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Oral Cancer

Volume 573: debated on Monday 13 January 2014

Motion made, and Question proposed, That this House do now adjourn.—(Claire Perry.)

I am particularly delighted to see my hon. Friend the Minister on the Front Bench because she understands my unusual form of English, which is really quite helpful.

I must first declare a double interest as chairman of the all-party parliamentary group on dentistry and as a very part-time practising dentist. This means that I am a member of the profession that faces the detection and treatment of the appalling disease of oral cancer. Over the years I have detected perhaps seven cases among my patients. We picked them up at a very early stage, and I believe that as a result those involved were all successfully operated on and treated without disfigurement, and survived.

I recall being called in by a colleague for a second opinion on a patient who was very well known in the media. I confirmed my colleague’s opinion that the small growth behind the lower right wisdom tooth was cancer. My colleague referred him to a specialist oral surgeon. The patient then disappeared off our horizon. He did not return for regular check-ups or go to the oral surgeon. As I said, he was a famous media personality. About two years later, news reports stated that he had died in spite of late treatment involving massive oral surgery disfigurement. As we later discovered, he had not wanted to hear my advice or my colleague’s. He went to see his GP, who gave him a bottle of some green fluid to paint on the ulcer, thus allowing the cancer to grow. This sad example indicates the first problem of oral cancer—that there is insufficient awareness among the public, among general medical practitioners, and even, regrettably, within the dental profession.

Last November, there were two cancer campaigns. The campaign on prostate cancer—Movember—caught the public imagination thanks to the proliferation of sometimes quite hideous hairy growths just under the nose on predominately male faces. The other campaign was an oral cancer awareness campaign. It was very successful within the dental profession but did not catch the public awareness. This is deeply disturbing, first, because prevention and cure is possible if the disease is found easily and early, and secondly, because of the increasing prevalence of the disease.

The latest available reports and figures relating to oral cancer do not make encouraging reading. In short, the problem is worsening each year and is set to continue to do so unless decisive action is taken on a national level. Across the globe, oral cancer is now one of the 10 most common neoplasms. About 6,000 new cases of oral cancer are reported annually in the UK, with 1,800 deaths related to the disease each year. The total number of new cases per annum has been steadily rising for the past three decades, to the extent that there are now 35% more new cases a year than 30 years ago. The problem has become so acute that oropharyngeal cancer is the fastest growing cancer in Scotland and is a similar, significant problem in the rest of the UK. To quote the British Dental Association:

“No other cancers have shown such a significant increase in their incidence. Furthermore, treatment of many cancers is showing impressive improvement in survival, but oral cancer continues to have high death rates.”

As I alluded to earlier, a key factor is late diagnosis, which brings me to my first point. Public awareness would be a huge help. Yawning is really dangerous, Mr Speaker, from a dentist’s point of view. That lump—that ulcer—in the mouth, particularly if it is painless, needs to be seen by a dentist. More dentists should be aware and look at the soft tissue, not just the teeth.

The second and third factors are tobacco and excess alcohol, particularly when the two are combined. I will not dwell on them, because the Minister, the Government and previous Governments are well aware of the detrimental health factors relating to both. Dentists have a role to play, particularly in persuading their patients to give up tobacco smoking. I suspect that the Minister will enlighten us a little further on that in due course.

The fourth factor, and the one on which I believe decisive action can be taken, is tackling the human papillomavirus. It is a very large family of viruses that infect the skin and lining of the cervix, vagina, anus, mouth and throat. There are two groups. One group—HPV 6 and 11—is relatively low risk, causing laryngeal and genital warts, while the other group carries a high risk of causing cancer. They are key in causing 13 different types of cancers, but of these viruses perhaps HPV 16 is the most dangerous.

The last figures I have quickly managed to find on new cases of HPV-related cancers in the UK are from 2009, when 7,538 females and 6,484 males were affected. In 2010, 2,016 males and 2,253 females died in the UK as a result of HPV-associated cancers, namely cervical, penile, vaginal, vulval, laryngeal and oral. In UK males, the greatest proportion of those cancers involved new cases and deaths as a result of oral cancer. In females, oral cancer is a relatively close second to cervical cancer.

The number of annual cases of HPV-causing cancers in men is rising significantly. They are not just oral cancers; they cover other areas as well. Indeed, if recent incident trends continue, the annual number of HPV-positive oropharyngeal cancers may surpass the annual number of cervical cancers by 2020.

