One of the salient but silent public health problems, oral
cancer is a killer disease but with a cure. It gives rise to disabilities and
death but the possibility of survival is surprisingly high when detected early.
Therefore, oral cancer screening procedures are a mandatory know-how for dental
surgeons working at any level. Starting from their days of their undergraduate
education to the training they receive during their house-job, they should end
up in a position where they are able to identify all suspicious lesions and
search for prompt specialist opinion where they are fazed or unsure.

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A cross sectional questionnaire based study was conducted
amongst 150 house officers from Sardar Begum Dental College Peshawar, Khyber College
of Dentistry Peshawar and Prime Dental College Peshawar. A self-designed close
ended questionnaire with 4 open ended questions was distributed amongst all the
house officers of the above mentioned.



Of the 150 house officers approached, 128 filled the
questionnaire with a response rate of 85.33%. Only 0.8% of the total
participants i.e. only 1 participant managed to score above average knowledge
regarding oral cancer screening methods while 58.6% had average knowledge,
30.2% were below average and 10.2% had poor knowledge. 81.3% said they didn’t
feel adequately trained to screen patients for oral cancer and 95.3% felt a
need for its improved training during their respective bachelor’s program.


The study brings to light a dire need for an improved
approach towards oral cancer screening methods during the undergraduate years
in the dental colleges of Peshawar.







Oral cancer is
the eighth most common cancer worldwide11. It includes cancers of
the lip, tongue and rest of the oral cavity, except for cancers of the major
salivary glands1. In developing countries mostly and in some under
developed countries, it is responsible for sizeable mortality and morbidity
rates. Though on an estimate cancer incidence is 14 million new cases, alone oral
cancer has a 1.8% mortality worldwide and claims about 300.000 deaths (2.1%)
annually2, 3.  

Patient survival
presenting with late stage disease is only 30% whereas detection at an early
stage has shown that survival from oral cancer at 5 years is better than
90%,. The survival rate for oral cancer over 5-years has remained less than 50%
over the last 50 years for the following reasons11 12: (i) Diagnosis
at advanced stages for 60% cases (III and IV); and (ii)) Oral cancer is subject
to the “field cancerisation phenomenon”, and has the highest risk of
development of second primary tumors of any cancer.

But even after
all this, if caught early, oral cancer is extremely treatable (i.e., in stage 1
or 2)8. Unfortunately, late stage diagnosis (i.e., stage 3 or 4) is
all too common 9 and the most common cause is the failure to obtain
an oral cancer screening from a dentist or physician 10.

Early diagnosis
for oral cancer is ensured by the immediate response of professionals and
patients to early signs and symptoms so that a prompt diagnosis and a focused treatment
plan can be formed before the disease becomes advanced. However, an estimated
30% of patients wait more than three months before consulting a healthcare
professional about signs of oral cancer4. Delayed presentation has
been found to be influenced by the process of symptom interpretation, knowledge
of oral cancer, coping responses and barriers to seeking help such as problems
with access and their social circumstances and responsibilities.5

A number of screening
techniques have been proposed for oral cancer. The simplest of which involves
visual examination of the oral mucosa as shown by Kujan et al in 2006. In a Cochrane review it was concluded
that there was not enough evidence to determine whether oral screening by
visual examination, or any other modality, in the general population could
reduce mortality from oral cancer Kujan et al in 2006, but in researches conducted by Field et al in 1995, Lim et al in 2003 and Speight et al in 2006, it has been suggested by an increasing
number of studies that oral screening could very feasibly be carried out
economically as a part of routine dental checkups in general dental practice.7

A handful of
countries in the world like Cuba, have a national oral cancer screening program.
The program uses annual visual examination in dental practices as found by Fernandez Garrote et al in 1995. While there is some evidence that
repeated screenings led to a reduced likelihood of advanced stage oral cancer (Sankaranarayanan et al, 2002), overall there has been limited evidence
of a shift from advanced to earlier stage oral cancer following introduction of
the programme (Fernandez Garrote et al, 1995). 7

Another advantage
of oral cancer screening is that during a routine exam, informing high risk
patients that you are checking for early signs of oral cancer, could prove to
be a golden opportunity to educate them about the existence of oral cancer and
advise them on preventive measures and early detection. The British Dental
Association (BDA) does advise that patients should normally be told that an
oral cancer check is being carried out.6


