|Year : 2019 | Volume
| Issue : 2 | Page : 95-100
Digital possibilities in the prevention and early detection of oral cancer in the WHO South-East Asia Region
Om Prakash Kharbanda1, Anupama Ivaturi1, Harsh Priya1, Gampo Dorji2, Shalini Gupta1
1 Centre for Dental Education and Research, All India Institute of Medical Sciences, World Health Organization Collaborating Centre for Oral Health Promotion, New Delhi, India
2 World Health Organization Regional Office for South-East Asia, New Delhi, India
|Date of Web Publication||30-Aug-2019|
Om Prakash Kharbanda
Centre for Dental Education and Research, All India Institute of Medical Sciences, World Health Organization Collaborating Centre for Oral Health Promotion, New Delhi
Cancers of the lip and oral cavity are the most common cancers among men in the World Health Organization (WHO) South-East Asia Region. Most cancers of the oral cavity are attributable to tobacco smoking, smokeless tobacco use and areca-nut product use, alone or in combination, and excessive consumption of alcohol. These risk factors are highly prevalent in parts of the region. This paper outlines an integrated framework for oral cancer prevention, which includes a strengthened primary health-care workforce, enhanced community engagement and a positive policy environment. Operationalizing this framework could be greatly facilitated by the application of digital technologies. Robust evidence exists for the effectiveness of using appropriately trained primary health-care workers to screen for oral cancer by oral visual examination; this can be combined with counselling for risk-behaviour modification as part of an overall strategy on noncommunicable diseases. This needs to be supported by greater overall community engagement, for example to tackle low levels of awareness of the harmful effects of smokeless tobacco and areca-nut products. A strong policy environment that supports and promotes these efforts is essential, along with the enforcement of the measures required by the WHO Framework Convention on Tobacco Control. Despite the burden of disease, oral cancer has been a neglected area of public health. This paper considers how the positively disruptive effects of digital technology may enable much-needed acceleration in prevention and control efforts.
Keywords: areca nut, digital health, oral cancer, oral visual examination, tobacco, South-East Asia
|How to cite this article:|
Kharbanda OP, Ivaturi A, Priya H, Dorji G, Gupta S. Digital possibilities in the prevention and early detection of oral cancer in the WHO South-East Asia Region. WHO South-East Asia J Public Health 2019;8:95-100
|How to cite this URL:|
Kharbanda OP, Ivaturi A, Priya H, Dorji G, Gupta S. Digital possibilities in the prevention and early detection of oral cancer in the WHO South-East Asia Region. WHO South-East Asia J Public Health [serial online] 2019 [cited 2020 Jul 4];8:95-100. Available from: http://www.who-seajph.org/text.asp?2019/8/2/95/264853
| Oral cancer in the WHO South-East Asia Region and current service delivery|| |
The burden of cancers of the lip and oral cavity is high in the World Health Organization (WHO) South-East Asia Region. The Globocan data sets report that cancers of the lip and oral cavity were the fourth most common of the 2 003 789 new cancer cases in the region in 2018. In men in the WHO South-East Asia Region, neoplasms of the lip and oral cavity have the highest incidence of all cancers. The buccal mucosa is the most common site for oral cancer in south and south-east Asia. More than 75% of oral cancers are attributed to use of tobacco, areca-nut products and alcohol, which are endemic risk behaviours in many parts of the region. Other risk factors include use of hookahs/waterpipes, consumption of nitrosamine-rich foods, infection with human papillomavirus, exposure to ultraviolet light and a diet low in fruits and non-starchy vegetables.
In the region, most people with oral cancer present at advanced stages, which necessitates expensive and aggressive treatment and results in low cure rates. By contrast, the treatment for early-stage oral cancer is simple and effective, with survival rates exceeding 90% at 5 years. Visual screening of the oral cavity has been widely evaluated for its feasibility, safety, acceptability, accuracy in detecting oral potentially malignant lesions and oral cancer, and efficacy and cost-effectiveness in reducing oral cancer mortality. Visual screening involves systematic visual and physical examination of the intraoral mucosa under bright light, followed by inspection and digital palpation of the neck for any enlarged lymph nodes.
