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MINI SYMPOSIUM: HEAD AND NECK
Year : 2012  |  Volume : 49  |  Issue : 1  |  Page : 21-26
 

Demographic and clinical profile of oral squamous cell carcinoma patients: A retrospective study


1 Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery,VSPM Dental College and Research Centre, Nagpur, Maharashtra, India
2 Radiotherapy, Radiation Chemo Oncologist, RST Cancer Institute and Research Centre, Nagpur, Maharashtra, India
3 Head and Neck Department, RST Cancer Institute and Research Centre, Nagpur, Maharashtra, India

Date of Web Publication25-Jul-2012

Correspondence Address:
R Shenoi
Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery,VSPM Dental College and Research Centre, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.98910

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 » Abstract 

Background: Oral cancers are one of the ten leading cancers in the world. However, in India, it is one of the most common cancer and constitutes a major public health problem. Aim: The purpose of this study was to evaluate, retrospectively, the epidemiologic profile of patients with oral squamous cell carcinoma (OSCC). Materials and Methods: OSCC cases were retrospectively analyzed from January 2008 to September 2010 for age, gender, occupation, duration of the symptoms, habits (tobacco and alcohol consumption), site of primary tumor, and TNM staging, and the findings were formulated to chart the trends in central India population. Results: Male to female ratio was 4.18:1. Mean age was 49.73 years. The most common site of presentation of tumor was in mandibular alveolus region. Tobacco chewing was the major cause for the development of OSCC. Maximum number of patients, i.e., 201 (68.14%) were presented within 6 months of onset of symptoms. Majority of patients were presented in Stage III (82.37%). Correlation between the two variables, i.e., site to habits, staging to site involved, staging to duration of the disease, staging to habits, and staging to age of the patient, were found to be statistically nonsignificant (P>0.05). Conclusions: The aim of the study was the demographic description of oral squamous cell carcinoma. Most of the cases report at advanced stages of the disease which often leads to delay in the management coupled with the fact that health care centers are burdened with long waiting lists. Strategies to overcome the present situation must be undertaken by oral health programs for the early diagnosis and prevention and management and follow up of oral cancer.


Keywords: Clinical data; epidemiology; oral squamous cell carcinoma


How to cite this article:
Shenoi R, Devrukhkar V, Chaudhuri, Sharma B K, Sapre S B, Chikhale A. Demographic and clinical profile of oral squamous cell carcinoma patients: A retrospective study. Indian J Cancer 2012;49:21-6

How to cite this URL:
Shenoi R, Devrukhkar V, Chaudhuri, Sharma B K, Sapre S B, Chikhale A. Demographic and clinical profile of oral squamous cell carcinoma patients: A retrospective study. Indian J Cancer [serial online] 2012 [cited 2019 Jul 17];49:21-6. Available from: http://www.indianjcancer.com/text.asp?2012/49/1/21/98910



 » Introduction Top


Cancer is the major cause of morbidity and mortality all over the world and is one of the leading causes of death in all societies, with its relative position varying with age and sex. Oral and oropharyngeal carcinomas are the sixth most common cancers in the world. [1] The incidence of oral squamous cell carcinoma (OSCC) remains high. [2] Oral cancers have a significant impact on the patient's quality of life, because of the functional loss that results with the treatment modalities even with the highest care rendered nowadays. In India, oral cancer is one of the most common cancer and constitutes a major public health problem. Of all the oropharyngeal malignancies reported to the SEER (Surveillance, Epidemiology, and End Results program of the National Cancer Institute of the United States Public Health Service) registries in the USA between 1973 and 1987, apart from lesions of the salivary glands, gingivae, nasopharynx, nasal cavity, and sinuses, more than 95% were squamous cell carcinomas. [3] Upper aerodigestive tract alcohol- and tobacco-related oral squamous cell carcinomas are thus the major head and neck cancers. [4]

The suffering, disfigurement, and death associated with oral cancers is definitely avoidable, due to easy surgical accessibility of the site, well-recognized causative factors, and the precedence by precancerous lesions, providing an excellent opportunity for early detection and control.

