According to research published by Cancer Research UK, oral cancer rates are due to rise dramatically over the next two decades. Dental practitioners will be on the front lines, when it comes to early diagnosis. Cancer mortality rates may be dropping overall, but deaths from oral cancer are predicted to increase over the next few decades. Recently released new figures have been reported in the media and highlight this worrying trend.
It makes early detection and referral by dental practitioners more important than ever.Saving Faces runs an electronic diagnostic advice service for dentists.
The following is a report on the service and some comments from one of the dentists who has experience of the service.
“I can’t see a reason why every practice in the UK shouldn’t be signed up”
Volunteers from Saving Faces attended the British Dental Association Conference in Manchester this year to promote its fast-track diagnostic service that promises to dramatically improve the care of patients with suspected mouth cancer.
Three patients, Eileen Kane, Abul Khairat and Roy Hume, who explained the advantages of the diagnostic advice service to patients, and whose stories helped illustrate that there are cases that remain undiagnosed by dentists, also joined them on the stand.
Early diagnosis of mouth cancer increases the chances of survival from 50 per cent to 90 per cent. Primary care clinicians still occasionally miss cancer but more often don’t know the best surgeons to refer to in their locality. This wastes valuable time in starting treatment.
For just £3 a week*, the Saving Faces Diagnostic Advice Service (SFDADS) helps speed up the referral process and ensures referral to the most appropriate surgeons near to where the patient lives.
One dentist, who signed up to the service last summer, is Mark Kent. On the two occasions that he has used the service, he has received a detailed response by the end of the same day.
“I feel that this is a fantastic use of one’s resources,” said Dr Kent.
“It is amazingly reassuring from my point of view and means that I can provide an excellent service to my patients. This makes the cost of it almost irrelevant - I am investing in the care of my patients.
“Receiving an opinion from a specialist so quickly really helps allay patients’ fears. I can’t see a reason why every practice in the UK shouldn’t be signed up. I have used the service twice but I could have used it 100 times and the cost would remain the same.”
The dentist, who splits his time between Middlesex and central London and has been practising since 1983, said he first heard about the diagnostic service when lecturing at the Royal Society of Medicine about a year ago. He heard a presentation by oral and maxillofacial surgeon Prof Iain Hutchison, the founder of Saving Faces, and thought it sounded like a great idea.
Saving Faces Liaison Officer, Dr Louise Lemoine, said: “Dentists simply will never have the experience of looking at as many different lesions of the mouth as oral and maxillofacial (OMF) surgeons. The dentists that we spoke to at the conference were especially impressed by the fact that this service quickly reassures patients with benign disease whilst dealing promptly with those with mouth cancer.”
Participating dentists upload patient details and electronic images of suspect lesions onto a secure system. Their patient is guaranteed to receive an urgent diagnostic service from a consultant oral and maxillofacial surgeon within three days, meaning the dentist can rapidly reassure those with benign disease within days of seeing them. Those with serious disease are immediately referred to surgeons with the appropriate expertise at their nearest hospital.
Every penny raised from subscriptions will be used to fund the world’s first National Facial and Oral Research Study Centre (NFORSC). NFORSC’s work will improve treatment for all patients worldwide. The OMF surgeons receive no payment and are providing this service voluntarily. The donation can be claimed as a practice expense or, if given from a personal account, can be claimed back on tax. The dentist also transfers litigation risk to the OMF surgeon once the referral has been sent so there is never a risk of the dentist being sued by the patient. This is particularly important as a growing number of patients are taking legal action against dentists missing early cancers.
Each referral is evaluable for one hour’s CPD and dentists and their staff can also attend an annual free conference, which also contributes to their CPD requirements. And those signing up receive a Charter Mark Certificate of membership for their waiting room, as well as a poster showing photographs of common lesions and a desktop calendar listing the symptoms of mouth cancer to remind receptionists to give patients with these symptoms an urgent appointment.
* Saving Faces asks for a small subscription of £3 per week per dentist (or £9 per week for practices with three or more partners) payable by annual direct debit.
