Abstracts

Introduction

According to the GLOBOCAN 2020 database from the International Agency for Research on Cancer (IARC), an estimated 500,000 oral and oropharyngeal cancer cases occurred worldwide in 2020. This disease has a high incidence in South and Southeast Asia and the Western Pacific. Yet, countries like Brazil, United States, and several European nations also report expressive numbers ¹1. Rutkowska M, Hnitecka S, Nahajowski M, Dominiak M, Gerber H. Oral cancer: the first symptoms and reasons for delaying correct diagnosis and appropriate treatment. Adv Clin Exp Med 2020; 29:735-43.. Oral and oropharyngeal cancer predominantly affects men ¹1. Rutkowska M, Hnitecka S, Nahajowski M, Dominiak M, Gerber H. Oral cancer: the first symptoms and reasons for delaying correct diagnosis and appropriate treatment. Adv Clin Exp Med 2020; 29:735-43.^,22. Gormley M, Gray E, Richards C, Gormley A, Richmond RC, Vincent EE, et al. An update on oral cavity cancer: epidemiological trends, prevention strategies and novel approaches in diagnosis and prognosis. Community Dent Health 2022; 39:197-205., often leading to late-stage diagnoses, elevated mortality and morbidity rates, high treatment and rehabilitation costs, and significant social burden ³3. Walsh T, Warnakulasuriya S, Lingen MW, Kerr AR, Ogden GR, Glenny AM, et al. Clinical assessment for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev 2021; (12):CD010173.^,44. Hertrampf K, Jürgensen M, Wahl S, Baumann E, Wenz HJ, Wiltfang J, et al. Early detection of oral cancer: a key role for dentists? J Cancer Res Clin Oncol 2022; 148:1375-87.. Control of risk factors and early detection remain the most effective strategies for preventing oral and oropharyngeal cancer and increasing survival rates.

Primary prevention, aimed at averting disease onset, includes public education about risk factors such as discouraging tobacco use, limiting alcohol intake, promoting sun-safe lip protection, advocating for HPV vaccination, and emphasizing the importance of a healthy diet ²2. Gormley M, Gray E, Richards C, Gormley A, Richmond RC, Vincent EE, et al. An update on oral cavity cancer: epidemiological trends, prevention strategies and novel approaches in diagnosis and prognosis. Community Dent Health 2022; 39:197-205.^,55. Zamani M, Grønhøj C, Jensen DH, Carlander AF, Agander T, Kiss K, et al. The current epidemic of HPV-associated oropharyngeal cancer: an 18-year Danish population-based study with 2,169 patients. Eur J Cancer 2020; 134:52-9.^,66. Nielsen KJ, Jakobsen KK, Jensen JS, Grønhøj C, Von Buchwald C. The effect of prophylactic HPV vaccines on oral and oropharyngeal HPV infection: a systematic review. Viruses 2021; 13:1339..

