JFOA Journal

Introduction

Early diagnosis and treatment of OC can improve mortality and morbidity [17]. Prevention and early detection actions have the opportunity not only to reduce the incidence but also to improve the survival rate. This responsibility was substantially shared by dentists and physicians. In general, SCC of the oral cavity are suitable for early detection due to easily accessible for a direct oral examination; also, the disease is linked with clearly identifiable risk factors. Screening for OC may be helpful if the malignant lesion can be identified earlier and treated successfully. Oral cancer screening is a clinical examination of the oral cavity includes a visual inspection of the neck, lips, labial, and buccal mucosa, the floor of the mouth, gingiva, tongue, and palate includes palpating the lymph nodes an abnormality that lasts for more than two weeks should be evaluated for biopsy [18,19]. Previous research has shown that delayed referrals to the specialist for intervention are due to insufficient general health practitioner’s Knowledge in OC and recognition of the hallmark lesions [20]. Some of Primary Care Physicians (PCPs) and dentists misdiagnose OC with other lesions that show similar Clinical pictures [21]. However, there are barriers to early diagnosis Related to patient awareness and physician training. Several studies have been done to assess the Knowledge and Practice of PCPs and dentists about OC including Knowledge of clinical features, risk factors and practice related to oral lesions, Confirmed inadequate Knowledge including lack of awareness of risk Factors and clinical features [22-24]. The study was conducted in the UK reported that general medical practitioners fell less confident about diagnosing OC [25]. Many studies have shown the significance of evaluating the magnitude of understanding of OC diagnosis by physicians and highlighted the need for enhanced education [22,25]. Therefore, the purpose of this study was to assess mean Knowledge of PCPs on clinical features and risk factors related to oral cancer, and to determine the practice of PCPs toward oral examination and prevention of primary risk factors of OC.

Literature Review

I began looking for prior literature in January 2018 using MEDLINE, EBSCO, GOOGLE SCHOLAR databases. I used knowledge, practice, primary care physicians, oral cancer, and early detection as keywords in my research review, non-English studies were excluded. PCPs have an important role in early diagnosis of OC; they have experienced several patients with oral concerns and therefore should lead to early diagnosis and referral to the therapy expert. The prevention of OC is a crucial objective globally if this cannot be achieved; we should detect or diagnose OC in the early phases in order to successfully treat it.

Prevention and early detection of this issue need public awareness and general practitioners better education to be able to identify OC. Professional diagnostic delay in oral cancer will usually rely on the physician’s interpretation of the patient’s risk factors and clinical symptoms, a diagnostic delay is assessed by the duration of days that have occurred since the person identifies the first sign and/or symptom until a final diagnosis is achieved [26]. Study was done to explore diagnostic delay in new patients with OC indicated that the professional delay was the most related variable to the tumor stage [27]. In addition, patients with upper aero digestive tract cancer with professional delays greater than One month was noticed to have an increased risk of becoming diagnosed with latestage disease[28]. Early asymptomatic OC differs significantly from advanced cancers in their clinical pictures, and prognosis. Early detection and excision of pre-malignant lesions of OC may reduce malignant transformations [29]. Localized oral lesions less than 4 cm that have not spread to the regional lymph nodes can be treated effectively; as a result, five-years of survival rates exceed 80 percent [30].  Screening for OC might be useful, because of the easily detectable pre-cancerous lesions, early invasive cancers, and improved survival after treatment of early-stage cancers. The American Cancer Society recommends that adults aged 20 years or more who have health checks should have the oral cavity examination as part of a cancer-related checkup [31]. The American Dental Association recommends that health providers should be alert for signs of oral malignant lesions during the oral examination, especially who use tobacco or heavy alcohol consumption [32].

