Delayed Diagnosis of oral Malignancy:

Its crucial effect on management and prognosis

Dr Hassan El Abdin

Introduction

Malignant condition of the oral cavity comprises about 5.6% of all malignant tumours of the human body, in Saudi Arabia1.

It is the third most common tumour in females and the fourth in males.1

Ajarim,D Proce Saudi Oncol Symp 1995

Introduction

In the United States, it is relatively uncommon, and represent 2.5% of the total.2

Shafer JADA 1975

In the Scandinavian countries, it comprises about 2% of all malignant tumours, and the prognosis is poor compared with malignancies in other sites.3

Bruun Oral Surg

1976

Introduction

Delayed diagnosis of malignant condition and particularly of the oral cavity, is of crucial importance for the clinical management, cost of care and the outcome.

Introduction

Oral malignant conditions can be easily diagnosed.

Not only, is the oral cavity accessible to examination, but the oral lesion produces a recognizable warning signs

Introduction

Despite the fact that oral cavity is second only to skin in the accessibility for examination and early detection of cancer, the five-year survival rate is low.

It is varies between 15% - 52% which is the fifth lowest 5-year survival rate.

Introduction

The survival of oral cancer patient depend on early diagnosis and treatment.

Most studies on oral malignancy prove that the mortality rate drops effectively, if the lesions are recognized & treated early.4

James,A.G

Introduction

Tongue cancer, the 5-year survival rate will rise from 15% to 55% if the lesion is diagnosed and treated while it is small and localized.

Introduction

Unfortunately, early lesions are frequently asymptomatic, small, innocuous and overlooked by the clinician during routine oral examination.

Introduction

It is the responsibility of the cliniciancarefully examine any suspicious lesion.

refer immediately for histological investigation

The clinicians are also responsible for informing the population regarding the risk factor

IntroductionUnlike other malignancies, oral lesions and the surrounding tissues continue to cause considerable mortality and serious morbidity in this country.

The delay was linked to the patient as well as the clinician even though examination the oral cavity is easily performed.

Introduction

Patient’s delay involves the time elapsed from first symptoms to consulting a dentist or physician

Clinician’s delay is the period during which the patient is under care until diagnosis.

Aim of the Study

To investigate the role of the general dental practitioner in the early diagnosis and referral of oral cancer patient and relate this to the treatment and prognosis.

To study and analyze the factors responsible for such delay

Methods & Patients:

The records of thirty-seven (37) patients diagnosed with malignant lesions were retrospectively reviewed.

All the patients were diagnosed at the Oral & Maxillofacial surgery department and verified histologically by the division of Oral Pathology at the college of Dentistry and the Pathology department at KKUH and college of Medicine

Methods & Patients:

The following parameters were evaluated;• sex, age, symptoms, referral diagnosis

• time lapse from first symptoms until consultation

• final diagnosis, previous treatment, final treatment and survival period

Definitive treatment took place at KKUH and Riyadh Military Hospital

Result: Distribution of cases according to sex

Sex Number %

Male 23 62.2

Female 14 37.8

Total 37 100%

Result: Distribution of patients according to age

Age Number %

Group I: 5 – 10 years 2 5.4

Group II: 11 – 20 years 2 5.4

Group III: 21 – 30 years 3 8.1

Group IV: 31 – 40 years 10 27.0

Group V: 41 – 50 years 16 43.3

Group VI: 51 and up 4 10.8

Total 37 100%

Results: Distribution of cases according to race

Race Number %

Saudi 29 78.4%

None Saudi 8 21.6%

Total 37 100%

Result: Distribution of case according to histogenesis

Tumour diagnosis Number %

Mucoepidermoid carcinoma 14 37.8

Squamous cell carcinoma 12 32.4

Extra-nodal non-Hodgkin lymphoma 4 10.8

Rhabdomyosarcoma 2 5.6

Adenoid cystic carcinoma 1 2.6

Acinir cell carcinoma 1 2.6

Osteosarcoma 1 2.6

Metastatic adenocarcinoma 2 5.6

Total 37 100%

Result: Sites of Oral Tumours

Site Number %

Palate 19 51.4Floor of the mouth 2 5.4Tongue anterior, lateral border 3 8.1Cheek 2 5.4Retromolar area & Ramus 4 10.8Upper alveolus 3 8.1Maxillary sinus 2 5.4Others 2 5.4

Total 37 100%

Result: Chief complaint at presentation

Type of complaint Number %

Swelling 27 73.0

Persistent ulcer 5 13.5

Pain 3 8.1

Disturbances in sensibility 2 5.4

Total 37 100%

Result: Initial mismanagement & inappropriate therapy

Type of therapy Number

Repeated antibiotic therapy 34

Repeated teeth extraction 9

Denture readjustment 3

Oral medicine & periodontal treatment 17

Total 63

Result: Type of treatment instituted

Type of treatment Number %

Surgery alone 18 48.7

Surgery and radiotherapy 10 27.0

Surgery, radio. & chemotherapy 4 10.8

Radiotherapy & chemotherapy 3 8.1

No treatment 2 5.4

Total 37 100

Discussion:

Oral malignant lesion constitute less than 5% of all malignant tumours occurring in the Kingdom Mortality from oral cancer shows slight decline but is still considerable with 5-year survival rate less than 50%. It the fifth lowest.6

Yelllowitz, et al J Am Dent Assoc 1995

Discussion

In this study the mortality rate constitute around 16.2% and the 2-year survival approaches 83.8%.

The 5-year survival 64.9% and the 10-year rate 45.9%

Discussion:

The prognostic factors for a higher 5-year survival rate include site, size, TNM stage, histology and response to treatment.

Discussion:

A consistent and direct relationship was found between the delay in the diagnosis and tumour size, nodal involvement, presence of metastasis and histological grade of the disease.

Discussion:

The result of this study suggest that, among patients with oral malignancy, a professional delay of 3 months and more, are contributing to an increased risk for being diagnosed as a late stage disease.

Discussion:

Delay was the predominant feature in all the cases and it was mainly the clinician who was to blame in this study

The period varied between 3 months in a case of ENNHL and 16 months for the adenoid cystic carcinoma

Discussion:

All lesions that do not respond to adequate therapy in 14 days should be suspected of being malignant and the patient should be referred to a specialist for proper diagnosis.

A high index of suspicion is a prerequisite for early diagnosis and referral of patients with oral cancer for better prognosis

Discussion:

Patients suffering from malignant tumours of the oral cavity may wait for 3 months or longer before consulting a physician or dentist.7

The lack of patient awareness about the seriousness of the disease they have, is the main reason.

Pogrel Brit Dent.J 1974

Discussion:

In our study more than one third of the patients (37%) delayed seeking professional advice for more than 3 months and around 25% for more than a year, after being aware of the lesion.

The study revealed that limited and sometimes bias cancer knowledge play a major role in this delay.

Discussion:

In 1990, a European conference held in Denmark recommended that GDP should play an important role in preventing oral cancer and performing oral screening.

Discussion:

In 1990 the British Postgraduate Medical Federation has issued a video entitled “the importance of being early” to the dental practices.5

It was to promote early detection and early referral. Any delay in referral represents a failed early diagnosis.

Brit.D.J, 170;5: 1991

Conclusion:

Treatment of early lesion carries an excellent prognosis

Dentists will require greater training in the recognition of warning signals and causes of delayed diagnosis of early and even late malignant conditions of the oral lesion

Conclusion:

Medical schools exposes their students to very little education in oral cancer and in fact to the problem of oral diseases in general.

Reluctance of dentists and medical practitioners in referring undiagnosed case?