|Year : 2014 | Volume
| Issue : 3 | Page : 618-622
Approach of pharmacists and herbalists while offering guidance on potentially malignant oral lesions: A cross-sectional survey
Abhishek Gouraha1, Nilesh Arjun Torwane2, Saurabh Yadav3, Ashish Maheshwari4
1 Department of Oral Pathology, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
2 Department of Public Health Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
4 Department of Oral and Maxillofacial Surgery, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
|Date of Web Publication||14-Oct-2014|
Nilesh Arjun Torwane
Department of Public Health Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Objectives: To investigate the approach of both pharmacies and herbalists' shops while offering a proper advice for patients seeking guidance on a potentially malignant oral lesion.
Materials and Methods: A cross-sectional, descriptive study was undertaken using the standardized patient approach on a representative sample of pharmacies and herbalists' shops in Bhopal city. The study sample was selected by stratified random sampling technique and was contacted by telephone. Our patient's introductory statement was, "I have a painful ulceration on the tongue since 3 months. What would you advise?" To avoid the hypothetical bias in telephone answers, another study was designed for two regions of the city, of which pharmacies were visited in one and herbal shops in the other one.
Results: A total of 497 establishments were contacted. Out of these, 368 were pharmacies (74.1%) and 129 were herbalists' shops (25.9%). Patients with potentially malignant lesions were more frequently referred to a dentist (16.03%) or a physician (23.36%) by the pharmacies compared to the herbalists' shops. In contrast, most of the herbalists' shops prescribed over-the counter (OTC) remedies (66.66%) and showed no interest in referring the patient to a dentist or a physician.
Conclusion: Apart from pharmacists, the new probable off-clinical counselors (herbalists and pharmacy assistants) have been identified as potential factors of patient diagnostic delay in oral cancer. Educational strategies to improve advice and referral for these identified groups should be designed.
Keywords: Herbalists, oral cancer, pharmacists, pre-malignant lesions
|How to cite this article:|
Gouraha A, Torwane NA, Yadav S, Maheshwari A. Approach of pharmacists and herbalists while offering guidance on potentially malignant oral lesions: A cross-sectional survey. J Can Res Ther 2014;10:618-22
|How to cite this URL:|
Gouraha A, Torwane NA, Yadav S, Maheshwari A. Approach of pharmacists and herbalists while offering guidance on potentially malignant oral lesions: A cross-sectional survey. J Can Res Ther [serial online] 2014 [cited 2020 Jun 4];10:618-22. Available from: http://www.cancerjournal.net/text.asp?2014/10/3/618/137947
| > Introduction|| |
Oral cavity cancer [International Classification of Diseases-O-3 (ICD-O-3) C00-C08]  is the 8 th most frequent cancer in the world among males and the 14 th common cancer among females, accounting for nearly 3% of all cancer cases worldwide.  Annually, it is estimated that 127,459 deaths are caused from oral cavity cancer worldwide (C00-C08), of which 96,720 deaths occur in less-developed countries.  Globally, the main risk factors related to oral cavity cancer are tobacco and alcohol use, independent of the type of tobacco or alcoholic beverage, ,, with the association being synergistic.
India has one of the highest rates of oral cancer in the world, accounting for one-third of the total cancer burden. This figure continues to increase and accounts for 50-70% of the total cancer mortality, , as compared to US where oro-pharyngeal cancers account for 3% of all diagnosed malignancies. ,
The oral cancer survival rate after 5 years of diagnosis approximates 50-55%, making it one of the lowest among other major cancers.  The 5-year survival rate is 75% for those with localized disease at diagnosis, but only 16% for patients with cancer in late stages because in the majority of cases, the cancer is diagnosed in stages 3 and 4 with lymph node metastasis. , Early diagnosis can improve the chance of survival up to 80%.  Clinicians can increase the survival rates if a cancerous lesion is detected at an early stage, or if a precursor lesion (dysplasia) is discovered and treated prior to malignant progression. 
