ORAL CANCER – THE INDIAN SCENARIO
Dr. L. Krishna Prasad,
Principal, SIBAR Institute of Dental Sciences.
Incidence:
The incidence rates of Cancer in India was reported to be 111 in males & 116 in females, per 1,00,000
population. (Tanuja Rastogi, Susan Devsa, Punam Mangtani , Aleyamma Mathew , Nicola Cooper , Roy
Kao and Rashmi Sinha. Ethnicity and Health Cancer incidence rates among South Asians in four
geographic regions: India, Singapore, UK and US. International Journal of Epidemiology 2008; 37:147 –
160).
Cancers in the lung, stomach, Oral cavity, oesophagus, and oropharynx are the five most common
cancers among males in 2008. Cancers in the breast, cervix, ovary, stomach, mouth are the five most
common cancers among females in 2008. (Cancer incident data: India 2002 – 2006). Oral cancer is the
third most common cancer among males and fourth among females. (Cancer incident data: India 2002 –
2006).
Table 1: Top ten cancers in males (2007 – 2008)
Common cancer in 2007 - 08
Lung
CIR
11.3
Stomach
10.6
Oral cavity
9.3
Oesophagus
6.8
Oropharynx
6.4
Lymphomas
5.5
Hypopharynx
4.2
Leukamia
4.2
Prostate
4.0
Larynx 3.7
Crude incidence rate (CIR) / 100,000
Top ten cancers in females (2007 – 2008)
Common cancer in 2006 - 2008 CIR
Breast 30.2
Cervix 17.2
Ovary 7.0
Oral Cavity
5.8
Stomach
5.6
Oseophagus
3.9
Lung
3.8
Lymphoma
3.4
Leukaemia
3.3
Rectum 205
Crude incidence rate (CIR )/1,00,000
(Courtesy : Cancer incident data: Chennai , India 2002 – 2006).
Cancer pattern by year wise in males (2006 – 2008)
Common cancer in 2006 - 2008 Year 2006
CIR
ASR
Year 2007
CIR
ASR
Year 2008
CIR
ASR
Lung
10.1
11.8
11.6
13.3
12.0
13.7
Stomach
10.0
11.4
11.8
13.2
9.9
10.8
Oral cavity
8.0
8.5
8.2
8.7
10.4
10.8
Aesophagus
6.7
7.7
7.2
8.0
6.6
7.4
Oropharynx
6.6
7.8
5.3
7.2
6.0
6.7
Lymphomas
5.3
5.8
5.6
6.2
5.7
6.1
Hypopharynx
4.0
4.6
3.5
4.0
5.0
5.7
Leukemia
3.7
4.5
4.4
4.5
4.6
5.2
Prostate
4.4
Larynx 3.3
5.1
3.8 3.7
4.2
4.3
4.0
4.1
3.4
3.8
4.8
Crude incidence rate / 1,00,000 (CIR), Age standardized rate / 1,00,000 (ASR)
A three year study for cancer cases in males showed a gradual increase in the incidence rate from 2006
to 2008. The increased incidence of Lung and Oral cavity cancers may be attributed to smoking &
chewing of tobacco from the younger age.
Top ten cancers in females (2007 – 2008)
Common cancer in 2006 - 2008 Year 2006
CIR
ASR
Year 2007
CIR
ASR
Year 2008
CIR
ASR
Breast 30.4
32.1
30.2
31.6
29.9
31.2
Cervix 18.9
20.6
16.4
17.9
16.3
17.9
Ovary 6.6
7.2
7.0
7.4
7.2
7.8
Oral Cavity
6.1
6.8
6.4
7.2
4.8
5.1
Stomach
5.4
5.9
6.3
6.8
5.1
5.4
Oesophagus
4.4
4.9 3.8
4.2
3.5
3.9
3.8
4.1
4.0
4.3
Lung
3.5
3.9
Lymphoma
3.2
Leukaemia
3.6
Rectum 2.1
3.4
4.0
2.3
2.6
3.7
3.9
3.2
3.3
2.9
3.2
3.4
3.6
2.9 2.8
3.0
A three year study of cancers in females revealed a decreased incidence of breast cancers which may be
due to the increased awareness and recent advanced diagnostic techniques. Oral cancer cases also
showed a significant decrease which could be because of the increased awareness on the risk associated
with tobacco consumption.