Secondary prevention focuses on early diagnosis which is paramount in identifying early-stage oral and oropharyngeal cancer and oral potentially malignant disorders ⁷7. Abati S, Bramati C, Bondi S, Lissoni A, Trimarchi M. Oral cancer and precancer: a narrative review on the relevance of early diagnosis. Int J Environ Res Public Health 2020; 17:9160.^,88. Nagao T, Warnakulasuriya S. Screening for oral cancer: future prospects, research and policy development for Asia. Oral Oncol 2020; 105:104632.. Given its silent onset, many patients only seek professional help when experiencing pain or difficulties with eating, speaking, or swallowing, contributing to delayed oral and oropharyngeal cancer diagnoses ¹1. Rutkowska M, Hnitecka S, Nahajowski M, Dominiak M, Gerber H. Oral cancer: the first symptoms and reasons for delaying correct diagnosis and appropriate treatment. Adv Clin Exp Med 2020; 29:735-43.^,22. Gormley M, Gray E, Richards C, Gormley A, Richmond RC, Vincent EE, et al. An update on oral cavity cancer: epidemiological trends, prevention strategies and novel approaches in diagnosis and prognosis. Community Dent Health 2022; 39:197-205.^,99. Thankappan K, Subramanian S, Balasubramanian D, Kuriakose MA, Sankaranarayanan R, Iyer S. Cost-effectiveness of oral cancer screening approaches by visual examination: systematic review. Head Neck 2021; 43:3646-61.^,1010. Cheung LC, Ramadas K, Muwonge R, Katki HA, Thomas G, Graubard BI, et al. Risk-based selection of individuals for oral cancer screening. J Clin Oncol 2021; 39:663-74.. Visual examination offers a simple, non-invasive, inexpensive, safe, and easily accessible method for detecting suspicious oral lesions, with diagnosis confirmation achieved by incisional biopsy ²2. Gormley M, Gray E, Richards C, Gormley A, Richmond RC, Vincent EE, et al. An update on oral cavity cancer: epidemiological trends, prevention strategies and novel approaches in diagnosis and prognosis. Community Dent Health 2022; 39:197-205.^,88. Nagao T, Warnakulasuriya S. Screening for oral cancer: future prospects, research and policy development for Asia. Oral Oncol 2020; 105:104632.. This assessment can be conducted opportunistically during routine dental appointments or as part of a screening program, which can be population-based or geared towards high-risk individuals. The latter, such as tobacco and alcohol users, might not regularly visit the dentist, rendering the opportunistic approach less effective ³3. Walsh T, Warnakulasuriya S, Lingen MW, Kerr AR, Ogden GR, Glenny AM, et al. Clinical assessment for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev 2021; (12):CD010173.^,1010. Cheung LC, Ramadas K, Muwonge R, Katki HA, Thomas G, Graubard BI, et al. Risk-based selection of individuals for oral cancer screening. J Clin Oncol 2021; 39:663-74.. Indeed, visual screening focusing on high-risk individuals ¹⁰10. Cheung LC, Ramadas K, Muwonge R, Katki HA, Thomas G, Graubard BI, et al. Risk-based selection of individuals for oral cancer screening. J Clin Oncol 2021; 39:663-74. was associated with a reduction in mortality as demonstrated by the Kerala Oral Cancer Screening Trial in India, the sole randomized study conducted on this matter ³3. Walsh T, Warnakulasuriya S, Lingen MW, Kerr AR, Ogden GR, Glenny AM, et al. Clinical assessment for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev 2021; (12):CD010173.^,1111. Sankaranarayanan R, Ramadas K, Thara S, Muwonge R, Thomas G, Anju G, et al. Long term effect of visual screening on oral cancer incidence and mortality in a randomized trial in Kerala, India. Oral Oncol 2013; 49:314-21.. Unlike breast and cervical cancer, population-based oral cancer screening has not proven to be a fully effective approach ⁹9. Thankappan K, Subramanian S, Balasubramanian D, Kuriakose MA, Sankaranarayanan R, Iyer S. Cost-effectiveness of oral cancer screening approaches by visual examination: systematic review. Head Neck 2021; 43:3646-61.^,1212. World Health Organization. Tackling NCDs: 'best buys' and other recommended interventions for the prevention and control of noncommunicable diseases. https://www.who.int/publications/i/item/WHO-NMH-NVI-17.9 (accessed on 22/Jul/2022).
https://www.who.int/publications/i/item/... .

Considering the scarcity of data concerning oral and oropharyngeal cancer prevention, as highlighted by the IARC Perspective on Oral Cancer Prevention ¹³13. Bouvard V, Nethan ST, Singh D, Warnakulasuriya S, Mehrotra R, Chaturvedi AK, et al. IARC perspective on oral cancer prevention. N Engl J Med 2022; 387:1999-2005., this scoping review sought to systematically map primary prevention and early detection strategies for oral and oropharyngeal cancer as outlined in the national cancer plans and noncommunicable disease (NCD) plans of all World Health Organization (WHO) Member States, looking for essential differences and possible gaps in prevention efforts.

Materials and methods

Protocol and registration

The study protocol was registered in the Open Science Framework (OSF) platform on July 22, 2022 (https://osf.io/89jf5), and available at https://doi.org/10.17605/OSF.IO/Z59BM. This review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR).

Eligibility criteria

Eligibility criteria were established following the Participants-Concept-Context (PCC) framework recommended by the Joanna Briggs Institute (JBI) for scoping reviews ¹⁴14. Peters MDJ, McInerney P, Godfrey CM, Khalil H, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth 2020; 18:2119-26..

Participants: adults;

Concept: cancer plans that addressed primary prevention (including tobacco, alcohol, diet, ultraviolet radiation exposure, and HPV) and secondary prevention (opportunistic examination, population-based screening, screening in high-risk individuals, self-examination, and telemedicine) of oral and oropharyngeal cancer;

Context: WHO Member States.

The main research questions, sub-questions and supplementary data table are intricately linked with the scoping review protocol registered on the OSF.

Some of the 194 WHO Member States developed subnational plans for their different regions, such as Australia (Western Australia, Northern Territory, Queensland, South Australia, New South Wales, Victoria, and Tasmania), the United Kingdom (England, Wales, Scotland, and Ireland), and the United States with its 62 units (states, districts, territories, and tribes). Thus, this study searched for cancer plans on 264 self-governing political entities or similar bodies (territories, tribes, among others) (Figure 1).

Information sources

Websites with potentially relevant documents on efforts against cancer like the International Cancer Control Partnership (ICCP; https://www.iccp-portal.org/), the U.S. National Comprehensive Cancer Control Program (NCCCP; https://www.cdc.gov/cancer/ncccp/index.htm), and the European Partnership for Action Against Cancer (EPAAC; http://www.epaac.eu/) were consulted until March 28, 2023. We set no restrictions on the date, language, or status of the documents.