Diagnostic delays in oral cancer have been classified as "patient delay," "delay by patients," and "scheduling delay." ,,,,,,, Several studies have been done to determine the cause of this delay and it has been found that dentist, physician, and the patients are equally responsible for it.  Also, factors like accessibility to health care system and ancillary staff were found to be related for early diagnosis of cancer. ,, Most of the studies in this field have concentrated on the knowledge and attitudes of the staff working at medical and dental centers, but only a few investigated the other possible sources of information where the patients can seek advice from. 
Community pharmacists have long served as the medication experts of the health care team and, due to their knowledge and accessibility, are frequently approached by the public to answer health-related questions.  Several data are available indicating that pharmacists encounter patients with problems related to oral health and their advice can play key role in preventing many of the oral problems within the pharmacy setting. , Herbalists have been perceived by public as expert health counselors who can provide care by alternative medicine. Though the role of pharmacists in disease prevention and health promotion is well established, the role of herbalists is controversial.  The use of alternative remedies before visiting a health care professional has been identified as a significant independent predictor of diagnostic delay.  In spite of these facts, very few studies have investigated the awareness related to oral cancer amongst herbalists as a potential source of diagnostic delay and a new potential educational objective.
So, an attempt has been made to assess the approach of both pharmacies and herbalists' shops while offering a proper advice for patients seeking guidance on a potentially malignant oral lesion.
| > Materials and methods|| |
The aim of the present study was to investigate the pattern of advice given to a potential cancer patient at the pharmacies and herbalists' shops.
Source of a data
The required information for the study was obtained from the chemists and herbalists.
Study design and study setting
Based on the standardized simulated patient approach, a cross-sectional, comparative study was conducted among the chemists and herbalists in Bhopal city.
The study was conducted from March 2013 to May 2013 for a period of 2 months.
The ethical approval was obtained from the ethical committee.
Details of the study
All the available chemists and herbalists who responded to a telephonic survey were included in the study. The chemists and herbalists who did not respond were excluded from the study.
Chemists' addresses and phone numbers were obtained from the registration office of the pharmacists located in the city of Bhopal, and the data on herbal shops were retrieved from the telephone directories and web search. A total of 891 pharmacies and 223 herbal shops were identified.
Sample design and sample size calculation
The study sample was selected by stratified random sampling for a 95% confidence level and an expected proportion of 15% (design effect = 1) by using SPSS software version 20. The resulting sample sizes for a 5% precision were 241 for pharmacies and 76 for herbalists' shops. Each one of these establishments (shops) was contacted on phone.
In order to avoid a hypothetical bias in telephone answers, another study methodology was designed. In this, two most populated regions of the city were located. The pharmacies of one region and the herbal shops of the other one were visited. The type of establishment to visit in each region was randomly selected, and the sample size was calculated by using the same parameters as for the telephone survey. All the establishments already selected for the telephone interview were excluded from the second method, resulting in 127 pharmacies and 53 herbal shops, which were selected by using a simple random sampling technique.
The simulated patient/mystery shopper method  was used, in which an individual interacts with the interviewee according to a previously prepared script. The mystery shopper (standardized patient) was a 58-year-old male who used to smoke 30-40 cigarettes per day for the last 40 years. The patient described an ulcerated lesion on the tongue with features of malignancy. Our patient's introductory statement was: "I have a painful ulceration on the tongue since 3 months. What would you advise?" The responses obtained were recorded on a proforma designed for recording the data.
The recorded data were coded and entered into a personal computer. The statistical analysis was performed by using the statistical software SPSS version 16. The variables were characterized by their frequencies, and differences between groups were assessed by using Chi-square tests. The significance level was set at 5%.
| > Results|| |
A total of 497 establishments were contacted. Out of these, 368 were pharmacies (74.1%) and 129 were herbalists' shops (25.9%). Among these, 241 chemists (48.4%) and 76 herbalists (15.2%) were interviewed by the telephonic survey and 127 (25.5%) pharmacies and 53 (10.6%) herbal shops were visited. All the chemists and herbalists responded to the survey.
