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Detecting oral cancer in the post-Covid Era: Unfit for purpose or golden opportunity?

Euan Mackinnon is an Academic F2, Department of Primary Care at Brighton and Sussex Medical School and Dentist.

Sangeetha Sornalingam is a Senior GP Teaching Fellow at Brighton and Sussex Medical School.

Max Cooper is a GP and Senior Lecturer in GP, Department of Primary Care, Brighton and Sussex Medical School.

The close-proximity transmission of COVID-19 risks causing a surge in late-presenting oral cancers. Opportunities for detection are being missed in primary medical and dental services. GPs have been advised not to examine the oral cavity unless essential whilst wearing full PPE. Over 14 million dental appointments were missed in 2020. Between March and June 2020, primary care dental services were reduced to emergencies only. Although routine dentistry has now resumed, emergencies remain prioritised and fewer patients are seen per session. “Fallow time” between aerosol generating procedures has cut capacity by between one third and three-quarters.

Pre-COVID, head and neck cancer was already a disease that presented late with 62% of cases diagnosed at stage III or IV. Unsurprisingly, more advanced disease is linked with greater morbidity and mortality. There is emerging evidence globally that COVID-19 lockdowns have reduced head and neck cancer referrals to secondary care and that primary tumour size is significantly larger at presentation.1 Prompt interventions are required now to reverse this worrying trend.

Pre-COVID, head and neck cancer was already a disease that presented late.

Current Referral Guidance: Fit for Purpose?

In an ideal world, patients with suspicious oral lesions would be triaged and referred by their dentist. In reality, only 44.5% of the adult population have attended a dental appointment in the previous two years, a figure likely to now be worse due to government enforced lockdowns. Pre-COVID, just over 50% of oral cancer referrals in the UK were made by GPs.2,3 Current NICE guidelines suggest that if a patient presents to the GP with a non-healing ulcer in the oral cavity of more than three weeks duration or a persistent unexplained neck lump, then a referral to Oral and Maxillofacial Surgery should be made on a two-week wait pathway. Ambiguity exists, however, for less clear cut but suspicious pathologies. A lump on the lip or within the oral cavity, a red patch (erythroplakia) or red/white patch (erythroleukoplakia) should be referred urgently for assessment by a dentist within two weeks. This puts the onus on the patient to arrange (and possibly pay for) a dental appointment as no formal referral pathway between GPs and dentists currently exists. Barriers to accessing dental care are significant and include treatment anxiety, financial cost, self-perception of need and lack of access.4 This informal referral process is not fit for purpose and risks diagnostic delay for patients, especially in the wake of the COVID-19 pandemic.

Barriers to accessing dental care are significant.

Re-thinking oral cancer detection in the Post-COVID Era

GPs cannot become patients’ dentists and must encourage all patients to register with a dentist for regular checkups. Checking dental registration status should become part of new patient registration and appropriate signposting advice provided. Despite some GP concerns over indemnity for dental problems, NICE guidelines underline the need for GPs to provide care for key problems (e.g. dental abscess), where access to dental care is impossible or where patients become systemically unwell or there is a risk to their airway. GPs must use clinical judgement in offering analgesia, antibiotics, or referral. This also constitutes an opportunity for GPs to detect suspicious lesions and educate patients who might otherwise not engage in oral health.

The recent reduction in serious disease from COVID-19 due to vaccination means that now is the time for GPs to be proactive in resuming intra-oral examination.1 Telemedicine is suboptimal for this, not least because neck palpation for lymphadenopathy is essential. A strategy must be found to address ambiguous referral criteria for erythroplakia/erythroleukoplakia. Lack of access to a dentist disproportionally affects lower socio-economic groups who are statistically at higher risk of developing oral cancer.

As oral cancer most frequently presents late, GP efforts must go hand in hand with public health measures.

GPs should consider these barriers a “yellow flag” for increased oral cancer risk. One way forward is financial recognition of this workload in general practice and its contribution to tackling health inequality. Remuneration according to strict referral criteria could increase detection rates, especially among “deep end” surgeries serving deprived communities. Basic oral examination is quick to perform: with appropriate training, it could be included in routine GP health checks.

As oral cancer most frequently presents late, GP efforts must go hand in hand with public health measures. This could include educating patients (as per breast and testicles) in basic self-examination of the mouth. There is a clear need for increased awareness, proactive examination and greater public engagement to prevent a surge in late presenting oral cancers in the post-COVID era.

As we emerge from lockdown, the crucial role of the GP in detecting oral cancer must not be overlooked.

References

  1. Mackinnon E, Sornalingam S, Cooper M. Urgent call to prevent late stage presentation of head and neck cancer. BMJ. 2021;373:n1194.
  2. Rogers SN, Pabla R, McSorley A, Lowe D, Brown JS, Vaughan ED. An assessment of deprivation as a factor in the delays in presentation, diagnosis and treatment in patients with oral and oropharyngeal squamous cell carcinoma. Oral Oncology 2007; 43(7):648-655
  3. Crossman T, Warburton F, Richards MA, Smith H, Ramirez A, Forbes LJL. Role of general practice in the diagnosis of oral cancer. Br J Oral Maxillofac Surg. 2016;54(2):208–12.
  4. Krishnan L, C. S. A, Kumar P. Barriers to access dental care services among adult population: A systematic review. Journal of Global Oral Health. 2020;3:54-62.

 

Featured photo by Bermix Studio on Unsplash

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