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The causes of mouth cancer are well understood. Tobacco use, which includes chewing as well as smoking, especially in conjunction with the excessive intake of alcohol, dramatically increases a person’s chance of suffering from the disease. It is thought that tobacco use and alcohol account for about 80 per cent of cases. People who smoke and drink excessively are up to 30 times more likely to develop the condition than those who do not. Some of the biggest users of tobacco are the ethnic communities. Chewing tobacco is a special problem because few people know that it can cause mouth cancer and other serious diseases.
We also know that early detection improves the chances of survival and allows for simpler treatment. At any one time, nearly 13,000 people in the UK are living with oral cancer. But there is much work that must be done. The profile of those suffering with mouth cancer appears to have shifted slightly in recent years, with younger sufferers and a growth in the proportion of females affected. These trends must be monitored and further research must be carried out
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As a dentist myself, I understand the important role that dentists play in detecting oral cancer. Because we recall our patients for regular check-ups, we are one of the few groups of health professionals who regularly and routinely screen our patients and are ideally placed to spot white and red patches and ulcers that do not heal—the early symptoms of the condition. So ensuring that everyone is able to access a dentist really is vital to early detection of the condition. The problems many patients face accessing NHS dentistry have been well documented and must be solved.
As important as ensuring that patients are able to access the health professionals most likely to spot symptoms of mouth cancer is ensuring that dentists are well placed to provide screening and preventive care. May 2007 saw the publication of a Department of Health report, Smokefree and smiling, which made numerous excellent recommendations about the ways in which dental teams can be trained in smoking cessation, how they can offer counselling on risk factors and refer patients to stop smoking services. We have read much about the challenges presented to dentists’ provision of preventive care by the current NHS dental contract in England, and it is imperative that the review of dental services by Professor Jimmy Steele, published today, really addresses those problems and allows dentists to engage properly in the kind of preventive care they are so well placed to provide. The report is encouraging. It said:
“Just as health is the desired outcome of the rest of the NHS, so health should now be the desired outcome for NHS dentistry, while good oral health and the quality of the service should be the benchmarks against which success is measured”.
We, as legislators, also have a role to play. The British Dental Association, along with a whole host of other organisations in healthcare, is urging us to support the tobacco control measures in the Health Bill. Those measures are targeting the point of sale display advertising of tobacco products and cigarette vending machines that can lead to young people taking up smoking. Action is required in three key areas: raising the profile of the condition; its risk factors; and the importance of early treatment would encourage more people who suspect that they are suffering with the condition to seek help. Ensuring that patients can access dental care where sufferers are most likely to be detected would improve early detection rates, giving those who suffer with mouth cancer a better chance of survival. Finally, equipping those dental professionals with the time and tools to deliver really effective preventive care could lead to fewer people smoking and drinking excessively, and suffering with mouth cancer in the first place.
7.56 pm
Baroness Barker: My Lords, one always approaches this subject knowing that the first thing one must do is to congratulate the noble Baroness, Lady Gardner of Parkes, on her tenacity on the subject and the very clear way in which she puts together the case that she wishes to make. She makes it with commendable regularity, so I thank her very much for her introduction.
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The noble Baroness is right to focus our attention on what are rare cancers. Only 1.7 per cent of all cancers are mouth cancers, so it is not a condition for which there is a national screening programme. With uncommon diseases it is most cost-effective to screen people who have an increased risk of developing them. As she set out, over many years, dental professionals have become more aware and highly trained to do preventive work and to pick out those patients who might well be at risk. Is it now possible to get dental practitioners into places where they are likely to encounter those who are in the high-risk groups who are not as likely to present at the dentist. I agree entirely with what the noble Baroness, Lady Gardner, said about free dental check-ups. I absolutely agree with that.
The noble Lord, Lord Colwyn, talked about the fact that there are guidelines for GPs on when they should think about referring people on to a mouth cancer specialist. I wonder whether there is now a case for looking at that guidance for those referrals again to see whether it is specific enough, in the same way as the guidance is to dentists about proactively setting out to identify high-risk groups.
I want to talk about pre-cancerous conditions. These are the two medical conditions that the noble Lord, Lord Colwyn, talked about which cause abnormal areas in the mouth or throat; they are harmless to begin with, but if they are left untreated, they can turn into a cancer. They are Leukoplakia and Erythroplakia.
