Oral Cancer: Screening -- Adults


General

Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults.

Frequency of Service

No information available.

Risk Factor Information

Tobacco and alcohol use are major risk factors for oral cancer. A total of 20% to 30% of cases of oral cancer worldwide are attributable to cigarette smoking. In the United States, up to 75% of cases of oral cancer may be attributable to tobacco and alcohol use. Additional risk factors include male sex, older age, use of betel quid, ultraviolet light exposure, infection with Candida or bacterial flora, and a compromised immune system. Sexually transmitted oral HPV infection (HPV-16) has recently been recognized as an increasingly important risk factor for oropharyngeal cancer. In the United States, the prevalence of oropharyngeal cancer due to oral HPV infection is probably as high as 80% to 95%. The prevalence of oral HPV infection is associated with age, sex, number of sexual partners, and number of cigarettes smoked per day. The effect of multifactorial risk assessment and screening for risk factors on oral cancer morbidity and mortality is unknown.


Clinical

Patient Population Under Consideration

This recommendation applies to asymptomatic adults aged 18 years or older who are seen by primary care providers. This recommendation focuses on screening (visual inspection and palpation) of the oral cavity performed by primary care providers and not dental providers or otolaryngologists.

Assessment of Risk

Tobacco and alcohol use are major risk factors for oral cancer. A total of 20% to 30% of cases of oral cancer worldwide are attributable to cigarette smoking. In the United States, up to 75% of cases of oral cancer may be attributable to tobacco and alcohol use. Additional risk factors include male sex, older age, use of betel quid, ultraviolet light exposure, infection with Candidaor bacterial flora, and a compromised immune system.

Sexually transmitted oral HPV infection (HPV-16) has recently been recognized as an increasingly important risk factor for oropharyngeal cancer. In the United States, the prevalence of oropharyngeal cancer due to oral HPV infection is probably as high as 80% to 95%. The prevalence of oral HPV infection is associated with age, sex, number of sexual partners, and number of cigarettes smoked per day. The effect of multifactorial risk assessment and screening for risk factors on oral cancer morbidity and mortality is unknown.

Screening Tests

The primary screening test for oral cancer is a systematic clinical examination of the oral cavity. According to the World Health Organization and the National Institute of Dental and Craniofacial Research, an oral cancer screening examination should include a visual inspection of the face, neck, lips, labial mucosa, buccal mucosa, gingiva, floor of the mouth, tongue, and palate. Mouth mirrors can help visualize all surfaces. The examination also includes palpating the regional lymph nodes, tongue, and floor of the mouth. Any abnormality that lasts for more than 2 weeks should be reevaluated and considered for biopsy.

Oropharyngeal cancer is difficult to visualize and is usually located at the base of the tongue (the back third of the tongue), the soft palate (the back part of the roof of the mouth), the tonsils, and the side and back walls of the throat. A comprehensive examination of the oropharynx may require referral to a dental provider or specialist, which is outside the scope of this recommendation.

Additional tests proposed as adjuncts to the oral cancer screening examination include toluidine blue dye staining, chemiluminescent and autofluorescent lighting devices, and brush cytopathology. These screening and adjunct tests have not been adequately tested in primary care nondental settings. Although there is interest in screening for oral HPV infection, medical and dental organizations do not recommend it. Currently, no screening test for oral HPV infection has been approved by the U.S. Food and Drug Administration (FDA). Evaluating the accuracy of tests that detect oral HPV infection is a potentially promising area of research.

Suggestions for Practice Regarding the I Statement

This recommendation is intended for primary care providers and does not pertain to dental providers or otolaryngologists. Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx during the clinical encounter. In deciding whether to screen for oral cancer, primary care providers should consider the following factors.

Potential Preventable Burden

Up to 75% of cases of oral cancer may be attributed to tobacco and alcohol use. Since 1979, the incidence rate of oral cavity cancer in the United States has been decreasing because of the reduced consumption of alcohol and smoking prevalence.

