IAGS 39:920-925, 1991
SPECIAL ARTICLE
Oral Cancer Screening in the Elderly Denise J. Fedele, DMD, MS,* Judith A. Jones, DDS, MPH,t and Linda C. Niessen, DMD, MPH, MPpS
Oral cancers represent approximately 3% of all cancers diagnosed in the United States. Oral cancer is one-fifth as common as cancer of the breast, colon, and lung but more than twice as common as cervical cancer. Incidence rates for oral cancer are highest among older men. Epidemiologic data identify alcohol and tobacco as major risk factors associated with the disease. Screening for oral cancer is a simple, non-invasive procedure which can be easily incorporated into the comprehensive assessment of
older patients. Oral cancer screening can detect early, localized lesions which are associated with an improved prognosis. Five-year survival rates are more than four times greater in individuals with localized lesions than those with distant metastases. Since older Americans visit their physician more often than their dentist, the physician's medical examination provides an excellent opportunity to screen for oral cancers. J Am Geriatr SOC 39:920-925,1991
he Department of the Health and Human Services program Healthy People 2000 has set a national goal to reduce the oral cancer incidence by the year 2000.' In pursuit of this goal clinicians can follow the American Cancer Society guidelines for cancer screening in older adults.' In contrast to recent articles highlighting controversies surrounding screening for colorectal, cervical, and breast ~ a n c e r s , ~ screening -~ for oral cancer is a simple, non-invasive procedure which can easily be integrated into the comprehensive assessment of older patient^.^ Further, geriatricians should feel comfortable performing an oral cancer screening examination. Since 5-year survival rates' are more than four times greater in individuals with localized lesions than in those with distant metastases, the detection of early oral cancer can make a significant contribution toward reducing complicationsassociated with advanced disease and its treatment. This paper reviews current trends regarding oral cancer and discusses epidemiology and risk factors, methods for early detection, lesions associated with oral cancer, and indications for referral.
ORAL CANCER TRENDS AND RISK FACTORS The American Cancer Society estimates that just over one million new cancer cases will be diagnosed in 1991. Of these cancers, 30,800 (approximately 3%) will be oral cancers. Oral cancers include malignancies of the lip, tongue, pharynx, and other areas of the mouth such as the gingiva, buccal mucosa, hard and soft To place oral cancers in perspective with other cancers, estimated new cases and deaths for several types of malignancies, for all ages, are shown in Table 1.' The age-specific incidence rates for oral cancer are higher for men than women and steadily icrease from middle adulthood until the seventh decade of life for both genders (Figure l.)." The average age at the time of oral cancer diagnosis is between 60 and 63, with over 95% of oral cancers occurring after the age of 40.1','2 The high rate among older adults may be attributed to long-standing exposure to carcinogens." Over the past three decades, the incidence rate of oral and pharyngeal cancer has remained unchanged at approximately 11cases per 100,000 population,'o while the male to female ratio has changed from 6:l to 2:l.I3 The American Cancer Society estimates that 8,150 people will die as a result of oral cancer in 1991: Mortality associated with oral cancer has shown little improvement compared to other cancers'; deaths due to oral cancer vary greatly with the location of the malignancies. On a percentage basis, malignant lesions in certain locations contribute disproportionately to oral cancer deaths (Figure 2).' For example, lip cancer,
T
From the 'Geriatric Dental Program, Veterans Affairs Medical Center, Perry Point, Maryland and Baltimore College of Dental Surgery, Baltimore, MD; the tGeriatric Dental Program, Veterans Affairs Medical Center, Bedford, Massachusettsand Harvard School of Dental Medicine, Boston, Massachusetts;and the $Geriatric Oral Mediane Program, Baylor College of Dentistry, Dallas, Texas and Veterans Affairs Medical Center, Dallas, Texas. Address correspondence and request for reprints to Dr. Denise J. Fedele, Dental Service (160),Veterans Affairs Medical Center, Perry Point, MD 21902.
0 1991 by the American Geriatrics Society
0002-8614/91/$3.50
ORAL CANCER SCREENING IN THE ELDERLY
IAGS-SEPTEMBER 1991-VOL. 39, NO. 9
TABLE 1. ESTIMATED NEW CANCER CASES AND DEATHS FOR SELECTED SITES 1991, USA’ New Cases Deaths ~~
Oral cavity Colon-rectum Lung Breast Cervix uteri Prostate
loo
~
30,800 157,500 161,000 175,900
13,000 122,000
~
8,150 60,500 143,000 44,800 4,500 32,000
1
40
20
0 8085 8589 75.79 8k
4041 50-54 6084 70-74 45-49 5559
AGE
-
‘per 100.00. SEER, 1981 85. ALL RACES
FIGURE 1. Age-specific cancer incidence rates* for oral cavity and pharynx.
Tonaue
Phar y n i 47
t:,TlMAitD
NEW CALES
ESTIIVIAlED DEATHS
FIGURE 2. Cancer of buccal cavity and pharynx (oral) by location and percent-US 1991. Source: American Cancer Society, 1991.
estimated to comprise 12% of all oral cancers in 1991, is expected to account for only 103 (1%)of the deaths due to oral cancer. By contrast, cancer of the pharynx, estimated to be 30% of oral cancers in 1991, is expected to account for 47% of deaths dues to oral malignancies in that same year. Epidemiological data have identified the use of all forms of tobacco and the excessive use of alcohol as
921
major risk factors for oral ~ a n c e r s . ~Further, ~ - ~ * a synergistic relationship between alcohol and tobacco has been suggested. The effects of alcohol and tobacco combined are multiplicative and considered to account for 75% of all oral cancers in the United States.” Other risk factors which may be associated with increased risk for oral cancer are poor oral hygiene, malnutrition, and Hummer-Vinson Syndrome.”
