Many organizations and publications are focusing broad public attention on the danger signs of and available means to prevent oral and pharyngeal cancer. Among these are The Journal of the American Dental Association, through this supplement; the Report on the Future of Dentistry commissioned by the ADA; the surgeon general’s report on oral health; Healthy People 2010—our Nation’s Health Objectives; the National Institute of Dental and Craniofacial Research, or NIDCR; National Cancer Institute; Division of Oral Health at the Centers for Disease Control and Prevention, or CDC; a new privately funded ADA-led outdoor billboard campaign; and numerous dental schools, dental societies and statewide programs.^1–9 Indeed, it is easy to argue that the single most important service a dentist can provide is an oral cancer examination, because it is one of the few dental services that can save a patient’s life when performed routinely.

To assist others in the development of community-based efforts to elevate the public’s awareness of the causes and deadliness of oral cancer, as well as the importance of tobacco use cessation, we will review some high-impact regional outreach programs and some national initiatives.

	ORAL CANCER CONSORTIUM

TOP ABSTRACT ORAL CANCER CONSORTIUM MARYLAND MODEL FOR ORAL... NATIONAL EFFORTS CONCLUSION REFERENCES

 
In early 1999, the dental schools at Columbia University, New York University, the State University of New York at Stony Brook, and the University of Medicine and Dentistry of New Jersey along with the New York City Health and Hospitals Corporation and ABC-TV formed a coalition to increase public awareness about oral cancer. This coalition—the Oral Cancer Consortium—now consists of more than 20 institutional members, including the New Jersey Dental Association and the New York County Dental Society, and it continues to grow.³ Indeed, it is the largest such coalition in the country and has proven to be effective in training area dentists in oral cancer diagnostic techniques and in conducting large annual regional cancer screening programs.

The most effective tool identified is the use of live remote television broadcasts to entice consumers to the regional oral cancer screenings and into their own dentists’ offices.

To date, thousands of patients have been examined free of charge in these screenings; both cancerous and precancerous lesions have been identified, and lives likely have been saved. However, although this screening program is important, it is not an end in itself. The primary purpose of these screenings is to serve as a significant media event to focus public attention on oral cancer, and to create a sense of urgency among consumers that prompts them to visit their private dentists and ask to receive an oral cancer examination. Ultimately, oral cancer examinations must become a routine part of dental examinations if more oral cancers are to be detected in early, curable stages of the disease.

The approach of the Oral Cancer Consortium is to reach the public through several media techniques, and to reach area dentists through a combination of continuing education courses, an interactive online oral cancer course ("www.nyu.edu/dental/ce/oralcancerscreening.html") and alumni mailings sponsored by various institutions. The public media campaign includes public service announcements on ABC-TV, a Web site ("www.oral-cancer.org"), advertisements placed in major newspapers (Figure), radio and television interviews with members of the Oral Cancer Consortium and declarations of an Oral Cancer Awareness Week by both the governor of New York and the mayor of New York City.

View larger version (27K): [in this window] [in a new window]   Figure. Oral cancer screening advertisement.

In the 1999 screening, the local ABC-TV morning meteorologist, broadcasting live from New York, interviewed representatives from each dental school in the consortium. These interviews included discussions about the causes of oral cancer, the deadliness of the disease and the components of an oral cancer examination. In fact, a dentist performed an oral cancer examination live on camera. To make the experience less intimidating to patients, this activity occurred in a festive atmosphere in which breakfast was served, a band played and staff members urged the public to come to the oral cancer screening site. In total, about 18 minutes of air time was provided by the network—a valuable contribution in a major media market such as metropolitan New York.⁴

For the 2000 screening, a well-equipped dental van was parked outside the New York County Dental Society, which is in a busy part of mid-town Manhattan. The ABC-TV weather anchorman broadcast live from outside the van, and a line of patients quickly wrapped around the corner, generating considerable excitement about this issue. Four segments appeared on the evening and late news that night, during which the public was introduced to a new painless brush biopsy technique.

