Oral cancer is the sixth most common cancer worldwide. Primary care dentists and GPs both have roles to play in diagnosing the disease.
It is key that all primary care practitioners are aware of the signs and symptoms of oral cancer. They should know when and where to refer. Effective collaboration between practitioners will optimise care. It can lead to better patient outcomes. For GPs, that means providing support, advice and information to patients. This is so patients can get a dental assessment and dental care before starting radiotherapy (where necessary). General dental practitioners (GDPs) should also communicate with and notify GPs when referring a patient through the suspected cancer pathway.
Approximately 8,300 cases of oral cancer are diagnosed each year in the UK. That’s 1 in 50 cancer diagnoses. Approximately 2,300 people die from the disease each year. Around half of all oral cancers are at an advanced stage when they are diagnosed. Early diagnosis of oral cancer is important for many reasons:
- Early diagnosis leads to better survival. A patient with an early cancer has a 90% chance of being cured. Patients with advanced disease have less than a 25% chance of being cured.
- Early diagnosis leads to a better quality of life. Patients with early disease can often be treated with a simple operation to remove their cancer. Patients with more advanced disease often need more disfiguring surgery. This has a much greater impact on their ability to speak and swallow. They are also more likely to need radiotherapy treatment that is associated with a lifelong decrease in quality of life.
- Early diagnosis saves the NHS money. Treating a patient with advanced cancer is three times more expensive than treating early cancer.
Presentation
Oral cancer is not common. Most primary care dentists or GPs will not see cases regularly. It is vital that doctors, dentists, nurses, therapists and hygienists maintain a high level of awareness for any new symptoms or lesions in a patient’s mouth. Providers should consider how they carry out examination of the mouth in the context of coronavirus (COVID-19).
There are several signs and symptoms often associated with oral cancer to be aware of. These include:
- ulcers (present for three weeks or more and usually unilateral)
- white patches (leukoplakia)
- red patches (erythroplakia)
- speckled red and white patches (erythroleukoplakia)
- lumps on lip or in the mouth (not typical of simple mucocele or polyps)
- lumps in the neck
- unexplained pain or bleeding.
Where does oral cancer occur?
Oral cancer can occur anywhere in the mouth, but there are a few areas where it is more common, including:
- lateral tongue (the sides of the tongue)
- ventral tongue (the under-surface of the tongue)
- the floor of the mouth.
- retromolar region around the site of the lower wisdom teeth.
Risk factors
Oral cancer is twice as common in men than in women, but it is important to remember anyone can get oral cancer. Several risk factors are strongly associated with oral cancer:
- Smoking or chewing tobacco is associated with around a third of all cases of oral cancer. Drinking alcohol is associated with around a quarter of cases. The risk for people who drink alcohol and also smoke is many times greater than for people who only smoke or only drink.
- Using betel nut, paan or betel quid is an important risk factor for oral cancer in the UK. It is common in parts of Asia, where it is responsible for making oral cancer the commonest form of cancer.
- Age, socio-economic deprivation and human papillomavirus (HPV) are all also risk factors.
Patient management following cancer treatment
Patients who have had radiotherapy to the head and neck are at high risk of a number of complications. The short and long-term sequelae of oral cancer treatment can have significant consequences for patients’ oral health. These patients may have:
- dry mouth
- oral mucositis
- infection (oral thrush)
- pain
- altered taste
- increased caries rates.
There may be a need for GPs to prescribe, usually as advised by a member of the patient’s multidisciplinary team. Dentists can only prescribe, through the NHS, medications listed on the Dental Practitioners’ Formulary. Some patients may not have a relationship with a dental practice. Where appropriate, GPs should support patient’s oral health by prescribing to support their cancer care plan. This includes:
- saliva substitutes
- analgesics or pain relief
- high fluoride toothpaste
- mouthwash.
Key actions for primary care practitioners
Key actions that you should consider:
- Maintaining a high index of suspicion in any patient with unexplained mouth symptoms or lesions.
- Detecting and onward referral through the two-week suspected cancer pathway. This is for those with a persistent unexplained neck lump or oral ulceration (present for more than three weeks).
- Detecting and urgent referral to a GDP (where one is available) for patients with a lump on the lip or in the mouth, or a red or white patch. If no GDP is available, you should make an urgent referral to secondary care.
- Referring to a GDP for dental assessment before starting oral cancer treatment.
- Giving smoking and alcohol cessation advice at every opportunity.
- Giving sexual health advice in relation to HPV.
- Encouraging regular checks and dental attendance in all patients with above-mentioned risk factors.
- Having clearly defined referral processes and improved communication, and facilitating better access to a GDP for patients with suspected oral cancer. This includes patients in residential care and those with barriers to access.
- Validating your referral by following up with the patient. Ensure they have been assessed and managed within the two-week timescale.
When we inspect
We use these regulations when we review if the practice is safe, effective, responsive, caring and well-led. When we inspect, we look at the culture of the organisation. This relates to:
- Regulation 9: Person-centred Care
- Regulation 12: Safe care and treatment
- Regulation 17: Good governance