Abstract
Introduction
Head and neck cancers are common in the developing nations, especially in the south-east Asia. They account for the commonest malignancy type in India and pose a major public health concern. Oral cancer is the commonest of all head and neck malignancies.
Material and methods
It is a prospective study done from January 2017 to July 2018 at a tertiary care centre with patient population ranging from 22 to 87 years of age. All the 128 patients, irrespective of their gender, with a proven malignancy of the oral cavity were observed for various epidemiological and disease characteristics.
Results
Oral cavity cancers were more common in males than females. It is prevalent in the age group of 60–70 years. The most common site of involvement is the buccal mucosa followed by the tongue. Tobacco chewing and smoking is the most significant risk factor associated. The most commonly involved neck nodes are level I and II lymph nodes.
Conclusion
Oral cancers are common in Indian population. It presents at advanced stage due to poor socioeconomic status of the patients. However, it has also been seen in younger population owing to increasing use of tobacco products. Preventive strategy, based on the epidemiological characteristics, is the need of the hour to reduce the disease burden.
Keywords: Head and neck malignancy, Epidemiology, Oral cancer, Tobacco, Risk factors, Prevention
Introduction
Head and neck malignancy is the commonest type of malignancy in India and oral cancer accounts for over 30% of total cancer burden in the country [1]. Head and neck malignancy are a recognized public health concern in the South east Asian region, especially India, because of the alarming growth rate. In India, 10% of all the cancers affecting females and around 25% of those affecting the males are head and neck cancers [2]. In contrast to the South-east Asian region, head and neck malignancy form only 1–4% of all cancers in the Western Countries [3]. Oral cancers are the commonest of the head and neck squamous cell cancer (HNSCC) in the South-east Asian region, while the cancers of oropharynx and tongue are more common in the Western Countries [4]. The difference in the predominant sites of occurrence of cancers may largely be related to various habits prevalent in the respective regions [5]. In India, 60–80% oral cancers are diagnosed late at advanced stages of cancer reducing the patient survival rates [6]. Oral cancer has various risk factors. Smoking, chewing tobacco and betel nut and alcohol consumption are considered major preventable risk factors. Also, oral cancer affects predominantly the lower socio-economic strata patients because of greater exposure to the risk factors like tobacco chewing [7].
There are geographic variations in the incidence of head and neck malignancy which reflects different prevalent risk factors and lifestyle habits which includes tobacco and alcohol use, nutritional deficiencies, radiation exposure, occupational hazards and human papilloma virus infection. Understanding the epidemiology of various cancers holds the key in designing and planning preventive policies based on research based evidence [8].
Methods
A total of 128 consecutive patients who presented at department of Otorhinolaryngology tertiary care centre in Uttar Pradesh, India and histolopathologically proven squamous cell carcinoma of the oral cavity were included in the study.
It was a prospective observational study from January 2017 to July 2018. The patients were observed for their various epidemiological characteristics like age and sex distribution, sub-site of oral cavity, location of distant metastasis, tumour staging, symptoms, associated risk factors and other features associated with advanced disease.
A detailed informed consent was obtained from all the patients for participating in the study.
Inclusion Criteria
Age group from 21 to 90 years, fresh cases of histopathologically proven primary cancer of oral cavity were included in the study.
Exclusion Criteria
Cancer originating from other sites and extending to oral cavity, previously operated or irradiated patients and those unwilling to participate in the study.
Results
Of the total 128 patients, oral cavity cancers were seen to be common in males (71.87%) than in females (28.12%). Majority of the patients affected were in elderly age group and the commonest age group affected was 61–70 years (37.50%) while only 2 (01.56%) cases were seen in the age group 21–30 years and 4 (03.12%) cases seen in the age group of 31–40 years (Figs. 1, 2, 3).
Fig. 1.
Nodal involvement
Fig. 2.
Bar diagram representing numbers of patients as against T and N stages (n = 128)
Fig. 3.
A patient of oral carcinoma who underwent wide local excision with neck dissection and pectoralis major myocutaneous flap reconstruction
The commonest sub-site of oral cavity affected was buccal mucosa (25.78%) followed by tongue (21.09%), lower alveolus (21.09%), retromolar trigone (11.72%), floor of mouth (10.16%), mandible (05.47%) and upper alveolus (04.69%).
Tobacco chewing was observed to be the most significant risk factor, seen in 83 patients (64.84%) while tobacco chewing along with smoking in 49 (38.28%) and tobacco chewing along with alcohol consumption in 53 (41.41%) patients. Quantity consumed was not documented (Tables 1, 2, 3, 4, 5, 6, 7, 8).
Table 1.
Age distribution
| Age group (years) | Number of patients (n = 128) |
|---|---|
| 20–30 | 2 (01.56%) |
| 31–40 | 4 (03.12%) |
| 41–50 | 15 (11.72%) |
| 51–60 | 18 (14.06%) |
| 61–70 | 48 (37.50%) |
| > 70 | 41 (32.03%) |
Table 2.
Sex distribution
| Gender | Number of patients (n = 128) |
|---|---|
| Male | 92 (71.87%) |
| Female | 36 (28.12%) |
Table 3.
Site of involvement
| Site of involvement | Number of patients (n = 128) |
|---|---|
| Buccal mucosa | 33 (25.78%) |
| Tongue | 27 (21.09%) |
| Lower gingivobuccal sulcus | 27 (21.09%) |
| Retromolar trigone | 15 (11.72%) |
| Floor of mouth | 13 (10.16%) |
| Mandible | 7 (05.47%) |
| Upper gingivobuccal sulcus | 6 (04.69%) |
Table 4.
