Increases in HPV-linked cancers in parts of US with high smoking rates

A new paper in JNCI Cancer Spectrum, published by Oxford University Press, finds increases in both men and women for several HPV-related cancers in low-income counties or those with high smoking rates. Increases were slower in the highest-income US counties or those with low smoking rates.

In the era of collective decline in cancer rates, human papillomavirus (HPV)-associated anal, oropharyngeal, and vulvar cancer is still rising. Risk factors for HPV-associated cancers include smoking and risky sexual activities, both behaviors likely more common in poorer parts of the United States.

Researchers here used the Surveillance, Epidemiology, and End Results database, a National Cancer Institute database that provides nationwide information on cancer statistics, to investigate HPV-associated cancers by US county-level income and smoking prevalence between 2000 and 2018.

They found that anal and vulvar cancer among women and anal cancer incidence among men increased significantly in the lowest-income counties and counties with high smoking rates, while the increases were slower in their counterparts.

Cervical cancer incidence plateaued, rising not at all in the highest income counties, but increasing 1.6% a year in the lowest income counties. Oropharyngeal cancer rates among women increased by 1.3% a year in low-income counties and only by .1% in high-income areas. Anal cancer rates among women increased by 3.2% in low-income counties but by only 2.6% in high-income areas. For vulvar cancer, rates increased 1.9% a year in the lowest-income counties but only vs. 0.8% a year in the highest-income counties. Vaginal cancer rates increased by 2% a year in low-income counties and declined by .3% in wealthier areas.

Among men, oropharyngeal cancer rates increased by 2.1% a year in low-income counties and by 1.7% per year in high-income counties. Anal cancer rates increased by 3.9% in low-income areas but increased by only 1.5% in high-income counties.

Counties with high smoking prevalence, which are also often low-income counties, had marked increases in cancer rates compared to their counterparts. Anal cancer among women increased by 5% a year for those living in high-smoking counties and only 1.9% a year for those living in lower smoking-rate counties. Vulvar cancer increased by 3.8% a year a year for those living in high-smoking counties and only .6% for those living in lower smoking-rate counties.

Oropharyngeal cancer rates among men increased by 2.7% a year in high-smoking areas, but only by 1.5% in low-smoking counties. Anal cancer incidence rates among men increased by 4.4% in high smoking-rate counties, but only by 1.2% in lower smoking-rate counties.

“HPV vaccination and cervical cancer screening are the cornerstone interventions to prevent avoidable suffering caused by six cancers,” said the study’s senior investigator, Ashish Deshmukh. “Unfortunately, cervical cancer screening rates declined in recent years and HPV vaccination rates remains 15% points lower in rural low-income counties. The COVID-19 pandemic has further disrupted the delivery of preventative care. Urgent and collective efforts are needed to prevent growing disparities from worsening.”

The paper, “Trends in the Incidence of Human Papillomavirus-Associated Cancers by County-Level Income and Smoking Prevalence in the United States, 2000-2018,” is available (at midnight on March 3, 2022) at https://academic.oup.com/jncics/article-lookup/doi/10.1093/jncics/pkac004.

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Eva Grayzel, Cancer Survivor

Eva Grayzel is an oral cancer survivor that is about increasing awareness and the need for oral cancer screening.

Eva Grayzel, a nationally recognized Master Storyteller and performance artist, was diagnosed at age 33 with stage IV oral cancer and given a 15% chance of survival. After regaining her deep vibrant voice, Eva applied her stage skills to communicate the depth of her experience in a unique and powerful way. For over a decade, Eva’s programs have captivated dental professionals worldwide. A champion for early detection, Eva founded the Six-Step Screening™ oral cancer awareness campaign for which she was recognized by the American Academy of Oral Medicine. Eva is the author of two children’s books, ‘Mr. C Plays Hide & Seek’ and ‘Mr. C the Globetrotter,’ in the Talk4Hope Family Book Series.

Part I:  Becoming a Storyteller

My life changed at the sound of a bell. I was pursuing a career as an actress in New York City while intercepting boredom with interactive stories for 8-12 year olds at an after-school program. One day, the principal came into the room furious, “Didn’t you hear the bell ring?” she demanded. “This delay has caused quite a traffic jam outside!” Students protested, “Wait! Tell us the rest of the story.” Her mouth dropped. This was unprecedented – students begging to stay after the bell. Within 5 years, ‘Story Theater’ carved out a career for me as a motivational storyteller providing value-rich assembly programs, educational keynotes at Professional Day conferences and Teacher-In-Service programs on interactive storytelling techniques. 

