Abstract
The objective is to assess the role of socio-economic factors and health-seeking behavior in treatment delay in oral and oropharyngeal cancer in our population. This article adapts—design: prospective study and setting: tertiary care centre. We studied 153 patients with oral and oropharyngeal squamous cell carcinoma who were managed in the department of otolaryngology and head and neck surgery between January 2006 and December 2007. There were 127 male patients (83%) and 26 females (17%) with ages ranging from 22 years to 70 years. Fifty-nine patients (39%) presented to us with early stage disease (i.e. stage I and II), whereas, 94 patients (61%) presented with late stage disease (i.e. stage III and IV). Of the 59 patients presenting with early stage disease, 20 were illiterate and 39 literate with 28 patients (47%) belonging to low socio-economic status and 32 patients (54%) having an access to primary health centre (PHC). Of the 94 patients presenting with late stage disease, 53 were illiterate and 41 literate with 58 patients (62%) belonging to low socio-economic status and 38 patients (40%) having an access to primary health centre. Literacy, socio-economic status, access to primary health centre and health-seeking behavior of our population has a significant association with the stage of presentation of patients with oral and oropharyngeal cancer.
Keywords: Squamous cell carcinoma, Oral cavity, Oropharynx, Head and neck, Socio-economic factors
Introduction
Although, there have been reports of an overall declining incidence of head and neck squamous cell carcinoma (HNSCC) in our population over the past few years, it still remains one of the commonest site for cancer in our country [1, 2]. Amongst the HNSCCs, carcinoma of the oral cavity and oropharynx predominates in our population [1, 3]. This may be attributed to a relatively high prevalence of use of smokeless tobacco in our population [2]. The prognosis of patients with these cancers depends upon a wide range of factors that may be grouped into patient-, tumour- and treatment-related [4]. Amongst the various patient-related factors, the socio-economic factors and health-seeking behavior of the patients may have a direct bearing on the stage of disease at presentation, and thus, on the overall prognosis [5–9]. Most of the data highlighting the role of these factors is attributable to studies in the western literature [5, 7–9]. The relevant literature pertaining to our population is extremely scarce [6]. Due to a significant difference in the socio-economic profile and health-seeking behavior patterns between our population and the western populations, the available data cannot be extrapolated onto our population. The present study is aimed at studying the role of socio-economic factors and health-seeking behavior in treatment delay in oral and oropharyngeal cancer in our population.
Patients and Methods
One hundred and fifty three patients with biopsy proven squamous cell carcinoma of the oral cavity and oropharynx who were treated in the Department of Otolaryngology and Head and Neck Surgery at Maulana Azad Medical College and associated Lok Nayak Hospital between January 2006 and December 2007 were included in the study. Patients with other malignancies (i.e. lymphoma, sarcoma, minor salivary gland malignancies) and patients unwilling to comply were excluded.
All the patients underwent a clinical staging in accordance with the TNM system of the American Joint Commission of Cancer Staging [10] at the time of presentation. On the basis of staging, the patients were divided into 2 groups: Group 1 with early stage disease at presentation (i.e. stage I and II) and group 2 with late stage disease at presentation (i.e. stage III and IV).
Age, sex, predisposing factors, previous treatment history, duration of symptoms, clinical evaluation and knowledge of risk factors were recorded. Kuppuswamy classification [11] (Table 1) was used to assess the socio-economic status and literacy level of all the patients.
Table 1.
