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Screening for Oral Cancer

A Targeted Evidence Update for the U.S. Preventive Services Task Force

Evidence Syntheses, No. 102

Investigators: , MD, MS, , MPH, , MS, and , MD, MPH.

Author Information
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 13-05186-EF-1

Structured Abstract

Objectives:

To assess whether screening for oral cancer reduces morbidity or mortality and to determine the performance characteristics of the oral screening examination for cancer or potentially malignant disorders (PMDs).

Data sources:

Building on previous searches, we searched Medline from January 2008 through July 2011. We supplemented searches with bibliographies from retrieved articles and from previous U.S. Preventive Services Task Force (USPSTF) reviews.

Methods:

One investigator reviewed citations at the title and abstract level; two investigators independently reviewed potentially relevant citations at the full-text level using predefined inclusion and exclusion criteria. A single investigator extracted study characteristics and results; a second investigator confirmed data. Two investigators rated the studies for internal validity using USPSTF criteria. Evidence was described in text and tables and summarized by qualitative analysis.

Results:

Evidence for the effect of oral screening on morbidity and mortality came from a single, large randomized, controlled trial (n=191,873) conducted in a population with high disease prevalence using home-based screening by advanced health workers. Screened subjects had no significant difference in incidence or mortality rates from oral cancer compared with subjects who were not screened. However, screened subjects had oral cancer diagnosed at lower stages and with greater 5-year survival. Within the subgroup who used tobacco or alcohol (n=84,600), screened subjects had a lower mortality rate from oral cancer than subjects who were not screened. Evidence for the performance characteristics of the screening examination came from seven primary studies (n=49,120), most conducted in settings with much higher incidence and mortality from oral cancer than the United States. Studies also had considerable heterogeneity in design and showed wide variation in performance characteristics. Screening examinations by general dentists in the United Kingdom among 2,336 presumably higher-risk patients age 40 years and older showed sensitivity for oral cancer or PMD of 71 to 74 percent, with positive predictive value of 67 to 86 percent and specificity of 98 to 99 percent. Adding toluidine blue dye to a screening examination did not significantly change its performance, as measured by the malignant transformation rate or incidence of oral cancer.

Conclusions:

We found no evidence on screening either a general or a selected high-risk population for oral cancer in the United States. Screening subjects in a high-prevalence population outside the United States lowered the stage of oral cancer at diagnosis and improved 5-year survival. However, survival differences could represent length or lead-time bias. Screening subjects in the subgroup who used tobacco or alcohol reduced the mortality rate from oral cancer. Subgroup analyses, however, were post-hoc and should be viewed as exploratory. The performance characteristics of the screening examination varied widely, with applicable results only from dentists addressing higher-risk patients in the United Kingdom. However, sensitivity and specificity estimates were for PMDs as well as cancers, and do not represent a clear screening strategy that is applicable to U.S. practice. We found no evidence that any adjunctive device affects the performance of the screening examination.

Acknowledgements: The authors gratefully acknowledge the following individuals for their contributions to this project: C. Samuel Peterson, Smyth Lai, MLS, and Kevin Lutz, MFA. The USPSTF wishes to acknowledge the contributions of Drs. Kenneth Lin, Melissa Camp, and Val Finnell and Lolita Ramsey for their support of the preliminary work.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. HHS-290-2007-10057-I Prepared by: Kaiser Permanente Research Affiliates Evidence-based Practice Center2

Suggested citation:

Olson CM, Burda BU, Beil T, Whitlock EP. Screening for Oral Cancer: A Targeted Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 102. AHRQ Publication No. 13-05186-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; April 2013.

This report is based on research conducted by the Kaiser Permanente Research Affiliates Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No HHS-290-2007-10057-I). The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

2

Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227

Bookshelf ID: NBK132472PMID: 23617014

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