Part 2: Transition to Motivational Speaking

A non-healing sore on my tongue was eventually diagnosed as stage IV oral cancer. Tragically ironic for a storyteller! The radical surgery and treatment was devastating but my outcome was extraordinary.

A couple of years later, the ADA (American Dental Association) launched an awareness campaign with the message, ‘There is a painless way to know if this is serious.’ The voicemail I left on their 800 line was succinct, “You need to know my story and I want to help you.” They called back.

In 2003, for the first time, I told my very personal story in a public way, with 9K dentists in the audience at the Annual ADA Conference. My call to action motivated doctors from across the country to request a presentation for their regional dental meetings. My speaking career took off. Patient stories matter. 

Part 3: A Calling to Patient Advocacy

As I contemplated my own extraordinary recovery, silence was not an option. I couldn’t stand by and allow what happened to me, happen to others. Dental offices seemed to lack the material to educate patients about oral cancer. Committed to raising awareness, Six-Step Screening was born. More than a personal choice, I feel an obligation to be a part of the revolution, awakening healthcare providers to the urgency of detecting oral cancer in the early stages and educating the general public.

Part 4: Using Storytelling to Build Business

After a keynote presentation at a dental conference, a Henry Schein sales manager confessed, ‘If my team could tell a story like you do, we would be golden.’

I was all in, “Let me give a workshop for your team on finding and crafting the story to build rapport with clients and inspire trust.” Three weeks later, a rookie to the team claimed it was her story that scored the sale of their highest ticket item. Since then, I’m hired to do what I love, what comes naturally to me: craft stories to have a meaningful impact and create a lasting impression.

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Eva Grayzel, Master Storyteller and Visionary Survivor

Website

Author of: M.C. Plays Hide & Seek

Award-winning children’s book to minimize fear and promote dialogue around cancer.

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Biggest Misconceptions about HPV

Every year, around 3,000 new cases of cervical cancer are reported in the UK. Despite approximately 99.8 per cent of cases being preventable, there are still many misconceptions surrounding cervical cancer. Human papillomavirus (HPV) is the cause of the majority of cases of cervical cancer. HPV is a group of viruses that are spread during sexual activity, some of which do not cause any noticeable symptoms, the NHS explains.

Due to the way in which HPV is spread, some believe that it is similar to other sexually transmitted infections.

However, considering the fact that most women are likely to get HPV at some point in their lives and that it cannot be fully prevented, this isn’t necessarily the case. On Thursday, a new study found that the HPV vaccine cuts cervical cancer by almost 90 per cent. Rebecca Shoosmith, head of support services at Jo’s Cervical Cancer Trust, has spoken with The Independent to help dispel 11 of the biggest misconceptions that continue to perpetuate conversations about HPV.

1. Only women get HPV

While cervical cancer is seen as a cancer that affects women, as it can afflict any person with a cervix, HPV can affect anybody.

The majority people are likely to contract HPV in their lifetime if they are sexually active “regardless of gender”, Ms Shoosmith explains.

“HPV doesn’t discriminate!” she adds.

2. HPV is rare

Because HPV is known as the primary cause of cervical cancer, this may lead to the assumption that it is only contracted by a small number of people.

“HPV is actually really common with around four in five of us getting it at some point,” Ms Shoosmith says.

3. HPV is an STI

While it is typically transmitted through sexual contact, Jo’s Cervical Cancer Trust is trying to encourage people not to call it a sexually transmitted infection.

“Unlike many STIs, it can’t be fully prevented nor can it be treated,” Ms Shoosmith explains.

“Also due to how common it is, it is really unhelpful to call it an STI. It’s much more rare to not get HPV.”

4. Having HPV means you will definitely be diagnosed with cervical cancer

“Having it does not at all mean you will be diagnosed with cancer,” Ms Shoosmith states.

“Infections are really common and cervical cancer is rare.”

The Jo’s Cervical Cancer Trust representative outlines that the human body typically clears itself of the HPV infection “without it doing the body any harm”. “In some cases it can cause cells to change, which is why smear tests are so important as they mean any changes can be picked up.”