Donna Shalala, then-secretary of the U.S. Department of Health and Human Services, endorsed the approach of the Oral Cancer Consortium, which is being incorporated by several other groups around the country. Area dentists have embraced the program, and another, expanded screening will be conducted in the fall of 2001. Consortium members are committed to helping other groups develop programs, and will eagerly share media materials and expertise. In addition to ABC-TV, sponsors of the program have included Zila Pharmaceuticals (Phoenix, Ariz.) and OralScan Laboratories (Suffern, N.Y.), as well as some of the dental schools in the consortium.

	MARYLAND MODEL FOR ORAL CANCER PREVENTION AND EARLY DETECTION

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Maryland took a somewhat different approach from that of the regional consortium; it developed a state model of oral cancer prevention and early detection. The basis for this is that states have different populations, different oral cancer incidences and different mortality rates. In addition, state practice acts and other laws (for example, those that address tobacco purchasing and use) vary greatly. Thus, in the early 1990s, a small group began a partnership with the ultimate aim of decreasing morbidity and mortality from oral cancer in Maryland. The rationale for such an effort was simple; the oral cancer incidence was moderately high and the mortality rate was deplorable, especially among African-American males.

Partners. The state’s partners included the American Cancer Society; local health departments; local churches; the Maryland Department of Health and Mental Hygiene; the University of Maryland’s schools of dentistry, medicine and nursing; the National Institute of Dental and Craniofacial Research, or NIDCR; health care provider associations (for example, dentists, nurse practitioners, dental hygienists, family practice physicians); and the Department of Veterans Affairs. Their plan was to develop, implement and evaluate programs to prevent and control the onset of premalignant and malignant lesions, with the ultimate goal of reducing morbidity and mortality from these cancers. Long-range objectives included the following:

– increasing the public’s awareness, knowledge and understanding of oral cancer prevention;

– increasing health care practitioners’ awareness and understanding of their role in oral cancer prevention and early detection;

– increasing the number of oral cancer examinations performed by health care providers;

– developing activities, policies, regulations and legislation aimed at improving access to programs for oral cancer prevention and early detection as well as successful treatment.

Needs assessment. A statewide needs assessment was conducted to determine which interventions were appropriate and could be implemented and, most important, whether the outcomes of these interventions could be measured. Also, participants envisioned that the baseline data could be used as leverage to obtain funding for the intervention phase. Thus, numerous organizations and individuals were invited to help with the needs assessment, including the partner groups mentioned above, as well as several dental students and volunteer researchers from the United States and abroad. Briefly, the needs assessment (phase I) consisted of the following:

– mail surveys to determine the knowledge and practices of Maryland dentists, dental hygienists, adult and family nurse practitioners and family practice physicians concerning oral cancer^5–10;

– a telephone survey to assess the knowledge and practices of adults regarding risk factors for, and signs and symptoms of, oral cancers and whether respondents had ever had an oral cancer examination²;

– focus groups composed of all-provider groups and the public to obtain more in-depth information regarding knowledge and practices related to oral cancer^11–15;

– a determination of the best methods for educating providers (through continuing education) and the public about oral cancer prevention and early detection;

– a determination of the stage at which most oral cancers were detected and which practitioners were most likely to have diagnosed them.

Many providers did not know the two most important types of lesions for which to look or the most common sites of oral cancer.

Overall, the findings demonstrated that the general adult public in Maryland was not knowledgeable about oral cancer prevention and early detection.² Further, only 20 percent of these adults reported that they had received an oral cancer examination in the past year. Unfortunately, the researchers also found that when asked why they had not had an oral cancer examination, most respondents replied that their dentist or physician did not tell them to have one or that they did not know they were supposed to have such an examination.²

The results of another study showed that most oral cancers in Maryland were detected at a late stage and were diagnosed by physicians.¹⁶ Furthermore, although most surveyed dentists and dental hygienists reported providing oral cancer examinations, the majority of respondents did not palpate—an important part of the examination—and did not provide examinations to edentulous patients.^6,7,11 Moreover, many providers did not know the two most important types of lesions for which to look (that is, red and white patches) or the most common sites of oral cancer (that is, lateral borders of the tongue, floor of the mouth and lips).

