Support for a Campus Tobacco-Free Policy among Non- Smokers: Findings from a Developing Country

Background: A tobacco-free workplace policy is identified as an effective means to reduce tobacco use and protect people from second-hand smoke; however, the number of tobacco-free policies (TFP) remains very low in workplaces in Malaysia. This study explored the factors affecting support for a tobacco-free policy on two healthcare campuses in Malaysia, prior to the implementation of TFP. Materials and Methods: This crosssectional study was conducted among 286 non-smokers from two healthcare training centres and two nearby colleges in Malaysia from January 2015 to April 2015. A standardized questionnaire was administered via staff and student emails. The questionnaire collected information on sociodemographic characteristics, support for a tobacco-free policy and perceived respiratory and sensory symptoms due to tobacco exposure. Bivariate and multivariate logistic regression analyses were performed to estimate the independent effects of supporting a tobacco-free campus. Results: The percentage of individuals supporting completely tobacco-free facilities was 83.2% (N=238), as opposed to 16.7% (N=48) in support of partially tobacco free facilities. Compared to the supporters of partially tobacco-free facilities, non-smokers who supported completely tobacco-free health facilities were more likely to be female, have higher education levels, to be very concerned about the effects of other people smoking on their health and to perceive a tobacco-free policy as very important. In addition, they perceived that tobacco smoke bothered them at work by causing headaches and coughs and, in the past 4 weeks, had experienced difficulty breathing. In the multivariate model, after adjusting for sociodemographic characteristics and other factors, only experiencing coughs and headaches increased the odds of supporting a completely tobacco-free campus, up to 2.5- and 1.9-fold, respectively. Conclusions: Coughs and headaches due to other people smoking at work enhances support for a completely tobacco-free campus among non-smokers.     

A Pilot Test of a Church-Based Intervention to Promote Multiple Cancer-Screening Behaviors among Latinas

We assessed the feasibility, acceptability, and initial impact of a church-based educational program to promote breast, cervical, and colorectal cancer screening among Latinas ages 18 years and over. We used a one-group pre-/post-evaluation within a low-income, Latino Baptist church in Boston, MA. Participants completed interviewer-administered assessments at baseline and at the end of the 6-month intervention. Under the guidance of a patient navigator (PN), women from the church (peer health advisors, or PHAs) were trained to deliver evidence-based screening interventions, including one-to-one outreach, small group education, client reminders, and reduction of structural barriers to screening. The PN and PHAs also implemented a health fair, and the pastor integrated health information into regular sermons. At pre-intervention, nearly half of the sample did not meet screening guidelines. The majority (97 %, n?=?35) of those who completed the post-intervention assessment participated in intervention activities. Two thirds (67 %) reported talking with the PN or PHAs about health issues. Participation in small group education sessions was highest (72 %), with health fairs (61 %) and goal setting (50 %) also being popular activities. Fourteen percent also reported receiving help from the PN in finding a primary care provider. This study supports the feasibility and acceptability of churches as a setting to promote cancer screening among Latinas.     

Barbers Against Prostate Cancer: A Feasibility Study for Training Barbers to Deliver Prostate Cancer Education in an Urban African American Community

The goal of this pilot study was to assess the feasibility of training barbers to deliver a brief culturally and literacy appropriate prostate cancer educational intervention to urban African American men. Eight barbers received training to deliver a 2-month educational intervention in the barbershop and completed pre- and posttest training assessments. The training workshops led to a significant increase in mean prostate cancer knowledge scores among the barbers (60% before vs. 79% after; P < 0.05). The barbers also reported positively on the intervention in terms of satisfaction and relative ease of engaging clients. Training barbers to deliver a prostate cancer educational intervention is a feasible strategy for raising prostate cancer awareness of the disease among a priority population.     

Community Based Intervention for Tobacco Cessation: A Pilot Study Experience,North East India

Background: North East India has a high prevalence of tobacco consumption, but only few individualsseekhelp for tobacco cessation. Impact of community based tobacco cessation intervention in this part needs moreresearch. Materials and Methods: Retrospective analysis was done on the dataset from a community-basedtobacco cessation intervention pilot project conducted in Guwahati metro during 2009-10. Subjects, both maleand female tobacco users, age > 15 years, permanent residents of these blocks giving consent were included inthe study. Results: The sample was 800 tobacco users, of whom 25% visited any health care provider duringlast 12 months and 3% received tobacco cessation advice. An 18% quit rate was observed at six weeks followup, more than the National average, with a 47% quit rate at eight months, while 52% of subjects reduced use.Conclusions: Higher tobacco quit rate and reduced tobacco use, no loss to follow up and negligible relapsewas observed with this community based intervention design. Such designs should be given more emphasisfor implementation in specified communities with very high tobacco consumption rates, cultural acceptance oftobacco and less motivation towards quitting.     

