Perceptions and Practices of General Practitioners towards Oral Cancer and Emerging Risk Factors among Indian Immigrants in Australia: A Qualitative Study

Background: In Australia, Indian immigrants are one of the fastest-growing communities. Since oral cancer is widespread in India, the indulgence of Indians in customs of areca (betel) nut use in Australia may be linked to the recent rise in oral cancer cases. Since GPs (general practitioners) are primary healthcare providers, it is pivotal to ensure the oral cancer awareness of GPs. This study aimed to explore oral cancer risk-related knowledge, beliefs, and clinical practices of GPs in Australia. Methods: Fourteen semi-structured interviews were conducted with GPs practicing across New South Wales and Victoria. Purposive and snowball sampling were used for recruitment. Data were analysed through a directed content analysis approach. Results: All GPs were knowledgeable of major oral cancer causative factors including tobacco and alcohol, but some had limited understanding about the risks associated with areca nut preparations. Positive attitudes were evident, with all participants acknowledging the importance of oral cancer risk assessment. Most GPs recalled not performing oral cancer routine check-ups. Conclusion: GPs presented good oral cancer knowledge except for emerging risk factors such as areca nut use. Varied beliefs and inconsistent clinical practices relating to oral cancer screening is concerning. Accessible oral cancer training around emerging risk factors may benefit GPs.

Leveraging Clinical Decision Support and Integrated Medical-Dental Electronic Health Records to Implementing Precision in Oral Cancer Risk Assessment and Preventive Intervention

Introduction: Precision medicine is focused on serving the unique needs of individuals. Oral and oropharyngeal cancer risk assessment identifies individual risk factors while providing support to reduce risk. The objective is to examine potential current and future strategies to broadly implement evidence-based oral and oropharyngeal cancer risk assessment and screening in dental practices throughout the United States. Methods: Feasible and effective oral cancer risk assessment and risk reduction strategies, ripe for implementation in dental practice, were identified in the published literature. Results: The Screening, Brief Intervention, Referral for Treatment (SBIRT) model is a feasible approach to assessing individual oral cancer risk and providing risk reducing interventions in the dental setting. HPV is a more recently identified risk factor that dentistry is well positioned to address. Evidence supporting the utilization of specific risk assessment tools and risk reduction strategies is summarized and future opportunities discussed. Discussion: Current knowledge of risk factors for oral and oropharyngeal cancers support the recommendation for dental providers to routinely assess all patients for risk factors, educate them about their personal level of cancer risk, and recommend actions to reduce relevant risk factors. Individuals ages 9–26 should be asked about their HPV vaccination status, educated about HPV and oropharyngeal cancer and receive a recommendation to get the HPV vaccination.

Risk-Based Selection of Individuals for Oral Cancer Screening

PURPOSE: We evaluated proof of principle for resource-efficient, risk-based screening through reanalysis of the Kerala Oral Cancer Screening Trial. METHODS: The cluster-randomized trial included three triennial rounds of visual inspection (seven clusters, n = 96,516) versus standard of care (six clusters, n = 95,354) and up to 9 years of follow-up. We developed a Cox regression–based risk prediction model for oral cancer incidence. Using this risk prediction model to adjust for the oral cancer risk imbalance between arms, through intention-to-treat (ITT) analyses that accounted for cluster randomization, we calculated the relative (hazard ratios [HRs]) and absolute (rate differences [RDs]) screening efficacy on oral cancer mortality and compared screening efficiency across risk thresholds. RESULTS: Oral cancer mortality was reduced by 27% in the screening versus control arms (HR = 0.73; 95% CI, 0.54 to 0.98), including a 29% reduction in ever-tobacco and/or ever-alcohol users (HR = 0.71; 95% CI, 0.51 to 0.99). This relative efficacy was similar across oral cancer risk quartiles ( P interaction = .59); consequently, the absolute efficacy increased with increasing model-predicted risk—overall trial: RD in the lowest risk quartile (Q1) = 0.5/100,000 versus 13.4/100,000 in the highest quartile (Q4), P trend = .059 and ever-tobacco and/or ever-alcohol users: Q1 RD = 1.0/100,000 versus Q4 = 22.5/100,000; P trend = .026. In a population akin to the Kerala trial, screening of 100% of individuals would provide 27.1% oral cancer mortality reduction at number needed to screen (NNS) = 2,043. Restriction of screening to ever-tobacco and/or ever-alcohol users with no additional risk stratification would substantially enhance efficiency (43.4% screened for 23.3% oral cancer mortality reduction at NNS = 1,029), whereas risk prediction model–based screening of 50% of ever-tobacco and/or ever-alcohol users at highest risk would further enhance efficiency with little loss in program sensitivity (21.7% screened for 19.7% oral cancer mortality reduction at NNS = 610). CONCLUSION: In the Kerala trial, the efficacy of oral cancer screening was greatest in individuals at highest oral cancer risk. These results provide proof of principle that risk-based oral cancer screening could substantially enhance the efficiency of screening programs.

