mHealth Solutions for the challenge of Oral Cancer in India


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mHealth Solutions for the challenge of Oral Cancer in India

Rodrigo Mariño, Bernardo de Alvarenga, and Manuel Vidaurre

Thanks to Joao Afonso, Ignacio de Leon and Elias Vidaurre for his review and inputs

Proposed solution for the Challenge: Oral Cancer in India by Team 40726

Existing Strategies

Oral cancer is one of the few life-threatening conditions in dentistry. With approximately 650,000 new cases annually, head and neck squamous cell carcinoma (HNSCC) is the eighth most common cancer worldwide.[1] Tobacco and alcohol consumption are the most common risk factors for HNSCC.[2] People who drink heavily and smoke are at an even greater risk.  However, in recent years there is a rapidly growing body of epidemiologic, clinical and molecular data focusing on the etiologic role of human papillomavirus (HPV) in HNSCC.[3-5] HPV infection is the most prevalent viral sexually transmitted infection in the world [6]. In addition to these risk factors, oral cancer occurs more frequently among people who chew areca nuts, betel nuts, paan and gutka (a common practice among some people in India and Asia).

Although with early diagnosis patients have high survival after 5 years, its treatment might cause dry mouth, loss of oral function (chewing, swallowing) and disfigurement.  Oral cancer is an extremely deadly form of cancer.  These cancers have a low survival rate because the disease is often not diagnosed until it is advanced. In countries like Australia more people die from oral than cervical cancer.

Non-technical Strategies

To address this situation patients are examined to determine health related characteristics (i.e., any changes in the soft tissues of the mouth), and to identify individuals at-risk.  Nonetheless, these examinations are not routinely conducted, not even among high-risk individuals.  This is because of lack of access and because routine oral examination does not  always check for this.

Routine examinations (including self-examination) allow for the detection of these conditions. Oral Cancer frequently goes unnoticed in its early, curable stages.  This is because some of these life-threatening conditions, in particular precancerous ones, may be painless, may not bleed, and may not involve swelling.

Prevention

Conventional oral cancer prevention programs are available.  These programs aim to:

  • If one is outdoors a lot, one uses sunblock on one's lips, and wear a hat with a wide brim to block the sun's harmful rays.

  • Stop using tobacco.

  • Cut back on the amount of alcohol one drinks.

  • Stop or reduce drinking and smoking at the same time.

  • For those who are habitual betel nut chewers, cut back or stop it use.

  • Annual check up for high-risk individuals.

However, this might be unrealistic for under-served groups or communities.  For these groups, as well as for the general population, the strategy is to promote self-examination.  This is very important because the disease frequently goes unnoticed in its early, curable stages. In addition, HPV vaccine is being now advocated to prevent these cancers.

Diagnosis

Face to face screening conducted by health professions (e.g., dentist). These professionasl may use of intraoral camera with white light and fluorescent light to detect malignant tissues.

Referral protocols for patients presenting with suspicious lesions or diagnosed with oral cancer  [7].

Establishing effective inter-disciplinary management strategies, including an awareness of psycho-social support networks [7].

Existing mHealth solutions

Diagnosis

Use of teledental intraoral camera operators to conduct remote assessments

Online training modules for non-oral health professionals on how to conduct conventional oral mucosa examinations.

New solution ideas that meet different factors of the problem

Solution 1: Prevention of Risk Factors

Self-control against risky behaviors can reduce a important fraction of the burden of disease HNSCC. According to Keeney, the leading cause of death is "personal decision making", accounting for over one million deaths annually only in the USA. These "risky" personal decisions represent a confrontation between short-term benefits (relaxing after smoking a cigarette) with long-term adverse effects (oral/pulmonary cancer)..

Humans, even when we know what is best, sometimes lack self-control [8]. Most of us, at some point, have eaten, drunk, or spent too much, and exercised, saved, or worked too little. The behavioral economics have developed some strategies to help us for increase or self-control [9], the main are:

  • Reward Substitution. substitute an alternate short-term reward that is immediate and therefore more motivating that the long-term reward .

