NAMS task force report on oral cancer

EXECUTIVE SUMMARY Oral cancer is the term described as cancers occurring in the mouthparts that include lips, cheeks, sinuses, tongue, hard and soft palate, or the base of the mouth extending up to the oropharynx. Globally, oral cancer ranks 17th among all types of cancer in terms of both incidence and mortality. India has the largest number of oral cancer cases in the world, and this constitutes more than one-third of the total global burden. In India, oral cancer ranks as the second most common cancer, and is the number one cancer among males. In India, around 130,000 new cases and >75,000 deaths were reported only in the year 2020, with an expected doubling of incidence by 2040. This burden of oral cancer is further complicated by the late-stage diagnosis and low survival rates. In India, the majority of oral cancer cases are reported in the advanced stages, and hence, the chances of cure are very low. This report provides an insight into oral cancer as a public health problem in India, along with etiology and strategies to diagnose, treat, and prevent it while providing recommendations to improve upon the availability and delivery of treatment for oral cancer. The predominant risk factor for developing oral cancer is tobacco consumption. The continual use of tobacco in both smoking and smokeless forms is a major contributor to tumor development in the oral cavity. Other risk factors such as alcohol, diet and nutrition, oral thrush, dental problems, chronic irritation from sharp teeth or ill-fitting dentures, and human papillomavirus (HPV) infection also contribute to the burden. Further, social, cultural, and psychological factors too play an important role in developing oral cancer. Oral potentially malignant disorders (OPMDs) are a diverse group of conditions that are the precursors of oral cancer. It is important to recognize that a patient diagnosed with an OPMD has an increased risk of developing oral cancer compared to a person with a healthy mucosa. Lesions such as Erythroplakia, Erythroleukoplakia, Leukoplakia, Proliferative verrucous leukoplakia, Submucous fibrosis, Palatal lesions associated with reverse smoking, oral lichenoid lesions, oral lichen planus, smokeless tobacco keratosis, and more are the common OPMDs seen in the country. Oral cancer screenings, which are conducted to identify any clinical premalignant phase (accessible to visual inspection), are usually done on a mass scale and shows a decreased burden of advanced oral cancer incident cases and deaths as compared to no screening. Among the screening strategies, it is suggested that high-risk screening is cost-effective compared to mass screening at periodic intervals. Oral cancer screening methods vary across healthcare settings, each with its advantages and limitations. While visual inspection remains a fundamental tool, adjunctive technologies are sometimes used in dental clinics; community outreach programs and telemedicine extend accessibility to screening. The Ministry of Health and Family Welfare, Government of India, has prepared a universal and objective operational framework for cancer screening and management that aims to promote, coordinate, and conduct research to better understand, detect, diagnose, and treat cancer. The framework makes it mandatory to perform screening of oral, cervix, and breast cancer for males and females above the age of 30. Concerning oral cancer treatment, several modalities are available; however, the cure depends on the cancer stage when diagnosed and the delay in starting treatment. Primary surgery is the preferred modality of treatment for a vast majority of operable oral cancers. Radiotherapy is an alternate for early-stage oral cancers with comparable control rates to surgery. Typically, the primary treatment for oral cancer is surgery. The primary goal of surgical resection is to ensure complete removal of the tumor tissue. However, the potential negative impacts on appearance and functionality due to the extent of the disease and the necessary surgical removal stress the importance of using less invasive surgical methods. The National Cancer Grid Management Guidelines for early-stage cancer recommends surgical local excision with a minimum of 1 cm gross margin, accompanied by appropriate neck dissection and suitable reconstruction. For advanced stages, surgery is preferred, along with adjuvant radiotherapy or chemotherapy. Oral cancer in its entirety imposes a significant fiscal burden on a national, institutional, family, and individual level. Funding of cancer care in India is a complex mixture of state and government accountabilities, with the government shouldering most of the responsibility. Oral cancer as such, has not been given a separate budget in India, but it is covered under various facilities of the government, schemes, and programs for cancer. This report entails the Task Force Committee recommendation for screening, diagnosis, prevention, and management of oral cancer, along with research, policy, and advocacy recommendations to address this immense public health problem in the country.