Kuppuswamy’s revised classification for socioeconomic status
| Education | A. Score |
|---|---|
| 1. Professional degree (or Hons or MA above) | 7 |
| 2. BA or BSc degree | 6 |
| 3. Intermediate or (post high school diploma) | 5 |
| 4. High school certificate | 4 |
| 5. Middle school certificate | 3 |
| 6. Primary school certificate | 2 |
| 7. Illiterate | 1 |
| Occupation | B. Score |
|---|---|
| 1. Professional | 10 |
| 2. Semiprofessional | 6 |
| 3. Clerical, shopkeeper | 5 |
| 4. Skilled workers | 4 |
| 5. Semiskilled worker | 3 |
| 6. Unemployed | 1 |
| Income (rupees) | C. Score |
|---|---|
| 1. Above 6000 | 12 |
| 2. 3000–5999 | 10 |
| 3. 2250–2999 | 6 |
| 4. 1500–2249 | 4 |
| 5. 900–1499 | 3 |
| 6. 300–899 | 2 |
| 7. <300 | 1 |
| Score (A + B + C): class | |
| 26–29 | I Upper Class/I Professional |
| 16–25 | II Upper Middle Class/II Managerial |
| 11–15 | III Lower Middle Class/III Clerical/Skilled |
| 5–10 | IV Upper Lower Class/IV Semiskilled |
| Below 5 | V Lower Class/V Unskilled |
Required laboratory and radiological investigations were done and the patients were managed according to the standard protocols.
Results
Of the 153 patients, 127 (83%) were male and 26 (17%) were female. The youngest patient was 22 years and the eldest 70 years (Fig. 1). One hundred and eleven patients (73%) presented with oral cavity and 42 patients (27%) with oropharyngeal carcinomas.
Fig. 1.
Showing age distribution of patients with oral and oropharyngeal cancer
Of the 111 patients presenting with oral cavity cancer, 90 (81%) were male and 21 (19%) were female. The commonest site was found to be buccal mucosa (41%) (Table 2). The most common presenting symptom was a mass/ulcer in the oral cavity, followed by pain, dysphagia and trismus. The most commonly identifiable risk factor was tobacco chewing (Table 3). Fifty-one patients each had a well differentiated and a moderately differentiated malignancy on histopathological evaluation, whereas, nine patients had a poorly differentiated squamous cell carcinoma (Table 4). Forty-four patients had cervical lymphadenopathy on presentation.
Table 2.
Sites of presentation in the oral cavity
| Sub-site | Number of patients |
|---|---|
| Upper lip | Nil |
| Lower lip | 09 |
| Buccal mucosa | 45 |
| Oral tongue | 18 |
| Floor of mouth | 09 |
| Lower alveolus | 12 |
| Upper alveolus/Hard palate | 18 |
| Total | 111 |
Table 3.
Number of patients with various risk factors for different sub-sites in the oral cavity
| Sub-site | Upper lip | Lower lip | Buccal mucosa | Oral tongue | Floor of mouth | Lower alveolus | Upper alveolus |
|---|---|---|---|---|---|---|---|
| Risk factors (no. of Patients) | |||||||
| Smoking | Nil | Nil | 18 | 07 | 06 | 04 | 15 |
| Tobacco chewing | Nil | 11 | 32 | 13 | 02 | 14 | 03 |
| Alcohol | Nil | Nil | 04 | 03 | 05 | 05 | Nil |
Table 4.
Showing histological differentiation of tumours at various sub-sites in the oral cavity
| Histological grade of differentiation (no. of patients) | |||
|---|---|---|---|
| Sub-site | Well differentiated | Moderately differentiated | Poorly differentiated |
| Upper lip | Nil | Nil | Nil |
| Lower lip | 05 | 04 | Nil |
| Buccal mucosa | 14 | 22 | 09 |
| Oral tongue | 10 | 08 | Nil |
| Floor of mouth | Nil | 09 | Nil |
| Lower alveolus | 08 | 04 | Nil |
| Upper alveolus/Hard palate | 14 | 04 | Nil |
| Total | 51 | 51 | 09 |
Of the 42 patients presenting with oropharyngeal cancer, 37 (88%) were male and 5 (12%) were female. The commonest site was found to be the base of tongue (Table 5). The commonest presenting symptom was dysphagia. The most common identifiable risk factor was smoking (Table 6). Twenty-seven patients had a moderately differentiated squamous cell carcinoma on histopathological evaluation, whereas, 15 patients had a poorly differentiated squamous cell carcinoma (Table 7). Twenty-nine patients had cervical lymphadenopathy on presentation.
