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Melanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB Division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.

Welcome. Today we’re talking about trends and oral cancer survival in Alabama. My guest is Dr. Anthony Morlandt. He’s an oral and maxillofacial surgeon and an associate professor at UAB Medicine. Dr. Morlandt, I'm so glad to have you with us today. Tell us a little bit about the current state of oral cancer. What’s the prevalence in the country and specifically in Alabama?

Anthony Morlandt, MD, DDS, FACS (Guest): Well thank you Melanie. Good morning. Alabama has long been known for being number one in things like Roll Tide football and War Eagle football. But in terms of oral and oropharyngeal cancer, we’re currently ranked as number five. We had 880 estimated cases reported in 2019, and about 180 deaths from oral cavity and oropharyngeal cancer. So a fair number. Nationwide, we see 53,000 new cases a year.

Host: Wow. That’s quite a statistic. So how are the risk factors in Alabama being examined to discover those trends and survival rates? Tell us why you think this is happening.

Dr. Morlandt: Well, it’s traditionally been thought that tobacco and alcohol act synergistically to create tumors, or at least allow for premalignant conditions such as dysplasia, which may present as a white patch or a red patch or a combination of those. That these premalignants will undergo malignant transformation due to the tobacco and alcohol influence. In 2007, the World Health Organization identified HPV, and in particular high risk subtype 16, as a causal agent responsible for the development of oropharyngeal cancer. So work out of Johns Hopkins and other important centers have demonstrated this massive upswing in new cases of oropharyngeal cancer, and actually a decrease in the non-HPV related oropharyngeal and oral cavity cases, which is probably related to smoking cessation efforts. I know here in Alabama and in most other states in the union, it’s illegal to smoke in restaurants and in bars. So we’re seeing that that has caused some improvement in those non-HPV related cases.

There are other agents that are really poorly identified and may be related to genetic polymorphism, specific alterations or mutations in the human genome. So for that reason, we’re seeing this increase in young female patients, in particular young Caucasian female patients with oral cavity cancer. The most common site for an oral cavity tumor is the tongue. So these are patients who are non-smokers, non-drinkers developing mouth cancer in their 20s and 30s. Anecdotally, that’s what I'm seeing a lot in my practice are these young patients who see a dentist regularly, who have excellent health, who don’t have vices like tobacco and alcohol, and still have HPV negative tongue cancer. So it’s a very interesting group that really warrants further investigation.

Host: Well, that is an interesting group because my next question was going to be where in the continuum of diagnostic criteria is HPV a factor in this trend? Are there higher rates of HPV in Alabama, or is this a country wide thing?

Dr. Morlandt: Well, the interesting part about an HPV infection is almost everyone is exposed to the human papilloma virus at some point. Because of that, that individual may develop antibodies and even express HPV DNA in their serum. Of all of the HPV types—the types that cause oral and genital warts, the type that cause malignancies such as oropharyngeal cancer or cervical cancer—of all of those types, there’re only a few high risk subtypes that are associated with the development of cancer. So after your body clears the HPV virus, you have to have an overexpression of these particular oncoproteins, which are called E6 and E7. If those are overexpressed, these patients can then develop by way of oncogenesis and malignant transformation can then develop the actual malignancy.

There is a spot in the transition zone between the keratinized thicker tissue, protective tissue lining the oral cavity that you might see on the hard palate and around the teeth related to the gingiva. There’s a transition between that thicker, healthier tissue, more robust, and the softer lining non-keratinized mucosa of the oral pharynx. So at that junction, which you can see by looking in your mouth as the junction between the hard palate and the soft palate, you can identify by speaking and seeing where the vibration occurs. At that junction, there’s a bit of an access point for these viral cells or these viruses to invade the normal mucosal cells. So it’s hard to pin down exactly how many patients who have been exposed to HPV will actually develop cancer because there’s so many steps in the process of oncogenesis.

Host: Then let’s talk about awareness, disparities. Not only in research models because we know that’s gone on for years, but in the availability of healthcare and awareness. Are these stratified by stage of diagnosis? Do you see that there’s disparities in more of the rural communities even knowing about the risks for oral cancers? Tell us what strategies you employ to raise that awareness and what you see happening.

