Oral Oncology 105 (2020) 104632

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Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology

Screening for oral cancer: Future prospects, research and policy T

development for Asia
Toru Nagaoa,⁎, Saman Warnakulasuriyab
a
Department of Maxillofacial Surgery School of Dentistry, Aichi Gakuin University, Nagoya, Japan
b
Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, WHO Collaborating Centre for Oral Cancer, UK

ARTICLE INFO ABSTRACT

Keywords: Although the incidence of oral cavity cancer is high among low and middle income countries in Asia where the
Oral cancer risk habits (tobacco smoking, tobacco chewing and betel quid use) are common, the benefits for introducing oral
Precancer cancer screening for the whole population in these countries still remains controversial. It is disappointing, but
Oral potentially malignant disorders not surprising that many of studies, without control arms, could not provide a clear answer as to whether
Screening
screening is effective in reducing mortality or combating rising incidence trends. Only one Indian study that
Early detection
Tobacco and areca nut
reported a randomized controlled trial (RCT) elucidated that mass screening for high risk groups could sig-
nificantly reduce the cancer mortality or down-stage cancers detected by screening. Several professional orga-
nizations that considered any potential benefits of oral cancer screening remain unconvinced that the current
knowledge on its natural history, available tests and interventions to treat potentially malignant disorders satisfy
the desirable criteria to recommend organized screening for oral cancer.
In this review we discuss advantages and disadvantages for oral cancer screening particularly with reference to
high incidence countries in Asia. If screening is undertaken, we propose that it is targeted to high risk groups and to
combine screening with education on risky life-styles so that overall incidence can be reduced in the future. Further
research on increasing public awarenes and impact of professional education such as e-learning to reduce diag-
nostic delays, studies on the natural history of oral potentially malignant disorders and cancer, comprehensive
tobacco and areca nut cessation programs, developing tools to identify high-risk individuals and high-risk lesions
are proposed.

Introduction
During the past four decades the feasibility of oral cancer screening
has been researched in a few countries in several health care settings.
Various outcomes on the impact of screening for oral cancer to promote
the early detection are reported. A randomized controlled trial (RCT)
conducted in India for the first time has demonstrated a reduction of
mortality in high-risk individuals detected by visual screening [1].
However, the evidence presented is limited to one study, externally
assessed as at high risk of bias. Furthermore, a critical review by the
Cochrane Group found that this study did not account for the effect of
cluster randomization in the analysis [2]. A national oral cancer pro-
gram was initiated in Cuba in 1983 and by the year 1990 reported an
increase in stage I cancers as evidence of its efficacy [3]. The Cochrane
Review on this topic however, concluded that there is lack of sufficient
evidence to uphold the introduction of population-based screening for
the early detection of oral cancer worldwide [3]. More recently, an
organized, population-based oral cancer screening program directed at
2,334,299 high-risk Taiwanese citizens who were cigarette smokers
and/or betel quid chewers demonstrated the effectiveness of down
staging oral cancer by screening and also significantly reducing oral
cancer mortality (compared with non-attendees for screening) in a
geographic area near Taipei city [4]. However, limitations of the study
are noted in that the repeated screening rate was low (21%) and the
follow up of screened participants was restricted to short time periods.
The benefits and effectiveness of conducting oral cancer screening for a
whole population still remains controversial.
The objective of this review is to critically appraise the studies so far
conducted to examine what research may be feasible in the future to aid
policy development for Asia.

