Oral Cancer Early detection and prevention program using mhealth approach

1. Estimating the proportion of population at high risk for oral cancer. Long term surveillance is important in oral cancer and this will help follow up patients at risk over the years. In populations where high risk is identified need based screening can be carried out in other populations with a similar socio cultural milieu
2. Attrition rates for different steps of screening i.e. field level, field to PHC, adherence to chemo prevention and tobacco cessation advice as well as secondary or tertiary care referral advice.
3. Assess the role of Frontline Health providers (ASHAs Accredited Social Health Activist) as a primary contact to facilitate early detection and timely referral.

The overall survival of Indian patients with oral cancer is 20-25% lower than patients in developed countries. Biocon Foundation integrated its mHealth approach (mobile health) for early detection of oral cancer into the health care delivery system in association with Government of Karnataka under the project “Screen and Treat”- Oral Cancer. This was a scale up module of the existing mHealth approach which has been running since 2011 with a reach of 60,000 people. Screening included oral examination of all adults aged over 18 years with record of patient’s demographics [&] habit history and Treatment included chemo preventive medications for Oral Potentially Malignant Disorders (OPMDs) and a provision to refer advanced cases to nearby tertiary center. Two Primary Health Centre, representing Northern and Southern Karnataka were randomly selected. Accredited Health Social Activists (ASHA) were trained to identify Oral Potentially Malignant Disorders (OPMDs) by oral examination and facilitate Electronic Data Capture on digital sheets. Patients with lesions were referred to the Primary Health Centre (PHC) where a coordinator at a designated Non-Communicable Disease Desk performed general health checkup, captured the photos of the oral lesions by a mobile phone, uploaded the data and counseled the patient for tobacco cessation. This data is viewed by a remote specialist who advises a management plan. 3930 people were screened over 3 months. 67% (2638) were positive for usage of tobacco and 83% (2201) with habit were positive for oral pre-cancerous lesions. Most lesions were found in the cheek and with 40% (872) presenting with a white patch 872(40%), followed by a white and red patch 506 (23%) and 105 (5%) with restricted mouth opening. Cost of screening per person was Rs 59. Biocon Foundation’s innovative approach ensured a digital record for long-term surveillance, improved patient compliance and was cost effective. Screening of all adults improved awareness, triaged the high-risk group and established e-Health records for the entire village in resource-constrained settings. Chemo-preventive drug aided in reversal of oral lesions and improved self-care of the high-risk group. Capacity building of ASHAs, facilitated timely referral, long term monitoring and integration with other healthcare deliveries.

Diagnosis is often delayed in marginalized at-risk populations living in rural areas with lack of access to primary health care, low health literacy, and poor adherence to follow up. There is significant need to create referral pathways from primary to secondary care and their effects on delay in diagnosis and stage of presentation for OSCC. Efficient diagnosis and management strategies for early stage OSCC and pre-malignant lesions often require a specialist’s input. In rural and resource restricted settings there are few primary healthcare providers and even fewer specialists. Using the mhealth system, local healthcare worker can screen patients in rural areas, obtain triage guidance, and send images to specialists. Remote specialists can guide non-specialists to identify suspicious lesions, narrow differential diagnoses, decide on biopsy and follow up strategies for early stage oral cancer and pre-malignant lesions.
This input from specialists can be extremely valuable to the non-specialists in rural settings for early diagnosis of OSCC. The cost of screening per person using this platform is Rs 58. It is therefore a cost effective screening module which requires low skill and resources and can be scaled up in partnership with government and community based organizations