The Potential Role of Telemedicine in Early Detection of Oral Cancer: A Literature Review.

The 5-year survival rates of oral cancer have not improved significantly since many decades. It is believed that "diagnostic delay" plays a critical role in determining the prognostic outcomes. At present, the coronavirus disease (COVID-19) pandemic has led to drastic changes within a short period of time and has resulted in many serious consequences at different levels worldwide. Although it is evident that COVID-19 is a major concern when it comes to people's health, it carries with it a message of hope, a desire to survive, and an opportunity to address many unprecedented challenges. This has left the doors wide open to use "telemedicine" as an essential tool to counter the rapid shift in health-care services and to meet the high demands in different health specialties including oral medicine. The aim of this review is to explore the potential roles of telemedicine in early detection of oral cancer and to highlight both the benefits and the limitations of the available applications and technologies. The clinical applications of telemedicine show a great potential in early detection of oral cancer, but the evidence of their effectiveness is still not conclusive. This needs to be investigated, especially in the developing countries where "telemedicine" may prove to be highly valuable in the future. Copyright:

INTRODUCTION

The 5-year survival rates of oral cancer have shown only slight improvement since many decades. They may reach above 80% if cancer is detected at early stages and may drop below 30% in advanced cases. Unfortunately, most cases are diagnosed with late-stage cancer leading to high levels of morbidity and mortality eventually. This could be attributed to “diagnostic delay,” the time from the first signs or symptoms to the time of definitive diagnosis. It consists mainly of patient-related factors “patient delay,” professional-related factors “professional delay,” and system-related factors “system delay.” Ideally, these factors should be controlled, targeted, or modified in different circumstances. However, cancer is a heterogeneous disease having a wide range of biomolecular and morphological make-up with various clinical presentations mimicking the appearance of innocuous lesions or conditions. These “cancer-related factors” are beyond our control. At present, the coronavirus disease (COVID-19) pandemic represents unprecedented challenge and a serious natural disaster affecting people worldwide. Sadly, the widespread of the disease has resulted in tragic loss of millions of lives and in deep impact on the human physical, mental, and social well-being at different levels. On the other hand, COVID-19 pandemic has made the doors wide open to use “telemedicine” like never before. The application of telemedicine in disasters was first reported in the mid-1980s, but the current advanced telecommunication technology made it more appealing to apply telemedicine to meet the high demands of health services and to counter the major disruption caused by COVID-19. As a result, these services have shifted rapidly and dramatically. Multiple waivers implemented to facilitate the acceptance of telemedicine by law.[1] Medical insurance companies changed some policies gradually. Some professional organizations proposed emergency guidelines on the management of head-and-neck cancer patients to avoid any delay during COVID-19.[2] This review aims to explore the potential roles of telemedicine in early detection of oral cancer and to highlight both the benefits and the limitations of the available applications and technologies described in the literature.

TERMINOLOGY

The World Health Organization (WHO) defines “Ehealth or e-health” as the use of information and communication technologies (ICT) for health and health-related fields. The wider spectrum of e-health applications includes telemedicine/telehealth. Telemedicine was introduced to the scientific literature in 1970s. There is no universally accepted definition of telemedicine because ICT keep evolving continuously. The American Telemedicine Association (ATA) defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status.” Both WHO and ATA use “telemedicine” and “telehealth” synonymously and interchangeably, although “telemedicine” is more commonly used. Sometimes, “telemedicine” is strictly used for remote clinical services provided by health professionals only, while “telehealth” refers to remote nonclinical services such as preventive care, administrative meetings, and education.[3] The American TeleDentistry Association defines teledentistry as “The use of electronic information, imaging, and communication technologies, including interactive audio, video, data communications as well as store and forward technologies, to provide and support dental care delivery, diagnosis, consultation, treatment, transfer of dental information and education.” “Teledentistry” was introduced in 1994. It has improved access to oral health care with reduced time and cost, especially for rural areas and underserved population. This could minimize health disparities and rural-urban health gaps. The delivery of clinical oncology services from a distance for diagnosis, treatment, and patient follow-up using information and communication technology is called “Teleoncology.”