⁎
Corresponding author at: Department of Maxillofacial Surgery, School of Dentistry, Aichi Gakuin University, 2-11, Suemori-Dori, Chikusa-Ku, Nagoya, Aichi 464-
8651, Japan.
E-mail address: tnagao@dpc.agu.ac.jp (T. Nagao).

https://doi.org/10.1016/j.oraloncology.2020.104632
Received 14 August 2019; Received in revised form 5 February 2020; Accepted 4 March 2020
1368-8375/ © 2020 Elsevier Ltd. All rights reserved.
T. Nagao and S. Warnakulasuriya
Epidemiology
According to the GLOBOCAN 2018, the number of incident cases for
lip and oral cavity cancer in the world was estimated at 354,864, with
an age-standardized incidence rate, 5.8 for men and 2.3 for women per
100,000. GLOBOCAN also estimated 177,384 deaths, with an age
standardized mortality rate, 2.8 for male and 1.2 for female per
100,000 [5]. Lip and oral cavity cancer are rated the fourth most
common malignancy occurring worldwide in men (8.7 per 100,000) in
low/medium income countries (by Human Development Index-HDI),
whereas in high/very high income countries (by HDI) is not within the
10 most common cancers with an incidence level lower at 3.9 [5].
Highest rates are reported in Southern and South East Asia (e.g., India
and Sri Lanka) and also in the Pacific Islands. Papua New Guinea, has
the highest estimated incidence rate worldwide, in both sexes [5].
Among men, oral cancer is also the leading cause of cancer death in
India and Sri Lanka [6–8]. Other high incidence countries include
France, Hungary, Brazil, Cuba and Puerto Rico [9]. The incidence of
oral cancer is increasing in many Eastern European countries. Oro-
pharyngeal cancer has been rising in both North America and Europe
particularly in the younger birth cohorts [10,11]. Five-year survival
figures for oral cancer have not improved (50–60% overall survival)
and the figures have remained static in the last few decades, except in
few tertiary cancer treatment centres in the USA and in Europe [11].
Risk factors for oral cancer
Despite good evidence-based reports on the aetiology of oral cancer
in the global literature [5], public awareness on causative factors for
oral cancer remains very low. International Agency for Research on
Cancer (IARC) through its Monograph Program has reported on carci-
nogenic substances that are hazardous and may increase the risk of
cancers of the oral cavity in humans [12–14]. These include tobacco
(both smoked and smokeless), alcohol and betel quid (areca nut)
chewing with or without tobacco, all amounting to hazardous lifestyles
[15]. Several meta-analyses of published cohort and case-control stu-
dies have also confirmed significantly elevated risks for these agents in
different population groups [16–21]. Though these risk factors are
common for the oral cavity and the oropharynx, infection with human
papillomavirus is an emerging risk factor particularly for oropharynx
(the sites include posterior tongue, tonsil, soft palate and lateral and
posterior walls of oropharynx) suggesting a possible link to sexual
transmission of this virus in partners who may also be at risk of cervical
cancer [22]. The public often remain concerned about factors that are
controversial for causation of oral cancer e.g. trauma, dentures, spicy
food, alcohol-containing mouthwashes and HIV infection [23] and the
health professionals need to be aware of these contro versial issues that
are best ignored in population approaches to screening and to focus on
major risk factors.
Higher rates of oral cancer are reported in deprived populations
[24] and socioeconomic differences are partially attributable to the
population prevalence of tobacco smoking and alcohol use in various
socioeconomic strata [25]. Poor nutrition may also account for an in-
creased risk in deprived societies [26]. Young people presenting with
tongue cancer are the exception as a proportion of them come from
affluent groups [27]. Any associations of deprivation or dietary factors
to aforementioned risky lifestyles are more likely in the older adults. It
is therefore clear that a high-risk individual for oral cancer in Asian
countries could be identified based on three major risk factors (tobacco,
alcohol and areca nut use) particularly among groups from poor so-
cioeconomic status stratified by their level of education, income and
