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….