The type of contact (telephone vs. visit) for chemists (P = 0.216) and herbalists (P = 0.319) showed no significant difference in terms of the kind of advice given. So, data were merged and analyzed as two single samples: Chemists and herbalists. The responses obtained are shown in [Table 1].
Patients with potentially malignant lesions were more frequently referred to a dentist (16.03%) or a physician (23.36%) by the pharmacies compared to the herbalists' shops. 32.33% pharmacies prescribed over-the-counter (OTC) medications and advised the patient to visit a dentist or a physician. In contrast, most of the herbalists' shops prescribed OTC remedies (66.66%) and showed no interest in referring the patient to a dentist or a physician.
In the prescription, majority of the pharmacists offered mouthwashes with different compositions. On the other hand, herbalists' shops mainly prescribed neem (Azadirachta indica) (37.8%) or honey (29.3%) preparations. 10.32% pharmacies wanted to see the patient, while only 3.87% herbalists wanted to do the same.
There was uniformity within the "other answers" group. At the pharmacies, the standardized patient was asked to come back later in the day, while the herbal shops referred the patient to a chemist. The differences between the responses of chemists and herbalists were statistically significant (P = 0.000).
During the visit to the pharmacies, majority of the interviewees (97.9%) disclosed their qualifications. So, it was possible for us to categorize them into two groups: Pharmacist and pharmacist assistant. In the 127 pharmacies visited, 103 were pharmacists and 24 were pharmacist assistants. The kind of responses received from both (pharmacists and assistants) is presented in [Table 2].
|Table 2: Response received from the pharmacists and pharmacist assistants|
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Pharmacy assistants were found to be more likely to recommend OTC remedies (70.83%) than the pharmacists (15.53%) and were also significantly less likely to refer patients to a dentist or a physician than the pharmacists did.
| > Discussion|| |
The present study evaluated the attitude of pharmacists and herbalists toward patients seeking advice for oral cancer symptoms. A total of 497 pharmacist and herbalist establishments were assessed. For this assessment, a simulated patient/mystery shopper method was adopted. Standardized patients with a structured script had been previously used to study the diagnostic delay in oral cancer, and also, they have proved useful for assessing practical abilities. , In order to disclose the hypothetical bias in telephone answers, another study was designed where the pharmacies and herbal shops were visited by the interviewee.
Many studies have shown that early diagnosis and treatment is the key to better survival rate for the oral cancer patients. Unfortunately, almost half of the oral cancers are diagnosed at advanced stages (III or IV), with the 5-year survival rates ranging from 20-50%. , This can be attributed to the diagnostic delay which is defined as the number of days elapsed since the patient notices the first sign and⁄or symptom until a definitive diagnosis is reached.  Among the many factors that play a role in the process of reaching a diagnosis, research has focused mainly on primary care dentists and physicians, ancillary personnel, and patient awareness. ,
Pharmacists are recognized as one of the most accessible health care professionals for the general population.  Hence, they have a greater responsibility to direct those in need of immediate medical attention to proper health care professionals. Despite this, pharmacists have been identified as a source of diagnostic delay in oral cancer.  In our study, only 16.03% (n = 59) of the pharmacists directly referred the patients to dentists for further assistance, while 32.33% (n = 119) of them prescribed OCT preparation and then referred the patient to a dentist or a physician. On the other hand, most of the pharmacist assistants were in favor of prescribing the OTC prescriptions instead of referring the patients to a physician or a dentist.
