The purpose of this study was to assess the participation of Canadian oral and maxillofacial surgeons (OMSs) in the various phases of oral, lip, and oropharyngeal cancer care.
Materials and Methods
A survey was conducted to quantify participation in oral, lip, and oropharyngeal cancer care and assess participation ranging from screening for malignancy to active treatment and rehabilitation of those with late-stage disease.
Three hundred ninety-one surgeons were contacted and 206 (52.7%) responded to the online survey. The survey showed 98.1% of respondents were involved with cancer screening and 97.1% were involved in prevention and early intervention (monitoring and treatment) of premalignant lesions. In addition, 95.1% of respondents participated in diagnosis and staging of tumors. Early-stage cancer was managed surgically by 49.5% of respondents, whereas 11.2% of respondents managed late-stage disease. Management of oral rehabilitation was performed by 79.0% of respondents.
OMSs are an integral part of all phases of oral and oropharyngeal cancer care, including primary surgical oncology, in Canada. Although OMSs in Canada participate widely in integral prevention and survivor rehabilitation programs, few members participate in late-stage disease management and regional multidisciplinary care teams.
Oral, lip, and oropharyngeal cancers encompass up to 75% of all head and neck cancers, accounting for 2% of all cancers in women and 4% in men. In Canada, it is estimated that 4,000 people were diagnosed with oral cancer in 2012. With an incidence of 12 in 100,000, oral cancer is the seventh most common cancer in Canadian men, with a lifetime probability of developing oral cancer of 1 in 66. Globally, oral and pharyngeal cancer is a greater burden than in North America. Incidence rates are as high as 42 in 100,000 in southeast Asia. Outcomes for patients with oral and oropharyngeal cancer are largely dependent on early detection and stage at diagnosis of disease. Early-stage lesions that require less invasive surgical procedures and potentially no medical therapy have a higher survival rate, less morbidity, and better quality-of-life outcomes. Five-year survival rates for early (stage 1 and 2) oral and oropharyngeal cancer range from 60 to 80%, whereas late-stage (stage 3 and 4) cancers have a 20 to 50% 5-year survival. Two-year survival in stage 1 upper aerodigestive tract cancer (including oral, lip, and oropharyngeal cancer) is approximately 90% versus 50% for 2-year survival for stage 4 cancer of the same sites. Despite the importance of early detection, only 14% of adults in the United States have reported having an oral cavity examination at any point during their life and only 7% within the past year. Although this percentage might be larger in some areas of the world, it highlights the lack of surveillance present in an industrialized country.
Dentists in Canada are the primary point of care for oral cavity examination and screening. Common dental visits, such as those for the treatment of caries, periodontal maintenance, recall visits, and prosthodontic reconstruction (ie, visits excluding specific examinations for symptoms of neoplasia and cancer), provide an opportunity to perform oral cancer screening alongside other investigations. General dental practitioners (not primary care physicians) are the most likely primary care providers to identify early-stage malignancies incidentally while performing history and physical examination of the oral and maxillofacial complex. The frequency of routine examination of the mouth and jaws and the larger amount of time devoted to oral and maxillofacial pathology in North American dental training compared with medical training likely account for dentists' increased detection of early-stage oral and oropharyngeal cancer compared with primary care physicians.
Cancer care as a whole is not limited to primary oncologic surgery. Education about the risk factors for cancer, disease prevention through risk factor modification, and appropriate screening play important roles in minimizing the impact of these cancers. After identification of a suspicious lesion, diagnosis and staging using tissue biopsies and appropriate imaging are important steps to characterize the lesion, ultimately directing definitive management of the disease. Survivorship programs and the management of common morbidities and complications affecting the oral cavity that subsequently influence quality of life after treatment of lip, oral, and oropharyngeal cancer are critical. These morbidities are listed in Table 1 .