5. HPV is curable

Ms Shoosmith emphasises that while it cannot be fully treated, the majority of cases of the infection – nine in 10 – are cleared by the body’s immune system.

She adds that treatment can be provided for cells that have changed.

6. A vaccination isn’t safe

“The vaccine is very safe and extremely effective,” Ms Shoosmith affirms.

“It protects against seven out of 10 cases of cervical cancer, so combined with cervical screening it offers a fantastic degree of protection.”

7. If someone’s partner has the virus, this means they have cheated

While it can be transmitted through sexual activity, it can live undetected in the body for around two decades.

This means it can be extremely difficult to pinpoint exactly when a person contracted it.

“Having the virus is no sign that someone has cheated at all,” Ms Shoosmith says.

8. People who use condoms are not at risk of contracting the virus.

While wearing a barrier-form of contraception such as a condom can reduce a person’s risk of getting the virus. It is not a 100 per cent foolproof preventative measure.

“As HPV lives on the skin, condoms won’t fully protect against it,” Ms Shoosmith explains.

“Other sexual contact like touching or oral sex can pass on too.”

9. If you don’t have sex, you won’t contract HPV

The virus lives on the skin, it is not only spread through penetrative sex.

It can pass from person to person through other forms of sexual activity, Ms Shoosmith outlines.

“If you’ve ever had any kind of sexual contact – that includes oral sex, any touching of genitals or sharing sex toys – you could have come into contact with HPV.”

10. There are HPV screenings for men

While there are currently no screenings for men, boys are now being offered the vaccine in schools, Ms Shoosmith states.

In July 2019, it was announced that boys in the UK were to be offered the jab for the first time in a bid to reduce cancer rates.

11. People with HPV always exhibit symptoms

“There are no symptoms and most people who have it will never actually know that they have it,” Ms Shoosmith explains.

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Can Oral Cancer Screenings Be Covered by Medical Insurance?  

By Crystal May, Co-Founder and COO of Devdent

Oral cancer continues to take lives and it is not partial to economic status. Most recently, we saw this with the tragic death of Eddie Van Halen, who died as a result of his oral cancer. Oral cancer had been an ongoing battle for Eddie Van Halen for nearly 20 years and, unfortunately, it ended his life at the age of 65. According to the Oral Cancer Foundation close to 53,000 Americans will be diagnosed with oral or oropharyngeal cancer this year. It will cause nearly 10,000 deaths, and the survival rate at five years is close to 50%.  The death rate for oral cancer is actually higher than other major cancers, including cervical cancer, Hodgkin’s lymphoma and many others.  Why is this? It’s because oral cancer is hard to discover or diagnose early, so the disease is already highly developed upon diagnosis. Even today, there is still no comprehensive national guideline for screening.

As oral cancer continues to negatively impact the health of those around us, it has become critically important that dental professionals play their role in promoting awareness of the disease and finding oral cancer in its earliest stages. No other healthcare professional has been given both the time and opportunity to screen for and promote early detection of oral cancer like dentistry has. The vast majority of dentists and hygienists received training during their clinical education on the proper method of performing an oral cancer evaluation. We know what to look for but we’ve also learned over the years that by the time you can see oral cancer with the naked eye, it’s in later stages with a 50% mortality rate. This isn’t any different than most of the things we see in the oral cavity, similar to caries. By the time the lesion is large enough to be completely visible, it’s too large to be easily treated and involves more complex procedures. So, we utilize technologies like radiographs and other caries detection tools to aid in early diagnosis. Oral cancer screenings have advanced in this area as well and we now have tools at our disposal that can help with early visualization of lesions. But how do we convince patients of the critical nature of an oral cancer examination when external factors, such as cost, often become a barrier to screening acceptance? How do practices balance the investment in cutting edge technologies with the need to cover costs associated with screenings?

While we would all love to believe that patients would want this service as a preventative measure, we know that money is a huge factor in case acceptance. It is estimated that in 2010 approximately $3.2 billion dollars were spent in the United States to treat head and neck cancers. According to the Oral Cancer Foundation. With that type of budget, medical payers are well aware that reimbursement for screenings and early detection of oral cancer is far less expensive than paying for end-stage disease. If we can demonstrate to patients that medical insurance is covering these advanced screenings on a regular basis, and that there is a minimal out of pocket cost to the patient, the value of the service could potentially skyrocket. I believe oral cancer screenings can become a service that patients now seek out instead of avoid.

