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Covering Letter
Abstract Page
Title of the article: Clinico-epidemiological profile of Oral cancer: A hospital based study.
Abstract:
Research questions: 1.What is the profile of Oral cancer (Oral cavity) cases reported in the
hospital?
Objective: To study the profile of the Oral cancer cases associated with it.
Study Design: Hospital based, Cross -sectional study.
Settings: Shri Siddhivinayak Ganapati Cancer Hospital, Miraj, Maharashtra
Participants: 160 cases of Oral cancer reported in Shri Siddhivinayak Ganapati Cancer Hospital, Miraj,
Maharashtra during 1st March 2005 to 28th February 2006.
Study Variables: Demographic characteristics, tobacco, clinco-pathological characteristics.
Statistical analysis used: Percentages and Proportions
Results: Majority of the subjects included in the study belonged to 40-70 years age group. Most of the
subjects belonged to upper lower and lower socio-economic scale according to modified Kuppuswamy
socio-economic scale. It was found that 75 (47%) subjects consumed tobacco and 22 (14%) males
were tobacco smokers in the form of bidis. Histopathologically 37 cases were diagnosed as verrucous
carcinoma, 52 cases as well differentiated squamous cell carcinoma, 37 cases as moderately
differentiated squamous cell carcinoma and 34 cases as poorly differentiated squamous cell
carcinoma. Histopathological examination was used as a diagnostic tool in all. Surgical intervention
was used in 130 (81.25%) subjects.
Conclusions: In the present study majority of the Oral cancer cases were well differentiated squamous
cell carcinoma and were presented in advanced stages of disease.
Key-words: Oral cancers, tobacco use, Western Maharashtra.
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Text
Introduction:
India appears to be in a triple disadvantage. The communicable diseases still continue to cause
morbidity and mortality, though on smaller scale compared to past. Even before it has been possible to
bring them under total control, non-communicable diseases are showing an ever increasing incidence.
In addition, some new diseases, unknown in the past, have started causing outbreaks.
Further to it, it is observed that cancers are increasingly seen in both genders and all the age groups
due to a complex interaction of various risk factors. To implement the proper intervention measures it
is essential to have the baseline data regarding frequency, distribution, determinants of cancers in the
population including the diagnostic and prognostic information. This total bulk of information means
the population based cancer registry. However in our country the PBCR has not evolved yet.
Therefore we need to rely upon the hospital based cancer registry (HBCR).
Oral cancer is one of the most common cancers in developing countries. India also has one of the
highest rates of oral cancer in the world, mostly attributed to high prevalence of tobacco usage.
Though many studies on it have been carried out in the different parts of the country, the available
literature indicates no such study in Western Maharashtra. With this background the present study was
carried out and it may be considered as a baseline enquiry into the subject.
Subjects and Methods: The present study is a Hospital based, Cross -sectional study conducted at
Shri Siddhivinayak Ganapati Cancer Hospital, Miraj, Maharashtra carried out for the period of one
year from 1st March 2005 to 28th February 2006. Retrospective questionnaire study was carried out on
160 confirmed cases of Oral (Oral cavity) cancer reported in the hospital for the study period.
Informed consent was taken from all subjects.
Study Variables included demographic characteristics, tobacco usage, clinico-pathological
characteristics. Statistical analysis used was percentages and proportions.
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Results:
Table 1.1: Cancers of Oral cavity- Number (#) and Proportion (%) according to sub-site (2005-2006)
Sub-site
#
%
Tongue
101
63
Cheek
25
15.60
Gums
13
8.10
Vestibule of mouth
11
6.9
Palate
10
6.25
Total
160
100
Higher proportions of cancers were seen in tongue which accounted for 63% of all cases. The
Other sub-sites affected were cheek, gums, vestibule of mouth and palate.
Table 2.1: Number (#) and Proportion (%) according to Sex, Sex Ratio Percent
Of Oral cancer cases (2005-2006)
Males
#
125
S
Females
%
#
%
78.13
35
28.87
Sex
Ratios%
Total
cases
1.25
160
Number of male patients per 100 female patients
The sex ratio percent was 1.25 indicating majority were male subjects.
