Papua New Guinea (PNG) has been identified as having the highest incidence rates of the oral cavity and oropharyngeal cancer (OCC-OPC) in the world for the past few years . Home to a population of about 9 million, each speaking one of approximately 800 different languages, most live in rural regions where access to basic health services is often limited . Together with low literacy rates, low income, and insufficient knowledge of personal healthcare, the high prevalence of betel quid and tobacco use has been said to pose a serious threat to the health sector in PNG .
Oral cancers have challenged public health in PNG since as early as the 1950s when the cancer registry was established and able to record data in 1958 . From 1958 – 1962, a large portion (18.1%) of all cancers recorded and registered during that period were oral cancers . By 1985, betel quid was still not strongly believed to be a direct carcinogenic substance due to the lack of research and data available in PNG . However, by the year 2012, Papua New Guinea was now recognised as having the highest global incidence and mortality rate related to the oral cavity and oropharyngeal cancer .
According to GLOBOCAN, these 2012 rates would nearly double by 2030. It is predicted that by then, 144 new cases of oropharyngeal cancers (OPCs) and 1,836 new cases of oral cavity cancers will be diagnosed in PNG . Reports for 2018 support this statement, listing PNG as the country with the highest rate of lip and oral cavity cancer in the world with an age-standardized rate of 20.4 per 100,000 . In comparison, the second-highest rated country, Pakistan, has the only other double-digit age-standardized rate of 12.2 per 100,000 . All other countries ranked fall below 10.0 per 100,000 .
GLOBOCAN, however, states that these figures for PNG have been extrapolated from rates from Fiji and the Solomon Islands . The differences in the ethnic mix, as well as the gap in data collection in rural areas, leave the real prevalence of oral cancers in the country unknown , .
The major risk factors of OCC-OPCs in PNG are smoking and the chewing of betel quid, a combination of the areca nut, a part of the Piper betel plant, and slacked lime . With estimates of betel quid chewers at about 80% of the population, it isn’t unusual that oral cancer comprises about 25% of all cancers in PNG, compared to 2% in Australia .
Much of the challenges in early detection and diagnosis of oral cancers have to do with the increased privatization of dental practices, delayed diagnosis, low number of dental therapists, technicians, and only one oral and maxillofacial surgeon in the country till 2017 .
According to Dr. Barry Reed, there are four types of delays that result in late diagnosis and treatment . First is the delay in patients not seeking dental care early due to their lack of information on early symptoms . The second cause of delay is when the health worker doesn’t recognise the early signs of oral cancer, thereby delaying early treatment . The third cause of late diagnosis is the length of time it takes to arrange a biopsy for treatment to commence . And the fourth type of delay occurs when attempting treatment . Since there is a limited number of specialists and long waiting lists, many patients aren’t treated as soon as they should . The delay for most patients may take anywhere from 6 to 8 months or even longer .
Even though the government has not listed oral health as one of the priority areas in its National Health Plan, there are positive strides being made. The University of Papua New Guinea dental school has had occasional visits from specialists from Australia in a cooperative effort to train more dental professionals equipped with the knowledge and skills to bring about positive changes in their posts . In addition, there are five main policy recommendations described by Crocombe, Siddiqi, and Kamae, that would address most of the oral health concerns .
As mentioned, these recommended policies include:
Promoting population oral and general health with anti-smoking & anti-betel quid chewing .
Population oral health promotion to include salt fluoridation, affordable toothbrushes & toothpaste, school-based dental health education, dental screening & fissure sealant program .
Promoting personal dental treatment care to focus on urgent oral treatment, atraumatic restorative treatment, and routine dental care .
Health workers should be trained in dental and oral cancer screening, oral health promotion, fluoride applications, and glass ionomer sealants .
Government monitoring oral health care workers’ numbers, size, composition, and mix to ensure the most appropriate workforce .
Governments could also provide improved dental equipment, facilities, programs aimed at discouraging risk factors like smoking, alcohol, and chewing betel quid . As more people become educated, there may be a more positive shift toward personal healthcare.
In addition, Reed also proposed three key factors that may reduce delay in diagnosis . The first is the education of both health workers and the public on early signs and symptoms of oral cancer . The second is that dentists need to be upskilled in biopsy techniques . His third suggestion is that an effort must be made to reduce the three most common causes of oral cancer in PNG – betel nut chewing, tobacco use, and heavy alcohol consumption .
The battle against oral cancer is still ongoing in Papua New Guinea. Only if changes are made from the government down to each individual would we see a dramatic shift in the tide.
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