Oral cancers have a multifaceted etiology. [5] A plethora of lifestyle and environmental factors has been identified as the risk factor for oral cancers. However, smoking, tobacco chewing, and alcohol consumption are widely considered to be major preventable risk factors. In addition, the synergistic effects of tobacco and alcohol compounds the problems.

In view of the relative common presentation, delay in diagnosis is also frequent which could be correlated to patient delay (in looking for professional care), professional delay (in reading the diagnosis), or both. Thus, knowledge of the varied presentation and an experienced eye can go a long way in preventing the high morbidity and mortality associated with oral cancers. [6]

A pertinent issue for consideration is rich lymphatic supply of the oral cavity, which results in many cases being detected first in the advanced stage itself. Late presentation may be attributed to patients' ignorance of symptoms and lack of concern for the disease.

The purpose of this study was to evaluate, retrospectively, the epidemiologic profile of patients with oral squamous cell carcinoma.


 » Materials and Methods Top


A retrospective study of 295 patients with a histological confirmed diagnosis of oral squamous cell carcinoma was carried out in VSPM Dental College and Research Centre and Rashtrasant Tukdoji Cancer Institute and Research centre, Nagpur, from January 2008 to September 2010. Most of the patients included in the study were from below poverty line. The institutional ethics committee cleared the protocol and the data pertaining to these patients was entered in a standardized questionnaire. This included medical history, age, gender, occupation, habits of tobacco ingestion, and alcohol intake, duration of symptoms, site of the primary tumor and size of tumor (TNM staging).

A statistical analysis was done on the data collected and the results were formulated. Correlation using chi-square test between the two variables, i.e., site to habits, staging to site involved, staging to duration of the disease, staging to habits, and staging to age of the patient were done.


 » Results Top


There were 295 cases of squamous cell carcinoma of the oral cavity confirmed by biopsy from January 2008 to September 2010. Two hundred thirty-eight patients (81%) were males and 57(19%) were females [Table 1]. The male: female ratio was 4.18:1.
Table 1: Gender distribution

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The largest number of patients in the study 82 (27.8%) were seen in the age group 51 to 60 years followed by the age group 41 to 50 (25.76%). The youngest of all patients affected was 20-year old and the oldest was 86 years. The least number of patients were in the age group less than 70 years (4.07%). The mean age of the patients of oral cancer was 49.73 years. The age distribution is shown in [Table 2].
Table 2: Age distribution

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The site distribution of the lesions in oral cavity has been listed in [Table 3]. The mandibular alveolus was the most frequently involved site, accounting for 135 cases (45.76%), followed by buccal mucosa 70 cases (23.73%). Tongue was involved in 54 cases (18.31%) and maxillary alveolus in 17 (5.76%) patients. Nine patients had involvement of lip (3.05%), in six patients (2.03%) floor of mouth, and four patients had palate (1.36%).
Table 3: Primary site

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The occupation of the patients was recorded and is reported in [Table 4]. The most frequent occupation was farming (33.9%).
Table 4: Occupation

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The personal habits revealed that most of the patients [94 (31.86%)] were tobacco chewers; this was followed by those who had the habit of both tobacco chewing and smoking which represented 55 cases (18.64%). Forty-seven patients (15.03%) had habit of all the three - smoking, tobacco chewing and consumption of alcohol. Sixteen patients (5.42%) were addicted to alcohol but were not consuming tobacco in any form. A small group of the patients 5.08% did not have any of these three habits. However, it was not possible to analyze alcohol, smoking, and tobacco use in terms of quantity, quality, and frequency of use [Table 5].
Table 5: Personal habits

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Duration of symptoms varied between 1-6 months in 68.14% of cases, 6-9 months in 19.66%, 9-12 months in 4.75%, and more than 1 year in 7.46 % [Table 6].
Table 6: Duration of symptoms

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Majority of patients, i.e., 243 (82.37%) were in Stage III. Thirty patients (11.53%) presented in stage II and 18 patients (6.1%) in stage IV. None of the patients had presented in stage I [Table 7].
Table 7: Staging

