July 1, 2003
by Dr. Bohdan Kryshtalskyj, BSc., DDS, DOMSA, MRCD(C), FACD, FADI
As an oral and maxillofacial surgeon, I want to bring to the readership’s attention an issue of great importance to the public as well as to the profession. It involves the unilateral government withdrawal of funding for the interpretation of oral pathology tissue biopsies and subsequent detection of oral cancer.
Oral cancer kills approximately 3,000 Canadians annually, however, we know empirically that the chances for survival improve greatly with early detection and prevention. Early diagnosis is the key. The survival of oral cancer patients depends most importantly on the stage of disease at the time of diagnosis. The five-year survival rate after early diagnosis is about 80 percent. This rate plummets to 20 percent after a late diagnosis. There is little improvement in the 50 percent five-year survival rate of Squamous Cell Carcinoma patients over the last 40 years. This is largely attributed to detection of the tumour at a time when local/regional spread has already progressed.
Dentists play a vital role in the diagnosis and treatment of this disease. Dentists are in the best position to detect symptoms of oral cancer. It is rare that physicians conduct as thorough an examination of the mouth as dentists can. In fact, studies worldwide conclude that “the detection of oral Squamous Cell Carcinoma during a non-symptom-driven screening exam resulted in a lower clinical stage of tumour and that this event is more likely to occur in a dental office.”
Pre-malignant lesions such as leukoplakia, erythroplakia, erythroleukoplakia, hyperkeratosis with dysplasia, dysplasia and carcinoma in-situ which are prevalent in 29 out of 1,000 patients. Seven percent of all leukoplakia and up to 26 percent of clinically suspicious oral leukoplakias can be diagnosed by biopsy as severe epithelial dysplasia or squamous cell carcinoma.
In the United States, states such as New York, Maryland, North Carolina, and Kentucky the government has instituted significant cancer detection and treatment programs. Furthermore, they have encouraged programs regarding smoking cessation therapy and awareness. Yet in spite of compelling evidence of the importance of early detection, as of April the 1st of this year, Cancer Care Ontario is no longer funding the interpretation of oral pathology biopsies specimens at either the University of Toronto or the University of Western Ontario.
For many years, this vital biopsy service has been partly supported by Cancer Care Ontario. Under the OHIP schedule of benefits, the interpretation of biopsy material submitted by dentists including dental specialist, is not an eligible benefit for the medical pathologist. Historically the two dental schools have been subsidizing this cost to the patient. However, budgetary pressures make this level of continued support impossible. As a result, both universities now have to charge a fee of $94.12 per biopsy to the submitting dentist or dental specialist for the service. This cost must then be recovered from the patient, or the patient’s insurance company by the dentist.
The implications are serious. Any patient undergoing a biopsy, even cancer unrelated, to teeth or gingivae by a dentist from any office in Ontario no longer has access to publicly funded microscopic interpretation of this tissue by a pathologist.
This lack of government funding has serious consequences for the public. This invaluable diagnostic tool will now no longer be available EQUALLY to all of our patients. This is happening at a time when the provincial government, as recently as three months ago, made a public pledge to expand Cancer Care across the province to improve access to care. Thus a two-tier system is instantly created.
THOSE WHO CAN PAY FOR THE BIOPSY TEST — THOSE WHO CANNOT
There is another terrible irony in this cutback. At a time when the dental profession is striving to make oral cancer examinations a routine and annual procedure for the protection of our patients, and epidemiological data point to early detection of localized lesions as the important approach to decreasing morbidity and mortality, the government is making it even more difficult for the public to access the diagnosis and treatment of dentistry’s No. 1 killer. People in northern regions such as Natives and Innuit, will no longer have this care. People who are needy and subsidized by government funding such as CINOT, and the Welfare programs will no longer have this care. We need a publicly-funded system, not a system that only the rich and privately insured system and only the privileged can access with a cheque book.
I believe it is important for our profession to demonstrate leadership on this issue. We have an opportunity to make a significant difference simply because it is the right thing to do based on sound humanitarian grounds. Letting go of government funding for biopsies is not in the public interest! Early detection is. I urge you to write to your MPP and encourage his/her support for the expert oral pathology services that the general public has recently been deprived of.