I know from my researches that dental practitioners are well aware of these conditions; I am not sure that the awareness has yet sufficiently translated through to the general public. I wonder whether the Government have considered engaging with the dental profession to see what can be done to improve general information to the public about pre-cancerous conditions.
The noble Baroness, Lady Gardner, mentioned the British Dental Health Foundation calling on the Government to act on new research which reveals that oral screening can provide all-important early detection. I understand that the Department of Health has worked with Cancer Research UK on pilot projects in east London and north-east London, where health experts are alerting patients to predisposing symptoms, such as persistent mouth ulcers. Could the Minister in her reply give an update on this research and the likely changes in practice which may arise from it?
I understand that at last year’s Mouth Cancer Action Week, the WHO oral cancer expert called for dentists to be given greater powers to prescribe smoking cessation treatments. Would the noble Baroness say whether that is likely to happen as part of the Government’s overall strategy to bring about a decrease in smoking?
The noble Baroness, Lady Gardner, referred to the health technology assessment and its conclusion that opportunistic screening for oral cancer is probably the most cost-effective approach. Since that technology assessment was produced, I wonder whether work has gone into enabling dental practices to improve their own clinical audit and clinical governance in respect to oral cancer. The University of Glasgow has put together a template of a clinical audit, which a practice could
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My final point is that it is known that the human papilloma virus, HPV, is linked to mouth and oropharyngeal cancers. In a review of many studies, scientists found signs of HPV in just under one in four people with mouth cancer, and one in three people with of the oropharynx; HPV-16 was the most common type of HPV in these cancers. Given the welcome news last week that HPV is finally being recognised as an issue for men as well as for women—although clearly the number of women who die from cervical cancer is bigger—can the noble Baroness say whether sexual health clinics are made aware of the link between HPV and oral cancer? Furthermore, are there any protocols for ensuring that people who are diagnosed with HPV are automatically referred or advised to have a check-up with a dental practitioner?
I have not spent as much time on this subject or studied it in anything like as much detail as the noble Baroness, Lady Gardner, but I think that tonight she was right in that she invited the Minister to say how we can use the resources of dentists and other health professionals to act on what we know. We know that there are risk factors and high-risk groups, and targeting them, not just with information but also regarding prevention, has to be the way forward. It is therefore reasonable for her department to adopt a strategy for something which is, after all, a treatable condition provided that it is caught early enough.
8.05 pm
Earl Howe: My Lords, I believe that we owe my noble friend Lady Gardner a considerable debt for alerting us to the issue that she has raised this evening—and not only this evening but on numerous occasions over the years. As a dentist, she is of course perfectly placed to tell us about the incidence of mouth cancer and the importance of early detection, and I, for one, found her warning messages on that score extremely salutary.
Oral cancer, as has been said, is a term that embraces a number of different cancers affecting the inside of the mouth. It is not one of the commoner cancers in this country; nevertheless, it is a significant one. About 5,000 people a year are diagnosed with it, and it kills more people than cervical and testicular cancer combined. However, it is significant in another sense as well, because a great many people have never even heard of it and, of those who have, a high proportion do not know what the main risk factors for it are. That level of public ignorance is of concern because, in one sense at least, mouth cancer is like many others: the sooner it is detected in an individual, the better is the chance of long-term survival. Unfortunately and all too often,
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As my noble friend said, the incidence of mouth cancer is rising year on year, and, for reasons which are not understood, it is increasingly being found in younger people, especially younger women. That is quite different from the typical pattern of 50 years ago. My noble friend mentioned the main risk factors—tobacco and alcohol use—and of course we know that both smoking and drinking are causally associated with a range of cancers, not just this one. However, it is interesting to see from the figures how heavy drinking can dramatically worsen the chances of a man or a woman contracting this particular type of cancer, more so than for any other. At the same time, smoking and drinking are not the whole story. A quarter of all young people who present with mouth cancer have none of the standard risk factors. Why is that? We do not know.
Given the incidence of this cancer, the general degree of ignorance about it and the fact that it is not being detected early enough, my noble friend is absolutely right to ask whether a screening programme should be considered. Screening has of course been considered in the past. The National Screening Committee last reviewed the issue in, I think, July 2006 and decided against it. On the face of things, that conclusion seems questionable.