employment and also by nutrition.
Asian migrants to other continents continue the habit of betel quid
chewing following migration to the industrialized countries in the West
and suffer from “betel mania” [28,29]. The areca nut is highly addictive
and leads to dependency. Chronic use of areca nut leads to oral fibrosis
2
Oral Oncology 105 (2020) 104632
resulting in peculiar facial features and systemic manifestations that
have been termed as Gutka Syndrome [30]. Areca nut chewing causes
teeth staining, attrition of the dentition, and advanced periodontitis
leading to tooth loss [31]. Knowledge of these specific risk factors
particularly among Asians allows a strategy for high risk population
screening if that was to produce the best yield to improve outcome and
reap benefits from screening for oral cancer.
Factors that delay cancer detection in primary settings
Most patients affected by oral cancer ignore their symptoms and
arrive at a late stage of disease (mostly with T3 and T4 cancers). This is
largely due to poor awareness of cancer-related symptoms and many
are unaware that cancer could arise in the oral cavity. A meta-analysis
has estimated a mean delay of 3 months prior to the detection of oral
cancer [31], analyzed by retrieved articles from North America, Israel,
Thailand, Finland, Greece, Brazil, Japan and UK. Examination of types
of delay indicates patients are mostly to blame for the initial delay [32].
Lack of easy access to dental and medical facilities may contribute to
delay in presentation.
A study on diagnostic delay at a university hospital in southern
Thailand in 1990s found that the total delay was more prolonged in
some community groups, and those showing preference to taking an
alternative medicine; i.e. consuming traditional herbal medications
prior to healthcare professional (HCP) consultation [33]. Further, the
authors evaluated the impact of an open access system to health ser-
vices by offering universal health coverage (UHC). Ten years after the
implementation they again studied the diagnostic delay of OSCC and
concluded that the open access to the healthcare system had some in-
fluence on patients taking herbal medications in reducing delay [34].
The UHC reform solved only the access problem for these patients since
the duration of patient, professional and total delay remained un-
changed compared to their previous study. The authors concluded that
the delays were due to a lack of knowledge and awareness of both
patients and primary HCPs.
The outcomes from some studies highlight the need for education
(cancer symptoms) to communities as well as health care personnel in
improving cancer awareness to avoid delay during early part of the
cancer journey [35]. Even though the evidence from more than one
study on significant mortality reduction by screening is yet unavailable,
screening programmes have the inherent benefit of educating the public
on individual cancers and could mobilize and educate the public to
favorably improve public awareness that may reduce delay in pre-
sentation in a population.
Background scientific evidence
For most common cancers, particularly those arising in colorectum,
breast and cervix, relatively established population programmes
leading to a significant reduction in incidence and mortality of these
cancers in the screened populations are now documented. Suitable
screening tests and screening protocols for these cancers are fairly well
defined in the literature. For several decades oral cavity has been dis-
cussed as a target site that is amenable for screening mostly on the basis
that oral cancer presents in a site easily accessible for visual examina-
tions.
A screening program should have the capacity for oral cancer and
potentially malignant disorders to be detected before the symptoms
arise thus resulting in down staging of the disease. Furthermore, there
should be a demonstrable reduction in mortality in the screened po-
pulation after the lapse of several years. In relation to Wilson and
Junger criteria [36] oral cancer meets many of these objectives that
justifies screening. A Cochrane Review has previously considered this
evidence and confirmed that oral cancer is a screenable disease. A re-
view that examined the sensitivity and specificity of published studies