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Correlation using chi-square test between the two variables, i.e., site to habits, staging to site involved, staging to duration of the disease, staging to habits, and staging to age of the patient were done. All the above-said correlation was found to be statistically nonsignificant (P>0.05). Although, it was seen that patients with tobacco habits were at higher percentage risk of developing cancer [Table 8].
Table 8: Correlation between the variables

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 » Discussion Top


Worldwide, oral cancer is estimated to be the sixth most common cancer, prevalence being highest in India. [5] Understanding the epidemiology and the risk factors for oral cancers can help early identification and prompt treatment of patients with oral cancers. Early diagnosis of oral cancer is important as it leads to early institution of therapy that translates in a better prognosis. Late detection and diagnosis is directly proportional to increased morbidity and mortality.

The male-to-female distribution (4.18:1) was higher than that reported in most studies, except for the study in a Greek population [7] that found a ratio of 9.2:1. Pinholt et al.[8] observed almost equivalent numbers between men and women (1.2:1), even though other studies [9],[10],[11],[12] reported higher ratios (1.5:1, 1.48:1, 1.5:1, and 2.4:1, respectively). There is significant bias in the incidence of oral cancer amongst males, which can be attributed to the easy acceptance of habits by males. The consumption of tobacco and betel nut as a means of stimulants renders males more susceptible to oral cancers. Contrarily, in India, consumption of alcohol and tobacco is considered a taboo amongst the female population. However, this custom is nowadays gradually fading away, as females cutting across age and socio-economic lines are turning to these habits.

According to US National Cancer Institute SEER program, the mean age of diagnosis of oral cancer is 65 years. [3] In a study from Eastern India, mean age was 52.07 years. [13] Predictably in our study, the most affected age group was 51-60 years, youngest of all patients affected was 20-years old and the oldest was 86 years. The mean age of patients of oral cancer was found to be 49.73 years. Sankaranarayan et al.[14] found that the peak-age frequency of occurrence (the fifth decade of life) in India is at least a decade earlier than that described in the western literature. Gupta et al.[15] observed an increase in the incidence of oral cancer in the younger (less than 50 years) age group. Epidemiological study of oral cancer in India by Chattopadhyay et al.[13] and Mathew et al.[16] reported that in developing countries, oral cancer may affect younger men and women more frequently than seen in the western world. The high prevalence of the addiction to tobacco chewing among young adult men and women may explain the stable trend in oral cancer incidence in this group. [5],[17] We would like to state here that, ease at which tobacco and its related products are available at very affordable prices at the grocery stores and paan or betel quid kiosks is leading to people adopting this pernicious habit in this country.

Epidemiological studies have shown that the sites of occurrence for oral cancer differ widely. Tongue, lip, and floor of the mouth are the most frequent sites of lesions of squamous cell carcinoma in the oral cavity. [9],[10],[18],[19],[20] A study in western UP, reported that the most common site was buccal mucosa, followed by the retro molar area, floor of moth, lateral border of tongue, labial mucosa, and palate. [21] In this study, mandibular alveolus was the most frequent site because most of the patients tend to keep the tobacco in the form of quid in the buccal sulcus with close proximity to alveolus. This in turn led to constant irritation with chemical and physical insult of gingiva. Other studies [7],[22] have shown that the lip is the most constant site of squamous cell carcinoma in the oral cavity, even though the tongue was the second site in the majority of these studies.

Farming was the most frequent occupation of patients with squamous cell carcinoma in our study and the second in the study of Almodovar et al. [23] This can be explained as farmers are more indulged toward tobacco addiction as nicotine acts as the stimulant for them. As reported by Antoniades et al.[7] these patients generally have squamous cell carcinoma of the lip which can be explained by the higher UV ray exposure.

