understanding oral cancer · references choi sw, thomson p. increasing incidence of oral cancer in...

Understanding

Oral Cancerin the

Mariana Islands

LAWRENCE L. WILLIAMS, JR., MD

ENT SURGEON

“The views presented in this presentation

are the views of the author and not the

views of DoD or the Navy.”

Contents

Global Impact?

What does it look like?

How do we screen for it?

How do we treat it?

What causes it?

Local Challenges?

Global Impact

5th Most Common Cancer in the World

400,000 new cases a year

95% of all oral cancer is Squamous Cell Carcinoma (SCCa)

Majority of the studies from India, Hong Kong, and Taiwan.

Typically involving tongue and buccal mucosa in Southern/SE Asia and Oceana

Greatest Risk Factors:

Age

Tobacco use

Tobacco + Alcohol

Betel Nut

So, what’s the rub?

Globally over the past 50 years there has been a general trend in prognosis improvement with all cancers.

However, Oral Cancer prognosis, while improved still hasn’t matched the overall trend and it hovers around/above 50%

By the time oral cancers are discovered, they are usually Stage III/IV resulting in a poor prognosis.

What does it look like?

“Oral Potentially Malignant Disorders” (OPMD)

Leukoplakia

Erythroplakia

Oral Submucosal Fibrosis (OSF)

Sialometaplasia

Lupus

Lichen Planus

Oral Cavity Cancer

Squamous Cell Carcinoma (SCCa)

Salivary Gland Tumors

How Do We Screen?

Self examination

Dentist office visits

Primary Care Providers

Specialty Clinics (ENT and Oral Surgery)

How Could We Screen Better?

Focus screening techniques on high

risk groups

Focus on tobacco prevention

Broader community involvement

How Do we Treat?

Oral Potentially Malignant Disorders (OPMD)

Observation vs. Biopsy

Biopsy positive cancer (treat according to NCCN and AJCC)

Medical Interventions (Warnakulasuriya et al., 2016)

Vitamins and Antioxidants

Placental extract (homograft stimulating tissue regeneration)

Proteolytic enzymes

Steroid injections

Vasodilators

How Could We Treat Better?

Increase our coverage as providers

Rocha et al, 2017 : Increasing provider coverage (Family Health Strategy Teams) and $$$ → decreased

mortality over 10 yr period

Ensure we are screening better. The earlier we

catch it, the better the prognosis.

Cancer Staging

National Comprehensive Cancer Network (NCCN) Clinical

Practice Guidelines in Oncology – Head and Neck Cancers

(v.1,2019 - 3/6/2019)

American Joint Committee on Cancer (AJCC), pub 2017

AJCC Cancer Staging Manual, 8th Edition

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Surgical Interventions

Glossectomy +/- Neck Dissection

Reconstruction

Free flap

Pectoralis flap

Composite Resection +/- Neck Dissection

Reconstruction

Free Flap

FAMM Flap

Mandibulectomy +/- Neck Dissection

Reconstruction

Free Flap

Pectoralis flap

Local Challenges with Betel Nut and Tobacco

Betel Nut Chewing

Worldwide v. Local Prevalence

Why is it harmful?

Methods of Use

Teens and Tobacco

What is Betel Nut?

Epidemiology

600 million people worldwide prevalence

4th in worldwide use of psychoactive substances(include: nicotine, alcohol and cannabis)

Most common in India, Taiwan and Melanesia

Also common in Micronesia. Majority of the studies take place in Guam, CNMI, Federated States of Micronesia (FSM) and Republic of Palau and Republic of Marshall Islands.

Clear causal link to oral cancer has been established and well documented in the literature

Why is Betel Nut Harmful?

1987 - International Agency for Research on Cancer

(IARC) concluded “betel quid containing tobacco was

carcinogenic to humans.”

2004 – IARC revised their evaluation that betel quid even

“without tobacco” was carcinogenic. In addition,

areca nut (alone) is carcinogenic.