During this period, the incidence of HPV-positive oropharyngeal squamous-cell carcinoma has increased. Cancer registry data have shown that from 1988 to 2004, HPV-negative oropharyngeal cancer has decreased from 2.0 cases to 1.0 case per 100,000 persons and HPV-positive oropharyngeal cancer has increased more than 3-fold from 0.8 case to 2.6 cases per 100,000 persons. The overall prevalence of oral HPV infection is estimated to be 6.9% in adults aged 14 to 69 years in the United States. However, HPV prevalence can be as high as 20% for persons who have more than 20 lifetime sexual partners or currently use tobacco (more than 1 pack of cigarettes per day).

The prevalence of type-specific HPV-16 oral infection is estimated at 1% in adults aged 14 to 69 years (an estimated 2.13 million infected persons). Human papillomavirus-16 is associated with approximately 85% to 95% of cases of HPV-positive oropharyngeal cancer. Therefore, the increasing role of oral HPV infection as a risk factor for oropharyngeal cancer may warrant future assessment of the independent effect of HPV-16 on incidence and outcomes of oropharyngeal cancer and the health effect of screening persons who are HPV-16–positive.

Potential Harms

Suspected oral cancer or its precursors (such as erythroplakia, due to its high risk for transformation to cancer) detected through examination require confirmation by tissue biopsy, which may lead to harms. Harms of treatment of screen-detected oral cancer and its potential precursors (leukoplakia and erythroplakia) may result from complications of surgery, radiotherapy, and chemotherapy. The natural history of screen-detected oral cancer is not well-understood, and as a result, the harms from overdiagnosis and overtreatment are unknown.

Current Practice

In a 2008 survey of U.S. adults, 29.4% of those aged 18 years or older reported ever having an oral cancer examination in which a physician, dentist, or other health professional pulled on their tongue or palpated their neck. It is unknown what percentage of these examinations were conducted by dentists rather than physicians or other health professionals. Adults aged 40 years or older are more likely to have ever had an examination than those aged 18 to 39 years, despite smoking status. Adults who are most at risk for oral cancer (current smokers aged ≥40 years) are less likely to have ever had an oral cancer examination than former smokers or adults who have never smoked.

Other Approaches to Prevention

The USPSTF recommends that clinicians screen all adults for tobacco use, recommend against tobacco use, and provide tobacco cessation interventions for those who use tobacco products. The USPSTF also recommends screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse by adults.

Other Considerations

Research Needs and Gaps

One of the most important research needs is a randomized, controlled trial assessing the benefits and harms of oral cancer screening in U.S. persons who are at increased risk, such as those with a history of tobacco and heavy alcohol use. Continued research is needed to determine the accuracy of primary care providers, dental hygienists, dentists, or other trained persons screening U.S. patients who are at increased risk. Also needed is longitudinal follow-up of screening studies applicable to the United States that will show the health effect of screening for oral cancer and a clear understanding of who is at high risk in the United States. In addition, given the higher risks for death from oral cancer among African Americans and men, more research is warranted about the risks and benefits of screening in these populations.

If HPV continues to become a more clinically significant risk factor for oropharyngeal cancer, the benefits of screening for HPV and selection of populations for oral cancer screening based on HPV status will need to be assessed. As the epidemiology evolves, the most effective screening examination will need to be determined. No screening test for oral HPV infection has been approved by the FDA. More research is needed to determine the benefits and harms of screening for oropharyngeal cancer. Other areas of research include learning about the natural history of oral HPV infection.

Vaccines that reduce the risk for HPV infection are available. Whether current vaccines can prevent infection at noncervical sites and help reduce the risk for oropharyngeal cancer is unknown. Research is needed to assess the efficacy of HPV vaccines in preventing infection at noncervical sites and in decreasing the risk for oropharyngeal cancer.

Rationale

No information available.


Others

The American Academy of Family Physicians concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. The American Cancer Society recommends that adults aged 20 years or older who have periodic health examinations should have the oral cavity examined as part of a cancer-related checkup. The American Dental Association recommends that providers remain alert for signs of potentially malignant lesions or early-stage cancer in patients during routine oral examinations, particularly for patients who use tobacco or have heavy alcohol consumption.


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