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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 102-108

Retrospective study of epidemiology and clinical profile of oral cavity cancers at a tertiary care center


Department of Medical Oncology, Madras Medical College, Chennai, Tamil Nadu, India

Date of Submission05-Jul-2020
Date of Decision12-Oct-2020
Date of Acceptance16-Oct-2020
Date of Web Publication16-Feb-2021

Correspondence Address:
Dr. T S Rahul
Department of Medical Oncology, RGGH, Madras Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_22_20

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  Abstract 


Objective: A retrospective study of patients attended to the Rajiv Gandhi General Hospital, Madras Medical College, Chennai, during January 2013 to December 2016, was carried out to assess the epidemiology and the clinical profiles of oral cavity malignancy.
Materials and methods: 794 patients who met the inclusion criteria of newly diagnosed patients with histopathologically confirmed oral cavity carcinoma, were taken for the retrospective study at Department of Medical Oncology.
Outcome measures: The clinical profile, risk factors, status of presentation, staging and compliance with treatment were the outcome measures.
Results & Discussion: The mean age of the study population was 53.04 years. Addiction to smoking was higher among all the male patients and the consumption of the tobacco was seen much more in the younger age group with decreasing tendency in the older age groups. Non-healing ulcer (83.2%) was the most common presenting complaint and the appearance of oral leukoplakia (29.9%) was more common in tobacco users and with increased frequency in the lower age group patients. The carcinoma tongue ant 2/3rd (42.2%) was the most common disease presentation, followed by buccal mucosa(25.5%), lower alveolus (15.7%), Floor of mouth (9%), lateral border of tongue (4.9%), lower and upper lip (2.26%) malignancies. 30 (3.77%) patients had instu lesion making stage 0 at presentation. Stage I 165(20.7%), stage II 150(18.9%), stage III 246(30.9%) stage IV 203(25.5%) and 9 patients showed distant metstasis at the time of presentation.
Conclusion: Appearance of oral pre-malignat lesions were predominantly seen in younger adults especially those who are addicted to pan chewing. In the study population, there was a habit of keeping the pan contents in the oral cavity especially at sites such as bucco-gingival foldings and buccal mucosa are showing occurrence of site specific increase in pre-malignat lesions and cancers. The implementation of cost-effective policies to reduce alcohol use and tobacco use, such as increasing prices (through taxation), restricting marketing, and counter-advertising,could also help to prevent a large number of oral cavity cancers along with health education to reduce the global burden of disease.

Keywords: Madras medical college, oral cavity cancers, pan chewing, premalignant lesions


How to cite this article:
Rahul T S, Tintu M V, Kumar S. Retrospective study of epidemiology and clinical profile of oral cavity cancers at a tertiary care center. Int J Oral Health Sci 2020;10:102-8

How to cite this URL:
Rahul T S, Tintu M V, Kumar S. Retrospective study of epidemiology and clinical profile of oral cavity cancers at a tertiary care center. Int J Oral Health Sci [serial online] 2020 [cited 2021 Feb 27];10:102-8. Available from: https://www.ijohsjournal.org/text.asp?2020/10/2/102/309445




  Introduction Top


Global estimates suggest 300,373 new cases of oral cancer and 145,000 deaths in 2012.[1] Worldwide age-standardized mortality estimates for lip and oral cavity cancer were 2.7/100,000 during the same year.[2] International Agency for Research on Cancer data indicate that the highest rates of oral cancer are found in Melanesia, South-Central Asia, and Eastern Europe, whereas the lowest rates are in Western Africa and Eastern Asia.[3] The incidence of oral cavity cancer seems to be decreasing in many parts of the world, which parallels regional declines in the tobacco epidemic.[4] Oral cavity cancers constitute a broad range of tumors with diverse etiologies by world region. In developed countries, approximately 75% of oral cavity cancers are attributable to tobacco smoking and alcohol consumption. In developing countries, risk factors also include the chewing of betel quid with or without tobacco, the use of pipes to smoke tobacco, and infection with high-risk human papillomavirus (HR-HPV) types (i.e., HPV16 and HPV18).[5],[6],[7] Other determinants are linked to environmental exposures, e.g., ultraviolet radiation (lip cancer), or deficiencies in dietary intake, e.g., fruits and nonstarchy vegetables (oral cavity and pharyngeal cancers).