Many health care providers have studied the reasons for delaying the diagnosis and treatment of OC and they found that reasons could be divided into three components: patient, professional, and time of intervention [33]. Some reasons for the professional delay have been identified include previous health exposure, Lack of recognized etiological variables and inappropriate referral to specialized facilities [28]. Also, studies have indicated a lack of patients awareness as an important element in delaying oral cancer referral and therapy [34,35]. Several studies have been done to assess the knowledge and practice of PCPs and dentists about OC, including knowledge of clinical features, risk factors, and practice related to oral lesions. Previous research has assessed the expertise of dental practitioners and their behavior towards OC and whether or not dentists have the required abilities. Whereas, PCPs have a major effect in primary prevention, Most of these researches were using self-reported surveys.

Many studies were conducted to evaluate knowledge of risk Factors, among primary care physicians. the study was conducted in Turkey (2014), indicated that nearly all PCPs were recognized that tobacco use and alcohol consumption were risk factors for OC, In addition, Most participants (84%) knew that Leukoplakia and Erythroplakia was linked with pre-malignant OC [36]. Canto MT, et al. reported that all physicians who responded to the study realized that tobacco and a past personal OC lesion were risk factors for oral cancers, 40 percent properly reported that the majority of OC were detected among those 60 years and older, the majority recognized alcohol use as a risk factor, half of them reported that lip cancer was associated with sun exposure and less than one-third acknowledged low fruits and vegetable intake were a risk factor for OC, almost 60 percent realized that most lesions of oral cancer were diagnosed in advanced phases [37].

Another study was performed in England found that general dental practitioners were generally more likely to identify alcohol as a risk factor compared to medical practitioners, alcohol was recognized as a risk factor only in 45 percent of general practitioners, This was a significant difference from dentists [38]. McCready Z, et al. evaluated the approach of osteopathic medical students regarding OC, nearly 95 percent chose the right response (tobacco) when asked which is the most significant risk the factor for OC, almost 27 percent of participants were able to properly define the tongue as the most prevalent site for oral cancer, as regards the clinical side, 46 percent of students recognized nonhealing ulcers as the most prevalent manifestation of oral cancer, the vast majority of students recognized squamous cell carcinoma as the most prevalent histology in oral cancer, the study limitations were low response rate and the questionnaire was not validated [39]. Whereas, Gbotolorun O, et al. found the floor of mouth and the tongue was recognized by 80 percent of participants as OC most prevalent locations, the majority of participants responded correctly to the smoked tobacco, increasing age, were risk factors for oral cancer, 70 percent of participants acknowledged Leukoplakia as a precursor to OC [24].

Furthermore, all respondents listed tobacco as a major risk factor for OC in Jordan study, however, half of the respondents recognized alcohol, chewing pattern and human papillomavirus as risk agents, 60 percent were able to identify a previous history of SCC as a risk factor. Fewer participants identified poor nutrition (25%), immunosuppression (30%), exposure to sunlight (20%), elderly age (35%) as risk triggers of OC, concerning knowledge of the types of oral lesions/conditions that may lead to cancer, (66%) of respondents knew Leukoplakia as a pre-cancerous lesion, Erythroplakia was known by 44 % of respondents [22]. A study has been done in Saudi Arabia 2012; they found that Human papillomavirus accurately responded, by almost 39 percent, Low fruit/vegetable intake responded correctly by19 percent. Previous lesions of OC were only noted by 53 percent, 91 percent identified obesity for non-risk factors, 87 percent of participants recognized hot beverages as known-risk factors and 73 percent considered spicy foods as non-risk factors, Reasons for insufficient evaluation, 47 percent of responding claimed that reason was insufficient time, 35 percent believed that too many patients did not allow them to take a proper medical history [23]. Many studies have been conducted to review the practice and prevention of the main risk a factor of OC among PCPs. Tanriover O, et al. found around half of the participants presumed that family physicians were not skilled to perform OC examination, most of them thought that they did not receive appropriate smoking Cessation training and alcohol cessation practice [36]. As in the Presence of Canto MT, et al., reported less than 5% of doctors performed an oral cancer examination to people 40 years of age and older, In relation, onethird of physicians who did not examine patients 40 years of age or older revealed that the main cause was Lack of training [37]. Greenwood M, et al. found, most participants claimed that they regularly screened oral mucosa for cancerous and pre-cancerous lesions, for referral processes, also both groups of doctors in most instances referred to oral and maxillofacial surgery [38].