PHYSICIAN AND DENTIST VISITS BY ELDERS The physician office visit, by virtue of its frequency, provides an excellent opportunity for a thorough oral cancer examination. National data demonstrate that elders have more physician than dental visits per year, as shown in Figure 3.l9,’’ The number of physician contacts increases from 6.5 per year in 55 to 64 year olds, to 8.3 contacts per year for individuals age 75 and older. By contrast, mean dental contacts decline in the aged from 2.5 in 55 to 64 year olds, to 1.6 contacts per year in individuals 75 and older. Currently, 35 percent of individuals age 75 and older visit the dentist annually compared to 89 percent of individuals age 75 and older visiting the physician a n n ~ a l l y . ’ ~ * ~ ~ EARLY DETECTION REDUCES MORTALITY AND MORBIDITY Early, localized oral cancers are often asymptomatic and therefore go undetected until regional or distant Studies indicate that 50 percent of disease is pre~ent.’~ tongue cancers have regional lymph node metastasis at the time the patient presents for treatment.’l Fiveyear survival data demonstrate greatly improved rates of survival and possible cure when disease is detected and treated while localized (Figure.$).’ Early detection of oral malignancies can result in a significant reduction in morbidity and mortality associated with the disease and its treatment. Further, detection of an asymptomatic oral cancer identifies individuals at high risk for development of other malignancies of the respiratory system and the upper digestive tract, since individuals with oral cancer are more prone to the development of other primary cancers of the larynx, esophagus, and lung.”, 14,z2 Early detection of oral cancers can significantly reduce the morbidity associated with treatment. An early tongue lesion (Stage I) can often be treated with radiation therapy or local resection, while an advanced lesion (Stage 111 and IV) requires more radical surgery and radiati~n.’~ When tumors are advanced, tissue losses and facial deformities resulting from surgical resections can create devasting psychosocial probl e m ~Additionally, .~~ thyroid dysfunction is a common sequel of neck radiationz5in advanced head and neck tumors. Oral complications associated with chemotherapeutic, surgical, and radiation therapy are mucos-
922
FEDELE ET AL
JAGS-SEPTEMBER 1991-VOL. 39, NO. 9
Male
lo F8
Female
1
1
lo UJ
0
2 z 86
3
$ 6
8
8
z4
z4
z 2
z 2
I
I
0
0 55-64
65+
65-74
75+
AGE
55-64
65+ 65-74 AGE
75+
W Physicians
I3 Dontists
FIGURE 3. Annual physician (1982-1983) and dentist (1986)contacts per person, by age and gender, in the US.'9.20
100 All Staoce 752
P e
r
0 Locallnd Regional
60
0
e
n t
40
20
0
EXTENT OF DISEASE
FIGURE 4. Five-year survival rates for oral and pharyngeal cancer, US, 1991.'
itis, xerostomia, secondary infections (candidiasis and herpes simplex are common), taste alterations, rampant dental caries, osteoradionecrosis, muscular dysfunction, and bone marrow suppression.
ORAL CANCER SCREENING Clinicians have a responsibility to perform a thorough head and neck examination as part of the physical assessment of their patient^.'^,'^ This simple, efficient, non-invasive procedure usually takes less than 2 minutesz6to perform. The goal of the exam is to detect any nodules, swellings, mucosal alterations (ulcerations, textural or color changes) and unexplained adenopathy. While many routines exist for an oral examination, each clinician must develop his or her own method, use it in all patients, and carefully document positive findings. The oral cancer examination may begin extraorally by inspection of the skin of the neck and face for any abnormalities, especially pigment changes. Careful pal-
pation of the pre- and post-auricular,parotid, submandibular, mental, superficial, and deep cervical and supraclavicular (Vichow's) lymph nodes is essential. Even in the absence of symptoms, a firm, unilateral neck node in a middle aged or older patient is suspicious of malignancy." In addition, movement of the hyoid bone laterally to produce a 'click" on each side can assist in ruling out carcinomas of the base of the tongue and epiglottis. The intraoral exam may involve palpation and direct and indirect in~pection.'~ The aid of a tongue depressor, a dental or laryngeal mirror, and good lighting, directed intraorally, is essential. All dentures must be removed for the intraoral cancer screening examination?6 The lips, buccal mucosa, gingiva, and hard palate are inspected and palpated. Fordyce's spots (ectopic sebaceous glands), linea alba (white line on the inside of the cheek adjacent to the biting surfaces of the teeth) and palatal tori are some normal deviations in these areas. To inspect the anterior floor of the mouth, and the anterior ventral surface of the tongue, ask the patient to place the tip of the tongue in contact with the hard palateI4(Figure 5). Wharton's duct, the opening of the sublingual/submandibular glands, is located at the base of the lingual frenum. Bidigital palpation of the tongue proceeds with one finger on the dorsum and one finger on the ventral surface of the tongue, starting anteriorly and progressing posteriorly on each side.z6Inspection of the posterior floor of the mouth, retromolar trigone, and posterior ventrolateral aspect of tongue is performed by grasping the tip of the tongue with a 2 X 2 gauze sponge and pulling it anteriorly and toward the opposite comer of the mouth (Figure 6). Inspection of the oropharynx, soft palate, uvula, and tonsillar pillars is accomplished by depressing the tongue with a mirror or tongue blade while the patient takes a deep breath"e26(Figure 7).To
IAGS-SEPTEMBER 1991-VOL. 39, NO. 9
FIGURE 5. xonnal anatomy of the anterior mouth floor and veneal tongue.