Farah Shiraz and Emmylou Rahtz are PhD students funded by Saving Faces, and here they tell us about the project they’re working on.
About our projectThe main goal of our project is to get a better understanding of how patients and their families feel after going through facial surgery, and we’re each working on different elements of the same overall project. Emmy’s research focuses on the patients themselves; people who have had head and neck cancer or injuries to the face, and looks at their emotional well-being. Farah’s project investigates the quality of life of partners as well as patients, and looks into how partners’ emotional states can influence patients’ well-being.We’re interested in the different ways people cope with what can be a very difficult experience, and which can lead to anxiety, depression and stress problems – whether they are going through it themselves, or supporting someone in their family through it. We are investigating this by asking people and their partners (if they have one) to answer a set of questionnaires for us, and to take part in an interview. Our hope is that our research findings will help medical staff to identify people who might need some extra emotional help, whether they are patients or their family members. If they can be identified and helped early on, this might lessen the distress. The journey so farWe’re nine months into our project now and we’ve carried out an audit with Professor Iain Hutchison on everyone who comes to the clinic: it consisted of a questionnaire that asked about patients’ health and well-being, and their experiences of coming to the clinic. People were really helpful, and we would like to thank everyone who filled it in. A few people commented that they didn’t think questions about feelings were relevant to them, or that they ‘don’t get emotional’; but it’s important to say that our aim is to get an overview of everyone’s reactions, not just those of one group or another. We want to find out what makes people react differently.It’s been a real eye-opener to see how very hard everyone works in the clinics, from the receptionists through to the consultants. They work long hours and can nearly always spare a smile or an encouraging word, and they still find time to help us out, whether helping us with the audit, introducing us to patients or explaining how something works. The surgeons are enthusiastic about our research and have been fully supportive in working with us to gain the best results for their patients. We’re fortunate to be supervised by three people who are eminent in their fields: as well as Professor Hutchison, we also work with Professor Ania Korszun and Professor Kamaldeep Bhui from Barts and the London School of Medicine and Dentistry. We’re also getting wonderful support from Saving Faces, and as we continue to work on our project, we’re confident we can give something back.The most enjoyable part for us so far has been attending the clinics where we have met some truly inspirational people amongst the staff and the patients. This has given us even more passion and motivation to continue with the project. What’s next?Our immediate next step will be to analyze the results from the audit; this will give us an indication of how common emotional problems are in the different clinics. At the same time we are starting on the next element of the project, when we’ll be recruiting new patients and their partners.You may have seen us the clinics already, when we’ve been asking people to fill in questionnaires, and if you haven’t seen us yet, you may come across us in the next few years recruiting new patients and their partners, or at a Saving Faces event. We look forward to meeting you.Emmy’s backgroundI originally studied English and earned a BA and MA in English Literature from Durham and King’s College London. I started out my working life in social research, specializing in learning and education, carrying out research projects mainly for universities and government organizations. I got more and more interested in how people think and feel, especially when they have to deal with difficult situations like illness and injury. So I went back to university in the evenings and got another degree – a BSc in Psychology – and now I’m pulling together all my experience and skills to work on this project.Farah’s backgroundI graduated in 2005 from Cardiff University with a Psychology degree and also have a Masters in Abnormal and Clinical Psychology. I have worked clinically as an assistant psychologist which involved working directly with individuals with severe emotional distress. I have also worked within child and family services offering emotional and practical support to families. From my clinical experience I learned that when clinicians were supporting families as well as patients it often helped in the patients’ road to recovery. This sparked my interest to raise awareness about the psychological needs of families as well as patients, as it’s often families – particularly partners – that provide the support and care for patients.
My name is Jag Dhanda, I am a BAOMS/FSF-Saving Faces Head and Neck Research Fellow at the University of Liverpool.
How did you come to do a PhD in oral cancer?
I am currently midway through a PhD, having taken time out of my higher surgical training in Oral and Maxillofacial Surgery. This training pathway requires both a medical and a dental degree, with up to eight years of further surgical training. My ambition is to pursue a career in academic head and neck surgical oncology and this is one of the reasons why I have interest in oral cancer research.