Apart from pharmacists, another informal off-clinical counsellor has been identified who may influence patients' health behavior. This includes the herbalist who generally distributes various traditional herbal medicines. There is wide use of alternative medicines by a large number of people worldwide. In countries like USA, UK, and Spain, herbal medicine is used by 12.9-20% of the people.  In south-east Asian region, including countries like India which has the second largest population in the world, the use of alternative medicine is much higher, ranging from 60 to 70%.  Hence, the role of herbalist becomes essential in avoiding diagnostic delays in cancer management. Our study found that herbalists who form a part of alternative medicine were clearly more inclined in prescribing OCT preparations for patients with oral lesions suspicious for malignancy instead of referring them to primary care clinics (66.66%, n = 86). Similar pattern was observed in a study conducted by Varela-Centelles et al.  Absence of regulations and standards in the practice of traditional medicine may explain the low oral cancer awareness detected in this group. 
The results of the study clearly show that herbalists and pharmacist assistants can act as possible factors in diagnostic delays of life-threatening conditions like oral cancer, which suggests that there is a need for specific attention to this group.
Educational strategies to improve advice and referral should be designed for this identified group. Also, multidisciplinary meetings, especially meetings with local dentists or practitioners, can improve the attitude of both pharmacists and herbalists, thereby improving the delivery of oral health care advice.
| > Conclusion|| |
Along with pharmacists, the underutilized potentially valuable group of herbalists can play an active role in general as well as oral health care promotion. Proper utilization of these commonly used health care professionals can help in earlier diagnosis and better outcome for patients suffering from oral cancer.
| > References|| |
Fritz A, Percy C, Jack A, Shanmugaratnam K, Sobin L, Parkin DM, et al
. Alphabetic Index. In: April Fritz, editor. International classification of diseases for oncology (ICD-O), 3 rd
ed. Geneva: World Health Organization; 2000.p. 179.
Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncol 2008;9:667-75.
Parkin DM, Pisani P, Ferlay J. Estimates of the worldwide incidence of 25 major cancers in 1990. Int J Cancer 1999;80:827-41.
Dangi J, Kinnunen TH, Zavras AI. Challenges in global improvement of oral cancer outcomes: Findings from rural Northern India. Tob Induc Dis 2012;10:5.
Devadiga A, Prasad KV. Knowledge about oral cancer in adults attending a dental hospital in India. Asian Pac J Cancer Prev 2010;11:1609-13.
Weinberg MA, Estefan DJ. Assessing oral malignancies. Am Fam Physician 2002;65:1379-84.
Weinberg MA. Oral cancer risk factors and the pharmacist's role in intervention. US Pharm 2006;8:79-84.
Messadi DV, Wilder-Smith P, Wolinsky L. Improving oral cancer survival: The role of dental providers. J Calif Dent Assoc 2009;37:789-98.
Mashberg A, Samit AM. Early detection, diagnosis, and management of oral and oropharyngeal cancer. Ca Cancer J Clin 1989;39:67-88.
Silverman S Jr, Gorsky M. Epidemiologic and demographic update in oral cancer: California and national data--1973 to 1985. J Am Dent Assoc 1990;120:495-9.
Silverman S Jr, Kerr AR, Epstein JB. Oral and pharyngeal cancer control and early detection. J Canc Educ 2010;25:279-81.
Alfano MC, Horowitz AM. Professional and community efforts to prevent morbidity and mortality from oral cancer. J Am Dent Assoc 2001;132(Suppl):24S-9S.
Allison P, Franco E, Feine J. Predictors of professional diagnostic delays for upper aerodigestive tract carcinoma. Oral Oncol 1998;34:127-32.
Dimitroulis G, Reade P, Wiesenfeld D. Referral patterns of patients with oral squamous cell carcinoma, Australia. Eur J Cancer B Oral Oncol 1992;28B: 23-7.
Jovanovic A, Kostense PJ, Schulten EA, Snow GB, van der Waal I. Delay in diagnosis of oral squamous cell carcinoma: A report from the Netherlands. Eur J Cancer B Oral Oncol 1992;28B: 37-8.
