Transcript Introduction

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 clinician
carefully examine any suspicious lesion.
refer immediately for histological
investigation
The clinicians are also responsible for
informing the population regarding the
risk factor
Introduction
Unlike 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
37
100%
Total
Results: Distribution of cases according to race
Race
Number
%
Saudi
29
78.4%
None Saudi
8
21.6%
37
100%
Total
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
37
100%
Total
Result: Sites of Oral Tumours
Site
Number
%
Palate
19
Floor of the mouth
2
Tongue anterior, lateral border
3
Cheek
2
Retromolar area & Ramus
4
Upper alveolus
3
Maxillary sinus
2
Others
2
51.4
5.4
8.1
5.4
10.8
8.1
5.4
5.4
100%
Total
37
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
37
100%
Total
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
37
100
Total
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?