Health: Cancer

Baroness Gardner of Parkes Excerpts

Tuesday 9th October 2012 Grand Committee

Asked By

[Baroness Gardner of Parkes]

To ask Her Majesty’s Government what assessment they have made of the increase in cases of cancer of the head and neck, in particular in younger age groups.

[Baroness Gardner of Parkes]

My Lords, my reason for bringing this debate today is to improve awareness of the increase in cases of cancer of the head and neck, and to consider what actions should be taken to deal with these very unpleasant and often fatal conditions. Tongue cancer and mouth cancer are the most common in the group of cancers of many sites within the head and neck area. My particular interest is oral cancer, which, as a former dentist, I look on as cancer of the mouth, but the definition includes head, neck and throat cancers, and the title of the debate is to widen the subject.

Oral cancer is the 15th most common cancer in the UK. Assessment is important but progress towards earlier diagnosis, urgent follow-up and specialist treatment is the real essential. Great work is being done in study, research and treatment, in London by the Eastman Dental Institute, King’s College London Dental Institute and the Royal Marsden, and others in different parts of the country. I would like to record my thanks to these organisations, and to the Oracle Cancer Trust, a charity that does much to help patients and increase awareness, for the data it provided me for this debate.

To quote from a review article published in Oral Diseases in 2010:

“Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimise diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a ‘scheduling delay’ in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices”.

In the UK, between 1989 and 2006 there was a 51% increase in oral, tonsil and base of tongue cancers in men, from seven per 100,000 of the population to 11 per 100,000. Unfortunately, almost half of the oral cancers are diagnosed at stages 3 or 4, which are the advanced stages. Delay in diagnosis is now considered to be either patient delay or professional delay. Diagnostic delay is measured by the number of days elapsed since the patient notices the first signs and/or symptoms until a definitive diagnosis is reached. Studies suggest that 30% of patients delay seeking help for more than three months following the discovery of symptoms of oral cancer. There is a great need to improve public awareness not only of the condition but of the need to seek assessment as soon as possible, thus increasing the possibility of effective treatment. Early diagnosis can decrease morbidity and may improve overall long-term survival. In cases of laryngeal cancer, diagnostic delay has a remarkably worsening effect on survival.

What is the cause of oral cancer? Most cases of carcinoma are linked to lifestyle factors and should therefore be preventable. Most important is the excessive use of tobacco and alcohol, and in some groups, betel quid juice is relevant. Diet is significant, and another reason in favour of fresh fruit and vegetables. The recommended five portions a day should include red, yellow and green fruits. In a minority of cases, particularly among younger patients where known risk factors are absent, human papilloma virus, HPV infection, is now thought to be a likely cause. HPV infection has also been considered as a cause of oropharyngeal cancer. It is hoped that the recent HPV vaccination programme in teenage girls may have a longer beneficial impact on the incidence of this cancer. People with poor dental health, such as sharp broken teeth, dental sepsis or trauma from ill-fitting dentures, are at a slightly increased risk. An ulcer—a lesion that breaks the surface lining of the mouth—that fails to heal within two weeks with the appropriate therapy and correction of any possible causative factors, and for which no other diagnosis can be established, should be suspected of being a malignant ulcer. Hardening or enlargement of the lymph nodes in the neck are another warning sign, and attention must be sought by the patient.

There are many potentially malignant conditions, but I do not have time to list them today. It is for clinicians to be aware of these and to diagnose them. The public need simply to be aware that any noticeable change in the mouth should not go unheeded. Dental professionals need to keep abreast of the latest developments, and they can do this through lifelong learning, as they remain the major diagnosticians. However, it is essential that family doctors should be aware of oral anatomy so that they know the difference between normal and abnormal. When carried out competently, screening of oral mucosa should not take more than three minutes, and training should mean that these procedures are effective. Dentists should give advice to patients to enable them to recognise the signs and symptoms at an early stage and thus to seek early treatment. This would help, but it needs to go wider than that; pharmacists and dental hygienists need to do this as well.

A study published in 2010 in the British Dental Journal showed that oral cancer is an important health issue in Scotland. Some of the young appreciate that alcohol and tobacco are causative factors, but the findings suggest that even among people who have the disease, understanding of the link between alcohol, tobacco and oral cancer is still limited. A number of people could recall the related television campaign and supported the view that it had played an important part in their own diagnosis and treatment. The West of Scotland Cancer Awareness Project, funded by Cancer Research UK, led many patients to make an initial appointment with a health professional to have symptoms investigated. I understand that this is the body which financed the television programme. This is a most important message, and a number of patients with oral cancer reported that it was the programme that had saved them. I hope that the Minister will pass that message on to the Department of Health.

Intra-oral cancer is particularly lethal, whereas cancer of the lip is less so. In my early practising days, many of my patients presented with a white patch on their lower lip. This is called leukoplakia and is considered pre-cancerous. In those days it was common to see men walking around with a fag hanging on their lip. Holding a cigarette or pipe almost constantly in place on that spot was one of the main causes of the symptom. Leukoplakia still occurs but for different reasons, as lifestyle habits have changed. The important thing to realise is that any white or red patch in the mouth should not be ignored. It requires proper assessment and treatment without delay.

I cannot say too often that early diagnosis is essential for the successful treatment of any cancer. Years ago, when we had free dental examinations, people went more regularly to the dentist, and early lesions were discovered, mostly by dentists. Dentists are usually still the first to see a mouth cancer, but it is essential that GPs are aware of the need to do routine checks, particularly if the patient has not had a dental check-up for some time.

Above all, the public need to be aware of the warning that comes with any change in their mouth, or any ulcer that does not heal. They should present immediately for assessment and possible treatment. If the practitioner—doctor, dentist or nurse—believes that there is cause for concern and the condition does not improve with treatment within two weeks, the patient should be referred for a biopsy, which is the only definitive diagnostic tool. If cancer is suspected, the referral must be marked “urgent”, in accordance with NICE criteria, to reduce the pre-treatment interval. The number of patients who attribute their successful treatment to the fact that they saw a Department of Health warning or information is high.

I will make a few brief points to close. There needs to be a referral change. In your Lordships’ House I have for some years pressed for mouth examinations to become routine when any patient attends an accident and emergency department or polyclinic—about which we seem to hear less now—and that in the interests of treating numbers and managing to finance this, unqualified staff could be trained in the first instance to carry out a quick check. If there is any cause for doubt about the mouth condition being normal, they would refer the patient up the line to either a specialist nurse or a dental hygienist who would then decide whether they should be referred further so that appropriate treatment could be provided, urgently if indicated. The previous Labour Government agreed that this would be a worthwhile thing to do and confirmed that semi-skilled health workers could carry out these brief mouth checks. It would not require qualified dentists or doctors at the preliminary stage. I still think that this would be very valuable and I press the Minister to give it serious thought.