Obviously, that trend will be affected by the success of HPV vaccines, which are advocated in this country for women but not for men. That is a little odd, because it appears that fewer men than women produce an immune response to HPV infection. HPV vaccines protect against HPV infection and disease, including cancers, in men as well as women.

Australia’s policy of vaccinating both males and females is producing herd immunity. The effect on HPV diseases, including cancers, has been quite dramatic. The last chart I happened to see showed a 90% decline in the number of patients—both men and women—diagnosed with genital warts, caused by HPV, at a Melbourne sexual health centre between 1 July 2004 and 30 June 2011.

HPV plays a role in oral cancer and it is clear that gender-neutral vaccination would lead to a dramatic reduction, over time, in a number of cancers, including oral cancer. Immunising boys and girls would achieve real herd immunity for all such cancers.

The burden of HPV-associated cancers is now almost the same on men as it is on women. Men currently face a significant and rising risk of HPV-associated diseases. I therefore put it to the Minister that it is not fair, ethical or socially responsible to have a public health policy that leaves 50% of the population vulnerable to infection. Such vaccination, combined with early detection and action on smoking and heavy drinking of alcohol, could save a huge number of lives just as we face a dramatic increase in oral cancer. I repeat that the next procurement round is in the offing: the moment and the opportunity is here now.

I congratulate my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing a debate on this important issue. It is a very current one, as I responded to a debate in Westminster Hall on HPV only last week. I will return to that point.

I want to restate the Government’s commitment to making England among the best in Europe in improving all cancer outcomes, including for oral cancers. As part of that, we are committed to reducing the incidence or oral cancers, improving diagnosis rates when it occurs and of course improving outcomes for people diagnosed with the disease. My hon. Friend mentioned the fact that the earlier the oral cancer is caught, the more successful that can be.

My hon. Friend outlined the scale of the challenge and, as he said, the numbers are quite stark. In 2011, the latest year for which we have information, more than 6,000 people in England were diagnosed with an oral cancer, and in the same year, more than 1,600 people died of the disease. That is, as it were, a milestone in a significant and worrying increase in incidence since the 1970s.

My hon. Friend touched on some of the issues, and the explanation for the trend relates to changes in the prevalence of the major risk factors for oral cancer, particularly heavy alcohol consumption and smoking. It is estimated that more than three quarters of cancers affecting the upper aerodigestive tract, including oral cancers, are caused by alcohol and tobacco. There are also such factors as the chewing of betel quid, which is more common among some south-east Asian populations. That is a risk factor for oral cancer and may have contributed to the trend.

Reducing the damage done to the health of the population though smoking and harmful drinking is absolutely a high priority if we are to make progress on tackling oral cancers. My hon. Friend will be aware of some of the health initiatives that we have taken, particularly the tobacco control plan and our alcohol strategy, which we continue to pursue with some real energy.

I am grateful to my hon. Friend for raising the issue of HPV, which, as I have said, was recently a subject of interest in Westminster Hall. It is good that it is being debated so thoroughly, including in making the link to the different kinds of cancer with which HPV is associated. He will know that there is growing evidence that the human papillomavirus, which is already linked to the development of the more than 99% of cases of cervical cancer in women, is a major risk factor for about a quarter of head and neck cancer cases.

If we can reduce incidence of HPV in females through high uptake of the national vaccination programme, a reduction of other HPV-associated cancers in females and males is likely to follow, but I will pick up my hon. Friend’s good point about herd immunity. Since 2008, more than 6 million doses of vaccine have been given in the UK, with 87% of the routine cohort of girls completing a three-dose course in the 2011-12 academic year. That is one of the highest uptakes of any vaccination programme in the developed world.

I know that my hon. Friend is keen that HPV vaccination should become universal. When the Joint Committee on Vaccination and Immunisation first developed its recommendations, it concluded that should vaccine uptake among girls be high, the vaccination of boys was likely to provide little additional benefit in preventing cervical cancer in girls, which was of course the primary purpose of that vaccination programme. That result proved to be the case in the UK.

The JCVI has, however, recognised that the protection that accrues from reduced transmission from vaccinated girls under the current programme may not be provided to men who have sex with men. In last week’s debate, my hon. Friend the Member for Finchley and Golders Green (Mike Freer) introduced the idea that in some places, particularly those where a large number of people were born abroad or travel abroad, such factors are also a threat to the argument about herd immunity.