It is clear that
screening for and early detection of cancer and pre-cancerous lesions have the
potential to reduce the morbidity and mortality of this disease. 13A cross sectional descriptive, questionnaire-based survey
method was conducted to assess the level of KAP regarding oral cancer screening
among the house officers in the dental colleges of Peshawar city, KPK.
Questionnaires were distributed amongst male and female house officers of
Sardar Begum Dental College, Khyber College of dentistry and Prime Dental College.
A list of all the house officers was obtained from the SAS of the respective
colleges. Prior to conduct of the study, ethical clearance was obtained from
the Respective ethical committees.A total of 180 house officers are present in the afore
mentioned dental colleges. All these house officers were selected for this
study. The study was conducted over a period of two months. After informing the
participants about the aim of the study and obtaining consent, questionnaires
were distributed amongst them in their respective wards. To ensure honesty and
prevent improper data entry, the house officers were supervised during the
procedure. Participation was voluntary. The questions were
derived from different articles. The questionnaire was prepared in English and
contained 25 questions split into three sections i.e. knowledge, attitude and
practice. 4 of the questions in the knowledge section were open ended
questions. A pilot study was initially conducted before distribution amongst
the house officers. 3 questions were discarded and the final questionnaire thus
comprised of 25 items with 12 knowledge, 8 attitude and 5 practice based
questions. For the purpose of analysis, each correct answer was given score “1”
and wrong answers were given score “0”. Questions left unmarked were also given
“0”. Answers to open-ended questions were in the form of a fixed number of
points. To assess these answers, we had a key for which every correctly
mentioned point was scored “1” mark. Overall individual scores on the questions
were based on the number of correct answers. The results were hypothesized with response scores which
significantly related to the level of KAP`s regarding oral cancer screening
among the study participants.The data was entered into IBM SPSS 20 from the
questionnaires and analyzed. Results

Out of the 170 house officers, 130 house officers
participated in the study with a response rate of 76.47%. Table 1 shows a
majority of the participants to be females (66.9% n=87) and only (33.1%n=43) to be male

Of the most
common cancers in the world is oral cancer. 267,000 new cases and 128,000
deaths globally are reported annually. Two thirds of these cases are reported
from developing countries1. One of the lowest 5 years survival
rates is for oral cancer. 40% of all cancers in South Asia are diagnosed to be
oral cancers. In the Indian subcontinent, the incidence of oral cancer is very
high at about 3–7 times more than in countries with more resources. Our country
along with our neighbor India is at the top in the prevalence of oral cancer in
the world. Furthermore, we remain to be the population with oral cancer being
the most common cancer among the male population. Oral cancer is the third most
common cancer in India after cervical and breast cancer among women. The
age-standardized incidence rate of oral cancer is reported at 12.6/100,000
people. Reasons that can be attributed to the amplified prevalence of oral
cancer in the Indian subcontinent include high exposure to sunlight due to
farming, smoking, and other smokeless tobacco habits, alcohol, spicy food, and
neglect of overall oral health. It is said that one-third of all oral cancers
are preventable and one-third of them occur due to risk factors. 2

Screening for oral cancer is one of the most important but
overlooked factor in early diagnosis of the disease.

Questions included in the knowledge section were fairly
basic and to be expected from house officers. Data analysis showed that only 1
participant was able to get a cumulative score enough to come in the above
average knowledge category. 57.7% of the participants scored in the average
knowledge category while almost half of this figure was below average at
30%.  A 10% of the participants remained
in the poor knowledge category. These are alarming figures as the questions
were designed to be simple and basic.

Almost half of the participants considered their knowledge
to be insufficient regarding oral cancer screening methods. Keeping in mind
that these are all fresh graduates in their house job, which means they have
not even left their institutes this is not comforting. Strong educational
intervention is advised in the undergraduate curriculum.

A strong majority of the participants (81.5%) felt
inadequately trained to screen patients for oral cancer. 71.5% felt they were
adequately trained to perform a proper lymph node palpation. 7.7% didn’t think
it was necessary to perform a complete oral cavity examination other than
palpation of lymph nodes routinely in patients. There is a strong need for
improved training regarding screening methods for oral cancer, as was indicated
by 95.4% of the participants, while an even greater 97.7% showed interest in
getting more information on oral cancer screening.

An astounding 43.1% said they were never taught any oral
cancer screening procedure during their bachelor`s program.

In the practice section of the questionnaire, 54.6% said
they didn’t practice complete oral cavity examination in patients
routinely.63.1% said they didn’t routinely practice screening for oral cancers
in high risk patients. 48.5% said they routinely performed lymph node palpation
in high risk patients. 17.7% said they don’t keep patients with oral lesions on
follow up.

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