Risk factors:
According to the study conducted by R. Sankaranarayana in 1990, chewing pan along with tobacco (CI
29.50), smoking bidi (CI 5.57) and drinking alcohol (CI 3.93) were statistically significant factors for
developing oral cancer (R. Sankaranarayana , Stephen W Duffy, G Padmakumary , Nicholas E Day, M
Krishna Nair. Risk factors for cancer of the buccal and labial mucosa in Kerala, Southern India. Journal of
Epidemiology and Community Health 1990; 44: 286 - 292)
Frequency, relative risk and confidence interval in males:
Factor Category
Pan Tobacco
Never
≤ 10 per day
11 – 20 per day
21 – 30 per day
31 – 40 per day
≥ 41 per day
37
11
35
39
48
70
1.00
6.90
5.80
7.70
13.24
37.75
------------
(2.83
16.8)
(3. 33
10.11)
Cases RR
CI
Significant
(4.43
13.38)
(7.51
23.22)
(19.49
73.12)P ≤ 0.001
Bidi
Never
≤ 20 per day
21 plus per day 125
17
94
1.00
2.68
2.47
---------
(1.35
5.30)
( 1.74
3.49 )
Cigarette
P ≤ 0.001
Never
≤ 20 per day
21 plus per day
235
4
9
1.00
0.16
0.66
---------
(0.19
1.82)
( 0.30
1.44 ) NS
Bidi and Cigarette
≤ 20 per day
21 plus per day
Never
203
10
35
1.00
1.19
1.27
---------
(0.54
2. 59)
( 0.81
2.00 ) NS
Alcohol Never
≤ 20 per day
21 plus per day
165
24
17
1.00
1.48
2.50
---------
(0.71
3. 07)
( 1.59
3.93 ) P ≤ 0.001
Frequency, relative risk and confidence interval in Females
Factor Category
Pan Tobacco
≤ 10 per day
11 – 20 per day
21 – 30 per day
31 – 40 per day
Never
Cases RR
CI
Significant
≥ 41 per day
168
48
49
48
19
13
1.00
1.79
3.80
7.74
21.30
54.93
------------
(0.78
4.07)
(1.85
7.75)
(4.00
15.00)
(9.59
47.36)
(21.18
142.42)
P ≤ 0.001
RR= Relative risk; CI = Confidence interval
(Courtesy: R. Sankaranarayanan etal JECH 1990)
Preventive programmes:
India is one among the many developing countries that has formulated a National Cancer
Control Programme (NCCP). This programme is designed for controlling the tobacco related cancers,
early diagnosis and treatment of cervical and uterine cancers and distribution of therapeutic services.
(50 years of cancer control in India. Cancer prevention and control in India., Cherian Varghese, Page 5253)
Primary prevention is the most cost effective programme as it aims to reduce the incidence of cancer
risk. 50% of the oral cancers occurring in males are tobacco related and a large proportion of them can
be prevented by anti-tobacco programmes. Teenage is the time when such deleterious habits of
Tobacco usage are picked up. So, this group of students should first be targeted for such awareness
programs. In the school curriculum, messages which help to lead a healthy life style and awareness
about the harmful effects of tobacco usage and alcohol intake should be involved.
Cancer prevention needs to be considered as a part of the non communicable disease prevention
programme, which can make it more effective and feasible. (50 years of cancer control in India. Cancer
prevention and control in India., Cherian Varghese, Page 52-53).
Every year, approximately one million people in India are diagnosed with oral cancer and half of them
die within 12 months of diagnosis due to lack of awareness regarding oral cancer. Etiology of this cancer
related death in males is associated with a well established risk habits such as tobacco, areca nut and
alchol.
Some steps with which we can reduce the oral cancers are –
1.
Reduce tobacco consumption
2.
Promoting oral health in population
3.
National alcohol control policy
4.
Areca nut Control
5.
National cancer screening programme
Reduce tobacco consumption:
According to GATS (Global Adult Tobacco Survey) by the Ministry of health and family welfare
released in 2010, nearly 160 millions of the Indian population is using smokeless tobacco, which is an
alarming finding. Early detection will make a significant impact if tobacco consumption rate remains
high. Tobacco is responsible for 1 in 5 male deaths, particularly in the middle age group. Men who
smoke will decrease their life span for 10 years because of tuberculosis, respiratory disease, heart
disease and cancer. To avoid consumption of tobacco we have to follow certain policies like –
1.
Increasing taxes on all tobacco products
2.
Counselling about poor oral hygiene and adverse effects of using tobacco, areca nut, alcohol etc
3.
Ban tobacco containing food substances under food safety and standard acts of India 2011.
Promoting Oral health in Indian population:
Poor oral hygiene and specific bacterial microbial flora in the oral cavity have been linked with
development of oral cancers. Some viruses like EBV, HPV and Opportunistic flora like Candida albicans
have also been implicated in carcinogenesis. Promotion of health life style is influenced greatly by
knowledge, aptitude and hygiene at all levels of society. Health education is the best for promoting oral
health.
