Increasing the awareness of oral cancer by harnessing the influence of celebrities

INTRODUCTION

It has never been easier to follow the life of a celebrity. When something significant happens, followers receive notifications instantly. It is well documented that celebrities have a role in creating awareness for issues relevant to the public, including cancer. This includes cancers of the breast, lung, and bowel, to name a few.^[1,2] In the 1980s, Russian–American actor Yul Brynner (d. 1985), in conjunction with the American Cancer Society (ACS), was involved in an intensive anti-smoking campaign following his diagnosis of lung cancer. Powerfully, he proclaimed the simple message, “Do not smoke. Whatever you do, just do not smoke.”^[3,4] A paucity of research exists, however, on the effect of celebrities on the awareness of oral cancer and oropharyngeal cancer (OC/OPCs).^[5]

OC/OPCs are the most common types of (non-dermatologic) head-and-neck malignancies. The most common sites for presentation are the tongue, tonsils, oropharynx, gums, and the floor of the mouth.^[6] Various risk factors are associated with OC/OPC, the most significant being tobacco.

Drinking alcohol also increases the risk. Combined, the incidence is 30-fold that of the abstentious.^[7] Survival rates for OC/OPC are stage-related. Early diagnosis has a 5-year survival rate of 59–84%, compared to 23–70% for advanced (regional or distant) disease at diagnosis. Raising awareness and, thus, early diagnosis is of critical importance.^[8] Google is the most popular internet search engine, enjoying a market share of around 80% in most Western countries.^[9] In 2006, a program called Google Trends was developed, which can be used to investigate the popularity of a search term or topic from 2004 onward. Studies using Google Trends and other technologies have reported on the impact of celebrities on awareness of common cancers.^[2,10,11]

MATERIALS AND METHODS

Google Trends was used to investigate Google search patterns related to OC/OPC in the US between 2004 and 2023. The inclusive topic of “head-and-neck cancer” (HNC) was used in preference to “oral and oropharyngeal cancer,” as Google Trends would only show results for people who typed in that exact phrasing. The results were then refined to uncover specific searches relating to OC/OPC.

The program measured the frequency with which HNC was searched and divided it by the total number of searches completed during the selected period. The ratio is then reported on a linear graph called the “Interest Over Time.” The graph’s X-axis represents the time, and the Y-axis represents “interest.” A value of 0% demonstrates a topic having very little popularity, while a score of 100% represents peak interest.

When the popularity of the topic “HNC” on Google exceeded 50%, the top searches were analyzed. Google Trends offers an option to investigate the most popular search terms within the topic of HNC. The most popular terms are labeled “Breakout,” representing a significant increase in popularity compared to the same search before gaining popularity.

RESULTS

During the study period (2004–2023), six peaks of 50% over baseline related to HNC were seen [Figure 1].^[12] The tallest peaks on the graph occurred in September 2010 and June 2013. HNC-related Google searches from September to August 2010 are shown in Figure 2 and are related to the actor Michael Douglas. Michael Douglas is an actor associated with movies such as Wall Street, Basic Instinct, and The Avengers [Figure 2].^[13] On August 16, 2010, Douglas announced to the public that a tumor had been found on the back of his throat.^[14] Within hours, millions of people became aware of his cancer. Three years later (June 2, 2013), an article titled, Michael Douglas: Oral Sex Caused My Cancer, was published by the Guardian.^[15] In this, the actor described his journey since being diagnosed with cancer. Shortly thereafter, USA Today, CBS News, and others ran the story. In addition to Douglas’s prominence, the article’s salacious title garnered readers. The most popular search terms between May and July 2013 were about Michael Douglas [Figure 3].^[16]

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Figure 1:

Google Trends screen capture of peaks related to “Head and Neck Cancer,” 2004–2023.

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Figure 2:

The ten most popular search terms related to Head & Neck Cancer (HNC), August - September 2010. These dates were used to isolate the peak of September 2010, and to investigate related search terms. Eight of the ten terms contain the name Michael Douglas.

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Figure 3:

The ten most popular search terms related to Head & Neck Cancer (HNC), May-July 2013. Eight of the ten terms contain the name Michael Douglas. His wife, Catherine Zeta-Jones was mentioned in the article.

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Another peak occurred at the end of October 2011. Two celebrities’ announcements coincided with this uptick [Figure 4].^[17] John Mayer is an American singer. In mid-September of 2011, he announced the postponement of performances due to a granuloma.^[18] Although not cancerous, one “breakout” is “John Mayer throat cancer.” Adele, an English pop singer, attracted even more attention. On October 04, 2011, she announced the cancellation of a tour due to a vocal cord hemorrhage.^[19] Rumors swirled on that she had cancer, with #PrayForAdele trending worldwide. In October, a spokesperson for Adele reiterated that “all other reports regarding any other condition are 100% false.”^[20] Months later, another spike corresponded with Adele winning six Grammy Awards (February 13, 2012).

