Tiresias

“And the world will be better for this.”

Joe Darion

My friends

Today Tiresias would like to revisit oral cancer. Over 650,000 people develop oral cancer every year. Over 330,000 die every year. 2% to 5% of these have pre-cancerous lesions, mostly leucoplakia. The vast majority are in under-developed countries. The incidence of oral cancer is growing exponentially. In the developed world there is screening of people with pre-cancerous lesions, but even so, the five-year survival of oral cancer is less than 50% the US and in Australia. Even with the current state of art screening many patients present with already metastasised cancers. Those with pre-cancerous lesions, leucoplakia, attend oral medicine clinics and are screened, regularly, six-monthly. They are examined and have biopsies taken, which are sent off to pathology centres. The biopsies are prepared, then examined by a specialist histopathologist, who examines hundreds, mostly pre-cancerous specimens. There is a significant false negative rate, and not just because the histopathologist is human, but most often because of tissue sampling, and the biopsy, missing the malignant cells. And there is also, of course a significant false positive rate, which is hidden under the “better safe than sorry” cover. And then when cancer is seen or thought to be seen (Better safe than sorry – that for the histopathologist), the patient is organised to have extensive oral surgery, and oral surgery is not trivial. Furthermore, under the current state of the art, there is no intra operative edge detection. Consequently, there is either incomplete resection, or excessive excision of oral tissue, with excessively wide margins (again, better to be safe than sorry – that is for the surgeon). But taking unnecessarily wide margins in the mouth is anything but trivial. Even taking a little less normal tissue has very large consequences to the patient, for the rest of their lives. And then the 5-year survival is 50%. And this is the gold standard in the most medically advanced countries in the world. There is no doubt that this “gold standard” will be revolutionised by Optiscan’s confocal laser endomicroscopy, allowing real time, in vivo, in clinic and in the operating theatre pathology.

But what of the underdeveloped countries? What of the countries where oral cancer is common, rising, and accounts for most of the cases? They do not have the sophisticated medical infrastructure for screening, for taking biopsies and sending them to histopathological laboratories. They do not have specialist histopathologist. They do not have even the system to get the right samples across. All this requires the development of the whole medical and general infrastructure which is unlikely to take place for decades.

But there is another way. Optiscan real time microscopy can leap-frog all this and allow direct instantaneous in the field screening and diagnosis of oral cancer in developed and developing countries. This can be instituted quickly, without the development of the huge expensive and difficult medical infrastructure that would be necessary otherwise.

Optiscan confocal laser endomicroscopy would enable under-developed and developing countries to leapfrog the entire lack of medical infrastructure and enable in the field real-time screening and diagnosis of oral cancer in the entire population. How would this work? At present, to screen a patient, they need to be seen by an oral surgeon who can take a biopsy, store the specimen in an appropriate medium, and send it to pathology centre. The specimen must be sorted, it must be prepared, stained, sliced, mounted, and then examined by a specialised histopathologist, it must be reported, the report must come back the surgeon, the patient must be recalled, followed up and treated appropriately. There is no way this is possible in most countries in the world where oral cancer is prevalent.

So, how would the Optiscan alternative work? A technician or a person simply trained in using the Optiscan probe can scan the mouth. This can be done on the road, in towns and villages. There would be Artificial intelligence support which can identify suspicious spots. These instantly reviewed on-line, by a remotely located pathologist, who can be anywhere in the world. Instant diagnosis. This is the dream of Tiresias. This is what the Tiresias thinks. Tiresias wonders if Bill Gates or somebody from the Gates Foundation read HC and Tiresias.