In 2017, we investigated the current service delivery mechanisms in the region for early detection and prevention of oral cancer; the national focal points for the oral health services of Bhutan, Nepal and Sri Lanka completed an open-ended digital questionnaire. The responses, together with our knowledge of the situation in India, were categorized as positive factors, barriers and opportunities for improving oral cancer prevention, screening and early detection (see Box 1).
| The Integrated Framework for Oral Cancer Prevention|| |
This Integrated Framework for Oral Cancer Prevention in the WHO South-East Asia Region has been developed by the Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, which is a WHO Collaborating Centre for Oral Health Promotion. The regional guidance on which the framework is based was put together in consultation with the WHO Regional Office for South-East Asia and built on the operational guidelines and implementation framework developed for the Government of India., A training module was developed for primary health-care workers on early detection and referral of suspected oral cancers as part of the WHO Package of essential noncommunicable disease interventions and healthy lifestyle interventions.
As shown in [Figure 1], the framework comprises three independent but mutually reinforcing components: a strengthened primary health-care workforce; greater community engagement; and a positive policy environment. Operationalizing this framework will be greatly facilitated by the application of digital technologies. Digital technologies are rapidly changing the composition and delivery of health services. Introducing these technologies can be positively disruptive, in that it opens up new ways of delivering community-based services that are more suited to an era of rising noncommunicable diseases and ageing populations than the traditional hospital-based service model. Digital interventions to improve public health can be exploited for oral cancer screening and early detection, with the aim of reducing the burden of oral potentially malignant lesions and oral cancer. A number of web platforms and mobile health applications offer interventions for early detection and screening of oral cancer. These involve training and empowerment of health-care providers, machine learning to interpret images for diagnosis, the creation of digital hubs for screening, and patient education. The countries in the region are at different stages in relation to the various aspects of the framework and in terms of adopting digital solutions to improve the delivery of health services. This perspective paper briefly describes the framework and illustrates how digital technology might be used to amplify and accelerate results.
Strengthening the primary health-care workforce
All the countries in the region have cadres of health-care workers providing front-line services, including auxiliary nurse midwives, staff nurses, community health workers, lady health visitors and multipurpose workers. These primary health-care workers are ideally placed to implement risk reduction through behavioural interventions and to conduct visual oral examinations and teach oral self-examination. Their role may include the direct provision of behavioural interventions for tobacco use or harmful use of alcohol, or referral for such interventions. As the primary health contact point at household level, these health-care workers are best placed to coordinate, document and report on the care pathway for patients.
Research carried out over the past three decades has demonstrated the feasibility of using front-line health workers to screen for oral cancer. In a study in the 1980s in Sri Lanka, 34 primary health-care workers were trained to examine the mucosa of the oral cavity. In return for an incentive per case, they were asked to perform the examination on people aged 20 years and over as part of their routine work, which included house-to-house visits. In a year, the primary health-care workers examined almost 30 000 people and demonstrated a very satisfactory level of diagnostic accuracy. This study showed that use of primary health-care workers for the early detection of oral cancer and oral potentially malignant lesions was feasible and provided a valuable example of the community-based approach for early detection of oral cancer.
A study in 1982–1983 in rural Kerala, India, found that incorporating an early oral cancer detection programme into the existing health-care infrastructure was feasible and beneficial. Basic health workers responsible for household visits to help control communicable diseases and implement family planning were trained to identify individuals at high risk for oral cancer, perform visual oral examinations and refer appropriately. A 10-year study in the same location involved a range of tobacco-cessation interventions delivered annually to individuals and small groups, including one-to-one counselling, a film, posters and messages broadcast on the local radio station. The educational interventions reduced both tobacco use and the incidence of oral potentially malignant disorders.
A large cluster randomized controlled trial in Kerala, India, involved trained health workers screening high-risk tobacco and alcohol users during home visits. Visual oral inspection was undertaken in bright daylight with the additional use of a flashlight. Screening was repeated every 3 years for a maximum of four cycles. The 15-year follow-up data showed a 38% reduction in oral cancer incidence and an 81% reduction in mortality in participants who complied with all the screening rounds.