Billing Medical Insurance For Oral Cancer Screenings

So how do we tap into this medical benefit for patients? First and foremost, you need to be educated about medical billing in general. Dentists can bill medical insurance for a very long list of medically necessary dental procedures. We teach our dental providers to use these three qualifying questions to determine if medical necessity can be proven.

1 – Does the patient’s oral condition or diagnosis affect the rest of the body?

2 – Does the patient’s medical condition or medication affect the oral cavity?

3 – Are we screening for medical conditions?

With oral cancer screenings, we are answering yes to the third question. We are screening our patients for a medical condition.

In order to meet the coding requirements to bill medical insurance for oral cancer screenings, you must be using a tool to aid in this screening – this cannot be a visual evaluation only. Assuming you are using an adjunctive tool, you will also need the following 4 things to be successful.

1- Proper Coding

2- Adequate Documentation

3- Proper Claims Submission

4- Proper credentialing as a medical billing provider

I will describe the coding and documentation requirements in this post. For more information on claim submission or provider credentialing, please visit www.devdent.com for comprehensive webinars and resources on the topic of medical billing.

Proper Coding:

There are only two codes that need to be used when billing medical insurance for an oral cancer screening. The first is the CPT code, or the procedure code.  You will use 82397 – chemiluminescent assay. Then you will need the ICD-10 code or diagnosis code. You will use Z12.81 – encounter for screening for malignant neoplasm of oral cavity. With these two codes together, you are telling the medical insurance your medical story. You used a luminescent tool to screen the oral cavity for malignant neoplasms. It’s important that you realize that because you are using a screening code, the diagnosis is irrelevant. So, you do not need to have a pathologist report or any other specialist involved in order to bill for the screening.

Adequate Documentation:

A common format for charting when billing medical insurance is the S.O.A.P clinical note layout. This simply takes your clinical notes and breaks it down into four parts:

  • S-Subjective
  • O-Objective
  • A-Assessment
  • P-Plan

To document an oral cancer screening, you need to identify in the Assessment section that you used a specific tool to screen the patient for oral cancer. The Objective section would include any findings, which may be within normal limits, or that you identified something abnormal. The Plan section would include what your plan of action is.

Here is an example of the SOAP note for a routine hygiene patient that completed a VELscope oral cancer screening.

S: 33-year-old female presents today for a 6-month prophy with exam and x-rays. Patient has no pain or problems to report and updated her medical history to show headaches and weight gain.  She reports no medication use.

O:  4 BWX and 2 PA’s were taken per the doctor’s order.  Radiographs show a small M lesion on #18, all others are WNL. Completed an oral cancer screening using the VELscope.  Completed FMP.

A: #18 will need treatment for the MO caries. Oral cancer screening was WNL. FMP was WNL, prophy with handscale.

P: 18 MO Composite, RTC for annual Oral Cancer Screening, RTC 6 months for prophy and exam.

Medical Insurance’s Analysis for Oral Cancer Screening

The next question you might be asking is “what will insurance pay?” As with any time you’re billing medical insurance, the allowable amount is a little bit elusive. To give you a starting point, we completed a detailed verification of benefits on our last 10 patients, nationwide, and got specific benefits for oral cancer screening. The average allowable ranged between $25-$75 per screening. Of the payers we called, here is the coverage breakdown.

Anthem, Blue Cross of ID, BCBS of Western NY, BCBS of OK, and Independent Health will cover the oral cancer screenings at 100% with no deductible to satisfy with no frequency limitations shown. This means that patients with these plans would pay no out-of-pocket for the service.

Cigna and United Health Care both offer coverage at 75-100%, depending on the plan but the deductible must first be satisfied.

Lastly, BCBS of MI has no coverage for this service.

This analysis tells us that many of the major payers consider this to be preventative or diagnostic in nature and do not require the deductible to be satisfied before they pay. It also tells us that we need to be comfortable explaining to our patients that depending on the coverage they have, there may be an out-of-pocket cost to them.

