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Preventing and Controlling Oral and Pharyngeal Cancer: Recommendations from a National Strategic Planning Conference

Preventing and Controlling Oral and Pharyngeal Cancer: Recommendations from a National Strategic Planning Conference

During the past decade,
federal health agencies have focused on reducing the incidence of
oral and pharyngeal cancer and increasing the 5-year survival rate
from these cancers in the United States. Beginning with a consortium
of health agencies in 1992 (including a
strategic planning conference in 1996 and a follow-up meeting in 1997
),
the CDC has been involved in concerted efforts to establish a
national plan for preventing and controlling these cancers. This
report presents recommended strategies for action from the 1996
conference and a list of priority recommendations from the 1997
meeting. These recommendations will enable the CDC to develop a
coordinated national plan to reduce morbidity and mortality from oral
and pharyngeal cancer in the United States.

Oral and Pharyngeal Cancer

Oral cancer (ie, cancer of the lip, tongue, floor
of the mouth, palate, gingiva and alveolar mucosa, buccal mucosa, or oropharynx)a
accounts for 2% to 4% of cancers diagnosed annually in the United
States; approximately two-thirds occur in the oral cavity, and the
remainder occurs in the oropharynx. In 1998, this diagnosis will be
made in an estimated 30,300 Americans; approximately 8,000 deaths
(5,200 males and 2,800 females) are expected in this year.
Ninety-five percent of cases of oral cancer occur among persons >
40 years old, and the average age at diagnosis is 60 years. In 1950,
the male-to-female ratio of oral cancer incidence was approximately
6:1; by 1997, it was approximately 2:1. The changing ratio is likely
the result of the increase in smoking among women in the past three
decades. In addition, cancer is an age-related disease, and in the
United States, the number of women > 65 years old now exceeds the
number of men > 65 years by almost 50%.

a Hereafter, pharyngeal cancer is also included in the term "oral
cancer."

During 1990 to 1994, the annual incidence rate among black males in
the United States was 1.6 times higher than the rate among white
males (20.1 vs 12.9 new cases per 100,000) and the annual mortality
among black males was 2.5 times higher (7.6 vs 3.1 deaths per
100,000); the annual incidence rate among black females was slightly
higher than that among white females (5.6 vs 4.9 new cases per
100,000), as was the annual mortality (1.8 vs 1.2 deaths per
100,000). Despite aggressive combinations of surgery, radiation
therapy, and chemotherapy, the 5-year survival rate for oral cancer
is poor (blacks, 35%; whites, 55%).

Tobacco smoking (ie, cigarette, pipe, or cigar smoking), particularly
when combined with heavy alcohol consumption (ie, ³
30 drinks per week), has been identified as the primary risk factor
for approximately 75% of oral cancers in the United States. The use
of tobacco in other forms (ie, snuff and chew) has also been
identified as a risk factor, as have certain other lifestyle and
environmental factors (eg, diet and occupational exposure to sunlight).

Approximately 90% of oral cancer lesions are squamous cell
carcinomas. Persons who have oral cancer often develop multiple
primary lesions (ie, field cancerization), and they develop second
primary tumors at a rate of approximately 4% annually. Persons having
primary oral cancer are more likely to develop a second primary
cancer of the aerodigestive tract (ie, oral cavity, pharynx,
esophagus, larynx, and lungs). The initially diagnosed disease
accounts for one-half of the deaths caused by oral cancer; one-fourth
of these deaths are due to a second primary cancer; and the remaining
one-fourth are attributable to other illnesses.

Diagnosing cancers at an early stage is crucial to improving the
survival rate and reducing morbidity. At the time of diagnosis of
oral cancer, 36% of persons have localized disease, 43% have regional
disease, and 9% have distant disease (for 12%, the disease is
unstaged). The 5-year survival rate for persons having oral cancer is
81% for those with localized disease, 42% for those with regional
disease, and 17% for those with distant metastases. During the past
decade, stage at diagnosis has not changed significantly.