However, I think that we have to be quite clear about what should govern a decision of this kind. The National Screening Committee employs well established criteria when considering whether to screen for a disease. One of them is that for a screening programme to recommend itself, a simple, safe, precise and validated screening test has to be available. There is a type of dye called toluidine blue which can be used as a marker for malignancy. However, I understand that the tests that have been done with this dye suggest that it is neither effective nor cost-effective as a screening tool in a primary care setting. Another type of screening is routine oral examination, but in the general population routine screening is not seen as attractive because a high proportion of suspicious-looking lesions turn out to be perfectly innocuous. Taking a biopsy from every patient with a suspicious lesion would therefore lead to a high proportion of false-positive referrals, and many would regard that as an unacceptable price to pay for the benefit achieved.
The NSC also insists that the precise manner in which a condition develops, and the speed of onset, should be adequately understood before we start screening for it, because without this knowledge you cannot set screening intervals. These are things that we still do not know about for squamous cell carcinoma, which is the most common form of oral cancer. Nor do we know enough about the warning signs. My noble friends are better qualified than I to talk about this. With mouth cancer, there are two sorts of precancerous lesions that a dentist or doctor might spot: red ones and white ones. The red ones are rarer, but are quite good predictors of cancer; while the white ones, which are more common, are not. As yet, we do not properly
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For cancer detected in its early stages, treatment is certainly effective, if our measure of success is the five-year survival rate. However, if the cancer is at stage three or four, which it frequently is, the five-year survival rate is the same now as it was in the 1960s —in other words, pretty poor. What is more, any therapy that is given is often disfiguring and highly debilitating. Doctors admit that the protocols for the clinical management of oral cancers need to be a lot better.
So, for a number of powerful reasons, the idea of a general screening programme for mouth cancer is problematic. The committee has therefore recommended alternative strategies. One is to say that dentists should be involved directly in promoting smoking cessation and safe alcohol programmes to their patients. I would like to hear what the Minister says about that. We have heard this proposal also from Dr Saman Warnakulasuriya of the World Health Organisation.
The other is to suggest that, instead of screening the general population, which has been shown not to be cost-effective, we should target those groups of people who are most at risk and screen them opportunistically. The cost-effectiveness of this sort of screening looks a lot better. This was done in the recent research study conducted in southern India that was mentioned by my noble friend, where the targeting of high-risk groups of tobacco and alcohol users led to a sizeable increase in the rate of early detection of oral cancer. The study prompted the British Dental Health Foundation to advocate doing something similar here. I understand that pilot projects are under way already in east and north-east London, under the auspices of the Department of Health in collaboration with Cancer Research UK. It would be interesting to hear from the Minister what these projects consist of, and how they are progressing. Depending on their timescale and what results are achieved, will the Government consider rolling out the initiative to other areas of the country—and what are they are doing to improve public awareness of oral cancer generally? I am not clear whether the information initiatives mentioned by the noble Lord, Lord Warner, when he answered a Question from my noble friend in 2005, are still current.
There is an obvious point here. If there is to be any hope of implementing preventive strategies for oral cancer, GPs, and principally dentists, are in the front line. The unfortunate fact is that since the new dental contract was introduced in 2006, access to NHS dentistry has not risen, as was the intention, but fallen, as my noble friend pointed out. The contract pays dentists for performing an annual allocation of “units of dental activity”, which they must meet if they are not to find some of their income being clawed back. At the same time, the system of registering with an NHS dentist has been abolished, which has seriously weakened the ability of dentists to look after the long-term oral
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If the Government are resolutely determined to cling on to this contract, which so far they have seemed to be, something really needs to be done to address this obvious deficit in preventive oral healthcare. The Steele report may provide us with some of the necessary pointers. There has to be a way of ensuring that NHS dentistry is more available to at-risk individuals: principally, people in lower socio-economic groups and ethnic minority communities who use tobacco and alcohol. I hope that the Minister can provide us with some convincing reasons to think that we are on the right course to achieve this.
8.15 pm
Baroness Thornton: My Lords, I congratulate the noble Baroness on her work on these important matters and on the issues that she brings to the attention of the House.
I will put the challenges that we face in reducing mortality from mouth cancer into the context of improvements in the treatment of cancer as a whole and the role of the National Screening Committee. I will also address the dentistry issues.