Visual oral examination is therefore an established method of detecting oral potentially malignant disorders and early stages of oral cancer when delivered by trained caregivers. The sensitivity and specificity of visual oral examinations are moderately high. Based on the evidence, the recent report of an expert group recommended visual oral examination by well-trained auxiliary health workers combined with tobacco and alcohol reduction counselling as the primary screening strategy in India. The expert group noted that, because tobacco users are a high-risk group for noncommunicable diseases generally, this strategy offers an opportunity to address multiple noncommunicable diseases in the same setting. The expert group recommends that oral cancer screening should target adults aged 30–60 years in high-risk populations, with the aim of screening once every 3 years.
Implementation strategies using digital solutions
All the countries in the region are affected by epidemiological transition, characterized by a greater need for prevention and management of noncommunicable diseases. Therefore, the challenge is how to sensitize a front-line health workforce traditionally focused on maternal, child and communicable diseases to the requirements of the evolving disease burden, such as oral cancer screening and early detection. Training primary health-care workers in early detection and prevention of oral cancer has been incorporated into the national cancer control strategies of India and Sri Lanka. In India in 2016, for example, robust guidelines and capacity-building plans were developed. These were integrated into the population-based screening programme for noncommunicable diseases. Thus, as part of the strategic shift to comprehensive primary health care, oral cancer has been included in the screening and prevention programme for noncommunicable diseases, along with cervical cancer, breast cancer, and hypertension and diabetes. A framework has been developed to guide local implementation and capacity building at state and district levels. Sri Lanka has an integrated programme for cervical, breast and oral cancer, with mobile units for oral cancer screening.
Primary health-care workers may be engaged in behavioural interventions for cessation of use of tobacco, areca-nut products or alcohol, conducting visual oral examinations or teaching oral self-examination. All these tasks can be facilitated using digital technologies. For example, visual oral examinations can be accompanied by showing a video on self-examination, oral hygiene and warning signs that should be reported. Coordination, documentation and reporting are also some of the tasks that the primary health-care care workers take on to ensure continuity of service delivery. These can be digitized using portable devices to monitor coverage, problem areas, feedback and various other aspects of service delivery. Portable devices such as tablets may also be used for community education and for collecting data for monitoring and evaluation of services.
The National Informatics Centre and Government of Tamil Nadu have set up an innovative digital screening strategy that has accelerated screening, diagnosis, follow-up and treatment for oral cancer and oral potentially malignant lesions. A mobile app developed by the National Informatics Centre was loaded onto tablets that have been issued to every primary health-care centre to be used by dental surgeons or assistants. The app prompts the collection of registration details, provides information on risk factors and symptoms, and allows images of lesions to be captured. Cases are referred to higher-level institutions as required. Follow-up and treatment are also tracked by the app. Dental surgeons and assistants and other health-care workers in the network can share and discuss cases digitally.
India’s Ayushman Bharat comprehensive primary health-care initiative is undertaking a population-based noncommunicable diseases programme. This is a referral-based programme where health workers screen all individuals aged 30 years and over for hypertension, diabetes and oral, breast and cervical cancers. At-risk individuals are progressively referred to higher public facilities, diagnosed, treated and then managed for life at the primary health-care level. In this programme, community health workers will be issued with tablets with preloaded screening algorithms designed to help in collecting data, recording findings and making referrals. The portable devices will also be used to monitor coverage, detect problems and collect feedback. The digital link will enable faster and uninterrupted communication between the primary and the tertiary health-care levels.
Digital technologies have been essential for scaling up to roll out population-based screening training, for which in-person training is neither feasible nor economically viable. To date, the Extension of Community Outcomes project has been successful in India; in this hub-and-spokes model, experts (the hub) provide a virtual training course for community health-care workers (the spokes). Further efforts to harness digital technology to link experts with front-line health workers also show promise, and initiatives using Massive Open Online Courses and teleconsultations are in development.
