Promoting oral cancer screening by general practitioners in Australia: Strengthening primary healthcare

Oral cancer is among the top 10 most common cancers^1,2 and encompasses malignancies of the lip and oral cavity.¹ In 2022, it was estimated that 5189 Australians would be diagnosed with head and neck cancer.³ Over 89% of these cancers were projected to be oral cancers, consisting of 659 lip cancers and 707 mouth cancers.⁴ Although there has been a major reduction in lip cancers, new oral cancer diagnoses have not significantly changed and are predicted to increase.⁴

Aim

This paper provides an overview of oral cancer and explores how routine oral cancer screening by general practitioners (GPs) for at-risk individuals could improve early detection and treatment and lead to better health outcomes.

Discussion

Despite advances in diagnosis, treatment and management strategies, oral cancer has a relatively low five-year survival rate, at around 50%,⁵ mostly due to diagnostic delays.

Since the COVID-19 pandemic started, there has been a decline in the number of all types of cancer diagnoses (including oral cancers) in Victoria,⁶ and this trend has been mirrored across Australia.⁷ This is possibly a presentation artefact of these patients due to COVID-19 pandemic-related factors, including pandemic restrictions, which particularly affected routine health (medical and dental) services,⁸ and changes to health-seeking behaviour. This is concerning, and a 51% rise in new cancer cases and a 36% increase in cancer deaths is projected to occur between 2020 and 2044.⁹

Oral cancer and emerging modifiable risk factors

Oral cancer is linked with risk factors such as age >45 years (especially men), tobacco use, alcohol consumption, areca (betel) nut chewing and limited access to dental care.^1,10,11 Areca nut chewing (a common practice in some subcontinents including South Asia)¹² is a growing trend in Australia, coinciding with an increasing number of immigrants, which might affect the rate of oral cancer diagnosis in the future.¹² An emerging subgroup of non-smoking and non-drinking middle-aged women with tongue cancers is also concerning.¹⁰ These shifting oral cancer trends in terms of modifiable risk factors, clinical features and subpopulations emphasise the importance of oral cancer awareness.

The role of GPs in oral cancer prevention

GPs are often the first point of contact for individuals seeking healthcare services in Australia. In 2021–22, almost 90% of Australians received at least one Medicare-subsidised service, with a standard consultation being the most common presentation.¹³ In contrast, for 2020–21, only 48% of Australians had seen a dental professional in the past 12 months.¹⁴ The frequency of these consultations illustrates the pivotal role of GPs in primary healthcare and provides an opportunity for ‘proactive’, tailored health promotion targeting oral cancer prevention and early detection.¹⁵

Those at risk of developing oral cancer (eg older age, people engaging in higher rates of alcohol and/or tobacco use, people from low socioeconomic backgrounds, refugees, and culturally and linguistically diverse populations) tend to have irregular dental attendance and are more likely to see GPs for routine medical care.^12,16,17 An Australian study of newly diagnosed oral cancer cases found that prior to diagnosis in the asymptomatic phase, patients had visited their GP far more often than they had visited their dental practitioner.¹⁸ Capacity building of GPs can assist with early diagnosis and timely treatment of oral cancer, thereby improving prognosis for oral cancer and health outcomes.

A quick guide for GPs on oral cancer prevention

An Australian study showed there was an average diagnostic delay of approximately four months between symptom onset and initial histological diagnosis.¹⁹ To date, there is limited evidence to implement a formalised population oral cancer screening program, such as that for cervical cancer screening.²⁰ Therefore, oral cancer screening is reliant on recording a thorough medical history and visual examination. Initial lesions of oral cancer are generally painless, and hence, patients reporting any unexplained and/or non-healing changes or symptoms in the mouth for more than two to three weeks (eg a persistent ulcer, red patches, lumps, a sore throat, or erythematous or speckled lesions) should have an oral cancer screen.²¹ Risk-associated screening should be done on a case-by-case basis for patients aged 45 years or over and for those who are current or past substance users (eg alcohol, tobacco or betel nut/quid). Oral cancer screening can be performed through a comprehensive oral cavity examination with readily available equipment, including gloves, a mouth mirror, a tongue depressor and a torch (Figure 1).²¹ The most high-risk sites for oral cancer are the lateral margins of the tongue and the floor of the mouth, but a thorough extraoral (ie face, jaw, chin and neck) and intraoral (ie lips, buccal/labial/lingual mucosa, attached gingiva, tongue, floor of the mouth and hard/soft palate) examination is essential to undertake oral cancer screening.²¹ This type of screening can be conducted by GPs and dental professionals.

Figure 1. A general practitioner performing oral cancer screening with a patient.²¹

The clinical presentation of oral cancer is highly variable, with the most common feature of a persistent non-healing ulcerated lesion sometimes in association with other symptoms like loose teeth or bleeding, pain or numbness in the mouth or face.¹ Other signs and symptoms of oral cancer are listed in Table 1.

GP e-learning module – Oral Cancer: Prevention, early detection and referral

Oral cancer screening and prevention forms an integral part of the Australian Cancer Plan 2023–2033²² and the Aboriginal and Torres Strait Islander Cancer Plan.²³ The Victorian Department of Health funded the Oral Cancer Screening and Prevention Program led by Dental Health Services Victoria (DHSV). DHSV led the collaboration with partners including the University of Melbourne, Victorian Cancer Centre, the Victorian Comprehensive Cancer Centre and The Royal Australian College of General Practitioners (RACGP) to develop and launch the Oral Cancer: Prevention, early detection and referral e-learning module.²⁴ To support GPs, this e-learning module is now available on the RACGP’s gplearning website. Another useful resource for oral cancer is included in the Therapeutic Guidelines – Oral and Dental.²⁵

Conclusion

The burden of oral cancer is increasing in the Australian population. GPs can play a vital role in oral cancer prevention and early detection by undertaking oral screening in primary healthcare. This can be achieved through the engagement of GPs in professional development activities such as the Oral Cancer: Prevention, early detection and referral e-learning module.

Key points

• Disruptions to routine access to health services caused by the COVID-19 pandemic have resulted in a reduction in all cancer diagnoses.
• New oral cancer diagnoses are expected to increase in Australia.
• Patients seek health advice more readily from GPs than from dental practitioners.
• Diagnostic delays for oral cancer are a major contributor to poorer health outcomes.
• Supporting GPs in their role for screening, prevention and early detection of oral cancer can potentially improve health outcomes.