary prevention (i.e., reducing risk factors) and early detection. Although persons at high risk for the disease are more likely to visit a physician than a dentist, physicians may be less likely than dentists to perform an oral cancer examination on such patients (17-21). Thus, all primary-care providers must assume more responsiblity for counseling patients about behaviors that put them at risk for developing this cancer, examining patients who are at high risk for developing the disease because of tobacco use or excessive alcohol consumption (22), and referring patients to an appropriate specialist for management of a suspicious oral lesion. Comprehensive education of medical and dental practitioners in diagnosing and promptly managing early lesions could facilitate the multidisciplinary collaboration necessary to detect oral cancer in its earliest stages. Furthermore, because of the public's lack of knowlege about the risk factors for oral cancer and because this disease can often be detected in its early stages (21,23), the public's awareness of oral cancer (including its risk factors, signs, and symptoms) must also be increased.
Oral cancer occurs in sites that lend themselves to early detection by most primary health-care providers and, to a lesser extent, by self-examination. Heightened awareness in the general population could help with early detection of this cancer and could stimulate dialogue between patients and their primary health-care providers about behaviors that may increase the risk for developing oral cancer. Recent advances in understanding the molecular events involved in developing cancer might provide the tools needed to design novel preventive, diagnostic, prognostic, and therapeutic regimens to combat oral cancer. Acquiring greater knowledge of the biology, immunology, and pathology of the oral mucosa may also help to reduce the morbidity and mortality from this disease.
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