Abstract

Background: Oral squamous cell carcinoma (OSCC) is significantly higher in India as about 70% of the cases are reported in the advanced stages leaving five-year survival rates around 20% only. Primary prevention and early diagnosis were found to be novel approaches to avert cancer cases and related deaths. In India, organized prevention and early detection efforts are still lacking.

Aim and objectives: To investigate the correlation between sociodemographic characteristics and clinicopathological presentation of oral squamous cell carcinoma.

Materials and methods: Single hospital-based crossectional retrospective study was carried out at the Department of Head and Neck Oncology, Acharya Harihar Post Graduate Institute of Cancer, Cuttack for a period of three years from October 2018 to September 2021.

Results: A total of 418 cases of histopathologically confirmed OSCC were reported during this study period.  There were 314 (75.11%) male and 104 (24.88%) female patients. The mean (± SD) age of the patients was 52.29 ± 13.37 years with ranging from 21 to 89 years. When checked for the association between tumor stage (early stage I/II and late-stage III and IV) and sociodemographic characteristics,we found middle age male,rural residency,low soccioeconomic status,illiteracy, chewing gutkha  7-10 numbers per day more than 10 years, were significantly associated with the late-stage tumors. Similarly, tumor at left buccal mucosa and border of tongue, moderately and poorly differentiated tumor, underlying Type 2 diabetes, diagnosis more than 10 months after the onset of symptoms were significantly associated with late stage presentation.

Conclusion: There is an important need to initiate public awareness programs in our region to control and prevent oral cancer by screening for early diagnosis and supporting a tobacco-free environment.

Introduction

Oral cancer is a major global public health problem. It is the sixth most common type of cancer with a mortality rate of ~50%. [1] Around 77,000 new cases and 52,000 deaths are reported annually, which is approximately one-fourth of global incidences. In the Indian subcontinent, where it ranks among the top three types of cancer in the country, which accounts for over thirty percent of all cancers reported in the country and quickly becoming a global health priority.[2][3]

As compared to the west, the concern of oral cancer is significantly higher in India as about 70% of the cases are reported in the advanced stages leaving five-year survival rates around 20% only.[4] Prevention against major risk factors (such as any form of tobacco use, alcohol use, high risk human papillomavirus infection, poor nutrition, and chronic trauma) and early detection through screening and relatively inexpensive treatment averts cancer cases and related deaths. In India, organized prevention and early detection efforts are still lacking.[5]

In the regional context, the estimation of socio-demographic characteristics, elucidation of major risk factors and their association with clinicopathological factors and disease outcome is of utmost importance for planning further region-specific health care strategies.

The high burden of oral cancer in Odisha with a paucity of literature in this regard prompted us to investigate, is there any association between sociodemographic characteristics and clinicopathological presentation of OSCC in our geographical region?

Materials and methods

This single hospital-based crossectional retrospective study was carried out on patients who were diagnosed and treated for OSCC at the Department of Head and Neck Oncology, Acharya Harihar Post Graduate Institute of Cancer, Cuttack over a period of three years from October 2018 to September 2021.

Inclusion Criteria:

• Patients of any age with histopathological diagnosis of OSCC.

Exclusion criteria:

• Cases for which data were incomplete or not available in the clinical records.
• Patients with malignancies of the salivary glands, nasopharynx and hypopharynx and metastatic tumors were excluded from the study.
• In cases with no precise information about the primary location.

Socio-demographic details such as gender, age, family history of cancer, chewing & smoking habits details, marital status, educational level, occupation, socio-economic status were obtained and tabulated according to the previous study protocol.[6] In addition, details about clinical presentation and underlying disease history were also collected.

Clinicopathological data (tumor type, grade, anatomical site, tumor size, and TNM staging were retrieved from hospital records. The staging was done according to AJCC 8th Edition criteria and grouped as Early stage (I, II) and Late-stage (III, IV). All the data were collected according to the regulations of the protection of data privacy.

Statistics:

Continuous data were summarized as the mean ± standard deviation (SD), and percentage and proportions were calculated for categorical data. Categorical groups were compared by Chi-square test (χ2), taking the significance level to be 5% (P < 0.05).