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Table2.2: Number (#) and Proportion (%) of Cancers by Broad Age Groups (2005-2006)
Age group
20-30
30-40
40-50
50-60
60-70
70+
All ages
Male
Female
Total
#
%
#
%
#
%
07
5.06
0
00
7
4.03
27
21.06
02
5.71
29
18.12
30
24.0
09
25.71
39
24.37
26
20.08
09
25.71
35
21.87
30
24.0
11
31.42
41
25.62
5
4.0
4
11.42
09
5.62
125
100
35
100
160
100
Majority of the cases belonged to age group 40-70 years. The minimum age of the patient was 27
years; maximum age of the patient was 92 years. Proportions of cases decreased in extremes of ages.
Table2.3: Number (#) and Proportion (%) of Cancers by Socio-economic status (2005-2006)
Socio-economic status
#
%
Upper
16
10.0
Upper middle
12
7.50
Lower middle
46
28.75
Upper lower
64
40
Lower
22
13.75
Total
160
100
Majority of the patients belonged to lower middle and upper lower socio-economic status as per the
modified Kuppuswamy scale.
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Table2.4: Number (#) and Proportion (%) of Cancers by tobacco habits (2005-2006)
Tobacco chewing
75
47
Tobacco smoking
22
12
Tobacco chewing as well as
12
7.5
30
18.75
smoking
Tobacco as well as alcohol
consumption
Almost 87% cases had habit of tobacco consumption with or without alcohol. 75 subjects (47%) had a
habit of chewing tobacco. These subjects mainly consumed Gutkha. Only 10 female subjects had
habit of chewing tobacco.
Out of 160 subjects, 30 had a habit of tobacco consumption (chewing or smoking) associated with
alcohol consumption. None of the female subject smoked or consumed alcohol.
Table2.5: Number (#) and Proportion (%) of Cancers by Staging (2005-2006)
Staging
#
%
Stage I
45
28.13
Stage II
85
53.13
Stage III
30
18.75
Total
160
100
72% cases were in stage II and stage III of the disease. Only 28% cases were in stage I.
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Table2.6: Number (#) and Proportion (%) of Cancers by Histopathology patterns (2005-2006)
Histopathology
#
%
Verrucous carcinoma
37
23.1
Well differentiated squamous cell
52
32.5
37
23.1
34
21.2
160
100
carcinoma
Moderately differentiated
squamous cell carcinoma
Poorly differentiated squamous
cell carcinoma
Total
Histopathologically 37 cases were Verrucous carcinoma, 52 were Well differentiated squamous cell
carcinoma, 37 were Moderately differentiated squamous cell carcinoma and 34 cases were Poorly
differentiated squamous cell carcinoma.
Table2.7: Number (#) and Proportion (%) of Cancers by Diagnostic tool used (2005-2006)
Diagnostic tool
#
%
Histopathology examination
160
100
The form of diagnosis in all subjects of Oral cancer was through microscopy examination.
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Table2.8: Number (#) and Proportion (%) of Cancers by modality of treatment given (2005-2006)
Modality
#
%
Surgery
130
81.25
Surgery+ Radiotherapy
30
18.75
Chemotherapy
0
0
Surgery+ Radiotherapy
0
0
160
100
+Chemotherapy
Total
Surgery as a treatment modality was used in 130 cases, while in 30 cases combination therapy
(Surgery+ Radiotherapy) was deployed.
Discussion:
Oral cancer is a major problem in India and accounts for 50-70% of all the cancers diagnosed as
compared to 2-3% in UK and USA1. In the present study tongue was the predominant sub-site of oral
cavity involved followed by cheek mucosa and gums. Our findings are in agreement with the findings
of all the Hospital Based Cancer Registry (HBCR) across the country2.
High proportion of cases among males may be due to high prevalence of tobacco consumption habits
among males in our society. Females in Indian society are not indulged in tobacco smoking or alcohol
consumption. Most of the subjects belonged to lower middle and upper lower socio-economic class.