Feasibility,Acceptability and Findings from a Pilot Randomized Controlled Intervention Study on the Impact of a Book Designed to Inform Patients about Cancer Clinical Trials

This study was conducted to assess the feasibility, acceptability, and changes in knowledge among cancer patients assigned to receive a 160-page book on experimental cancer therapies and clinical trials. We enrolled 20 patients with cancer who had never participated in a clinical trial and randomly assigned them to receive the book either during week 1 or week 4 of the study. We collected baseline patient demographic and cancer-related information as well as knowledge about cancer clinical trials at week 0. Follow-up surveys were administered at weeks 3 and 6 for both study groups. Comparisons were made within and between groups randomized to receive the book early (at week 1) to those who received it later (at week 4). One hundred percent of data were captured in both groups at baseline, which decreased to 77.8 % by week 6. The vast majority of participants found the book moderately or very useful (89 % in the Early Group at week 3 and 95.5 % in the Late Group at week 6). Within group pairwise comparisons found significant difference between baseline and week 6 in content-specific knowledge scores among participants in the Late Group [79 % versus 92.1 %, p?=?0.01). Global knowledge scores increased significantly for variables reflecting knowledge that promotes decisions to participate in clinical trials. Providing published reading material to patients with cancer is both feasible and acceptable. Offering information to patients about cancer clinical trials, using a book designed for patients with cancer may influence knowledge related to decision to participate in clinical trials.     

90Y Glass Microspheres for the Treatment of Unresectable Metastatic Liver Disease from Chemotherapy-Refractory Gastrointestinal Cancers: A Pilot Study

Purpose

This prospective pilot single-institution study was undertaken to document the feasibility, safety, and efficacy of treatment of liver-dominant metastatic gastrointestinal cancer using ⁹⁰Y glass microspheres.

Methods

Between June 2010 and November 2012, 30 adult patients (22 men, eight women; median age 61 years) with metastatic chemotherapy-refractory unresectable colorectal (n?=?15), neuroendocrine (n?=?9), intrahepatic cholangiocarcinoma (n?=?3), pancreas (n?=?2), and esophageal (n?=?1) carcinomas underwent 45 lobar or segmental administrations of ⁹⁰Y glass microspheres. Data regarding clinical and laboratory adverse events (AE) were collected prospectively for 6 months after each treatment. Radiographic responses were evaluated using Response Evaluation Criteria in Solid Tumors, version 1.1. Time to maximum response, response duration, progression-free survival (hepatic and extrahepatic), and overall survival were measured.

Results

Median target dose and activity were 111.6 Gy and 2.5 GBq per treatment session, respectively. All but three clinical AE were grade 1 or 2 in severity. Serious AE included an unplanned hospital admission for carcinoid crisis, grade 3 vomiting, and grade 4 gastric ulcer. Patients with colorectal cancer had hepatic objective response rate (ORR) of 27 % and a disease control rate (DCR) of 73 %. Median progression-free and overall survival were 1.0 and 4.9 months, respectively. Patients with neuroendocrine tumors had hepatic ORR and DCR of 78 % and 100 %, respectively. Median progression-free survival was 18.5 months for this cohort.

Conclusions

Y glass microspheres device has a favorable safety profile and achieved prolonged disease control of hepatic tumor burden in a subset of patients, including all patients enrolled in the neuroendocrine cohort.     