The use of machine learning (also known as deep learning) for medical image interpretation is an area of intense research in many medical specialties. Research is under way in several institutions to investigate the potential of this technique to facilitate classification of oral lesions. The policy think tank of the Government of India, NITI Aayog, is at an advanced stage of launching a programme to develop a national digital repository of annotated and curated cancer pathology images. Another related project under discussion is an imaging biobank for cancer, which would provide an unprecedented opportunity for use of artificial intelligence to inform decision-making in cancer treatment at low cost.
Enhanced community engagement
The empowerment and engagement of communities will be essential to reduce the burden of oral cancer in the region. Information, education and communication strategies should follow a life-course approach, whereby materials on risk factors and early detection are targeted at different age groups, including school children, adolescents, parents, adults and older people. Digital media sent via text, voice or multimedia messages have a powerful role to play in reaching these different population segments. For example, communication materials aimed at changing attitudes and behaviours in relation to tobacco use can be tailored to different populations. Through the Be he@lthy, be mobile initiative, WHO and the International Telecommunication Union promote noncommunicable disease prevention using mobile technology. There is extensive evidence that mobile phone-based support for smoking cessation is effective, and the initiative provides guidance on the development and deployment of national tobacco cessation programmes.
In India, the National Tobacco Control Programme and the Ministry of Health and Family Welfare, with support from the Be he@lthy, be mobile initiative, implemented a tobacco cessation programme. Two-way mobile phone messaging between the individual seeking to quit and programme specialists provides dynamic support for those who wish to quit. The government has recently released a second version of the platform, which delivers the content through text messages or interactive voice responses in 12 languages. The programme’s progress is monitored in real time through an online dashboard that records the number of registrations, disaggregated by factors such as gender, geography and type of tobacco use. To date, the programme has over 2.1 million self-registered users. A Be he@lthy, be mobile handbook on the use of mobile technology for oral health is in development. Digital communications could also be deployed to break down barriers to visiting health-care providers, explain the benefits of early detection and remove the stigma about a diagnosis of oral cancer.
Digital communications also have an important role to play in addressing the urgent need to educate the public on the dangers associated with tobacco, areca-nut products and alcohol and on early signs of oral cancer. A particular focus of health promotion campaigns should be tackling the lack of understanding of the harsh realities of the harms associated with using tobacco and areca-nut products.
Positive policy environment
A conducive policy environment is essential for health systems to deliver the continuum of prevention, early detection and treatment initiatives that must be implemented if reductions in oral cancer morbidity and mortality are to be achieved. One key policy requirement is empowering and deploying front-line health workers to carry out screening. In addition, strong policies to reduce preventable risk behaviours are essential. These should be embedded within robust overall policies that promote and facilitate healthy lifestyle choices.
Tackling the tobacco epidemic is an urgent priority, since one in four smokers globally and more than 80% of the world’s smokeless tobacco users reside in the WHO South-East Asia Region. In 2008, WHO introduced a package of six evidence-based tobacco control demand reduction measures that have been proven to reduce tobacco use and assist countries in fulfilling their obligations under the WHO Framework Convention on Tobacco Control (FCTC). These measures, known as the MPOWER package, reflect one or more provisions of the framework: M, monitoring tobacco use and prevention policies; P, protecting people from tobacco smoke; O, offering help to quit tobacco use; W, warning about the dangers of tobacco; E, enforcing bans on tobacco advertising, promotion and sponsorship; and R, raising taxes on tobacco. Countries in the WHO South-East Asia Region have achieved various levels of success in implementing the FCTC and the MPOWER package, but many challenges remain. These include the continued relative affordability of tobacco products, despite tax and price rises; use of multiple and diverse tobacco products; high use of smokeless tobacco; interference by the tobacco industry; the introduction of new tobacco products; and the accessibility of these products to young people. The PRACTICAL guidance for policy-makers was launched in 2017 to further accelerate the implementation of the WHO FCTC throughout the region. As noted by the guidance, the tobacco industry is using the internet and social media to market its products in a powerful way. It is therefore worth considering how digital solutions can be exploited to support the policy measures recommended by the PRACTICAL guidance. For example, campaigns can help to generate public support for various tobacco control policies, such as smoke-free legislation and tobacco cessation, so social media and other digital platforms could be used strategically to counteract the tobacco industry’s narrative.