In Conclusion

Oral cancer screenings are a service every dentist should consider offering in their practice. We know that traditional intraoral exams are not adequate and are adding to the late diagnosis and high mortality rate of this specific cancer. We also know that patients are paying for many preventative tests in an effort to detect cancer early, like mammograms and colonoscopies. It’s time oral cancer gets the attention it deserves and no profession is better positioned to do this than dentistry. It’s clear that by offering billing of medical insurance for oral screening to your patients, you can remove the financial barrier that may prevent patients from accepting oral cancer screening services.

 

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Increasing VELscope Acceptance: Session 6 – Case Study & Conclusion

How to Improve VELscope Acceptance – An Interview with Dr. Ray Morgan

Over the past few sessions, you have learned how to approach the topic of oral screening with your patients, address objections and, as a result, improve case acceptance. In our final module, Janet Hagerman interviews Dr. Ray Morgan with The Art of Cosmetic Dentistry, a Georgia practice with a case acceptance rate of 90% for VELscope screenings. Watch and learn what this practice does that makes them so successful.

Subscribe to our blog to stay up to date on the next videos in this series. If you have questions about this video series or for more information on VELscope screening, please reach out to a member of our team at 877.278.3799 or click the button below to connect with us.

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Increasing VELscope Acceptance: Session 4 – Handling Objections

How to Improve VELscope Acceptance – Handling Objections

You’ve been through the complete discovery process we outlined in the previous session. Now, it’s time to handle objections that your patient may have to VELscope screening. From cost concerns to the patient not wanting to know if they could potentially have oral cancer, you’ll need to be prepared to address any issues the patient raises and adequately convey the importance of oral screening.

This week’s video is Session 4: Handling Objections.

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Increasing VELscope Acceptance: Session 3 – Light Their Fire – The Discovery Process

How to Improve VELscope Acceptance – The Discovery Process

Every patient is unique. Your approach to presenting clinical information should be tailored to each individual patient in order to connect with them on a more personal level. In this module, you’ll learn how the discovery process and the types of questions you ask your patients can impact VELscope case acceptance.

This week’s video is Session 3: Light Their Fire – The Discovery Process

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Increasing VELscope Acceptance: Session 2 – Setting the Stage

How to Improve VELscope Acceptance – Setting The Stage

Communication with your patients is key and the approach you utilize when addressing oral cancer screening is equally critical. Taking a proactive approach regarding preparation for these patient conversations will set the stage for success. However, your passion and conviction about the importance of oral cancer screening are what really make the difference.

This week’s video is Session 2: Setting the Stage for Case Acceptance With VELscope.

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How Does the VELscope Work?

David Morgan, PhD

What is the VELscope and How Does the VELscope Work?

The VELscope is a device that is used as an adjunct to the Comprehensive Oral Examination (COE), aiding clinicians in visualizing oral mucosal abnormalities, including infections, trauma, oral cancer and pre-cancerous dysplasia. We often are asked about the technology behind the VELscope and the evidence for its efficacy as an adjunctive oral screening tool. In this article, we will take a look at the VELscope device, how the VELscope works via the principle of tissue fluorescence and what encompasses a typical VELscope examination.

The VELscope System

In order to understand how the VELscope works, let’s take a look at the device itself. The VELscope relies on two key components – an LED ring that emits a specific wavelength of blue light and an eyepiece with an integrated optical filter. The combination of shining light into the oral cavity and viewing the patient’s oral mucosa via an optical filter are what allows clinicians to observe cellular and structural tissue changes and, therefore, visualize areas that warrant further investigation. This brings us to the principle of tissue fluorescence.

Tissue Reflectance Versus Tissue Fluorescence

Traditional oral mucosal examination tools utilize the concept of tissue reflectance, where clinicians use standard white light to illuminate the oral cavity and conduct an oral examination. The VELscope, on the other hand, relies on the principle of tissue fluorescence rather than reflectance. Tissue fluorescence is caused by fluorophores, which are chemical compounds that react to light excitation. When exposed to the blue light of the VELscope, fluorophores respond by emitting their own light at a longer wavelength, which can be observed via the optical filter in the VELscope eyepiece. It’s the excitation of fluorophores, or lack thereof in some instances, that enables the VELscope to visualize cellular change in the oral mucosa.