The low socio-economic status may be a risk factor for poor oral hygiene thereby further increasing
the risk of oral cancer in tobacco consumers. Balaram et al have shown similar findings in their study3.
In our study leading sites among Oral cancers were tongue followed by cheek. It can be correlated by
the tobacco consumption habit of the subjects as tobacco consumption is a well established risk factor
for development of Oral cancer4, 5. In India smokeless use includes betel quid, gutkha, mawa, zarda,
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khaini and snuf. Many of these products are chewed while some are applied in the oral cavity6. Most
of the time they are kept under lips or in the cheeks from where it is gradually absorbed after dilution
with saliva. Smokeless tobacco contains over 2000 chemicals, many of which have been directly
related to cause cancer7. The tongue particularly the side of the tongue, cheeks are the site of
maximum insult and thus are affected most the time. 30 cases in our study had the habit of tobacco
consumption which was also associated with alcohol consumption. Data indicate that oral cancer can
also be caused by high concentrations of alcohol, and that alcohol appears to have a synergistic effect
in tobacco users8.
In our study 128 cases (80%) displayed squamous cell carcinoma. Our findings are in agreement with
the findings of all the Hospital Based Cancer Registry (HBCR) across the country2. Most of the
patients as evident in the present study turn up in advanced or relatively advanced stages of disease.
This is the crux of problem because studies have shown that detecting oral cancer in early stages offers
the best chance of long term survival.
Conclusions: The Tobacco Related Cancers represent the most preventable form of cancer in our
society. Additionally, cancers in easily accessible parts of body highlight the possibility of easy and
early detection of cancers in the population. Oral cavity cancer is a Tobacco Related Cancer occurring
in a very easily accessible part of body amenable for self and clinical examination.
Oral cancer is amenable to primary prevention. It requires intensive public education and motivation
to change life style. Life style is defined as personal customs or habits of individual or group of
individuals. It alludes to their active adaptation to the social milieu, which develops as a product of
need for integration and socialization. With regard to health, lifestyle refers to dietary habits, use of
substances such as alcohol and tobacco.
Limitations of the present study: This being the first study of its kind in the Western Maharashtra, it
was imperative that a cross sectional study was done than going for in-depth probing of any specified
parameter.
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Recommendations: Though it is not pertinent to apply the observation of hospital based study to
general population, in the light of fact that the cancers are showing continuous upward trends, it is
desirable to suggest the appropriate intervention measures and strategies.
1.
Cancer education campaign should be enhanced for general public and should be important
component in health care.
2. Prospective long term study is required for the estimation of age at onset of Oral cancer, which
will help in various interventions for prevention and control of cancers.
3. Life style intervention curriculum and anti-tobacco curriculum need to be introduced in the
schools.
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References:
1. Park K, editor. Park’s Textbook of Preventive and Social Medicine. Jabalpur: Banarsidas
Bhanot Publications 18th edition; 2005. Pp. 307.
2. Consolidated Report of Hospital Based Cancer Registries 2004-2006. Available from
http://www.pbcrindia.org/HBCR_Report_2004-06.pdf [Last cited 2011 Oct 6].
3. 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.
4. 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
5. Gupta PC. Incidence rates of oral cancer and natural history of oral precancerous lesions in a
ten year follow up study of Indian villagers. Community dentistry and oral epidemiology,
1980; 8: 287-333
6. Sinha DN. Report on oral tobacco use and its implications in Southeast Asia. Available from
www.searo.who.int/linkfiles/nmh_oraltobaccouse.pdf (Last accessed 15th October, 2011)
7. Khandekar SP, Bagdey PS, Tiwari RR. Oral cancer and some epidemiological factors: A
hospital based study. Indian Journal of Community Medicine, 2006; 31(3):157-159
8. Bull WHO, 1984; 62(6): 817-830.
Acknowledgement: Shri Siddhivinayak Ganapati Cancer Hospital, Miraj, Maharashtra