PATIENT-RELATED FACTORS

The “patient delay” is the time interval between the patient first noticing signs and symptoms to the time of the first consultation with a health-care provider. Hence, the first and the most critical step starts with patients in many circumstances. Patient-related factors account for approximately 60% of the diagnostic delay of cancers and patient delay could range from 1.6 to 5.4 months.[4] The prognosis may worsen significantly if patient delay exceeds 3 months. About 30% of oral cancer patients take more than 3 months before their first consultation with a health-care provider.[5] These differences could be related to socioeconomic levels, cognitive, and psychological factors. Some patients seek medical attention only if problem severely disturbs their lifestyle functionally or aesthetically. Patients may lack knowledge, awareness or may be in denial or fear of the seriousness of the problem. They may also be under the misconception that dentists are for teeth and gums only.[6] Some patients may avoid visiting their doctors because they found it hard to talk to.[7] Furthermore, treatment could be delayed or rejected by patients who prefer trying traditional medicine or herbal remedies. Mobile Health is clearly beneficial nowadays since two-thirds of the world's population own mobile phones.[7] Telemedicine shows high acceptance levels among patients and health-care providers.[8] It helps in identifying patients at high risk, improving accessibility to health-care, controlling diseases, starting initial treatment, avoiding complications, arranging efficient referrals, providing emotional/social support, and minimizing any delays and travel cost especially for underserved patients population in rural areas where there is a shortage of health-care providers.[9] Telemedicine may prove to be a safe alternative in providing health services to control not only uncommunicable diseases but also communicable diseases like COVID-19. Patients' attendance was reported to improve 11%, while medication adherence 22%.[7] Many studies reported positive results using internet-based preventive and smoking cessation programs. Telemedicine could also be used in oral cancer screening programs. The currents smartphones technology enables patients to take high-quality pictures by themselves and to make teleconsultation in a time-efficient manner. However, self-examination of the oral cavity could be challenging for elderly patients, pediatric patients, and patients with disabilities, particularly, if the suspicious lesions are located far posteriorly in the oral cavity. Telemedicine may be too sophisticated or not user friendly for some patients because of age, level of education, computer literacy, digital literacy, unawareness, lack of interest, high expectation, and language barriers.[10] Patients were reported to have a positive first impression, but not necessarily for the rest of their experiences. Electronic communication could be perceived as lacking “empathy” in comparison to personal contact.[11] Patients tend to complain about their doctors' poor communication skills regardless of their clinical competency. Formalized communication program has been developed to minimize patients' complaints and to reach higher satisfaction levels.[7] Informed consents should cover any possible technical failures affecting diagnosis and/or treatment.

PROFESSIONAL-RELATED FACTORS

The “professional delay” is the time interval from the first consultation with a health-care provider to the final histological diagnosis of cancer. Like “patient delay,” the average time caused by professional delay may be different from one country to another. In fact, it could be different from one region to another within the same country. The range of professional delay was reported to be from 5 to 21 weeks.[12] The cut-off point of professional delay was estimated to be 6 months after which the prognosis may worsen significantly.[5] The possible causes include lack of knowledge and experience, inadequate clinical examination, low index of suspicion, co-morbidity, poor treatment planning or follow-up, inefficient referral system, and biopsy processing time. At present, the gold standard in screening oral suspicious lesions is the conventional oral examination, while the gold standard in the diagnosis is the scalpel biopsy. Several adjunctive diagnostic technologies have been developed in recent decades to aid in detecting oral cancer at early stages. Professional delay could be avoided with proper use of scientific knowledge and diagnostic tools. The importance of early cancer detection must be emphasized at the undergraduate training level. Telemedicine opens many nontraditional doors in dental education. This has become the role and not the exception during COVID-19 pandemic, since remote teaching and learning are getting more popular worldwide along with continuing education programs, teleconferencing, scientific research, quality assurance, and proficiency testing by many professional authorities. It helps in improving health-care accessibility, identifying high-risk patients, managing referrals, and providing preventive and remote therapeutic support at a reasonable cost, especially for the newly graduates working in rural areas.[13] This could be beneficial for developing countries. Telemedicine has been widely accepted method to ensure safety of both patients and health- care providers amid COVID-19 pandemic and to assist patients in receiving consultations, urgent treatments, or follow-ups. Fairness and equity in the delivery of health-care services necessitate implementing various guidelines during COVID-19 pandemic based on high-risk patients' prioritization. The highest priority will be given to those patients who have rapidly growing tumors with expected excellent prognosis after treatment. In contrast, those patients who have slowly growing tumors or those elderly patients with advanced stages of cancer, when a cure is improbable, will be given the lowest priority.[11] Telemedicine has received a level of satisfaction among health-care workers. Strengthening of the professional-patient relationship could be achieved using remote communication, even in those emotionally challenging situations where bad news are carried out to patients or their families.[14] Some clinicians may consider remote communication with patients as “impersonal care” or more challenging relatively to direct personal contact. Professional limitations may also include lacking of licensing, having language barriers, being technically-challenged, or concerned about diagnostic accuracy, unfair competition, medicolegal, and copyright issues.[10] The clinical findings must be correlated with the histopathologic evaluation to confirm the diagnosis. The College of American Pathologists defines the turnaround time (TAT) as “the time from the day the specimen is received in the lab to the day the final report is signed out.” For most routine cases, the TAT should be within 2 working days.[15] The first example of “Telepathology” goes back to the late 1960s. However, the term “Telepathology” was introduced in 1986, and it has become a rapidly growing field currently.[16] The ATA defines “Telepathology” as “a form of communication between medical professionals that include the transmission of pathology images and associated clinical information for the purpose of various clinical applications including, but not limited to, primary diagnoses, rapid cytology interpretation, intraoperative and second opinion consultations, ancillary study review, archiving, and quality activities.” There are many other terms used interchangeably to describe “Telepathology” including digital microscopy, remote robotic microscopy, video microscopy, virtual microscopy, and telemicroscopy. The Armed Forces Institute of Pathology showed that telepathology could be a reliable method.[17] Due to COVID-19 pandemic, the accumulative efforts of the College of American Pathologists, the Food and Drug Administration, and other national agencies in the USA have changed the current regulations that limit remote review of pathology slides. As a result, a temporary waiver was issued to allow remote “sign out” by pathologists. Several privacy and security guidelines have been developed by some organizations such as the ATA, the Canadian Association of Pathologists, and Royal College of Pathologists.[18] There is a trend among medical schools in the United States to offer digital pathology courses and to build virtual slide laboratories for trainees to acquire nontraditional set of skills and experience.[19] It forms an effective platform for interprofessional communication. It also allows reviewing virtual slides by many pathologists or pathology trainees simultaneously by replicating sections even from too small biopsies for training, assessment, and examination purposes. However, telepathology needs converting microscopic glass slides into digital slides before transmission, the original quality of the image could be lost or degraded, and the data files would be large to transfer. International standards are yet to be established.[20] Although telepathology is growing rapidly, its adoption still needs to be improved and integrated into the standard practice of pathology. The cost of these high-end imaging systems and the telecommunication technology required could be very crucial factors, especially in developing countries. The main barrier seems to be “a resistance to change among the humans rather than the limitation of the machines.”[20]

