The Oral Cancer Advocate

Oral squamous cell carcinoma lesion

With money from a commercial enterprise, the ADA is beginning a three year campaign to raise oral cancer awareness. This is a good thing, but the problem is they are using that company’s marketing rhetoric instead of good science to sell the message. The message of the new ads is “We can prevent oral cancer,” taken right from Oral CDx’s marketing literature.

Under that tongue (picture above) is a squamous cell carcinoma, oral cancer. (The whitish lesion, not the dark spot which is just vascularization near the surface of the tissue). If your dentist or hygienist does a brush biopsy / brush cytology of that spot, I guarantee you that it will still be oral cancer. They have not “PREVENTED” anything by doing this. It is what it is. The ADA has made a huge mistake here in their new awareness program by allowing the marketing rhetoric of a commercial company, in this case Oral CDx, to dictate what the awareness program is all about. When the ADA adopts this stance they weaken their stature and look like an organization that only is interested in raising awareness of oral cancer and its early detection when someone else is willing to pick up the tab. Worse, it is the triumph of marketing over science.

This is the second time they have done so with this commercial company, the first was in 2001 when CDx gave them 2.5 million dollars to run a billboard campaign that no one remembers. Hey, I’m a big believer that when the tide comes in all boats rise, and because of that, at least part of this program is a good thing. The words oral cancer and early detection are getting out there in the same sentence to an American populace that hasn’t even heard of the disease for the most part, let alone the need for early detection of it. But oral cancers are NOT like colon cancer that requires a polyp to exist before it can become full-blown cancer. Or cervical cancer that requires a persistent HPV infection prior to the development of a malignancy. To compare using brush cytology in the mouth, of visible lesions, to either of those is wrong. There is no “mandatory” oral precancerous lesion that always appears before manifestation of this disease. Many times even the primary disease itself can be occult and not visible, only detectable early through the palpation and touching of the tissues – feeling for indurations or hard spots, or in some cases the primary lesion is completely occult right up until a metastasis of the disease is discovered as an enlarged lymph node in the neck, and the primary is never found. A brush biopsy DOES NOT prevent this disease.

Let’s say you have a leukoplakia under a tongue. It’s a huge thing – like half and inch long and three eights of an inch tall. Only about 25% of the time do these things go over to the dark side and become malignant. But they need dealing with (removal) or regular monitoring by a professional (less desirable in my opinion). With a brush biopsy you have to SCRUB the suspect tissue to the point of bleeding to get the proper collection of cells. Is a dentist going to do that over a lesion the size I just described? Hardly. And there is no way to tell where in that large lesion a group of cells that is going malignant might reside. Given this, you couldn’t just collect a few cells from the front or the back of it. Brush biopsy in this case is probably not the path to go down. You could have an oral surgeon laser off the whole thing, or you could watch it for changes (less desirable idea), because only a quarter of them actually become malignant.

The gold standard for diagnosis of cancer is a conventional punch or incisional biopsy. It gives you a core of tissue (if done with a small punch), and all the stratum of the different layers of cells intact. This is an important issue to a pathologist looking at that sample. Brush cytology gives you scrambled eggs… you don’t know where in the total thickness/layers of the tissue the cells scrapped off with the brush came from. Even Oral CDx literature (as required by the FDA) says that if you get a positive test result from them, you have to have it confirmed with a conventional biopsy anyway. If that is the case, generalists who are uncomfortable making the call should let the oral surgeon, oral medicine specialist, etc. make the call to biopsy or not when the patient is sent to them for a second opinion of any suspect tissue.

I get it that this idea is to keep dentists from watching and waiting while a potential malignancy develops in the mouth, because this has been a problem with things for some time. Actually that has been a smaller problem than the fact that not enough dentists are actually doing opportunistic screenings on their entire patient populations at all. This brush system has been around for years and it has not won a place in dentistry in all that time. The fact is, that a general dentist, when he finds suspect tissues, is better served by sending that patient for a second opinion to an oral surgeon, or especially to an oral medicine specialist (they are usually not in private practice but at institutions like dental schools),than messing around doing an indeterminate brush biopsy. Dentistry has a well established referral system, and with the potential of a cancer prospering un-referred on their watch, which is deadly for the patient, and exposes the dentist to significant legal liability, this makes the most sense.

As a patient I have learned that several sets of eyes, and differently trained minds with different types of clinical experience, yield the best end result when deciding what something is, or what should be done.

It is disappointing that the only time the ADA wants to get into the fray and try to do something in the oral cancer arena, it requires someone else to pick up the tab to get them interested. The oral cancer insert in their magazine JADA several years ago was paid for (in spades) by outside organizations like NYU, OCF, the NIDCR and others, the last billboard awareness campaign in 2001 with an equally off the mark marketing tone from CDx which stated “Don’t let it grow up to be cancer” was paid for by someone with a product to push, and now this. Of course their charter is not necessarily to help the public. They are a professional association to serve the interests of dentists, not the public.