Search strategy

Initial searches were conducted on the ICCP and EPAAC websites. Self-governing political entities and similar entities were selected in the “national plans” section and their most recent cancer plans and NCD plans (only available on the ICCP) were extracted. Searches on the NCCCP website were performed individually for each state, territory, or tribe, resulting in the selection of the most recent document available. Documentary search was first conducted in English and modified to match the language of the region of interest. Translation was achieved with help of the Google Translate application (https://translate.google.com). We evaluated plans in various languages, including Spanish (e.g., Chile, Cuba, Guatemala, Panama), French (e.g., Ivory Coast, Mauritania, Senegal, Belgium, Switzerland), German (e.g., Austria), Bosnian (Bosnia and Herzegovina), Portuguese (e.g., Brazil, Cape Verde, Portugal), Czech (Czech Republic), Greek and Japanese.

Selection process

Selection was performed by two researchers (M.F.P.M. and M.C.F.L.M.). Both searched for plans on the websites, determined which were potentially eligible according to the eligibility criteria, and assessed the texts in full. Most documents were in English and for those not available in English, Google Translator application aided the translation. Some plans from the same self-governing political entity were excluded due to duplicity or because they addresses specific types of cancer (e.g., breast, cervix). When more than one plan was available for the same self-governing political entity or similar entity, selection considered only the most recent. Documents were then excluded if they failed to address the following terms related to cancer: “oral”, “oropharyngeal”, “oropharynx”, “pharyngeal”, “pharynx”, “mouth”, “lip”, “head and neck”, “oral squamous cell carcinoma”, “oropharyngeal squamous cell carcinoma”, or “throat”. Of the remaining documents, only those that discussed risk factors and oral and oropharyngeal cancer prevention strategies were included. A consensus meeting was held between the researchers. Disagreements were resolved by a third reviewer (M.A.).

Data extraction

A draft-charting form developed in Microsoft Excel spreadsheets (https://products.office.com/) was used to determine which data to extract. Two researchers (M.F.P.M. and M.C.F.L.M.) independently entered the following information: document characteristics (title, type, year of publication, expiration date), access link, primary prevention strategies for oral and oropharyngeal cancer (e.g., tobacco control, limiting alcohol consumption, HPV vaccination, diet, and sun exposure protection), and secondary prevention strategies (e.g., population-based screening, screening of high-risk individuals, opportunistic screening, self-exam recommendation, and telemedicine as an aid to diagnosis). In case of disagreement, a third reviewer (M.A.) was consulted to reach a consensus. Additional strategies to reduce the oral and oropharyngeal cancer burden were also extracted.

Synthesis of results

Results were categorized according to the main public strategies. A check table featuring self-governing political entities or similar entities grouped by WHO regions was created. Plans were presented on the rows. Topics related to the sub-questions were represented in columns which enabled identifying strategies, concept reviews, and additional information are available at: https://doi.org/10.17605/OSF.IO/Z59BM.

Results

Selected plans

Website search identified a total of 743 documents. Of the 264 self-governing political entities and similar entities, some had a cancer plan whereas others presented only an NCD plan, some had both and others had none. After applying the selection criteria, 325 plans remained. Of these, 162 were excluded for not addressing the established cancer-related terms. The remaining 163 plans had their full text examined in more detail. Plans that failed to discuss oral and oropharyngeal cancer risk factors or did not list primary or secondary prevention strategies for oral and oropharyngeal cancer (n = 29) were removed. Finally, 134 plans from 124 self-governing political entities and similar entities were included in the study (Figure 2). Thus, only 124 (47%) of the 264 self-governing political entities and similar entities addressed risk factors and preventive strategies for oral and oropharyngeal cancer, including 73 national plans and 51 subnational plans (one from Australia, two from the United Kingdom and 48 from the United States) across 76 (39.2%) WHO Member States. Southeast Asia had the highest percentage of self-governing political entities and similar entities with oral and oropharyngeal cancer strategies (81.8%), followed by America (63.5%). Western Pacific (24.2%) and the Eastern Mediterranean region (23.8%) had the lowest coverage.

Characteristics of selected plans

Of the 134 documents included, 116 were retrieved from the ICCP website (87 cancer plans and 29 NCD plans), and 18 cancer plans were obtained from the NCCCP website. Of the 124 self-governing political entities and similar entities whose plans were reviewed, 62 (50%) had updated documents and 54 (43.55%) had outdated documents, defined as those with expiration dates up to and including 2023. Moreover, 8 (6.45%) featured only the publication dates. Netherlands, Niger, Palau, Indiana and the American Indian Cancer Foundation (both from the United States) presented plans with the shortest period (two years). Finland and Saudi Arabia had plans with the longest expiration date (11 years). Most self-governing political entities and similar entities presented plans with an expiration date of four years (38%). Oregon’s plan (United States) went the longest without updating (last update in 2005). Ireland had the document with the longest expiration date (2022-2032). Summary of the primary data and the link to the documents are presented in supplementary data register: https://osf.io/z59bm; protocol: https://osf.io/89jf5/.

Oral and oropharyngeal cancer preventive strategies in the plans

Preventive strategies were categorized into primary and secondary prevention (early detection) actions for oral and oropharyngeal cancer: 84.7% of the plans addressed risk factors and oral and oropharyngeal cancer-related strategies to combat them, and 46% recommended strategies for early detection (Table 1).