Applying the findings. These findings have been used in several ways, including being shared with a variety of groups, such as state provider associations (for example, a state medical society) and state legislators. Based on the data from these studies, the state assembly passed legislation to develop statewide oral cancer prevention programs. This legislation, which was strongly supported by Maryland Gov. Parris Glendening and the state health department, provided funds to the state’s Office of Oral Health. The office is using these funds to develop an oral cancer examination training program for health care providers, an educational and awareness program for providers, and a campaign for the public.

Oral cancer awareness week. In addition, the governor proclaimed Sept. 16–22, 2001, as Maryland Oral Cancer Awareness Week. It is interesting to note that the week’s media activities were patterned largely after those used by New York’s Oral Cancer Consortium. Free oral cancer examinations were provided at numerous sites throughout the state and the closing event took place at the National Museum of Dentistry in Baltimore. Many dignitaries attended, including U.S. Chief Dental Officer Dr. Dushanka V. Kleinman and key state legislators who sponsored the oral cancer legislation.

Educational materials about oral cancer examinations and risk factors, including one for people with low literacy, were developed, tested and published for use during the week’s activities as well as later on. All of the materials are available on the Internet ("www.Maryland-oralcancer.org"). The initiative will continue during the winter and spring of 2002, with additional media and educational interventions anticipated.

In addition, the Maryland Department of Health and Mental Hygiene identified oral cancer as one of seven targeted cancers in the state for which tobacco settlement funds are to be used. Because of their special interest in oral cancer prevention, six Maryland counties, including two of the largest jurisdictions in the state, opted to target oral cancer prevention in their use of these funds.

The surgeon general’s report on oral health¹⁷ and Healthy People 2010¹⁸ also included the information from Maryland’s needs assessment. Moreover, these results were the basis on which the NIDCR and the National Cancer Institute led a Request for Applications on State Models of Oral Cancer Prevention and Early Detection for a three-year phase I needs assessment. Five grants have been funded and, thus, more statewide activities are anticipated. Depending on the results of the phase I grants, phase II grants (which consist of interventions) will be funded in the future.

	NATIONAL EFFORTS

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Other institutions have initiated prevention and early detection activities as well. For example, the Division of Oral Health, CDC, is working with a consortium of public and private-sector organizations to develop a national program for the prevention, early detection, and control of oral and pharyngeal cancers. Building on a strategic planning conference held in 1996¹⁹ cosponsored by the CDC, ADA and NIDCR, CDC has facilitated meetings of the Oral Cancer Work Group, a coalition of federal and state agencies and private health-related organizations, in 1997, 1999 and 2001. Recommended strategies being addressed cover four main areas: public health policy; public education; professional education and practice; and data collection, evaluation and research.¹⁹

The CDC Division of Oral Health also has awarded grants to several state cancer registries to evaluate the completeness, timeliness and quality of oral and pharyngeal cancer data. These projects will enhance our understanding of the burden of these cancers and provide insight into effective preventive strategies and justification for increased efforts and commitment of resources.

Brian R. Hill, an oral cancer survivor, recently established an exciting foundation called the Oral Cancer Foundation ("www.oralcancerfoundation.org"). The foundation is a nonprofit entity designed for advocacy and service to increase awareness and understanding about oral cancer prevention, early detection and treatment. At the forefront of the foundation’s agenda is the goal to establish in the minds of the American public the need to undergo annual oral cancer examinations.

	CONCLUSION

TOP ABSTRACT ORAL CANCER CONSORTIUM MARYLAND MODEL FOR ORAL... NATIONAL EFFORTS CONCLUSION REFERENCES

 
Collectively, the activities described above, along with others not cited, suggest that after decades of simply accepting the grim statistics associated with dentistry’s No. 1 killer, we are on our way to truly making a difference. Each of us can make a difference, whether it is on a one-to-one basis with patients in offices or clinics, or as part of a group effort in our communities. Individually and collectively, we can make a significant difference in reducing the morbidity and mortality rates from oral cancer.