Those who are involved in the generality of reducing mortality should be proud of the clear and impressive story of real improvement that is unfolding for cancer patients and their families. We are better at preventing, detecting and treating cancer. Among people under 75, almost 9,000 lives were saved in 2007 compared with in 1996. Unfortunately, as the noble Baroness, Lady Gardner of Parkes, mentioned, we have so far not had the same success in reducing the toll of mouth cancer on the nation’s health.
As noble Lords have mentioned, mouth cancer affects around 4,900 people each year, and around 1,700 people die from the disease. The incidence of the disease has increased by 34 per cent over the past 10 years, and the mortality rate has increased by 9 per cent. As noble Lords have also mentioned, the evidence shows that tobacco, combined with excessive alcohol, is associated with 75 per cent of mouth cancer cases. It is therefore a largely preventable disease. However, the noble Earl is perfectly right to point to the fact that the prognosis is good where symptoms are detected early. Our problem is in detection and the need for more research.
I will first address noble Lords’ points about dentists and other issues, and then come back to the pilots in east London and the north-east which the noble Earl mentioned. In fact, I think everyone who has spoken so far has mentioned access to dentists and its importance. Indeed, the Steele report is out today and is pointing us to the way forward.
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It is true that access to dentists fell when the new system was introduced, but that is being reversed and access is now up. It had grown to 27 million by September 2008 and to 27.3 million by December 2008. New services are opening, and increased investment gives us confidence that the numbers will continue to grow. However, access is still down by 0.9 million since the reforms, and we are still committed to ensuring that everyone who wants access to an NHS dentist can have it by March 2011. We absolutely accept that there is no room for complacency, and although the past two quarters show sustained growth and that new practices are opening, we know that we need to keep on the case and continue to ensure that we make progress.
We also acknowledge that the detection of mouth cancer depends on people being able to access a dentist. Earlier today, we mentioned in statements on Professor Jimmy Steele’s review of dental resources that he endorsed the measures that we are taking to improve access and made recommendations on providing information to patients on dental services that are available under the NHS. He proposes information for dentists on how to improve the quality of the care they provide, and we accept his recommendations. We are working through the financial implications of those right now.
The noble Baroness, Lady Gardner, made a point about polyclinics. As it happens, my noble friend Lord Darzi went to the Harrow polyclinic today and saw that it is providing comprehensive dental services. We are encouraging team working in dentistry, something that the noble Baroness is very concerned about and has previously raised with me. So, for example, as dental hygienists already examine their patients’ mouths when treating periodontal disease, we will consider whether their role might be extended. It might be that dental nurses, with appropriate training, also have a role here; both hygienists and nurses could conduct examinations under the overall direction of a dentist, and that would not require new legislation. The noble Baroness has raised a very interesting and innovative point that we are going to consider.
The challenge, of course, is getting people at risk to visit a dentist. Several noble Lords mentioned that. That is absolutely the challenge, and we know that people who are heavy smokers and heavy drinkers are members of the group who do not present themselves regularly for dental examinations. Accordingly, the department has concentrated on raising awareness of the risk factors and the predisposing symptoms mentioned by the noble Lord, Lord Colwyn, and the noble Earl, Lord Howe.
In 2005, the department made a grant of £100,000 to Cancer Research UK to run the Open to Mouth Cancer Campaign. Under this pilot campaign, publicity was given to the predisposing symptoms of mouth cancers—ulcers that do not heal, white and red spots on the gums and tongue—and advised people to consult a dentist, a general practitioner or a pharmacist if they considered that they were at risk. Two sites were chosen.
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In Newcastle and Gateshead, men and women over 40 who smoked and/or drank heavily were the target audience. The aim was to encourage high-risk individuals to visit a dental practitioner for a soft-tissue mouth check, using a voucher that could be collected from the local pharmacy. Early results from phase one, which ran for four months from January to April 2007, show that pharmacists gave out 205 vouchers to members of the public. Of those distributed, 66 per cent of the vouchers went to non-dental attendees, 54 per cent to smokers, and 34 per cent to drinkers. Fifty people made appointments with a dentist for soft-tissue checks. Five were referred to secondary care, and one patient remains in continuous follow-up.
In Tower Hamlets, the target audience for screening were Bangladeshi men and women over 40, especially tobacco and areca nut users. Oral cancer checks were delivered in community locations, using a mobile dental unit. The checks seem to have lead to an increase in oral cancer diagnoses at the Royal London Hospital. There were eight oral cancer diagnoses in 18 months from June 2006 to December 2007, a number usually seen in a five-year period.
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