Without doubt the paucity of clinical and translational research in head and neck oncology has been a major obstruction to improving outcomes for patients in the past. Despite all the advances in surgical approaches, imaging techniques and chemoradiotherapy, only small overall improvements have been seen in patient survival. This is also evident with only 2.4% of head and neck cancer patients recruited to randomised trials. Comparative research from other malignancies such as haematological and breast have made significant progress by combining the disciplines of translational molecular studies, clinical trials and clinical practice with obvious clinical benefit measured in outcomes. It is this observation that has been a key motivator for me to undertake research in translational cellular and molecular oncology in head and neck cancer.
What is your project about?
Oral cancer remains a debilitating disease and can profoundly affect speech and swallowing. The most adverse factor for survival in oral cancer is extracapsular spread (ECS), where the disease spreads from the mouth to lymph nodes in the neck and subsequently spills out from them. ECS is the most biologically aggressive metastatic phenotype in oral cancer. Our research group has previously demonstrated a genetic expression pattern in oral tumours that could be used as a molecular signature to predict the likelihood of individuals having ECS. One of the main aims of my research was to validate this expression profile in biopsy tissue collected from 110 patients with oral cancer, and to provide clinical data to determine how good this molecular signature is at predicting ECS. The clinical data from patient follow-up after surgery confirmed the devastating consequences of ECS and were consistent with a larger previous study in which only 23% of patients with ECS survived 5 years. Current methods for detecting ECS prior to surgery using MRI scans were shown to be only accurate in detecting the disease in 6.8% of patients.
The second aim of the project was to establish head and neck cancer cell lines from patients with and without ECS. These will be used in future work looking at factors influencing cell migration and invasion. Six cell lines from patients with ECS, one with lymph node metastasis without ECS and two cell lines from patients without metastasis have been created in the laboratory by growing cells from tumour tissue. We will examine their behaviour to see if there any difference between the cells and to try to explain these differences, at the molecular level, and how this may lead to ECS. By identifying the molecular processes that cause ECS we hope to identify potential targets for future therapies.
What did you find so far? What are the implications of your work?
I have developed three dimensional culture models using these cell lines with different cell types. By comparing the features of these models with the original tumours I was able to demonstrate consistency in the appearance of invading cells in both the original tumour and the models. I have also show that a more aggressive invasive appearance can be induced in a cell type associated with cancer, called keratinocytes, by mixing them with another type called fibroblasts, from patients with non-metastastic disease.
The next phase of my research is to explore the affects of existing drugs used in the treatment of metastatic head and neck cancer on the models that I have developed. In the future I will investigate the affects of promising new therapies, which could someday have a role to play in the treatment of ECS in head and neck cancer.
Together with the insights form the gene expression signature and the culture models I have developed I hope to contribute to the development of biomarkers for ECS. Upon discovery of such biomarkers there are obvious clinical applications, such as selection criteria for randomised trials. A sensitive form of pre-treatment molecular classification would be invaluable in guiding the application of new therapeutic approaches such as chemotherapy, monoclonal antibodies or neoadjuvant TPF (taxane, platinum, 5-FU) for which a phase III trial has been recently funded by CRUK in Liverpool.
Who are the people who help you with your research?
My research experience and ambitions have been supported by the kind support given by the Saving Faces Charity and the British Association of Oral and Maxillofacial Surgeons. They have funded the second year of my PhD am I am very grateful for the opportunity that Professor Iain Hutchison has given me. The first year was funded by the Royal College of Surgeons with a Surgical Research Fellowship and further support was also obtained from the Clatterbridge Cancer Research Charity.
I have also had guidance and inspiration from my supervisor Mr Richard Shaw and would also like to thank my other supervisors Professor Ross Sibson and Dr Janet Risk. The Oral and Maxillofacial Consultants at Aintree Hospital in Liverpool, Professor James Brown, Professor Simon Rogers and Ms Fazilet Bekiroglu have also kindly supported this research.