As a side note, how is it that the Oral CDx brush bears the ADA seal of approval as a product, yet in the ad using it as the means to change the world, the ADA says they do not endorse the product? Someone didn’t think this through very well. Perhaps if someone like CDx was offering me 9+ million dollars to do something (as they have with the ADA), I might rush into it as well….

Tags: Adjunctive Screening Devices, Screening, The ADA by oc advocate
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When I started writing this site, I was sure that it was something that would remain non-political, but in this post I break that choice.

This week I had the opportunity to talk to a family that has recently lost their son to oral cancer. A man in his early thirties, a non smoker, athlete, and a father of two daughters. There are many aspects to this tragedy that I could explore here. The lack of early detection screenings in his dental appointments, his ignoring some hoarseness that persisted for several months, the treatments that were conducted initially by a small, local city hospital with minor cancer capabilities – which did not bring to bear all the potentially beneficial medical assets soon enough, and much more. But this particular entry is about the recent ruling by the high courts related to who in our population may have access to drugs which are not yet approved, but have shown potential in the trials to date and may even save a life. The current state of the situation is that there has been a ban on their use, regardless of the willingness of a patient to fully accept the risks associated with that use. Most of the patients who have petitioned for this ability have been in terminal disease states with no other hopes. Certainly the drug manufacturers have been quiet about much of this as they are regulated by the FDA’s rulings, but you have to believe that they too would be interested to see if a particular drug had impact or not, if only from a scientific perspective and not a compassionate one.

I can think of no greater means by which this administration, under the leadership of President Bush (and those that support his power base) has debilitated our country, for decades into the future, than his appointments to the judiciary and specifically to the supreme court. US Court of Appeals judge Thomas Griffith has ruled this week that “there is no right, deeply rooted in this nation’s history and tradition, of access of experimental drugs to the terminally ill.” It must be noted that Griffith, recently appointed by Bush, is a relatively young man. As such he has the potential to be making inane comments like this for decades to come. It is no surprise that Bush’s newly conservative weighted Supreme Court supported this ruling, and refused to hear the case themselves.

This is yet another instance, Iraq comes to mind immediately, in which “compassionate conservatives ” are willing to kill people in order to protect them. This distinction is not just academic, it is much more. What conservatives on the courts refuse to comprehend, is that the Bill of Rights is a list of rights that the citizens of this country grant to the government, NOT vice versa. The ruling should have been that the government has no fundamental right to deny potentially life saving or life extending drugs and treatments to dying patients… particularly when all parties concerned are cognizant of the inherent risks, willing to accept the consequences of their decisions, and no others are harmed through the process in any manner.

There were options and opportunities, granted with significant inherent risks for this young man with oral cancer. We will never know if those options would have given him a few more months with his family to communicate that which is now forever unsaid, or even to have defeated this disease and lived on. Thank you judge Thomas Griffith – I wonder how you would feel, were this you in a life and death battle, and how that might impact your decision making process. One only has to remember the reversal of opinion from other compassionate conservatives, like Ronald Regan and his wife, when they found themselves on the other side of a horrible disease issue that they failed to champion when the chance was theirs. Lastly, I note the recent statements made by John McCain, the current conservative front runner for the white house. There are many things to like about this man, but his recent statement that we might still be in Iraq a hundred years from now made my jaw drop… which was then followed by a statement to appease the conservative base, that he would appoint more conservative judges to the supreme courts were he elected. Remember that 6 of the nine judges will be 70 or older next year. I do not favor a liberal court, but one that has balance, and whose opinions are not based in ideological agendas. Our next president can take us to more of the same in judicial conservatism, or to balance. Any thinking person should consider this as one of the core issues when they cast their next ballot.

Tags: Oral Cancer News by oc advocate
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It’s bad enough what tobacco has done to health in the world, and even with the huge settlements from lawsuits against big tobacco, it isn’t about to go away or be less of a corporate profit center. What we need to never forget is that those lawsuits revealed that the tobacco companies have consistently lied to EVERYONE, not just to the addicted consumers, but to the government as well. They have NO track record of any honesty, and have only tried to deceive people in their pursuit of corporate greed. I think that one of the most insidious forms of this, which most people are not aware of, is the way that they are using buzz marketing or “word of mouth” techniques, straw men posters and bloggers, and video which appears to be consumer produced, to stealth market their products. When you know a tobacco company is behind something, it sets you to a certain path in your thinking (pro or con). If it appears an average person is saying it, you may believe them or not, but you may be completely unaware that they are paid to post a positive viewpoint, blog, or produce YouTube videos promoting or glamorizing tobacco by these firms. This is worse than outright advertising in my book. Stealth marketing of products is a growing trend in the world. It’s not just in tobacco, but this posting focuses on that. As new products like Snus attempt to gain marketshare in the US to replace the tobacco companies diminishing ranks of addict customers, we should be aware of how they are selling to us under other guises. In particular we should be thinking of how our youth may not be aware of this technique, and the impact that it may have on their decision making. This is certainly a vehicle to initiation of tobacco use that needs to be monitored, and controlled. Of course with our own White House planting stories in the media, employing fake reporters, and having public forums that are only attended by those in favor of the viewpoint being expressed (and not telling anyone about this attendee screening process) there isn’t much hope in this administration for control or change. Nice example to set W.