  • Ulysses contract is a freely-made decision contract in which you know your future self will be tempted and you bind your current self to prevent your future self from misbehaving.

  • Avoiding Ego Depletion [10].  Self-control operates as a limited resource, akin to strength or energy, after use- leaving the depleted self subsequently vulnerable to impulsive and undercontrolled behaviors on the self's resources, which are also used for decision-making can be replenished by rest and positive emotions.

Additionally to this tehre is also Gamification [11-13] for the use of game thinking and game mechanics in a non-game context in order to engage users and solve problems could be used in this context for improve prevention of Oral Cancer.

Solution 2: Early Diagnostic and Treatment

How can an app/phone help  other than through information and pictures? Can we use the camera in the phone for any diagnostic purpose?

Online training modules for non-oral health professionals on how to conduct conventional oral mucosa examinations or self-examinations with multimedia materials and instructions. Apps may remind to do it periodically and what to look for, and provide information of sites where to find more information.  Apps may also remind to take HPV vaccination.

There are apps [14-18], that use a mobile phone to take pictures of the area of concern, that allow the inclusion of Medical History, and the patient’s concerns.

Saliva tests. Saliva contains biomarkers which allow for easy and simple detection of initial stages of cancers, including oral cancer [19,20].  The test could be conducted by the patient him/herself using a portable kit, and the result obtained after e few seconds.  These results could then be sent to the patients’ and/or the health professional’s mobile phone.

Effective solution

Implementing an mHealth solution for Prevention of Risk Factors

Based on a framework using behavioral economics and gamification a mHealth solution for prevention of risk factors for Oral Cancer can be developed. The main idea is to provide a mechanism for the users to have knowledge about oral hygiene and risk factors but most importantly design strategies that could work for them in order to have desirable behaviours and reduce the risks. In order to do that, a mobile app could be developed using a behavior-change gamification framework with leading boards, badges, health knowledge quizzes, competitions, challenges, formation of teams, rewards, and others. But it should be enforced by Ulysses Contracts (using auditors from the social network of the person and bidding money for achieving the result), Rewards Substitutions (defining small but short-term rewards that will be granted if the desire behavior is performed) and Replenish Ego (encouraging rest and positive emotions). Social network integration of the app will offer a way to use social proof as a way to encourage healthier behaviors. We are exploring the possibility to be sponsored by the savings in the health sector for the reduction of Oral Cancer. Offering cash prizes for achievement could be also another reinforcer of healthier behaviors. Paying the patient for performance - results seem good while there is a reward, but compliance gets normalized once reward system gets removed.

The tracking of healthier behaviors will use the sensors and GPS of the mobile devices integrating the information with social media sites and other services in the cloud. Using also Machine Learning and Probabilistic Graphical Models, patterns of behavior will be identified for encouraging the behavioral change or for analyzing the early diagnosis pictures for screening presumptive cases.

Also we will include the support of smart alerts and warning messages for remembering prophylactic actions and screening.

Geolocation of risk sites and appropriate warning messages.

Geolocation of risk individuals (based on census data) and targeted campaigning by public health institutions

Any outcome deriving from mobile health and voluntary compliance must base itself on personal responsibility for health care. Compliance can only be incentivized, either through monetary means or regular medical follow-up. The use of behavioral economics proven strategies and a behavior-change gamification will increase the odds of self-control and healthier decisions and behaviors on users of the system.

The doctor’s role should be minimal, first at the introduction of the program to set patient-specific parameters (frequency of risky behaviour, state of health condition) and at milestones offering bigger rewards. As milestones can be reached by different people at different stages, our application should allow for such flexibility.

The possibility for using the collected data and associating that with outcomes could be the basis for an ongoing cohort study using datamining and data science techniques.