Wildt J, Bundgaard T, Bentzen SM. Delay in diagnosis of oral squamous cell carcinoma. Clin Otolaryngol Allied Sci 1995;20:21-5.
Kerdpon D, Sriplung H. Factors related to delay in diagnosis of oral squamous cell carcinoma in Southern Thailand. Oral Oncol 2001;37:127-31.
Onizawa K, Nishihara K, Yamagata K, Yusa H, Yanagawa T, Yoshida H. Factors associated with diagnostic delay of oral squamous cell carcinoma. Oral Oncol 2003;39:781-8.
Bruun JP. Time lapse by diagnosis of oral cancer. Oral Surg Oral Med Oral Pathol 1976;42:139-49.
Andersen BL, Cacioppo JT. Delay in seeking a cancer diagnosis: Delay stages and psychophysiological comparison processes. Br J Soc Psychol 1995;34:33-52.
Shafer WG. Initial mismanagement and delay in diagnosis of oral cancer. J Am Dent Assoc 1975;90:1262-4.
Guay AH. Access to dental care: Solving the problem for underserved populations. J Am Dent Assoc 2004;135:1599-605; quiz 1623.
Diz Dios P, Padrón González N, Seoane Lestón J, Tomás Carmona I, Limeres Posse J, Varela-Centelles P. ''Scheduling delay'' in oral cancer diagnosis: A new protagonist. Oral Oncol 2005;41:142-6.
López- Jornet P, Camacho-Alonso F, Molina Miñano F. Knowledge and attitude towards risk factors in oral cancer held by dental hygienists in the Autonomous Community of Murcia (Spain): A pilot study. Oral Oncol 2007;43:602-6.
Iwanowicz SL, Marciniak MW, Zeolla MM. Obtaining and providing health information in the community pharmacy setting. Am J Pharm Educ 2006;70:57.
Ghalamkari HH, Rees J, Saltrese-Taylor A, Ramsden M. Evaluation of pilot health promotion project in pharmacies: (2) Clients' initial views on pharmacists' advice. Pharm J 1997;258:314-7.
Priya S, Madan Kumar PD, Ramachandran S. Knowledge and attitudes of pharmacists regarding oral health care and oral hygiene products in Chennai city. Indian J Dent Res 2008;19:104-8.
Varela-Centelles P, Pedrosa R, Lopez-Niño J, Sánchez M, Gonzalez-Mosquera A, Mendez A. et al
. Oral cancer awareness at chemist's and herbalist's shops: New targets for educational interventions to prevent diagnostic delay. Oral Oncol 2012;48:1272-5.
Warnakulasuriya S. Living with oral cancer: Epidemiology with particular reference to prevalence and life-style changes that influence survival. Oral Oncol 2010;46:407-10.
Neville BW, Day TA. Oral cancer and precancerous lesions. CA Cancer J Clin 2002;52:195-215.
Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009;45:309-16.
Gómez I, Warnakulasuriya S, Varela-Centelles P, López-Jornet P, Suárez- Cunqueiro M, Diz-Dios P, et al
. Is early diagnosis of oral cancer a feasible objective? Who is to blame for diagnostic delay? Oral Dis 2010;16:333-42.
Kumar S, Heller RF, Pandey U, Tewari V, Bala N, Oanh KT. Delay in presentation of oral cancer: A multifactor analytical study. Natl Med J India 2001;14:13-7.
Watson T, Hughes C. Pharmacists and harm reduction: A review of current practices and attitudes. Can Pharm J (Ott) 2012;145:124-7.e2.
Shaikh BT, Hatcher J. Complementary and alternative medicine in Pakistan: Prospects and limitations. Evid Based Complement Alternat Med 2005;2:139-42.
Rogers SN, Hunter R, Lowe D. Awareness of oral cancer in the Mersey region. Br J Oral Maxillofac Surg 2011;49:176-81.
[Table 1], [Table 2]