McCready Z, et al. figured, half of the respondents will refer patients to an otolaryngologist when they encounter patients with oral lesions [39]. Gbotolorun O, et al. study reported that 25 percent of PCPs ask about smoked tobacco use, also disclosed that basic oral examination was performed only by 35 percent, the Physicians in the research stated that their absence of oral examination training resulted in their behavior [24]. Jordan study Discovered, only 17% of respondents indicated that they regularly conducted oral cancer screening, whereas 62% of respondents reported asking patients about smoking habits, less than half of the participants regularly offered patients with counsel on smoking cessation and alcohol counseling [22].

Several studies were done to evaluate the practice of family physicians in smoking cessation counseling. Alomari M, et al. tend to find, only 39 percent indicated assessing patients desire to stop smoking, almost 28 percent revealed talking to smokers about counseling options [40]. Another study found that most general medical physicians did not ask about smoking only if the patient had tobacco-related symptoms [41].

With regard to barriers to smoking cessation counseling. Eldein H, et al. recognized boundaries linked to physicians and health care providers including lack of training, unavailability of time and inaccessibility of nicotine replacement treatment, whereas the four barriers linked to patients were lack of patient motivation, culture stresses, relapse and withdrawal symptoms, and the inability of follow-up, The current research showed insufficient knowledge and practice versus the positive attitude of family physicians with regard to smoking cessation counseling [42].

A series of research showed insufficient knowledge, including a lack of awareness of risk factors and clinical features. Study in Maryland Academy of Family Physicians found, gaps in knowledge and practices among participants. Only 8 percent of participants had a High knowledge of OC on both indicators [37]. Greenwood M, et al. reported that dentists were more able to detect multiple presentations of OC and pre-malignant lesions than medical physicians [38]. McCready Z, et al. estimated that nearly eighty percent of learners felt undereducated about OC [39]. Hassona Y, et al. found an insufficient degree of knowledge among health care practitioners [22]. A study has been done in Saudi Arabia revealed that relative data indicates that professionals do not have adequate knowledge of the OC risk factors or its detection and prevention [23].

For consideration of professional background and OC knowledge. The study was conducted in England (2001) found dentists were more able to detect multiple presentations of oral cancer and pre-Malignant lesions than physicians [38]. Gbotolorun O, et al., stated that no significant association of background characteristics (i.e., gender, years of training, additional qualification) with a high score of knowledge [24]. It is the same as in Hassona Y, et al. [22]. Canto MT, et al. showed that those who are new graduated have fewer knowledge scores than those who are old graduated [37].

Regarding the opinions of primary health care physicians on their education in OC. McCready Z, et al. estimated nearly 90% of participants reported that they would be interested in obtaining continuing education classes on OC topic [39]. It is the same as in Tanriover O, et al. [36] and Jaber L, et al. [23]. Study in Maryland Academy of Family Physicians found, more than 75 percent of family physicians agreed that they were properly trained to provide counsel on tobacco and alcohol cessation, more than 60 percent of respondents were willing to continue education about oral cancer [37]. Greenwood M, et al. suggested combined workshops with physicians and dentists could be useful in the future, optimizing resources and enabling shared self- improvement among practitioner members [38]. Hassona Y, et al. (2015) suggested the use of case-based strategy including medical pictures and videos, as these techniques may be more efficient in enhancing practical abilities such as identification and screening of OC [22].