Primary prevention for oral and oropharyngeal cancer

Searching risk factors and primary prevention strategies for oral and oropharyngeal cancer revealed that 84.7% of the surveyed self-governing political entities and similar entities addressed these aspects, but not all of them covered all oral and oropharyngeal cancer risk factors comprehensively (Table 1). Of these, 63.7% highlighted the association between tobacco use and oral and oropharyngeal cancer, whereas 35.5% emphasized alcohol intake. HPV vaccination to prevent oropharyngeal cancer was mentioned in 54%. A healthy diet was cited as a protective factor for oral and oropharyngeal cancer by 10.5% of self-governing political entities and similar entities, whereas only U.S. states of Illinois and Oregon (1.6%) listed sun exposure as a specific risk factor for lip cancer (Table 1). Notably, 20% of the self-governing political entities and similar entities linked oral and oropharyngeal cancer only to tobacco, 2% to alcohol consumption, and 22% exclusively associated it with HPV infection. In most plans, association with HPV was related to oropharyngeal (throat) cancer, but some documents linked it to head and neck cancer and mouth cancer. Considering all risk factors, 9.5% related oral and oropharyngeal cancer to tobacco and alcohol use and 19.1% associated it to the three most cited risk factors, i.e., tobacco, alcohol, and HPV. Only Illinois linked oral and oropharyngeal cancer to the five leading risk factor: tobacco, alcohol, HPV, diet, and sun exposure (Table 2). Other associations were found in 27.6% of self-governing political entities and similar entities with oral and oropharyngeal cancer risk factors and prevention strategies in their plans. Figure 3 highlights WHO Member States with cancer plans that include information on risk factors and primary prevention strategies for oral and oropharyngeal cancer. The diverse initiatives outlined in these documents aimed at preventing oral and oropharyngeal cancer by minimizing exposure to recognized risk factors were summarized and categorized into three levels: policy-based (regulatory), system-focused (community), and awareness-driven (educational systems) (Box 1).

Secondary prevention for oral and oropharyngeal cancer

The main strategies of national cancer control programs for early detection of oral and oropharyngeal cancer were addressed by 46% of the self-governing political entities and similar entities included. Of these, 29% recommended opportunistic examination, 14.5% suggested screening of high-risk individuals, and 2.4% advocated population-based screening. Only Cuba and two countries in Southeast Asia (India and Myanmar) indicated population-based screening (Figure 4). Regardless of the type of screening, visual/oral examination was the preferred method. The recommended time interval between assessments ranged from 1 to 5 years. Regarding age, Cuba suggested the youngest age range (screening those over 15 years old) and Bhutan the oldest (over 40 years old). Providing education for the general population on oral self-examination was recommended by seven self-governing political entities and similar entities (5.6%). Of these, five (Bangladesh, Panama, Sudan, and the U.S. states of North Dakota and West Virginia) also indicate opportunistic examination for early detection, and the other two suggested population-based screening (India) and screening of high-risk individuals (Sri Lanka). Telemedicine to support oral and oropharyngeal cancer prevention strategies was only mentioned by Chile.

Notably, the cancer plans from Virginia (United States), Hungary, Palau, Thailand, and Suriname advocated training physicians and dentists to detect oral cancer lesions. India recommended screening by physicians, dentists, and community health workers, whereas the Maldives indicated screening by doctors, dentists, community health workers and nurses. In the case of state do Arkansas (United States), the recommendation extended to doctors, dentists, nurses, and dental hygienists.

Discussion

Despite WHO recommendations for the formulation or adjustment of oral health promotion and prevention policies and strategies, including for oral and oropharyngeal cancer ¹⁵15. World Health Organization. Oral health: action plan for promotion and integrated disease prevention. https://apps.who.int/gb/ebwha/pdf_files/WHA60/A60_16-en.pdf (accessed on 22/Jul/2022).
https://apps.who.int/gb/ebwha/pdf_files/... , the findings of the present scoping review indicated that a significant number of WHO Member States do not include oral and oropharyngeal cancer prevention strategies in their cancer plans and NCD plans on websites with potentially relevant documents for action against cancer: ICCP, NCCCP, and EPAAC.

Evidently, some plans may not have been included in this review due to unavailability on the platforms created for consultation. Search for non-WHO Members was unsuccessful on the websites used for data collection. We performed an additional search on government websites to identify national policies or strategies concerning oral and oropharyngeal cancer, but the lack of standardization across Health Ministries and Cancer Institutes websites in different countries and the difficulties in translating various languages resulted in an ineffective and inconsistent search process. Consequently, the present findings may not fully represent oral and oropharyngeal cancer policies or the acknowledgment of tobacco use, alcohol consumption, sun exposure, HPV infection, and unhealthy diet as risk factors, as other documents may exist in countries whose plans were not included.

