DavidIConway TheDentalElf DrAlRoss brocklehurstp JanClarkson2 SimonShepherd amp MentalElf Introductions Oral cancer risk and prevention overview David Conway A human factors perspective ID: 1041334
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1. Round the #ElfCamfire with @DavidIConway @TheDentalElf @Dr_Al_Ross @brocklehurstp @JanClarkson2 SimonShepherd & @Mental_Elf
2. IntroductionsOral cancer risk and prevention overview David ConwayA human factors perspective Al RossAlcohol brief interventions in practice Simon Shepherd Cochrane reviews & early detection Paul Brocklehurst Oral Health Assessment Guidelines Jan ClarksonSummary and close David Conway / Derek Richards Running order
3. Risk Factors
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5. West of Scotland Cancer Awareness Project WOSCAP2005 Patients and public at centre
6. Head and neck cancer [subsites]Oral cancer – oral cavity / “mouth” cancer OCC – oropharyngeal / “throat” cancer OPC Oral cancer - definitions [www.enacademic.com]
7. Global Head & Neck Cancer Burden[World Cancer Report, 2014]
8. HPV cancers greater burden in less developed countriesexcept OPC greater in more developed countries [Forman et al 2012] OPC incidence increased esp in high income countriesOCC incidence flat-lining or decreasing in men globallyOCC incidence increasing in women [Chaturvedi et al 2013]
9. EAS rates of HNC sub-sites by sex in England 1995-2025[Louie KS et al. Oral Oncol 2015 51; 4:341-348]●
10. [Junor EJ et al. BMJ 2010;340:c2512] EAS rates of various cancers by sex in Scotland, 1987-2006
11. Age-Specific Incidence Rates of Oral Cancer in Scotland per 100,000 Person-Years at Risk Median Age = 65 years
12. INHANCEwww.inhance.utah.edu/
13. Analytical epidemiology – Risk Factors INHANCE Methods: Conway DI, et al. Enhancing epidemiologic research on head and neck cancer: INHANCE - The INternational Head And Neck Cancer Epidemiology consortium. Oral Oncol. 2009;45(9):743-6. Findings: Winn DM, et al. The INHANCE consortium: Towards a better understanding of the causes and mechanisms of head and neck cancer. Oral Dis. 2015 Mar 24. 35 studies; 25,500 cases and 37,100 controls North America, South/Latin America, Europe – but ltd (SE) Asia
14. Risk Factors Confirmed tobacco and heavy alcohol as main risk factors Precise estimates Joint effects Dose-response Smokeless tobacco Benefits of quitting Smoking in never drinkers OR 2.13 (95%CI 1.53 - 2.98) Alcohol in never tobacco users OR 2.04 (1.29 - 3.21) [Hashibe et al, 2007] Interaction: PAR for tobacco and alcohol = 72% (61 - 79) 4% alcohol alone, 33% tobacco alone, and 35% combined [Hashibe et al, 2009]
15. Risk Factors Dose response: Smoking - fewer cigs/day over a longer period was worse than - more cigs/day over a shorter time cf Alcohol - higher intake for a shorter time was worse than - lower intake for a longer time BUT Not - “everything in moderation” Smoking > larynx Alcohol > oral cavity / pharynx [Lubin et al, 2009]
16. Risk Factors Smokeless tobacco (oral cavity): Snuff OR 3.01 (1.63 - 5.55) Tobacco chewing OR 1.81 (1.04 - 3.17) [Wyss et al. 2013] Benefits of quitting: Smoking - Immediate: 1-4 years after stopping - & = risks of never smokers 20+ years Alcohol - Only emerges after 20 years [Marron et al. 2009]
17. Risk factors - socioeconomic31 studies from 27 countries23,964 cases of head and neck cancer and 31,954 controls2.5 (2.02 - 3.09) fold increased risk for low vs high education and income1/3 not explained by tob/alc OR 1.61 (1.13 - 2.31) in never tob/alcNo diff by subsite, sex, age, countryBUTGreatest in high income inequality countries [Conway et al 2015]
18. HPV
