Oral Cancer Screening: A High-Tech Approach to Saving Lives Jan. 23, 2008, 1:15 a.m.
“Oral Cancer Screening:
A High-Tech Approach to Saving Lives”
by Shauna Gilmore, DDS
Oral cancer strikes roughly three times as many victims as cervical cancer. One North American dies of oral cancer every hour of every day.
When I graduated from dental school, the main group of individuals having a higher likelihood of oral cancer was older males who use tobacco and heavy amounts of alcohol. Today, an increasing number of oral cancer victims are younger females. In fact, an article in the May 10, 2007 New England Journal of Medicine concluded that “oropharyngeal was significantly associated with oral HPV Type 16 (HPV-16) infection.” In effect, this means that anyone who is sexually active is potentially at risk for developing oral cancer through exposure to the human papilloma virus.
There was another fact about oral cancer that I just could not ignore: roughly two-thirds of the time it is detected, it is at late stages. What makes this especially tragic is that the 5-year survival rate when detected in late stages is only 22%; however, when detected at early stages, this survival rate can leap to 80% or higher. Not only is there a screaming need for earlier detection of oral cancer and no one is better-suited to fill this need than the dental office. Dentists and hygienists know more about—and spend more time examining—the oral cavity than any other health care providers.
I decided that I had a responsibility to my patients to step up and augment the conventional incandescent light (white light) exam that we had been giving all of our patients as part of our semi-annual hygiene exams. In 2005, the only technology I was aware of was the Visilite which involved a chemiluminescent disposable stick and an acetic acid rinse. This was an improvement over merely doing a “white light” exam, but I had numerous patient complaints about the taste of the vinegar-based rinse.
At the August 2006 Academy of General Dentistry Annual Meeting in Denver, I saw a presentation on the VELscope Oral Cancer Screening System. I was impressed by this technology, but it had not received Federal Drug Administration approval yet. So I put it on my technologies to watch list, because it was easier to use and the tissue fluorescence visualization technology did not require the use of any rinses.
The VELscope system’s handpiece emits a safe blue light that excites natural fluorescence in the oral mucosa--both in the epithelium and underlying connective tissue. While this fluorescence response is highly sensitive to dysplasia and oral cancer, it is equally sensitive to other disease processes going on inside the tissue. When I look through the handpiece, such changes make themselves apparent by causing alterations in the fluorescence pattern; abnormal tissue typically appears as a dark area that stands in contrast to the typical pattern of the fluorescence produced by the healthy tissue.
In April of 2007, the VELscope system was granted two expanded indications for use by the FDA on the basis of several published studies. The first clearance indicates that the VELscope system can be used to help identify precancerous and cancerous tissue that may not be apparent to the naked eye. The second clearance indicates that the VELscope system can be used by surgeons to help determine the appropriate surgical margin when surgery is warranted. This clearance was prompted by one study showing that in roughly half of the cases examined, surgery failed to remove 100% of the cancerous or precancerous tissue even when the surgeon’s margin was 10 mm outside the clinically apparent margin for the most part. No other adjunctive device has received these two indications for use.
Since the VELscope had FDA approval, I needed to decide if the technology was right for my practice. It can be a real guessing game trying to differentiate between those technologies that will end up on your shelf collecting dust, and those that will end up transforming your practice in ways you never imagined. While I consider myself a fairly tech-savvy clinician, I certainly don’t have any magic formula for evaluating new technologies. However, I have had good luck ensuring that any technologies I adopt meet most or all of the following four criteria:
It is not often that a new technology clearly meets all four of these criteria, but the VELscope Oral Cancer Screening System did. Its underlying technology platform was developed with over $50 million in research, most of it funded by the National Institutes of Health. The majority of the supporting research was conducted by the British Columbia Cancer Agency (BCCA). The BCCA is generally credited with demonstrating the effectiveness of the Pap smear for general screening programs; these programs are widely considered to have been responsible for a 70% reduction in the incidence of cervical cancer over the past several decades.
I have had my VELscope system for four months as of this writing, and I have been quite please. Both my hygienist and I were able to get up-and-running in relatively short order. In fact, my hygienist handles the VELscope system screenings with about 90 percent of our patients. Typically, she will call me in if she sees something that concerns her.
When this happens, I will usually question the patient to see if there is a logical reason for whatever abnormality we might be observing. For example, I might ask the patient if he or she might have recently burned the suspect area with a hot beverage, or if he or she chews the inside of the cheek. In some cases, the cause of the problem might be visually apparent to me, such as improperly-fitting dentures or braces. If my visual observation and questioning do not enable me to confidently rule out a more significant problem, I will typically ask the patient to return for further observation in two weeks. If the situation has not improved, I will usually conduct a brush biopsy or refer the patient to an oral surgeon.
To date I have conducted brush biopsies with four patients. With two patients, the diagnosis was that the tissue was “abnormal”, which means it is not necessarily cancerous or precancerous. With the other two, however, the diagnosis came back as precancerous. Both of these patients were tobacco users, and both have stopped using tobacco as a result of this experience.
In our practice we recommend that all adult patients receive a comprehensive oral cancer examination including VELscope system screening twice a year as part of their regular hygiene exams. We charge $48 per year for the adjunctive screening with the VELscope system. Fortunately, approximately 65% of our patients agree to the screening. I suspect that this percentage will continue to increase over time, especially as more and more insurance companies agree to reimburse for this expense. (The VELscope system screening is covered under CDT reimbursement code D0431.) Our patients find the VELscope screening to be very convenient and comfortable. It is completely non-invasive and adds only 2-to-3 minutes to the overall exam.
When I decided to purchase the VELscope system over four months ago, I felt that it would meet all five of my criteria for new technologies, and in fact it has: it has enabled me to improve the care I provide my patients; I was able to incorporate it into my practice almost seamlessly; my patients find the screenings to be highly convenient; and finally, most of my patients feel that the price of the screening is quite reasonable.
In our practice, the VELscope system is most certainly not sitting on a shelf collecting dust. And my patients, four of them in particular, are very happy about that fact.