| Anticipated roadblocks and ways forward|| |
Controlling oral cancer requires prevention measures that are focused on tobacco, areca-nut products and alcohol use and on early detection at the primary health-care level. Without organized prevention and early detection and treatment efforts, oral cancer will continue to be a dominant public health problem across the region. Efforts need to be made to improve the currently low levels of advocacy for visual oral examination and early detection efforts for the prevention of oral cancer. While programmes on maternal and child health and communicable diseases may continue to be the focus at the primary-care level, priorities are shifting towards noncommunicable diseases, and oral cancer must be included in policy planning. A key concept to communicate is the lead time gained through early detection of oral potentially malignant lesions and oral cancer. Equally important is the need to tackle tobacco and areca-nut product use among primary health-care workers, which detracts from health promotion activities.
Nevertheless, progress is being made in some parts of the region; this may serve as a model for others to adopt and adapt to their local circumstances. Such adaptations should consider the positively disruptive effects that digital technology may have for the much-needed acceleration of efforts to prevent and control oral cancer.
Source of support: None.
Conflict of interest: None declared.
Authorship: AI drafted the paper; all other authors provided critical input and reviewed the paper.
| References|| |
Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M et al.
Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):e359–86. doi:10.1002/ijc.29210d.
Shield KD, Ferlay J, Jemal A, Sankaranarayanan R, Chaturvedi AK, Bray F et al.
The global incidence of lip, oral cavity, and pharyngeal cancers by subsite in 2012. CA Cancer J Clin. 2017;67(1):51–64. doi:10.3322/caac.21384.
Sankaranarayanan R, Ramadas K, Amarasinghe H, Subramanian S, Johnson N. Oral cancer: prevention, early detection, and treatment. In: Gelband H, Jha P, Sankaranarayanan R et al.
, editors. Cancer: disease control priorities, third edition. Washington, DC: World Bank; 2015.
Package of essential noncommunicable (?PEN) disease and healthy lifestyle interventions: training modules for primary health care workers. New Delhi: World Health Organization Regional Office for South-East Asia; 2018 (https://apps.who.int/iris/handle/10665/274260
, accessed 18 July 2019).
Alami H, Gagnon MP, Fortin JP. Digital health and the challenge of health systems transformation. mHealth. 2017;3:31. doi:10.21037/mhealth.2017.07.02.
Warnakulasuriya KA, Ekanayake AN, Sivayoham S, Stjernswärd J, Pindborg JJ, Sobin LH et al.
Utilization of primary health care workers for early detection of oral cancer and precancer cases in Sri Lanka. Bull World Health Organ. 1984;62(2):243–50.
Mehta FS, Gupta PC, Bhonsle RB, Murti PR, Daftary DK, Pindborg JJ. Detection of oral cancer using basic health workers in an area of high oral cancer incidence in India. Cancer Detect Prev. 1986;9(3–4):219–25.
Gupta PC, Mehta FS, Pindborg JJ, Bhonsle RB, Murti PR, Daftary DK et al.
Primary prevention trial of oral cancer in India: a 10-year follow-up study. J Oral Pathol Med. 1992;21(10):433–9.doi:10.1111/j.1600-0714.1992.tb00970.x.
Sankaranarayanan R, Ramadas K, Thara S, Muwonge R, Thomas G, Anju G et al.
Long term effect of visual screening on oral cancer incidence and mortality in a randomized trial in Kerala, India. Oral Oncol. 2013;49(4):314–21. doi:10.1016/j.oraloncology.2012.11.004.
Rajaraman P, Anderson BO, Basu P, Belinson JL, Cruz AD, Dhillon PK et al.
Recommendations for screening and early detection of common cancers in India. Lancet Oncol. 2015;16(7):e352–61. doi:10.1016/S1470-2045(15)00078-9.
Strengthening human resource for health in South-East Asia: time for action and commitment. New Delhi: World Health Organization Regional Office for South-East Asia; 2015 (https://apps.who.int/iris/handle/10665/164332
, accessed 18 July 2019).