Subjects and methods

A cross-sectional questionnaire-based survey was distributed to 154 PCPs. questionnaire was adopted from (LeHew C.et al, 2007), with modifications applied [43]. The questionnaire validation process has been performed by given to three experts, to assess the content and face validity, and then it was tested for reliability by a test re-test stability. The final structured questionnaire consisted of five sections: demographics characteristics, items on knowledge of risk factors for oral cavity cancer, 10 of them were risk factors, and 3 were non-risk Factors. Eleven items on knowledge of diagnostic items & prognosis of oral cancer. The section related to Practice towered Oral lesion, five items discussing opinions of PCPs about their education in OC. Furthermore, a pilot survey was conducted among 40 participants to evaluate the reliability of the questionnaire.

Sample

The sample size is calculated using OpenEpi software, which uses the formula n = [DEFF*Np(1-p)]/ [(d2/Z21-α/2*(N1)+p*(1-p)]. The total population size was 220. Therefore, the sample size was 154. The sample was gathered by simple random sampling using the electronic random number generator, in order to choose 154 participants of the numbered 220 list that includes all doctors inclusion criteria were all primary health care physicians work in PSMMC in Riyadh including (family medicine residents, specialists, consultants, general practitioners in primary care).

Exclusion criteria are including non-primary care physicians.

Ethical considerations

The ethical committee of the military service department at the Ministry of defense and research ethics committee of the research center in Prince Sultan Military Medical City (PSMMC) reviewed and approved the study. Confidentiality has been maintained throughout the study.

Data analysis

The data collected from study participants were entered using a data entry form through google forms, then it was coded in the linked excel File and transferred to SPSS software (version 24). The study scales were developed to calculate the percent of correct answers for each of the three scales included in the study (the knowledge on risk factors scale, the knowledge on diagnosis scale, and the Practice towards Oral lesion scale). These scales were tested for internal consistency using Cronbach alpha to confirm the results of the test-retest survey.

The study reported a univariate analysis of the background characteristics, as well as the items included in each scale to assess knowledge and Practice in oral cavity cancer. The evaluation of participants’ knowledge and Practice was graded in three categories, where those who achieved less than 33% of the total score were graded as low, 33-66% were graded as intermediate and more than 66% were graded as high. In addition, univariate analysis was performed to describe participants’ opinions on their education on oral cavity cancer. Bivariate analysis was used to identify possible confounders in the general characteristics of study participants. The mean values for Practice and knowledge scales were reported, as well as the standard deviation to compare the dispersion in the study data. The results included the analysis of variance (ANOVA) test to evaluate statistical significance between scales mean values and background characteristics.

Results

Of the original sample of 154 PCPs, 126 questionnaires were returned for a response rate of (81.8%). The General Characteristics of the responding PCPs are presented in Table 1. The mean age was 34.62 years, (46%) were males while (54%) were females. The majority (44%) of the participants had only an MBBS degree, while 38% are Board Certified in family medicine, only (6%) had a Master degree. Most (44%) of the participants had Experienced in Medical Practice for <5 years.

Table 1: General characteristics of study participants (n=126 participants).

Knowledge of risk factors and diagnostic items for oral cavity cancer. The percentages of respondents who replied correctly to each the question in the knowledge of risk factors is shown in Figure 1. Most participants answered correctly that the use of tobacco (97%), Qat chewing (83%) and alcohol consumption (78%) were risk factors of OC. (72%) Correctly indicated that the majority of OC are diagnosed in Advance age. Nearly half of the participants correctly identified Male gender as a risk factor. A family history of SCC and Human papillomavirus was recognized by (76%) and (56%) of respondents respectively. However, Low consumption of fruits and vegetables were only recognized by (40%), only one-third correctly identified exposure to sunlight as the risk of lip cancer. for non-risk factors, Obesity recognized by(32%). In addition, Aphthous ulcer and Consuming of spicy and hot foods were recognized by (36%) and (37%) of respondents respectively as non-risk factors.

Figure 1: Participants knowledge on risk factors of oral cavity cancer (n=126 participants).