ORAL CANCER SCREENING IN THE ELDERLY
923
palpate the floor of the mouth bidigitally, the index finger of one. hand is placed below the chin, and a finger of the other hand palpates the anterior floor of the mouth, proceeding on each side posteriorly?6 When salivary gland enlargement and/or xerostomia are noted, parotid and submandibular glands should be milked to assess the quantity, quality and consistency of saliva. To milk the parotid gland, place one finger at the preauricular area and move the finger forward along the path of the duct. The submandibular gland is milked by placing one finger in the submandibular triangle of the neck with a movement toward the menton of the chin. Salivary glands with normal function will produce at least one drop of clear, watery saliva when milked.26Parotid saliva is expressed from Stensen’s duct located opposite the first maxillary molars. Submandibular saliva is noted from Wharton’s duct located behind the lower incisor teeth.
INDICATIONS FOR REFERRAL The warning signs of oral cancer are a non-healing ulcer, a persistent white or red lesion, a lesion which bleeds easily, difficulty chewing and swallowing, and difficulty moving the tongue or mandible.2 Pain or irritation may or may not be present with early lesion~.~’ Traumatic oral lesions will resolve or improve after the etiologic agent is removed. Patients with suspected traumatic lesions should be referred to a dentist to rule out dental etiology. Removable oral protheses are the most common cause of traumatic lesions. Oral lesions which persist after 2 weeks should be biopsied to confirm or rule out malignancy. Most intraoral biopsies are easily performed by a physician or dentist. FIGURE 6. Soma1 anatomy of the lateral border of the Ninety percent of oral cancers develop in a horsetongue, retromolar trigone, and posterior mouth floor. shoe-shaped area as described by Moore.” Three sites within the oral cavity appear to be predisposed to the development of squamous cell carcinoma: the floor of the mouth, the ventrolateral aspect of the tongue, and the soft palate complex (soft palate proper, lingua1 aspect of retromolar trigone, and anterior tonsillar pillar).I4In addition, metastases from lung or breast malignancies may have gingival or oral soft tissue manifestations which can be detected during the oral examinati~n.’~Furthermore, adenocarcinomas of the maxillary sinus can invade inferiorly and present as a painless intraoral swelling of the palatal area (Figure 8). Conversely, potentially malignant lesions on the anterior floor of the mouth close to an edentulous mandibular alveolar ridge must be differentiated from a denture sore. Oral erythroplakia and leukoplakia are potentially (but not always) precancerous in the oral cavity (Figure 9).30Erythroplakia has been reported by Mashberg as FIGURE 7. Normal anatomy of the oropharynx, softpalate, the most common presentation of early cancer.I4 The tonsillar pillars, and posterior dorsal tongue. most common site in women is the gingiva; in men,
7L*
IAGS-SLY1 LMLltK I Y Y I - V U L 351,
F C U E L E C 1 AL
NU. 9
*-
FIGURE 8. Adenocarcinoma of the maxillary sinus which presented as a painless swelling of the palate.
FIGURE 10. Squamous cell carcinoma of the anterior mollth floor.
FIGURE 9. Mixed lesion of the anterior mouth floor exhibiting both erythroplakia and leukoplakia.
FIGURE
11. Candidiasis of the ventral surface of the
tongue.
the floor of the mouth and the retromolar trigone are to confirm the presence of hyphae. It is also important the most common locations.” The term leukoplakia is to note that candidiasis may exist concurrently with used to characterize a white lesion without any specific other oral mucosal lesions, such as l e ~ k o p l a k i aOral .~~ physical or chemical etiology, other than toba~co.’~ It manifestations of lichen planus may also be clinically is estimated that about 5% of leukoplakia lesions will indistinguishable from an oral cancer.12 become cancerous over a 20-year period.” SUMMARY Candida albicans, a yeastlike fungus which normally A thorough examination of the oral cavity is an easy occurs in the mouth, can become a clinical problem when it transforms from a commensal to a pathogenic and efficient method to detect early oral cancers. No state. Oral candidiasis can cause significant discomfort invasive diagnostic procedures are necessary. Early and may lead to systemic inv~lvement.~~ Predisposing detection and treatment of oral cancers are associated factors which potentiate the transformation of the or- with a sigruficant reduction in morbidity and mortality. ganism include: use of removable dental prostheses, Health professionals and policy planners have emsteroid or antibiotic therapy, salivary dysfunction, en- phasized the importance of directing health issues todocrinopathies, malignancies, and immunologic or nu- wards the needs of the aging population. Since oral tritional deficiencies. Oral candidiasis presents with a cancer occurs primarily in adults aged 60 and older, wide range of clinical manifestations which may be the prevention, detection, and treatment of oral maligsimilar to some other oral conditions, including oral nancies will continue to be a major health concern into (Figures 10 and 11). Clinical diagnosis of the next century. Efforts made by public awareness oral candidiasis must be supplementedby oral cytology groups and health professionals to decrease consump-
JAGS-SEPTEMBER 1991-VOL 39, NO. 9
tion of alcohol and tobacco may reduce future &ease and Because detection of oral cancer results in decreased morbidity and mortality associated with the disease, geriatricians must: (l) be proficient in performing the Oral cancer screening exam, (2) be knowledgeable of the wide range of normal variation in the oral anatomy, and (3) develop mechanisms for referral and follow-up of patients who present with suspicious oral lesions.