Table 5.
Sites of presentation in the oropharynx
| Sub-site | Tonsil | Base of tongue | Soft palate | Posterior pharyngeal wall | Total |
|---|---|---|---|---|---|
| Number of patients | 15 | 21 | 06 | Nil | 42 |
Table 6.
Number of patients with various risk factors for different sub-sites in the oropharynx
| Sub-site | Tonsil | Base of tongue | Soft palate | Posterior pharyngeal wall |
|---|---|---|---|---|
| Risk factors (no. of Patients) | ||||
| Smoking | 10 | 18 | 05 | Nil |
| Tobacco chewing | 05 | Nil | 03 | Nil |
| Alcohol | 06 | 08 | 07 | Nil |
Table 7.
Showing histological differentiation of tumours at various sub-sites in the oropharynx
| Histological grade of differentiation (no. of patients) | |||
|---|---|---|---|
| Sub-site | Well differentiated | Moderately differentiated | Poorly differentiated |
| Tonsil | Nil | 07 | 08 |
| Base of tongue | Nil | 17 | 04 |
| Soft palate | Nil | 03 | 03 |
| Posterior pharyngeal wall | Nil | Nil | Nil |
| Total | Nil | 27 | 15 |
Of the 153 patients, 59 patients (39%) presented with early stage disease (i.e. stage I and II) and 94 patients (61%) presented with late stage disease (i.e. stage III and IV).
Of the 59 patients presenting with early stage disease, 50 were male and 9 were female with 51 patients presenting with oral cavity cancer and 8 patients with oropharyngeal cancer. Most of the patients with early stage disease presented in the age group of 31–40 years (Fig. 2). The average delay between onset of first symptom and presentation to us was 2 months. Twenty patients (34%) were found to be illiterate. Twenty-eight patients (47%) belonged to low socio-economic status, whereas, 31 patients (53%) belonged to middle or high status. Thirty-two patients (54%) had an access to a PHC and were aware of it. Thirty-seven patients (63%) consulted a qualified practitioner/PHC before being referred to our centre, whereas, 22 patients (37%) consulted unqualified practitioners/alternative medical practitioners or received no treatment before coming to us (Table 8). Most of the patients were aware of the potential harmful effects of smoking, tobacco chewing and alcohol intake. Twenty-five patients (42%) were aware of their probable diagnosis before coming to us and four patients (16%) out of these associated malignancies with a social stigma or considered it to be a communicable disease. Thirty-nine patients (66%) had good oro-dental hygiene practices and 35 patients (59%) were aware of HIV/AIDS.
Fig. 2.
Showing age distribution of patients presenting with early and late stage disease
Table 8.
Showing various consultations sought by patients with early and late stage disease before presenting to us
| Early stage disease | Late stage disease | |
|---|---|---|
| Consultation sought | ||
| Qualified practitioner/PHC | 37 | 37 |
| Unqualified practitioner | 05 | 15 |
| Ayurveda/herbs | 03 | 05 |
| Homeopathy | 03 | 03 |
| Spiritual healing | 04 | 12 |
| Massage | 01 | 04 |
| Folk remedies | 03 | 10 |
| Others/no consultation | 03 | 08 |
Of the 94 patients presenting with late stage disease, 77 were male and 17 were female with 60 patients presenting with oral cavity cancer and 34 patients with oropharyngeal cancer. Most of the patients presented in the age group of 31–40 years (Fig. 2). The average delay between onset of first symptom and presentation to us was four and a half months. Fifty-three patients (56%) were found to be illiterate. Fifty-eight patients (62%) belonged to low socio-economic status and 36 patients (38%) belonged to middle or high status. Thirty-eight patients (40%) had an access to a PHC and were aware of it. Thirty-seven patients (39%) consulted a qualified practitioner/PHC before being referred to us, whereas, 57 patients (61%) consulted unqualified practitioners/alternative medical practitioners or received no treatment before coming to us (Table 8). Majority of the patients were aware of the harmful effects of smoking, tobacco chewing and alcohol intake. Thirty patients (38%) were aware of their probable diagnosis before coming to us and 20 patients (56%) out of these associated malignancies with a social stigma or considered it to be a communicable disease. Thirty patients (32%) had good oro-dental hygiene practices and 37 patients (39%) were aware of HIV/AIDS.