International differences in the distribution of oral cavity cancers may be due to differences in etiology, diagnostic workup, prognosis, and treatment. Existing studies have been limited to cancer registry comparisons that currently lack global coverage. There is a critical need to first develop a better understanding of the geographical distribution of new cases of oral cavity cancers by major subsites to determine and to provide an appropriate allocation of health-care resources at the local level.

Accordingly, this study describes and compares the year-specific, sex-specific, and age-specific incidence rates of oral cavity, cancers by subsite examining their major causes, as well as the prospects for effective interventions to reduce the future burden.

Tobacco chewing, alcohol consumption, and HR-HPV infection are the major risk factors for oral cavity cancers, with tobacco smoking and alcohol consumption having synergistic effects.[8] In the Indian subcontinent (particularly in India and Sri Lanka) and in large parts of Southern Asia (particularly in southern China and Thailand), where the incidence of these cancers is highest, tobacco smoking and chewing, with or without betel quid, are the premier causes.

Five-year survival rates for cancers of the oral cavity are approximately 50% for Europe and are expected to be lower in developing countries.[9] Furthermore; prognosis depends largely on how early the cancer is diagnosed and the specific site of the carcinoma. For example, cancers of the tongue, which has a rich blood supply and lymphatic drainage, are much more likely to metastasize than other cancers. HR-HPV positivity impacts on survival, with HR-HPV-related oral cavity cancers associated with a better prognosis.[10] Thus, given the prevalence and impact of various factors on the risk of oral cavity cancers, early detection and prevention are important.

Many countries lack both population-based cancer registries and the interoperability of health information systems to capture these data. Furthermore, many countries lack information on the risk factors for oral cavity including the population patterns of tobacco use, alcohol consumption, and HR-HPV infections. Thus, there is a need for expanded and improved surveillance systems for disease-driven databases, types and difference in risk factors exposure, incidence, apart from mortality and survival data. These data are necessary to plan, implement, and evaluate cancer prevention and control activities.

Aim

This study aims to assess the epidemiology, clinical profile and the treatment undergone for the patients attended to the department of medical oncology, Madras Medical College, Chennai, during 2013 January to 2016 December.


  Materials and Methods Top


A retrospective study of patients attended to the department of medical oncology, Madras Medical College, Chennai, during 2013 January to 2016 December, was carried out.

Inclusion criteria

  1. Newly diagnosed patients with histopathologically confirmed carcinoma oral cavity attending the hospital
  2. Performance status of 0–3.


Exclusion criteria

  1. Previously diagnosed patients and undergone treatment outside with histopathologically confirmed carcinoma oral cavity attending the hospital
  2. Performance status of 4.


Assessment

The recorded data of thorough history and clinical examination performed including oral cavity examination, investigations such as chest X-ray, ultrasonography abdomen, contrast-enhanced computed tomography head and neck, complete blood count, renal function test, liver function test, and urinalysis will be obtained. Direct laryngoscopy was done routinely and triple endoscopy was performed only in patients clinically suspicious of synchronous second primary. Tumor size was examined clinically and by imaging prior to the treatment.

Surgery

The extent of surgical resection was dictated by extent of primary disease at presentation. Wide local excision was performed in all the patients with neck dissection. Regional lymph node dissection was done in all the patients except in fixed or N3 nodal status.

External beam radiotherapy

Primarily inoperable, Stage III and IV, as well as selected postoperative patients with risk factors such as margin and node positivity were irradiated by external beam radiation with megavoltage beams on telecobalt (Co60) machine with a total dose of 60 Gy–66 Gy given in 30–33 fractions of 2 Gy per fraction, 5 fractions per week as a single modality or starting 1st day of the first chemotherapy in concurrent settings.