Two-hundred eighty patients were associated with habits of tobacco, alcohol consumption, and smoking. Only 15 of these patients did not report any habit. Tobacco is easily available in India and current marketing of tobacco and gutka in one-rupee pouches has been extremely accessible to all people. The pouches containing tobacco do not carry the graphic images illustrating damage to the body as a result of consumption of tobacco as well as statuary warnings unlike that on cigarette packs worldwide. Andre et al.[24] observed a deleterious effect of the consumption of alcohol even with nonsmokers or casual smokers. In our study, 123 patients reported with combined habituation with alcohol, smoking and tobacco. Country liquor - a form of locally brewed alcohol that is cheap and easily available, finds favor for consumption with laborers and farmers. The effect of consuming tobacco and alcohol leads to a dangerous synergy of expression of the disease. Sanghvi et al.[25] observed that the risk ratio for oral cancers were four-fold in chewers, two-fold in smokers, and four-fold in chewers and smokers both. Warnakulasuriya, [5] in his paper opined that, other than major risk factors like tobacco, alcohol, and betel quid, several emerging risk factors namely heredity and familial risk, marijuana (cannabis) smoking, khat chewing, medicinal nicotine use, HIV infection, and alcohol containing mouthwashes are likely to be associated with oral cancer. In our study however, these factors were not analyzed as the patients whose records were checked, were mostly from the lower socioeconomic strata where oral hygiene is not maintained properly or the fact that these patients used tobacco products as a dentifrices.

A study in Western UP revealed that smokeless tobacco habit (60%) was more prevalent that bidi or cigarette smoking habits (36.26%) in both males and females. [21] A cross-sectional study of reverse smoking and its association with premalignant and malignant lesions of the palate was conducted in the north coastal areas of Andhra Pradesh, India, which came with a conclusion that reverse smoking, induced significantly more lesions than conventional chutta smoking, and was a major determinant of subsequent palatal cancer. [26]

The delay in diagnosis of oral squamous cell carcinoma could be correlated to patient delay (in looking for professional care), professional delay (in reading a diagnosis), or both and presumably has some bearing on the size of the tumor presented. The time interval between the onset of symptoms and the start of treatment depends on various factors such as patient behavior, clinical course of the illness and the quality of the health services. [27] A study in Cordoba, Argentina, reported that, both patients and professionals were responsible for the delay in diagnosis. The study indicated that the professional delay was the most associated variable to the stage of tumor. [6] In our study maximum number, i.e., 201 patients (68.14%) presented within 6 months of onset of symptoms. This can be attributed to the fact that because of poverty, illiteracy, and possibly resorting to home remedies, all leading to delay by the patients. Most of the patients have to earn their living by daily wages and the loss of working day's means a loss of wages. Hence, these patients refer late as compared to western data. [28]

Majority of patients, i.e., 243 (82.37%) were presented in Stage III, 34 patients (11.53%) presented in Stage II and 18 patients (6.1%) in Stage IV. None of the patients had presented in Stage I.


 » Conclusions Top


An epidemiological profile of the population of Central India for the patients diagnosed of oral squamous cell carcinoma has been sketched here. The commonest age of presentation was in the sixth decade of life with male predominance (81%). Mandibular alveolus was the most commonly affected site. Most of the patients had associated habits of tobacco and alcohol. Majority of the cases were reported at the advanced stage that depicts the negligence of the health care among the population.

The alcohol and tobacco consumption are the mains risk factors of oral cancer. [29],[30],[31] Widely spread educational campaigns against determinant factors of oral cancer, such as high consumption of tobacco, length of tobacco exposure, associated early establishment of such habit, are urgent in order to reduce oral cancer incidence rates. Moreover, programs should be developed emphasizing the early diagnosis due to its impact on patient's survival rate, quality of life, and treatment costs. Therefore, urgent changes in public health programs must be undertaken aiming to target the population using more efficient means, which in turn should take into account the low level of information concerning oral cancer and its main risk factors. Strategies to overcome the present situation should include not only regular dental attendance, but also oral health programs for the prevention of oral cancer. It must also involve a multidisciplinary approach in the early diagnosis of oral cancer with the participation of other health professionals.

 
 » References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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