ORAL CANCER SCREENING IN THE ELDERLY
925
14. Mashberg A, Samit AM. Early detection, diagnosis and management of oral and oropharyngeal cancer. Cancer 1989;3967-88. 15. Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res . - 1988:48:3282-3287. 16. Mashberg A, Garfinkel L, Hams S. Alcohol as a primary risk factor in oral squamous cancer. CA 1981;31:146-155. 17. American Cancer Society: Smokeless Tobacco: A Medical PerC A 87-(25M)-No. 3313. spective. 18. Winn DM. Smokeless tobacco and cancer: the epidemiologic evidence, Cancer 1988:38:236-243. 19. Vital and Health Statistics, National Center for Health Statistics: Health Statistics on Older Persons. 1986 Series 3, No. 25. Hyattsville, MD: DHHS Publication No. (PHS)87-1409. 20. Vital and Health Statistics, National Center for Health Statistics: REFERENCES Use of Dental Services and Dental Health. 1986 Series 10, No. 165. Hyattsville, MD: DHHS Publication No. (PHS)88-1593. 1. Department of Health and Human Services: Healthy People 21. Holmstrup P, Pindborg JJ. Oral mucosal lesions in smokeless 2000: National Health Promotion and Disease Prevention Obtobacco users. Cancer 1988;38:230-235. jectives. Washington, DC, DHHS, USPHS, 1990. 22. National Cancer Institute. Oral Cancers Research Report. Be2. American Cancer Society: Cancer facts and figures-1991. 91thesda, MD: DHHS, NIH Publication No. 88-2876. 500M-No 5008.91, Atlanta, GA. 3. Clinical Practice Committee, American Geriatrics Society: 23. Spiro RH. Squamous cancer of the tongue. Cancer 1985;35:252256. Screening for breast cancer in elderly women. J Am Geriatr SOC 24. Jacobs C. The internist in the management of head and neck 1989;37883-884. cancer. Ann Intern Med 1990;113:771-778. 4. Clinical Practice Committee, American Geriatrics Society: Screening for cervical carcinoma in elderly women. J Am Geriatr 25. Posner MR, Ervin TJ, Miller D et al. Incidence of hypothyroidism following multimodality treatment for advanced squamous cell SOC1989;37:885-887. cancer of the head and neck. Laryngoscope 1984;94:451-454. 5. Robie PW. Cancer screening in the elderly. J Am Geriatr SOC 26. Niessen LC, Jones JA, Lonergan JJ. Oral examination of the 1989;37:888-893. geriatric patient. Geriatr Med Today 1986;5:113-116. 6. Barry P, Katz PR. On cancer screening in the elderly. J Am 27. Guralnick WC. Clinical manifestations of oral cancer. In: Shklar Geriatr SOC1989;37:913-914. G ed. Oral Cancer: The diagnosis, Therapy, Management and 7. Jones ]A. Integrating the oral examination into clinical practice. Hospital Practice 1989;24:23-30. Rehabilitation of the Oral Cancer Patient. Philadelphia: WB 8. St. Anthony's ICD-9-CM Code Book. Washington, DC: St. AnSaunders, 1984, pp 6-7. thony Hospital Publications, Inc., 1988. 28. Moore C: Anatomic origins and locations of oral cancer. Am J Surg 1967;1 14:510-5 13. 9. Silverberg E, Boring CC, Squires TS. Cancer statistics, 1990. Cancer 1990;40:9-26. 29. Pindborg JJ. Atlas of Disease of the Oral Mucosa. Philadelphia: WB Saunders Company, 1985, pp 86,88,190. 10. National Cancer Institute, Division of Cancer Prevention and Control. 1987 Annual Cancer Statistics Review, Bethesda, M D 30. Pindborg JJ. Oral Cancer and Precancer. Bristol: John Wright and DHHS, NIH Publication No. 88-2789. Sons Ltd, 1980, p 15. 31. Lehner T. Oral candidiasis. Dent Practitioner 1967;17:209-216. 1 1 . Silverman Jr. S, Gorsky M. Epidemiology and demographic update in oral cancer: California and national data - 1973 to 32. Wright BA, Fenwick F. Candidiasis and atrophic tongue lesions. 1985. J Am Dent Assoc 1990;120:495-499. Oral Surg Oral Med Oral Pathol 1981;51:55-61. 12. Myers EN, Cunningham MJ. Treatment of choice for early 33. Baughman RA. Median rhomboid glossitis: a developmental carcinoma of the oral cavity. Oncology 1988;2:18-24. anomaly? Oral Surg Oral Med Oral Pathol 1971;31:56-65. 13. Chen I, Katz RV, Krutchkoff DJ. Epidemiology of oral cancer in 34. Daftary DK. The presence of candida in 723 oral leukoplakias Connecticut: 1935-1985 (abstract). J Dent Res 1989;68:910. among Indian villagers. Scand J Dent Res 1972;80:75-79.