Chemotherapy

With respect to the performance status patients were received either weekly injection cisplatin 40 mg/m2 or 3 weekly injection cisplatin 100 mg/m2 regimen given intravenously starting on day one of radiation. Premedication with injection dexamethasone 8 mg IV, and a 5HT3-receptor antagonist as antiemetic with hydration with 1000 ml NS followed by mannitol 20 g followed by cisplatin in 500 ml Normal saline followed by injection calcium gluconate, KCl, MgSO4 1ampule, in 500 ml Normal saline followed 500 ml ringer lactate. Antiemetic prophylaxis will be continued with 5HT3 receptor antagonist orally for 3 days after each cycle of chemotherapy.

Treatment monitoring and follow up

The patients were followed-up monthly for first 3 months followed by three monthly for 3 years, then 6 monthly from completion of therapy to assess response, toxicity and disease status. At follow-up patients were undergone thorough clinical examinations for detection of loco-regional disease. Patients who drop out or do not complete planned course of treatment were excluded.


  Results Top


A total of 794 patients who fulfilled the criteria were included in the study. Out of which, 754 patients completed the treatment as scheduled. There were 17 dropouts during the proposed intervention, 23 patients were assigned for palliative chemotherapy due to the disease burden at the time of presentation [Figure 1].
Figure 1: Year-wise appearance of oral cavity cancers

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The mean age of this study population was 53.04 years, ranging from 9 to 99 years. Majority 30.73% of patients were in the age group of 51–60 years. 143 patients (18.01%) are below the age of 40 years, 41 patients (5.16%) were the age group of above 71 years [Figure 2].
Figure 2: Age-wise distribution

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538 (67.7%) patients out of 794 were male and 256 patients were female. 762 patients were lower class and 32 were lower middle class economic status, and among females 226 (88.6%) were house wives and 30 (11.4%) were manual labors [Figure 3].
Figure 3: Socio-economic status.#The socio economic status was assessed based on per capita monthly income, using modified BG Prasad socio economic status, Revised income categories for all India (IW) 2014

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Addiction to smoking was higher among all the male patients and the consumption of the tobacco was seen much more in the younger age group with decreasing tendency in the older age groups. Among females the addiction to tobacco was noted in the middle aged group and in young. 16.87% had no history of any addictions [Figure 4].
Figure 4: Age-wise presentation of risk factors

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Nonhealing ulcer (83.2%) was the most common presenting complaints in all the age groups. The appearance of oral leukoplakia (29.9%) was more common in tobacco users and with increased frequency in the lower age group patients. Occurrence of other symptoms like ulcerative mass, dysphagia, bleeding, etc., noted with decreasing frequency [Figure 5].
Figure 5: Age group-wise presentation of symptoms

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Thirty (3.77%) patients had Carcinoma in situ (CIS) lesions making stage 0 at presentation. Stage I 165 (20.7%), Stage II 150 (18.9%), Stage III 246 (30.9%), Stage IV 203 (25.5%), and nine patients showed distant metastasis at the time of presentation. N3 nodal status was noticed in 20 patients invariably among the ca tongue disease status [Figure 6].
Figure 6: Stage-wise presentation

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The commonest histology was squamous cell carcinoma constituting 743 (93.5%), followed by carcinoma In situ 30 (3.77%) and other histological variants including adenoid cystic carcinoma, melanoma, osteosarcoma, rhabdomayosarcoma, and dermatofibrosarcoma all together 2.7% (21 patients).

