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Indian Journal of Community Medicine

Oral Cancer and Some Epidemiological Factors: A Hospital Based Study

Author(s): S P Khandekar, P S Bagdey, R R Tiwari

Vol. 31, No. 3 (2006-07 - 2006-09)

S P Khandekar1, P S Bagdey2, R R Tiwari3

Abstract

Research Question: What is the profile of oral cancer cases reported in the hospital? Objective: To study the profile of the oral cancer cases associated with it. Study Design: Cross-sectional. Study Setting: Government Dental College and Hospital, Nagpur. Participants: 80 cases of oral cancer reported in the Government Dental College and Hospital Nagpur during 1998-2000 Study Variables: Demographic characteristics, oral cancer characteristics, tobacco use. Statistical Analysis: percentages, proportions. Results: Majority of the subjects included in the study belonged to 51-60 years age group. Most of the subjects belonged to lower middle and upper lower socio-economic scale according to modified Kuppuswamy’s socio-economic scale. It was found that the 57 (71.3%) subjects consumed tobacco in the form of betel quid or khaini and 31 (63.3%) males were tobacco smokers in the form of cigarettes and bidis. Alveolus was the common site of oral cancer being present in 55% of the subjects. Histo-pathologically 22 cases were diagnosed as verrucous carcimonma, 27 cases as well differentiated squamous cell carcinoma, 16 cases as moderately differentiated squamous cell carcimonma and 15 cases as poorly differentiated squamous cell carcinoma, 16 cases as moderately differentiated squamous cell carcinoma and 15 cases as poorly differentiated squamous cell carcinoma. Conclusion: In the present study, majority of the cases were squamous cell carcinomas and were presented in the advanced stages of the disease.

Keywords: Oral Cancer, Tobacco Use, Central India

Introduction

These days the world is heading towards various types of non-communicable diseases, which are also known as modern epidemics. Among these modern epidemics cancer is the second commonest cause of mortality in developed countries. In the developing countries cancer in among the ten commonest cause of mortality. Cancer, which is defined as abnormal growth of cell, can affect any tissue or organ of body. Oral cancer is one of the most common cancers in developing countries. In the United States, oral cancer represents approximately 13% of all cancers thereby translating into 30,000 new cases every year. Smokeless tobacco use has been implicated for the etiology of the oral pre-cancerous and cancerous lesions. In the South Asian region over one-third of tobacco consumed is smokeless2. Traditional forms like betel quid, tobacco with lime and tobacco tooth powder are, commonly used and the use of new products is increasing, not only among men but also among children, teenagers, women of reproductive age, medical and dental students. In India, where chewing tobacco is used with betel nuts and reverse smoking (placing the lit end in the mouth) is practiced, there is a stricking incidence of oral cancer- these cases account for as many as 50% of all cancers. While cases of oral cancers are seen in patients who do not use tobacco, these constitute a very small percentage of all oral cancers. Though many studies have been carried out in the different parts of the country, only few studies have been carried out in the Central India. With this background the present study was carried out to study the clinical profile of the oral cancer cases and to study the association of tobacco in its causation.

Material and Methods

The present cross-sectional study was carried out in the department of oral pathology at Government Dental College and Hospital, Nagpur. The study was carried out during 1999-2000. All the cases reporting to the dental out patient department for the oral complaints and where a provisional clinical diagnosis of oral cancer was suspected were included in the study. In all 117 such patients reported during the study period. Interview technique was used as a tool for collection of clinical information. However because of incomplete data on ex-smokers, 13 subjects were excluded. Out of remaining, 104 subjects 24 did not agreed for the biopsy. Thus the final analysis included the data for only 80 subjects. After taking informed consent from each patient the biopsy was carried out according to the TNM classification of the American Joint Committee for cancer staging and end results reporting4. This classification includes four stages depending on primary tumor, regional lymph node involvement and distant metastasis. Histopathological staging was done by Byrne’s grading system. Statistical analysis included calculation of percentages and proportions.

Table I : Distribution of Study Subjects According to Demographic Characteristics

Characteristics Number
of
subjects
(%)
Age (in years)
< 30 4 (5)
31-40 8 (10)
41-50 18 (22.5)
51-60 35 (43.8)
61-70 11 (13.7)
≥71 4 (5)
Sex
Male 49 (61.3)
Female 31 (38.7)
Socio-economic status*
Upper 3 (3.8)
Upper middle 7 (8.7)
Lower middle 26 (32.5)
Upper lower 24 (30.0)
Lower 20 (25.0)
* According to modified Kuppuswamy’s socio-economic scale 4

Table II: Distribution of Study Subjects According to Tobacco Habits Characteristics

Characteristics Number
of
subjects
(%)
Type
Tobacco chewing 57 (71.3)
Tobacco smoking 31 (63.3)
Tobacco chewing as well as smoking 18 (22.5)
Duration *
<5 years 7 (12.3)
5-10 years 21 (36.8)
≥10 years 29 (50.9)
Dose #
<20g/day 12 (21.1)
20-40g/day 27 (47.4)
>40g/day 18 (31.5)
* included only males, # Included only tobacco

Table III: Distribution of Study Subjects According to Clinical and Histopathological Staging

Staging Number
of
subjects
(%)
(TNM)
Stage I 28 (35.0)
Stage II 14 (17.5)
Stage III 19 (23.75)
Stage IV 19 (23.75)
Histopathological (Bryne’s)
Verrucous carcinoma 22 (27.5)
Grade I squamous cell carcinoma 27 (33.75)
Grade II squamous cell carcinoma 16 (20.0)
Grade III squamous cell carcinoma 15 (18.75)