reports a high discriminatory ability of visual screening [37]. Though
T. Nagao and S. Warnakulasuriya
compliance for screening is generally high, attendance by positively
screened subjects for confirmatory tests has to be improved to make
screening acceptable in Asian Pacific countries [38]. In order to im-
prove outcomes reported in these quasi-experimental studies, over di-
agnosis (false positives) should be minimized.
There are systematic reviews [2,39–42] that have evaluated the
effectiveness of oral cancer screening in countries from India, Sri Lanka,
Italy, UK, Japan, Thailand, Pakistan, Cuba, Hungary, USA and Canada.
These reviews concluded that there is limited evidence to substantiate
the impact of oral cancer screening programmes at the present time due
to small effect size.
Research of cost effectiveness of oral cancer screening is quite
limited due to the few numbers of RCTs that exist. Speight et al. eval-
uated the cost-effectiveness for opportunistic oral screening undertaken
in the UK directed at high-risk groups attending general dental practices
[43]. Compared to population or invitational screening programs they
reported that opportunistic screening in dental practices may be cost-
effective [43]. An Indian group has estimated the cost-effectiveness of
organized mass screening by their RCT study and concluded that visual
inspection offered to a high-risk population is cost-effective. Targeting a
screening program to a high-risk group enables the service to be offered
at a modest cost in a limited-resource setting such as in India [44].
Screening test is to be repeated at regular intervals to benefit the
screened population. The optimal interval for repeating a screening test
for the detection of oral cancer potentially malignant disorders has not
yet been demonstrated, in order to obtain the best results. But one study
that performed repeat oral examinations on a cohort of 6,340 subjects
in Aichi, Japan has shown that annual screening allows detection of
new cancers and potentially malignant disorders [45].
Feasibility programs for oral cancer detection have been reported
from a few high incidence countries [3,46,47]. Primary health care
workers (Sri Lanka) or Basic Health Workers (India) have been cali-
brated to examine the oral cavity and these ancillary care workers have
successfully undertaken examinations of large numbers of people with
acceptable accuracy [48] and in a reproducible manner as found in two
regions in Sri Lanka [49]. However, these studies were not randomized
with control groups to assess the impact of screening on morbidity and
mortality. This means that recommendations for mass screening cannot
be based on these early studies [50]. Only randomized controlled trial
so far reported was from Trivandrum, India (TOCS study) and reported
oral visual screening can reduce mortality (only) in high-risk in-
dividuals [1].
A further study was undertaken in Taiwan where the incidence of
oral cancer is high, with the objective of reducing oral cancer mortality.
Chuang et al. [4] performed a population-based intervention study in a
high-risk group. More than 2 million smokers and/or areca nut chewers
were screened by visual examination and with an additional screening
adjunct. The authors reported that the relative risks of overall incidence
rate and death rate of oral cancer in the screening group were 0.69
(95% CI, 0.68–0.72) and 0.74 (95% CI, 0.72–0.77) respectively com-
pared with the absence of screening after adjustment for confounders.
Multiphase screening by integrating oral cancer screening into
general health screening was undertaken in Japan in 1980s and was
shown to be effective at improving citizens’ health [51]. In Hungary
where the incidence and mortality rate of oral cancers is increasing,
oral examinations have been carried out as additional to X-ray
screenings for lung cancer [52]. Screening at workplace offers another
opportunity to target industrial and office workers who cannot be
reached easily by visiting homes as tried in Chandigarh, India and
among Japanese workers in the UK [53,54].
Major concerns raised against oral cancer screening programs are
several folds: (a) non-participation by at-risk subjects when invited to
do so (b) Lack of agreement on evidence-based treatment interventions
