Oral and Oropharyngeal Cancers Surveillance and Control in Alberta: A Conceptual Framework

Background: Oral cancer is a deadly public health issue worldwide with steady survival rate (50%-60%) for decades. Alberta is positioned as the 4th province for oral cancer incidence and related death prevalence in Canada. While the importance of early detection of oral cancer is well-documented, Alberta lacks a solid oral cancer screening and prevention strategy, and little is known about the province’s oral cavity cancer (OCC) and oropharyngeal cancer (OPC) status. Objectives: The overall goal of this PhD research was to generate a comprehensive knowledge of oral and oropharyngeal cancer in Alberta and develop a conceptual framework that may contribute to improving health of Albertans. Methods: A convergent mixed-method design was used wherein findings from quantitative and qualitative data analyses were merged. In phase 1, I conducted a scoping review to gather the existing information about OCC and OPC in Alberta including prevalence, demographics, mortality, morbidity, initiatives, allocated funding, and health system functioning. Phase 2 was a population level cross-sectional study, done for the first time in Alberta, to collect oral health profile data and associated risk factors for OCC and OPC from one of the most vulnerable demographic populations in Edmonton. In phase 3, I used a qualitative design to explore barriers to early detection of OCC and OPC in Alberta at the clinician-patient-system level using initial medical consultation notes of oral cancer patients. Results: In phase 1, Alberta Cancer Registry data (2005-2017) showed that most of the OCC and OPC lesions were diagnosed at an advanced clinical stage (i.e. III and IV), with a high percentage of them being in stage IV (OCC= 45.2%, OPC= 82.4%). Survival levels were lowest in rural and First Nations areas. Further, 35% of HPV-associated cancers were linked to oropharyngeal cancers, which were more prevalent in men and younger age groups. No routine public oral cancer screening program currently exists in Alberta. General practitioners/dentists refer patients to specialists, often with long waiting times. In phase 2, a total of 322 participants with a mean (SD) age of 49.3 (13.5) years completed the study. Among them, 71.1% were male, 48.1% were aboriginal, and 88.2% were single. The prevalence of oral cancerous lesions was 2.4%, which was higher than the recorded oral cancerous lesion prevalence in Canada (0.014%-1.42: 10,000) and Alberta (0.011%- 1.13:10,000). The clinical examinations indicated that 55 of the participants (17.1%) presented with potentially malignant oral lesions (PMOL), 176 (54.7%) of participants had oral lesion/inflammatory changes of oral mucosa, and 61.5% had high level of Decayed, Missing, Filled Teeth (DMFT) scores. Risk of cancerous/PMOL was 1.68 times higher in participants living in shelters vs. those living alone. Oral lesion/inflammatory changes of the oral mucosa showed a significant association with cancerous/PMOL (p<0.001) compared to those who did not have cancerous/PMOL. In phase 3, five main categories were identified from qualitative analysis of 34 initial medical consultation notes of oral cancer patients: patient appraisal interval, help-seeking interval, formal diagnosis interval, pre-treatment interval, and contributing factors. In addition to biological factors, health-related behaviours, sociodemographic and tumor characteristics, other risk factors that negatively contributed to early detection of oral and oropharyngeal cancers included factors related to patients, providers, and healthcare system. Conclusions: The project successfully gathered the information from numerous resources to provide a comprehensive overview of what we already knew and shed light on dark and previously unseen corners of our provincial OCC and OPC challenges. This study revealed that OCC and OPC patients in Alberta continue to be diagnosed in stage IV, with high mortality rates. The prevalence of oral PMOL in the Boyle McCauley Street, an underserved community in Edmonton, was higher than that of the general population. Our study supports the need for developing opportunistic oral cancer screening and oral health promotion strategies in deprived communities and at -risk patients. The main contributors to total patient delay identified in this research were patients’ general lack of awareness about early symptoms of oral cancer and high-risk anatomic areas, inaccurate clinical judgement of attending physicians and dentists, and lengthy access to care. A sustainable plan is needed for enhancing public awareness and implementation of a solid curriculum for the training of medical and dental students.

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