Evidence in human studies with betel quid +/- tobacco

Evidence in animal studies with areca nut (alone)

Less evidence in any study with betel leaf and slaked lime

Significance

Customs variation in betel nut preparation and consumption within Micronesia and how this variation differs among ethnic communities.

In 2014, “Areca (betel) Nut Chewers’ Health Project” was a crossectional study, n=300, >18yo, Guam and Saipan

Identify patterns from chewing behaviors with a validated questionnaire

2 tier oral screening performed by an Oral Hygienist and Dentist

Results amplified the findings in a 2011 pilot study

2 chewing patterns

2 Styles of Betel Nut Chewing(in the Marianas)

Class 1 Chewers “Chamorro Style”

Ripe areca nut (without quid)

Longer chew

Less often, less nuts

Swallow nut

Class 2 Chewers “Yapese Style”

Unripe areca nut (with quid)

Shorter chew

More often, more nuts

No swallow

Style and Risk

What does this tell us?

Consider focused screening on “Yapese style” chewers.

Mobile Dental Units

Increased training of PCP’s

How though?

How do we target our screening effectively?

How do we maintain compliance and effective followupafter screening?

How do we get patients to stop?

Betel Nut

Cessation Trial

Clinical Trial : NCT02942745

Recruiting since 10/2016 and ends 8/2019 ->18yo Guam or Saipan

2 arms

Experimental: Intensive 5 session intervention program over 22 days and then at 6 months

Placebo: Betel nut cessation booklet

Outcome measures

#self-report quit (after 22 days and then again at 6 months)

Biomarkers in saliva (after 22 days and then again at 6 months)

Betel Nut Prevalence in Guam

What’s the prevalence on Guam?

Worldwide its 10-20%

(Paulino et al, 2017) Aim : pull data from Betel Nut Chewers Pilot Study from (Paulino et al., 2014) and look for trends using national surveillance data in Guam.

Chamorro prevalence decreased from 2011 to 2015

(16.6% - 13%)

However Non-Chamorros doubled (6.6% - 12.5%)

Prevalence – rest of Micronesia…

Betel Nut Prevalence in

Micronesia (excluding the

Marianas) - 2017

N = 1200

First study to report

prevalence across FSM,

Palau, Marshall Islands

42% !!!

Bu-ee!

Bua!

Pugua!

Pu!

Pue!

What’s It called?

Behaviors

Cross-sectional study in Guam (n=30) using a validated survey:“Betel Nut Dependence Scale”

16 questions which were grouped:

Reasons Started

Reasons to Chew

Cultural Importance

Social Importance

Social Acceptance

Reasons to Quit

Methods to Quit

vs.

Addiction with Children

Cross-sectional studies (n=420) among high schoolers in Saipan (1st

Study) compared to Pohnpei and Yap (2nd Study) - 2015

39.1% Saipan chewed

38% Pohnpei chewed

90% + Tobacco

91% Yapese chewed

64% + Tobacco

Dose Response Relationship

Vaping

Vaping may be a gateway to tobacco use especially in new or young users.

Strong association of prior e-cigarette use with cigarette initiation

x8.5 higher than no exposure in low-risk youths

x2 higher than prior other tobacco product use!

Interesting Case

74 year old male aspirated a

betel nut 2 months prior.

Hospitalized for pneumonia

and treated with IV abx.

Setup

Summary

Oral Cancer Prognosis still lags the average among all cancers

Improved screening from all providers

Betel nut prevalence tied to strong cultural/family traditions and through tobacco use

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Thank you!

Lawrence L. Williams, Jr., MD

LCDR, MC, USN

ENT Surgeon

Department Head

Otolaryngology - Head and Neck Surgery

Naval Hospital Guam

lawrence.l.williams14.mil@mail.mil

671-344-9793

“The views presented in this presentation are the

views of the author and not the views of DoD or

the Navy.”