After statistical evaluation of data using Fisher Exact Test, there was found to be a significant association (P value < 0.05) between literacy, socio-economic status and stage of presentation with low levels of literacy and low socio-economic status associated with late/advanced stage at presentation.
Discussion
Head and neck is one of the commonest sites for squamous cell carcinomas in our country. Amongst HNSCCs, oral cavity and oropharyngeal carcinomas predominate [1–3]. India is a high-risk region for oral and oropharyngeal cancer due to a high prevalence of tobacco use, particularly chewing (in both sexes), bidi smoking and alcohol drinking in male population [5]. Our country accounts for a quarter of the world burden of oral cancer [12]. Apart from alcohol and tobacco, low level of education, gender, dietary habits and poor oro-dental hygiene have also been found to be associated with a high risk of oral and oropharyngeal cancer [7].
Despite improvements in diagnosis and loco-regional treatment, the long-term survival in oral and oro-pharyngeal cancer has not increased significantly over the past four to five decades and is amongst the lowest of the major cancers world wide [13, 14]. The observed 5-year survival rate in an Indian population has been reported to be as low as 30.5% in a recent study [5]. Such low survival rates have been accredited to advanced age and advanced clinical stage at presentation. Clinical stage at presentation is directly linked to the delay in seeking treatment on part of the patients [6]. The various factors associated with treatment delay that have been reported in the past include: gender [15], age of patient, site of tumour [16], ignorance, rural/urban difference, fear of mutilating surgery [17] and psycho-social factors [6].
The present study is aimed at identifying the role of socio-economic factors and the health-seeking behavior of patients suffering from oral and oropharyngeal cancer in our population in treatment delay. Our study comprised 153 patients, out of which, 83% were male and 17% were female. This gender distribution was similar to a few of the studies in the past [2], whereas, some studies report a much higher incidence of females suffering from these cancers [6, 7].
Of these, 73% of the patients had cancer of the oral cavity with buccal mucosa as the most common site (41%). Although, oral tongue is considered the most common site for carcinoma in the oral cavity according to western literature [18], the rampant use of chewable tobacco can be attributed to the relatively higher incidence of involvement of buccal mucosa in our country [2, 6]. Seventeen percent of the patients in our study had oropharyngeal cancer with the base of tongue as the commonest site (50%). The most commonly reported oropharyngeal site for cancer in western literature is the tonsil. The most commonly identifiable risk factors for both oral as well as oropharyngeal cancer in our study were tobacco chewing, smoking and alcohol intake. The other reported risk factors in the past include low socio-economic status, gender, dietary habits and poor oro-dental hygiene [7].
Thirty-nine percent of the patients presented to us with early stage disease (stage I and II). These results were comparable to a study on Indian population in the past where 32% of the patients presented with a localized cancer [5]. However, another Indian study in the past reported 50% of the patients presenting in early stages [19].
Thirty-four percent of the patients with early-stage disease and 56% of those with late stage disease were found to be illiterate. Forty-seven percent of the patients with early stage disease and 62% of those with late stage disease belonged to low socio-economic strata. There was a statistically significant association of the literacy levels and the socio-economic status of the patients with their stage of presentation to us. The results were similar to a few of the studies in the past [17, 20], whereas, some other studies have found no significant effect of socio-economic status or literacy on treatment delay [6, 16, 21].
