Abstract
Oral cancer is a major health problem worldwide (over 300,000 new cases identified each year) with numbers projected to climb steadily. Although the site is easily accessed, it is most often detected at late-stage, leading to high mortality and morbidity rates that have shown little change for decades. Much of the projected increase in this disease will occur in low- and middle-income countries with very limited resources.
Oral cancer is a good target for employing systems models for prevention and intervention. It shares etiology with many cancers (tobacco usage, alcohol consumption, diet, and infection) so prevention approaches have a universal application. Common challenges exist in both developing and wealthier countries: low awareness of health care professionals, low public awareness, low priority within public health, inequities in care, infrastructure and human resources deficits, system fragmentation and lack of coordinated advocacy and leadership. Approaches tend to be treatment rather than prevention focused. There is a need for development of new strategies for management of the disease.
The objective of this presentation is to describe a population health-focused approach taken in British Columbia to improve oral cancer control that has drawn together provincial resources, integrating them into a comprehensive system of structures and players. The effort spans the continuum of care (prevention, early detection, diagnosis and treatment of the disease) working through multiple approaches, at multiple levels and across multiple sectors. Its growth is guided through partnerships and networks with health professionals and societies, by social marketing and epidemiological surveillance, and by technology development for early detection, risk assessment and cancer treatment within an ongoing NIH-funded longitudinal study.
The approach has grown around an opportunistic screening network of dentist and ENT surgeons that has existed in British Columbia for ∼27 years. This network is linked through a centralized oral biopsy service to referral resources to facilitate patient management. We have engaged and empowered this network through a combination of approaches (focus groups of community dental health professionals, continuing education forums, news releases, journal publications, and social marketing strategies) with an aim to increase awareness of the importance of screening activity and to build social norms among dental professionals to enhance their ownership of this domain. In collaboration with the College of Dental Surgeons of British Columbia, a Guideline was released in 2008 to move activities from an ad hoc to a standardized, quality controlled approach, with formal integration of screening into the regular oral exam for each patient. This has resulted in increased screening among dental professionals who have seen the guideline, among whom 84% screen as part of routine exams, compared to 65% of those not aware of the guideline.
A second offshoot of activity within the program is the development within the Oral Biopsy Service of an Oral Leukoplakia and Dysplasia Registry that will link to the British Columbia Cancer Registry to track the impact of changes in practice on outcomes. This project is supported by the Canadian Partnership Against Cancer (CPAC) with input from other provincial oral biopsy services across Canada. This will allow for development of parallel dental network and registry structures to better define the natural history of the disease and improve its management at a national level.
We expect to reach 2/3 of the BC population through a strengthened dental office network and referral pathway. However, access to this network remains a challenge for the remaining population. Tailored strategies are being developed in partnership with the South Asian community, the Vancouver First Nations community, the Downtown Eastside in Vancouver, and rural BC. Since developing countries share many of the same barriers to health care utilization with these underserved communities, we have opened dialogues with international partners to gain input and provide knowledge exchange around facilitators and barriers to screening activities in low-resource settings.
This increased screening activity has been coupled to the development of a streamlined referral pathway for risk assessment in dysplasia clinics for standardized risk assessment and follow-up of high-risk patients (an NIH-NIDC-funded initiative). These clinics use technology developed within an ongoing longitudinal study to identify and assess high-risk lesions: optical devices to improve clinical visualization; high-throughput computer microscopy systems to predict future behavior of early lesions in a cost-effective fashion, using subtle histological and cytological indicators; and molecular markers of risk. The impact of this technology on driving change in clinical practice is already apparent. Optical fluorescence technology has been used to detect occult disease in patients going to surgery. Its use to guide surgical margin delineation has resulted in a marked reduction in recurrence rates ∼10 fold or more (from ∼25% recurrence to close to zero) that is now being explored in multicenter randomized control trial for device efficacy supported by the Terry Fox Research Institute. This initiative promises to facilitate the better management of early disease detected within the system, and provides a structure for rigorous assessment of these innovations as well as a foundation for knowledge translation and scale-up.
Conclusion: We are engaged in trials of innovative technology, social mobilization, and knowledge translation to support system-wide change for equitable population-based control of oral cancer in British Columbia. This effort is a model that demonstrates how resources can be pulled together and optimized to provide a centralized structure for shaping new approaches to detection, management, and prevention of disease.
Citation Information: Cancer Prev Res 2010;3(12 Suppl):PL05-04.
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