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(Drug information on 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.
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.
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.
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.