Fifty-four percent of the patients presenting with early stage disease had an access to a PHC, whereas, only 40% of the patients with late stage disease had this access. This difference in distribution of PHCs reflects the lack of primary health care facilities available in our country. PHCs form the first referral unit in our health care system and deprivation of primary health care facility, especially to low socio-economic strata of our population may significantly contribute towards their late presentation.
Thirty-seven percent of the patients presenting with early stage disease and 61% of those with late stage disease consulted unqualified local practitioners or practiced alternative medicine or took no consultation at all before coming to us. The use of alternative medicine and the treatment delay caused by that has been well-documented in the past [9, 22, 23]. In the developed countries, the use of alternative medicine is primarily attributable to the psychological distress over potential, often mutilating treatments [24, 25]. However, in our study the consultation of unqualified local practitioners/alternative medicine could be attributed to the sheer ignorance and lack of primary health care facilities as most of such consultations were sought by the individuals with low literacy levels/who had no access to a PHC/who were unaware of their probable diagnosis.
Thus, we would like to conclude that illiteracy and low socio-economic status are significantly associated with treatment delay in oral as well as oropharyngeal cancer patients in our population. Similarly, unavailability of primary health care services also seems to be contributory towards this delay. These identified predictors of delay may be used in designing an educational intervention program for patients with oral and oropharyngeal cancers, since prevention is better than cure.
References
- 1.Elango JK, Gangadharan P, Sumithra S, Kuriakose MA. Trends of head and neck cancers in urban and rural India. Asian Pac J Cancer Prev. 2006;7(1):108–112. [PubMed] [Google Scholar]
- 2.Mehrotra R, Singh M, Gupta RK, Singh M, Kapoor AK. Trends of prevalence and pathological spectrum of head and neck cancers in North India. Indian J Cancer. 2005;42(2):89–93. doi: 10.4103/0019-509X.16698. [DOI] [PubMed] [Google Scholar]
- 3.Yeole BB, Kurkure AP, Koyande SS. Geographic variation in cancer incidence and its patterns in urban Maharashtra, 2001. Asian Pac J Cancer Prev. 2006;7(3):385–390. [PubMed] [Google Scholar]
- 4.Massano J, Regateiro FS, Januario G, Ferreira A. Oral squamous cell carcinoma: review of prognostic and predictive factors. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(1):67–76. doi: 10.1016/j.tripleo.2005.07.038. [DOI] [PubMed] [Google Scholar]
- 5.Yeole BB, Ramanakumar AV, Sankaranarayanan R. Survival from oral cancer in Mumbai (Bombay), India. Cancer Causes Control. 2003;14(10):945–952. doi: 10.1023/B:CACO.0000007965.61579.b2. [DOI] [PubMed] [Google Scholar]
- 6.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(1):13–17. [PubMed] [Google Scholar]
- 7.Guneri P, Cankaya H, Yavuzer A, Guneri EA, Erison L, Ozkul D, El SN, et al. Primary oral cancer in a Turkish population sample: association with sociodemographic features, smoking, alcohol, diet and dentition. Oral Oncol. 2005;41(10):1005–1012. doi: 10.1016/j.oraloncology.2005.06.002. [DOI] [PubMed] [Google Scholar]
- 8.Munck K, Ali MJ, Murr AH, Goldberg AN. Impact of socioeconomic status on the diagnosis to treatment interval in Waldeyer’s ring carcinoma. Laryngoscope. 2005;115(7):1283–1287. doi: 10.1097/01.MLG.0000165382.83891.92. [DOI] [PubMed] [Google Scholar]