for the management of oral leukoplakia following detection and (c) the
natural history of the disease is not well defined as a proportion of
cancers may arise de novo. As only a limited number of oral cancers can
3
Oral Oncology 105 (2020) 104632
be picked up in a population screening programme and the reality of
identifying early oral cancer in general practice remains low [55], de-
tection of asymptomatic cancers or potentially malignant disorders,
particularly oral leukoplakias and oral submucous fibrosis is considered
efficacious in outcome measures.
The inaugural Global Oral Cancer Forum (GOCF), held in New York
in 2016 summarized the status quo of current approaches to oral cancer
screening, [56]. At this conference, invited experts presented the cri-
teria of the UK National Screening Committee (UKNSC) [57] that de-
termine the policy for a screening program. Among the 19 criteria that
address the suitability for incorporation to a state-funded health system,
oral cancer screening was categorized in 10 met, 5 questionable and 4
un-met [58].
Oral leukoplakia as a main target disease for screening
Based on a systematic review and a meta-analysis of 22 published
studies global prevalence of oral leukoplakia was recently estimated at
4.11% (95% CI: 1.98–6.97). [59]. The proportion of oral cancers arising
from oral leukoplakia has been estimated at 17–35% [60]. The early
detection of oral leukoplakia therefore serves the purpose of secondary
prevention of oral cancer, although some cancers may arise de novo. All
leukoplakias do not transform to cancer [61] and at present the de-
tection of oral epithelial dysplasia following biopsy remains the stan-
dard way of distinguishing high-risk from low-risk leukoplakia. Lack of
calibration in reporting dysplasia [62] and the subjective nature of
dysplasia grading [63] contribute to the challenges in the process of
evaluation of who may have the highest risk lesions following screening
and investigations.
A risk-factor model suitable for selecting subjects who may present
with undiagnosed oral potentially malignant disorders has recently
been derived and validated in Sri Lanka [64]. The model has the fol-
lowing characteristics: age, socio-economic status (SES), betel quid
chewing, smoking and alcohol use, with scores ranging from 0 − 16. A
total score of 12 as the cut-off yielded the best sensitivity (95.5%) and
specificity (75.9%) for a positive detection. We propose that this model
be applied to populations in South Asia for invitational screening so
that screening can be directed to high-risk individuals to undertake an
oral examination. Other clinical factors associated with a progression to
cancer include sex, site and type of lesion [65]. However, these clinical
factors are based on estimates and have not been tested in any pro-
spective studies.
Biomarkers are increasingly researched for cancer detection. No
single molecular marker has the ability to determine patients or leu-
koplakia lesions at risk of transformation to oral cancer [66]. So far, the
candidate markers that may accurately predict which leukoplakias may
transform to cancer include loss of heterozygosity in 3p and 9p [67] and
DNA aneuploidy [68]. Adjunctive aids when applied at chair-side may
accelerate the decision for taking a biopsy from a suspicious area of oral
mucosa but this area needs further research. The current status is re-
viewed in the next section.
Adjunctive methods for early detection
Several adjunctive techniques are commercially available to po-
tentially assist in the screening of healthy asymptomatic subjects with
the objective of early detection of disease or picking up occult oral
cancerous lesions or potentially malignant disorders. Same tests have
also been proposed for stratification of potentially malignant disorders
that carry a higher risk.
The proposed non-invasive diagnostic aids for the detection of
squamous cell carcinomas and potentially malignant disorders include
oral brush biopsy and cytology [69], fluorescent instruments [70] and
narrow band imaging (NBI) [71], making the tissue aceto-white [72]
and staining with toluidine blue [73]. Testing of these aids has been
undertaken in secondary care facilities but not in primary care.
 T. Nagao and S. Warnakulasuriya