In October 2013, the JCVI agreed to set up a sub-committee on HPV vaccination to assess, among other issues, extending the programme, as a priority, to men who have sex with men, to adolescent boys or to both. The HPV sub-committee is scheduled to meet for the first time on 20 January, when it will assess currently available scientific evidence and consider what further evidence is required to advise the Committee on the suitability of possible changes to the HPV programme. Any proposals for the vaccination of additional groups will require supporting evidence to show that it would be a cost-effective use of NHS resources, as my hon. Friend would expect. Public Health England has begun preliminary modelling to assess the impact and cost-effectiveness of vaccinating men who have sex with men in anticipation of further guidance when the HPV sub-committee meets. It plans then to undertake further work to assess the impact and cost-effectiveness of vaccinating adolescent boys against HPV infection.

These are complex issues, and the development of the evidence base, including mathematical models, by Public Health England, as well as the Committee’s deliberations, will take time. That process is important for ensuring that decisions are made using the best quality evidence, so we cannot hurry it. I explored with officials the possibility of taking those decisions more rapidly, but that relates to the quality of the evidence being assessed and the necessity of building the right models. That brings with it the concerns that my hon. Friend and other hon. Members have raised about fitting in with the timetable for vaccine procurement, and on that I can give a little reassurance. Should the JCVI recommend the targeted vaccination of men who have sex with men, flexibility in the contracted volumes within the current vaccine contract may allow such a programme to be undertaken without the need for a new round of vaccine procurement, if additional vaccine is available from the manufacturer in the required quantities.

I also undertook last week to explore with officials the flexibility in our contract and the potential for extending it to give us time to negotiate different procurement arrangements in the event that the JCVI makes that recommendation for adolescent boys, who obviously comprise a much larger cohort. We are not quite certain yet, but I am fairly sure that we are getting promising signals about the possibility of flexibility in those contract negotiations. I hope that gives my hon. Friend some reassurance that if that is what the Committee recommends, we would be in a position to respond without missing an entire procurement cycle, but I will continue to look at that closely.

I want to take this opportunity to talk not just about prevention, but to remember the importance of rapid diagnosis. My hon. Friend graphically illustrated the tragic consequences of late diagnosis or of an early diagnosis being ignored. With early-stage diagnosis, five-year survival rates are more than 80%, which is very good by the standard of these things. Clearly, doctors and dentists have a vital role to play. Since 2005, the “Referral Guidelines for Suspected Cancer”, published by NICE, have supported GPs in identifying symptoms of oral cancer and urgently referring patients. That guidance is currently being updated.

Furthermore, all dentists are now aware that patients presenting for dental care is an opportunity—quite rightly, as my hon. Friend said—to assess any symptoms that might suggest oral cancer and refer them if appropriate. A new patient pathway being piloted in 94 practices—he might be aware of this—includes an oral health assessment requiring dentists to examine the soft tissue of the mouth; assess a patient’s risk factor in relation to oral cancer; and offer advice on lifestyle changes. Given what we have said about the relevance of lifestyle to the potential for developing oral cancer, that is very important. Those pilots are under way, and a great deal is being learned from them.

Once a cancer has been diagnosed, both dentists and GPs can use an urgent referral pathway to ensure patients get rapid treatment. The latest data showed that 95.5% of patients urgently referred with suspected head and neck cancer, including oral cancer, were seen by a specialist within two weeks, which is excellent progress. To ensure that patients get appropriate treatment, NHS England published a service specification for head and neck cancer last summer. This was based on NICE guidance and set out what NHS England expects to be in place for providers to offer evidence-based, safe and effective services.

The Government have committed £23 million to the radiotherapy innovation fund, which has supported radiotherapy centres across England to deliver increased levels of intensity modulated radiotherapy. That is a more accurate form of radiotherapy that reduces the risk of patients with oral cancers suffering side effects such as permanent dryness of the mouth as a result of treatment.

There is good news on research that I would like to relay to my hon. Friend. The clinical research network of the National Institute for Health Research is currently recruiting patients to 30 studies into head and neck cancer, of which five are focused on HPV-associated cancer. The NIHR also funds 14 experimental cancer medicine centres across England jointly with Cancer Research UK. Two of the centres have a disease focus on oral cancer.

I thank my hon. Friend for raising this subject. It is good that it is being brought up regularly in the House. That will illustrate to the JCVI how much interest Parliament is taking in its work as it deliberates on the potential extension of the HPV programme. I hope that he has found the debate helpful and is reassured about our commitment to reducing the incidence of oral cancer and improving the outcomes for those who are diagnosed with the disease.

Question put and agreed to.

House adjourned.