Oral cancer is the sixth most common cancer in the world with around 300 000 new cases annually,¹ with a five-year survival rate after diagnosis of 40%.² In Portugal, there are about 1000 new cases per year and 500 deaths.² Oral cancer appears more frequently in men (2:1 ratio male / female) after the fourth decade, although it has been documented worldwide, an increased number of this cancer in younger adults and women.³

Oral cancer is a preventable disease, where smoking and alcohol, considered the main risk factors, are present in 90% of cases, both having a synergistic effect.¹

Spino-cellular cell carcinoma constitutes about 90% of cancers of the oral cavity. The most frequent sites for the appearance of squamous cell carcinoma are the lateral edges of the tongue (40%), the floor of the mouth (30%) and the lower lip.⁴

One of the levels of preventive medicine is secondary prevention. It is known that an early detection, supported by an efficient screening program, allows the correct diagnosis of potentially malignant lesions or in early stages, which allows to provide the best possible treatment and thus enable an increase in the survival rate.

There is a consensus that in oral cancer, the greater the delay in diagnosis, the more advanced the stage of the disease will be.⁴ When diagnosed at an early stage, the 5-year survival rate is 80%, a value that is opposed to 30% - 50% registered in patients diagnosed in advanced stages.⁴

Given these data, on 1 March 2014, the National Oral Health Promotion Program (PNPSO) was extended to include early intervention in oral cancer. The General Directorate of Health (DGS) warned of the need to carry out the opportunistic screening of oral cancer every 2 years in the population at risk - male smokers, 40 years old or more and alcoholic habits.⁵ A positive screening, with the identification of potentially malignant lesions, would imply the issuance of a referral diagnostic check to a professional qualified to perform the differential diagnosis of lesions of the oral cavity.⁶

By definition, an opportunistic screening is done in an individual approach and that can occur whenever the user makes use of an appointment. However, it is often overlooked, as it is yet another procedure to be carried out, among so many others, equally important and necessary, in a consultation time that is usually short. It is also known that the COVID-19 pandemic has aggravated the oral health situation in Portugal. On the one hand, according to the Report of the Court of Auditors of 2020, the activity of medical consultations in Primary Health Care (CSP), in the months of March to May 2020, decreased by 15% compared to the same period of the previous year , a reduction of 1 156 689 consultations and reduction of face-to-face consultations (-57%).⁷ Even before the pandemic, according to the 2019 Oral Health Barometer,⁸ more than 30% of Portuguese did not go to the dentist or only did so in case urgency and almost 10% had no teeth. All of these factors contribute to a reduction in opportunities for oral cancer screening.

This information leads to the question of whether it would be beneficial to implement an organized population screening for cancer of the oral cavity, as it exists for breast cancer and cervical cancer, for example.

In 2017, an intervention program in the field of preventive medicine was implemented in the Azores, the PICCOA, Intervention Program in Oral Cavity Cancer in the Azores, which aims to detect, early, pre-malignant or malignant lesions in the oral cavity and forward them, with priority, for evaluation and subsequent treatment and hospital follow-up. This is an annual screening of all men and women who, in that year, turned 40; 45; 50; 55; 60; 65; 70 and 75 years old, through a consultation performed by the dentist, at the Health Center, or through a consultation of all cases with symptoms, pre-malignant or malignant, of oral cancer, referred by medical professionals and, by filling and delivery, to each user included in the screening, an individual oral health bulletin (BISO 40+).⁹ In addition to screening, health education is also carried out, explaining the risk factors, ways of prevention, warning signs and encouraging the patient to perform self-examination of the oral cavity. In the PIPCOA¹⁰ activities report, there was a marked increase in the participation rate (16.8% in 2017 to 31.4% in 2019), 4045 users were tracked in 2017, 6032 in 2018 and 7283 in 2019. By over these 3 years, 11 cancers and 140 lesions with malignant potential were detected. These data contrast with the national ones, since from 2014 to 2019, around 440 malignant or pre-malignant lesions were detected, in a total of 8 thousand patients covered. PICCOA’s conclusions are very positive, because in addition to giving the possibility of early diagnosis of malignant and pre-malignant pathologies of the oral cavity, it provided users with greater speed in accessibility to the provision of health care and, fundamentally, proved to be a program with a strong preventive and oral health promotion component.

At the end of last year, another hope emerged, which may soon be another instrument for the early diagnosis of oral cancer, the study “Cell-free DNA: A Tool for The Diagnosis and Follow-up of Oral Cancer?” by a team from the Faculty of Medicine of the University of Coimbra, who explored the potential of liquid biopsies in the diagnosis and monitoring of patients with oral cancer.

The organized screening programs for population-based oncological diseases, in addition to promoting health through literacy and control of risk factors, allow the identification of precursor lesions of malignant situations or early stages of the disease, through early diagnosis and with the use of less aggressive therapeutic techniques improve health outcomes.

Why not transform a screening that is currently done opportunistically, with doctors who are often not trained and who have difficulty fitting in a reduced consultation time, in an organized screening?

Why not recreate what has been applied in the Azores to the rest of the country?