A fascinating study (very important link)  by Australian researchers [4] investigates the prevalence of smoking-related videos on YouTube. One of the study’s authors and a global authority on tobacco marketing, Professor Simon Chapman of the School of Public Health at Sydney University [2,3,4,5], has been quoted in the media as accusing tobacco manufacturers of hijacking YouTube by flooding it with videos of glamorous, smoking teens. YouTube and other popular social sites like Facebook and MySpace are running riot with pro-smoking messages which appear to have the fingerprints of tobacco companies all over them. In November 2006, when the authors conducted the research for their study, the use of the search term “smoking” returned 29,325 videos. For an Australian blogger’s reaction, see Melissa’s Blog.

Chapman says that tobacco companies are probably responsible for some of the most sophisticated online video promotions, with clips ranging from pro-smoking propaganda to images of celebrity smokers and seductive women smoking cigarettes. Smoking fetish videos are strangely popular. A video mentioned in the study depicts two women blowing smoke into each other’s mouths. It had 221,033 views and 142 comments. The majority of feedback was positive (e.g., “Smokin’ HOT HOT HOT. Loved it”). Others were less impressed (e.g., “Lung cancer becomes a STD. Nice.”) My attempt to follow the link provided by the authors led to a dead end. Some of the smoking fetish videos are restricted to those over the age of 18, and require registration. Interested readers can go to www.smoking-models.com for abundant examples of the genre.

The invasion of YouTube would be in line with the increasing use of “below the line” forms of viral cigarette marketing, such as promotions at dance parties, disguising market research as sampling promotions, and themed nights in bars and at music festivals. Just as tobacco-company marketers have a presence on youth-friendly venues, it is quite conceivable that they also have a presence on youth-friendly websites. Here is another quote from Simon Chapman: “If I was a tobacco marketer I’d be saying, ‘It’s not illegal; it’s an international market and it’s unregulated,’ and it goes right to the heart of what I believe will be the future of tobacco marketing.”

Although it is devilishly difficult to prove, it seems clear that young people are being encouraged to take up smoking through pro-tobacco stealth marketing on YouTube. According to the Word of Mouth Marketing Association (WOMMA), stealth marketing is any practice designed to deceive people about the involvement of marketers in a communication. Of course, from the tobacco biz there are only denials and claims that they are clear about their responsibilities to society and their obligations under the tobacco control laws of the countries in which they operate. They admit to the use of buzz marketing techniques, which are to be distinguished from stealth marketing by being, well, less stealthy.

The tobacco companies could never be criticized for slack performance [1]. Despite overall decreases in youth smoking, thousands of children under the age of 18 still start smoking every day, especially in developing countries. To increase demand among these groups, new, more targeted marketing strategies are being developed. Flavoured cigarettes, with alluring names like Dark Mint, Cool Myst, Midnight Berry and Mocha Taboo, have been successfully flogged in the United States. Complemented by stylish and colourful packaging, these candied cancer sticks contain invisible flavour delivery pellets inside their filters. Fortunately, many states have agreed on an outright ban of such confections, and the American Lung Association is advocating a total ban. As far as I know, they are not permitted in Canada. Whatever happens, the hawkers of halitosis will continue to take advantage of any opportunities, including Web 2.0 innovations, to bring lips to butts.

The good news is that YouTube and the like are obvious vehicles for the dissemination of anti-smoking messages. Health Canada has placed their latest anti-smoking ad on YouTube, and some of the brilliant thetruth.com ads can also be found on the site. Particularly striking is a Marlboro Man spoof entitled You don’t always die from tobacco.

The authors conclude their article with some suggestions:

1. YouTube could be lobbied to broaden its definitions of unacceptable material to include those that depict smoking.

2. YouTube could be urged to adopt a rating system for smoking in videos.

3. YouTube is an obvious vehicle for the dissemination of anti-smoking messages. Smoking cessation organizations will need to avoid the corporate marketing pitfall of hiring actors and being deceitful about the origins of the video content. Working with real people who are actually quitting smoking and producing inexpensive video blogs is another possible way for tobacco control to maximize this new form of media.
While the world wide web is being used extensively to sell cigarettes, its largely unregulated status holds much potential as a vehicle for the promotion of both smoking and non-smoking. The web has become a battleground for the lungs of our adolescents, says Professor Chapman.