Oral Potentially Malignant Disorders among Dental Patients: a Pilot Study in Jordan

Background: To determine the prevalence, types, and risk factors of oral potentially malignant disorders(OPMDs) among a group of Arab Jordanian dental patients, and to evaluate their awareness and attitudes towardearly diagnosis and treatment. Materials and Methods: A total of 1,041 patients attending a University Hospitalfor dental care were examined for the presence of OPMDs. Histopathological examination was performed onall cases clinically diagnosed and patients were directly interviewed to evaluate their knowledge and attitudestoward early detection and treatment of oral cancer. Results: The prevalence of OPMDs overall was 2.8%.Lichen planus/lichenoid lesions were the most common lesions (1.8%) followed by leukoplakias (0.48%), chronichyperplastic candidiosis (0.38%), and erythroplakia (0.096%). Smoking, alcohol, and age (>40 years) werethe main identifiable risk factors. Patients with OPMDs displayed a general lack of awareness and negativeattitudes towards early diagnosis and treatment. Conclusions: OPMDs among Arab dental patients are relativelyuncommon and awareness about oral cancer among Jordanian dental patients is low. Interventions to improvepublic knowledge about oral cancer and attitudes toward early diagnosis and treatment are urgently indicated.     

Sun Protection Practices among Children with a Family History of Melanoma: a Pilot Study

The goal of this pilot study was to assess sun protection practices and correlates among children with a family history of melanoma, a high risk and understudied group. Sixty-eight melanoma cases, recruited through the Los Angeles County cancer registry, completed a survey. Survivors provided data on 110 children (mean age?=?8.11 years). Although most children used sunscreen (79 %), half experienced a recent sunburn. The mean sun protection level for the sample was similar to levels observed among average risk children. Efforts to reduce sunburn frequency and improve sun protection among these vulnerable children appear warranted.     

Development and Implementation of a Simulation-Based Educational Workshop on Gynecological Brachytherapy: Pilot Study at a National Meeting

PurposeDespite the importance of brachytherapy in the curative treatment of locally advanced cervical cancer, reviews of practice patterns in the United States have identified a decline in brachytherapy use in clinically appropriate patient populations. A survey of radiation oncologists identified lack of time and lack of guidance as barriers. To address these barriers, the purpose of this study was to develop a simulation-based educational (SBE) gynecologic brachytherapy workshop.Methods and materialsThe SBE gynecologic brachytherapy workshop was developed with expertise from 2 institutions, combining procedural simulation with a practical discussion of brachytherapy applicator insertion techniques. The primary outcome was feasibility of workshop deployment, defined as completion of all workshop components in the time allotted. Preworkshop and postworkshop surveys were also administered to assess efficacy, a secondary outcome.ResultsThe workshop took place at a national radiation oncology meeting, and all workshop components were completed in the 2 hours allotted. SBE stations focused on (1) fiducial placement, (2-3) applicator selection, (4) suturing, and (5) pelvic examination and applicator placement. Fourteen participants completed surveys. Respondents included residents and attending physicians. More than 50% of respondents were from academic practices and practiced gynecologic brachytherapy weekly or more. Curricular objectives for this workshop were for ≥20% trainees to report increased confidence in practice and ≥20% of trainees to report increased familiarity with applicators. After participation in the workshop, confidence in applicator choice improved in 9 of 13 participants (69%), confidence in complication management improved in 8 of 13 participants (62%), and familiarity with applicators improved in 7 of 13 participants (54%). These differences were statistically significant at α = .05.ConclusionsThis study demonstrated feasibility in using simulation for gynecologic brachytherapy education at a national meeting. Although most respondents were experienced in brachytherapy, more than half reported increased confidence and familiarity with aspects of the procedure after the workshop. Future work should address interstitial needle placement and improved time management of workshop stations.     

Liver Cancer-Specific Isoform of Serine Protease Inhibitor Kazal for the Detection of Hepatocellular Carcinoma: Results from a Pilot Study in Patients with Dysmetabolic Liver Disease