SPECIAL ARTICLE
Oral Cancer Screening in the Elderly Denise J. Fedele, DMD, MS,* Judith A. Jones, DDS, MPH,t and Linda C. Niessen, DMD, MPH, MPpS
Oral cancers represent approximately 3% of all cancers diagnosed in the United States. Oral cancer is one-fifth as common as cancer of the breast, colon, and lung but more than twice as common as cervical cancer. Incidence rates for oral cancer are highest among older men. Epidemiologic data identify alcohol and tobacco as major risk factors associated with the disease. Screening for oral cancer is a simple, non-invasive procedure which can be easily incorporated into the comprehensive assessment of
older patients. Oral cancer screening can detect early, localized lesions which are associated with an improved prognosis. Five-year survival rates are more than four times greater in individuals with localized lesions than those with distant metastases. Since older Americans visit their physician more often than their dentist, the physician's medical examination provides an excellent opportunity to screen for oral cancers. J Am Geriatr SOC 39:920-925,1991
he Department of the Health and Human Services program Healthy People 2000 has set a national goal to reduce the oral cancer incidence by the year 2000.' In pursuit of this goal clinicians can follow the American Cancer Society guidelines for cancer screening in older adults.' In contrast to recent articles highlighting controversies surrounding screening for colorectal, cervical, and breast ~ a n c e r s , ~ screening -~ for oral cancer is a simple, non-invasive procedure which can easily be integrated into the comprehensive assessment of older patient^.^ Further, geriatricians should feel comfortable performing an oral cancer screening examination. Since 5-year survival rates' are more than four times greater in individuals with localized lesions than in those with distant metastases, the detection of early oral cancer can make a significant contribution toward reducing complicationsassociated with advanced disease and its treatment. This paper reviews current trends regarding oral cancer and discusses epidemiology and risk factors, methods for early detection, lesions associated with oral cancer, and indications for referral.
ORAL CANCER TRENDS AND RISK FACTORS The American Cancer Society estimates that just over one million new cancer cases will be diagnosed in 1991. Of these cancers, 30,800 (approximately 3%) will be oral cancers. Oral cancers include malignancies of the lip, tongue, pharynx, and other areas of the mouth such as the gingiva, buccal mucosa, hard and soft To place oral cancers in perspective with other cancers, estimated new cases and deaths for several types of malignancies, for all ages, are shown in Table 1.' The age-specific incidence rates for oral cancer are higher for men than women and steadily icrease from middle adulthood until the seventh decade of life for both genders (Figure l.)." The average age at the time of oral cancer diagnosis is between 60 and 63, with over 95% of oral cancers occurring after the age of 40.1','2 The high rate among older adults may be attributed to long-standing exposure to carcinogens." Over the past three decades, the incidence rate of oral and pharyngeal cancer has remained unchanged at approximately 11cases per 100,000 population,'o while the male to female ratio has changed from 6:l to 2:l.I3 The American Cancer Society estimates that 8,150 people will die as a result of oral cancer in 1991: Mortality associated with oral cancer has shown little improvement compared to other cancers'; deaths due to oral cancer vary greatly with the location of the malignancies. On a percentage basis, malignant lesions in certain locations contribute disproportionately to oral cancer deaths (Figure 2).' For example, lip cancer,
T
From the 'Geriatric Dental Program, Veterans Affairs Medical Center, Perry Point, Maryland and Baltimore College of Dental Surgery, Baltimore, MD; the tGeriatric Dental Program, Veterans Affairs Medical Center, Bedford, Massachusettsand Harvard School of Dental Medicine, Boston, Massachusetts;and the $Geriatric Oral Mediane Program, Baylor College of Dentistry, Dallas, Texas and Veterans Affairs Medical Center, Dallas, Texas. Address correspondence and request for reprints to Dr. Denise J. Fedele, Dental Service (160),Veterans Affairs Medical Center, Perry Point, MD 21902.
0 1991 by the American Geriatrics Society
0002-8614/91/$3.50
ORAL CANCER SCREENING IN THE ELDERLY
IAGS-SEPTEMBER 1991-VOL. 39, NO. 9
TABLE 1. ESTIMATED NEW CANCER CASES AND DEATHS FOR SELECTED SITES 1991, USA’ New Cases Deaths ~~
Oral cavity Colon-rectum Lung Breast Cervix uteri Prostate
loo
~
30,800 157,500 161,000 175,900
13,000 122,000
~
8,150 60,500 143,000 44,800 4,500 32,000
1
40
20
0 8085 8589 75.79 8k
4041 50-54 6084 70-74 45-49 5559
AGE
-
‘per 100.00. SEER, 1981 85. ALL RACES
FIGURE 1. Age-specific cancer incidence rates* for oral cavity and pharynx.
Tonaue
Phar y n i 47
t:,TlMAitD
NEW CALES
ESTIIVIAlED DEATHS
FIGURE 2. Cancer of buccal cavity and pharynx (oral) by location and percent-US 1991. Source: American Cancer Society, 1991.
estimated to comprise 12% of all oral cancers in 1991, is expected to account for only 103 (1%)of the deaths due to oral cancer. By contrast, cancer of the pharynx, estimated to be 30% of oral cancers in 1991, is expected to account for 47% of deaths dues to oral malignancies in that same year. Epidemiological data have identified the use of all forms of tobacco and the excessive use of alcohol as
921
major risk factors for oral ~ a n c e r s . ~Further, ~ - ~ * a synergistic relationship between alcohol and tobacco has been suggested. The effects of alcohol and tobacco combined are multiplicative and considered to account for 75% of all oral cancers in the United States.” Other risk factors which may be associated with increased risk for oral cancer are poor oral hygiene, malnutrition, and Hummer-Vinson Syndrome.”