Results

The demographic characteristics of the study subjects are depicted in Table I. Majority of the subjects included in the study belonged to 51-60 years age group. 49(61.25%) of the subjects were male while 31 (38.75%) were females. Most of the subjects belonged to lower middle and upper lower socio-economic scale according to modified Kuppuswamy’s socio-economic scale. Tobacco consumption habits and dose and duration of such habits among study subjects are shown in Table II. 57 (71.3%) subjects consumed 4 tobacco in the form of betel quid or khaini and 31 (63.3%) males were tobacco smokers in the form of cigarettes and bidis. There were 18 (22.5%) subjects who were using tobacco in both chewing as well as smoking form. None of the female smoked tobacco. Among tobacco-chewers majority (87.7%) were having this habit for >5 years. According to dose, (47.4%) was consuming about 20-40 rams tobacco/day. In 55% of the subjects alveolus was the commonest site while carcinoma aurum was present in only one case. Table III shows the TNM and histopathological staging or oral cancer. 47.50% of the cancer cases were in the advanced stages i.e. stage III and IV of TNM classification. Hostopathologically 22 cases were diagnosed as well differentiated squamous cell carcinoma, 16 cases as moderately differentiated squamous cell carninoma and 15 cases as poorly differentiated squamous cell carcinoma.

Discussion

Oral cancer is commonest cancer in India accounting for 50-70% of total cancer mortality1. High proportion of cases among males may be due to high prevalence of tobacco consumption habits among males. Moreover, tobacco is consumed in both chewing and smoking form in males whereas in our society females are not indulged in tobacco smoking1,7,9. Most of the subjects belonged to lower middle and upper lower socio-economic scale. The low socioeconomic status may be a risk factor for poor oral hygiene thereby further increasing the risk of oral cancer in tobacco chewers. Balaram et al have shown similar findings in their study among cases of oral cancer10.

In the present study, majority of the cases of carcinoma alveolus may be correlated with the tobacco chewing habit. Smokeless “Spit” tobacco contains over 2000 chemicals,5 many of which have been directly related to causing cancer. Wrapped inside a betel leaf and plated in the side of the mouth, tobacco has been chewed for centuries in India. This is commonly called as khaini. But in the last decade tobacco companies have started selling tobacco in ready-packaged small sachets. Mostly these quids are kept under lips from where it is gradually absorbed after dilution with saliva. Thus the tongue particularly the side of the tongue (farthest back in the mouth) the floor of the mouth (that area beneath the tongue) and alveolus are the site of maximum insult and thus are maximally affected.

Though, oral cancers occur at a site which is accessible for clinical examination and amendable to diagnosis by current diagnostic tools, the crux of the problem is that majority of the cases report late to the health care facility as evident from the findings of present study1,10,11. This reduces the chances of survival because the studies have shown that detecting oral cancer in early stages, when these are amendable to single modality therapies, offers the best chance of long term survival12.

Tobacco consumption is well established risk factor for development of oral cancer1,3,9,11. It is related to dose and during of tobacco consuming habits as noticed in the present study. Earlier studies have also shown an increasing risk with the increased consumption of tobacco10. Thus on the basis of findings of present study, health education of the community regarding hazards of tobacco consumption in terms of development of oral cancer; complete durability of cancer in earlier stages and education about danger signals of oral cancer (leukoplakia, erythroplakia) is recommended.

References

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  2. Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia, Respiratory. 2003; 8(4) : 419-431.
  3. Dikshit RP, Kanhere S. Tobacco habits and risk of lung, oropharyngeal and oral cavity cancer : a population-based case-control study in Bhopal, India. Int J Epidemiol. 2000; 29(4) : 609-614.
  4. Desai PB, Rao RS. TNM classification and staging of intraoral lumors in caner cells. Oral Caner, 1987; 62 : 73-77.
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  8. Mehta FS, Pindborg JJ. Spontaneous regression of oral leukoplakias among Indian villagers in a 5-year follow-up study. Community Dentistry and Oral Epidemiology, 1974; 2 : 80-84.
  9. Mathew lpe E, Pandey M, Mathew A, Thomas G, Sebastian P, Krishnan Nair M. Squamous cell carcinoma of the tongue among young Indian adults. Neoplasia, 2001; 3(4) : 273- 277.
  10. Balaram. P, Sridhar H, Rajkumar T, Vaccarella S, Herrero R, Nandakumar A. Oral cancer in southern India : the influence of smoking, drinking, paan chewing and oral hygiene. International Journal of Cancer, 2002; 98(3) : 440-445.
  11. Gupta PC et al. Incidence rates of oral cancer and natural history of oral precancerous lesions in a 10-year follow-up study of Indian villagers. Community Dentistry and Oral Epidemiology, 1980; 8 : 287-333.
  12. Yeole BB, Ramanakumar AV, Sankaranarayanan R. Survival from oral cancer in Mumbai (Bombay), India. Cancer Causes Control, 2003; 14(10) : 945-952.

1 Deptt. of Dentistry, Indira Gandhi Medical College, Nagpur.

2 Deptt. of Preventive and Social Medicine, Indira Gandhi
Medical College, Nagpur.

3 Occupational Medicine Division. National Institute of
Occupational Health, Ahmedabad
E-mail: [email protected]

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