Table 1
A sample of oral cancer screening trials reported from both high and low incidence countries.
Country Year Screening Target No. of examined Coverage (%) Referred (%) Attended (%) Correctly Sensitivity (%) Specificity (%) Positive No. of Per 100,000 No. of % Investigators
method population referred predictive cancers precancers
(%) value (%)

India 1983 Mass 1,17,281 39,331 34 1 72 45 59 98 31 20 51 – – Mehta et al. [47]

screening
India 1996/ Mass 78,969 69,896 89 6 60 40 82 85 40 149 213 1597 4 Ramdas et al.
98 screening [79]
(RCTa)
Sri Lanka 1981/ Mass 87,277 29,295 34 4 54 62 95 81 58 4 14 1220 4 Warnakulasuriya
82 screening et al. [46]
Sri Lanka 1982/ Mass 72,867 57,124 78 6 62 80 97 75 80 20 35 2193 4 Warnakulasuriya
83 screening et al. [49]

4
Japan 1996/ Mass 52,058 19,056(9,536)b 36.6 (18) 1 69 96 92 – 78 2 10 77 0.8 Nagao et al. [51]
98 screening
Hungary 2001 Mass 10,000 5,034 50 – – – – – – 0 – 188c 4 Dombi et al. [52]
screening
c
UK 2003 Opportunistic – 2,265 – – – – – – – 2 88 92 4 Lim et al. [99]
screening
Taiwan 2004/ Mass 4,234,393d 23,34,299 55.1 0.7 91 92 – – 61 for oral 4110 180 11,051 0.47 Chuang et al. [4]
2009 screening preccancer
22.7 for
oral cancer

a: Randomized controlled trial.

b: Excludes repeat examinations.
c: Screened subjects were not re-examined by a specialist.
d: With habits of cigarette smoking, or betel quid chewing, or both.
Oral Oncology 105 (2020) 104632
T. Nagao and S. Warnakulasuriya Oral Oncology 105 (2020) 104632

The RCT in Keelung, Taiwan mentioned in an earlier section used
Toluidine blue staining for oral screening to determine if the method
would reduce cancer incidence by a higher yield of oral premalignant
lesions in the screened population. A non-significant reduction by 21%
in oral cancer incidence was reported in the screened group (28 × 10−5
vs. 35.4 × 10−5) [74]. Unfortunately, adjunctive techniques when ap-
plied in primary care have failed to improve the sensitivity or specifi-
city of screening beyond clinical visual examination [75].
Improving screening abilities and advising on primary prevention
Performance by physicians and dentists on preventive programs
directed at oral cancer control has been reported and appear to differ by
the training they have received in graduate programs [76]. The Spanish
Dental Council has taken initiatives to train their workforce in oral
cancer screening [77] and similar policy initiatives are recommended
for high risk countries. Many free access web learning (e-learning)
programmes have been provided for training health professionals.
However, these resources on screening for oral cancer have been as-
sessed to provide heterogeneous information both in quality and con-
tent [78].
Education for the public
The success of a screening program initially lays with population
participation. As shown in Table 1, compliance to attend screening has
varied, ranging from 34 to 89% [46,79]. Interestingly two of the studies
with lowest and highest compliance rates were both conducted in India.
A second examination by a specialist is needed to confirm a positive
screen but compliance to attend a secondary centre has also been poor,
ranging from 52 to 72%. The accessibility of the referral centre, lack of
health literacy and other competing duties appear to impact on non-
attendance [80]. Provision of brief health education using a leaflet as
was undertaken in a UK study at the time of referral is known to change
patient behavior [81]. This approach might be useful only for selected
groups of people. Poor follow up of positively detected cases can at-
tenuate the success of a screening program in a rural setting [82].
However, health awareness meetings for villagers on oral cancer might
help. Mobile technologies and electronic transmission of screen de-
tected images have been tested in India that may prove useful for re-
mote populations who are unable to attend secondary care facilities for
re-examinations [83]. A simple explanation by a health worker during a
visit following a screen examination has shown to improve the com-
pliance for re-examinations [49].
Oral health professionals could provide smoking and areca nut
chewing cessation advice at the point of care [84–86] or during
screening events [87] at minimum cost. The National Cancer Institute
recently recommended developing evidence-based screening methods
to improve case detection among areca nut users [88].
Reducing inequalities has a major role in improving the health of a
nation [89]. Creating awareness and education on oral cancer within
the society involving the pharmaceutical companies, private organiza-
tions and governmental agencies must be encouraged.
Further research
To plan an appropriate screening programmes, selecting appro-
priate screeners based on available human resources, a knowledge on
local risk factors, causes for delay, and improving secondary medical
facilities are essential requirements. We have limited information on
the natural history of oral precancer and cancer, what treatments are
effective for oral leukoplakia and what screening tests may detect
OPMDs that are likely to transform. Most oral cancer screening pro-
grams reported so far have been limited to a single examination of the
population, the only exemptions being an annual screening program
conducted in Aichi Prefecture in Japan from 1985 to 1988 [45] and in
Trivandrum, India (TOCS study) where ∼60% of screen positive sub-
jects had been reinvestigated, completing at least two rounds of
screening [79]. This single RCT conducted so far has been criticized for
methodological weaknesses as too few clusters were selected and did
not fulfill CONSORT Guidelines [2]. More studies are needed if we are
to present evidence to National Agencies that oral cancer is a screenable
disease. These areas need further research.
Table 1 lists the outcome from selected screening programmes for
oral cancer and precancer. Based on our own experience having un-
dertaken several screening programmes in both high and low risk
countries, we propose that initiating public health programmes and
research would be desirable on the following themes: improving health
literacy on oral cancer; examining the natural history of oral cancer and
determining the efficacy of medical or surgical intervention in RCTs;
value and place of screening adjuncts and molecular markers; and
testing different models for screening based on demographics particu-
larly identifying people at risk.
With regards to the patient’s delay, it would be desirable to un-
derstand why they came so late and their responses recorded and
analyzed qualitatively. Such a qualitative study was reported from
Scotland [90] exposing patient factors. Majority were unaware of risk
factors or initial symptoms of oral cancer. Guidelines are available to
plan oral cancer examinations for those individuals classified as high
risk [91].
Factors and approaches to consider in setting up further research
programmes are summarized in Table 2. Educational resources for
training staff/screeners are now available [92]. These need consider-
able work up by expert groups to logically select appropriate metho-
dology based on evidence and sanctioned by peers.
The National Cancer Institute [93], the American Cancer Society
[94], Canadian Task Force [95], American Academy of Oral Medicine
[96] and the UK Working Group on oral cancer [97] all recommended
that an oral examination should be included in a periodic health ex-
amination. However, Clinical Practice Guidelines on screening and