PHYSICIAN AND DENTIST VISITS BY ELDERS The physician office visit, by virtue of its frequency, provides an excellent opportunity for a thorough oral cancer examination. National data demonstrate that elders have more physician than dental visits per year, as shown in Figure 3.l9,’’ The number of physician contacts increases from 6.5 per year in 55 to 64 year olds, to 8.3 contacts per year for individuals age 75 and older. By contrast, mean dental contacts decline in the aged from 2.5 in 55 to 64 year olds, to 1.6 contacts per year in individuals 75 and older. Currently, 35 percent of individuals age 75 and older visit the dentist annually compared to 89 percent of individuals age 75 and older visiting the physician a n n ~ a l l y . ’ ~ * ~ ~ EARLY DETECTION REDUCES MORTALITY AND MORBIDITY Early, localized oral cancers are often asymptomatic and therefore go undetected until regional or distant Studies indicate that 50 percent of disease is pre~ent.’~ tongue cancers have regional lymph node metastasis at the time the patient presents for treatment.’l Fiveyear survival data demonstrate greatly improved rates of survival and possible cure when disease is detected and treated while localized (Figure.$).’ Early detection of oral malignancies can result in a significant reduction in morbidity and mortality associated with the disease and its treatment. Further, detection of an asymptomatic oral cancer identifies individuals at high risk for development of other malignancies of the respiratory system and the upper digestive tract, since individuals with oral cancer are more prone to the development of other primary cancers of the larynx, esophagus, and lung.”, 14,z2 Early detection of oral cancers can significantly reduce the morbidity associated with treatment. An early tongue lesion (Stage I) can often be treated with radiation therapy or local resection, while an advanced lesion (Stage 111 and IV) requires more radical surgery and radiati~n.’~ When tumors are advanced, tissue losses and facial deformities resulting from surgical resections can create devasting psychosocial probl e m ~Additionally, .~~ thyroid dysfunction is a common sequel of neck radiationz5in advanced head and neck tumors. Oral complications associated with chemotherapeutic, surgical, and radiation therapy are mucos-
922
FEDELE ET AL
JAGS-SEPTEMBER 1991-VOL. 39, NO. 9
Male
lo F8
Female
1
1
lo UJ
0
2 z 86
3
$ 6
8
8
z4
z4
z 2
z 2
I
I
0
0 55-64
65+
65-74
75+
AGE
55-64
65+ 65-74 AGE
75+
W Physicians
I3 Dontists
FIGURE 3. Annual physician (1982-1983) and dentist (1986)contacts per person, by age and gender, in the US.'9.20
100 All Staoce 752
P e
r
0 Locallnd Regional
60
0
e
n t
40
20
0
EXTENT OF DISEASE
FIGURE 4. Five-year survival rates for oral and pharyngeal cancer, US, 1991.'
itis, xerostomia, secondary infections (candidiasis and herpes simplex are common), taste alterations, rampant dental caries, osteoradionecrosis, muscular dysfunction, and bone marrow suppression.
ORAL CANCER SCREENING Clinicians have a responsibility to perform a thorough head and neck examination as part of the physical assessment of their patient^.'^,'^ This simple, efficient, non-invasive procedure usually takes less than 2 minutesz6to perform. The goal of the exam is to detect any nodules, swellings, mucosal alterations (ulcerations, textural or color changes) and unexplained adenopathy. While many routines exist for an oral examination, each clinician must develop his or her own method, use it in all patients, and carefully document positive findings. The oral cancer examination may begin extraorally by inspection of the skin of the neck and face for any abnormalities, especially pigment changes. Careful pal-
pation of the pre- and post-auricular,parotid, submandibular, mental, superficial, and deep cervical and supraclavicular (Vichow's) lymph nodes is essential. Even in the absence of symptoms, a firm, unilateral neck node in a middle aged or older patient is suspicious of malignancy." In addition, movement of the hyoid bone laterally to produce a 'click" on each side can assist in ruling out carcinomas of the base of the tongue and epiglottis. The intraoral exam may involve palpation and direct and indirect in~pection.'~ The aid of a tongue depressor, a dental or laryngeal mirror, and good lighting, directed intraorally, is essential. All dentures must be removed for the intraoral cancer screening examination?6 The lips, buccal mucosa, gingiva, and hard palate are inspected and palpated. Fordyce's spots (ectopic sebaceous glands), linea alba (white line on the inside of the cheek adjacent to the biting surfaces of the teeth) and palatal tori are some normal deviations in these areas. To inspect the anterior floor of the mouth, and the anterior ventral surface of the tongue, ask the patient to place the tip of the tongue in contact with the hard palateI4(Figure 5). Wharton's duct, the opening of the sublingual/submandibular glands, is located at the base of the lingual frenum. Bidigital palpation of the tongue proceeds with one finger on the dorsum and one finger on the ventral surface of the tongue, starting anteriorly and progressing posteriorly on each side.z6Inspection of the posterior floor of the mouth, retromolar trigone, and posterior ventrolateral aspect of tongue is performed by grasping the tip of the tongue with a 2 X 2 gauze sponge and pulling it anteriorly and toward the opposite comer of the mouth (Figure 6). Inspection of the oropharynx, soft palate, uvula, and tonsillar pillars is accomplished by depressing the tongue with a mirror or tongue blade while the patient takes a deep breath"e26(Figure 7).To
IAGS-SEPTEMBER 1991-VOL. 39, NO. 9
FIGURE 5. xonnal anatomy of the anterior mouth floor and veneal tongue.