19. Necessary cause of cervical cancerHPV-16 and -18 oncogenic typesIncreasingly implicated in oropharyngeal cancerOral HPV infection 25% of HNC, 80%OPCNatural history – prevalence, incidence, persistence, and determinants not well understoodHPV – Human Papilloma Virus infection
20. Oropharyngeal cancer - sexual history / oral HPVSexual history INHANCE 6 or more lifetime sexual partners OR 1.25 (1.01 -1.54) 4 or more lifetime oral sex partners OR 2.25 (1.42 - 3.58)- Early age (≤18) of sexual debut OR 2.36 (1.09 - 2.33) [Heck et al, 2010]Oral HPV HPV16 OR 14.6 (6.3, 36.6) [D’Souza NEJM et al 2007] HPV16 E6 antibodies 30.2% OPC vs 0.8% controls OR 132.0 (65.3 - 266.9) [Anantharaman et al 2013]
21. Older > 65yearsMales > FemalesPoorer socioeconomic circumstancesSmokingAlcohol[Oral HPV – exposure]Risk profile / prediction
22. “The aim of every epidemiology study in cancer is to prevent it” [Clemmensen, 1965] Prevention Understanding risk -> Prevention / Policy
23. HPV-driven cancers [for another campfire] [Kreimer, 2014]Non HPV-driven cancer [Watt, 2007] Prevention approaches
24. Prevention principlesAge not an issue - in terms of risk factors, but also in terms of riskRisk reduces when stop behavioursOral Health Assessment – history / ask the questionsSignposting / referral pathwaysTailored advice / support - recognise socioeconomic circumstances
25. Prevention / early detection ???Evidence for prevention in practice ?Some evidence of effectiveness and cost-effectiveness of opportunistic screening Questions remain:What constitutes EBM prevention / early detection? Can role of risk assessment and profiling assist? [age, sex, smoking, alcohol, SES – INHANCE]Given low volume: is early detection realistic?Inequalities in access / uptake to the opportunity?What are other barriers and facilitators to screening?
26. Al Ross: What can a human factors perspective offer to oral cancer prevention and early detection in the primary care / dental setting? What are the likely major barriers and facilitators to implementation?
27. Simon Shepherd: Can you provide an overview of your PhD research on alcohol (brief) interventions in dental settings? What are the likely major barriers and facilitators to implementation?
28. Paul Brocklehurst Can you summarise the evidence on your Cochrane Reviews on early detection in the dental settings? What are the likely major barriers and facilitators to implementation?
29. Jan Clarkson What is the latest evidence / guidance / position on oral health assessment in the dental setting? How could oral cancer prevention / early detection fit with this? What are the likely major barriers and facilitators to implementation?
30. P SummaryPrevention in practice Risk profiling / stratifying?Smoking cessation counselling and signposting ?Alcohol - brief interventions ?Early detectionOral health assessment / early detection ?
31. Team, collaborators, and fundingDental School - Lorna Macpherson, Alex McMahon, John Gibson, Heather Gray, Lucy Dunbar, JeremyBagg. Students: Katharine Sharpe (PhD), Naeema Al Bulushi (PhD), Mitana Purkayastha (PhD), KateIngarfield (PhD), Sweta Marthur (PhD), Andrew Pye (MSc) , Collaborators Glasgow – West of Scotland HNC MCNInformation Services Division, Scottish Cancer Registry – David BrewsterHealth Protection Scotland – Kevin PollockHPV Reference Laboratory, University of Edinburgh – Kate CuscheriUniversity of Dundee – Jan Clarkson, Linda YoungUniversity of Bristol – Andy NessInternationalINHANCE members – Wolfgang AhrensARCAGE Europe – 14 centres, 10 countriesBremen Institute for Prevention Research and Social Medicine (BIPS) WHO IARC – International Agency for Research in Cancer – Paul BrennanUniversity of Utah – Mia Hashibe Funding: UICC Fellowship / IARC Visiting Scientist AwardsWHO IARCScottish Government Chief Scientist OfficeNHS Education for Scotland NHS National Services Scotland
32. Thank you ...