Figure 2 shows the percentages of respondents who responded correctly to each question in the Knowledge of diagnostic items & prognosis of OC. More than 80% of respondents knew that early diagnosis of oral cancer could improve the 5-year survival rate almost two-third recognized the non-healing oral ulcer is the most strongly implicated premalignant condition of the Oral cavity. Those most common type of oral cancer is SCC that was answered correctly by (59%). When asked regarding possible OC clinical presentations (75%) of respondents identified correctly that early OC lesions usually appear as small, Painless lesions. Further, (60%) identified leukoplakia (white lesion) could be considered precursors to oral cancer. Whereas, only (37%) knew that erythroplakia is the most strongly implicated premalignant condition of the oral cavity. Roughly (60%) of respondents defined, a non-healing oral ulcer for more than two weeks is suspicious for OC. The tongue and the mouth floor are the most frequent locations for OC were answered correctly by (33%). When asked regarding the referral pattern (46%) of participants would refer the patient to the inappropriate specialty. The mean Knowledge score on risk factors was 57 (intermediate Knowledge) & the mean Knowledge score on diagnostic items was 56 (intermediate Knowledge) (Table 2).

Figure 2: Participants knowledge on diagnostic items and prognosis of oral cancer (n = 126 participants).

Practice of Primary health care physicians towered Oral lesions

With regard to the examination of the oral mucosa of patients with risk factors for OC only (5%) of participants reported that they always performed examination. In addition, (18%) claimed that they always palpate lymph nodes of the head and neck in a patient with an oral ulcer. When we asked about their action when they encounter a patient with unhealed oral ulcer more than two weeks only one-third of participants would always refer for biopsy. While (57%) of the respondents reported that they always ask patients with risk factors for OC about the smoking status. Regarding smoking cessation counseling with patients who have risk factors of OC only (32%) Would provide 100% of the time for each patient (Figure 3). The mean score of Practice was 57 (intermediate Practice) (Table 2).

Table 2: Descriptive statistics of scales included in the study (n=126).

Figure 3: Participants practice toward oral lesions (n=126 participants).

We asked physicians about their education in OC only (12%) felt that they are adequately educated in lesions of OC. Furthermore, (83%) agree that there is a need for additional education and (84%) Of the respondents would be interested in learning more about OC through educational activities (Figure 4).

Figure 4: Participants opinions about their education on oral cancer (n=126 participants).

Patterns of knowledge and practice toward of oral cancer

Only (34%) of participants had a consistently high score in an index of knowledge of risk factors, and (38%) in diagnostic items, in addition, (13%) scored low on risk factors knowledge and (21%) Scored low on knowledge of diagnostic items practice scores were calculated for each participant, (40%) scored high whereas, (14%) Ranked low (Figure 5).

Figure 5: Distribution of Participants according to Knowledge and Practice toward Oral Cancer (low indicate <33%, intermediate 3366%, and high >66% of the total score).

Comparing knowledge of diagnostic items scores by demographic characteristics

Medical degree and experience in medical practice were significantly higher knowledge scores (p<0.05). There was no statistically relevant relationship between knowledge scores and age (Table 3).

Table 3: Comparing knowledge on diagnosis items scores by demographic characteristics (n=126 participants).

 Comparing practice scores by demographic characteristics

Age and medical degree were significant (p<0.05) between participants. Whereas, experience in medical practice was not significant (Table 4).

Table 4: Comparing practice scores by demographic characteristics (n=126 participants).

Discussion

Despite progress in cancer diagnosis and therapy, oral cancer continues associated with a poor survival rate, which reflects a continuing challenge [3]. Adequate knowledge about OC is a necessity for PCPS caring for patients, to limit the relatively elevated mortality and morbidity associated with oral cancer; its early detection needs to be improved. OC prevention is a crucial global objective if this cannot be attained; we should detect or diagnose OC in the early stages in order to treat it effectively. In the present study, we wanted to assess the mean knowledge of PCPs on clinical features and risk factors related to oral cancer, and to determine the practice of PCPs toward oral examination and prevention of primary risk factors of OC.