Reliable non-invasive biomarkers for the surveillance of patients at risk of hepatocellular carcinoma (HCC) development represent an unmet medical need. Recently, the liver-cancer-specific isoform of serine protease inhibitor Kazal (LC-SPIK) has been proposed as a valuable biomarker for the detection of HCC in patients with chronic liver disease of viral etiology. In the present study, we assessed the diagnostic accuracy of LC-SPIK, alone or in combination with standard serologic biomarkers (i.e., alpha-fetoprotein and protein induced by vitamin K absence or antagonist-II, PIVKA-II), for the detection of HCC among patients with dysmetabolic liver disease. A total of 120 patients with non-alcoholic fatty liver disease (NAFLD), including 62 patients with a diagnosis of HCC and 58 with cirrhosis but without tumor, were retrospectively analyzed. The serum levels of LC-SPIK were measured by enzyme-linked immunosorbent assay (ImCare Biotech, Doylestown, PA). The serum LC-SPIK values were significantly different between patients with HCC (24.3, 17.6–39.8 ng/mL) and those with cirrhosis but without tumor (11.7, 8.7–18.2 ng/mL) (p < 0.001). By receiver operating characteristic curve analysis, we observed an area under the curve (AUC) of 0.841 for the detection of HCC; the combination with PIVKA-II further increased the accuracy to AUC = 0.926 (cross-validation). The promising results observed in the present pilot study foster additional research to investigate the usefulness of LC-SPIK for the stratification of the risk of HCC development in patients with NAFLD and advanced liver disease.     

Immune Biomarkers in Blood from Sarcoma Patients: A Pilot Study

The main role of the host immune system is to identify and eliminate cancer cells, which is a complex process, but it is not a fail-safe mechanism. Many sarcoma patients succumb to this disease despite treatments rendered. The aim of this pilot study was to compare the levels of CD4⁺ T-cells, T-regulatory (Treg) cells, and cytokines such as tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), interleukin-17A (IL-17A), and transforming growth factor-beta-1 (TGF-β1) in peripheral blood leukocytes of sarcoma patients and healthy controls. For gene expression studies, total ribonucleic acid (RNA) was extracted from peripheral blood leukocytes and genes that were differentially regulated in peripheral blood leukocytes of sarcoma patients compared with healthy controls were determined using a commercial T-helper cell differentiation quantitative polymerase chain reaction (qPCR) array. Flow cytometer analysis was performed on blood samples from 26 sarcoma patients and 10 healthy controls to identify the levels of CD4⁺ T-cells and T-reg cells. The level of cytokines in plasma and culture supernatant were quantified using commercial enzyme-linked immunosorbent assay (ELISA) kits. A marked reduction in the percentage of CD4⁺ T-cells (p = 0.037) and levels of TNF-α (p = 0.004) and IFN-γ (0.010) was observed in sarcoma patients. Gene expression analysis showed five genes (homeobox A10 (HOXA10), GATA binding protein 3 (GATA3), prostaglandin D2 receptor 2 (PTGDR2), thymocyte selection associated high mobility group box (TOX), and C-C motif chemokine receptor 3 (CCR3)) were dysregulated (p < 0.05) in sarcoma patients. This study suggests that T-helper-1 immune responses are reduced in sarcoma patients.     

广西原发性肝癌高危人群的茶多酚干预研究

目的:评估茶多酚对广西原发性肝癌高危人群在黄曲霉毒素暴露中的预防效果。方法:本研究采用随机双盲法进行为期1 年的茶多酚干预性试验,共有130 例经过筛选的实验对象,严格按照随机双盲法分为两组:茶多酚组和安慰剂组;各组分别服用茶多酚500mg/d 和相应的安慰剂;并在多个时间点采集血液样品,利用放射免疫法检测不同时间点两组实验对象血清中的黄曲霉毒素白蛋白加合物水平。结果:130 例实验对象的血清中均可检测到黄曲霉毒素白蛋白加合物。两组中茶多酚干预组实验对象血清的黄曲霉毒素白蛋白加合物水平呈下降趋势,并在服用茶多酚12个月后呈现显著性降低的情况（P<0.05）;而安慰剂组实验对象血清各时间点的黄曲霉毒素白蛋白加合物水平未出现显著性的改变（P>0.05）。 结论:茶多酚可以降低原发性肝癌高发人群黄曲霉毒素的暴露水平。      

The Direct and Indirect Costs of Cancer among the Lower-Income Group: Estimates from a Pilot and Feasibility Study