- 9.Davis GE, Bryson CL, Yueh B, McDonell MB, Micek MA, Fihn SD. Treatment delay associated with alternative medicine use among veterans with head and neck cancer. Head Neck. 2006;28(10):926–931. doi: 10.1002/hed.20420. [DOI] [PubMed] [Google Scholar]
- 10.Manual for staging of cancer. Philadelphia: JB Lippincott; 1988. [Google Scholar]
- 11.Mishra D, Singh HP. Kuppuswamy’s socioeconomic status scale-a revision. Indian J Pediatr. 2003;70(3):273–274. doi: 10.1007/BF02725598. [DOI] [PubMed] [Google Scholar]
- 12.Parkin DM, Pisani P, Ferlay J. Global cancer statistics. CA Cancer J Clin. 1999;49(1):33–64. doi: 10.3322/canjclin.49.1.33. [DOI] [PubMed] [Google Scholar]
- 13.Swango PA. Cancers of the oral cavity and pharynx in the United States: an epidemiologic overview. J Public Health Dent. 1996;56(6):309–318. doi: 10.1111/j.1752-7325.1996.tb02458.x. [DOI] [PubMed] [Google Scholar]
- 14.Shiboski CH, Shiboski SC, Silverman S., Jr Trends in oral cancer rates in the United States, 1973–1996. Community Dent Oral Epidemiol. 2000;28(4):249–256. doi: 10.1034/j.1600-0528.2000.280402.x. [DOI] [PubMed] [Google Scholar]
- 15.Elwood JM, Gallagher RP. Factors influencing early diagnosis of cancer of the oral cavity. Can Med Assoc J. 1985;133(7):651–656. [PMC free article] [PubMed] [Google Scholar]
- 16.Williams RG. The early diagnosis of carcinoma of the mouth. Ann R Coll Surg Engl. 1981;63(6):423–425. [PMC free article] [PubMed] [Google Scholar]
- 17.Kumar S, Agarwal SP, Gupta CK. Investigation of factors causing delay in the treatment of oral mucosal cancer. Indian J Oral Maxillofac Surg. 1993;8:41–47. [Google Scholar]
- 18.Watkinson JC, Gaze MN, Wilson JA (2000) Tumours of the lip and oral cavity. In: Stell and Maran’s head and neck surgery, 4th edn. Butterworth-Heinemann, Oxford, pp 275–318
- 19.Sankaranarayan R. Oral cancer in India: an epidemiologic and clinical review. Oral Surg Oral Med Oral Pathol. 1990;69(3):325–330. doi: 10.1016/0030-4220(90)90294-3. [DOI] [PubMed] [Google Scholar]
- 20.Shukla HS, Kumar S, Avasthi K, Naithani YP. An investigation of delay in treatment of breast cancer. Indian J Med Res. 1981;73(5):815–818. [PubMed] [Google Scholar]
- 21.Samet JM, Hunt WC, Lerchen ML, Goodwin JS. Delay in seeking care for cancer symptoms: a population-based study of elderly New Mexicans. J Natl Cancer Inst. 1988;80(6):432–438. doi: 10.1093/jnci/80.6.432. [DOI] [PubMed] [Google Scholar]
- 22.Ernst E, Cassileth BR. The prevalence of complementary/alternative medicine in cancer: a systematic review. Cancer. 1998;83(4):777–782. doi: 10.1002/(SICI)1097-0142(19980815)83:4<777::AID-CNCR22>3.0.CO;2-O. [DOI] [PubMed] [Google Scholar]
- 23.Patterson RE, Neuhouser ML, Hedderson MM, Schwartz SM, Standish LJ, Bowen DJ, et al. Types of alternative medicine used by patients with breast, colon, or prostate cancer: predictors, motives and costs. J Altern Complement Med. 2002;8(4):477–485. doi: 10.1089/107555302760253676. [DOI] [PubMed] [Google Scholar]
- 24.Hammerlid E, Ahlner-Elmquist M, Bjordal K, Biorklund A, Evensen J, Boysen M, et al. A prospective multicentre study in Sweden and Norway of mental distress and psychiatric morbidity in head and neck cancer patients. Br J Cancer. 1999;80(5–6):766–774. doi: 10.1038/sj.bjc.6690420. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, et al. Prevalence, predictive factors and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer. 2000;88(12):2817–2823. doi: 10.1002/1097-0142(20000615)88:12<2817::AID-CNCR22>3.0.CO;2-N. [DOI] [PubMed] [Google Scholar]