CLINICAL MANAGEMENT OF PREMALIGNANT ORAL LESIONS

Data present in the literature suggest that oral screening in high-risk patients could prevent about 40000 deaths from oral cancer worldwide. This perspective in the fight against oral cancer—supporting prevention through screening as a potential major target of every health organisation worldwide. Oral cancer is a significant public-health threat, accounting for 270 000 new cases annually1 and with one of the lowest survival rates (fewer than 50% of patients surviving more than 5 years). Furthermore, in the past few decades despite advances in the detection and treatment of many other malignancies, this rate has remained disappointingly low and relatively constant. Rather than prevalence, the most peculiar characteristic of oral cancer is the apparently unexplainable imbalance between its global burden and the potential theoretical ease in decreasing morbidity and mortality with early detection. Oral cancer is almost always preceded by visible changes in the oral mucosa which allows clinicians to detect and treat effectively early intraepithelial stages of oral carcinogenesis. Nevertheless, most oral cancers are currently detected at a late stage, when treatment is complex, costly, and has poor outcomes. Paradoxically, the percentage of oral cancers diagnosed in the early stages is similar to that of colon cancers (36%). Lack of awareness in the public of the signs, symptoms, and risk factors for oral cancer, as well as a disappointing absence of prevention and early detection by health-care providers, are both believed to be responsible for the diagnostic delay. It is strange to think that, at present, pelvic examination and Pap smears appear more acceptable than looking in the mouth,6 for both patients and physicians. The surgical approach of premalignant lesions consists of two procedures: the incisional biopsy which appears to be one of the most useful tool in the diagnostic phase, and the excisional biopsy which represents an important aid in the treatment of early intraepithelial stages of oral carcinogenesis (mild, moderate, severe dysplasia and carcinoma in situ) that generally precede the development of invasive OSCC. Both procedures are easy to perform and in many cases are useful to obtain a complete resolution. Current research mainly focuses on therapies for advanced oral cancers. As a result we have been spending hundreds of millions of dollars in treating patients, two-thirds of whom will die within 3–5 years, consuming educational and scientific resources on procedures burdened by high costs and poor results, or on expensive molecular studies that are not easy to reproduce or can be applied to a small percentage of patients only. It is now time for a new deal. A first step has already been taken by WHO, which has recently issued a commitment to action against the neglected burden of oral cancer, mainly by strengthening prevention. Nevertheless, so far, there has been no evidence to support the use of visual examination as a method of screening for oral cancer. Organisations should change, at least in part, their policy, transferring resources from conventional fields to new methods of preventive intervention with greater effectiveness and lower cost. The screening for oral cancer is a simple non-invasive procedure, which needs only a 5-min visual inspection of the oral mucosa with lighting, gauze, and gloves, whereas the detection of most solid malignancies in their early asymptomatic stages almost always requires special, costly, and often invasive techniques. Clinical screening and early surgical treatment for oral cancer is easy, effective, cheap, and saves lives