Out of 794 patients, carcinoma tongue anterior 2/3rd (42.2%) was the most common disease status, followed by buccal mucosa (25.5%), lower alveolus (15.7%), Floor of mouth (9%), lateral border of tongue (4.9%), lower and upper lip (2.26%) malignancies [Figure 7].
Figure 7: Site of presentation

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Seven hundred and fifty four patients completed the treatment as scheduled [Figure 8]. There were 17 dropouts during the proposed intervention, 23 (2.89%) patients were assigned for palliative chemotherapy due to the disease burden at the time of presentation. And among in all those patients presented with extensive disease status the primary site of lesion was tongue, out of which nine patients showed distant metastasis, lung being the site of secondary deposits in all of them.
Figure 8: Treatment modality

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  Discussion Top


Early diagnosis and screening

Early recognition of the symptoms and signs, as well as prompt diagnosis of precancerous lesions and oral cavity cancers is vital to patient survival. In developing countries, like India there is often a lack of resources, including inadequate cancer screening and treatment facilities and a scarcity of trained personnel (in particular, oncopathologists, histotechnologists, and cyto-technologists). Demanding, improvement in health resources and access to them in our country should be a priority. First, there is no standard or routine screening test to diagnose oral cavity cancers and no screening guidelines have been provided for the early detection of oral cavity leukoplakia and erythroplakia lesions or cancers. A recent Cochrane review found only one published community randomized-control study in which the primary aim was to assess the effects of oral cavity cancer screening on mortality.[11] That study, which was performed in India, found that visual oral screening of high-risk groups could reduce oral cavity cancer mortality by at least 29%.[12] However, additional studies are required to assess the effectiveness of screening programs based on the number of deaths prevented versus the costs of screening program as well as the potential harms caused by over diagnosis and overtreatment. Therefore, although there is no evidence of effectiveness, visual inspection for oral leukoplakia and erythroplakia lesions and for oral tumors during dental visits or regular family physician appointments in high-risk groups may be able to reduce oral cavity cancer mortality. Finally, to assist in the rapid detection of likely oral cavity cancers, referral criteria should be developed to aid in prioritizing the biopsy (which is required for diagnosis) of highly probable malignant lesions.[13]

Etiology and epidemiology

Oral cavity cancer is more predominant among middle-aged men who use tobacco and alcohol. Apart from cigarette smoking and use of alcohol, HPV infection, marijuana smoking and betel quid uses have also been implicated as causative factors in the formation of squamous cell carcinomas of the upper aero digestive tract. Leukoplakia is seen with oral carcinoma in approximately 29.9% of cases in the present study.

Oral cavity cancers were traditionally being thought of as a disease mainly affecting people of older age group.[14] The pattern observed in our study population is different. The cases are observed at an early age of life. This increased incidence of oral cancer at a younger age group may be due to genetic damage, attributed to the indiscriminate usage of substances, mainly tobacco and tobacco-related products over a prolonged period of time. Most oral cancers (93.5%) are squamous cell carcinoma, and the average age of diagnosis is approximately 53 years, making this an important issue in the middle and younger age population in our study. As the prognosis depends on the cancer stage at the time of diagnosis, early detection and treatment provide better out come in oral cancers. Event though, the oral cavity provides an easily accessible site for identification of a cancerous lesion, oral cancers often fails to be diagnosed until the lesion is quite large and metastasized to the lymph nodes in our country.

Proper examination of the patient with fully extend tongue, grasping it with gauze, and viewing the posterior lateral borders is an essential component of an oral soft tissue examination. Good lighting and a mouth mirror or tongue depressor are the only instruments required for routine screening examinations. Patients should be encouraged to conduct a self-examination at regular intervals in conjunction with daily oral care and measures to prevent traumas related to sharp teeth. However, all patients should be taught how and what to look for in their mouths. Anything that does not appear normal, on both sides of the mouth, and does not go away within 7–10 days warrants a check evaluation by a physician.

The risk of recurrence or appearances of second malignancy, in patients who have undergone treatment for oral cancer continue to be high, particularly if they continue to use tobacco and/or alcohol. 16.87 percent of oral cancer lesions are not associated with the typical risk factors of tobacco and alcohol in our study. Since age is being a risk factor for them, all senior patients seen in a practice should undergo a routine and thorough oral cancer screenings.