Is Big Tobacco Stealth Marketing to YouTubers? By usmedstudent (Added to YouTube: 10 May 2007) A Harvard medical student discusses the implications of the study by Chapman and Freeman.

“I was stunned to learn that YouTube videos containing smoking imagery may be paid for by tobacco companies. Some of these videos with smoking imagery include anywhere from vlogs to movie clips. It’s sad, but in hindsight, given the tobacco industry’s track record, I shouldn’t have been surprised…”

Other videos on buzz marketing and stealth marketing:

Tobacco’s stealth marketing

http://www.youtube.com/watch?v=jevfwAwgAc4

Youtube Members In Stealth Marketing Scam

http://www.youtube.com/watch?v=tCQ5XPUkRl0

As One Gatherings : The Future Of Stealth Marketing

http://www.youtube.com/watch?v=qltsWjnVY6I

Allan Brandt – Health Research and the Tobacco Industry

http://video.aol.com/video-detail/allan-brandt-health-research-and-the-tobacco-industry/4101659155

Complete video at: http://fora.tv/fora/showthread.php?t=810
Medical historian Allan Brandt discusses the history of conflict between health researchers and the American tobacco industry. Allan Brandt researched “The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America,” and after doing so for twenty years, he has become one of the top expert witnesses for tobacco-related state and federal cases. In 2004 Brandt took the stand as an expert witness for two full days of cross-examination in the case of U.S. vs. Phillip Morris. The judge’s opinion referenced Brandt’s testimony nearly 200 times and for the first time ever tobacco companies were found to be in violation of Federal racketeering statutes. Now, in “The Cigarette Century,” Brandt presents the definitive history of the cigarette, both as the ultimate cultural icon and as the produce that shaped US agriculture, big business, medicine, and regulatory policies in the 20th century. Making extensive use of previously secret corporate documents which became available in the last decade as a result of litigation, Brandt offers critical analysis of the cigarette controversy and how the industry used sophisticated public relations to invent a modern “disinformation” campaign. — Allan Brandt is the Amalie Moses Kass Professor of the History of Medicine at Harvard Medical School, and holds a joint appointment in the Department of the History of Science at Harvard University.

References:

1. Brandt AM. The cigarette century: the rise, fall, and deadly persistence of the product that defined America. Basic Books; 2006.

2. Chapman S. Falling smoking prevalence: how low can we go? Tobacco Control 2007;16:145-7.
Large public awareness campaigns to inform and motivate millions of smokers about quitting seem destined to remain a feature of everyday life in wealthier nations. However, very few poorer nations can afford to even get to the starting line with such campaigns and try in vain to inform their communities via valiant, low-budget efforts at publicity on World No Tobacco Day. A sustained international initiative to fund major public awareness campaigns in nations that could never afford to run such campaigns would make a huge difference to nations in which such awareness remains rudimentary. The profligacy of some areas of tobacco control expenditure in some industrialised nations is embarrassing when there are now many more smokers and deaths caused by smoking in less developed nations.

3. Chapman S. Public health advocacy and tobacco control: making smoking history. Wiley-Blackwell; 2007.
A major new book on advocacy and smoking prevention from the editor of Tobacco Control.

4. Freeman B, Chapman S. Is YouTube telling or selling you something? Tobacco content on the YouTube video sharing website. Tobacco Control 2007;16:207-10
Smoking imagery is prolific and accessible on YouTube. The effectiveness of overt tobacco advertising and sponsorship bans is well established. The industry has responded to these bans by implementing “buzz” or “viral” marketing techniques, such as nightclub and dance party promotions. This paper analyses possible tobacco industry content on the burgeoning consumer-generated media website, YouTube. Tobacco control efforts need to embrace this new medium, in order to counter pro-smoking messages and maximize media advocacy opportunities.

5. Gartner CE, Hall WD, Chapman S, Freeman B. Should the health community promote smokeless tobacco (snus) as a harm reduction measure? PLoS Medicine 2007;4(7)e185 doi:10.1371/journal.pmed.0040185 [you can listen here to a Radio 6PR Perth interview of Coral Gartner (11.12mins & 10.2mb) & Simon Chapman (11.06mins & 10.1mb) discussing this paper]
Smokeless tobacco [low nitrosamine oral snuff, or Swedish "snus"] has low appeal for the overwhelming majority of the world’s smokers. There are profound risks in letting tobacco industry tigers off their leash to use snus to subvert the hard-won provisions of the Framework Convention on Tobacco Control—provisions that include a ban on all tobacco advertising. Such a ban has already been achieved in some nations, but not in the US, from where much of the enthusiasm for snus now comes.

Tags: Tobacco Harm Reduction by oc advocate
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