Presentation
| Symptoms | Number of patients (n = 128) |
|---|---|
| Neck swelling | 85 |
| Ulcer | 73 |
| Burning sensation | 69 |
| Trismus | 64 |
| Foreign body sensation | 59 |
| Pain | 56 |
| Odynophagia | 48 |
| Increased salivation | 44 |
Table 5.
Nodal metastasis at presentation
| Neck node involvement at presentation | Number of patients (n = 128) |
|---|---|
| No node | 43 (33.59%) |
| Level I | 42 (32.81%) |
| Level II | 32 (25.00%) |
| Lower nodal levels | 11 (08.59%) |
Table 6.
T stage of primary tumour
| Tumour stage (T stage) at presentation | Number of patients (n = 128) |
|---|---|
| T1 | 18 (14.06%) |
| T2 | 40 (31.25%) |
| T3 | 42 (32.81%) |
| T4 | 28 (21.87%) |
Table 7.
N stage
| Lymph node stage (N stage) at presentation | Number of patients (n = 128) |
|---|---|
| N0 | 47 (36.72%) |
| N1 | 24 (18.75%) |
| N2 | 54 (42.19%) |
| N3 | 3 (02.34%) |
Table 8.
Risk factors
| Risk factor | Number of patients |
|---|---|
| Tobacco chewing | 83 (64.84%) |
| Tobacco smoking | 35 (27.34%) |
| Tobacco chewing and smoking | 49 (38.28%) |
| Tobacco as well as alcohol | 53 (41.41%) |
A non healing ulcer was the commonest presentation (57.03%), followed by burning sensation at the site of involvement (53.91%), trismus (50.00%), foreign body sensation (46.09%), pain (43.75%), odynophagia (37.50%) and drooling of saliva (34.37%).
Neck swelling was present in 85 patients (66.40%) at presentation. Neck metastasis was seen commonly at level 1 (32.81%), level 2 (25.00%) and level 3 and 4 (08.59%). N2 stage was the most common stage of nodal presentation (42.19%) followed by N0 in (36.72%), N1 in (18.75%) and N3 in (02.34%).
The most common primary T stage was T3 (32.81%) followed by T2 (31.25%), T4 (21.87%) and T1 (14.06%).
The cases with advanced primary tumour T stages, mandible abutment and erosion was seen in 51 (39.84%) cases, skin involvement in 11 (08.59%) and infratemporal fossa involvement in 11 (08.59%) cases.
6 (04.69%) cases had distant metastasis; 5 cases with involvement of the lung (03.91%) and 1 with liver (00.78%).
Squamous cell carcinoma was observed on Histopathological examination in 97% cases. Other histological types included adenocarcinoma, adenoid cystic carcinoma and poorly differentiated carcinoma.
At this centre, the treatment included surgery, radiotherapy and chemotherapy. The indications for radiotherapy or surgery for early tumours of T stage T1 and T2 were also influenced by factors like age, social and economic factors and personal preference. T3 and T4 tumours required multimodal treatment, usually surgery followed by adjuvant radiotherapy or chemotherapy. Majority of patients at this centre underwent surgery along with adjuvant radiotherapy (74%).
Discussion
The most common cancers in males in south-east Asia are of the oral cavity, lungs, esophagus and stomach. In females the most common site is uterine cervix, breast and oral cavity. The head and neck cancer is the most common cancer in south-east Asian region and it is the commonest cancer in males in India whereas they form only 1–4% of all the cancers in the Western countries [3]. The age adjusted incidence rates varies from 20 per 100,000 of population in India to 2 per 100,000 in Middle East region [5]. Oral cancer is the most prevalent form of head and neck cancers in India. Tobacco smoking and use of smokeless tobacco have been identified as main risk factors for oral cancer in the South East Asian population [9, 10].
Most of the affected patients in our study were in 5–7th decade of life, with 51.56% patients falling in the age group of 51–70 years. This is similar to the data reported by Antunes and Antunes [11] which showed 55.82% of their patients falling in the age group.
In our study, 71.87% of patients were males and 28.12% were females. It was similar to the study conducted by Larizadeh et al. [12] wherein they observed 73% patients were males and 27% were females. Similarly, Bhattacharjee et al. [13], in their study observed 74% of the patients were males and 26% were females.
Tobacco chewing was the most significant risk factor seen in our study which was present in 64.84% of the patients. Combined tobacco chewing and alcohol consumption was present in 41.41% patients. Tobacco chewing was observed to be a major risk factor in development of oral cancer in the study by Muwonge et al. [14] Smokeless tobacco is used in many forms in the population which includes chewing tobacco alone or mixed with other ingredients like betel quid, areca nut, slaked lime or mishri. Tobacco contains various carcinogens which include N-nitrosamine, nitrosamino acids, volatile aldehydes and various poly nuclear agents.
In the present study, the oral cancer patients presented late with 32.81% patients presenting with T3 tumour stage, 31.25% in T2 stage, 21.87% in T4 stage and only 14.06% in T1 stage. 66.41% of the cases had neck swelling at presentation with commonest nodal presentation of N2 (42.19%). The possible factors for delayed presentation include poor socioeconomic status of patients, lower literacy rates, higher cost of care and poor accessibility to primary health care. Majority of the patients of oral cancer in the present study belong to lower middle socioeconomic class. 75–80% of cancer present in late stages of the disease increasing the morbidity and mortality [15].
Conclusion
The major challenges for the management of oral cancer in India are the lower socioeconomic class, scarcity of healthcare workers, inability to afford the treatment, illiteracy, lack of awareness of the risk factors and rampant cultural beliefs leading to delay in treatment. With increasing cancer patients, cancer control programs have been initiated for achieving prevention and early diagnosis and treatment. The understanding of various epidemiological characteristics, therefore, holds paramount importance for better planning and execution of cancer control programs.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interests.
Ethical Approval
The study was approved by the institutional ethics committee.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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