Oral Cancer Strategic Planning Conference

Background

In 1992, a consortium of health agencies led by the CDC and the
National Institute of Dental Research (NIDR) of the National
Institutes of Health began to establish goals, objectives, and
programs to reduce oral cancer morbidity and mortality in the United
States. The Oral Cancer Work Group, which was formed as part of this
initiative, subsequently developed short- and long-term goals for
preventing and controlling oral cancer. A list of these goals was
disseminated to interested organizations and individuals in 1993.

One of the recommendations of the Oral Cancer Work Group was to
summarize the state of the science regarding oral cancer. In
response, the CDC commissioned nine background papers regarding the
prevention, control, and treatment of the disease and addressing
current knowledge, emerging trends, opportunities, and barriers to
further progress. The authors, representing several specialties and
expertise, drew on current literature reviews, in-depth critiques,
and personal experience.

The Oral Cancer Work Group also suggested that the CDC convene a
conference to develop national strategies to help make oral cancer
prevention and control a higher public health priority. Subsequently,
the CDC, in partnership with NIDR and the American Dental Association
(ADA), formed a conference planning group. The planning group, along
with a larger cadre of oral cancer experts, developed a draft set of
strategies. This draft and the nine background papers were
distributed to invited participants before the conference.

Conference Format

The Oral Cancer Strategic Planning Conference was held August 7 to 9,
1996, at the ADA headquarters in Chicago. Participants included 125
invited experts in oral cancer prevention, treatment, and research;
both the private and public sectors were represented. Following brief
welcoming remarks by ADA, CDC, and NIDR representatives, nationally
recognized experts made presentations on the etiology of oral cancer,
its epidemiology, ongoing and needed research, and clinical
experience with five other cancers (ie, leukemia and breast,
cervical, lung, and prostate cancers). A survivor of oral cancer
described the human impact of the disease.

Conference participants broke into five work groups: advocacy,
collaboration, and coalition building; public health policy; public
education; professional education and practice; and data collection,
evaluation, and research. Each work group had a chairperson and
co-chairperson who were preselected from the conference participants;
toward the conclusion of the conference, chairpersons presented their
work groups’ recommended strategies to all of the conference
participants, who provided oral and written feedback. The work groups
made revisions, including comments raised during the general session.

After the conference, the recommended strategies were disseminated to
all participants for final review and comments. These last comments
were incorporated to produce the finalized recommended strategies to
reduce oral cancer morbidity and mortality in the United States.

Recommended Strategies from Work Groups

Advocacy, Collaboration, and Coalition Building

The work group on advocacy, collaboration, and coalition building
(eg, formation by the oral health community of partnerships with
other health professionals and public or private organizations to
facilitate increased awareness of the risk factors for oral cancer)
developed three main recommended strategies.

Establish an ongoing, institutionalized mechanism to implement and
monitor progress made regarding the recommended strategies developed
during the conference.

Urge professionals in oral health and other health disciplines to
become more actively involved in community health concerns,
especially in preventing tobacco and heavy alcohol use, by: (1)
developing a comprehensive advocacy training program for a core group
of oral health professionals; (2) recruiting persons from the health
community and enrolling them in a national database for tobacco and
oral cancer advocacy; (3) designing outreach programs to encourage
local and state dental societies to be proactive in oral cancer and
related coalitions; (4) establishing an advocacy network of oral
cancer survivors; and (5) developing a speakers bureau of sports
figures and other prominent persons willing to speak about risk
factors for oral cancer and the importance of its early detection.

Promote the publication and dissemination of the US Department of
Health and Human Services’ biennial Report to Congress on
Tobacco Control Activities in the United States
. This document,
mandated by the Comprehensive Smoking Education Act of 1984 and the
Comprehensive Smokeless Tobacco Health Education Act of 1986, should
review completely the health effects of and trends in tobacco use. It
should also serve as a tool to update policymakers, the media, and
the public on smokeless tobacco use and oral health.

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