Background: Healthcare in Malaysia is largely publicly funded, however, cancer could still result in out-of-pocket (OOP) expenses, which may burden the affected patients. This is especially relevant to those in the lower-income group. This pilot study was conducted to estimate the direct and indirect costs of cancer and evaluate the feasibility of obtaining these costs information from the lower-income cancer patients undergoing treatment. Methods: A cross-sectional study of patients with cancer was conducted in Hospital Kuala Lumpur between September and October 2020. Self-reported data from the patients were collected using face-to-face interviews. Detailed information about cancer-related OOP expenses including direct medical, direct non-medical, and productivity loss in addition to financial coping strategies were collected. Costs data were estimated and reported as average annual total costs per patient. Results: The mean total cost of cancer was estimated at MYR 7955.39 (US$ 1893.46) per patient per year. The direct non-medical cost was the largest contributor to the annual cost, accounting for 46.1% of the total cost. This was followed by indirect costs and direct medical costs at 36.0% and 17.9% of the total annual costs, respectively. Supplemental food and transportation costs were the major contributors to the total non-medical costs. The most frequently used financial coping strategies were savings and financial support received from relatives and friends. Conclusion: This study showed that estimation of the total cost of cancer from the patient’s perspective is feasible. Considering the significant impact of direct non-medical and indirect costs on the total costs, it is vital to conduct further exploration of its cost drivers and variations using a larger sample size.     

A Self-Help Guided Psychoeducational Intervention for Indonesian Women with Breast Cancer Symptoms: Development and Pilot Feasibility Study

Background: Delay in the diagnosis of breast cancer (BC) may lead to an advanced stage of the disease and apoor prognosis. A psychoeducational intervention can be crucial in helping women with BC symptoms complete theexamination procedures and reduce diagnosis delay of BC. Objective: To develop a psychoeducational interventionto reduce the delay of BC diagnosis among Indonesian women with BC symptoms. Methods: The development ofthe intervention included an inventory of crucial elements in developing psychoeducation through literature review aswell as consultation with BC patients and healthcare providers. Additionally, we developed PERANTARA as the firstpilot version of the self-help guided psychoeducational intervention. PERANTARA is an abbreviation for “PengantarPerawatan Kesehatan Payadura”, which means an introduction to breast health treatment. The pilot feasibility studycombined an expert review and a pilot testing in hospital settings. A semi-structured interview and the client satisfactioninventory were utilized to measure feasibility and acceptability of the intervention for Indonesian women with BCsymptoms. Results: PERANTARA contained an oncologist’s explanation about BC and the BC survivors’ testimonyto reduce the time to diagnosis. The pilot study results showed that most patients were satisfied with and trusted onPERANTARA. Conclusion: PERANTARA was feasible and acceptable for Indonesian patients with BC symptoms.The development framework suggested in this study can be applied to develop psychoeducational packages for otherpatients group, in particular, those interventional packages aimed at reducing diagnosis and treatment delays and nonadherence.     

Cervical Cancer and HPV Knowledge and Awareness: An Educational Intervention among College Students in Guam

Background: Compared to the U.S. population, cervical cancer (CC) incidence is significantly higher among the CHamoru, Micronesian, and Caucasian populations in Guam. From 2008-2012, CC was the fifth most common cancer diagnosed on the island. Despite the prevalence of CC and low HPV vaccine uptake, there is a concerning lack of awareness and preventative behavior among young adults.  This study was aimed at influencing college students’ knowledge and awareness of CC, CC screening, HPV, and the HPV vaccination. Methods: We delivered a 30-minute educational intervention to a sample of 108 university students in a classroom setting. The effect of the educational intervention was measured through a pre-and post-test on CC and HPV health behaviors, knowledge, and awareness. Results were analyzed using SPSS and an exact McNemar’s test was used to examine the difference in the proportion of correct answers to the tests. Two-way mixed ANOVA was used to examine between (gender, ethnicity, and class level) and within subjects (pre-and post-test) program effects. Results: Of the 108 participants, only 39 (36.1%) reported being vaccinated for HPV, 23 (21.3%) had not been vaccinated, and 46 (42.6%) did not know if they had been vaccinated for HPV.  Only forty-one (60.3%) female participants had had a Pap smear. When comparing the pre-to-posttest responses, most questions had an increase in correct responses. Time also influenced CCA and HPV knowledge and awareness scores as there was a significant increase in scores from the pre- to post-test. Conclusion: The educational intervention was an effective tool for increasing knowledge and awareness of CC, HPV, and HPV vaccination among college students. While study results demonstrate the educational intervention’s success as a baseline measure of knowledge, the inclusion of behavioral outcome measures, such as intent to get vaccinated or screened, could result in more robust future studies.     