National Alcohol control policy:
Alcohol is one of the leading risk factor in under developed/developing countries and third
largest risk factor after chewing and smoking forms of tobacco. Tobacco and alcohol are responsible for
the loss of 58.3 million lives every year. Consumption of alcohol leads to oral cancer, very commonly
involving the tongue and floor of the mouth. Alcohol will increase the permeability of oral mucosa to
harmful tobacco carcinogens.
Areca nut control:
It is one of the psycho–stimulant and addictive substance. WHO classified areca nut under
Group – I human carcinogens, with sufficient evidence of increased risk of OSMF, premalignant oral
lesions and cancers of the oral cavity. Cancers caused by betel nut chewing shows a strong dose
response relationship for frequency and duration of chewing.
National Oral cancer screening Program:
This program may help in the early detection and in the prevention of oral cancers. All the dentists and
doctors (Clinicians) need to perform careful examinations of the oral cavity in those with high-risk habits
and those with symptoms and signs. Dentists are the best at oral screening and regular visit may lead to
detection at early stage. Periodic visit to the dentist as a part of routine health check-up will have
positive impact. In spite of the lacking support from the literature review, oral examination can be a
simple but effective tool to make individuals more conscious about their oral health. (Pankaj Chaturvedi.
Effective strategies for oral cancer control in India. Journal of Cancer Research and Therapeutics –
Supplement 2 – 2012 – Volume 8)
Mahatma Gandhi quotation:
“If you want to find a solution, go and live where the problem is”
Oral cancer is our unique problem and we, as dental professionals, are the ones who can deal with it
effectively and find a solution.
Public awareness:
A study in 1995 on the Level of awareness about oral cancer among public in Great Britain revealed that
77% of the public respondents were aware of the possibility of the occurrence of cancer in the mouth
due to smoking. (Tanuja Rastogi, Susan Devsa, Punam Mangtani , Aleyamma Mathew, Nicola Cooper,
Roy Kao and Rashmi Sinha. Ethnicity and Health Cancer incidence rates among South Asians in four
geographic regions: India, Singapore, UK and US. International Journal of Epidemiology 2008; 37:147 –
160).
Horowitz et.al. in 1990 observed that tobacco use was the only risk factor correctly identified among
young individuals. (Horowitz A M, Nourjah P and Gift H C. US adult knowledge of risk factors and signs of
oral cancer: 1990. JADA 1995; 126:39-45).
95% identified tobacco in any form as a risk factor and
only 25% indicated alcohol also as one of the risk factor for developing oral cancer. (Raczkowska A,
Zakrzewska J, Pogorzelska B. Pilot study on polish public’s knowledge and attitudes towards oral cancer.
Oral Dis 1997; 3(Sup 2): S35).
A study done by Harri’s etal in 1996 showed that 90% of alcohol misusers were also smokers of tobacco.
(Harris CK, Warnakulasurya KAAS, Johnson N W, Gelbier S, Peters T J. Oral health in alcohol misusers.
Community Dental Health 1996; 13:199 – 203). The combination of alcohol and smoking increases the
risk for the occurrence of oral cancers, by up to 44 %, when compared with non smokers and occasional
smokers.
Future activities:
National cancer control programme has developed a 10 years plan to reduce the oral cancer by 20 –
30% by the year 2020. But we have to include some key activities in the 10 year plan like –
1.
Development of guidelines for management of oral cancer and potentially malignant lesions
2.
Establishment of a wise surveillance system of oral cancer and potentially malignant lesions
3.
Utilization of risk factors model for early detection of oral cancer
4.
Support and strengthening the ongoing early detection programme
PROGRAMS TO BE UNDERTAKEN AT VARIOUS ELVELS FOR AN EFFECTIVE CANCER CONTROL
Regional cancer center (RCC)
(Health promotion / Home care / Early detection / Pain relief / palliative care / Comprehensive cancer
treatment / Organise screening programmes / Cytological training / Basic and applied research /
Training of all categories of personnel / Cancer registries / Epidemiology)
Medical college Hospital
(Health promotion / Home care / Early detection / Pain relief / Palliative care / Treatment of common
cancer / Training of medical officers / Paramedical personals)
District Hospital
(Health promotion / Home care / Early detection / Pain relief / Palliative care / Treatment of common
cancer)
Taluk hospital / Sub district hospital
(Health promotion / Home care / Early detection / Pain relief / Palliative care)
(Courtesy: 50 years of cancer control in India. Cancer prevention and control in India., Cherian Varghese,
Page 57)