Regrettably, many plans were excluded as they did not specifically address oral and oropharyngeal cancer-associated risk factors. Some plans discussed tobacco control strategies to prevent lung cancer and other diseases but did not emphasize the risk for oral and oropharyngeal cancer. Similarly, although many plans cited means to combat excessive alcohol consumption, HPV infection, and unprotected sun exposure as preventive measures against, respectively, liver, cervical, and skin cancer, they did not link these factors to oral and oropharyngeal cancer. Despite the well-established association between tobacco use and an increased risk of oral cancer, only 79 (63.7%) self-governing political entities and similar entities included here explicitly reported this link in their publicly accessible cancer plans. This does not imply that the remaining 45 (36.3%) self-governing political entities, or the other countries excluded from the review sample due to the absence of specific oral and oropharyngeal cancer references, are unaware of tobacco as a health risk factor or lacked preventive measures. Rather, it indicates that oral and oropharyngeal cancer-specific information was not included in the available documents despite covering preventive measures against tobacco use.

Among those indicating oral and oropharyngeal cancer prevention strategies, most focus on primary prevention and less than half address secondary prevention. Moreover, the plans showed a significant heterogeneity in the strategies presented.

Of the plans included in this review, only 19.1% explicitly discuss the three main well-defined risk factors associated with oral and oropharyngeal cancer, i.e., tobacco, alcohol, and HPV. Notably, only the cancer plan of Illinois cited all the well-established oral and oropharyngeal cancer risk factors, including tobacco, alcohol, HPV, diet, and lip sun exposure.

Several plans (21%) focused solely on HPV, followed closely by those that only addressed tobacco (20%). This emphasis on HPV probably stems from the progressive increase trend in HPV-related oropharyngeal cancer over the past two decades in several countries ¹⁶16. Carlander AF, Jakobsen KK, Bendtsen SK, Garset-Zamani M, Lynggaard CD, Jensen JS, et al. A contemporary systematic review on repartition of HPV-positivity in oropharyngeal cancer worldwide. Viruses 2021; 13:1326.^,1717. Bosetti C, Carioli G, Santucci C, Bertuccio P, Gallus S, Garavello W, et al. Global trends in oral and pharyngeal cancer incidence and mortality. Int J Cancer 2020; 147:1040-9., particularly among youth and men ¹⁸18. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, Curado MP, Ferlay J, Franceschi S, et al. Worldwide trends in incidence rates for oral cavity and oropharyngeal cancers. J Clin Oncol 2013; 31:4550-9.. Immunization plays a pivotal role in preventing a significant percentage of morbidity, disability, and deaths associated with cancer-causing infectious agents ¹⁹19. Sallam M, Dababseh D, Yaseen A, Al-Haidar A, Ettarras H, Jaafreh D, et al. Lack of knowledge regarding HPV and its relation to oropharyngeal cancer among medical students. Cancer Rep (Hoboken) 2022; 5:e1517.. Including HPV vaccination in the WHO Expanded Program on Immunization (EPI) has led to significant advancements in cancer prevention (Box 1). While some plans outline strategies to expand HPV vaccination programs to reduce cervical cancer incidence, limited attention is given to raising awareness and knowledge about the risk of HPV infection for oropharyngeal cancer. Remarkably, among the ten countries with the highest oropharyngeal cancer incidence, as selected by the age-standardized rate indicator for both genders on GLOBOCAN 2020 (Denmark, France, Romania, Belarus, Cuba, Hungary, Republic of Moldova, Slovakia, Slovenia and Australia) ²⁰20. World Health Organization. Global Health Observatory. https://www.who.int/data/gho (accessed on 22/Jul/2022).
https://www.who.int/data/gho... , seven overlooked HPV infection as a crucial risk for oral and oropharyngeal cancer in their plans, highlighting a significant gap in addressing the disease burden.

Tobacco use (in any form) remains the leading preventable cause for oral and oropharyngeal cancer ²¹21. Gupta AK, Kanaan M, Siddiqi K, Sinha DN, Mehrotra R. Oral cancer risk assessment for different types of smokeless tobacco products sold worldwide: a review of reviews and meta-analyses. Cancer Prev Res (Phila) 2022; 15:733-46.^,2222. Saxena R, Prasoodanan PKV, Gupta SV, Gupta S, Waiker P, Samaiya A, et al. Assessing the effect of smokeless tobacco consumption on oral microbiome in healthy and oral cancer patients. Front Cell Infect Microbiol 2022; 12:841465.. In 2003, WHO Member States adopted the first public global health treaty - the WHO Framework Convention on Tobacco Control -, adopting preventive measures against the globalization of the tobacco epidemic ²³23. World Health Organization. WHO Framework Convention on Tobacco Control. https://fctc.who.int/publications/i/item/9241591013 (accessed on 22/Jul/2022).
https://fctc.who.int/publications/i/item... . The IARC handbooks program’s first evaluation of oral cancer prevention found that tobacco smoking and alcohol consumption are the main drivers of oral cancer in most countries, with smokeless tobacco use and chewing of areca nut products standing as the leading causes in others, especially in South and Southeast Asia and the Western Pacific Islands ¹³13. Bouvard V, Nethan ST, Singh D, Warnakulasuriya S, Mehrotra R, Chaturvedi AK, et al. IARC perspective on oral cancer prevention. N Engl J Med 2022; 387:1999-2005.. Plans from self-governing political entities and similar entities in Southeast Asia were the ones that more addressed oral and oropharyngeal cancer risk factors and strategies, which is in line with the high incidence of the disease in this region ²⁴24. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009; 45:309-16.^,2525. Du M, Nair R, Jamieson L, Liu Z, Bi P. Incidence trends of lip, oral cavity, and pharyngeal cancers: Global Burden of Disease 1990-2017. J Dent Res 2020; 99:143-51.. In the Western Pacific region, however, only 24.2% self-governing political entities and similar entities presented risk factors and/or preventive strategies for oral and oropharyngeal cancer.