|Pain||Ingestion||Voice and Speech||Psychosocial|
|Odontogenic—caries||Decreased masticatory ability||Loss of anterior dentition required for ideal speech||Diminished self-confidence|
|Odontogenic—pulpal||Poor diet quality||Oral antral or nasal fistulae, velopharyngeal insufficiency||Poor dental cosmetic outcomes, eg,- loss of lip and smile esthetics|
|Odontogenic—periapical and space infection||Dysphagia||Poor soft tissue support or position||Poor maxillofacial cosmetic outcomes, eg, poor position of jaws and subsequent facial asymmetries|
|Osteoradionecrosis||Dysgeusia||Limited prosthesis feasibility||Loss of enjoyment of food|
|Xerostomia or mucositis||Trismus||Poor prosthetic function||Mood disorders|
Canadian health policy is set by regional or provincial advisory committees, resulting in discrepancies in policy outlining which health care providers comprise treatment teams across the country. Oral and maxillofacial surgeons (OMSs) are involved in all of these forms of oral, lip and oropharyngeal cancer care, but are not currently involved as primary oncologic surgeons in tertiary care multidisciplinary head and neck cancer teams in all provinces in Canada. Multiple fellowship-trained head and neck surgeons with OM surgery as their core surgical specialty are currently facing obstacles obtaining privileges to perform the full scope of head and neck cancer care. As a result of this lack of involvement of OMSs as primary oncologic surgeons, there can be a disconnect between the dental and medical professions in the diagnosis and surgical management of patients with oral and oropharyngeal cancer. Multiple visits to uninvolved general medical and dental practitioners and specialists can lead to delays in definitive treatment. Delays in time from identification of the suspected cancer to definitive treatment result in poorer patient outcomes. Because the most important prognostic factor in oral and oropharyngeal cancer is the stage at diagnosis, initiating treatment as soon as possible is essential to improve outcomes. In addition, a lack of true multidisciplinary approach could result in a surgical reconstruction not reflecting feasible prosthodontic and oral prosthetic rehabilitation plans, thus contributing to a lower quality of life for the patient after treatment.
Despite the lack of OMSs on some regional multidisciplinary head and neck cancer teams, OMSs provide many phases of oral and oropharyngeal cancer care on a routine basis across Canada. OMSs are trained in and involved with the rehabilitation of these complex patients. To quantify the participation of Canadian OMSs in oral, lip, and oropharyngeal cancer care, a survey was conducted identifying participation at various phases of care.
Materials and Methods
Six questions were developed to evaluate the participation of OMSs in head and neck cancer care, specifically the participation in management of oral, lip, and oropharyngeal cancer. Six phases in cancer care spanning screening, prevention, and education to early intervention, premalignant lesion management, and surgical oncologic management to post-treatment rehabilitation were identified in the survey's design. The specific detailed questions are presented in Table 2 . The response to each question was yes or no, indicating an OMS's involvement in the various phases of cancer care.
|1||I am involved in at least 1 of the following screening methods (examining oral cavity for lesions, palpating for lymph nodes, use of ancillary screening tools, ie, VELscope, Invisilight)||Yes or no|
|2||I am involved in prevention and early intervention in at least 1 of the following ways (risk factor management; education on impacts of smoking, alcohol, human papillomavirus, etc; identification or treatment of premalignant lesions such as leukoplakias)||Yes or no|
|3||I am involved in diagnostics and staging through at least 1 of the following modalities (biopsy examination, computed tomography, magnetic resonance imaging, etc)||Yes or no|
|4||I am involved in primary surgical management of stage 1 or 2 cancers of the lip or oral cavity or oropharynx (ie, of cancers that are <2 cm and do not involve the lymph nodes or bone or 2-4 cm not involving lymph nodes or bone)||Yes or no|
|5||I am involved in primary surgical management of late stage 3 or 4 cancers of the lip or oral cavity or oropharynx (ie, of cancers that are of any size involving the lymph nodes and bone or >4 cm)||Yes or no|
|6||I am involved in any or all of the following forms of rehabilitation (mastication, preprosthetic surgery, vestibuloplasties, dental implants, prosthetics, management of trismus [mouth opening], speech, or swallowing)||Yes or no|
OMS registration information with the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) was used to identify OMSs licensed to practice in Canada. In addition, regional OMS registration lists were used to contact nonmember OMSs. Three hundred ninety-one surgeons were identified and contacted electronically by the authors in conjunction with the CAOMS Maxillofacial Oncology and Reconstructive Surgery clinical interest group. Second and third reminder emails were sent 1 and 2 weeks after the initial notification. The survey was closed 1 month after initial contact. No financial incentive was used to encourage participation.