Lighting a spark: Global Oral Cancer Diploma program aims to advance and standardize oral cancer care worldwide

Snehal G Patel, MD, knows all too well the demands faced by world-leading experts in oral cancer care—he’s one of those specialists himself. But he considers it a privilege to edit two Global Oral Cancer Diploma program modules—Module 4: Diagnosis and workup and Module 5: Staging and outcome evaluation—and he hopes the program will ignite a spark for participants and inspire them to take up the mantle of their forebears and continue to advance oral cancer care and education. The Global Oral Cancer Diploma program is a 10-month, online collaborative initiative of AO CMF and the International Association of Oral Oncology (IAOO).

Let’s talk a bit about your background. What inspired you to pursue this career as a head of neck surgeon?

I'm a general surgeon by training, and then I went into surgical oncology as I got interested in taking care of patients with cancer. It’s very, very different when you're treating people with a life-threatening disease that's not likely to kill them instantly. There are so many layers involved in managing not just the disease, but the treatment, including its after-effects. And from a general surgeon's point of view, head and neck is not a typical area of interest. When I was training in India, I was exposed to head and neck surgery during general oncology training. Most people who are in training get drawn in by the anatomy in the head and neck region which is a very complicated area to work in surgically. But for me that was a minor part of it; what really intrigued me is the impact that these head and neck tumors—and specifically oral cavity cancer—have on patients: how they look, eat, speak, swallow, and breathe. It’s almost like the very existence of that person is at stake. Social interactions, family, work, pleasure—everything gets impacted. And it’s not just the tumor; it’s also the treatment because treatments have side effects, and basically anything that you do has the potential to tip the balance. If you do too little, they might not survive their cancer. If you do too much, you may adversely influence their quality of life. So that’s what really drew me in, and it's kept me excited about the field 25 plus years on. Giving back is not an opportunity that many people have, so I consider it a privilege.

When did you get involved with AO CMF?

Not too long ago. I have known AO CMF’s leading surgeons for a very long time. In the past, there was a kind of separation between head and neck surgery and craniomaxillofacial (CMF) surgery, but—thankfully—that has disappeared over the years and head and neck surgeons today are very actively involved in the world of CMF. In early 2020, the Global Oral Cancer Diploma Steering Committee met here in New York and I became involved in the curriculum development. I've always been involved with education, traveling all over the world to teach, and I have written several textbooks. My involvement in this diploma program is proof of the power of personal relationships and more importantly it’s an opportunity to give back.

My first involvement was developing a didactic lecture for the Global Oral Cancer Diploma Pilot, and then I took on the two modules as planned.

What unmet needs does this program fill?

I think it meets the need to reach a global audience of dentists, oral surgeons, and maxillofacial surgeons, who may not necessarily have access to world leaders in oral oncology. In general, during their training, they do not get the unique, comprehensive educational content that we are offering.

Who is the program aimed at?

My expectation is that it'll probably be trainees and specialists who are early on in their career.

What does the Global Oral Cancer Diploma program offer that surgeons can’t get anywhere else?

Obviously, it's very structured and it's didactic, and the faculty are all world leaders in the field. I started my career in a time and place when there was no internet. If you wanted to learn, you went to the library. And if there was a book that addressed your interests, you were lucky. Otherwise, you were on your own. This program is a perfect example of how modern technology has the potential to improve health care education and thereby impact patient outcomes around the globe. On a personal note, it provides me with a different perspective. If I can help in any way to further someone's knowledge, there's no better motivation for me.

How do you see the program ultimately benefiting patients?

The first and most obvious thing is that it will homogenize knowledge. There may be pockets of educational excellence in oral oncology globally, but it’s not in general to the standard we’d like to see. You want people to be meet a certain standard, and that's what the global online program is meant to do. I hope it will have a ripple effect in the local communities. I hope we light a spark and inspire younger folks to pick up the mantle and say, “Okay, this is worthwhile. It's worth learning and then passing on the knowledge to others.”

How important is the online aspect?

It’s extremely important: Participants don’t have to come to New York City
York City to learn from me, for example. Surgeon educators like me travel around the globe giving lectures and presenting at conferences, where we might interact with 600 or 1,000 people, but for every person we educate in this way, there are probably many more who can’t make it to event because of time, expenses, etc. The Global Oral Cancer Diploma program’s educational content is readily available. Just fire up your computer and it’s there when you want it—and it’s all structured. In my view, this is the best way of educating people. The online discussion forums—giving participants and faculty the opportunity to interact in real time—is another an aspect I’m really looking forward to. That's an opportunity that participants can't get anywhere else.

What is the scope of your work as a module editor?

It starts with of making sure the content is appropriate, but perhaps the most important
role was identifying the appropriate contributors and getting them to agree to be part of the program because these are very, very busy people. The contributors to Module 4: Diagnosis and workup are Amit Ritter (Israel), Axel Sahovaler (United Kingdom), Ronald Ghossein (United States), Deepak Kademani (United States), Sat Parmar (United Kingdom), Evan Rosen (United States), Hilda Stambuk (United States), Max Heiland (Germany), and Beatriz Korc-Grodzicki (United States). Contributors to Module 5: Staging and outcome evaluation are Bill Lydiatt (United States), Pablo Montero (Chile), Raja Seethala (United States), and Cristina Valero (Spain) . We have also had great administrative support from the AO Education Institute, which is an excellent, very streamlined machine.