Tobacco control remains a critical public health priority worldwide, with numerous strategies being developed and implemented to combat the detrimental effects of smoking (Box 1). We observed interesting and different measures, some of them leveraging the impact of social media to advocate for healthy lifestyle paradigms via partnerships with influential figures, including athletes and renowned artists. This approach effectively targets youth and children by using platforms like TikTok, Facebook, and Instagram, encouraging them to adopt healthier behaviors and steer clear of smoking. Another promising approach involves using technology to develop a phone application to assist individuals in quitting smoking by providing personalized support, resources, and mechanisms, thus empowering users on their journey toward tobacco cessation. Moreover, implementing public health system strategies plays a crucial role in ensuring widespread access to evidence-based cessation programs by standardizing tobacco screening, referrals, and interventions within healthcare settings thereby enhancing the likelihood of timely and effective support for individuals, especially the vulnerable.

Most of the reviewed plans fail to mention electronic nicotine delivery systems (ENDS) and their potential deleterious effects ²⁶26. Wilson C, Tellez Freitas CM, Awan KH, Ajdaharian J, Geiler J, Thirucenthilvelan P. Adverse effects of E-cigarettes on head, neck, and oral cells: a systematic review. J Oral Pathol Med 2022; 51:113-25.. Some documents, particularly those from U.S. states, highlight the existing evidence on ENDS use not being risk-free. Conversely, the New Zealand plan advocates regulating vaping products as a means of supporting smokers in transitioning to a less harmful alternative while also safeguarding children and youth against access to and use of these products.

The combination of tobacco use and alcohol intake increases the risk of oral and oropharyngeal cancer cancer development ²⁷27. Dal Maso L, Torelli N, Biancotto E, Di Maso M, Gini A, Franchin G, et al. Combined effect of tobacco smoking and alcohol drinking in the risk of head and neck cancers: a re-analysis of case-control studies using bi-dimensional spline models. Eur J Epidemiol 2016; 31:385-93.. Surprisingly, only 35.5% of the plans focused on halting alcohol consumption to prevent oral cancer. Endorsement of WHO’s Global Alcohol Action Plan 2022-2030 emphasizes the importance of prioritizing the reduction of harmful alcohol use in public health efforts targeting oral cancer prevention ²⁸28. World Health Organization. Global Alcohol Action Plan 2022-2030. https://www.who.int/teams/mental-health-and-substance-use/alcohol-drugs-and-addictive-behaviours/alcohol/our-activities/towards-and-action-plan-on-alcohol (accessed on 22/Jul/2022).
https://www.who.int/teams/mental-health-... . While public health initiatives have successfully decreased tobacco and alcohol prevalence thus contributing to a decline in oral cancer incidence, these achievements are likely a result of comprehensive campaigns focusing on physical activity and nutrition, albeit not explicitly directed toward oral cancer ²⁹29. LeHew CW, Weatherspoon DJ, Peterson CE, Goben A, Reitmajer K, Sroussi H, et al. The health system and policy implications of changing epidemiology for oral cavity and oropharyngeal cancers in the United States from 1995 to 2016. Epidemiol Rev 2017; 39:132-47.. Promoting awareness on an individual and community-based level of the harmful effects of alcohol and its association with cancer is generally effective in discouraging consumption ³⁰30. Ahuja NA, Kedia SK, Ward KD, Pichon LC, Chen W, Dillon PJ, et al. Effectiveness of interventions to improve oral cancer knowledge: a systematic review. J Cancer Educ 2022; 37:479-98.. Based on data collected from the plans, targeted communication campaigns, social media posting, and school health programs emerge as viable measures for raising awareness and addressing alcohol consumption. Additionally, the need to strengthen intersectoral collaboration among agencies involved in alcohol intake control, including health, education, law enforcement, and policy-making, was emphasized to ensure a comprehensive and impactful approach to effectively combat alcohol consumption.

Our findings suggest that primary prevention strategies are widely addressed by the countries that cite oral and oropharyngeal cancer probably due to WHO guidelines and the recognition of the implications these risk factors have for various cancer types and other illnesses.

