Should you be screened for oral cancer, and are companies profiting from the uncertainty?

Most dentists do a thorough visual mouth evaluation to screen for oral cancer.

Whether there is data to support this practice is in question, with few studies suggesting a mortality benefit. The recommendations themselves are extrapolated from studies looking at other cancers.

Like other diseases where there is a gray area surrounding the efficacy of screening, like ovarian, lung, or pancreatic cancer, companies are rushing in to profit from the lack of data.

In the case of oral cancer, this technology is known as VELscope. Dentists can charge for the study, and some insurers are reimbursing for the procedure. Although the test can detect more pre-cancerous cells versus visual inspection alone, there is no data as to whether this would save lives.

There is a high false positive rate, meaning that patients may receive unnecessary recommendations to visit an oral surgeon for biopsies of benign lesions.

Until there is more data, whether or not these tests benefit the patient, or the dentist’s and oral surgeon’s financial bottom line, will continue to be in question.

Comments

Anonymous
My dentist teaches at a highly-regarded dental school. He took over his dad’s practice after graduating from dental school. Like his father, my dentist eschews gimmicks. He does thorough exams, cleans and polishes teeth himself, offering a number of flavors of goop (his dad used the plain kind). He doesn’t take x-rays at each visit, and he makes sensible recommendations (e.g. whitening kits that can be inexpensively purchased at the store are just about as good as. shelling out big bucks, waterpiks are useful to augment one’s regular dental hygiene in some cases, a $20 sonic toothbrush is as good as a really expensive one), sends out lab work (like crowns), and so on. I’m pretty sure he would ROTFL if some rep came in and tried to market this test to him.
Perhaps this test might be appropriate for certain at-risk populations, but I wager there aren’t many folks using chewing tobacco in these here parts.
Anonymous
This hits close to home. In 1999, during a routine cleaning, my dental hygienist discovered a white spot at the base of my tongue. When it hadn’t cleared up six months later, my dentist referred me to a board-certified oral surgeon for a surgical biopsy. (I do not fall into any of the high-risk demographics.)
The biopsy came back benign and the surgeon removed the remainder of the lesion in a second surgery. Less than two months later the spot began to reappear. The surgeon removed it again. Again, the pathology was benign.
Twice more within the next year the spot recurred, and both times the surgeon removed it and the pathology came back benign. “I don’t know what’s causing it,” he said, “but we need to remove it whenever it comes back.” What did I know? He’s the expert.
The fifth surgery resulted in some damage to salivary gland tissue, causing duct blockage and painful swelling in my tongue. It took two further surgeries to correct that.
Within a 2-1/2 year period I underwent seven surgeries on the same area of my tongue, all stemming from that first white lesion noticed by the hygienist. There was never a malignancy or even pre-malignancy. The spot stopped coming back after the seventh surgery in early 2002.
In addition to the test described in this article, I understand that brush biopsies are now routinely used before surgery is considered. Apparently a good deal of progress has been made in the past 5-6 years in regards to oral cancer diagnosis. Wonderful thing that is.
14th Floor
(In the spirit of full disclosure, I handle marketing communications for LED Dental, makers of the VELscope.) I would like to suggest that the best way to understand how effective the VELscope can be is to talk to some of the almost 4,000 dental practitioners who are currently using the device. To that end, I recently conducted a survey of VELscope users and found that the overwhelming majority of users is very pleased with the VELscope. For example, when asked to rate their satisfaction with the VELscope’s ability to help them discover cancerous or precancerous tissue they otherwise would have missed, 94% indicated they were either “satisfied”, “very satisfied” or “extremely satisfied.” What’s more, 92% said they would recommend VELscope to a colleague, and nowhere in the research was there an indication that “false positives” is a significant issue. Given that the 5-year survival rate is only 22% when oral cancer is discovered in late stages (as is the case two-thirds of the time) but as high as 90% when discovered in early stages, real world experience suggests that the VELscope is an effective way for dental practitioners to enhance their ability to serve as the first lie of defense against this deadly and disfiguring disease.