Table 2
Factors to consider in oral cancer/precancer screening studies.
Models Population, opportunistic, work place, high risk groups, integral with other programs
Manpower Primarily dentists; nurses & hygienists with training; Asia: consider PHCW
Methods Visual (OVE), could be combined with toluidine blue, chemiuminescence & autoflourescence
Training Calibration of screeners; manuals and e-learning for training
Screening disorders Oral cancer, leukoplakia, erythroplakia, oral submucous fibrosis
Target population >40 years of age
High-risk population Regular smokers, betel quid chewers, heavy drinkers, low SES, under nutrition
Improving compliance Education, improve awareness
Frequency Annual screening may detect new OPMDs and by 3 yearly reduces mortality. Annual screening adds extra cost.
Confirmation of screen diagnosis Against specialist's diagnosis & biopsy
Evaluation Coverage & arrival rates, sensitivity, specificity, PPV and NPV
Benefits from an RCT Down staging, reduction in mortality compared to a control population

PHCW: primary health care workers; SES: socio-economic status; PPV: positive predictive value; NPV: negative predictive value.

5
T. Nagao and S. Warnakulasuriya
diagnosis of oral cancer is based on a low or very low level of evidence
[98]. Until evidence from further research on screening becomes
available these guidelines to the oral health professionals need to be
part of routine activity.
Conclusion
Oral cancer is a socio-public health problem in countries where its
incidence is high and where ironically medical and dental manpower
resources are limited. Primary prevention and early detection are key
issues, particularly in South, South-East and East Asian countries. There
is insufficient evidence to recommend for or against screening of
asymptomatic individuals for oral cancer based on one RCT that re-
ported benefits for screening high risk groups. The policy of oral cancer
screening ought to differ between less developed and developed coun-
tries due to differences in incidence patterns, literacy levels and to life
styles that are linked to this cancer. Capacity development in low in-
come countries and skill transfer through international agencies may
help to reduce the burden of oral cancer in the future.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgement
The authors would like to thank Dr. Pankaj Chaturvedi for his va-
luable suggestions on our manuscript.
Funding
The authors received no financial support for the publication of this
article.
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