In embracing technological innovations, telehealth emerges as a transformative tool to enhance the effectiveness of preventive measures. Several plans, especially those from U.S. states, highlighted strategies like expanding mass media campaigns, youth-focused community efforts, HPV vaccine reminders, and electronic screening for behavioral counseling in healthcare services. Moreover, telehealth was recognized as a valuable tool for promoting smoking cessation quitlines and widely disseminating early cancer warning signs. This can be particularly relevant in places with limited healthcare access where technological innovation makes preventive strategies more accessible, benefiting a broader population ³¹31. Neri AJ, Whitfield GP, Umeakunne ET, Hall JE, DeFrances CJ, Shah AB, et al. Telehealth and public health practice in the United States: before, during, and after the COVID-19 pandemic. J Public Health Manag Pract 2022; 28:650-6.^,3232. Shaffer KM, Turner KL, Siwik C, Gonzalez BD, Upasani R, Glazer JV, et al. Digital health and telehealth in cancer care: a scoping review of reviews. Lancet Digit Health 2023; 5:e316-27..

In addition to combating oral and oropharyngeal cancer risk factors, secondary prevention strategies could improve patient prognosis by early detection of the disease and appropriate treatment provision. Cancer screening, a key aspect of secondary prevention, offers two primary benefits: reduction of mortality and morbidity ³³33. Warnakulasuriya S, Kerr AR. Oral cancer screening: past, present, and future. J Dent Res 2021; 100:1313-20.^,3434. Warnakulasuriya S. Oral potentially malignant disorders: a comprehensive review on clinical aspects and management. Oral Oncol 2020; 102:104550.. In oral cancer prevention, screening also aims to identify individuals with oral potentially malignant disorders, a group of disorders with an increased risk for oral cancer ⁷7. Abati S, Bramati C, Bondi S, Lissoni A, Trimarchi M. Oral cancer and precancer: a narrative review on the relevance of early diagnosis. Int J Environ Res Public Health 2020; 17:9160.^,3434. Warnakulasuriya S. Oral potentially malignant disorders: a comprehensive review on clinical aspects and management. Oral Oncol 2020; 102:104550.. Clinical oral examination is the standard screening method, and evidence suggests that this low-cost approach effectively decreases oral and oropharyngeal cancer mortality in high-risk populations ¹³13. Bouvard V, Nethan ST, Singh D, Warnakulasuriya S, Mehrotra R, Chaturvedi AK, et al. IARC perspective on oral cancer prevention. N Engl J Med 2022; 387:1999-2005.^,3535. Mandrik O, Roitberg F, Lauby-Secretan B, Parak U, Ramadas K, Varenne B, et al. Perspective on oral cancer screening: time for implementation research and beyond. J Cancer Policy 2023; 35:100381.. Despite WHO recommendations, oral cancer screening for high-risk groups is not classified as a “Best-Buy” intervention, which indicates high-priority interventions ¹²12. World Health Organization. Tackling NCDs: 'best buys' and other recommended interventions for the prevention and control of noncommunicable diseases. https://www.who.int/publications/i/item/WHO-NMH-NVI-17.9 (accessed on 22/Jul/2022).
https://www.who.int/publications/i/item/... .

Results revealed that most countries implementing secondary prevention strategies employ opportunistic examination, including nations with a high oral and oropharyngeal cancer rate (e.g., Australia, Hungary, and Bangladesh), the effectiveness of which during regular dental visits is hindered as individuals with risk factors for oral and oropharyngeal cancer are less likely to seek dental care leading to a phenomenon known as “inverse screening law” ³⁶36. Ford PJ, Farah CS. Early detection and diagnosis of oral cancer: strategies for improvement. J Cancer Policy 2013; 1:e2-7.^,3737. Netuveli G, Sheiham A, Watt RG. Does the 'inverse screening law' apply to oral cancer screening and regular dental check-ups? J Med Screen 2006; 13:47-50.. Consequently, opportunistic examination for early detection of oral cancer often ends up targeting individuals who are at a lower risk for the disease. Despite WHO recommendations, screening for high-risk groups was suggested only by 14.5% of the plans citing preventive measures for oral and oropharyngeal cancer. Additionally, 29% of self-governing political entities and similar entities recommend opportunistic examination and 2.4% population-based screening. Notably, 5.6% of the plans described self-examination alongside other preventive measures.

In Kerala, India, the only randomized clinical trial conducted on oral cancer screening did not initially provide evidence for mortality reduction among the general population; however, a reanalysis conducted in 2021 revealed the effectiveness of oral cancer screening when specifically aiming at high-risk individuals. Additionally, visual inspection performed by trained health professionals proved to be an effective method for early detection. These findings highlight the importance of screening high-risk populations and ensuring adequate training for healthcare providers to conduct visual inspections for early detection of oral cancer ¹⁰10. Cheung LC, Ramadas K, Muwonge R, Katki HA, Thomas G, Graubard BI, et al. Risk-based selection of individuals for oral cancer screening. J Clin Oncol 2021; 39:663-74.^,1111. Sankaranarayanan R, Ramadas K, Thara S, Muwonge R, Thomas G, Anju G, et al. Long term effect of visual screening on oral cancer incidence and mortality in a randomized trial in Kerala, India. Oral Oncol 2013; 49:314-21.^,3838. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet 2005; 365:1927-33.. According to Bouvard et al. ¹³13. Bouvard V, Nethan ST, Singh D, Warnakulasuriya S, Mehrotra R, Chaturvedi AK, et al. IARC perspective on oral cancer prevention. N Engl J Med 2022; 387:1999-2005., using risk-based models for screening could be an appropriate approach for communities with high oral cancer incidence, despite acknowledging the programmatic challenges in selecting participants. Plans of several countries endorsed this method, including Bhutan, Finland, Malaysia, Marshall Islands, Micronesia, Nigeria, Palau, Seychelles, Sri Lanka, Suriname, Thailand, Timor-Leste, Zambia, as well as U.S. states and territories such as District of Columbia, New Jersey, Guam, Northern Marianas Islands, and American Samoa.