14th Floor
It should be noted that oral cancer is now suspected to be caused not only by chewing tobacco, smoking and alcohol, but also by the sexually-transmitted human papilloma virus (HPV). This is why health experts recommend that all adults have an oral cancer exam at least once a year.
Anonymous
You mention the VELscope’s ability to find “pre-cancer” as well as “cancer”. A high false positive rate, means that it’s not very accurate – but no one dies from false positives. What about the “false negative” rate? That’s where the dentist using the device tells the patient that everything’s fine, when it really isn’t. I’ve used the device and it’s an aid at best. If it makes people look harder or longer that’s fine, but truthfully, once I learned what to look for…I didn’t need the light. You still need to do either a brush biopsy (BrushTest) or a surgical biopsy to know for sure.
Anonymous
@14th floor: Given that the 5-year survival rate is only 22% when oral cancer is discovered in late stages (as is the case two-thirds of the time) but as high as 90% when discovered in early stages
Ever heard of lead-time bias? How much time it took for cancer to grow from an early stage to late stages? In order to compare two distances, you need to start from the same point of origin. But you aren’t doing it. You are moving the point of origin (detection) backwards in one case than comparing the distances between detection and death (destination). If a train crashes in Miami, you take it in NY, I take it in Washington, your survival since boarding a plane is longer, but you aren’t better off. Still unclear? Let’s say someone has oral cancer and dies at the age of 50. Let’s say the cancer is at a early stage when this person is 42 and in late stage when he is 48. If you detect it when this person is 42, the person lives 8 year after diagnosis – longer than 5 years. If you detect it when this person is 48, the person only lives two years. Do you think the person is better off having it detected at 42 if he still dies at the same time?
There is also a length bias, in that screening is likely to catch slower-growing cancers, so the whole reason some cancers are detected early is that they are less aggressive.
5-year survival numbers only make sense when you start from the same point of origin e.g. when you are testing how effective a particular treatment is. But with screening, the only numbers that are important is the reduction in mortality. I.e. if you were to have a study where you compared a large number of screened people with the similar number of non-screened and fewer people died from oral cancer among screened, than you could say screening is beneficial. This data is lacking.
I am not even talking about possible overdiagnosis.
@anonymous at 12:13:
When you screen general population false positives are indeed important especially in the absence of data that show mortality reduction from screening. Anon at 4:44 clearly showed the potential harm of false positives.
As to satisfaction – this is a non-issue. People today are conditioned to feel good about tests whether they are necessary or not. They also are conditioned to feel happy about the cases when something is caught early – even if this early detection didn’t do any good. Plus – ever heard the expression “plural of anecdotes isn’t data” that Kevin cited in the past.
Both of you – ever heard of screening infants for neuroblastoma in Japan. This was one example of screening that did more harm than good. Virtually no reduction in mortality, no reduction in the number of advanced cases diagnosed later and huge overdiagnosis. Yet, I bet the 5-year survival rates increased – due to overdiagnosis, and people were satisfied.
Just because there is a test that can detected a cancer early doesn’t mean it’ll save lives.
Anonymous
But, if a test can find pre-cancer early, and remove it…it never becomes cancer, and the patient lives. That’s exactly what the OralCDx brush biopsy is designed to do. It allows dentists to identify any changes at the cellular level – the earliest possible time. This has been proven to work throughout the body.If you find and remove precancerous cells… you can help prevent cancer – cervical, colon, and now oral. There’s no light that can do that.
Cells provide information. What information can you get from a dark shadowy mass in an apple green field – that there’s blood present? Is it a cheek bit, inflammation, carcinoma in situ? You’re still left making a judgment call, and you still haven’t “identified” what it is. Is that worth $6,000-$8,000?

Should you be screened for oral cancer, and are companies profiting from the uncertainty?

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