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Figure 4:

Timeline and the ten most popular search terms related to Head & Neck Cancer (HNC), September 2011-February 2012. Even though neither John Mayer nor Adele had malignancies, the search term `cancer’ appeared six times.

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A peak was observed on July 01, 2014. Figure 5 shows HNC-related Google searches from June to July 2014 [Figure 5].^[21] On July 1^st, 2014, Jamie Dimon, CEO of

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Figure 5:

The nine most popular search terms related to Head & Neck Cancer (HNC), June-July 2014. The top two search terms are Jamie Dimon, and six of the nine include `throat cancer’.

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JPMorgan, announced that he had been diagnosed with OC/OPC. In the statement, he mentioned that “the cancer was caught quickly, and my condition is curable.”^[22] At the time, the share price of JPMorgan fell almost 1% overnight.

Another peak occurred in January 2016. An investigation of the period from December 2015 to February 2016 revealed several celebrity-related announcements, displayed in Figure 6.^[23] On 24 December 2015, the singer Janet Jackson announced that she would postpone her tour due to undisclosed surgery. A source who claimed to be close to Jackson published the following, “Doctors found a growth on Janet’s vocal cords that could be serious.”^[24] To quell rumors, Jackson posted a message on Twitter denying she had cancer.^[25] The conflicting reports are associated with the slight increase in popularity on January 6. Eight days later, René Angélil, the husband and manager of Céline Dion, died from OC/OPC. Angélil noticed a lump on his neck in 1999. Following radiation and chemotherapy, he entered remission. In December 2013, the cancer recurred, and surgery was performed, unsuccessfully, to remove the tumor.^[26] The largest peak and the number one searched term during January of 2016 was “Chris Mortensen throat cancer.” On January 16, Entertainment and Sports Programming Network (ESPN) reporter Chris Mortensen announced that he would take leave for OC/OPC treatment. In the weeks and months prior, he described a “dull persistent ear-ache,” his tongue felt heavy, and he had difficulty swallowing. He ignored these symptoms until he spat up blood and noticed that the side of his neck was swollen.^[27,28] On 18 February, another increase in HNC occurred following the death of reality TV star “Big Ang” from OC/OPC. Following diagnosis, she had reported smoking for 40 years and encouraged others to stop.^[29]

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Figure 6:

Timeline and the ten most popular search terms related to Head & Neck Cancer (HNC), December 2015-February 2016.

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A Google Trends peak in June 2019 corresponds to announcements concerning David Mustaine and Beth Chapman [Figure 7].^[30] On June 17, 2019, David Mustaine, the singer of Megadeth, announced that he had OC/OPC.^[31] At a concert in October, he gave fans an update, informing them he was declared cancer-free.^[32] The largest peak in June of 2019 occurred on the 26^th. This corresponded with the death of the reality TV star Beth Chapman. In September 2017, she was diagnosed with stage 2 OC/OPC after seeking treatment for a persistent cough.^[33]

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Figure 7:

The ten most popular search terms related to Head & Neck Cancer (HNC), June-July 2019.

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DISCUSSION

Few studies have been conducted into any “celebrity effect” regarding OC/OPC, but this is not true for other malignancies. As described earlier, actor Yul Brinner appeared in print and television anti-smoking advertisements. This campaign was timed for release coincident with his death in 1986, the expectation being that this might add urgency to the message.^[3,4] Following her husband’s death from bowel cancer in 1997, Katie Couric used her platform on NBC’s Today Show to advocate for screening, something she has repeated following her own diagnosis of breast cancer in 2022.^[2,34] In May 2013, actress Angelina Jolie informed the public that she carried a mutation in the BRCA1 gene. With this mutation, she had an 87% chance of developing cancer and underwent a risk-reducing bilateral mastectomy.^[35] Her announcement had a profound impact on both patients and doctors. One study examining the effect of her announcement found that immediately after her announcement, BRCA gene testing across the US increased by 64%, and this increase in testing continued throughout 2013.^[36]