Results

A total of 418 cases of histopathologically confirmed OSCC were reported during this study period. There were 314 (75.11%) male and 104 (24.88%) female patients.The mean (± SD) age of the patients was 52.29 ± 13.37 years with ranging from 21 to 89 years. The maximum numbers of patients 278 (66.5%) were in the age group of 41-60 years. The difference in mean age between males and females was statistically significant (P = 0.116). The age and sex-wise distribution of oral squamous cell carcinoma are shown in [Table 1].

The data regarding habit history showed about 320 (76.55%) of patients had tobacco consumption habits either chewing or smoking form among which the most common habits were tobacco chewing 305 (95.31%). A total of 98 (23.44%) did not have any habits.The mean age of patients with habit of chewin was lower (46 years) than the mean age of patients without habit of chewing(51years).Amongst the types of chewable substances, only gutka was found to be significantly associated with the buccal cavity. The median duration of the habit in these cases was 8 years at an average frequency of 7 to 10 times per day. The socio-demographic characteristics of OSCC cases are shown in [Table 2].

The most common sites of OSCC, in both male and female patients, were found to be buccal mucosa 214 (51.19 %). The occurrence of OSCC at different sites, in males and females, did not have any statistical significance. Almost all patients were presented with ulceroproliferative growth. Out of total cases,136 (32.53 %) patients were reported to have type 2 Diabetes Mellitus as underlying comorbidity. Most of the cases were moderately differentiated OSCC 224(53.58 %), followed by poorly differentiated OSCC 158(37.79 %). The median duration between the onset of symptoms to final diagnosis was 3 months with range between 15 days to 7 months. The majority of patients, i.e.361 (86.36 %) were presented in late stage (Stage II &III). The clinicopathological presentation of oral squamous cell carcinoma cases are shown in [Table 3].

*The result is significant at p < .05.

When checked for the association between tumor stage (early stage I/II and late-stage III and IV) and sociodemographic characteristics,we found middle age male,rural residency,low soccioeconomic status,illiteracy, chewing gutkha 7-10 numbers per day more than 10 years, were significantly associated with the late-stage tumors. Similarly, tumor at left buccal mucosa and border of tongue, moderately and poorly differentiated tumor, underlying Type 2 diabetes, diagnosis more than 10 months after the onset of symptoms were significantly associated with late stage presentation [Table 4.

Disscussion

Our data's gender distribution was comparable with the previous studies.[7,8,9] High proportion of cancer among males may be due to the high prevalence of tobacco consumption habits . Contrarily, in India, consumption of alcohol and tobacco is considered taboo amongst the female population. However, this custom is nowadays gradually fading away, as females cutting across age and socioeconomic lines are turning to these habits. In India, the peak-age frequency of occurrence (5th decade of life) is at least a decade earlier than that described in the western literature. [10] 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. It could be due to easily being available at very affordable prices at the grocery stores and paan or betel quid kiosks. In this study, the site and size distribution was in agreement with other studies conducted in India, whereby the most frequent site of OSCC was buccal mucosa. [11] This might be due to the habitual practice of placing betel quid between teeth and buccal mucosa, as commonly observed in our population. This in turn led to constant irritation with chemical and physical insult. In our study 263 (62.91%) patients were presented after 8 months of the onset of symptoms. As in our area majority of patients were below the property line and have to earn their living by daily wages and the loss of working days means loss of wages and in addition patients comes from rural areas, illiteracy, possibly resorting to home remedies is the probable cause of late diagnosis as compared to western countries.[12] Although education plays an important role in the overall health of a country in terms of awareness toward the use of hazardous substances but in the South-Asian region, OSCC is highly associated with low socioeconomic status, where people are less aware of the consequences of carcinogenic compounds because of less education. The main reason is chewing areca nut-related products particularly in low SES, where it is believed to increase work capacity, alertness, suppress hunger, and are a cheap source of entertainment [13]. In another study Odds of developing buccal mucosa tumors in chewers (of any type of substance) and gutka users were 2 and 4 times higher than non-chewers respectively. Middle age, chewing habits, and occupation were significantly associated with the late-stage presentation of OSCC. (p<0.05).[14] In this study, the association between tumor stage (early stage I/II and late-stage III and IV) and sociodemographic characteristics,we found middle age male,rural residency,low soccioeconomic status,illiteracy, chewing gutkha 7-10 per day more than 10 years, were significantly associated with the late-stage tumors. Similarly, tumor at left buccal mucosa and border of tongue, moderately differentiated, underlying Type 2 diabetes, diagnosis more than 10 months after onset of symptoms were significantly associated with late stage presentation In another study correlation between the two variables, i.e., site to habits, staging to the site involved, staging to the duration of the disease, staging to habits, and staging to the age of the patient, were found to be statistically nonsignificant (P>0.05).[7] We also found a positive correlation between clinicopathological presentation (tumor site, grade 3, perineural invasion (PNI) positive, and lymphovascular space invasion (LVSI) positive) and late-stage diagnosis.