Dr. Morlandt: That’s a huge part of what we do at UAB. So I started the oral oncology service at UAB in collaboration with the department of otolaryngology and the great work that they’ve been doing there for 30 years to raise awareness. My particular focus has been to engage dentists and hygienists as first line defenders and identifiers of tumors. There have been a number of papers showing that patients with an oral cavity cancer, in about 75% of cases, will see a dentist or hygienist first.

Another paper from Journal of Oral and Maxillofacial Surgery in 2003 showed that patients who are seen by a dentist or hygienist have an earlier stage of diagnosis and are treated with better long term success than a patient who is initially seen by an urgent care clinic or an emergency department. The main reason for that is because asymptomatic tumors that are picked up by a dentist or hygienist are smaller, and it sort of makes sense. If I have a neck mass and I present to my neck doctor or if I have a large tongue ulcer or a tongue fungating exophytic lesion, then my stage is naturally higher, and my survival is lower.

So because of those realities and because of the significant increase in survival in catching these tumors early, UAB Oral and Facial Surgery has reached out to the dental community by way of lectures and continuing education. Also a Watch Your Mouth campaign which has launched just this month in April we’ve handed out bathroom cards for patients to do a self-examination with nine different points where they can examine their own mouth and throats. They can palpate their own neck. We’re educating dentists and hygienists to palpate the neck to find normal anatomy. We spend a lot of time in dental schools and with medical students to make sure that dentists and physicians, whether they're specialists or generalists, have at least the basic knowledge to find an oral cavity tumor.

When you talk to patients who are diagnosed, many times they’ve been through a very long course. They’ve seen six or seven different specialists. They’ve seen generalists. They’ve had antibiotics. They may have had a fine-needle aspiration of a neck mass, and all of these efforts tend to delay diagnosis and ultimately can impact survival. When Michael Douglas, the actor, spoke at our national meeting a few years ago, he said he saw six specialists prior to having a diagnosis. He had lots of resources at his disposal. So our patients in the rural parts of Alabama who don’t have access to many physicians and maybe don’t have ways to get around easily, and especially may be underfunded or underinsured, we really have to help them make sure that when they see an individual, they're getting the very best care and the earliest opportunity for intervention.

Host: Those are some great ways of outreach. Dr. Morlandt, how do you evaluate the impact of such programs on your outcomes? What have you seen as a result of all of this hard work and outreach?

Dr. Morlandt: Yeah. It’s tough because where increased availability occurs, we have increased utilization. So the more people we have looking for oral cancers and certainly premalignant disease, the more patients who are referred. So it may seem, in the short term, like our numbers are going up. I would prefer dentists and hygienists and primary care physicians to identify stage I tumors or premalignant diseases. We would rather take care of many of those patients before they end up presenting with stage IV disease. So it’s a little tough to assess that.

I would say since our efforts began, our case volume has exponentially increased. I think over time we’ll begin to see that these patients—While the numbers we’re treating here at UAB have increased, we’re seeing that many of those are earlier stage patients, earlier stage tumors, and their long-term survival is much improved.

Host: What an interesting topic and such great information. Doctor, as we summarize, what would you like listeners to take away from this about these trends in oral cancer, and where you see it going from here. What do you think is going to happen in the next five or ten years or so?

Dr. Morlandt: So one thing to remember is unlike colon cancer or breast cancer or prostate cancer, we have no widespread screening assay. You may have a blue light used to asses tissue auto-fluorescents or tissue reflectance by your dentist, but the pretest probability has to be sufficiently high to use that test in screening. What we do see is the incidence or oral cavity cancer is still fairly low, as the eighth most common malignancy in the United States. So there’s no screening assay. I can’t order a PSA. I can't do mammography. I can't do a colonoscopy. It has to be white light visualization with a trained eye, and then a scalpel biopsy for tissue diagnosis. So it means that we typically need to assess these patients early and often. They should be seen by a specialist, and we should have a limited, very low threshold for doing a biopsy. I think if we continue to do that in Alabama, we’re number five for incidents in the country. I think we can see that number drop dramatically. That would be very satisfying that UAB could be a part of that drive statewide and even regionally in the southeast.

Host: Thank you so much for coming on. As I said, what a fascinating topic and the way that those trends work. Thank you for sharing your expertise and discussing that with us today. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for tuning in.