How does the content of these two modules help surgeons navigate the patient's oral cancer journey?

These two modules are essentially the foundation for a successful outcome if you're treating a patient with oral cancer, because if you diagnose the cancer early, it obviously translates into a better outcome, and if you stage the patient accurately, that guides appropriate treatment. That's just fundamental for not only cancer survival, which obviously is the biggest goal, but it's also pivotal to understand that the treatment that you pick for the patient can cause tremendous side effects in terms of their quality of life, speaking, swallowing, breathing, eating, and how they perceive themselves, causing repercussions in almost every aspect of their lives. So, it is crucial to diagnose these cancers early and learn how to document them. There are aspects of pathology to consider, what the nuances are, how one feature influences the prognosis versus the other. There’s radiology which is so crucial because it’s important to learn how to use imaging to assess the extent of the tumor and its spread patterns based upon which you plan surgical resection and reconstruction followed by adjuvant treatment, and posttreatment surveillance.

What are some of the overlooked aspects for each of these two modules you’ve edited?

For Module 4: Diagnosis and workup, it’s simple things like how to photograph or document a lesion in the oral cavity. Aspects of pathology are often not understood, and perhaps most importantly, how to use radiographic imaging, how to interpret scans, how to plan treatment. There’s a heavy emphasis on radiology and pathology to plan the appropriate treatment. For Module 5: Staging and outcome evaluation, I’m fortunate enough to be the vice -chair of the American Joint Committee on Cancer (AJCC), the committee that stages cancer. So, the module contributors include the current chair and other members of the AJCC staging committee along with younger surgeons who have been at the forefront of developing prognostic tools for oral cancer. This is the level of input that we bring into the modules, because these are the people who are shaping the future. Global Oral Cancer Diploma program learners couldn't ask for more credibility or authoritative guidance than that. That’s a really unique aspect of the program.

It's also important to point out one thing that I've noticed in all my years of practice, especially for diagnosis and detecting oral cancer: Dental and oral surgery practitioners are not very confident in

diagnosing cancer. Why is that? It’s because they're not familiar with some of the features of early cancer. What does pre-cancer look? What are the options for solving a dilemma? If a dentist looks into a person's mouth and sees something that doesn't look right, the next step is to send the patient to an oral surgeon. If the oral surgeon is experienced enough, they might say that, okay, this doesn't look bad, let's watch it. But most times they'll end up doing a biopsy because they don't know. And while that may not be the wrong thing to do, it’s often done because you don't know what else to do—and that's not great for the patient because it's an unnecessary procedure. And the flip side of it is that there are many times where there’s an obvious cancerous lesion that is mistaken for some dental disease or gum problem or infection, and the patient lingers until it becomes obvious and then they come to someone like me. Neither of these situations is ideal. By highlighting to our learners what the features of early cancer are and educating them about how to diagnose cancer early, hopefully they'll be empowered and feel confident to order the appropriate next tests. And then they will feel comfortable communicating with the radiologist, pathologist, medical oncologist, radiation oncologist, etc., and this will allow them to make meaningful contributions because oral cavity cancer is not solely a surgical problem. You need input from a multidisciplinary team and by starting off on a firm footing, the hope is that whoever takes part in the Global Oral Cancer Diploma program will be able to confidently stand up and advocate for their patient.

Are there different key takeaways for Module 5: Staging and outcome evaluation?

Again, people don't understand how or why cancers are staged. There are so many nuances to assigning a stage and treating a patient that if you just do it by the book, you may be missing out on certain things unless you understand why you stage cancers, what the rationale is for the current staging system, what's missing, what are the other things that you should take into account, and how can we improve our staging and outcome evaluation in the future. When you are designing a treatment plan for a patient, you want to offer the best treatment to the patient, keeping the ideal of maximizing the chances of cancer cure while minimizing the side effects of treatment. So, that's what hopefully will come across in Module 5: Staging and outcome evaluation .

What are your two biggest priorities as the editor of these two modules?

Personally, my biggest priority was to have world leaders in the field to contribute content and mix in younger upcoming surgeons. There are very smart, very bright young folks around, but the reason to pick people who are established and have a name in the field was to allow folks who have no access to these people to be able to learn from them and also interact with them. So, that was the biggest priority. Obviously, ensuring the quality of the content, making it comprehensive, and easily understandable were also important.

How can the Global Oral Cancer Diploma program help surgeons outside of improving patient outcomes? How will it help surgeons advance in their fields?

Education is a two-way street. I'm teaching in order to educate people, but I can't tell you how much you learn when you try to teach. It is an amazing experience to be able to articulate something that you are only thinking about. Basically, as an educator you are trying to mold learners’ opinions and empower them to help another human being and—for me—that is the most awesome payback. Basically, I'm learning as much, if not more, than the person that I'm teaching. I tell my trainees the advances in the field are not going to come from people who've been practicing for 25 or 30 years; we usually have our blinders on and are set in our ways. We need to be challenged by people who are maybe naïve or not exposed to the dogma in the field. This program is an opportunity for me to learn about new things, get new ideas, and at the same time, hopefully improve the knowledge base.