Despite insufficient evidence supporting the effectiveness of population-based screening for oral cancer, India and Cuba, among the ten countries with the highest oral and oropharyngeal cancer incidence ²⁰20. World Health Organization. Global Health Observatory. https://www.who.int/data/gho (accessed on 22/Jul/2022).
https://www.who.int/data/gho... , endorse this strategy. Myanmar also recommends this approach despite present low incidence of the disease. This highlights the varied stances taken by countries with differing incidence rates in advocating for population-based screening.

Oral self-examination has been proposed as a simple, noninvasive procedure to facilitate early detection of oral cancer as it does not require a healthcare professional appointment. However, accurately identifying the absence of potentially malignant and malignant oral lesions is a challenge in this approach. Evidence supporting oral self-examination and remote screening is limited ³3. Walsh T, Warnakulasuriya S, Lingen MW, Kerr AR, Ogden GR, Glenny AM, et al. Clinical assessment for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev 2021; (12):CD010173.^,3939. Scott SE, Rizvi K, Grunfeld EA, McGurk M. Pilot study to estimate the accuracy of mouth self-examination in an at-risk group. Head Neck 2010; 32:1393-401..

The negative impact of cancer on a country’s health and development cannot be ignored. All governments are responsible for fulfilling the United Nations Resolution Goals - 2030 Agenda for Sustainable Development and achieving the best possible results in the fight against cancer. Implementing the necessary measures requires policy formulation based on available data, the appropriate mobilization and allocation of resources, active participation of all stakeholders and, above all, the government’s commitment to fostering education, equity in health, and initiatives to improve access and ensure comprehensive care in areas of greater vulnerability. As reinforced by the reviewed Plans, significant advances have been made in cancer prevention such as tobacco control programs and inclusion of HPV vaccination in the EPI. However, the focus on primary prevention suggests an overemphasis on individual accountability for risky behaviors. While promoting awareness and behavior change among individuals is crucial, it is equally important that governments take responsibility for improving the provision and quality of healthcare services, especially regarding early diagnosis and treatment, to maximize impact on reducing cancer mortality. Lack of balance between these two approaches can limit oral and oropharyngeal cancer prevention effectiveness.

Finally, results show that oral and oropharyngeal cancer prevention strategies were absent from cancer or NCD plans available on the consulted platforms for numerous countries. In cases where countries did recommend specific strategies, we observed significant diversity in both primary and secondary prevention actions with some critical points, such as the lack of correlation between oral and oropharyngeal cancer and the main risk factors. The impact of implementing oral and oropharyngeal cancer prevention strategies must be studied and reported over the long term, particularly in correlation with incidence and mortality data. A recent study by Martínez-Ramírez et al. ⁴⁰40. Martínez-Ramírez J, Saldivia-Siracusa C, González-Pérez LV, Zelaya FJMC, Gerber-Mora R, Cabrera OFG, et al. Barries to early diagnosis and management of oral cancer in Latin America and the Caribbean. Oral Dis 2024; 30:4174-84. point out limited implementation of oral cancer control plans as a major barrier to early diagnosis and management in Latin America and the Caribbean. It is crucial to assess the effectiveness of prevention measures in tackling the specific challenges posed by oral and oropharyngeal cancer and to monitor their influence on disease trends and outcomes. Long-term studies could provide valuable insights into the success of these strategies, contributing to refine global efforts in combatting oral and oropharyngeal cancer.

Conclusion

Our scoping review highlights that a significant number of WHO Member States do not include prevention strategies specifically tackling oral and oropharyngeal cancer in their cancer and NCD plans available on key organization websites. This should not imply an absence of an oral and oropharyngeal cancer policy in these countries, as other documents may exist. Plans indicating actions for oral and oropharyngeal cancer prevention focused significantly on primary prevention and a great variability in the presented strategies. The growing burden of this disease in many countries underlines the urgent need for enhanced public awareness and early detection efforts. Collaboration among healthcare providers, policymakers, and community stakeholders is crucial for implementing effective strategies, and our results can contribute to developing and improving cancer plans to combat oral and oropharyngeal cancer.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The manuscript is part of the doctorate thesis of the M. F. P. Marinho.

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