Awareness about Human Papillomavirus Vaccine and Its Uptake among Women from North India: Evidence from a Cross-Sectional Study

Objective: This study aims to estimate the prevalence of human papillomavirus (HPV) vaccine usage and determine the factors for awareness about HPV vaccine among women in reproductive age group. Methods: This is a cross-sectional survey under a cervical cancer prevention study. The sample size was 1020 women, aged 15-49 years [550 in Delhi and 470 in Rohtak]. Bivariate analysis and Fisher exact test along with binary logistic regression analysis were used to determine the factors for awareness. Result: About 18.0 % [Delhi: 24.2 % and Rohtak: 10.9 %] of the respondents had heard about the vaccine against cervical cancer. The women aged more than 30 years [AOR: 1.35; CI: 0.94, 1.94] were more likely to be aware of cervical cancer vaccine as compare to women of 30 years and less. However, the women from Rohtak [AOR: 0.90; CI: 0.48, 1.66] were less likely to be aware of vaccine against cervical cancer in reference to women aged 30 years and more [AOR: 1.61; CI: 1.01, 2.56] from Delhi. About 0.6 % [Delhi: 1.1 % and Rohtak: 0.0 %] of the respondents had received HPV vaccine. Conclusion: Women tend to have limited knowledge about cervical cancer vaccine and immunisation practices. The women’s demographic makeup varied significantly between the two sites, i.e , Rohtak and Delhi, which had an impact on how well they understood and utilised the cervical cancer vaccination. It is worth mentioning that none of the women from Rohtak had received the immunisation. The awareness of the cervical cancer vaccine among women from the Rohtak was lower than the Delhi women.     

Microsatellite Instability in Sporadic Colorectal Malignancy: A Pilot Study from Northern India

Background: Three molecular pathways are described as the genetic basis of colorectal tumorigenesis. Among these, microsatellite instability (MSI) has shown greatest promise in serving as a biomarker to determine disease aggression by tumour biology, recurrence, and response to chemotherapy. Methodology: This prospective observational pilot study included patients of colorectal cancers, in a population subset coming to a tertiary care hospital in northern India, who were operated with curative or palliative intent over a period of one year and followed up for a maximum of 55 months. The post-operative pathological assessment was done for MSI status using PCR technique, and an attempt was made to evaluate its correlation with conventional clinical and histological parameters, early recurrences, disease-free survival and overall survival in comparison to MSS type tumours in sporadic cases of colorectal malignancies. Results: Out of 38 patients of colorectal cancer, 26 were included in the study. Male to female ratio was 7:6 (n=14:12). Mean age of presentation was 48±14.2 years. Incidence of MSI was n=4 (15.4%). On subgroup analysis, age of presentation (p=0.044) and evidence of perineural invasion (p=0.017) was found to have significant statistical association with MSI tumour biology. Recurrence was seen in seven of the seventeen patients who previously had no synchronous or metastatic disease (41.2%). The mean disease-free survival for MSS was 21.32 months and was 25.25 months for MSI group which was statistically insignificant (p = 0.277). Out of four MSI tumour biology patients one was alive and without recurrence at 47 months. While the other two were alive and without recurrence till 27 months of follow-up.   Conclusion: Age and perineural invasion showed statistically significant association with MSI tumour biology. Due to the small sample size statistical significance was not established with site, recurrence rate, DFS and OS.     

Health-Seeking Behaviour and Delayed Presentation of Oral Cancer Patients in a Developing Country: A Qualitative Study based on the Self-Regulatory Model

Background: The aim of this study was to explore reasons for delayed health-seeking for late stage oral cancerpatients. Methods: Semi-structured in-depth interviews were conducted with 35 oral cancer patients with TNM stageIII to IV disease, who were treated at six tertiary regional centres managing oral cancer throughout Malaysia. Interviewswere audio-recorded, transcribed verbatim, coded using NVivo (version 10.0) qualitative software and analysedusing framework analysis. Results: Participants interpreted their early symptoms as a minor condition and did notconsider it as requiring immediate attention. Four types of coping strategies causing delayed help-seeking emerged:1) self-remedy 2) self-medication 3) seeking traditional healers and 4) consulting general medical practitioners (GPs)instead of dentists. Socio-economic factors, cultural beliefs and religious practices have some influence on diagnosticdelay. Conclusion: Low levels of public knowledge and awareness regarding early signs and symptoms of oral canceras well as GPs’ misdiagnosis of early lesions results in delayed diagnosis.