In another example, Chadwick Boseman, who played the Marvel superhero “Black Panther” unintentionally raised awareness for colon cancer. Following the 2020 announcement of his (publicly) unexpected death from cancer, Google searches for “colorectal cancer” and “colon cancer screening” increased by 598% and 707%, respectively.^[37] Disproportionately, this increase was seen in areas with high portions of African Americans, a group with traditionally lower rates of bowel cancer screening.^[37] Away from the US, in October 2011, former Brazilian President Lula da Silva revealed that he had been diagnosed with OPC due to smoking. Following the announcement, a spike in searches related to smoking cessation was seen in Brazil. The nation had previously sponsored cessation awareness events, but search rates were greater following Lula’s diagnosis than during the organized campaigns.^[38] In Australia, the 2022 diagnosis of OC from singer John Farnham also sparked public interest. Peaks were associated with his diagnosis and the broadcast of a documentary regarding the singer and his disease a year later in Australia. The specific breakout terms for these peaks feature “John Farnham surgery,” John Farnham health update,” “mouth cancer,” and “John Farnham in hospital” [Figure 8].^[39] Of particular note are the peaks of August 23, 2022, the announcement of Farnham’s surgery for tongue cancer, and July 23, 2023, when Farham’s son disclosed in a television documentary that his father was “cancer free.”

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Figure 8:

Google Trends graph for `John Farnham’. Of particular note are the peaks of 23 August 2022, the announcement of Farnham’s surgery for tongue cancer, and 23 July 2023, when Farham’s son disclosed in a television documentary that his father was “now cancer free”.

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To raise awareness for various cancers, public health agencies in the US have decided to have each month feature a different cancer. For example, October is Breast Cancer Awareness Month. Investigating “breast cancer” searches on Google reveals a spike every October, suggesting success.^[40]

However, the efficacy of campaigns varies between cancers. Unfortunately, no comparable spike is seen in April, which is Oral Cancer Awareness Month.^[41] The reason for this is unclear but may relate to OC/OPC’s lower prevalence and perceived relevance. Review of Google Trends spikes related to oral cancer in the absence of celebrity factors or awareness campaigns exists, but their cause is uncertain.^[5] Public health organizations, along with engaged celebrities, have two objectives when raising awareness for cancer. The first is to inform the public about a type of cancer to encourage screening and prevention. The second objective is to increase funding for cancer research. An example of the two being combined successfully is the relationship between the ACS and the National Football League. Since 2009, the program The Crucial Catch has encouraged breast cancer screening, raising millions of dollars for research.^[42] The reason celebrities garner public interest is inherent in itself and is commonly exploited for commercial gain. Health issues among the notable stimulate greater public attention than most other forms of marketing. This can occur without any intent on the part of the celebrity, and internet searches on related topics increase significantly. What cannot be certain, however, is the reliability of any health information.^[43,44]

While studies show that media campaigns raise awareness for oral cancer, few have determined if there is a direct correlation to actionable increases in screening. A study in Ireland investigated the effect of raising public awareness for oral cancer by hosting an oral cancer awareness day. The public was provided information about oral cancer, and researchers hosted free screenings for anyone interested. At the end of the awareness campaign, 1661 patients were examined. The results from screening showed that there was a total of 27 biopsies and a diagnosis of carcinoma in five patients.^[45] In addition to this study, another study examined the impact of an oral cancer marketing campaign in Michigan. Researchers used advertisements, billboards, and information sessions to raise awareness for oral cancer. Dentists and physicians also offered educational programs to encourage the public to be screened for oral cancer. The end of the study showed increased requests from patients to be screened.^[46] While evidence on the longer-term impacts of oral awareness campaigns is limited, these two studies demonstrate how an informed public can take steps to increase requests for oral cancer screenings. Given Oral Cancer Awareness Month’s relative lack of success in the United States compared to other awareness months, celebrity health issues may be a better vehicle for improving health information dissemination regarding OC/OCP.^[3,4,39] Difficulties with this as an approach exist, however. The first is the dependence on the unexpected misfortune of another. Moral qualms aside, this is inherently unpredictable. A second is the transitory nature of public interest. For any campaign to be mounted effectively, it must be of high quality, produced in advance, and “shelved” awaiting its unveiling. This necessitates significant flexibility and internet-based marketing expertise on the part of the sponsoring organization: Contextualizing the pre-prepared campaign to maximize “hits” and to do so within 24-h. To be clinically useful, any such program would need to include a patient pathway for screening: One that would need to be prompt, readily accessible, and inexpensive. Ideally, episodic “celebrity” campaigns would act to augment more traditional offerings.

CONCLUSION

The internet and associated social media platforms are powerful tools that offer the potential to raise public awareness to promote screening for OC/OCP. Incidents within the lives of the “rich and famous” offer the opportunity for misfortune to translate into beneficial outcomes. This may occur within the framework of national dental associations or similar bodies preparing education campaigns in anticipation of their swift rollout. To be effective, any such campaign must be developed with prompt, accessible, and inexpensive screening and treatment pathways. Google Trends has been demonstrated as a useful tool in investigating public behavior regarding internet search patterns.