Green Salad Intake Is Associated with Improved Oral Cancer Survival and Lower Soluble CD44 Levels

Deficiencies in fruit and vegetable intake have been associated with oral cancer (oral cavity and oropharyngeal). Salivary rinses contain measurable biomarkers including soluble CD44 (solCD44) and total protein, which are known markers of oral cancer risk. This study investigates the effect of nutritional factors on solCD44 and protein levels to evaluate oral cancer risk and survival. We evaluated solCD44 and protein levels from 150 patients with oral and oropharyngeal squamous cell carcinoma and 150 frequency-matched controls. We subsequently characterized the effect of food group consumption and these biomarkers on progression-free survival (PFS) and overall survival (OS). Patients reported eating fewer servings of salad (p = 0.015), while controls reported eating fewer servings of potatoes (p < 0.001). Oral cancer patients who consumed at least one serving per week of green salad were found to have significantly lower CD44 levels than those who ate salad less frequently (mean of log2[solCD44]1.73 versus 2.25, p = 0.014). Patients who consumed at least one serving per week of “salad or other vegetables” had significantly longer PFS (median 43.5 versus 9.1 months, p = 0.003, adjusted hazard ratio (HR) = 0.39 p = 0.014) and OS (median 83.6 versus 10 months, p = 0.008, adjusted HR = 0.04 p = 0.029). These findings suggest that dietary factors, namely greater green salad and vegetable intake, may be associated with lower CD44 levels and better prognosis in oral cancer patients.

Correlation of Salivary Thiocyanate Levels and Oral Cytological Changes in Smokers

Introduction: Smokers are found to have higher salivary thiocyanate (SCN) concentration compared to normal non-smokers. This elevated level of the SCN in the saliva of smokers may be responsible for oral cancer risk among smokers through nitrosation process. The objective of the study is to estimate salivary thiocyanate levels in tobacco smokers and non-smokers and correlate the levels of thiocyanate with cytomorphological changes in oral mucosa. Methods: This is a comparative cross-sectional study conducted among 40 non-smokers and 40 smokers in outpatient department of Kantipur Dental College. Salivary thiocyanate level was estimated from the saliva sample. Cytological atypia, cytomorphometric changes and micronuclei frequency was estimated from smear from buccal mucosa. Results: Mean salivary thiocyanate level in smokers (3.16 Mm/l 1.61 Mm/l) was higher compared to non-smokers (0.95Mm/l 0.54 Mm/l) which was statistically significant (P<0.001). There were also more atypical changes in smoker than that found in nonsmokers. The mean nuclear cytoplasmic ratio was also higher in smokers compared to nonsmokers which was statistically significant (P<0.001). Similarly, the micronuclei frequency in smokers (1.79 0.76) was also found higher compared to micronuclei frequency in non-smokers (1.24 0.74) which was statistically significant (P=0.002). However, the correlation between salivary thiocyanate level and cytomorphometric changes was weak. Conclusions: Estimation of salivary thiocyanate level and cytological changes are noninvasive, painless and prove to be an efficient tool in screening a large population as well as in aiding motivation of individuals for withdrawal of tobacco smoking.

Erythrocyte ω-3 polyunsaturated fatty acids are inversely associated with the risk of oral cancer: a case-control study

Objectives Evidence about ω-3 polyunsaturated fatty acids (ω-3 PUFAs) and oral cancer risk were limited. We aimed to evaluate the association of erythrocyte ω-3 PUFAs with the risk of oral cancer in a population from China. Methods Erythrocyte ω-3 PUFAs of 236 oral cancer patients and 300 controls were determined by gas chromatography. Restricted cubic spline and logistic regression were used to analyze the association between erythrocyte ω-3 PUFAs and oral cancer risk. The crude and adjusted OR with 95% CI was calculated. Stratification analysis was performed to explore the potential interaction between ω-3 PUFAs and other traditional risk factors such as smoking and drinking. Results Eicosapentaenoic acids (EPA), docosahexaenoic acids (DHA) and ω-3 index were negatively but non-linearly related to risk of oral cancer as observed by restricted cubic spline. The adjusted OR of EPA, DHA, and ω-3 index were 0.52 (95% CI: 0.35–0.76), 0.19 (95% CI: 0.08–0.44), 0.20 (95% CI: 0.09–0.44), respectively. Stratification analysis showed that the adverse correlation between EPA and oral cancer was only significant in the non-smoking group, while the adverse correlation of ɑ-linolenic acid (ALA), EPA, and DHA were only significant in the non-drinking group. General multiplicative interactions were observed between ω-3 PUFAs and smoking or drinking. Conclusions Adverse but non-linear associations were observed between erythrocyte EPA, DHA, ω-3 index, and oral cancer risk. Additionally, there were multiplicative interactions between ω-3 PUFAs and other behavior factors such as smoking and drinking. The protective effect of ω-3 PUFAs maybe more significant in the non-smoking or non-drinking population.