SYSTEM-RELATED FACTOR

The “system delay” describes delay caused by scheduling, referrals, and other administrative procedures within the time interval from the first contact with a health-care provider to the start of the treatment. Improving the accessibility of a health-care system, maintaining an effective referral system, and minimizing any scheduling delay are very essential components of a high-quality health-care system. The benefits or limitations of telemedicine should be compared to conventional alternatives and nontelemedicine health-care services, as the gold standard. The objective is to have a full Integration with the routine health-care system where telemedicine is comparable to face-to-face care or in-person care. Most of telemedicine studies were descriptive, pilot projects, or short-term outcome studies done in health centers, hospitals, universities, and dental schools. Only few studies reported in the developing countries.[21] There is no conclusive or consistent evidence about the effectiveness of the cost and long-term use of telemedicine. This could make it harder for policy makers to make reliable decisions based on a solid foundation.[17]

CANCER-RELATED FACTORS

Squamous cell carcinoma is the most common histopathologic type, accounting for 90% of oral cancer cases. The most common site is the lateral border of the tongue. The tumor site may have a prognostic value, since further delay is expected for those tumors located posteriorly. The diverse clinical manifestations of oral cancer could be deceiving to untrained eyes.[222324] What appears to be morphologically normal tissue under the microscope could have genetic or epigenetic changes that increase the risk of developing cancer in the surrounding tissue of the primary cancer site, “Field Cancerization.” Telemedicine could form an interactive network not only for remote diagnosis, consultation, close monitoring, education, but also for scientific collaboration to have better understanding of carcinogenesis mechanisms and the natural behavior of cancer. Altogether, this will help in building better standards of care and in providing a more positive impact on cancer prevention, diagnosis, and treatment eventually.[2526]

CONCLUSION

In summary, the clinical applications of telemedicine could be used in early detection of oral cancer. But the evidence of the effectiveness of such potential benefits is not yet conclusive. The lack of standards and the resistance to change may represent major challenges in catching up with other telemedicine applications in different specialties. The driving forces behind telemedicine are mainly the needs of both clinicians and patients and not technology alone. This has been clearly exemplified nowadays by the deep impact caused by COVID-19 pandemic and the huge shift toward patient-centered health services using telemedicine. Further investigations are needed in the future to address the effectiveness of health-care services via telemedicine considering the unique differences among communities in both developing and developed countries worldwide.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.