Fluorescence Patterns

When utilizing the VELscope, normal fluorescence patterns typically appear as a bright apple-green color, indicating that the fluorophores in the tissues of the oral mucosa are responding normally when exposed to blue light. Normal fluorescence patterns can also show a lack of fluorescence:  lymphoid aggregates, the fungiform papillae on the tongue and the heavily vascularized anterior tonsillar pillars are good examples of this. Abnormal fluorescence patterns allow clinicians to observe unhealthy areas of the mucosa, which may be overlooked with the naked eye during a typical white-light reflectance examination.

Abnormal fluorescence patterns typically arise from:

  • An increase in metabolic activity in the epithelium
  • A breakdown of the fluorescent collagen cross-links in the connective tissue layer beneath the basement membrane
  • An increase in tissue blood content, either from inflammation or angiogenesis (hemoglobin strongly absorbs fluorescence excitation [blue] and emission light [green])
  • The presence of pigments (e.g., melanin or amalgam particles) which absorb light

The below illustration gives a great overview of tissue fluorescence in relation to a typical VELscope examination:

As you can see, the light emitted by the VELscope penetrates below the tissue surface, allowing fluorescence patterns to be visualized beyond the epithelium and into the basement membrane. Abnormal epithelial cells and disruption of stromal collagen will not produce a normal fluorescence response, which can be observed through the VELscope.

It is important to note that while the VELscope is often referred to as an oral cancer screening device, the concept of tissue fluorescence covers a wide variety of oral abnormalities, allowing the VELscope to aid in visualizing many oral health concerns:

  • Viral, fungal and bacterial infections
  • Inflammation from a variety of causes, including lichen planus and other lichenoid reactions
  • Trauma
  • Oral cancer, including squamous papillomas and salivary gland tumors
  • Oral dysplasia

Clinicians should familiarize themselves with the typical fluorescence patterns that are presented by each of the above abnormalities. Our team has produced a series of training videos that cover a wide variety of topics, including fluorescence patterns, that can be viewed here.

A Typical VELscope Examination

A VELscope screening is painless, non-invasive and should take less than 2 minutes to complete. Typically, screenings are performed by a dentist or registered dental hygienist but is dependent upon health regulations in your state or province. We recommend discussing the VELscope examination with the patient so that they understand the importance of routine oral screenings and have the opportunity to ask any questions. The VELscope screening is then performed and may be documented via the VELscope photo system application and an Apple iPod touch*, which is connected to the device via a Vx Imaging Adapter. All findings are then recorded in the patient’s chart and the clinician will review to determine next steps, including determination if there is need for a referral to a specialist.

Studies on the Efficacy of the VELscope

There are many studies that have been performed to assess the effectiveness of tissue fluorescence visualization. We maintain a list of studies on our website that are available for in-depth education about the technology behind the VELscope device.

Other Tissue Fluorescence Technologies

While the VELscope is a widely known technology, there are other devices that employ tissue fluorescence as a method for visualizing oral abnormalities. While we believe the VELscope has a strong track record in the oral screening space, we do acknowledge that there are other options available. Dental practices interested in implementing adjunctive oral screening into their practice should research the options available to assess which device best fits the needs of their practice and patients.

So How Does the VELscope Work For My Practice?

I hope this article has provided you with useful insight as to how the VELscope utilizes tissue fluorescence to aid you in visualizing oral mucosal abnormalities. If you are interested in learning more about the VELscope and how it can work for your practice, please feel free to reach out to our team at 877.278.3799.

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Increasing VELscope Acceptance: Session 1 – Oral Cancer Today: Why Look For it?

How to Improve VELscope Acceptance

Many of our VELscope users ask us about the best methods for improving VELscope acceptance by their patients. While every situation and each patient is different, we generally recommend beginning with a discussion on VELscope oral screening in order to emphasize the importance of routine comprehensive oral examinations while addressing patient concerns about the screening process. We have partnered with patient experience expert Janet Hagerman to produce a video series that educates your clinical team on discussing the VELscope screening with your patients, addressing concerns about the screening process and improving your VELscope case acceptance.

This week’s videos include an introduction by Janet and Session 1: Oral Cancer Today: Why Look For It?

Subscribe to our blog to stay up to date on the next videos in this series. If you have questions about this video series or for more information on VELscope screening, please reach out to a member of our team at 877.278.3799 or click the button below to connect with us.

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