Conclusion

There is an important need to initiate public awareness programs in our region to control and prevent oral cancer by screening for early diagnosis and supporting a tobacco-free environment.

Conflict of interest: nil

Source of funding: nil

References

1. International Agency for Research on Cancer. Global Cancer Observatory: Cancer Today. iarc.fr https://gco.iarc.fr/today (2021).
2. Coelho KR. Challenges of the oral cancer burden in India. J Cancer Epidemiol. 2012; 2012:701932.
3. Laprise C., Shahul H.P., Madathil S.A., Thekkepurakkal A.S., Castonguay G., Varghese I., et al. Periodontal diseases and risk of oral cancer in Southern India: results from the HeNCe Life study. Int. J. Canc. 2016; 139:1512–1519.
4. Veluthattil A., Sudha S., Kandasamy S., Chakkalakkoombil S. Effect of hypofractionated, palliative radiotherapy on quality of life in late-stage oral cavity cancer: a prospective clinical trial. Indian J. Palliat. Care. 2019; 25:383.
5. Sankaranarayanan R, Ramadas K, Thara S, Muwonge R, Thomas G.et al  “Long Term Effect of Visual Screening on Oral Cancer Incidenceand Mortality in a Randomized Trial in Kerala, India.” Oral Oncology. 2013; 49 (4): 314–21.
6. Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, et al. Head and neck cancers—major changes in the American Joint Committee on Cancer eighth edition cancer staging manual.CA Cancer J Clin. 2017; 67(2):122–37.
7. Shenoi R, Devrukhkar V, Chaudhuri, Sharma BK, Sapre SB, Chikhale A. Demographic and clinical profile of oral squamous cell carcinoma patients: A retrospective study. Indian J Cancer 2012;49:21-6.
8. Khandekar SP, Bagdey PS, Tiwari RR. Oral cancer and some epidemiological factors: A hospital-based study. Indian J Community Med 2006;31:157-9.
9. Ganesh R, John J, Saravanan S. Socio-demographic profile of oral cancer patients residing in Tamil Nadu - A hospital-based study. Indian J Cancer 2013;50:9-13.
10. Sankaranarayan R. Oral cancer in India, an epidemiologic and clinical review. Oral Surg Oral Med Oral Pathol 1990;69:325-30.
11. Sharma P, Saxena S, Aggarwal P. Trends in the epidemiology of oral squamous cell carcinoma in Western UP: An institutional study.Indian J Dent Res 2010;21:316-9.
12. Ozlü T, Bülbül Y, Oztuna F, Can G. Time course from the first symptom to the treatment of lung cancer in the Eastern Black Sea Region of Turkey. Med Princ Pract 2004;13:211-4.
13. Flora MS, Massie-Taylor C, Rahman M. Betel quid chewing and its risk factors in Bangladeshi adults.WHO South-East Asia Journal of Public Health. 2012; 169.
14. Anwar N, Pervez S, Chundriger Q, Awan S, Moatter T, Ali TS.Oral cancer: Clinicopathological features and associated risk factors in a high-risk population presenting to a major tertiary care center in Pakistan. PLoS ONE.2020; 15(8): e0236359.