ORAL CANCER SCREENING IN THE ELDERLY
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palpate the floor of the mouth bidigitally, the index finger of one. hand is placed below the chin, and a finger of the other hand palpates the anterior floor of the mouth, proceeding on each side posteriorly?6 When salivary gland enlargement and/or xerostomia are noted, parotid and submandibular glands should be milked to assess the quantity, quality and consistency of saliva. To milk the parotid gland, place one finger at the preauricular area and move the finger forward along the path of the duct. The submandibular gland is milked by placing one finger in the submandibular triangle of the neck with a movement toward the menton of the chin. Salivary glands with normal function will produce at least one drop of clear, watery saliva when milked.26Parotid saliva is expressed from Stensen’s duct located opposite the first maxillary molars. Submandibular saliva is noted from Wharton’s duct located behind the lower incisor teeth.
INDICATIONS FOR REFERRAL The warning signs of oral cancer are a non-healing ulcer, a persistent white or red lesion, a lesion which bleeds easily, difficulty chewing and swallowing, and difficulty moving the tongue or mandible.2 Pain or irritation may or may not be present with early lesion~.~’ Traumatic oral lesions will resolve or improve after the etiologic agent is removed. Patients with suspected traumatic lesions should be referred to a dentist to rule out dental etiology. Removable oral protheses are the most common cause of traumatic lesions. Oral lesions which persist after 2 weeks should be biopsied to confirm or rule out malignancy. Most intraoral biopsies are easily performed by a physician or dentist. FIGURE 6. Soma1 anatomy of the lateral border of the Ninety percent of oral cancers develop in a horsetongue, retromolar trigone, and posterior mouth floor. shoe-shaped area as described by Moore.” Three sites within the oral cavity appear to be predisposed to the development of squamous cell carcinoma: the floor of the mouth, the ventrolateral aspect of the tongue, and the soft palate complex (soft palate proper, lingua1 aspect of retromolar trigone, and anterior tonsillar pillar).I4In addition, metastases from lung or breast malignancies may have gingival or oral soft tissue manifestations which can be detected during the oral examinati~n.’~Furthermore, adenocarcinomas of the maxillary sinus can invade inferiorly and present as a painless intraoral swelling of the palatal area (Figure 8). Conversely, potentially malignant lesions on the anterior floor of the mouth close to an edentulous mandibular alveolar ridge must be differentiated from a denture sore. Oral erythroplakia and leukoplakia are potentially (but not always) precancerous in the oral cavity (Figure 9).30Erythroplakia has been reported by Mashberg as FIGURE 7. Normal anatomy of the oropharynx, softpalate, the most common presentation of early cancer.I4 The tonsillar pillars, and posterior dorsal tongue. most common site in women is the gingiva; in men,
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FIGURE 8. Adenocarcinoma of the maxillary sinus which presented as a painless swelling of the palate.
FIGURE 10. Squamous cell carcinoma of the anterior mollth floor.
FIGURE 9. Mixed lesion of the anterior mouth floor exhibiting both erythroplakia and leukoplakia.
FIGURE
11. Candidiasis of the ventral surface of the
tongue.
the floor of the mouth and the retromolar trigone are to confirm the presence of hyphae. It is also important the most common locations.” The term leukoplakia is to note that candidiasis may exist concurrently with used to characterize a white lesion without any specific other oral mucosal lesions, such as l e ~ k o p l a k i aOral .~~ physical or chemical etiology, other than toba~co.’~ It manifestations of lichen planus may also be clinically is estimated that about 5% of leukoplakia lesions will indistinguishable from an oral cancer.12 become cancerous over a 20-year period.” SUMMARY Candida albicans, a yeastlike fungus which normally A thorough examination of the oral cavity is an easy occurs in the mouth, can become a clinical problem when it transforms from a commensal to a pathogenic and efficient method to detect early oral cancers. No state. Oral candidiasis can cause significant discomfort invasive diagnostic procedures are necessary. Early and may lead to systemic inv~lvement.~~ Predisposing detection and treatment of oral cancers are associated factors which potentiate the transformation of the or- with a sigruficant reduction in morbidity and mortality. ganism include: use of removable dental prostheses, Health professionals and policy planners have emsteroid or antibiotic therapy, salivary dysfunction, en- phasized the importance of directing health issues todocrinopathies, malignancies, and immunologic or nu- wards the needs of the aging population. Since oral tritional deficiencies. Oral candidiasis presents with a cancer occurs primarily in adults aged 60 and older, wide range of clinical manifestations which may be the prevention, detection, and treatment of oral maligsimilar to some other oral conditions, including oral nancies will continue to be a major health concern into (Figures 10 and 11). Clinical diagnosis of the next century. Efforts made by public awareness oral candidiasis must be supplementedby oral cytology groups and health professionals to decrease consump-
JAGS-SEPTEMBER 1991-VOL 39, NO. 9
tion of alcohol and tobacco may reduce future &ease and Because detection of oral cancer results in decreased morbidity and mortality associated with the disease, geriatricians must: (l) be proficient in performing the Oral cancer screening exam, (2) be knowledgeable of the wide range of normal variation in the oral anatomy, and (3) develop mechanisms for referral and follow-up of patients who present with suspicious oral lesions.