The most important among them is the use of tobacco. The Global Adult Tobacco Survey (GATS) conducted in India in 2009–2010 reported the highest prevalence of use of areca nut-based tobacco products among males in Madhya Pradesh followed by Gujarat, Maharashtra and Delhi. According to GATS, tobacco use in India has been higher among males than females.[15] Though, among middle-aged and elderly males and females, the pattern of use of chewing tobacco was the same. Tobacco use was found to be more common among the uneducated masses in India. This can often be related to less knowledge and awareness among the uneducated people regarding the health hazards of tobacco use. Poverty was associated with higher risk of use of chewing tobacco from our study population. Thus, it indicates that there is a relationship between these socioeconomic indicators and tobacco consumption, thereby leading to increased oral cancer incidence. In India, the nonawareness of health hazards of tobacco is strongly associated with its use. The severity of health risks associated with tobacco use is poorly understood by tobacco users that should be addressed and preventive measures should be taken among all the high risk population in the society. As appearance of oral premalignant lesions were predominantly seen in younger adults especially those who are addicted to pan chewing. Because, in the study population there was a habit of keeping the pan contents in the oral cavity especially at sites such as bucco-gingival folding and buccal mucosa are showing occurrence of site specific increase in premalignant lesions and cancers.

Prevention

The marked age differences in the distributions and patterns of oral cavity by subsite indicate that a large proportion of these cancers typically caused due to the risk factor exposure and are potentially avoidable. Furthermore, if current rates remain unchanged, the absolute burden of oral cavity, cancers are predicted to increase globally because of population aging and population growth, with the largest increase in new oral cavity cancer.

The cost-effective policies to reduce alcohol use and tobacco use, such as increasing prices (through taxation), restricting marketing, and counter-advertising could help to prevent a large number of oral cavity cancers as well as a large proportion of other tobacco-related and alcohol-related diseases. Furthermore, tobacco public health policy changes must be comprehensive, in that they should cover all forms of tobacco use including bidi and smokeless tobacco, which are especially popular in eastern/southeast Asia. Clinicians can also screen for tobacco use and harmful alcohol consumption among patients, with the aim of implementing brief interventions and/or prescribing smoking-cessation medications (in the case of tobacco).


  Conclusion Top


In this study, during the period of 4 years, a total of 794 patients who fulfilled the criteria were included. The mean age of the study population was 53.04 years. Addiction to smoking was higher among all the male patients and the consumption of the tobacco was seen much more in the younger age group with decreasing tendency in the older age groups. Among females the addiction to tobacco was noted in the middle aged group and in young. Nonhealing ulcer (83.2%) was the most common presenting complaints in all the age groups. The appearance of oral leukoplakia (29.9%) was more common in tobacco users and with increased frequency in the lower age group patients. Appearance of oral premalignant lesions were predominantly seen in younger adults especially those who are addicted to pan chewing. In the study population there was a habit of keeping the pan contents in the oral cavity especially at sites such as buccogingival foldings and buccal mucosa are showing occurrence of site specific increase in premalignant lesions and cancers. Even carcinoma tongue anterior 2/3rd (42.2%) was the most common disease status, followed by buccal mucosa (25.5%), lower alveolus (15.7%), Floor of mouth (9%), lateral border of tongue (4.9%), lower and upper lip (2.26%) malignancies. 30 (3.77%) patients had instu lesion making stage 0 at presentation. Stage I 165 (20.7%), Stage II 150 (18.9%), Stage III 246 (30.9%), Stage IV 203 (25.5%), and nine patients showed distant metastasis at the time of presentation.

Apart from health educations the implementation of cost-effective policies to reduce alcohol use and tobacco use, such as increasing prices (through taxation), restricting marketing, and counter-advertising, could help prevent a large number of oral cavity cancers as well as a large proportion of other tobacco-related and alcohol-related diseases and injuries that contribute to the global burden of disease. Furthermore, tobacco public health policy changes must be comprehensive, in that they should cover all forms of tobacco use including bidi and smokeless tobacco, which are especially popular in eastern/southeast Asia. Clinicians can also screen for tobacco use and harmful alcohol consumption among patients, with the aim of implementing brief interventions and/or prescribing smoking-cessation medications (in the case of tobacco).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

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



 

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