The proposed solution of prevention of risk factors will target behavioral change aid by mHelath using gamification and behavioral economics principles for encouraging healthier decisions and behaviors. This could reduce significantly the incidence of Oral Cancer because the main Risk Factors have an important population attributable fraction (PAF). PAF is the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario. In India, among men, 35% of oral cancer is attributable to the combination of smoking and alcohol drinking and 49% to pan-tobacco chewing. Among women, chewing and poor oral hygiene explained 95% of oral cancer.

References

  1. Westra W, The changing face of head and neck cancer in the 21st century: the impact of HPV on the epidemiology and pathology of oral cancer, Head and Neck Pathology, 2009;3:78-81.

  2. Chaudhary A, Singh M, Sundaram S, Mehrotra R, Role of human papillomavirus and its detection in potentially malignant and malignant head and neck lesions: updated review, Head and Neck Oncology, 2009;1:22.

  3. Allen C, Lewis J, El-Mofty S, Haughey B, Nussenbaum B, Human papillomavirus and oropharynx cancer: biology, detection and clinical implications, Laryngoscope, 2010;120:1756-1772.

  4. Nguyen N, Chi A, Nguyen L, Ly B, Karlsson U, Vinh-Hung V, Human papilomavirus-associated oropharyngeal cancer: a new clinical entity, QJM, 2010;103:229-236.

  5. Mannarini L, Kratochvil V, Calabrese L, Silva L, Morbini P, Betka J, Benazzo M, Human papilloma virus (HPV) in head and neck region: review of literature, Acta Otorhinolaryngol Ital, 2009;29:119-126.

  6. zur Hausen H: Papillomaviruses in the causation of human cancers - a brief historical account. Virol 2009, 384:260–265.

  7. FDI. World Dental Federation. FDI Policy Statement. Oral cancer.http://www.fdiworldental.org/media/11303/Oral-cancer-2008.pdf
  8. Richard H. Thaler and Shlomo Benartzi. Save More Tomorrow™: Using Behavioral Economics to Increase Employee Saving. Journal of Political Economy. Vol. 112, No. S1, Papers in Honor of Sherwin Rosen: A Supplement to Volume 112 (February 2004), pp. S164-S187 DOI: 10.1086/380085

  9. Baumeister, Roy F., et al. Ego depletion: Is the active self a limited resource?. Journal of personality and social psychology 74 (1998): 1252-1265.

  10. Norton, Michael, Daniel Mochon, and Dan Ariely. The'IKEA Effect': When Labor Leads to Love. Harvard Business School Marketing Unit Working Paper 11-091 (2011).

  11. Zichermann, Gabe; Cunningham, Christopher (August 2011). "Introduction". Gamification by Design: Implementing Game Mechanics in Web and Mobile Apps (1st ed.). Sebastopol, California: O'Reilly Media. p. xiv. ISBN 1449315399.

  12. Huotari, Kai; Hamari, Juho (2012). Defining Gamification - A Service Marketing Perspective. Proceedings of the 16th International Academic MindTrek Conference 2012, Tampere, Finland, October 3–5.

  13. Sebastian Deterding, Dan Dixon, Rilla Khaled, and Lennart Nacke (2011). From game design elements to gamefulness: Defining "gamification". Proceedings of the 15th International Academic MindTrek Conference. pp. 9–15.

  14. http://www.fiercemobilehealthcare.com/story/stanford-develops-smartphone-plug-detect-oral-cancer/2012-04-20  

  15. http://www.huffingtonpost.com/2012/04/20/oscan-oral-cancer-stanford_n_1438868.html

  16. https://play.google.com/store/apps/details?id=com.zappiertech.ocss&hl=en

  17. https://itunes.apple.com/hk/app/oral-cancer-app/id622408060?mt=8

  18. http://oralcancersupport.org/forums/ubbthreads.php?ubb=showflat&Number=152445

  19. http://newsroom.ucla.edu/portal/ucla/early-detection-biomarkers-of-153212.aspx

  20. http://www.slideshare.net/mukuldboy1/david-wong-advances-in-oral-cancer-prevention-applications-in-public-health


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