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14. Mashberg A, Samit AM. Early detection, diagnosis and management of oral and oropharyngeal cancer. Cancer 1989;3967-88. 15. Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res . - 1988:48:3282-3287. 16. Mashberg A, Garfinkel L, Hams S. Alcohol as a primary risk factor in oral squamous cancer. CA 1981;31:146-155. 17. American Cancer Society: Smokeless Tobacco: A Medical PerC A 87-(25M)-No. 3313. spective. 18. Winn DM. Smokeless tobacco and cancer: the epidemiologic evidence, Cancer 1988:38:236-243. 19. Vital and Health Statistics, National Center for Health Statistics: Health Statistics on Older Persons. 1986 Series 3, No. 25. Hyattsville, MD: DHHS Publication No. (PHS)87-1409. 20. Vital and Health Statistics, National Center for Health Statistics: REFERENCES Use of Dental Services and Dental Health. 1986 Series 10, No. 165. Hyattsville, MD: DHHS Publication No. (PHS)88-1593. 1. Department of Health and Human Services: Healthy People 21. Holmstrup P, Pindborg JJ. Oral mucosal lesions in smokeless 2000: National Health Promotion and Disease Prevention Obtobacco users. Cancer 1988;38:230-235. jectives. Washington, DC, DHHS, USPHS, 1990. 22. National Cancer Institute. Oral Cancers Research Report. Be2. American Cancer Society: Cancer facts and figures-1991. 91thesda, MD: DHHS, NIH Publication No. 88-2876. 500M-No 5008.91, Atlanta, GA. 3. Clinical Practice Committee, American Geriatrics Society: 23. Spiro RH. Squamous cancer of the tongue. Cancer 1985;35:252256. Screening for breast cancer in elderly women. J Am Geriatr SOC 24. Jacobs C. The internist in the management of head and neck 1989;37883-884. cancer. Ann Intern Med 1990;113:771-778. 4. Clinical Practice Committee, American Geriatrics Society: Screening for cervical carcinoma in elderly women. J Am Geriatr 25. Posner MR, Ervin TJ, Miller D et al. Incidence of hypothyroidism following multimodality treatment for advanced squamous cell SOC1989;37:885-887. cancer of the head and neck. Laryngoscope 1984;94:451-454. 5. Robie PW. Cancer screening in the elderly. J Am Geriatr SOC 26. Niessen LC, Jones JA, Lonergan JJ. Oral examination of the 1989;37:888-893. geriatric patient. Geriatr Med Today 1986;5:113-116. 6. Barry P, Katz PR. On cancer screening in the elderly. J Am 27. Guralnick WC. Clinical manifestations of oral cancer. In: Shklar Geriatr SOC1989;37:913-914. G ed. Oral Cancer: The diagnosis, Therapy, Management and 7. Jones ]A. Integrating the oral examination into clinical practice. Hospital Practice 1989;24:23-30. Rehabilitation of the Oral Cancer Patient. Philadelphia: WB 8. St. Anthony's ICD-9-CM Code Book. Washington, DC: St. AnSaunders, 1984, pp 6-7. thony Hospital Publications, Inc., 1988. 28. Moore C: Anatomic origins and locations of oral cancer. Am J Surg 1967;1 14:510-5 13. 9. Silverberg E, Boring CC, Squires TS. Cancer statistics, 1990. Cancer 1990;40:9-26. 29. Pindborg JJ. Atlas of Disease of the Oral Mucosa. Philadelphia: WB Saunders Company, 1985, pp 86,88,190. 10. National Cancer Institute, Division of Cancer Prevention and Control. 1987 Annual Cancer Statistics Review, Bethesda, M D 30. Pindborg JJ. Oral Cancer and Precancer. Bristol: John Wright and DHHS, NIH Publication No. 88-2789. Sons Ltd, 1980, p 15. 31. Lehner T. Oral candidiasis. Dent Practitioner 1967;17:209-216. 1 1 . Silverman Jr. S, Gorsky M. Epidemiology and demographic update in oral cancer: California and national data - 1973 to 32. Wright BA, Fenwick F. Candidiasis and atrophic tongue lesions. 1985. J Am Dent Assoc 1990;120:495-499. Oral Surg Oral Med Oral Pathol 1981;51:55-61. 12. Myers EN, Cunningham MJ. Treatment of choice for early 33. Baughman RA. Median rhomboid glossitis: a developmental carcinoma of the oral cavity. Oncology 1988;2:18-24. anomaly? Oral Surg Oral Med Oral Pathol 1971;31:56-65. 13. Chen I, Katz RV, Krutchkoff DJ. Epidemiology of oral cancer in 34. Daftary DK. The presence of candida in 723 oral leukoplakias Connecticut: 1935-1985 (abstract). J Dent Res 1989;68:910. among Indian villagers. Scand J Dent Res 1972;80:75-79.
